Skip to main content

Advertisement

SpringerLink
Log in

Prevention and Management of Pancreatic Fistula

  • review article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Despite significant improvements in the safety and efficacy of pancreatic surgery, post-operative pancreatic fistulae remain an unsolved dilemma. These occur when the transected pancreatic gland, pancreatic-enteric anastomosis, or both, leak rendering the patient at significant risk. They are especially important today since indications for resection (IPMN, carcinoma) continue to increase. This review considers definitions and classifications of pancreatic fistulae, risk factors, preventative approaches and offers management strategies for when they do occur. Key citations from the past seventeen years have been scrutinized, and together with personal experience, provide the basis for this review.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2

Similar content being viewed by others

References

  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. J Am Coll Surg 1997;185:18–24. Medline.

    PubMed  Google Scholar 

  2. Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch ORC, Obertop H. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 2000;232:786–795. DOI 10.1097/00000658-200012000-00007.

    Article  PubMed  CAS  Google Scholar 

  3. 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 Res 1991;11:1831–1848. Medline.

    PubMed  CAS  Google Scholar 

  4. Poon RT, Lo SH, Fong D, Fan ST, Wong J. Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg 2002;183:42–52. DOI 10.1016/S0002-9610(01)00829-7.

    Article  PubMed  Google Scholar 

  5. Bassi C, Dervenis C, Butturini G et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13. DOI 10.1016/j.surg.2005.05.001.

    Article  PubMed  Google Scholar 

  6. Bassi C, Butturini G, Molinari E, Mascetta G, Salvia R, Falconi M, Gumbs A, Pederzoli P. Pancreatic fistula rate after pancreatic resection: the importance of definitions. Dig Surg 2004;21:54–59. DOI 10.1159/000075943.

    Article  PubMed  Google Scholar 

  7. Lowy AM, Lee JE, Pisters PW, Davidson BS, Fenoglio CJ, Stanford P, Jinnah R, Evans DB. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 1997;226:632–641. DOI 10.1097/00000658-199711000-00008.

    Article  PubMed  CAS  Google Scholar 

  8. Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007;245:443–451. DOI 10.1097/01.sla.0000251708.70219.d2.

    Article  PubMed  Google Scholar 

  9. Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 2004;8:951–959. DOI 10.1016/j.gassur.2004.09.044.

    Article  PubMed  Google Scholar 

  10. 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. Ann Surg 2000;232:419–429. DOI 10.1097/00000658-200009000-00014.

    Article  PubMed  CAS  Google Scholar 

  11. Yeh TS, Jan YY, Jeng LB, Hwang TL, Wang CS, Chen SC, Chao TC, Chen MF. Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy—multivariate analysis of perioperative risk factors. J Surg Res 1997;67:119–125. DOI 10.1006/jsre.1996.4974.

    Article  PubMed  CAS  Google Scholar 

  12. Sato N, Yamaguchi K, Chijiiwa K, Tanaka M. Risk analysis of pancreatic fistula after pancreatic head resection. Arch Surg 1998;133:1094–1098. DOI 10.1001/archsurg.133.10.1094.

    Article  PubMed  CAS  Google Scholar 

  13. Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221:635–648. DOI 10.1097/00000658-199506000-00003.

    Article  PubMed  CAS  Google Scholar 

  14. 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. Surg Today 1998;28:719–726. DOI 10.1007/BF02484618.

    Article  PubMed  CAS  Google Scholar 

  15. Ishikawa O, Ohigashi H, Imaoka S, Teshima T, Inoue T, Sasaki Y, Iwanaga T, Nakaisumi A. Concomitant benefit of preoperative irradiation in preventing pancreas fistula formation after pancreaticoduodenectomy. Arch Surg 1991;126:885–889. Medline.

    PubMed  CAS  Google Scholar 

  16. Hoffman J. Does prior adjuvant chemoradiotherapy lead to a safer pancreatoduodenectomy? Ann Surg Oncol 2006;13:7–9. DOI 10.1245/ASO.2006.09.912.

    Article  PubMed  Google Scholar 

  17. Pratt WB, Callery MP, Vollmer CM. Risk prediction for development of pancreatic fistula utilizing the ISGPF classification scheme. World J Surg 2007;32:419–428. DOI 10.1007/s00268-007-9388-5.

    Article  Google Scholar 

  18. Sledzianowski JF, Duffas JP, Muscari F, Suc B, Fourtanier F. Risk factors for mortality an intra-abdominal morbidity after distal pancreatectomy. Surgery 2005;137:180–185. DOI 10.1016/j.surg.2004.06.063.

    Article  PubMed  CAS  Google Scholar 

  19. Pannegeon V, Pessaux P, Sauvanet A, Vullierme MP, Kianmanesh R, Belghiti J. Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment. Arch Surg 2006;141:1017–1076. DOI 10.1001/archsurg.141.11.1071.

    Google Scholar 

  20. Ridolfini MP, Alfieri S, Gourgiotis S, Di Miceli D, Rotondi F, Quero G, Manghi R, Doglietto GB. Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial? World J Gastroenterol 2007;13:5096–5100. Medline.

