Postoperative morbidity and mortality in pancreatic surgery is mainly attributable to sepsis and bleeding caused by staple line failure and pancreatic fistula.
Remnant pancreatitis, erosive hemorrhage, atony and delayed gastric emptying are common manifestations of staple line failure. Erosive hemorrhage, in particular, in which the vascular walls are being digested by pancreatic juice is an acute, life threatening clinical entity warranting immediate intervention.
Pancreatic staple line failure (4–20%)
The risk depends on the firmness of the pancreatic resection area.
Contrast enhanced abdominal CT imaging should be performed immediately if failure of the pancreatojejunostomy staple line is suspected (leakage of pancreatic juice in drains, fever of unknown origin, elevated CRP, leukocytosis, concomitant pancreatitis and intestinal atony).
Conservative treatment may be possible in local manifestations, minor leaks and mild clinical courses. Any abscess can be drained.
Revision surgery is indicated in more widespread manifestations. If there is good perfusion of the remnant pancreas and favorable local conditions, oversew the staple line, otherwise fashion a new anastomosis.
Remnant pancreatectomy is performed in advanced inflammatory responses, sever remnant pancreatitis with impaired perfusion and/or local necrosis.
Pancreatic fistula/postoperative pancreatitis
There is a particularly high risk of postoperative pancreatitis and/or fistula if the pancreatic parenchyma is very soft (e.g., in benign cystic neoplasms).
- Pancreatic fistula (POPF = postoperative pancreatic fistula; ISGPF definition and classification)
In 2005, the International Study Group for Pancreatic Fistula (ISGPF) developed a consensus definition based on the amylase level in the drained fluid:
Postoperative pancreatic fistula is defined as a fluid output of any measurable volume via an operatively placed drain with amylase activity greater than 3 times the upper normal serum value.
The clinical effects of postoperative pancreatic fistula are classified as grades A–C.
Grade A:
- Patient clinically unremarkable; persistent fistulation via the drain; no intraabdominal fluid collection (CT)
- No therapeutic consequences
Grade B:
- Patient clinically stable; peripancreatic fluid (CT) not fully evacuated via the indwelling drain
- Antibiotics; no oral nutrition; leave drain in place; if necessary, invasive intervention (ultrasound or CT-guided drainage); hospital stay usually prolonged
Grade C:
- o Patient clinically unstable (sepsis)
- Intensive care, interventional drainage or revision surgery required; frequently: bleeding complications; markedly increased mortality!
Drain management
- o Indwelling target drain:
Leave drain in place and ensure secure fixation
In case of pancreatic fistula infection, take swab for microbiology and initiate antibiotics, initial therapy according to the antimicrobial susceptibility testing of the bile duct swab collected intraoperatively; if necessary, tailor antibiotic protocol to any changes in the initial swab results - If the target drain has already been removed:
– CT-guided or transgastric drainage, take swab
CT angiography recommended to rule out pseudoaneurysm, which may develop due to inflammatory vascular erosion as a sequela of persistent grade B/C pancreatic fistula. Aneurysms should be managed angiographically by covered stents or coil embolization. Revision surgery should only be considered as a means of last resort.
This link shows an algorithm for the management of intestinal fistulas: Pancreatic fistula
Postoperative bleeding (PPH = postpancreatectomy hemorrhage; ISGPS definition and classification) (2–10%)
Compared to bleeding after other surgical procedures postpancreatectomy hemorrhage is characterized by its numerous manifestations in terms of cause, time, location, and severity.
Early extraluminal hemorrhage is often caused by inadequate intraoperative hemostasis, whereas late extraluminal bleeding usually develops as a result of vascular erosion or pseudoaneurysm. Postoperative pancreatic fistula is considered an important risk factor in late hemorrhage, and the latter is also associated with bile leakage, intraabdominal abscess and sepsis.
- Start of hemorrhage
- → Early = <24 hours postoperatively
- → Late = >24 hours postoperatively
- Location
- Intraluminal (primarily into the intestinal lumen):
Stress ulcer, anastomosis and vicinity, anastomosed pancreatic resection margin, pseudoaneurysm - Extraluminal (primarily into the abdominal cavity):
Pancreas bed; resection site; liver; anastomosis and vicinity; divided vessels; pseudoaneurysm - Combined:
Pseudoaneurysm → tryptic erosion of the vessel wall by pancreatic secretions with formation of perivascular hematoma, which can either drain into the abdominal cavity (extraluminal) or gain access to the GI tract, e.g., via anastomotic staple line failure (intraluminal)
- Grade
- Minor:
Low to moderate blood loss; Hb drop <3 g/dL; patient only slightly impaired → no surgical intervention required; endoscopy and volume/packed RBC (1–3) replacement will suffice - Major:
Massive blood loss, HB drop >3 g/dL
Patient markedly impaired (tachycardia; hypotension; oliguria; shock), transfusion of → 3 packed RBCs required
Invasive measures indicated: Angiography with coiling or stenting, revision surgery
This link shows an algorithm for the management of postpancreatectomy hemorrhage: Late hemorrhage
Delayed gastric emptying (8–15%)
Delayed gastric emptying (25–30%) independently of type of operation (preservation or non-preservation of the stomach)
Rule out retention / intraabdominal staple line failure → symptomatic
- Leave nasogastric tube in place or insert new tube
- Prokinetics
- Parenteral nutrition
Failure of the bilioenteric anastomosis(2%–6%)
- Patient stable without signs of peritonitis leave target drain in place, check drainage volume, work-up with CT study, possibly MRCP.
- Revision surgery with placement of a T-drain and suture; re-anastomosis rarely indicated
This link shows an algorithm for the management of biliary leaks: Biliary leaks
Failure of the jejunal anastomosis
- Upper GI series and CT-study with water soluble contrast agent cannot rule out leakage of the jejunal anastomosis!
Deciding factor here is the clinical situation of the patient: Pain with signs of local and general peritonitis or sepsis with elevated levels of infection parameters in lab studies→ even if work-up is inconclusive, do not delay revision surgery
