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After Distal Pancreatectomy Pancreatic Leakage from the Stump of the Pancreas May Be Due to Drain Failure or Pancreatic Ductal Back Pressure

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Hypothesis

The method to lower postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) involves controlling risk factors for leakage from the pancreatic stump.

Goal

The aim of this study was to identify controllable risk factors for POPF.

Methods

In order to promote homogeneity, we used a single surgeon case series and then calculated POPF with a public web-based tool based on the severity classification system of the International Study Group of Pancreatic Surgery (ISGPS). A total of 223 consecutive cases of DPs were reviewed. DP involved the same hand-sewn fish-mouth closure of the pancreatic stump. All received postoperative epidural anesthesia. Logistic regression analysis identified risk factors for clinically relevant POPF (grade B/C).

Results

Mortality was zero. ISGPS gradings were: no POPF 53%, grade A = 32%, B = 13.9%, and C = 0.9%. The clinical-relevant POPF (B/C) rate was 14.8% of which 24% represented surgical drain failure due to lack of patency and/or misplaced from their original location. Preoperative endoscopic ablation and/or stenting of Wirsung’s duct was a significant risk factor to lower grade B/C leak (3%). Multivariate analysis identified two controllable risk factors—intraoperative blood loss >1,000 ml and those who did not undergo preoperative endoscopic interventions of Wirsung’s duct. In the group with presumed intact pancreatic sphincters (no endoscopic intervention, n = 177), the use of postoperative intravenous opioids (with epidural failure) was a risk factor for B/C leak (34%). These findings suggest that increased back pressure in the pancreatic duct has a role in promoting pancreatic stump leakage.

Conclusions

Using the ISGPS definition and its web-based tool, the incidence of clinically relevant leakage was 14.8% in 223 cases of DP. Opportunities to lower this rate are improving our surgical drain technology, limiting intraoperative blood loss, and avoiding postoperative intravenous narcotics with epidural analgesia.

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Abbreviations

ASA:

American Society of Anesthesiologists

BMI:

Body mass index

CI:

Confidence interval

CT:

Computed tomography

DGE:

Delayed gastric emptying

DM:

Diabetes mellitus

DP:

Distal pancreatectomy

ERCP:

Endoscopic retrograde cholangiopancreatography

FNA:

Fine needle aspiration

ICU:

Intensive care unit

IPMN:

Intraductal papillary mucinous neoplasm

IR:

Interventional radiology

ISGPS:

International Study Group of Pancreatic Surgery

IV-PCA:

Intravenous patient-controlled analgesia

LOS:

Length of hospital stay

MCN:

Mucinous cystic neoplasm

NG:

Nasogastric

OR:

Odds ratio

PCEA:

Patient-controlled epidural anesthesia

POD:

Postoperative day

PV:

Portal vein

SCN:

Serous cystic neoplasm

SMV:

Superior mesenteric

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Authors and Affiliations

  1. Section of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA

    Yasushi Hashimoto & L. William Traverso

  2. Center for Pancreatic Disease, St. Luke’s Hospital System, 100 East Idaho St., Suite 301, Boise, ID, 83702, USA

    L. William Traverso

Authors
  1. Yasushi Hashimoto
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  2. L. William Traverso
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Correspondence to L. William Traverso.

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Hashimoto, Y., Traverso, L.W. After Distal Pancreatectomy Pancreatic Leakage from the Stump of the Pancreas May Be Due to Drain Failure or Pancreatic Ductal Back Pressure. J Gastrointest Surg 16, 993–1003 (2012). https://doi.org/10.1007/s11605-012-1849-y

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  • DOI: https://doi.org/10.1007/s11605-012-1849-y

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