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286 J. C. King et al.
Fig. 27.3 Computed tomography scan showing pancre-
aticojejunostomy leak. a - pancreatic remnant, b - peripancreatic fluid collection, c - pancreatic duct stent
SIRS in the presence of apparently adequate
drainage. It should be stressed that re-operation
for major pancreatic anastomotic disruptions is
and should be an extremely rare event. As noted
above, an overwhelming majority of these situations can be managed with nonoperative percutaneous drainage and aggressive critical care
management (Fig. 27.2).
Once the abdomen is opened, retractors are
placed, and exploration of the abdomen is commenced, the pancreatic, biliary, and enteric suture lines are inspected. Evacuation of pancreatic
ascites/fluid collection(s) should be performed
along with copious irrigation of the peritoneal
cavity. As most of these re-explorations occur in
the early postoperative period, there are rarely
intense adhesions. Great care should be taken not
to disrupt the fragile hepaticojejunostomy and
gastrojejunostomy during exploration. Once the
disruption of the pancreatic anastomosis is identified, the relative condition of the pancreatic tissues and bowel is taken into consideration when
determining the next step. Several interventions
can be considered and the pros and cons of each
are carefully weighed with the patient’s condition (Table 27.4). Most often there is a marked
inflammatory response to pancreatic leakage
Table 27.2 International Study Group on Pancreatic Surgery ( ISGPS) definition of postpancreatectomy hemorrhage.
(Adapted from [19])
Definition of postpancreatectomy hemorrhage (PPH)
Time of onset
Early hemorrhage (≤ 24 h after the end of the index operation)
Late hemorrhage (> 24 h after the end of the index operation)
Location
Intraluminal (intraenteric, e.g., anastomotic suture line at stomach or duodenum, or pancreatic surface at anastomo-
sis, stress ulcer, pseudoaneurysm)
Extraluminal (extraenteric, bleeding into the abdominal cavity, e.g., from arterial or venous vessels, diffuse bleeding
from resection area, anastomosis suture lines, pseudoaneurysm)
Severity of hemorrhage
Mild
Small or medium volume blood loss (from drains, nasogastric tube, or on ultrasonography, decrease in hemoglobin
concentration <
Mild clinical impairment of the patient, no therapeutic consequence, or at most the need for noninvasive treatment
with volume resuscitation or blood transfusions (2–3 units packed cells within 24 h of end of operation or 1–3
units if later than 24 h after operation)
No need for re-operation or interventional angiographic embolization; endoscopic treatment of anastomotic bleeding
may occur provided the other conditions apply
Severe
ge volume blood loss (drop of hemoglobin level by ≥
Lar
Clinically significant impairment (e.g., tachycardia, hypotension, oliguria, hypovolemic shock), need for blood trans-
fusion (> 3 units of packed cells)
Need for invasive treatment (interventional angiographic embolization, or relaparotomy)
3 g/dL)
3 g/dL)
28727 Major Disruptions of Pancreaticojejunostomy
Table 27.3 International Study Group on Pancreatic Surgery ( ISGPS) classification of postpancreatectomy
hemorrhage. (Adapted from [19])
Classification of PPH: clinical condition, diagnostic, and therapeutic consequences
Grade Time of onset, location,
A Early, intra- or extraluminal,
B Early, intra- or extraluminal,
C Late, intra- or extraluminal,
US ultrasound, CT computed tomography, ICU intensive care unit, PPH post-pancreatectomy hemorrhage
a
Late, intra- or extraluminal, mild bleeding may not be immediately life-threatening to patient but may be a warning
sign for later severe hemorrhage (“sentinel bleed”) and is therefore grade B
b
Endoscopy should be performed when signs of intraluminal bleeding are present (melena, hematemesis, or blood loss
via nasogastric tube)
severity, and clinical impact
of bleeding
mild
severe
or
Late, intra- or extraluminal,
a
mild
severe
Clinical condition Diagnostic
Well Observation, blood
Often well/intermediate, very rarely
life-threatening
Severely impaired,
life-threatening
consequence
count, US and, if
necessary CT
Observation, blood
count, US, CT, angiography, endoscopy
Angiography, CT,
endoscopy
b
Therapeutic consequence
None
Transfusion of fluid/
blood, ICU, therapeutic
b
endoscopy
tion, relaparotomy for
early PPH
Localization of bleeding,
angiography, embolization, (endoscopy
relaparotomy, ICU
b
, emboliza-
b
) or
Table 27.4 Options for surgical management of major pancreatic anastomotic disruptions
Options for surgical management of major pancreatic anastomotic disruptions
Conversion of pancreaticojejunostomy to pancreaticogastrostomy
Wide local drainage with or without pancreatic duct ligation
Wirsungostomy or “bridge stent”
Completion pancreatectomy
causing edema, hyperemia, and friability of the
tissues. For this reason, simple suture repair of
the leaking anastomosis is doomed to failure and
should almost never be considered.
