Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy

Abstract

Background: Surgical management of severe pancreatic fistula after pancreatoduodenectomy remains challenging, and carries high mortality. The aim of this retrospective study was to compare different surgical techniques used at relaparotomy for pancreatic fistula after pancreatoduodenectomy, and to identify factors predictive of failure to rescue.Methods: A total of 43 patients after pancreatoduodenectomy developed a pancreatic fistula requiring relaparotomy. The perioperative data and outcomes were reviewed retrospectively.Results: Completion pancreatectomy, simple drainage of the pancreatic anastomosis and external wirsungostomy were performed in 17, 16, and 10 cases, respectively. The mortality rate for completion pancreatectomy was 47.1%, compared with 56.3% for simple drainage (p = 0.598) and 50.0% for external wirsungostomy (p = 0.883). Simple drainage was associated with a higher rate of further relaparotomies (56.3%) in comparison with completion pancreatectomy (23.5%, p = 0.055) and external wirsungostomy (0%, p = 0.003). A rescue resection of the pancreatic remnant after failed simple drainage resulted invariably in death. On multivariate analysis, the factors predictive of mortality after relaparotomy for pancreatic fistula were organ failure on the day of reoperation (p = 0.001) and need of further surgical reintervention (p = 0.007). Conclusion: Timely reintervention and appropriate surgical technique are essential for reducing mortality after reoperation for pancreatic fistula after pancreatoduodenectomy.

“Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach”—a narrative review

“…Other strategies include disconnection followed by exteriorization and bridge stenting may be used in some scenarios. Revising pancreaticoenteric anastomosis and switching to other techniques is not feasible in most of these scenarios and should not be done (141)(142)(143)(144)(145)(146)(147)(148)(149)(150).…”

Surgical Management of Postoperative Grade C Pancreatic Fistula following Pancreatoduodenectomy

“…Appropriate identification and treatment of patients with grade C pancreatic fistula who are at risk of rapid deterioration is vital to reduce postoperative mortality [10][11][12]. No clear criterion for revisional surgery in grade C pancreatic fistula has been described to guide the surgeon and the choice of the technique is relying on the patient's conditions, intraoperative findings, and surgeon's discretion [12][13][14][15]. According to the ISGPF definition [7], grade C pancreatic fistula requires reoperation and is related to organ failure and death.…”

“…These procedures are technically easier than CP and preserve pancreatic function. However, they often expose the patient to additional reoperations and associated complications because of the potential persistence of the pancreatic fistula [10][11][12][13][14][15][16]. Severe hemodynamic instability is an indication for performing a pancreas-preserving technique, particularly external wirsungostomy or debridement and drain placement.…”

Construction of a pancreatojejunostomy with an external stent: A technical description

“…Postoperative pancreatic fistula (POPF) is perhaps the most dreaded complication of a pancreatoduodenectomy, with a reported incidence of 10%–30% in the literature 1 . Various approach to mitigate this risk have been explored, with conflicting results in the literature 2 .…”

“…Postoperative pancreatic fistula (POPF) is perhaps the most dreaded complication of a pancreatoduodenectomy, with a reported incidence of 10%-30% in the literature. 1 Various approach to mitigate this risk have been explored, with conflicting results in the literature. 2 These include the use of pharmacological agents, various pancreatic anastomotic techniques, placement of pancreatic stents, glues and placement of drains.…”