Prävention und Management von postoperativen Komplikationen in der Pankreaschirurgie

Abstract

During the last decades mortality after pancreatic surgery has decreased. Nevertheless, morbidity still remains at a high level. It is important to differentiate between pancreatic head resection and distal pancreatectomy. The complication rates of both procedures are high, however the need for intervention to manage perilous complications is higher after pancreaticoduodenectomy. The main complications after pancreatic surgery are delayed gastric emptying (DGE), pancreatic fistula, anastomotic leakage and bleeding. The current literature on the different techniques of pancreatic anastomosis and pancreatic remnant closure, respectively, does not show consistent results or an advantage for a particular technique. The same is true for the perioperative use of somatostatin and its analogues for the prevention of complications. It is widely agreed that the smooth texture of the pancreas and a small pancreatic duct < 3 mm are risk factors for pancreatic leakage or fistula. Today, the trend is more for conservative or interventional therapy for pancreatic fistulas or intraabdominal collections with, e. g., persisting intraoperative drain, TPN, somatostatin therapy or CT-controlled drainage. The opinions about the optimal treatment of the dreaded postoperative bleeding differ significantly in the surgical community. There are early and late bleedings and the management varies from endoscopical treatment or angiographic coiling / stenting to revision. Nevertheless, every bleeding is accompanied with high mortality. Here we present a review of literature and demonstrate the various strategies for the management of complications.

Objective parameters aid the prediction of fistulas in pancreatic surgery

“…These results are in accordance with previous studies that found a non-fibrotic fragile pancreas is likely to predispose individuals to the development of POPF (5–7). Fibrotic pancreatic tissue is easier to handle for surgeons, while soft pancreatic tissue is difficult to sew, which partially explains the increased leakage rates of soft pancreatic tissue.…”

“…The outcome of pancreatic surgery, including the leakage rate, is dependent on the experience of the center and the individual surgeon, as well as the surgical technique. However, there are also patient-specific and tissue-determined risk factors for pancreatic leakage or fistula, which include the soft tissue texture of the pancreas (3) and a small pancreatic duct of <3 mm (5–7). While these risk factors are widely accepted, to date, no histological or molecular factors have been identified.…”

Behandlung postoperativer Passagestörungen, Cholangitis und Pankreatitis

“…Die Entlastung des oberen Gastrointestinaltraktes durch Anlage einer nasogastralen Sonde ist im Falle des Auftretens einer vME bewährter Expertenkonsens [7,33,56]. Das prophylaktische postoperative Belassen einer Magensonde gehör-te bis vor kurzem zur Routine insbesondere nach großen resezierenden Eingriffen.…”

Harmonic Scalpel versus Conventional Dissection Technique in Pylorus-Preserving Partial Duodenopancreatectomy

“…As a result of the decreased blood loss, the number of transfused blood units could be reduced by 80% in the present study. The amount of blood transfusions has been shown to be a negative prognostic factor after the resection of pancreatic cancer in multivariate analysis [6][7][8]. Thus, use of the harmonic scalpel may improve the outcome of patients with pancreatic adenocarcinoma.…”

“…Nowadays, in high-volume centers, the operative mortality rate is below 3%, whereas morbidity remains high with rates between 32 and 57% [3][4][5]. It has been shown that long operating times, intraoperative blood loss and the need for blood transfusions increase morbidity after pancreatic head resections [6,7]. It has also been suggested that patients with surgery for pancreatic cancer who received less than 2 units of blood had an increased survival rate [6] and that blood loss was an independent outcome predictor in multivariate analysis [8].…”