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Postoperative Pancreatic Fistula After Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy: Incidence, Risk Factors, Management, and Clinical Sequelae

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has improved survival in selected patients with peritoneal carcinomatosis. This study evaluates the morbidity of postoperative pancreatic fistula (PF) within the context of CRS and PIC.

Methods

Two hundred seventy-one consecutive CRS and PIC procedures were evaluated. Diagnosis and classification of postoperative PF were performed according to the international study group on PF criteria. The associations between 8 clinical and 20 treatment-related factors with postoperative PF were determined by univariate and multivariate analysis. The management and clinical sequelae of postoperative PF were discussed.

Results

Seventeen patients (6.3%) developed postoperative PF. None of these patients died during their in-hospital stay. Multivariate analysis identified three independent risk factors for PF: transfusion of ≥6 units of blood (P = 0.029), operation duration of ≥9 h (P = 0.035), and splenectomy (P = 0.020). Conservative management of PF was instituted in all 17 patients and was successful in 16 (94%). The overall time to PF closure was 26 (standard deviation 16) days after diagnosis. Although PF did not contribute to procedure-related mortality, it was associated with increased length of hospital stay (P < 0.001).

Conclusions

CRS and PIC presented an acceptable rate of PF that did not increase the procedure-related mortality. However, PF was associated with longer hospital stay. Most patients with PF were treated conservatively and did not require surgical intervention.

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References

  1. Yan TD, Brun EA, Cerruto CA, et al. Prognostic indicators for patients undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy for diffuse malignant peritoneal mesothelioma. Ann Surg Oncol. 2007;14:41–9.

    Article  PubMed  Google Scholar 

  2. Gonzalez-Moreno S, Sugarbaker PH. Right hemicolectomy does not confer a survival advantage in patients with mucinous carcinoma of the appendix and peritoneal seeding. Br J Surg. 2004;91:304–11.

    Article  CAS  PubMed  Google Scholar 

  3. Glehen O, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol. 2004;22:3284–92.

    Article  CAS  PubMed  Google Scholar 

  4. Elias D, Lefevre JH, Chevalier J, et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol. 2009;27:681–5.

    Article  PubMed  Google Scholar 

  5. Verwaal VJ, van Ruth S, de Bree E, et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol. 2003;21:3737–43.

    Article  PubMed  Google Scholar 

  6. Gusani N, Cho S, Colovos C, et al. Aggressive surgical management of peritoneal carcinomatosis with low mortality in a high-volume tertiary cancer center. Ann Surg Oncol. 2008;15:754–63.

    Article  PubMed  Google Scholar 

  7. Stephens AD, Alderman R, Chang D, et al. Morbidity and mortality analysis of 200 treatments with cytoreductive surgery and hyperthermic intraoperative chemotherapy using the Coliseum technique. Ann Surg Oncol. 2000;6:790–6.

    Article  Google Scholar 

  8. Glehen O, Osinsky D, Cotte E, et al. Intraperitoneal chemohyperthermia using a closed abdominal procedure and cytoreductive surgery for the treatment of peritoneal carcinomatosis: morbidity and mortality analysis of 216 consecutive procedures. Ann Surg Oncol. 2003;10:863–9.

    Article  CAS  PubMed  Google Scholar 

  9. Elias D, Goere D, Blot F, et al. Optimization of hyperthermic intraperitoneal chemotherapy with oxaliplatin plus irinotecan at 43°C after compete cytoreductive surgery: mortality and morbidity in 106 consecutive patients. Ann Surg Oncol. 2007;14:1818–24.

    Article  PubMed  Google Scholar 

  10. Saxena A, Yan TD, Morris DL. Critical assessment of preoperative and operative risk factors for complications after iterative peritonectomy procedures. Eur J Surg Oncol. 2009 (in press).

  11. Kusamura S, Baratti D, Antonucci A, et al. Incidence of postoperative pancreatic fistula and hyperamylasemia after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2007;14:3443–52.

    Article  PubMed  Google Scholar 

  12. Tansung T, Sugarbaker PH. Managment of pancreatitis due to pancreatic injury in cytoreductive surgery. Reg Cancer Treat. 1995;8:180–4.

    Google Scholar 

  13. ASA. New classification of physical status. Anesthesiology. 1963;24.

  14. Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996;82:359–74.