One option in a clinically stable patient with
completely viable pancreas is to convert a pancreaticojejunostomy to pancreaticogastrostomy.
We feel this option must be considered with great
caution given there is a substantial likelihood of
this second anastomosis leaking. In the instance
of a re-operation where debridement of the pancreatic neck and jejunal limb is required to obtain
healthy tissues, there will usually be insufficient
bowel length to create a tension-free anastomosis
between the pancreatic remnant and efferent jejunal limb. An intact biliary anastomosis should
not be reconstructed in order to gain more jejunal length in this setting. Therefore, due to the
mobility of the stomach and its proximity to the
pancreatic stump, a pancreaticogastrostomy may
be constructed. The anastomosis is performed to
the posterior wall of the stomach in two layers
as described by Yeo et al. [7] Briefly, the distal
2–3 cm of pancreatic remnant is dissected and a
2–3 cm gastrotomy is made. An outer layer of 3-0
silk and inner layer of 3-0 or 4-0 PDS is used
with the inner layer incorporating pancreatic duct
and mucosa where feasible. Alternatively, the
anastomosis may be performed in a single layer
[20]. The excess jejunal limb upstream of the
biliary anastomosis is brought to the skin as an
ostomy, oversewn, or resected depending on tissue viability, length of remnant, and/or condition
of the patient. A feeding jejunostomy should be
placed as well. Salvage pancreaticogastrostomy
was found to be associated with less postoperative diabetes (25 vs. 100 %), one grade B pancreatic fistula managed nonoperatively (25 %), and
no mortality when compared retrospectively with
completion pancreatectomy [21]. Randomized
288 J. C. King et al.
controlled data are lacking (and likely impossible
to obtain due to the rarity of this complication);
however, this approach appears to be a safe operative strategy in selected patients.
When a disruption of the anastomosis that is
not amenable to reconstruction is discovered at
the time of re-exploration or there is a marked inflammatory response, more definitive measures
must be taken to obtain a controlled fistula. In
situations where the anastomosis appears to be
largely intact, consideration can be given to establishing better evacuation and irrigation of the
pancreatic fluid with larger closed suction drains
or irrigating catheters (i.e., Axiom). One may also
place a pedicled omental or falciform flap over
the visceral vessels to prevent pseudoaneurysm
formation though clinical evidence to support
this is based on anecdotal/observational data. At
the very least, there seems to be little downside to
this approach, warranting its consideration [22].
Another possible approach is to deconstruct the
pancreatic anastomosis and ligate the main pancreatic duct. Neither wide drainage alone nor ligation of the pancreatic duct is preferred due to
the unavoidable adverse consequences of ongoing pancreatic leakage (sepsis, electrolyte disturbances, loss of exocrine function, nutritional
deficiency, ongoing major pancreatic fistula) or
pancreatic duct ligation (acute pancreatitis and
long-term pancreatic atrophy with complete
loss of exocrine and endocrine function). However, if the patient is in extremis at the time of
re-operation, a “damage control” approach may
be warranted in order to limit operative time with
an open abdomen and its attendant physiologic
consequences (hypothermia, fluid losses, coagulopathy, etc.).
