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The Landmark Series: Mitigation of the Postoperative Pancreatic Fistula

  • Pancreatic Tumors
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Abstract

Pancreatic fistula has been the defining complication and challenge of pancreatic surgery. Better awareness and mitigation of postoperative pancreatic fistulas has led to significant improvements in morbidity and mortality of pancreatic surgery. The definition and management of pancreatic fistulas has sequentially progressed over the last three decades; the literature ranges from retrospective, observational studies to prospective multicenter randomized controlled trials. The landmark literature contributions driving the perioperative management of pancreatic fistulas are detailed in this article.

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References

  1. McMillan MT, Vollmer CM. Predictive factors for pancreatic fistula following pancreatectomy. Langenbecks Arch Surg. 2014;399(7): 811–24.

    Article  PubMed  Google Scholar 

  2. Vining CC, Kristine K, Darryl S, Pierce P, Yaniv B, Kevin KR, et al. Risk factors for complications in patients undergoing pancreaticoduodenectomy: a NSQIP analysis with propensity score matching. J Surg Oncol. 2020;122(2):183–94.

    Article  PubMed  Google Scholar 

  3. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1): 8–13.

    Article  PubMed  Google Scholar 

  4. Enestvedt CK, Diggs BS, Cassera MA, Hammill C, Hansen PD, Wolf RF. Complications nearly double the cost of care after pancreaticoduodenectomy. Am J Surg.. 2012;204(3): 332–8.

    Article  PubMed  Google Scholar 

  5. Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer Jr CM. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg. 2007. 245(3):443–51.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer Jr CM. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013;216(1): 1–14.

    Article  PubMed  Google Scholar 

  7. Pratt WB, Callery MP, Vollmer CM. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg. 2008;32(3): 419–28.

    Article  PubMed  Google Scholar 

  8. Bassi C, Marchegiani G, Dervenis C, Sarr M, Hilal MA, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3): 584–91.

    Article  PubMed  Google Scholar 

  9. Pratt W, 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(9):1264–78 (discussion 1278–9).

    Article  PubMed  Google Scholar 

  10. Harnoss JC, Ulrich AB, Harnoss JM, Diener MK, Büchler MW, Welsch T. Use and results of consensus definitions in pancreatic surgery: a systematic review. Surgery. 2014;155(1): 47–57.

    Article  PubMed  Google Scholar 

  11. McMillan MT, Christein JD, Callery MP, Behrman SW, Drebin JA, Hollis RH, et al. Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy. Surgery. 2016;159(4):1013–22.

    Article  PubMed  Google Scholar 

  12. Rosso E, Casnedi S, Pessaux P, Oussoultzoglou E, Panaro F, Mahfud M, et al. The role of “fatty pancreas” and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy. J Gastrointest Surg. 2009;13(10):1845–51.

    Article  PubMed  Google Scholar 

  13. Mathur A, Pitt HA, Marine M, Saxena R, Schmidt CM, Howard TJ, et al. Fatty pancreas: a factor in postoperative pancreatic fistula. Ann Surg. 2007;246(6):1058–64

    Article  PubMed  Google Scholar 

  14. Miller BC, Christein JD, Behrman SW, Drebin JA, Pratt WB, Callery MP, et al. A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy. J Gastrointest Surg. 2014;18(1): 172–79 (discussion 179–80)

    Article  PubMed  Google Scholar 

  15. Trudeau MT, Casciani F, Ecker BL, Maggino L, Seykora TF, Puri P, et al. The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg. 2020.

  16. Ecker BL, McMillan MT, Asbun HJ, Ball CG, Bassi C, Beane JD, et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg. 2018;267(4): 608–16.

    Article  PubMed  Google Scholar 

  17. Al Abbas AI, Borrebach JD, Pitt HA, Bellon J, Hogg ME, Zeh HJ, et al. Development of a novel pancreatoduodenectomy-specific risk calculator: an analysis of 10,000 patients. J Gastrointest Surg. 2020;15:1–9

    Google Scholar 

  18. Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg. 1995;222(4): 580–8 (discussion 588-92).

  19. Cheng Y, Briarava M, Lai M, Wang X, Tu B, Cheng N, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev. 2017;9:CD012257.

  20. Berger AC, Howard TJ, Kennedy EP, Sauter PK, Bower-Cherry M, Dutkevitch S, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg. 2009;208(5): 738–47; discussion 747-9.

  21. Bai X, Zhang Q, Gao S, Lou J, Li G, Zhang Y, et al. Duct-to-mucosa vs invagination for pancreaticojejunostomy after pancreaticoduodenectomy: a prospective, randomized controlled trial from a single surgeon. J Am Coll Surg. 2016;222(1):10–8.

