Pancreatic fistula following pancreaticoduodenectomy: clinical predictors and patient outcomes

C Max Schmidt, Jennifer Choi, Emilie S Powell, Constantin T Yiannoutsos, Nicholas J Zyromski, Attila Nakeeb, Henry A Pitt, Eric A Wiebke, James A Madura, Keith D Lillemoe, C Max Schmidt, Jennifer Choi, Emilie S Powell, Constantin T Yiannoutsos, Nicholas J Zyromski, Attila Nakeeb, Henry A Pitt, Eric A Wiebke, James A Madura, Keith D Lillemoe

Abstract

Pancreatic fistula continues to be a common complication following PD. This study seeks to identify clinical factors which may predict pancreatic fistula (PF) and evaluate the effect of PF on outcomes following pancreaticoduodenectomy (PD). We performed a retrospective analysis of a clinical database at an academic tertiary care hospital with a high volume of pancreatic surgery. Five hundred ten consecutive patients underwent PD, and PF occurred in 46 patients (9%). Perioperative mortality of patients with PF was 0%. Forty-five of 46 PF (98%) closed without reoperation with a mean time to closure of 34 days. Patients who developed PF showed a higher incidence of wound infection, intra-abdominal abscess, need for reoperation, and hospital length of stay. Multivariate analysis demonstrated an invaginated pancreatic anastomosis and closed suction intraperitoneal drainage were associated with PF whereas a diagnosis of chronic pancreatitis and endoscopic stenting conferred protection. Development of PF following PD in this series was predicted by gender, preoperative stenting, pancreatic anastomotic technique, and pancreas pathology. Outcomes in patients with PF are remarkable for a higher rate of septic complications, longer hospital stays, but in this study, no increased mortality.

References

    1. Schmidt CM, Powell ES, Yiannoutsos CT, et al. Pancreaticoduodenectomy: a 20-year experience in 516 patients. Archives of Surgery. 2004;139(7):718–727.
    1. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Annals of Surgery. 1997;226(3):248–260.
    1. Trede M, Saeger HD, Schwall G, Rumstadt B. Resection of pancreatic cancer—surgical achievements. Langenbeck's Archives of Surgery. 1998;383(2):121–128.
    1. Balcom JH, IV, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Archives of Surgery. 2001;136(4):391–398.
    1. Bassi C, Falconi M, Salvia R, Mascetta G, Molinari E, Pederzoli P. Management of complications after pancreaticoduodenectomy in a high volume centre: results on 150 consecutive patients. Digestive Surgery. 2001;18(6):453–458.
    1. Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. Journal of Gastrointestinal Surgery. 2004;8(8):951–959.
    1. Kazanjian KK, Hines OJ, Eibl G, Reber HA. Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Archives of Surgery. 2005;140(9):849–855.
    1. Cullen JJ, Sarr MG, Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. The American Journal of Surgery. 1994;168(4):295–298.
    1. Büchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z'Graggen K. Pancreatic fistula after pancreatic head resection. British Journal of Surgery. 2000;87(7):883–889.
    1. van Berge Henegouwen MI, De Wit LT, Van Gulik TM, Obertop H, Gouma DJ. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. Journal of the American College of Surgeons. 1997;185(1):18–24.
    1. Sarr MG The Pancreatic Surgery Group. The potent somatostatin analogue vapreotide does not decrease pancreas-specific complications after elective pancreatectomy: a prospective, multicenter, double-blinded, randomized, placebo-controlled trial. Journal of the American College of Surgeons. 2003;196(4):556–565.
    1. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Annals of Surgery. 1995;222(4):580–592.
    1. Aranha GV, Hodul P, Golts E, Oh D, Pickleman J, Creech S. A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreaticoduodenectomy. Journal of Gastrointestinal Surgery. 2003;7(5):672–682.
    1. Suc B, Msika S, Fingerhut A, et al. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Annals of Surgery. 2003;237(1):57–65.
    1. Lillemoe KD, Cameron JL, Kim MP, et al. Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? Results of a prospective randomized trial. Journal of Gastrointestinal Surgery. 2004;8(7):766–774.
    1. Büchler MW, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. The American Journal of Surgery. 1992;163(1):125–131.
    1. Pederzoli P, Bassi C, Falconi M, Camboni MG. Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. British Journal of Surgery. 1994;81(2):265–269.
    1. 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. British Journal of Surgery. 1995;82(9):1270–1273.
    1. 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. Annals of Surgery. 2000;232(3):419–429.
    1. Lowy AM, Lee JE, Pisters PWT, et al. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Annals of Surgery. 1997;226(5):632–641.
    1. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13.
    1. Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Annals of Surgery. 1995;221(6):635–648.
    1. Yeh T-S, Jan Y-Y, Jeng L-B, et al. Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy—multivariate analysis of perioperative risk factors. Journal of Surgical Research. 1997;67(2):119–125.
    1. 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. Surgery Today. 1998;28(7):719–726.
    1. Bartoli FG, Arnone GB, Ravera G, Bachi V. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature. Anticancer Research. 1991;11(5):1831–1848.
    1. 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(5):766–771.
    1. Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase postpancreaticoduodenectomy complications? Journal of Gastrointestinal Surgery. 2000;4(3):258–268.
    1. Lygidakis NJ, van der Heyde MN, Lubbers MJ. Evaluation of preoperative biliary drainage in the surgical management of pancreatic head carcinoma. Acta Chirurgica Scandinavica. 1987;153(11-12):665–668.
    1. Conlon KC, Labow D, Leung D, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Annals of Surgery. 2001;234(4):487–494.
    1. Al Sharaf K, Ihse I, Dawiskiba S, Andrén-Sandberg Å. Characteristics of the gland remnant predict complications after subtotal pancreatectomy. Digestive Surgery. 1997;14(2):101–106.
    1. Sato N, Yamaguchi K, Chijiiwa K, Tanaka M. Risk analysis of pancreatic fistula after pancreatic head resection. Archives of Surgery. 1998;133(10):1094–1098.
    1. Hamanaka Y, Nishihara K, Hamasaki T, et al. Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage. Surgery. 1996;119(3):281–287.
    1. Peng SY, Mou YP, Liu YB, et al. Binding pancreaticojejunostomy: 150 consecutive cases without leakage. Journal of Gastrointestinal Surgery. 2003;7(7):898–900.
    1. Roder JD, Stein HJ, Böttcher KA, Busch R, Heidecke CD, Siewert JR. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study. Annals of Surgery. 1999;229(1):41–48.
    1. Howard JM. Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection. Journal of the American College of Surgeons. 1997;184(5):454–457.
    1. Wada K, Traverso LW. Pancreatic anastomotic leak after the Whipple procedure is reduced using the surgical microscope. Surgery. 2006;139(6):735–742.

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