Pancreatic fistula

Abstract

Pancreatic fistula is a common complication after pancreatic resections, its incidence ranges from 10 to 30 % in most series. It is not a life-threatening complication in most cases; however, it prolongs the hospital stay, increases the treatment costs and delays adjuvant therapy in malignant disease. Various definitions of pancreatic fistula have been proposed, they are mostly based on the volume, duration, and amylase concentrations of fluid in perioperatively or postoperatively placed drains. It makes comparison of the results difficult. Thus it is advisable to use a uniform definition of the pancreatic fistula and the definition of the ISGPF seems to be optimal. This universal definition is nowadays widely accepted and used. ISGPF defines pancreatic fistula as output via an operatively placed drain (or a subsequently placed percutaneous drain) of any measurable volume of drain fluid on or after postoperative day 3, with an amylase content greater than 3 times the upper normal serum value. The fistula is then graded according to the clinical impact in grades A, B, and C. There are known three main risk factor categories for the development of pancreatic fistula: related to the pancreatic disease, related to the patient, and related to the surgical procedure. Most of the risk factors for the development of pancreatic fistula cannot be influenced. There are two basic options for the prevention of pancreatic fistula: pharmacological intervention (administration of somatostatin and its analogues) and technical modifications of the pancreatic remnant treatment. Routine administration of octreotide is not advisable in all pancreatic surgical procedures. Rather selective administration in high risk cases is suitable. The second option is modification of pancreatic remnant treatment. Most of the studies studying various modifications of the pancreatic remnant treatment were retrospective with lower level of evidence. There were only a few properly designed randomized trials and they did not prove benefit of one method over another. Besides the technique, the results depend on the experience of surgical department and above all experience of an individual surgeon who performs the pancreatic resection. The therapy of pancreatic fistula is based on the clinical severity. Fistulas grades A and B according to the ISGPF are always treated conservatively. The patients with fistula grade C usually require intensive care, they are in sepsis, and have failure of one or more organs. The clinical condition requires miniinvasive drainage of the peripancreatic collections or re-operation. There are two basic strategies for the reoperations: surgical drainage of the collections or completing total pancreatectomy. Total pancreatectomy was preferred in the past, however this procedure is technically very demanding with high mortality. Nowadays most of the authors prefer surgical drainage; this procedure is technically less demanding, has lower mortality, the endocrine function of pancreas is protected, and the patients usually need no further interventions. In conclusion, postoperative pancreatic fistula remains to be a significant problem in pancreatic surgery. The research nowadays continues with the goal to lower the incidence of pancreatic fistula; new techniques and interventions are tested in number of clinical trials. © 2013 by Nova Science Publishers, Inc. All rights reserved.