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Chapter 9 / Complications of Pancreatic Surgery 101
The most important treatment goal of pancreatic fistula
m
anagement focuses on complete drainage of extraluminal pancreatic
exocrine juices. We routinely place a closed-suction Silastic drain (10 at
or 19 round Jackson-Pratt) anterior to the PJ anastomosis. It is drawn
behind the stomach and the left lobe of the liver, which usually maintains
its proper position on top of the PJ suture line. It is cut long enough so
that its tip lies next to the hepaticojejunostomy anastomosis; thus, it will
drain a leak from either site eectively. If the drain output does not appear
turbid or contain bile, the drain is routinely removed on postoperative day
5 to 7, when the patient is eating a regular diet. A high-volume output of
serous uid does not inuence this decision, but if the character of the
uid is suspicious, the amylase level is checked. If a pancreatic stula is
present, the drain is left in place. If the patient’s white blood cell count
is elevated, or if they are febrile, broad-spectrum antibiotics are started
and a CT scan performed to look for any undrained uid collections,
which should be drained by the interventional radiologist with CT scan
or ultrasound guidance (Fig. 9.1). e uid is sent for culture and amy-
lase concentration, and the antibiotics are then tailored to the specic
organisms. Once all signs of infection resolve, the patient is discharged
with the surgical drain (and any additional percutaneous drains) in place.
Before discharge, around postoperative day 10, the drains are taken o of
suction and allowed to drain into a plastic bag. e patient is seen within
the next week in the clinic. e drains are removed if their output has
been under 10mL/d for a period of at least 2 to 3 consecutive days. If the
stula persists several weeks after discharge, we obtain a stulagram and
at that time replace the original drain with a red rubber catheter (Fig. 9.2).
Occasionally, the tip of the original drain has migrated inside the lumen
of the bowel. If this is the case, the replacement tube is positioned more
supercially. is will hasten closure of the stula, and the drain can be
removed. If a low-output stula (<50mL/d) persists several weeks after
drain exchange, rather than immediately removing the drain, it is backed
out by 3 to 4cm each week, so the stula track can heal behind the drain.
Using this strategy, we have never had to reoperate on a patient for a post-
operative stula after a PD.
e use of somatostatin for the prevention or treatment of postop-
erative pancreatic stulas has been examined. Overall, it does not decrease
stula development, hasten its closure, or alter its morbidity. Somatostatin
does decrease the stula volume, which can help with management of elec-
trolyte deciencies, nutritional status, and skin breakdown in high-output
stulas. Short-acting somatostatin is administered as 100 μg subcutane-
ously three times per day; the long-acting variety, which is eective for 1
month, is preferred.
If a stula persists for 2 to 3 months in patients who undergo distal
pancreatectomy, despite drain exchange as described above, endoscopic
retrograde cholangiopancreatography (ERCP) and a pancreatic duct stent
are indicated. e ERCP can conrm the site of the leak and identify any
downstream ductal strictures that may contribute to the persistence of
the stula. Even without a stricture, a stent in the main pancreatic duct
that traverses the duodenal papilla decreases the pressure in the duct,
which likely hastens stula closure. To avoid stent-related complications
(migration, erosion, infection, stricture formation, etc.), the stent must be
removed within 2 months at most.
If, despite all of these measures, the pancreatic stula does not close
after at least 6 months, then surgical internal drainage may be indicated.
A stulojejunostomy is created with a Roux-en-Y jejunal limb sewn to the
stulous tract as close to the pancreas as possible.
Section I / Pancreas102
FIGURE 9.1 Postoperative pancreatic stula managed with a percutaneous drain. A. CT
scan (coronal views) taken on postoperative day 6 after a pylorus-preserving Whipple resec-
tion for a duodenal cancer reveals a posterior leak from the pancreaticojejunostomy (arrow
highlights intra-abdominal uid collection). B. Repeat CT scan obtained 5 days after a per-
cutaneous drainage catheter was placed reveals complete resolution of the collection and
the tip of the radiology drain (arrow).