A variation of local drainage of the pancreatic
bed that can avoid the undesirable consequences
of pancreatic duct ligation or completion pancreatectomy (see below) is Wirsungostomy. Drainage of the pancreatic duct can be performed expeditiously in patients with significant physiologic
derangement without concern for breakdown of
a second, high-risk pancreatic anastomosis. After
dismantling the dehiscent pancreatic anastomosis
and debridement of the distal pancreatic stump as
necessary, a 6–10F silastic tube with end and side
holes is inserted into the main pancreatic duct
and exteriorized through the right flank. A pancreaticojejunostomy is then performed later once
the fistula is controlled, infected fluid is drained,
sepsis is resolved, and the patient has recovered
completely from operation (mean 130 days after
re-operation in one study) [23]. This is usually
done with a Roux-en-Y limb of jejunum to the
fistula tract rather than directly to the pancreatic
duct itself. Mortality was 17 % and the function
of the pancreatic remnant was preserved in 75 %
of patients (though no biochemical/objective
measures of exocrine or endocrine function were
made) [23]. Alternatively, a “bridge stent” using
a similar silastic tube sutured in place to the jejunum and pancreatic stump may be used to bridge
the gap resulting from pancreaticojejunostomy
dehiscence. This technique diverts pancreatic
fluid away from the peritoneum and preserves
the pancreatic remnant, avoiding pancreatic endocrine and exocrine dysfunction or loss [24].
The most definitive operation to correct disruption of the pancreatic anastomosis is completion pancreatectomy [25]. This is usually performed in conjunction with splenectomy though
the spleen may be preserved [26]. Certainly,
completion pancreatectomy is required when the
pancreatic remnant is found to be nonviable at
the time of re-operation, which can be observed
in rare cases of postpancreatectomy pancreatitis.
Clearly, ischemic or necrotic bowel should be
resected to viable tissue. If the initial pancreatic
reconstruction was with a pancreaticogastrostomy, the gastrotomy can be oversewn in one or
two layers. Sump drainage of the stomach with
a nasogastric tube is generally indicated following repair. Finally, tube jejunostomy should be
performed for postoperative nutritional support.
Careful attention to postoperative glycemic control is paramount for these critically ill patients.
Loss of both insulin and glucagon secretion precipitates wild swings in blood glucose that may
be difficult to manage, particularly in the setting
of sepsis. Consultation with an endocrinologist
may be warranted for acute management as well
as to establish long-term follow-up care.
Outcomes following completion pancreatectomy for major pancreatic duct disruption
28927 Major Disruptions of Pancreaticojejunostomy
following PD are generally poor, as might be
expected [26]. Undoubtedly, this is in large part
due to the emergent nature of operation in a profoundly ill patient, often with serious underlying
comorbidity (i.e., pancreatic malignancy, malnutrition, other).
As was described following Wirsungostomy,
relaparotomy to establish a pancreatic-enteric
anastomosis in patients managed with long-term
catheter drainage of a persistent pancreatic fistula
may be performed months later [27]. In the author’s personal experience, at least 6
months are
necessary to allow resolution of the inflammatory
changes, restitution of nutrition, and maturation of the fistula track. As is the case in patients
with major pancreatic duct disruption following
acute pancreatitis, it is often not feasible, nor desirable, to dissect out the pancreatic parenchyma
in order to fashion an anastomosis to the bowel.
