Complications - Pancreatogastrostomy

Since the PG is performed as part of a pancreatoduodenectomy, please use the link to our article "Duodenohemipancreatectomy with Blumgard anastomosis and bilio-pancreatic separation (Merheim procedure)”

Postoperative pancreatic fistula (POPF) drives the high morbidity after pancreatic head resection, mainly due to the associated sepsis and hemorrhage. Some trials have demonstrated the superiority of pancreatogastrostomy in terms of clinically significant postoperative pancreatic fistulas.

Unlike in some prior trials, a higher incidence of gastroparesis post pancreatogastrostomy was noted.

The rate of intraluminal PPH (postpancreatectomy hemorrhage) seems to be higher versus PJ; this is mostly attributed to bleeding from the PG anastomosis or cut surface of the pancreas.

Various supportive measures have been employed in an attempt to increase the safety of pancreatic anastomosis and thus reduce the leakage rate. The available evidence for this is inconclusive. Somatostatin analogs are recommended as protective measure in high-risk pancreatic anastomoses. Restrictive fluid protocols during surgery and in the early postoperative period also appear to lower the fistula rate. Routine placement of a perianastomotic targeted drain is recommended because it can significantly reduce mortality following pancreatoduodenectomy.

Pancreatic anastomotic failure (4%-20%)

The risk depends on the consistency of the pancreatic resection surface.

If failure of the pancreaticojejunostomy is suspected (pancreatic secretion via drains, unexplained fever, CRP elevation, leukocytosis, concomitant pancreatitis, and atony), the patient should undergo immediate CT study of the abdomen with intravenous contrast enhancement.

If the failure is localized, the leakage small, and the clinical course mild, non-surgical management can be attempted. Concomitant abscesses can be drained by interventional means.

Relaparotomy is indicated in more extensive findings. If the pancreatic remnant is well perfused and local conditions are favorable, the suture line may be resutured; otherwise, the anastomosis should be refashioned.

Completion pancreatectomy is indicated in advanced inflammatory reaction of the surrounding tissue, in severe remnant pancreatitis with impaired perfusion and/or in local necrosis.

Pancreatic fistula/postoperative pancreatitis

The risk of developing postop. pancreatitis and/or fistula increases with very soft pancreatic parenchyma (e.g., benign cystic neoplasia) in particular.

Pancreatic fistula (POPF = postoperative pancreatic fistula; ISGPF definition and classification)

In 2016, the International Study Group for Pancreatic Fistula (ISGPF) updated their definition of pancreatic fistula based on the amylase level in the drain fluid:

Any measurable volume of drain fluid on or after postoperative day 3 with amylase level >3 times the upper limit of normal amylase value for each specific institution. The condition needs to be clinically relevant

Originally (2005), the clinical effects of postoperative pancreatic fistula were classified as grades A–C.

Grade A: Clinically unremarkable patient, persistent fistula secretion via the drain, no intra-abdominal fluid collection (CT).

• no therapeutic consequences—grade A has now been renamed biochemical leak (BL)

Grade B: Patient clinically stable, peripancreatic fluid (CT) not fully drained via percutaneous drain, signs of infection without organ failure.

• Antibiotics, no oral nutrition, drain left in place; invasive intervention (sonographic or CT-guided drainage) if necessary; inpatient length of stay usually prolonged.

Grade C: Patient clinically unstable (sepsis) with organ failure

• ICU, interventional drainage or re-laparotomy; bleeding complications common; mortality significantly increased!

Drain management

With targeted drain still indwelling:

– Leave the drain in place and ensure secure fixation.

– If the pancreatic fistula is infected, take a swab and administer antibiotic protocol; initial treatment according to the antibiogram of the intraoperative bile duct swab; once new swab results are available, adjust antibiotic protocol as needed.

With targeted drain already removed:

– Place a CT-guided or transgastric drain. Take a swab.

In persistent pancreatic fistula grade B or C, CT angiography is recommended to rule out pseudoaneurysm, which arises from inflammatory vascular erosion secondary to pancreatic fistula.  In case of an aneurysm, angiography with radiological embolization or insertion of a covered stent should be performed. Relaparotomy is the last resort.

This link shows an algorithm for the management of pancreatic fistulas: Pancreatic fistula

Postoperative hemorrhage (PPH = postpancreatectomy hemorrhage; ISGPS definition and classification) (2%–10%)

Unlike in hemorrhage after other surgical procedures, the unique feature of postoperative hemorrhage after partial pancreatic resection lies in the numerous possible variants regarding cause, timing, location, and severity.

A frequent cause of early extraluminal hemorrhage is inadequate intraoperative hemostasis. Secondary extraluminal hemorrhage, on the other hand, usually develops from erosion of blood vessels or pseudoaneurysms. Postoperative pancreatic fistula is considered an important risk factor for secondary bleeding, and there are also associations with bile leakage, intraabdominal abscess, and sepsis.

Onset of hemorrhage

→ early = < 24 h postoperatively

→ late = > 24 h postoperatively

Location

Intraluminal (primarily into the intestinal lumen):

      Stress ulcer, anastomotic region, anastomosed pancreatic resection surface, pseudoaneurysm.

Extraluminal/intracavitary (primarily into the greater sac):

      Pancreatic bed; resection region; liver; anastomotic region; divided vessels; pseudoaneurysm.

Combined:

      Pseudoaneurysm → tryptic erosion of the vascular wall by pancreatic secretions with formation of a perivascular hematoma that either drains into the greater sac (extraluminal) or may communicate with the GI tract, e.g., via anastomotic failure (intraluminal).

Severity

• Minor Mild to moderate blood loss, Hb drop < 3 g/dL, only mild patient impairment → no surgical intervention required, endoscopy and volume/PRBC transfusion adequate (1-3 units).
• Major: Severe blood loss, HB drop > 3 g/dL, severe patient impairment (tachycardia, hypotension, oliguria, shock), substitution → 3 PRBCs required.
• Invasive measures indicated: Angiography with coiling or stenting, re-laparotomy.

This link shows an algorithm for the management of secondary hemorrhage in pancreatic surgery: Secondary hemorrhage

Gastroparesis (25%-30%)

-> Rule out intraabdominal obstruction/anastomotic failure → symptomatic

• Leave the gastric tube in place or insert a new one
• Prokinetics
• Parenteral nutrition