Skip to main content

Advertisement

SpringerLink
Log in

Outpatient Drainmanagement of patients with clinically relevant Postoperative Pancreatic Fistula (POPF)

  • ORIGINAL ARTICLE
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Purpose

Postoperative pancreatic fistula (POPF) is a common complication after pancreatic surgery associated with extended hospitalization, increased medical costs, and reduced quality of life. The aim of the present study was to analyze the feasibility of ambulatory drainage and develop an ambulatory management algorithm.

Methods

Patients with POPF grade B or C (according to the ISGPF classification) between Jan. 2005 and Dec. 2014 that required persistent drainage were identified from a prospectively collected database. Postoperative events and clinical outcomes were retrospectively analyzed.

Results

A total of 132 out of 887 patients (14.8%) developed a POPF (grade B or C), and 45 (34.1%) were discharged from the hospital with percutaneous drainage. For patients with grade B fistulas, the mean hospital stay was significantly shorter compared to patients with grade C fistulas (mean 27.7 vs. 40 days; p = 0.0285). About 40% of patients with ambulatory drainage developed a complication, but only 28.9% required readmission. Of those, 52.9% did not require specific treatment and 26.3% were treated with a new drain placement. None of the patients developed major complications, and there was no difference in the frequency of complications between the two groups (p = 0.872). The duration of drain persistence was significantly shorter for patients with grade B fistulas than for those with grade C fistulas (52.2 vs. 85.9 days; p = 0.0007).

Conclusions

Ambulatory drainage management is feasible in selected patients. No severe complications occurred during ambulatory drainage management. A management algorithm is recommended as this could possibly reduce medical costs and improve quality of life.

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

Fig. 1

Similar content being viewed by others

References

  1. Hackert T, Werner J, Buchler MW (2011) Postoperative pancreatic fistula. The Surgeon : Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 9(4):211–217. doi:10.1016/j.surge.2010.10.011

    Article  PubMed  Google Scholar 

  2. Hackert T, Hinz U, Pausch T, Fesenbeck I, Strobel O, Schneider L, Fritz S, Buchler MW (2016) Postoperative pancreatic fistula: we need to redefine grades B and C. Surgery 159(3):872–877. doi:10.1016/j.surg.2015.09.014

    Article  PubMed  Google Scholar 

  3. Distler M, Kersting S, Ruckert F, Kross P, Saeger HD, Weitz J, Grutzmann R (2014) Chronic pancreatitis of the pancreatic remnant is an independent risk factor for pancreatic fistula after distal pancreatectomy. BMC Surg 14:54. doi:10.1186/1471-2482-14-54

    Article  PubMed  PubMed Central  Google Scholar 

  4. Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, Tomazic A, Bruns CJ, Busch OR, Farkas S, Belyaev O, Neoptolemos JP, Halloran C, Keck T, Niedergethmann M, Gellert K, Witzigmann H, Kollmar O, Langer P, Steger U, Neudecker J, Berrevoet F, Ganzera S, Heiss MM, Luntz SP, Bruckner T, Kieser M, Buchler MW (2011) Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 377(9776):1514–1522. doi:10.1016/S0140-6736(11)60237-7

    Article  PubMed  Google Scholar 

  5. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula D (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13. doi:10.1016/j.surg.2005.05.001

    Article  PubMed  Google Scholar 

  6. Moskovic DJ, Hodges SE, Wu MF, Brunicardi FC, Hilsenbeck SG, Fisher WE (2010) Drain data to predict clinically relevant pancreatic fistula. HPB : the Official Journal of the International Hepato Pancreato Biliary Association 12(7):472–481. doi:10.1111/j.1477-2574.2010.00212.x

    Article  Google Scholar 

  7. Grutzmann R, Ruckert F, Hippe-Davies N, Distler M, Saeger HD (2012) Evaluation of the international study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center. Surgery 151(4):612–620. doi:10.1016/j.surg.2011.09.039

    Article  PubMed  Google Scholar 

  8. Lermite E, Pessaux P, Brehant O, Teyssedou C, Pelletier I, Etienne S, Arnaud JP (2007) Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy. J am Coll Surg 204(4):588–596. doi:10.1016/j.jamcollsurg.2007.01.018