The preferred approach in these situations is to
create an anastomosis of the fibrotic drain tract to
a Roux-en-Y limb of jejunum [28, 29]. The jejunal–fistula tract anastomosis should be made as
close as possible to the pancreatic parenchyma to
prevent closure of the fistula tract. Anastomosis
should not be made to a matured pseudocyst wall
or abscess cavity as this is associated with surgical failure and recurrent fistula [30]. Technique
for fistula–enteric anastomosis is quite variable:
The authors approach it much the same way as
a conventional pancreatic anastomosis. An outer
layer of interrupted seromuscular jejunum with
2-0 silk to the fibrotic tissues surrounding the
drain tract followed by a duct to drain tract layer
with 4-0 PDS. It may be advisable to leave a
drain in the fistula tract and create a Witzel tube
jejunostomy through the Roux limb to the abdominal wall, particularly if the drain tract was
not robust [24].
Generally patients will require a period of
care in the intensive care unit for further resuscitation and management of ongoing sepsis,
hemodynamic monitoring, and MSOF. Empiric
antibiotics begun preoperatively should be continued until culture data allow for narrowing of
antimicrobial coverage. Ongoing “prophylactic”
antibiotics should not be utilized without some
objective data indicating the presence of infection (positive culture, ongoing fevers, continued
SIRS without alternative explanation, etc.). Operative drains are maintained on closed suction
drainage or continuous irrigation (Axiom type)
as appropriate.
Nutritional support should be instituted as
soon as possible. Protein catabolism in the postoperative period can be severe and some degree
of hyperalimentation may be necessary to maintain nutritional balance. Caloric needs should be
calculated and titrated based on nitrogen balance
and nutritional indices such as prealbumin, albumin, ferritin, and body weight. Initially, total
parenteral nutrition (TPN) is likely to be required
until postoperative ileus has resolved, vasopressors are weaned, and gut perfusion allows enteral
alimentation. As soon as is feasible, enteral nutrition, preferably via jejunostomy tube placed
at the time of re-operation or nasojejunal tube,
should begin. For patients with ongoing pancreatic fistula following re-operation, a randomized
controlled trial of enteral versus parenteral nutrition showed increased rates of fistula closure at
days in patients maintained
30
on enteral nutrition [31]. Additionally, for critically ill patients,
there are fewer infectious complications and a
trend toward improved survival in patients treated with enteral nutrition [32]. Nasogastric tube
(NGT) feeding is suboptimal as an enteral feeding route due to risks of aspiration, long-term
NGT complications (dislodgement, aspiration,
sinusitis, erosion of nasal mucosa), and the high
incidence of delayed gastric emptying (DGE) associated with pancreatic fistula following PD.
When the patient is able to begin oral alimentation, this should be initiated keeping in mind that
nutritional supplementation with tube feedings
may be required for some time as oral intake is
increased. This can often be accomplished by
continuous nocturnal jejunostomy feeds.
An important consideration in patients who
are tolerating oral alimentation is pancreatic enzyme supplementation. For patients undergoing
completion pancreatectomy, pancreatic exocrine
function is absent and enzyme supplementation
is mandatory. The same is true for patients with
significant postoperative fistulas as the diversion
290 J. C. King et al.
of pancreatic fluid creates an essentially apancreatic state in terms of exocrine function. For the
remainder of patients, enzyme supplementation
is initiated based on symptomatic postprandial
diarrhea/steatorrhea and should be treated with
pancrealipase 60,000 U with meals and may be
titrated upward for continued symptoms. Generally, smaller, more frequent meals (5–6/day) are
better tolerated and should be recommended. We
do not check fecal elastase or fecal fat levels routinely as these values are difficult to interpret and
do not predict the need for enzyme supplementation in postpancreatectomy patients.
Somatostatin analogues may be helpful to decrease the volume of drainage from recurrent/persistent pancreatic fistulae though data are lacking
on their efficacy in promoting complete healing
or spontaneous closure [33]. The authors employ
somatostatin as a three-times daily (TID) subcutaneous injection of 150 mcg in patients with
high-output pancreatic fistulas with associated
electrolyte abnormalities and/or skin excoriation.
