Skip to main content
SpringerLink
Log in

The unsolved problem of fistula after left pancreatectomy: The benefit of cautious drain management

  • Published:
Journal of Gastrointestinal Surgery

Abstract

The aim of the study was to identify factors related to the onset of pancreatic fistula and to define the characteristics of the fistula. The study group was composed of 123 patients who underwent left pancreatectomy since 1996. Pancreatic closure was accomplished by a hand-sewn technique (39 patients) or two kinds of mechanical staplers: Proximate (Ethicon Endo-Surgery, Cincinnati, OH) (46 patients) and Endo-GIA (United States Surgical, Norwalk, CT) (38 patients). Fistula was defined as output greater than 5 ml, with amylase × 5, after day 5. In case of fistula, the drain removal was scheduled at a daily output less than 5 ml. Mortality was 0%, morbidity was 48%, and pancreatic fistula rate was 34%. Fistula rate was 38% after hand-sewn closure, 26% after Proximate, and 39% after Endo-GIA (NS). None of the other factors (separate duct ligation, hand-sewn suture in addition to stapler, spleen preservation, use of pledgetted suture, sex, age, and indication for pancreatectomy) proved to be related to a reduction in the onset of fistula. All fistulas healed spontaneously. Mean fistula duration was 36 days; 92.8% of patients with fistula were discharged with drain. The policy of delayed drain removal allowed a low rate of fistula associated morbidity (16%) and of readmission (4.7%). In conclusion, fistula is an unsolved problem of left pancreatectomy. However, a careful drain management allows a good outcome in patients with fistula.

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

Similar content being viewed by others

References

  1. Lillemoe KD, Kaushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ. Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg 1999 May;229(5):693–698;discussion 698-700.

    Article  PubMed  CAS  Google Scholar 

  2. Benoist S, Dugue L, Sauvanet A, Valverde A, Mauvais F, Paye F, Farges O, Belghiti J. Is there a role of preservation of the spleen in distal pancreatectomy? J Am Coll Surg 1999 Mar;188(3):255–260.

    Article  PubMed  CAS  Google Scholar 

  3. Bonnichon P, Tong JZ, Ortega D, Louvel A, Grateau F, Icard P, Chapuis Y. Pancreatic flstula after left pancreatectomy. Frequency and severity. J Chir 1988 May;125(5):321–326.

    CAS  Google Scholar 

  4. Sheehan MK, Beck K, Creech S, Pickleman J, Aranha GV. Distal pancreatectomy: does the method of closure influence fistula formation. Am Surg 2002 Mar;68(3):264–267; discussion 267–268.

    PubMed  Google Scholar 

  5. Shoup M, Brennan MF, McWhite K, Leung DH, Klimstra D, Conlon KC. The value of splenic preservation with distal pancreatectomy. Arch Surg 2002 Feb;137(2):164–168.

    Article  PubMed  Google Scholar 

  6. Bilimoria MM, Cormier JN, Mun Y, Lee JE, Evans DB, Pisters PW. Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation. Br J Surg 2003 Feb;90(2):190–196.

    Article  PubMed  CAS  Google Scholar 

  7. Pachter HL, Pennington R, Chassin J, Spencer FC. Simpli.ed distal pancreatectomy with the Auto Suture stapler: preliminary clinical observations. Surgery 1979 Feb;85(2):166–170.

    PubMed  CAS  Google Scholar 

  8. Takeuchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Kori T, Nakajima H, Kuwano H. Distal pancreatectomy: is staple closure beneficial? ANZ J Surg 2003 Nov;73(11):922–925.

    Article  PubMed  Google Scholar 

  9. Buchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003 Dec;138(12):1310–1314; discussion 1315.

    Article  PubMed  Google Scholar 

  10. Adam U, Makowiec F, Riediger H, Trzeczak S, Benz S, Hopt UT. Distal pancreatic resection-indications, techniques and complications. Zentralbl Chir 2001 Nov;126(11):908–912.

    Article  PubMed  CAS  Google Scholar 

  11. Sugo H, Mikami Y, Matsumoto F, Tsumura H, Watanabe Y, Futagawa S. Distal pancreatectomy using the harmonic scalpel. Surgery 2000 Sep;128(3):490–491.

    Article  PubMed  CAS  Google Scholar 

  12. Sugo H, Mikami Y, Matsumoto F, Tsumura H, Watanabe Y, Futagawa S. Comparison of ultrasonically activated scalpel versus conventional division for the pancreas in distal pancreatectomy. J Hepatobiliary Pancreat Surg 2001;8(4):349–352.

    Article  PubMed  CAS  Google Scholar 

  13. Suc B, Msika S, Fingerhut A, Fourtanier G, Hay JM, Holmieres F, Sastre B, Fagniez PL; And the French Associations for Surgical Research. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Ann Surg 2003 Jan;237(1):57–65.

