Elsevier

The Surgeon

Volume 9, Issue 4, August 2011, Pages 211-217
The Surgeon

Review
Postoperative pancreatic fistula

https://doi.org/10.1016/j.surge.2010.10.011Get rights and content

Abstract

Postoperative pancreatic fistula is an important complication after pancreatic resection. The frequency of its incidence varies between 3% after pancreatic head resections and up to 30% following distal pancreatectomy. In recent years, the international definition of pancreatic fistula has been standardised according to the approach of the International Study Group on Pancreatic Fistula (ISGPF). Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically.

The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula.

Section snippets

Background

Pancreatic operations are technically challenging surgical procedures that require a high level of experience and standards with regard to resection and reconstruction. While these procedures were associated with high morbidity and mortality rates in the past, pancreatic surgery has significantly changed during the last two decades with regard to technical aspects as well as perioperative care.1, 2, 3, 4 Standardised resections are well-established and can be carried out today with low

Definition of postoperative pancreatic fistula

Pancreatic fistulae have been described by various authors using non-standardised definitions in the past.6, 13, 15, 16 In general, the leakage of enzyme-containing fluid from the pancreatic tissue or duct, of any origin and cause, is regarded as a pancreatic fistula. With regard to the postoperative situation, a leakage from the pancreatic stump or the anastomosis can frequently be observed in the very early phase after a resection. Therefore, it is necessary to further clarify the fistula

Procedure-specific incidence and risk factors for fistula development

The occurrence of a postoperative leakage of pancreatic juice is highly dependent on the performed resection and the underlying pancreatic pathology.6 Especially, soft pancreatic tissue texture without pre-existing fibrosis is regarded as a risk factor for fistula development.

Prevention of postoperative fistula

The use of octreotide and its analogues to prevent postoperative fistula is an approach which has been used since the 1990s.51, 52, 53, 54, 55, 56 Despite twenty years of clinical use and performance in numerous studies, a recent Cochrane meta-analysis56 concluded that evidence is still lacking to give clear recommendations or guidelines. While early RCTs favoured the use of octreotide and showed a 50% reduction of fistula rates51, 52, 53 these findings were not confirmed in later trials.54, 55

Fistula-associated complications

Once a pancreatic fistula is evident in the postoperative course, prevention of consecutive complications is essential. Commonly-observed complications are mainly caused by undrained pancreatic fluid and superinfection of fluid collections. As pancreatic fluid is an enzymatically active and aggressive substance, arrosional complications can affect the surrounding tissue, namely the intestinal, bile duct or vessel walls. This can lead to a leakage of increasing size at the pancreatic anastomosis

Management of pancreatic fistula

The management of postoperative fistula remains a therapeutic challenge and underlines the importance of specific surgical, radiological and, if necessary, anaesthesiological ICU care knowledge. As every fistula is a potentially life-threatening complication for the patient, early detection and careful management is of the highest priority to avoid consequent complications. Depending on the clinical symptomology and the condition of the patient, fistula management ranges from persisting

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