The TID regimen can be converted to a depot
dose of 20–30 mg intramuscular monthly. The
effect of therapy is assessed by volume of output
after 3 days, and if there has not been a ≥ 50 % decrease in fistula output, therapy is discontinued.
Otherwise, therapy is continued indefinitely until
spontaneous fistula closure or definitive therapy
to close the fistula is successful.
Occasionally, major pancreaticojejunostomy
disruptions will manifest as a pancreatic–cutaneous fistula rather than through well-controlled
drain tracks. In these situations, skin excoriation and breakdown can be severe and difficult
to manage, particularly when combined with an
open-wound and high-output fistula drainage. CT
scan of the abdomen should be performed to look
for undrained intra-abdominal fluid collection(s)
and, if found, these should be drained percutaneously. We find vacuum-assisted/negative pressure
wound dressings are particularly helpful as they
collect wound drainage and prevent skin damage
while facilitating wound granulation. Grossly infected wounds should be debrided prior to placing VAC dressings and careful examination for
fascial dehiscence performed. In cases where
fascial dehiscence is noted and bowel is visible
below, care must be taken not to apply the VAC
sponge directly to the bowel as negative pressure
may precipitate an enteric fistula.
Conclusion
Major pancreaticojejunostomy disruption is a
dreaded complication of PD that has significant attendant morbidity and mortality. Despite
the seriousness of the complication, there are
multiple options for management. We advocate
a thoughtful, deliberate approach that utilizes
non-operative techniques such as image-guided
percutaneous drain placement first and re-operation only for recalcitrant leaks or the sickest patients. Utilizing this management strategy
maximizes the chances for a successful outcome
following a major operative complication.
Key Points: How to Avoid Complications
1. Patient selection
2. Duct-to-mucosa anastomosis
3. Tension-free, well-vascularized anastomosis
4. Use of closed suction drains
5. Early removal of closed suction drains when
appropriate
Key Points: Diagnosis/Management
1. Clinical parameters
2. Imaging
3. Resuscitation
4. Operation
5. Postoperative management
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28
Introduction
In 1898, Halsted performed the first local excision of a carcinoma of the ampulla of Vater [1].
The pancreatic resection of periampullary tumors was popularized in a 1935 classic paper by
Whipple et al. [2]. Their two-stage pancreatoduodenectomy consisted of posterior gastroenetrostomy, ligation, and division of the common
bile duct and cholecystogastrostomy in the first
stage, followed by resection of the duodenum
and pancreatic head in the second stage. The pancreatic stump was closed with sutures, without
a pancreaticoenteric anastomosis. Whipple later
described the procedure performed in a single
stage in 1940. The reconstruction was modified
in 1942 to include pancreaticojejunostomy, due
to the high rate of pancreatic fistula after the closure of the pancreatic stump [3]. This may represent the first modification of a surgical procedure
to prevent pancreatic fistula.
By the mid-1990s, improvements in anesthesia, perioperative management, and the regionalization of care had decreased the surgical
mortality in most major centers to less than 5 %
for both pancreaticoduodenectomy and distal
pancreatectomy [4, 5]. Unfortunately, the postoperative morbidity remains high and still approaches 50 % even in large series [5, 6, 7]. The
key determinant of outcome after pancreatoduodenectomy remains the pancreaticoenteric
anastomosis. Although many pancreatic fistula
are self-limited problems that resolve over time,
sepsis and hemorrhage, due to a pancreatic leak
can be associated with mortality of 20–40 % and
result in prolonged hospitalization and increased
hospital costs [8]. Therefore, the management of
pancreatic fistula after a major operation requires
an evidence-based multidisciplinary approach
to “rescue” many patients from life-threatening
complications. Finally, in the cases with persistent fistulas, defined as fistulas present for
greater than 6 weeks, definitive treatment may be
necessary.
