Complications after pancreatic resection: Diagnosis, prevention and management

doi:10.1016/j.clinre.2013.01.003

Clinics and Research in Hepatology and Gastroenterology

Volume 37, Issue 3, June 2013, Pages 230-239

https://doi.org/10.1016/j.clinre.2013.01.003 Get rights and content

Summary

Background

Although mortality after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has decreased, morbidity still remains high. The aim of this review article is to present, define, predict, prevent, and manage the main complications after pancreatic resection (PR).

Methods

A non-systematic literature search on morbidity and mortality after PR was undertaken using the PubMed/MEDLINE and Embase databases.

Results

The main complications after PR are delayed gastric emptying (DGE), pancreatic fistula (PF), and bleeding, as defined by the International Study Group on Pancreatic Surgery. PF occurs in 10% to 15% of patients after PD and in 10% to 30% of patients after DP. The different techniques of pancreatic anastomosis and pancreatic remnant closure do not show significant advantages in the prevention of PF, nor does the perioperative use of somatostatin and its analogues. The trend is for conservative or interventional radiology therapy for PF (with enteral nutrition), which achieves a success rate of approximately 80%. DGE after PD occurs in 20% to 50% of patients. Prophylactic erythromycin may reduce the incidence of DGE. Gastric aspiration with erythromycin is usually effective in one to three weeks. Bleeding (gastrointestinal and intraabdominal) occurs in 4% to 16% of patients after PD and in 2% to 3% of patients after DP. Endovascular treatment can only be used for a haemodynamically stable patient. In cases of haemodynamic instability or associated septic complications, surgical treatment is necessary. In expert centres, the mortality rates can be less than 1% after DP and less than 3% after PD.

Conclusion

There is a need for improved strategies to prevent and treat complications after PR.

Introduction

Pancreatic surgery has long been burdened with high postoperative morbidity and mortality. Rates of mortality after pancreaticoduodenectomy (PD) have continuously decreased in recent years. However, morbidity remains high, especially after PD [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. In a study conducted at Johns Hopkins Hospital that included 650 patients who underwent PD, the morbidity rate was 41%, with a 14% rate of pancreatic fistula (PF) [8]. The postoperative mortality of distal pancreatectomy (DP) is presently close to 0%, and the rate of postoperative morbidity ranges from 9% to 31% [11], [12], [13], [14], [15]. PF is also the most frequent complication following DP, and it occurs even more frequently following DP than following PD [3], [6], [7], [8]. This review addresses the principal surgical complications after pancreatectomy, discusses their management, and specifies the existing preventive measures.

Section snippets

Methods

From January 2000 to June 2012, a PubMed/MEDLINE and Embase search was performed using the search words “fistula”, “leak”, “delayed gastric empting”, “bleeding”, “ischaemia”, “pancreatitis”, “biliary”, “abscesses”, “complications”, “morbidity”, or “mortality” combined with “pancreatectomy”, “pancreaticoduodenectomy”, “distal pancreatectomy”, or “left pancreatectomy”. The study was planned by the first and the last authors, who performed the initial literature search and wrote the draft

Definition and prevalence

The comparison of results from trials in the literature is difficult due to the variability of the definition of a pancreatic fistula (PF). This definition can be based not only on clinical or radiological criteria but also on an analysis of the drained liquid (e.g., the level of amylase and/or daily flow). In one study, the rate of PF varied from 10% to 29% according to four different definitions of PF [9]. After 2005 [10], the International Study Group on Pancreatic Fistula (ISGPF) defined PF

Definition and prevalence

The second principal complication after PD is the occurrence of DGE, the prevalence of which is between 20% and 50% [8], [66], [67], [68], [69]. Although DGE is not life threatening, it can severely alter the nutritional state of a patient and can prolong the postoperative hospitalisation. The wide range of rates for DGE can be explained in part by the various definitions for this complication. After 2007 [70], the ISGPS defined DGE as the impossibility of resuming oral feeding after the first