    Article  PubMed  Google Scholar 

  22. Ball CG, Pitt HA, Kilbane ME, Dixon E, Sutherland FR, Lillemoe KD. Peri-operative blood transfusion and operative time are quality indicators for pancreatoduodenectomy. HPB (Oxford). 2010;12(7):465–71.

    Article  PubMed  PubMed Central  Google Scholar 

  23. De Castro SM, Busch OR, Van Gulik TM, Obertop H, Gouma DJ. Incidence and management of pancreatic leakage after pancreatoduodenectomy. Br J Surg. 2005;92(9):1117–23.

    Article  PubMed  Google Scholar 

  24. Seykora TF, Ecker BL, McMillan MT, Maggino L, Beane JD, Fong ZV, et al. The Beneficial effects of minimizing blood loss in pancreatoduodenectomy. Ann Surg. 2019;270(1):147–57.

    Article  PubMed  Google Scholar 

  25. McMillan MT, Vollmer CM, Asbun HJ, Ball CG, Bassi C, Beane JD, et al. The characterization and prediction of ISGPF grade C fistulas following pancreatoduodenectomy. J Gastrointest Surg. 2016;20(2): 262–76.

    Article  PubMed  Google Scholar 

  26. McMillan MT, Allegrini V, Asbun HJ, Ball CG, Bassi C, Beane JD, et al. Incorporation of procedure-specific risk into the ACS-NSQIP Surgical Risk Calculator Improves the prediction of morbidity and mortality after pancreatoduodenectomy. Ann Surg. 2017;265(5): 978–86.

    Article  PubMed  Google Scholar 

  27. Heslin MJ, Harrison LE, Brooks AD, Hochwald SN, Coit DG, Brennan MF. Is intra-abdominal drainage necessary after pancreaticoduodenectomy? J Gastrointest Surg. 1998;2(4):373–8.

    Article  CAS  PubMed  Google Scholar 

  28. Conlon KC, Labow D, Leung D, Smith A, Jarnagin W, Coit DG, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg. 2001;234(4):487–93; discussion 493-4.

  29. Van Buren, G., Bloomston M, Hughes SJ, Winter J, Behrman SW, Zyromski NJ, Vollmer C, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014;259(4):605–12.

    Article  PubMed  Google Scholar 

  30. Witzigmann H, Diener MK, Kienkötter S, Rossion I, Bruckner T, Werner B, et al. No need for routine drainage after pancreatic head resection: the dual-center, randomized, controlled PANDRA trial (ISRCTN04937707). Ann Surg. 2016;264(3): 528–37.

    Article  PubMed  Google Scholar 

  31. Zhang W, He S, Cheng Y, Xia J, Lai M, Cheng N, et al. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev. 2018;6:CD010583

    PubMed  Google Scholar 

  32. Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg. 2010;252(2):207–14.

    Article  PubMed  Google Scholar 

  33. Molinari E, Bassi C, Salvia R, Butturini G, Crippa S, Talamini G, et al. Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients. Ann Surg. 2007;246(2): 281–7.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Trudeau MT, Maggino L, Chen B, McMillan MT, Lee MK, Roses R, et al. Extended experience with a dynamic, data-driven selective drain management protocol in pancreaticoduodenectomy: progressive risk stratification for better practice. J Am Coll Surg. 2020;230(5): 809–18.e1.

    Article  Google Scholar 

  35. Williams ST, Woltering EA, O’Dorisio TM, Fletcher WS. Effect of octreotide acetate on pancreatic exocrine function. Am J Surg. 1989;157(5): 459–62.

    Article  CAS  PubMed  Google Scholar 

  36. Montorsi M, Zago M, Mosca F, Capussotti L, Zotti E, Ribotta G, et al. Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery. 1995;117(1): 26—31.

    Article  CAS  PubMed  Google Scholar 

  37. Yeo CJ, Cameron JL, Lillemoe KD, Sauter PK, Coleman J, Sohn TA, 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(3):419–29.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Koti RS, Gurusamy KS, Fusai G, Davidson BR. Meta-analysis of randomized controlled trials on the effectiveness of somatostatin analogues for pancreatic surgery: a cochrane review. HPB (Oxford). 2010;12(3): 155–65.