    Article  PubMed  Google Scholar 

  9. Bassi C, Malleo G (2011) Pancreas: postoperative pancreatic fistula: use of enteral nutrition. Nat rev Gastroenterol Hepatol 8(8):427–428. doi:10.1038/nrgastro.2011.113

    Article  CAS  PubMed  Google Scholar 

  10. Tilara A, Gerdes H, Allen P, Jarnagin W, Kingham P, Fong Y, DeMatteo R, D'Angelica M, Schattner M (2014) Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections. J am Coll Surg 218(1):33–40. doi:10.1016/j.jamcollsurg.2013.09.001

    Article  PubMed  Google Scholar 

  11. Malleo G, Pulvirenti A, Marchegiani G, Butturini G, Salvia R, Bassi C (2014) Diagnosis and management of postoperative pancreatic fistula. Langenbeck's Archives of Surgery / Deutsche Gesellschaft fur Chirurgie 399(7):801–810. doi:10.1007/s00423-014-1242-2

    Article  Google Scholar 

  12. Schmidt CM, Choi J, Powell ES, Yiannoutsos CT, Zyromski NJ, Nakeeb A, Pitt HA, Wiebke EA, Madura JA, Lillemoe KD (2009) Pancreatic fistula following pancreaticoduodenectomy: clinical predictors and patient outcomes. HPB Surgery : a World Journal of Hepatic, Pancreatic and Biliary Surgery 2009:404520. doi:10.1155/2009/404520

    Article  Google Scholar 

  13. DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA (2006) Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 244(6):931–937; discussion 937-939. doi:10.1097/01.sla.0000246856.03918.9a

    Article  PubMed  PubMed Central  Google Scholar 

  14. Chebli JM, Gaburri PD, de Souza AF, Ornellas AT, Martins Junior EV, Chebli LA, Felga GE, Pinto JR (2004) Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis. J Clin Gastroenterol 38(9):795–800

    Article  PubMed  Google Scholar 

  15. Wolk S, Distler M, Mussle B, Sothje S, Weitz J, Welsch T (2016) Adherence to ERAS elements in major visceral surgery-an observational pilot study. Langenbeck's Archives of Surgery/Deutsche Gesellschaft fur Chirurgie 401(3):349–356. doi:10.1007/s00423-016-1407-2

    Article  Google Scholar 

  16. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  PubMed  PubMed Central  Google Scholar 

  17. Melloul E, Raptis DA, Clavien PA, Lesurtel M, European-African Hepato-Pancreato-Biliary A (2013) Poor level of agreement on the management of postoperative pancreatic fistula: results of an international survey. HPB : the Official Journal of the International Hepato Pancreato Biliary Association 15(4):307–314. doi:10.1111/j.1477-2574.2012.00599.x

    Article  Google Scholar 

  18. McMillan MT, Fisher WE, Van Buren G II, McElhany A, Bloomston M, Hughes SJ, Winter J, Behrman SW, Zyromski NJ, Velanovich V, Brown K, Morgan KA, Vollmer C (2015) The value of drains as a fistula mitigation strategy for pancreatoduodenectomy: something for everyone? Results of a randomized prospective multi-institutional study. Journal of Gastrointestinal Surgery : Official Journal of the Society for Surgery of the Alimentary Tract 19(1):21–30; discussion 30-21. doi:10.1007/s11605-014-2640-z

    Article  Google Scholar 

  19. Kawai M, Tani M, Terasawa H, Ina S, Hirono S, Nishioka R, Miyazawa M, Uchiyama K, Yamaue H (2006) Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg 244(1):1–7. doi:10.1097/01.sla.0000218077.14035.a6

    Article  PubMed  PubMed Central  Google Scholar 

  20. Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, Talamini G, Pederzoli P (2010) Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg 252(2):207–214. doi:10.1097/SLA.0b013e3181e61e88

    Article  PubMed  Google Scholar 

  21. McMillan MT, Malleo G, Bassi C, Butturini G, Salvia R, Roses RE, Lee MK, Fraker DL, Drebin JA, Vollmer CM Jr (2015) Drain management after pancreatoduodenectomy: reappraisal of a prospective randomized trial using risk stratification. J am Coll Surg 221(4):798–809. doi:10.1016/j.jamcollsurg.2015.07.005

    Article  PubMed  Google Scholar 

  22. Kazanjian KK, Hines OJ, Eibl G, Reber HA (2005) Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg 140(9):849–854; discussion 854-846. doi:10.1001/archsurg.140.9.849

