Pancreatic fistula – definition, risk factors and treatment options
Authors:
F. Čečka 1; B. Jon 1; Z. Šubrt 1,2; A. Ferko 1
Authors place of work:
Chirurgická klinika Fakultní nemocnice Hradec Králové a Lékařské Fakulty UK v Hradci Králové
přednosta kliniky: prof. MUDr. A. Ferko, CSc.
1; Katedra válečné chirurgie, Fakulta vojenského zdravotnictví, Univerzita Obrany Brno
vedoucí katedry: doc. MUDr. L. Klein, CSc.
2
Published in the journal:
Rozhl. Chir., 2013, roč. 92, č. 2, s. 77-84.
Category:
Review
Summary
Pancreatic fistula is a common complication after pancreatic resections. Its incidence oscillates between 10 and 30%. The differences in the incidence cited in the studies are due to the various fistula definitions. According to ISGPF, pancreatic fistula is an output -via an operatively placed drain (or a subsequently placed percutaneous drain) - of any measurable volume of drain fluid on or after postoperative day 3, with an amylase content higher than 3 times the upper normal serum value. The fistula is then classified according to the clinical impact in grades A, B, and C.
There are known three risk factor categories for the development of pancreatic fistula:
the risk related to the pancreatic disease, to the patient, and to the surgical procedure. Most of the risk factors for the development of pancreatic fistula cannot be influenced either prior to or during the surgery. There are two basic options for the prevention of pancreatic fistula: pharmacological intervention (administration of somatostatin and its analogues) and technical modifications of the pancreatic remnant treatment. However, the routine administration of somatostatin and its analogues is not advisable in all pancreatic surgical procedures. In high risk cases the selective administration is preferred. The second option is modification of pancreatic remnant treatment. Most of the studies dealing with various modifications of the pancreatic remnant treatment were retrospective with lower level of evidence. There were only a few properly designed randomized trials, and most of them did not prove benefit of one method over another. It has been shown that the results depend on the experience of a given surgical department, and above all on the experience of an individual surgeon who performs the pancreatic resection.
The therapy of pancreatic fistula is based on the clinical severity. Conservative approach is warranted in most patients. In cases when reoperation is required, there are two basic strategies: surgical drainage of the collections, and completion of total pancreatectomy. Total pancreatectomy was preferred in the past, however, this procedure is technically very demanding with mortality up to 80 per cent. Nowadays, most of the authors prefer surgical drainage; this procedure is technically less demanding, has lower mortality, the endocrine function of pancreas is protected, and the patients usually need no further interventions.
Key words:
Pancreatic fistula – pancreatic fistula definition – risk factors – pancreatic fistula therapy
Zdroje
1. Buchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003;138: 1310–1314.
2. Butturini G, Daskalaki D, Molinari E, Scopelliti F, Casarotto A, Bassi C. Pancreatic fistula: definition and current problems. J Hepatobiliary Pancreat Surg 2008;15:247–251.
3. Haddad LB, Scatton O, Randone B, et al. Pancreatic fistula after pancreaticoduodenectomy: the conservative treatment of choice. HPB (Oxford), 2009;11:203–209.
4. Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg 2004;21:54–59.
5. Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM, Jr. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007;245:443–451.
6. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13.
7. Čečka F, Jon B, Šubrt Z, Ferko A. The effect of somatostatin and its analogs in the prevention of pancreatic fistula after elective pancreatic surgery. Eur Surg 2012;44:99–108.
8. Lowy AM, Lee JE, Pisters PW, et al. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 1997;226:632–641.
9. Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000;232: 419–429.
10. Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 2004;8:951–959.
11. Matsusue S, Takeda H, Nakamura Y, Nishimura S, Koizumi S. A prospective analysis of the factors influencing pancreaticojejunostomy performed using a single method, in 100 consecutive pancreaticoduodenectomies. Surg Today 1998;28:719–726.
12. Cheng Q, Zhang B, Zhang Y, et al. Predictive factors for complications after pancreaticoduodenectomy. J Surg Res 2007; 139:22–29.
13. Gaujoux S, Cortes A, Couvelard A, et al. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery 2010;148:15–23.
14. Yeh TS, Jan YY, Jeng LB, et al. Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy—multivariate analysis of perioperative risk factors. J Surg Res 1997;67:119–125.
15. Cheng TY, Sheth K, White RR, et al. Effect of neoadjuvant chemoradiation on operative mortality and morbidity for pancreaticoduodenectomy. Ann Surg Oncol 2006;13:66–74.
16. Kleeff J, Diener MK, Z’graggen K, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 2007;245:573–582.
17. Klempa I, Schwedes U, Usadel KH. Prevention of postoperative pancreatic complications following duodenopancreatectomy using somatostatin. Chirurg 1979;50:427–431.
18. Lamberts SW, Van Der Lely AJ, De Herder WW, Hofland LJ. Octreotide. N Engl J Med 1996;334:246–254.
19. Buchler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–130.
20. Friess H, Beger HG, Sulkowski U, et al. Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis. Br J Surg 1995;82:1270–1273.
21. Hesse UJ, De Decker C, Houtmeyers P, et al. Prospectively randomized trial using perioperative low dose octreotide to prevent organ related and general complications following pancreatic surgery and pancreatico-jejunostomy. Acta Chir Belg 2005;105: 383–387.