    Article  PubMed  Google Scholar 

  14. Ohwada S, Ogawa T, Tanahashi Y, Nakamura S, Takeyoshi I, Ohya T, Ikeya T, Kawashima K, Kawashima Y, Morishita Y. Fibrin glue sandwich prevents pancreatic flstula following distal pancreatectomy. World J Surg 1998 May;22(5):494–498.

    Article  PubMed  CAS  Google Scholar 

  15. Suzuki Y, Kuroda Y, Morita A, Fujino Y, Tanioka Y, Kawamura T, Saitoh Y. Fibrin glue sealing for the prevention of pancreatic.stulas following distal pancreatectomy. Arch Surg 1995 Sep;130(9):952–955.

    PubMed  CAS  Google Scholar 

  16. Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez- del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001 Apr; 136(4):391–398.

    Article  PubMed  Google Scholar 

  17. Fabre JM, Houry S, Manderscheid JC, Huguier M, Baumel H. Surgery for left-sided pancreatic cancer. Br J Surg 1996 Aug;83(8):1065–1070.

    Article  PubMed  CAS  Google Scholar 

  18. Bernard P, Letessier E, Denimal F, Armstrong O, Le Neel JC. Techniques, indications and early results of splenic preservation during left pancreatectomy. Ann Chir 2002 Nov;127(9):697–702.

    Article  PubMed  CAS  Google Scholar 

  19. Fahy BN, Frey CF, Ho HS, Beckett L, Bold RJ. Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg 2002 Mar;183(3):237–241.

    Article  PubMed  Google Scholar 

  20. Hutchins RR, Hart RS, Pacifico M, Bradley NJ, Williamson RC. Long-term results of distal pancreatectomy for chronic pancreatitis in 90 patients. Ann Surg 2002 Nov; 236(5):612–618.

    Article  PubMed  Google Scholar 

  21. 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 de.nitions. Dig Surg 2004;21(1):54–59.

    Article  PubMed  Google Scholar 

  22. Suc B, Msika S, Piccinini M,Fourtanier G,Hay JM, Flamant Y, Fingerhut A, Fagniez PL, Chipponi J. French Associations for Surgical Research. Octreotide in the prevention of intraabdominal complications following elective pancreatic resection: a prospective, multicenter randomized controlled trial. Arch Surg 2004 Mar;139(3):288–294; discussion 295.

    Article  PubMed  Google Scholar 

  23. Lillemoe KD, Cameron JL, Kim MP, Campbell KA, Sauter PK, Coleman JA, Yeo CJ. Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2004 Nov;8(7):766–772; discussion 772-774.

    Article  PubMed  Google Scholar 

  24. Buchler M, Friess H, Klempa I, Hermanek P, Sulkowski U, Becker H, Schafmayer A, Baca I, Lorenz D, Meister R, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–131.

    Article  PubMed  CAS  Google Scholar 

  25. 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.

    Article  PubMed  CAS  Google Scholar 

  26. Montorsi M, Zago M, Mosca F, Capussotti L, Zotti E, Ribotta G, Fegiz G, Fissi S, Roviaro G, Peracchia A, et al. Ef.cacy of octreotide in the prevention of complication fistula after elective pancreatic resections: a prospective, controlled randomized trial. Surgery 1995;117:26–31.

    Article  PubMed  CAS  Google Scholar 

  27. Friess H, Beger HG, Sulkowski U, Becker H, Hofbauer B, Dennler HJ, Buchler MW. Randomized controlled multicentre multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis. Br J Surg 1995;82:1270–1275.

    Article  PubMed  CAS  Google Scholar 

  28. 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.

    Article  PubMed  CAS  Google Scholar 

  29. Yeo CJ, Cameron JL, Lillemoe KD, Sauter PK, Coleman J, Sohn TA, Campbell KA, Choti MA. 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.

    Article  PubMed  CAS  Google Scholar 

  30. Sarr MG, for the Pancreatic Surgery Group. The potent somatostatin analogue vapreotide does not decrease pancreasspecific complications after elective pancreatectomy: a prospective, multicenter, double-blinded, randomized, placebo-controlled trial. J Am Coll Surg 2003;196:556–565.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Pancreas Unit, San Raffaele Milan, Italy

    Gianpaolo Balzano M.D., Alessandro Zerbi M.D., Marco Cristallo M.D. & Valerio Di Carlo M.D.

Authors
  1. Gianpaolo Balzano M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alessandro Zerbi M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marco Cristallo M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Valerio Di Carlo M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gianpaolo Balzano M.D..

Additional information

Supported in part by a grant of A.I.R.C. (Associazione Italiana Ricerca sul Cancro).

Rights and permissions

Reprints and permissions

About this article

Cite this article

Balzano, G., Zerbi, A., Cristallo, M. et al. The unsolved problem of fistula after left pancreatectomy: The benefit of cautious drain management. J Gastrointest Surg 9, 837–842 (2005). https://doi.org/10.1016/j.gassur.2005.01.287

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1016/j.gassur.2005.01.287

Key words

Search

Navigation