    Article  PubMed  PubMed Central  Google Scholar 

  39. McMillan MT, Christein JD, Callery MP, Behrman SW, Drebin JA, Kent TS, et al. Prophylactic octreotide for pancreatoduodenectomy: more harm than good? HPB (Oxford). 2014;16(10): 954–62.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Allen PJ, Gönen M, Brennan MF, Bucknor AA, Robinson LM, Pappas MM, et al. Pasireotide for postoperative pancreatic fistula. N Engl J Med. 2014;371(9): 875–6.

    Article  PubMed  Google Scholar 

  41. McMillan MT, Malleo G, Bassi C, Sprys MH, Vollmer Jr CM. Defining the practice of pancreatoduodenectomy around the world. HPB (Oxford). 2015; 17(12):1145–54.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Winter JM, Cameron JL, Campbell KA, Chang DC, Riall TS, Schulick RD. et al. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg. 2006; 10(9):1280–90 (discussion 1290).

    Article  PubMed  Google Scholar 

  43. Smyrniotis V, Arkadopoulos N, Kyriazi MA, Derpapas M, Theodosopoulos T, Gennatas C, et al. Does internal stenting of the pancreaticojejunostomy improve outcomes after pancreatoduodenectomy? a prospective study. Langenbecks Arch Surg. 2010;395(3): 195–200.

    Article  PubMed  Google Scholar 

  44. Sachs TE, Pratt WB, Kent TS, Callery MP, Vollmer Jr CM. The pancreaticojejunal anastomotic stent: friend or foe? Surgery. 2013;153(5):651–62.

    Article  PubMed  Google Scholar 

  45. Poon RT, Fan ST, Lo CM, Ng KK, Yuen WK, Yeung C, et al. External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg. 2007;246(3): 425–33 (discussion 433–5).

    Article  PubMed  PubMed Central  Google Scholar 

  46. Pessaux P, Sauvanet A, Mariette C, Paye F, Muscari F, Cunha AS, et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg. 2011;253(5):879–85.

    Article  PubMed  Google Scholar 

  47. McMillan MT, Ecker BL, Behrman SW, Callery MP, Christein JD, Drebin JA, et al. Externalized stents for pancreatoduodenectomy provide value only in high-risk scenarios. J Gastrointest Surg. 2016;20(12): 2052–62.

    Article  PubMed  Google Scholar 

  48. Weber SM, Cho CS, Merchant N, Pinchot S, Rettammel R, Nakeeb A, et al. Laparoscopic left pancreatectomy: complication risk score correlates with morbidity and risk for pancreatic fistula. Ann Surg Oncol. 2009;16(10):2825–33.

    Article  PubMed  Google Scholar 

  49. Ecker BL, McMillan MT, Allegrini V, Bassi C, Beane JD, Beckman RM, et al. Risk factors and mitigation strategies for pancreatic fistula after distal pancreatectomy: analysis of 2026 resections from the international, multi-institutional distal pancreatectomy study group. Ann Surg. 2019;269(1):143–49.

    Article  PubMed  Google Scholar 

  50. Diener MK, Knaebel HP, Witte ST, Rossion I, Kieser M, Buchler MW, et al. DISPACT trial: a randomized controlled trial to compare two different surgical techniques of DIStal PAnCreaTectomy—study rationale and design. Clin Trials. 2008;5(5):534–45.

    Article  CAS  PubMed  Google Scholar 

  51. Kawai M, Hirono S, Okada KI, Sho M, Nakajima Y, Eguchi H, et al. Randomized controlled trial of pancreaticojejunostomy versus stapler closure of the pancreatic stump during distal pancreatectomy to reduce pancreatic fistula. Ann Surg. 2016;264(1):180–7.

    Article  PubMed  Google Scholar 

  52. Van Buren, G, Bloomston M, Schmidt CR, Behrman SW, Zyromski NJ, Ball CG, et al. A prospective randomized multicenter trial of distal pancreatectomy with and without routine intraperitoneal drainage. Ann Surg. 2017;266(3):421–31.

    Article  PubMed  Google Scholar 

  53. Kaiser J, Niesen W, Probst P, Bruckner T, Doerr-Harim C, Strobel O. et al. Abdominal drainage versus no drainage after distal pancreatectomy: study protocol for a randomized controlled trial. Trials. 2019;20(1): 332.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Seykora TF, Liu JB, Maggino L, Pitt HA, Vollmer Jr CM. Drain management following distal pancreatectomy: characterization of contemporary practice and impact of early removal. Ann Surg;2019.

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Correspondence to Charles M. Vollmer Jr. MD.

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Van Buren, G., Vollmer, C.M. The Landmark Series: Mitigation of the Postoperative Pancreatic Fistula. Ann Surg Oncol 28, 1052–1059 (2021). https://doi.org/10.1245/s10434-020-09251-6

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