A
B
Chapter 9 / Complications of Pancreatic Surgery 103
For nutritional support, patients with pancreatic stulas should not
be kept NPO but allowed to eat a regular diet. Studies have shown that
enteric intake is associated with a higher rate of stula closure. Serum albu-
min levels should be kept at greater than 3 to 3.5g/dL. Occasionally, supple-
mental calories with TPN are required as an adjunct to oral intake to reach
that nutritional goal. is is the case particularly in patients with nausea
and ileus, which can accompany stulas and may diminish patients’ appe-
tites. Loss of pancreatic exocrine secretions may also be associated with
electrolyte imbalances, as the uid is rich in bicarbonate and other essen-
tial electrolytes. Serum electrolyte levels should be routinely monitored in
patients in the hospital and after discharge.
DELAYED GASTRIC EMPTYING
Denition and Incidence
DGE is a common complication after PD. It is dened as high nasogastric
(NG) tube output in the postoperative setting requiring that the tube be left
in place for 10 or more postoperative days, emesis after NG tube removal
necessitating replacement of the tube, or failure to progress to a regular
diet without the use of prokinetics. DGE is not usually a serious event, but
it does prolong hospital stay, temporarily worsens quality of life, and can
occasionally lead to additional invasive procedures.
It is dicult to identify the incidence of DGE after PD, as the deni-
tion in the literature is quite variable. Randomized trials cite a rate from
0% to 57%, with an overall mean incidence of 15%. e International Study
Group on Pancreatic Surgery (ISGPS) published a complex consensus de-
nition in 2007, to standardize its meaning and enable the comparison of
new approaches aiming to reduce the rate of DGE.
e etiology of DGE is uncertain. Potential causes include decreased
plasma motilin concentrations due to duodenal resection, extended lymph
FIGURE 9.2 “Tubogram” reveals presence of pancreatic stula. A tubogram obtained
through a 16-Fr red rubber catheter 3 weeks after a pylorus-preserving pancreatoduode-
nectomy reveals contrast lling the jejunum at the level of the pancreaticojejunostomy
(arrow), conrming the presence of a pancreatic stula.
Section I / Pancreas104
node dissection along the hepatic artery with disruption of vagal and sym-
pathetic innervation to the antropyloric region, relative devascularization
or denervation of the pylorus after pylorus-preserving PD (PPPD), anasto-
motic disruption at the pancreaticojejuno stomy, and transient pancreatitis.
e issue of whether DGE is more common after PPPD than standard PD
has been debated. e results of studies are mixed, with rates of DGE higher
for PPPD in some studies and in PD in others. It is now generally accepted that
both operations are equivalent. e routine administration of postoperative
prokinetics to reduce the rate of DGE (e.g., erythromycin or metoclopramide)
has also not shown benet. ere is evidence that an antecolic duodenojeju-
nostomy (vs. retrocolic) after a PPPD lowers the rate of DGE.
Treatment
Our management of patients with DGE aims to minimize patient burden and
has led to universal cure of the condition with only a small minority of patients
requiring an additional intervention after surgery. We routinely place an NG
tube at the time of surgery, after the patient is under general anesthesia, and
leave it to intermittent suction overnight. It is removed on the rst morning
after surgery unless the output is extremely high (>1L), which occurs rarely.
Patients with DGE usually do not experience symptoms until postoperative
day 5 or later when they develop nausea, abdominal distension, or vomiting.
An NG tube is reinserted in patients with moderate or severe abdominal dis-
tension, vomiting, or an enlarged stomach evident on CT scan. It is placed to
intermittent suction and the amount of output recorded. Patients with DGE
usually have a high daily volume (>1.5L) of gastric or bilious output. A CT scan
of the abdomen and pelvis with oral and intravenous contrast is obtained to
determine the degree of gastric distension and to identify the presence of an
early postoperative bowel obstruction or undrained intra-abdominal uid
collections. DGE may be associated with a pancreatic stula, peripancreatic
uid collections, or an intra-abdominal abscess. e decision to obtain a CT
scan is not dependent on the presence of an elevated white blood cell count
or fever but rather on the patient’s symptoms as previously described. If uid
collections are present on the CT scan, and an infection is suspected, ultra-
sound- or CT-guided percutaneous drainage is performed. DGE associated
with undrained and infected uid collections usually resolves once the uid
has been drained. If the diagnosis of DGE is still unclear after the CT scan,
an upper gastrointestinal (UGI) contrast series is obtained. is conrms
delayed emptying of contrast from the stomach.