  23. Munoz-Bongrand N, Sauvanet A, Denys A, Sibert A, Vilgrain V, Belghiti J (2004) Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy. J am Coll Surg 199(2):198–203. doi:10.1016/j.jamcollsurg.2004.03.015

    Article  PubMed  Google Scholar 

  24. Klek S, Sierzega M, Turczynowski L, Szybinski P, Szczepanek K, Kulig J (2011) Enteral and parenteral nutrition in the conservative treatment of pancreatic fistula: a randomized clinical trial. Gastroenterology 141(1):157–163, 163 e151. doi:10.1053/j.gastro.2011.03.040

    Article  PubMed  Google Scholar 

  25. Fujii T, Nakao A, Murotani K, Okamura Y, Ishigure K, Hatsuno T, Sakai M, Yamada S, Kanda M, Sugimoto H, Nomoto S, Takeda S, Morita S, Kodera Y (2015) Influence of food intake on the healing process of postoperative pancreatic fistula after Pancreatoduodenectomy: a multi-institutional randomized controlled trial. Ann Surg Oncol 22(12):3905–3912. doi:10.1245/s10434-015-4496-1

    Article  PubMed  Google Scholar 

  26. Pedrazzoli S, Liessi G, Pasquali C, Ragazzi R, Berselli M, Sperti C (2009) Postoperative pancreatic fistulas: preventing severe complications and reducing reoperation and mortality rate. Ann Surg 249(1):97–104. doi:10.1097/SLA.0b013e31819274fe

    Article  PubMed  Google Scholar 

  27. Darnis B, Lebeau R, Chopin-Laly X, Adham M (2013) Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database. Langenbeck's Archives of Surgery / Deutsche Gesellschaft fur Chirurgie 398(3):441–448. doi:10.1007/s00423-013-1047-8

    Article  CAS  Google Scholar 

  28. Ricci C, Casadei R, Buscemi S, Minni F (2012) Late postpancreatectomy hemorrhage after pancreaticoduodenectomy: is it possible to recognize risk factors? JOP : Journal of the Pancreas 13(2):193–198

    PubMed  Google Scholar 

  29. Wellner UF, Kulemann B, Lapshyn H, Hoeppner J, Sick O, Makowiec F, Bausch D, Hopt UT, Keck T (2014) Postpancreatectomy hemorrhage--incidence, treatment, and risk factors in over 1,000 pancreatic resections. Journal of Gastrointestinal Surgery : Official Journal of the Society for Surgery of the Alimentary Tract 18(3):464–475. doi:10.1007/s11605-013-2437-5

    Article  CAS  Google Scholar 

  30. Wiltberger G, Schmelzle M, Tautenhahn HM, Krenzien F, Atanasov G, Hau HM, Moche M, Jonas S (2015) Alternative treatment of symptomatic pancreatic fistula. J Surg res 196(1):82–89. doi:10.1016/j.jss.2015.02.047

    Article  PubMed  Google Scholar 

  31. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic S (2017) The 2016 update of the international study group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161(3):584–591. doi:10.1016/j.surg.2016.11.014

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany

    Sebastian Hempel, Steffen Wolk, Christoph Kahlert, Jürgen Weitz, Thilo Welsch & Marius Distler

  2. Department of General and Vascular Surgery, St. Josefs Hospital, Freiburg, Germany

    Stephan Kersting

Authors
  1. Sebastian Hempel
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Steffen Wolk
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christoph Kahlert
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stephan Kersting
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jürgen Weitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Thilo Welsch
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Marius Distler
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

S.H. designed the study, collected and analyzed the data, and drafted the manuscript. S.K. and C.K. collected and analyzed the data. T.W., S.W., and J.W. contributed to the study design and the final manuscript. M.D. designed the study, collected and analyzed the data, and finalized the manuscript.

Corresponding author

Correspondence to Marius Distler.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

There was no funding for the present study.

Ethical approval and informed consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hempel, S., Wolk, S., Kahlert, C. et al. Outpatient Drainmanagement of patients with clinically relevant Postoperative Pancreatic Fistula (POPF). Langenbecks Arch Surg 402, 821–829 (2017). https://doi.org/10.1007/s00423-017-1595-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-017-1595-4

Keywords

Search

Navigation