22. Montorsi M, Zago M, Mosca F, et al. Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery 1995;117:26–31.
23. Pederzoli P, Bassi C, Falconi M, Camboni MG. Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Italian Study Group. Br J Surg 1994;81:265–269.
24. Suc B, Msika S, Piccinini M, et al. Octreotide in the prevention of intra-abdominal complications following elective pancreatic resection: a prospective, multicenter randomized controlled trial. Arch Surg 2004;139:288–294.
25. Shrikhande SV, Qureshi SS, Rajneesh N, Shukla PJ. Pancreatic anastomoses after pancreaticoduodenectomy: do we need further studies? World J Surg 2005;29:1642–1649.
26. Wente, MN, Shrikhande, SV, Muller, MW, et al. Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis. Am J Surg, 2007;193:171–183.
27. Sutton CD, Garcea G, White SA, et al. Isolated Roux-loop pancreaticojejunostomy: a series of 61 patients with zero postoperative pancreaticoenteric leaks. J Gastrointest Surg 2004;8:701–705.
28. Murakami Y, Uemura K, Hayashidani Y, et al. No mortality after 150 consecutive pancreatoduodenctomies with duct-to-mucosa pancreaticogastrostomy. J Surg Oncol 2008;97:205–209.
29. Bassi C, Falconi M, Molinari E, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. Surgery 2003;134:766–771.
30. Poon RT, Fan ST, Lo CM, et al. External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg 2007;246:425–433.
31. Winter JM, Cameron JL, Campbell KA, et al. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2006;10:1280–1290.
32. Kim Z, Kim J, Min JK, et al. Negative pressure external drainage of the pancreatic duct in pancreaticoduodenectomy. Hepatogastroenterology 2010;57:625–630.
33. Ferrone CR, Warshaw AL, Rattner DW, et al. Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg 2008;12:1691–1697.
34. Nathan H, Cameron JL, Goodwin CR, et al. Risk factors for pancreatic leak after distal pancreatectomy. Ann Surg 2009;250: 277–281.
35. Reeh M, Nentwich MF, Bogoevski D, et al. High surgical morbidity following distal pancreatectomy: still an unsolved problem. World J Surg 2011;35:1110–1117.
36. Diener MK, Seiler CM, Rossion I, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 2011;377: 1514–1522.
37. Kooby DA, Gillespie T, Bentrem D, et al. Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 2008;248:438–446.
38. Nigri GR, Rosman AS, Petrucciani N, et al. Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies. Surg Endosc 2011;25:1642–1651.
39. Vijan SS, Ahmed KA, Harmsen WS, et al. Laparoscopic vs open distal pancreatectomy: a single-institution comparative study. Arch Surg 2010;145:616–621.
40. Mabrut JY, Fernandez-Cruz L, Azagra JS, et al. Laparoscopic pancreatic resection: results of a multicenter European study of 127 patients. Surgery, 2005;137:597–605.
41. Song KB, Kim SC, Park JB, et al. Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection. Surg Endosc 2011;25:3364–3372.
42. Chou FF, Sheen-Chen SM, Chen YS, Chen MC, Chen CL. Postoperative morbidity and mortality of pancreaticoduodenectomy for periampullary cancer. Eur J Surg 1996;162:477–481.
43. Berger AC, Howard TJ, Kennedy EP, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg 2009;208:738–747.
44. Bassi C, Falconi M, Molinari E, et al. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 2005; 242:767–771.
45. Duffas JP, Suc B, Msika S, et al. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg 2005;189:720–729.
46. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222: 580–588.
47. Schmidt CM, Turrini O, Parikh P, et al. Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg 2010;145:634–640.
48. Loveček M, Neoral Č, Klos D, et al. Chirurgie karcinomu pankreatu na I. chirurgické klinice FN Olomouc. Rozhl Chir 2010; 89:731–739.
49. Dellaportas D, Tympa A, Nastos C, et al. An ongoing dispute in the management of severe pancreatic fistula: Pancreatospleenectomy or not? World J Gastrointest Surg 2010;2:381–384.
50. Shrikhande SV, D’Souza MA. Pancreatic fistula after pancreatectomy: evolving definitions, preventive strategies and modern management. World J Gastroenterol 2008;14:5789–5796.
51. Gueroult S, Parc Y, Duron F, Paye F, Parc R. Completion pancreatectomy for postoperative peritonitis after pancreaticoduodenectomy: early and late outcome. Arch Surg 2004;139:16–19.
52. Grobmyer SR, Hunt DL, Forsmark CE, Draganov PV, Behrns KE, Hochwald SN. Pancreatic stent placement is associated with resolution of refractory grade C pancreatic fistula after left-sidedpancreatectomy. Am Surg 2009;75: 654–657.
53. Frozanpor F, Lundell L, Segersvärd R, Arnelo U. The effect of prophylactic transpapillary pancreatic stent insertion on clinically significant leak rate following distal pancreatectomy: results of a prospective controlled clinical trial. Ann Surg 2012;255: 1032–1036.
54. Schäfer M, Heinrich S, Pfammatter T, Clavien P-A. Management of delayed major visceral arterial bleeding after pancreatic surgery. HPB 2011;13:132–138.
55. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH) – An International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142:20–25.
56. Roulin D, Cerantola Y, Demartines N, Schäfer M. Systematic Review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg 2011;15:1055–1062.
57. Ryska M. Radikalita resekčního výkonu u nemocných s karcinomem pankreatu z pohledu prodloužení života a jeho kvality. Rozhl Chir 2010; 89:725–730.
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