Once the diagnosis of DGE is suspected, patients are kept NPO. e
NG tube decompresses the stomach, which probably hastens its functional
recovery. It is left in place at least for 2 to 3 days until the output is minimal
and the patient can handle his or her own gastric and salivary secretions.
Occasionally, a trial of the NG tube to gravity may be useful.
A promotility agent, usually intravenous metoclopramide, is started
immediately after DGE is diagnosed and a bowel obstruction has been
excluded. Because metoclopramide is associated with numerous side
eects, particularly tardive dyskinesia in elderly patients, all patients
should be closely observed during its administration. If it is needed, eryth-
romycin is an alternate promotility agent that binds motilin receptors and
may be eective as well. Patients can be transitioned from intravenous
metoclopramide or erythromycin to an oral form once their NG tube has
been removed.
A peripherally inserted central catheter (PICC) line is placed early after
diagnosis, particularly in those patients in whom DGE is predicted to last
more than a few days. In these patients, TPN is begun and rapidly compressed
to infuse over a 12-hour period. Home health nursing is arranged to assist in
Chapter 9 / Complications of Pancreatic Surgery 105
home TPN care. Patients are discharged on TPN and a promotility agent and
allowed to slowly advance their diet at home. ey are seen in the outpatient
clinic on a weekly basis until the DGE resolves. Using this strategy, we have
found that almost all cases completely resolve within several weeks.
In rare instances, patients have a more prolonged course of abdominal
distention, nausea, or even intermittent vomiting that can require numerous
hospital readmissions. At each admission, NG tube decompression is repeated .
Occasionally, a percutaneous endoscopic gastrostomy tube has been placed to
minimize the symptoms and allow for gastric decompression at home. In our
experience, reoperation to deal with DGE has not been required.
POSTOPERATIVE HEMORRHAGE
Denition and Incidence
e International Study Group on Pancreatic Surgery (ISGPS) released a
consensus denition on postpancreatectomy hemorrhage in 2007, which
classies it according to severity and the time of onset after surgery. e
dierent severity classications include types A, B, and C with the latter two
involving major hemorrhage with a hemoglobin drop of greater than 3g/
dL. “Early postoperative hemorrhage” occurs within the rst 24 hours of
surgery; “late hemorrhage” occurs after 24 hours. Studies using these deni-
tions cite an incidence of postoperative hemorrhage at 3%.
Prior to the improvement of endoscopic and interventional radio-
graphic angiography techniques, post–pancreatic surgery hemorrhage
(PPH) was associated with an overall mortality rate of 50%. Mortality was
even higher in those patients presenting 72 or more hours after surgery.
e greatest risk of late PPH occurs in patients who develop postopera-
tive pancreatic stulas from a nonhealing pancreaticojejunostomy anas-
tomosis. Often, these patients also develop vascular abnormalities (e.g.,
pseudoaneurysms) that further worsen the outcome. e observation that
mortality rates have decreased with the development of improved nonop-
erative techniques has led to the overall goal of avoiding repeat surgery in
patients with late hemorrhage. is treatment strategy is in contrast to that
for patients with early postoperative hemorrhage, who should generally
undergo prompt operative reexploration.