    CAS  PubMed  Google Scholar 

  15. Sugarbaker PH. Peritonectomy procedures. Ann Surg. 1995;221:29–42.

    Article  CAS  PubMed  Google Scholar 

  16. Yan TD, Links M, Fransi S, et al. Learning curve for cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal surface malignancy—a journey to becoming a Nationally Funded Peritonectomy Center. Ann Surg Oncol. 2007;14:2270–80.

    Article  PubMed  Google Scholar 

  17. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an International Study Group (ISGPF) definition. Surgery. 2005;138:8–13.

    Article  PubMed  Google Scholar 

  18. Ahmad SA, Kim J, Sussman JJ, et al. Reduced morbidity following cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion. Ann Surg Oncol. 2004;11:387–92.

    Article  PubMed  Google Scholar 

  19. Akaishi E, Teixeira F, Katayama M, et al. Peritonectomy for peritoneal carcinomatosis: long-term outcomes from a single Brazilian institution. World J Surg. 2009;33:835–9.

    Article  PubMed  Google Scholar 

  20. Chand B, Walsh RM, Ponsky J, Brody F. Pancreatic complications following laparoscopic splenectomy. Surg Endosc. 2001;15:1273–6.

    Article  CAS  PubMed  Google Scholar 

  21. Pelz JO, Doerfer J, Dimmler A, Hohenberger W, Meyer T. Histological response of peritoneal carcinomatosis after hyperthermic intraperitoneal chemoperfusion (HIPEC) in experimental investigations. BMC Cancer. 2006;6:162.

    Article  PubMed  Google Scholar 

  22. Goh BK, Tan YM, Chung YF, et al. Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution. Arch Surg. 2008;143:956–65.

    Article  PubMed  Google Scholar 

  23. Kazanjian KK, Hines OJ, Eibl G, Reber HA. Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg. 2005;140:849–54; discussion 854–46.

    Article  PubMed  Google Scholar 

  24. Aranha GV, Aaron JM, Shoup M, Pickleman J. Current management of pancreatic fistula after pancreaticoduodenectomy. Surgery. 2006;140:561–8; discussion 568–9.

    Article  PubMed  Google Scholar 

  25. Pannegeon V, Pessaux P, Sauvanet A, et al. Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment. Arch Surg. 2006;141:1071–6; discussion 1076.

    Article  PubMed  Google Scholar 

  26. Li-Ling J, Irving M. Somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized controlled trials. Br J Surg. 2001;88:190–9.

    Article  CAS  PubMed  Google Scholar 

  27. Ridgeway M, Stabile B. Surgical managment and treatment of pancreatic fistulas. Surg Clin North Am. 1996;76:1159–73.

    Article  CAS  PubMed  Google Scholar 

  28. Abou-Assi S, Craig K, O’Keefe SJ. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol. 2002;97:2255–62.

    Article  PubMed  Google Scholar 

  29. Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg. 1997;84:1665–9.

    Article  CAS  PubMed  Google Scholar 

  30. Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ. 2004;328(7453):1407.

    Article  PubMed  Google Scholar 

  31. Esquivel J, Vidal-Jove J, Steves MA, Sugarbaker PH. Morbidity and mortality of cytoreductive surgery and intraperitoneal chemotherapy. Surgery. 1993;113:631–6.

    CAS  PubMed  Google Scholar 

  32. Conlon KC, Labow D, Leung D, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg. 2001;234:487–93; discussion 493–84.

    Article  CAS  PubMed  Google Scholar 

  33. 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;232:419–29.

    Article  CAS  PubMed  Google Scholar 

  34. Lillemoe KD, Cameron JL, Kim MP, et al. Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2004;8:766–72; discussion 772–64.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, University of New South Wales, St. George Hospital, Sydney, Australia

    Akshat Saxena BMedSc, Terence C. Chua BScMed (Hons), Tristan D. Yan BSc (Med), MBBS, PhD & David L. Morris MBChB, MD, PhD

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  1. Akshat Saxena BMedSc
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  2. Terence C. Chua BScMed (Hons)
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  3. Tristan D. Yan BSc (Med), MBBS, PhD
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  4. David L. Morris MBChB, MD, PhD
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Correspondence to Akshat Saxena BMedSc.

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Saxena, A., Chua, T.C., Yan, T.D. et al. Postoperative Pancreatic Fistula After Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy: Incidence, Risk Factors, Management, and Clinical Sequelae. Ann Surg Oncol 17, 1302–1310 (2010). https://doi.org/10.1245/s10434-009-0898-2

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