Definition and prevalence

Bleeding occurs in 4% to 16% of cases after a PD [35], [36], [55], [83], [84], [86], [87] and in 2% to 3% of cases after a DP [4], [5], [22]. After 2007 [88], the ISGPS defined postpancreatectomy haemorrhage using three parameters: onset, location, and severity. The onset is either early (≤ 24 hours after the end of the index operation) or late (> 24 hours). The location is either intraluminal or extraluminal. The severity of bleeding may be either mild or severe. Three different grades, A, B, and

Ischaemic complications

Ischaemic complications have a prevalence rate of approximately 1% and are essentially arterial in origin; they are linked to trauma during dissection or to a pre-existing stenosis of the superior mesenteric artery or the celiac trunk [93], [94]. The gastroduodenal artery is tied during a PD, suppressing subsidiary routes through the duodenopancreatic arcades in cases of proximal stenosis of the celiac trunk or the superior mesenteric artery. Stenoses of the celiac trunk occur most often due to

Biliary complications

A fistula from the biliary-digestive anastomosis occurs in 1% to 5% of cases [1], [3], [8], [98]. Bile leakage after hepatobiliary and pancreatic operations is defined as a bilirubin concentration in the drain fluid at least three times the serum bilirubin concentration on or after postoperative day 3 or as the need for radiologic or operative intervention resulting from biliary collections or bile peritonitis [99]. Using this criterion, the severity of bile leakage can be classified into three

Acute pancreatitis

The prevalence of acute pancreatitis is reported to be between 2% and 3% [2], [8], [98]. The systematic use of a CT scan in the first postoperative week revealed acute pancreatitis in 25% of cases [103]. It is difficult to evaluate the prevalence of this complication because an increase in the serum level of pancreatic enzymes is frequently observed after pancreatectomy [104]. The rate of occurrence varies depending on whether the definition is biological or radiological. Furthermore, there is

Digestive fistulas – intraabdominal abscesses

The occurrence of intraabdominal abscess after PD remains an important problem, and its incidence ranges from 3% to 8% [105]. This is a frequent cause of rehospitalisation. It seems that neither the type of pancreaticodigestive anastomosis nor the way in which it was prepared influences the appearance of this complication. A randomised prospective trial suggested that the use of abdominal drainage does not reduce the occurrence of intraabdominal abscess (6.8% versus 6.6%), and thus, their use

Mortality

The rate of mortality after pancreaticoduodenectomy has declined significantly in recent years [109]. The type of pancreatectomy has an influence on postoperative mortality; since 2000, the mortality rate has been less than 9% for PD [110] and less than 3.5% [109] for DP. In expert centres, these rates can be less than 1% after DP [4], [5] and less than 3% [1], [2], [3] or even zero [6], [7] after PD. In fact, expertise and the volume of pancreatic surgery activity have been reported as