K. D. Lillemoe ()
Definition of Pancreatic Fistula
Department of Surgery, Massachusetts General
Hospital, 55 Fruit Street, WHT506,
Boston, MA 02114, USA
e-mail: klillemoe@partners.org
Harvard Medical School, Boston, MA, USA
P. Y. Parikh
Department of Surgery, Stony Brook University,
Stony Brook, NY, USA
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_28,
© Springer Science+Business Media New York 2015
In general, a pancreatic fistula is defined as leakage of enzyme-containing fluid from the pancreatic parenchyma or duct regardless of origin and
cause. Pancreatic parenchymal or ductal disruptions may be iatrogenic or due to progression of
disease. Iatrogenic pancreatic fistulas usually result from operative trauma, resection of a portion
293
294 P. Y. Parikh and K. D. Lillemoe
of the pancreas, or from the complications of
endoscopic interventions usually during endoscopic retrograde cholangiopancreatography
(ERCP). Noniatrogenic fistulas typically result
from either acute or chronic pancreatitis, caused
most frequently by cholelithiasis or alcohol. A
pancreatic fistula can drain either internally or
externally. An internal pancreatic fistula is usually seen in patients with a history of pancreatitis,
where leakage is not controlled by the inflammatory response. Such fistulas may manifest as
pancreatic ascites or a pancreaticopleural fistula.
An external pancreatic fistula or pancreaticocutaneous fistula usually occurs after percutaneous
drainage of a pancreatic fluid collection/pseudocyst, following pancreatic debridement, or after
a pancreatic resection usually via an operatively
placed drain. With regard to the postoperative
pancreatic fistula, the leakage from the pancreatic anastomosis or the stump is usually observed
in the early days after a resection.
In the past, authors have described pancreatic
fistula using nonstandardized definitions. Inherent to the problem of defining pancreatic fistula
was that complications from leakage of pancreatic fluid present in multiple ways and can carry
multiple diagnoses including peripancreatic collection or intra-abdominal abscess. Documentation, that the fluid is rich in amylase, will define
the complication as a pancreatic leak and once
drained externally, is by definition a pancreatic
fistula.
Until 2005, 26 different definitions of postoperative fistula were used, resulting in a variety
of confusing scoring systems with limited clinical value. Furthermore, the reported incidences
of fistula of 2–50 % in different studies were
not comparable, making a scientific approach
to address this problem difficult. In 2005, the
International Study Group on Pancreatic Fistula
(ISGPF) consensus paper defined a postoperative
pancreatic fistula as the existence of any fluid
output via an intraoperatively placed or postoperatively inserted drain on or after postoperative
day 3 with an amylase content greater than three
times the upper normal serum value [9]. After
the diagnosis of fistula has been established from
this simple laboratory finding, it should be further classified regarding the clinical condition,
specific therapeutic measures, the duration of
treatment, consecutive complications, and the
outcome of the patient (Table 28.1). According
to ISGPF stratification of pancreatic fistulas,
grade A (low grade) resolves spontaneously and
needs no intervention; grade B (medium grade)
requires change in management or adjustment of
the clinical pathway, but patients are not severely
ill. Grade C fistula (high grade) is a refractory
postoperative pancreatic fistula that requires a
major change in the clinical management and
aggressive clinical intervention and is associated
with systematic illness and sepsis.
With this three-category system, a standardized definition was established, which was widely accepted, validated, and used worldwide by
Table 28.1 ISGPF grading system of postoperative pancreatic fistula. (Adapted from [44])
Criteria Grade A fistula Grade B fistula Grade C fistula
Clinical conditions Well Often well Ill-appearing/bad
Specific treatment No Yes/no Yes
Ultrasound/CT scan Negative Negative/positive Positive
Persistent drainage (> 3 weeks) No Usually yes Yes
Signs of infection No Yes Yes
Sepsis No No Yes
Reoperation No No Yes
Readmission No Yes/no Yes/no
Death related to fistula No No Ye s
Drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than
three times the serum amylase activity
ISGPF International Study Group On Pancreatic Fistula, CT computed tomography
29528 Persistent Pancreatic Fistula
all major study groups for the categorization of
patient data. Pratt et al. prospectively analyzed
postoperative complications in 176 patients after
pancreaticoduodenectomy [10]. In this study,
there were 53/176 patients (30 %) confirmed fistula—26 (15 %) type A, 21 (12 %) type B, and 6
(3 %) type C. Patients with grade A fistula had
shorter hospital stays and less secondary complications than patients with grade B and C fistula. Compared to patients with grade B fistula,
patients with grade C fistula had a longer hospital stay, a higher frequency of intensive care unit
(ICU) admissions, and more blood transfusions.