    PubMed  Google Scholar 

  21. Fernandez-del Castillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990s. Arch Surg 1995;130:295–299. Medline.

    PubMed  CAS  Google Scholar 

  22. Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997;226:248–257. DOI 10.1097/00000658-199709000-00004.

    Article  PubMed  CAS  Google Scholar 

  23. Buchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z’graggen K. Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87:883–889. DOI 10.1046/j.1365-2168.2000.01465.x.

    Article  PubMed  CAS  Google Scholar 

  24. Pratt WB, Maithel SK, Vanounou T, Callery MP, Vollmer CM. Postoperative pancreatic fistulas are not equivalent after proximal, distal, and central pancreatectomy. J Gastrointest Surg 2006;10:1264–1279. DOI 10.1016/j.gassur.2006.07.011.

    Article  PubMed  Google Scholar 

  25. Emick DM, Riall TS, Cameron JL, Winter JM, Lillemoe KD, Coleman J, Sauter PK, Yeo CJ. Hospital readmission after pancreaticoduodenectomy. J Gastrointest Surg 2006;10:1243–1252. DOI 10.1016/j.gassur.2006.08.016.

    Article  PubMed  Google Scholar 

  26. Fahy BN, Frey CF, Ho HS, Beckett L, Bold RJ. Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg 2002;183:237–241. DOI 10.1016/S0002-9610(02)00790-0.

    Article  PubMed  Google Scholar 

  27. Knaebel HP, Diener MK, Wente MN, Buchler MW, Seiler CM. Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 2005;92:539–546. DOI 10.1002/bjs.5000.

    Article  PubMed  CAS  Google Scholar 

  28. Kuroki T, Tajima Y, Kanematsu T. Surgical management for the prevention of pancreatic fistula following distal pancreatectomy. J Hepatobiliary Pancreat Surg 2005;12:283–285. DOI 10.1007/s00534-005-0990-3.

    Article  PubMed  Google Scholar 

  29. Lillemoe KD, Kaushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ. Distal pancreatectomy: Indications and outcomes in 235 patients. Ann Surg 1999;229:693–700. DOI 10.1097/00000658-199905000-00012.

    Article  PubMed  CAS  Google Scholar 

  30. Aranha GV. Central (middle segment) pancreatectomy: a suitable operation for small lesions of the neck of the pancreas. Hepatogastroenterology 2002;49:1713–1715. Medline.

    PubMed  Google Scholar 

  31. Sauvanet A, Partensky C, Sastre B et al. Medial pancreatectomy: a multi-institutional retrospective study of 53 patients by the French Pancreas Club. Surgery 2002;132:836–843. DOI 10.1067/msy.2002.127552.

    Article  PubMed  Google Scholar 

  32. Efron DT, Lillemoe KD, Cameron JL, Yeo CJ. Central pancreatectomy with pancreaticogastrostomy for benign pancreatic pathology. J Gastrointest Surg 2004;8:532–538. DOI 10.1016/j.gassur.2004.03.004.

    Article  PubMed  Google Scholar 

  33. Christein JD, Smoot RL, Farnell MB. Central Pancreatectomy: a technique for the resection of pancreatic neck lesions. Arch Surg 2006;141:293–299. DOI 10.1001/archsurg.141.3.293.

    Article  PubMed  Google Scholar 

  34. Bassi C. Middle segment pancreatectomy: a useful tool in the management of pancreatic neoplasms. J Gastrointest Surg 2007;11:726–729. DOI 10.1007/s11605-007-0179-y.

    Article  PubMed  Google Scholar 

  35. Kausch W. Das carcinom der papilla duodeni und seine radikale entfernung. Beitrage zur Klinischen Chirurgie 1912;78:439–486.

    Google Scholar 

  36. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann Surg 1935;102:763–779. DOI 10.1097/00000658-193510000-00023.

    Article  PubMed  CAS  Google Scholar 

  37. Strasberg SM, Drebin JA, Soper NJ. Evolution and current status of the Whipple procedure: an update for gastroenterologists. Gastroenterology 1997;113:983–994. DOI 10.1016/S0016-5085(97)70195-1.

    Article  PubMed  CAS  Google Scholar 

  38. Waugh JM, Clagett OT. Resection of the duodenum and head of the pancreas for carcinoma: an analysis of thirty cases. Surgery 1946;20:224–232.

    Google Scholar 

  39. Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, Lillemoe KD, Pitt HA. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222:580–592. Medline.

    Article  PubMed  CAS  Google Scholar 

  40. Mason GR. Pancreatogastrostomy as reconstruction for pancreatoduodenectomy: review. World J Surg 1999;23:221–226. DOI 10.1007/PL00013188.

    Article  PubMed  CAS  Google Scholar 

  41. Sikora SS, Posner MC. Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82:1590–1597. DOI 10.1002/bjs.1800821205.

    Article  PubMed  CAS  Google Scholar 

  42. Matsumoto Y, Fujii H, Miura K, Inoue S, Sekikawa T, Aoyama H, Ohnishi N, Sakai K, Suda K. Successful pancreatojejunal anastomosis for pancreatoduodenectomy. Surg Gynecol Obstet 1992;175:555–562. Medline.

