ReviewComplications after pancreatic resection: Diagnosis, prevention and management
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.
References (116)
- et al.
Perioperative outcomes for open distal pancreatectomy: current benchmarks for comparison
J Gastrointest Surg
(2011) - et al.
Surgical Apgar score predicts perioperative morbidity in patients undergoing pancreaticoduodenectomy at a high-volume center
J Gastrointest Surg
(2012) - et al.
Postoperative pancreatic fistula: an international study group (ISGPF) definition
Surgery
(2005) - et al.
Morbidity, mortality, and technical factors of distal pancreatectomy
Am J Surg
(2002) - et al.
Management and outcomes of postpancreatectomy fistula, leak, and abscess: results of 908 patients resected at a single institution between 2000 and 2005
J Am Coll Surg
(2008) - et al.
Résections limitées du pancréas pour tumeur intracanalaire papillaire et mucineuse non invasive
J Chir
(2008) - et al.
Risk factors and outcome in postpancreaticoduodenectomy pancreaticocutaneous fistula
J Gastrointest Surg
(2004) - et al.
Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy
Am J Surg
(2002) - et al.
Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy
Surgery
(2005) - et al.
Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy
Surgery
(2010)
The role of “fatty pancreas” and BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy
J Gastrointest Surg
Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy
J Am Coll Surg
Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized prospective dual-institution trial
J Am Coll Surg
A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy
Am J Surg
Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial
J Gastrointest Surg
Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial
Lancet
A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreaticoduodenectomy
J Gastrointest Surg
Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated?
Am J Surg
Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management
Am J Surg
Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation
Am J Surg
Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy
J Am Coll Surg
Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)
Surgery
Enteral nutrition prolongs delayed gastric emptying in patients after Whipple resection
Am J Surg
Factors influencing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy
J Am Coll Surg
A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy
Am J Surg
Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition
Surgery
Management of bleeding and leakage after pancreatic surgery
Best Pract Res Clin Gastroenterol
Results of non-operative therapy for delayed hemorrhage after pancreaticoduodenectomy
J Gastrointest Surg
Section du ligament arqué pour sténose extrinsèque du tronc cœliaque au cours d’une duodénopancréatectomie céphalique
J Chir
Endovascular stenting for celiac axis stenosis before pancreaticoduodenectomy
Surgery
Risk factors for complications after pancreatic head resection
Am J Surg
Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the international study group of liver surgery
Surgery
Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications
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
Ann Surg
Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreaticoduodenectomy
Ann Surg
The latent presentation of pancreatic fistulas
Br J Surg
Cited by (87)
Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon
2024, European Journal of Radiology OpenMore Than an ERAS Pathway is Needed to Meet Target Length of Stay After Pancreaticoduodenectomy
2022, Journal of Surgical ResearchCitation 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.
Clinical Efficacy of the Preservation of the Hepatic Branch of the Vagus Nerve on Delayed Gastric Emptying After Laparoscopic Pancreaticoduodenectomy
2021, Journal of Gastrointestinal Surgery