Treatment
Postoperative hemorrhage should be suspected in patients whose hemo-
globin decreases by more than 3g/dL over the rst postoperative day or
those who develop systemic evidence of hypovolemia and bleeding. Once
suspected, resuscitative treatment should be initiated rapidly and urgent
steps taken to determine the source of the bleeding, which is either extra- or
intraluminal (i.e., within or outside of the intestinal tract). Almost all bleed-
ing within the rst 24 to 48 hours is from an extraluminal source and is often
due to a technical error during the operation. Nevertheless, the coagulation
prole is checked to ensure that there is no evidence of synthetic liver dys-
function, manifested by a high prothrombin time (PT). If the coagulation
parameters are abnormal, fresh frozen plasma is promptly administered to
correct the decit. Patients who have had prolonged biliary obstruction and
high preoperative bilirubin may also have elevated PT levels due to vitamin
K malabsorption and deciency. ey should be given intravenous vitamin
K if their PT levels are elevated. If the platelet count is less than 50,000 per
dL, platelets should be transfused. However, the surgeon should have a
low threshold for return to the operating room for exploration, when most
patients will be found to have a correctable source of bleeding. Figure 9.3
illustrates the potential bleeding sources.
Section I / Pancreas106
Late PPH (>24 hours after surgery) can occur over a long time span that
extends to weeks or even months postoperatively. erefore, it is important
for the surgeon to be aware of this possibility and to educate the patients as
to the signs and symptoms, since most patients are at home when it occurs.
Unlike early PPH, which is almost always extraluminal, late PPH often is
intraluminal, although bleeding of either type can occur. Patients with intra-
luminal hemorrhage present like those with UGI bleeding; they experience
FIGURE 9.3 Common sites of bleeding after (A) pancreaticoduodenectomy or (B) distal
pancreatectomy. (From Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemor-
rhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) denition. Surgery
2007;142(1):20–5. PMID: 17629996.)
A
B
Chapter 9 / Complications of Pancreatic Surgery 107
hematemesis or melena. e most likely sources are the three surgical
anastomoses, and the duodenojejunostomy is the most frequent. An NG
tube is inserted to verify that blood is in the stomach. If it is present, a UGI
endoscopy is performed for both diagnostic and therapeutic purposes. If the
bleeding source is identied, cautery is applied or a clip is placed. Patients
must still be closely monitored for the ensuing 48 hours. If the source is not
identied, or if the suspected site of bleeding is an extraluminal site, the next
step is to employ selective angiography both to identify the bleeding site and
to stop the bleeding via various interventional angiographic techniques.
Selective angiograms of the celiac axis and superior mesenteric arteries are
performed (Fig. 9.4). As illustrated in Figure 9.3, the most common sources
of bleeding are the gastroduodenal artery and transverse pancreatic arcades
adjacent to the pancreaticojejunostomy anastomosis.
In rare instances, late PPH cannot be controlled via endoscopic or
angiographic techniques. If this is the case, the patient should be operated
upon urgently. If the source of bleeding is the pancreaticojejunostomy and
there is an associated anastomotic dehiscence, the anastomosis may also
need to be addressed. is can be done with placement of drainage cath-
eters, reinforcement of the anastomosis with additional sutures, or addi-
tional pancreatic resection. However, it should be stressed that surgery
for late bleeding is required infrequently today, when the patient is being
managed in a “center of excellence” where a skilled multidisciplinary group
is available. Reoperative surgery in this setting is still associated with an
extremely high mortality rate.
BILIARY FISTULA
Bile leaks from the choledochal/hepaticojejunal anastomosis occur in 1% to
2% of patients undergoing PD and are heralded by the appearance of bile in
the drain uid. If this occurs, the drain should be left in place until the leak
stops. If bile is still present when the patient is ready for discharge, they can
go home with the drain in place. It can be removed in the oce when there
is no longer any bile present. If there is no evidence of a bile leak, the biliary
drain is removed the day after the patient begins oral intake. Because the PJ
anastomosis is close to the bile duct anastomosis, pancreatic stula uid
can also be tinged with bile. Because a stula from either site is managed in
a similar way, it may not be necessary to determine its origin with certainty.
If this is required, a contrast injection through the drain tube can resolve the
question. Management of a high-volume (>200mL/d) bile leak is more com-
plex, often requiring percutaneous transhepatic biliary stent placement.
