2.1 Postoperative pancreatic fistula (POPF) - ISGPF definition and classification
In case of anastomotic suture line failure after pancreatic resection, inadequately drained pancreatic secretion will leak into the abdominal cavity and may erode adjacent vessels and anastomoses. The pancreas protects itself against autodigestion by secreting its enzymes as inactive precursors. These are only converted into the active enzymes by the enteropeptidase of the small intestine (near the anastomosis).
Due to different definitions of pancreatic fistula, the International Study Group for Pancreatic Fistula (ISGPF) developed a consensus definition in 2005 based on the amylase level in the drained fluid:
A postoperative pancreatic fistula is defined as an external fistula with a drain output of any measurable volume after postoperative day 3 with an amylase level greater than three times the upper limit of the 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, length of stay not prolonged
Grade B:
- Patient clinically stable; peripancreatic fluid (CT) not fully evacuated via the indwelling drain
- Antibiotics; no oral intake; leave the drain in place; if necessary, invasive intervention (CT-guided drainage); length of stay usually prolonged
Grade C:
- Patient clinically unstable (sepsis)
- Intensive care, interventional drainage or revision surgery required; frequently: Bleeding complications; markedly increased mortality!
Drain management:
– Leave drain in place and ensure secure fixation
– In case of pancreatic fistula infection, obtain swab for microbiology and initiate antibiotics, initial therapy according to the antibiogram of the bile duct swab collected intraoperatively; if necessary, adjust antibiotic protocol according to any changes in the initial swab results
- If the target drain has already been removed:
– CT-guided or transgastric drainage
CT angiography is recommended to rule out pseudoaneurysm, which may develop due to inflammatory vascular erosion as a sequela of pancreatic fistula, e.g. at the gastroduodenal/splenic/superior mesenteric/ or one of the hepatic arteries. Aneurysms should be managed angiographically by a covered stent or coil embolization. Revision surgery should only be considered as a means of last resort.
This link shows an algorithm for the management of pancreatic fistulas: Pancreatic fistula
2.2 Postpancreatectomy hemorrhage (PPH) - ISGPS definition and classification
Compared to bleeding after other surgical procedures postpancreatectomy hemorrhage is characterized by the numerous possible alternatives regarding cause, time, location and severity.
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
Pseudoaneurysm > tryptic erosion of the vessel wall by pancreatic secretion with development of perivascular hematoma, which can either drain into the abdominal cavity (extraluminal) or gain access to the GI tract, e.g., via anastomotic suture line failure (intraluminal).
Severity
- 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), replacement of > 3 packed RBCs required
Invasive measures indicated: Angiography with coiling or stenting, revision surgery
Early extraluminal hemorrhage is often caused by inadequate intraoperative hemostasis, whereas late extraluminal bleeding usually develops as a result of vascular erosion or pseudoaneurysm. The greatest danger for the patient is late extraluminal hemorrhage. Postoperative pancreatic fistula is considered an important risk factor for late hemorrhage, and the latter is also associated with bile leakage, intraabdominal abscess and sepsis.
This link shows an algorithm for the management of postpancreatectomy hemorrhage: Late hemorrhage
2.3 Delayed gastric emptying (DGE) - ISGPS definition and classification
- Leave gastric tube in place or insert new
- Prokinetic agents (metoclopramide i.v., prostigmine)
- Parenteral nutrition
2.4 Failure of the bilioenteric anastomosis
- Patient stable and 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
2.5 Failure of the jejunal anastomosis
- Jejunal secretions draining through the wound; suspect drainage fluid, i.e., either clearly jejunal contents or secretions with elevated bilirubin/amylase levels compared with serum; oral administration of toluidine blue and its appearance in the target drain.
- Drains already removed: Ultrasound- or CT-guided centesis, possibly with drainage
- 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!
This link shows an algorithm for the management of intestinal fistulas: Enterocutaneous fistula (small bowel)