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon
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Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.
A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading
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Morbidity and mortality from post-pancreatectomy haemorrhage (PPH) remains high. The International Study Group of Pancreatic Surgery (ISGPS) published guidelines to standardise definitions of PPH severity, management and reporting. This study aimed to i) identify the number of studies reporting PPH using ISGPS guidelines (Grade A, B or C) and ii) describe treatment modality success by grade.
A systematic literature review was performed, identifying studies reporting PPH by ISGPS Grade and their subsequent management.
Of 62 studies reporting on PPH management, 17 (27.4%) stratified by ISGPS guidelines and included 608 incidences of PPH: 48 Grade A, 274 Grade B (62 early, 166 late, 46 unspecified) and 286 Grade C.
96% of Grade A PPH were treated conservatively. Of 62 early Grade B, 54.8% were managed conservatively and 37.1% surgically. Late Grade B were managed non-operatively in 25.3% (42/166), with successful endoscopy in 90.9% (10/11) and angiography in 90.3% (28/31). In Grade C, endoscopic treatment was successful in 64.4% (29/45) and angiography in 90.8% (108/119). Surgical intervention was required in 43.5% early Grade B, 7.8% late Grade B and 33.2% Grade C.
PPH grading is underreported and despite guidelines, inconsistencies remain when using definitions and reporting of outcomes.
Delayed gastric emptying following distal pancreatectomy: incidence and predisposing factors
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Delayed gastric emptying (DGE) following elective distal pancreatectomy (DP) is poorly known. This study aimed to report incidence of DGE following DP, to identify its predisposing factors, and to assess its impact on hospital stay.
Patients who had elective DP without additional organ or vascular resection (2012–2017) in two academic hospitals were included. Factors predisposing to DGE, defined according to the International Study Group of Pancreatic Surgery, were identified by multivariate analysis. A systematic review was performed to evaluate DGE incidence following elective DP.
311 elective DPs were performed. Three perioperative mortalities (1.0%) were unrelated to DGE. DGE occurred in 31 (10.0%) patients (grade A = 21, grade B = 7, grade C = 3) with a median hospital stay of 16 (13–22) days versus 10 (7–14) without DGE (p < 0.001). In multivariate analysis, predisposing factors of DGE were age>75 years (OR = 4.32 [1.53–12.19]; p = 0.006), open approach (OR = 2.97 [1.1–8]; p = 0.031) and POPF grade B–C (OR = 2.54 [1.05–6.1]; p = 0.038). The systematic review identified 7 series including 876 patients with an overall 8.1% DGE incidence.
DGE complicates around 10% of elective DP. Laparoscopic approach and prevention of POPF should be encouraged to reduce DGE incidence.
More Than an ERAS Pathway is Needed to Meet Target Length of Stay After Pancreaticoduodenectomy
2022, Journal of Surgical Research
Citation Excerpt :
This single-institution study sought to elucidate factors which convey elevated risk of failing the ERAS pathway target LOS after PD. These results demonstrate that the two most common events associated with failure to meet target LOS were slow return of gastric and/or bowel function and work-up to evaluate for a pancreatic or hepaticojejunostomy leak, all known complications after PD.17 Interestingly, the study also identified a group of patients who did not meet ERAS target LOS solely because these patients were kept for additional observation out of surgeon subjective concern but without additional interventions.
Enhanced Recovery After Surgery (ERAS) protocols have been successfully instituted for pancreaticoduodenectomy (PD). This study evaluates reasons patients fail to meet length of stay (LOS) and areas for pathway improvement.
A multidisciplinary team developed and implemented an ERAS protocol for open PD in 2017. The study includes a medical record review of all patients who were perioperatively managed with the ERAS protocol and failed to meet LOS after PD procedures. Target LOS was defined as 7 d.
From 2017 to 2020, 44% (93 of 213) of patients using ERAS protocol after PD procedures failed to meet target LOS. The most common reason to fail target LOS was ileus or delayed gastric emptying (47 of 93, LOS 11). Additional reasons included work-up of leukocytosis or pancreatic leak (17 of 93, LOS 14), additional “night” of observation (14 of 93, LOS 8), and orthostatic hypotension (3 of 93, LOS 10). Of these additional 46 patients, 19 patients underwent computed tomography (on or after POD 7) and only four patients received additional inpatient intervention.
The most common reason for PD pathway failure included slow return of gastrointestinal function, a known complication after PD. The remaining patients were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than protocol modification.
Serum lipase on postoperative day one is a strong predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort
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Increased postoperative serum amylase has been recently reported to be associated with increased postoperative morbidity, but studies on postoperative serum lipase are limited. The aim of this study was to evaluate the value of postoperative serum lipase in predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).
A retrospective analysis was performed on 212 patients who underwent PD from September 2018 and March 2021, focusing on the association between postoperative day (POD) 1 serum lipase and CR-POPF.
Overall, 108 (50.9%) patients had elevated serum lipase levels (>68 U/L) on POD 1. Patients with elevated serum lipase exhibited a significantly higher incidence of CR-POPF (37.0% vs. 6.7%, p < 0.001). Receiver operating characteristic (ROC) analyses showed improved diagnostic accuracy for POD 1 serum lipase compared with POD 1 serum amylase in predicting CR-POPF (AUC: 0.801 vs. 0.745, p = 0.029). Elevated serum lipase on POD 1 and elevated serum CRP on POD 3 were identified as independent predictors of CR-POPF. A simple early postoperative model, consisting of POD 1 serum lipase levels and POD 3 serum CRP levels, showed good discrimination (AUC 0.76, 95% CI 0.69–0.83) to identify the onset of CR-POPF.
Serum lipase on POD 1 outperformed serum amylase on POD 1 in predicting CR-POPF after PD. The combination of POD 1 serum lipase and POD 3 serum CRP provides a reliable predicting model for CR-POPF.
Clinical Efficacy of the Preservation of the Hepatic Branch of the Vagus Nerve on Delayed Gastric Emptying After Laparoscopic Pancreaticoduodenectomy
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Delayed gastric emptying (DGE) is a common complication following laparoscopic pancreaticoduodenectomy (LPD), although it remains incompletely understood, and only few studies have investigated the clinical benefits of hepatic branch of the vagus nerve (HBVN) preservation on DGE after LPD until now. We intended to evaluate the effect of preservation of the HBVN during LPD on the incidence of DGE.
A total of 274 consecutive LPDs performed at a single center between July 2014 and December 2019 with available videos were retrospectively reviewed. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria, and HBVN condition during the LPD procedure was evaluated through a video review. Risk factors associated with DGE were assessed by performing univariate and multivariate logistic regression analyses. Postoperative outcomes between the HBVN-preserved and HBVN-injury groups were compared before and after propensity score matching (PSM).
One hundred fifty-six (56.93%) patients underwent LPD with HBVN-preserved and 118 (43.07%) with HBVN injury. DGE occurred in 33.2% of patients (n = 91) with grades B and C occurring at 13.9% (n = 38) and 7.7% (n = 21), respectively. Longer operative time, more EIBL, HBVN injury, POPF (grades B and C), postoperative hemorrhage, intra-abdominal infection, and Clavien-Dindo ≥III were identified as risk factors for DGE in the univariate analysis. Then, in the multivariate analysis, HBVN injury and intra-abdominal infection were found to be independent risk factors affecting the incidence of DGE (any grade) or clinically relevant DGE (grades B and C). Furthermore, the prevalence of DGE was significantly higher in the HBVN-injury group than in the HBVN-preserved group before and after PSM analysis (46.61% vs. 23.08%, P<0.001; 42.59% vs. 23.15%, P=0.013).
HBVN preservation during LPD might be associated with a reduced incidence of DGE as a framework for prospective quality improvement.