EXOCRINE AND ENDOCRINE INSUFFICIENCY
e incidence of symptomatic exocrine insuciency after pancreatic sur-
gery depends on the amount of parenchyma resected, the function of the
pancreas that remains, and the adequacy of mixing of the food with pan-
creatic enzymes and bile. e rst two indices can be estimated with some
degree of condence and the last cannot. us, we council our patients that
if at least 20% of a normal pancreas remains, it should be enough to provide
adequate digestive (and endocrine) activity. is is a reliable prediction for
patients who will und ergo a distal pancreatectomy, including removal of the
entire body and tail of gland, but it is less so for patients who will undergo
a pancreatoduodenectomy. To some degree, this is because many patients
with pancreatic tumors that have obstructed the main pancreatic duct
may have obstructive chronic pancreatitis in the remnant pancreas, lead-
ing to decreased exocrine function. But it is mostly due to the uncertainty
about how well ingested food will mix with the pancreatic secretions and
Section I / Pancreas108
FIGURE 9.4 Gastroduodenal artery pseudoaneurysm treated angiographically. A. A supe-
rior mesenteric artery angiogram reveals a gastroduodenal artery pseudoaneurysm from a
completely replaced hepatic artery (arrow). B. A 5 × 50 Viabahn stent placed across the
pseudoaneurysm with complete occlusion of the bleeding site maintaining perfusion to the
common hepatic artery distal to the pseudoaneurysm.
A
B
Chapter 9 / Complications of Pancreatic Surgery 109
bile in the small intestine. is is true for both a standard PD as well as the
p
ylorus-preserving variety; studies show that after either operation, gastric
emptying may be normal or faster or slower than normal. So the amount of
pancreatic enzymes secreted by the remnant pancreas may be adequate,
but if those enzymes do not mix well with the food, they cannot be eective.
It is likely that the majority of patients have some degree of malab-
sorption and steatorrhea (i.e., >7% excretion of ingested fat) after any major
pancreatic resection. We do not treat them unless there are symptoms of
weight loss or inability to gain weight, diarrhea, oily stools, and/or abdomi-
nal bloating. Treatment consists of supplemental enzymes with at least
30,000IU of lipase taken with each meal; half that amount should be taken
with snacks. Only rarely does fat intake need to be limited. All of our PD
patients also are given proton pump inhibitors permanently to minimize
the likelihood of marginal ulceration. It is important to make certain that
these are given as well to those patients who have had other types of pan-
creatic resection and who require pancreatic enzymes, especially if a non-
enteric preparation is used. is is because gastric acid can denature the
ingested enzymes, which makes them ineective. If patients continue to be
symptomatic, they are referred to a gastroenterologist with experience in
the treatment of pancreatic exocrine insuciency.
e incidence of endocrine insuciency (type I diabetes mellitus, DM)
depends mostly on the amount of pancreatic parenchyma removed. Its inci-
dence generally parallels the occu rrence of pancreatic exocrine insuciency
for each specic pancreatic operation. e maintenance of gastroduodenal
continuity also may be an important factor for the development of DM
because it maintains neurohumoral connections between the stomach, the
duodenum, and the pancreas. us, the development of diabetes appears
to be less likely after duodenum-preserving pancreatic resections done for
chronic pancreatitis (Beger, Frey), compared to a pylorus-preserving PD.
Patients with preexisting DM can experience worsening of their dis-
ease with pancreatic resections. Early in the postoperative period after any
type of major surgery including pancreatic resection, blood sugars are gen-
erally elevated. Later, if diabetes is suspected after patients resume a diet,
we request an endocrinology and dietary consult, and subsequent man-
agement of DM is supported by those individuals and, eventually, by the
patient’s internist. Patients should also be made aware of the signs/symp-
toms of hypoglycemia, since with the resection of alpha islet cell mass and
less available glucagon, the DM may be more brittle than usual.
Suggested Readings
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postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006
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Kazanjian KK, Hines OJ, Eibl G, et al. Management of pancreatic stulas after
pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg
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Liver
SECTION II