This study served to validate the ISGPF classification scheme in demonstrating minimal clinical
impact of type A fistulas, while showing more
complications and costs in patients with type B
and C fistula.
Procedure-Specific Incidence and Risk Factors for Pancreatic Fistula
The occurrence of a pancreatic fistula is highly
dependent on the type of surgical procedure performed and the underlying pancreatic pathology.
Soft pancreatic tissue texture without pre-existing fibrosis is regarded as a risk factor for fistula
development in all pancreatic procedures.
Pancreaticoduodenectomy
Pancreaticoduodenectomy is the treatment of
choice for patients with resectable carcinoma of
the pancreatic head and periampullary region. In
recent years, the mortality rate of pancreaticoduodenectomy has declined to < 5 %. However, the
overall morbidity remains at approximately 50 %
with the pancreatic fistula occurring in 5–40 % of
patients [6, 7]. In an attempt to understand pancreatic fistula after pancreaticoduodenectomy,
several risk factors have been identified. These
include patient risk factors (age, sex, bilirubin
level, and comorbid conditions), pancreas risk
factors (pancreatic texture, pancreatic duct size,
underlying patient pathology and blood supply
to the pancreatic remnant) and operative risk
factors (operative time, blood loss, anastomotic
techniques, and stent usage). Evaluation of these
risk factors led to the generally accepted theory
that a fibrotic pancreatic remnant facilitates the
pancreaticoenteric anastomosis, whereas, a soft
pancreatic remnant frequently results in a higher
pancreatic fistula rate.
Recently, a single 10-point fistula risk score
(FRS) was developed, for the prediction of
critically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy
using risk factors from the ISGPF classification
[11]. Based on an extensive analysis of pre- and
intra-operative variables, four distinct factors
were discovered: pancreatic duct size smaller
than 3 mm; soft pancreatic parenchyma; ampullary, duodenal, cystic, or islet cell pathology; and
excessive intraoperative blood loss (Table 28.2).
An aggregate of 0–10 points subsequently determines a patient’s fistula risk profile. Patients with
0 points have a negligible risk to develop a biochemical fistula or CR-POPF. Patients with 1–2
points have low-risk (14 %) of developing any
fistula with less than one-third developing CRPOPF. Patients who accumulate between 3 and
6 points are in intermediate risk and 25 % can be
expected to develop pancreatic fistulas, which
are twice as likely to be clinically relevant. Finally, patients who acquire 7 or more points are
considered high risk, because the incidence of
CR-POPF approaches 90 %. This FRS has been
internally and externally validated by a multiinstitutional study that confirmed that the FRS
was a strong prognostic tool for predicting the
development of CR-POPF after pancreaticoduodenectomy [12].
Distal Pancretectomy
Distal pancreatectomy is performed for all kinds
of pancreatic pathologies, including chronic inflammation and benign and malignant tumors.
Pancreatic fistulas are merely leakage of pancreatic fluid from the cut margin of the pancreatic remnant. The average reported pancreatic
fistula rates following distal pancreatectomy are
approximately 20–25 % ranging from 0 to 40 %
with approximately 97 % of these being type A
or type B fistulas [13, 14, 15]. Many different
factors like surgical stump management, spleen
preservation, tissue texture, or extent of surgical