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ReviewComplications after pancreatic resection: Diagnosis, prevention and management

Summary

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Definition and prevalence

Definition and prevalence

Definition and prevalence

Ischaemic complications

Biliary complications

Acute pancreatitis

Digestive fistulas – intraabdominal abscesses

Mortality

Disclosure of interest

J Gastrointest Surg

J Gastrointest Surg

Surgery

Am J Surg

J Am Coll Surg

J Chir

J Gastrointest Surg

Am J Surg

Surgery

Surgery

J Gastrointest Surg

J Am Coll Surg

J Am Coll Surg

Am J Surg

J Gastrointest Surg

Lancet

J Gastrointest Surg

Am J Surg

Am J Surg

Am J Surg

J Am Coll Surg

Surgery

Am J Surg

J Am Coll Surg

Am J Surg

Surgery

Best Pract Res Clin Gastroenterol

J Gastrointest Surg

J Chir

Surgery

Am J Surg

Surgery

J Gastrointest Surg

Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy

Ann Surg

One thousand consecutive pancreatectomies

Ann Surg

Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume

Ann Surg

Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment

Arch Surg

One hundred and forty-five consecutive pancreaticoduodenectomies without mortality

Ann Surg

Survival after pancreatoduodenectomy: 118 consecutive resections without an operative mortality

Ann Surg

Pancreatic fistula rate after pancreatic resection: the importance of definitions

Dig Surg

Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases

Ann Surg

Risk factors for pancreatic leak after distal pancreatecomy

Ann Surg

Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation

Br J Surg

Parenchyma-preserving resections for small non-functioning pancreatic endocrine tumors

Ann Surg Oncol

Incidence and management of pancreatic leakage after pancreatoduodenectomy

Br J Surg

Pancreatic fistulas and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature

Anticancer Res

A factor in postoperative pancreatic fistula

Ann Surg

Amylase value in drains after pancreatic resection as predictive factor of postoperative fistula: results of a prospective study in 137 patients

Review
Complications after pancreatic resection: Diagnosis, prevention and management