    PubMed  CAS  Google Scholar 

  43. Stojadinovic A, Brooks A, Hoos A, Jacques DP, Conlon KC, Brennan MF. An evidence-based approach to the surgical management of resectable pancreatic adenocarcinoma. J Am Coll Surg 2003;196:954–964. DOI 10.1016/S1072-7515(03)00010-3.

    Article  PubMed  Google Scholar 

  44. Roder JD, Stein HJ, Bottcher KA, busch R, Heidecke CD, Siewert JR. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy. A prospective study. Ann Surg 1999;229:41–48. DOI 10.1097/00000658-199901000-00005.

    Article  PubMed  CAS  Google Scholar 

  45. Mok KT, Wong BW, Liu Si. Management of pancreatic remnant with strategies according to the size of pancreatic duct after pancreaticoduodenectomy. Br J Surg 1999;86:1018–1019. DOI 10.1046/j.1365-2168.1999.01206.x.

    Article  PubMed  CAS  Google Scholar 

  46. Kingsnorth AN. Safety and function of isolated Roux loop pancreaticojejunostomy after Whipple’s pancreaticoduodenectomy. Ann R Coll Surg Engl 1994;76:175–179. Medline.

    PubMed  CAS  Google Scholar 

  47. Bilimoria MM, Cormier JN, Mun Y, Lee JE, Evans DB, Pisters PWT. Pancreatic leak after left pancreatectomy is reduced following pancreatic duct ligation. Br J Surg 2003;90:190–196. DOI 10.1002/bjs.4032.

    Article  PubMed  CAS  Google Scholar 

  48. Fahy BN, Frey CF, Ho HS, Beckett L, Bold RJ. Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg 2002;183:237–241. DOI 10.1016/S0002-9610(02)00790-0.

    Article  PubMed  Google Scholar 

  49. Henegouwen MI, Gulik TM, Akkermans LMA, Jansen JB, Gouma DJ. The effect of octreotide on gastric emptying at a dosage used to prevent complications after pancreatic surgery: a randomised, placebo controlled study in volunteers. Gut 1997;41:758–762. Medline.

    Article  Google Scholar 

  50. Buchler M, Friess H, Klempa I et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–130. DOI 10.1016/0002-9610(92)90264-R.

    Article  PubMed  CAS  Google Scholar 

  51. Pederzoli P, Bassi C, Falconi M, Camboni MG. Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Br J Surg 1994;81:265–269. DOI 10.1002/bjs.1800810237.

    Article  PubMed  CAS  Google Scholar 

  52. Vanounou T, Pratt WB, Callery MP, Vollmer CM. Selective administration of prophylactic octreotide during pancreaticoduodenectomy: a clinical and cost-benefit analysis in low- and high-risk glands. J Am Coll Surg 2007;205:546–557. DOI 10.1016/j.jamcollsurg.2007.05.011.

    Article  PubMed  Google Scholar 

  53. Suc B, Msika S, Piccinini M, Fourtanier G, Hay JM, Flamant Y, Fingerhut A, Fagniez PL, Chipponi J. Octreotide in the prevention of intra-abdominal complications following elective pancreatic resection: a prospective, multicenter randomized controlled trial. Arch Surg 2004;139:288–294. DOI 10.1001/archsurg.139.3.288.

    Article  PubMed  Google Scholar 

  54. Vanounou T, Pratt WB, Fischer JE, Vollmer CM, Callery MP. Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg 2007;204:570–579. DOI 10.1016/j.jamcollsurg.2007.01.025.

    Article  PubMed  Google Scholar 

  55. Shinchi H, Wada K, Traverso LW. The usefulness of drain data to identify a clinically relevant pancreatic anastomotic leak after pancreaticoduodenectomy? J Gastrointest Surg 2006;10:490–498. DOI 10.1016/j.gassur.2005.08.029.

    Article  PubMed  Google Scholar 

  56. Yeo CJ. Management of complications following pancreaticoduodenectomy. Surg Clin N Amer 1994;75:913–924.

    Google Scholar 

  57. Aranha GV, Aaron JM, Shoup M, Pickleman J. Current management of pancreatic fistula after pancreaticoduodenectomy. Surgery 2006;140:561–568. DOI 10.1016/j.surg.2006.07.009.

    Article  PubMed  Google Scholar 

  58. Kazanjian KK, Hines OJ, Eibl G, Reber HA. Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg 2005;140:849–854. DOI 10.1001/archsurg.140.9.849.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, St. 9, Boston, MA, 02215, USA

    Mark P. Callery, Wande B. Pratt & Charles M. Vollmer Jr

Authors
  1. Mark P. Callery
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wande B. Pratt
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Charles M. Vollmer Jr
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark P. Callery.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Callery, M.P., Pratt, W.B. & Vollmer, C.M. Prevention and Management of Pancreatic Fistula. J Gastrointest Surg 13, 163–173 (2009). https://doi.org/10.1007/s11605-008-0534-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-008-0534-7

Keywords

Search

Navigation