Pancreatic Fistula
- Common complication after distal pancreatectomy
- Generally resolves spontaneously if well-drained
- Main cause of postoperative morbidity after distal pancreatectomy
Especially with very soft pancreatic parenchyma (e.g., in benign cystic neoplasms), the risk of developing postoperative pancreatitis and/or fistula is increased.
- Pancreatic Fistula (POPF = postoperative pancreatic fistula; Definition and classification according to ISGPF)
In 2005, the International Study Group for Pancreatic Fistula (ISGPF) developed a definition based on the amylase concentration in the drainage fluid:
A postoperative pancreatic fistula is present with a threefold increase in amylase concentration in the drainage fluid (compared to the serum amylase concentration) from the third postoperative day.
The clinical impact of the postoperative pancreatic fistula is classified into Grades A – C.
Grade A:
- Clinically inconspicuous patient, persistent fistula through the drainage, no intra-abdominal fluid collection (CT).
- No therapeutic consequences
Grade B:
- Clinically stable patient, peripancreatic fluid (CT) not completely drained by the existing drainage.
- Antibiotics, oral fasting, leave drainage in place; possibly invasive intervention (ultrasound- or CT-guided drainage); usually prolonged hospital stay.
Grade C:
- Clinically unstable patient (sepsis)
- Intensive care unit, interventional drainage or re-laparotomy; frequent bleeding complications; significantly increased mortality!
Drainage Management
- With existing target drainage:
- Leave drainage in place and ensure secure fixation.
- Possibly parenteral nutrition
- In case of infected pancreatic fistula, take a swab and administer antibiotics, initial therapy according to the antibiogram of the intraoperatively obtained bile duct swab, adjust antibiotics if a new swab result is available.
- With already removed target drainage:
- CT-guided drainage placement or transgastric drainage, swab collection
In case of persistent pancreatic fistula Grade B/C, a CT angiography is recommended to exclude a pseudoaneurysm, which arises due to inflammatory vessel erosion on the basis of a pancreatic fistula. If an aneurysm is present, radiological embolization or placement of a covered stent should be performed via angiography. The last resort is a re-laparotomy.
An algorithm for the management of pancreatic fistulas can be found here: Pancreatic Fistula
Postoperative Hemorrhage (PPH = postpancreatectomy hemorrhage; Definition and classification according to ISGPS) (2-10%)
- Erosive bleeding, where the visceral vessel wall is digested by pancreatic juice, represents a life-threatening and highly acute condition that requires immediate intervention.
- The distinctive characteristic of postoperative bleeding after partial pancreatic resection compared to bleeding after other surgical procedures lies in the numerous possible variations regarding cause, timing, location, and severity.
- The cause of early extraluminal bleeding is often insufficient intraoperative hemostasis. Late extraluminal bleeding, however, usually develops due to erosion of blood vessels or pseudoaneurysms. An important risk factor for late bleeding is the postoperative pancreatic fistula, further associations exist with bile leak, intra-abdominal abscess, and sepsis.
- Onset of Bleeding
- Early = < 24 h postoperatively
- Late = > 24 h postoperatively
- Location
- Intraluminal (primarily into the intestinal lumen):
Stress ulcer, anastomosis region, anastomosed pancreatic resection site, pseudoaneurysm - Extraluminal/intracavitary (primarily into the free abdominal cavity):
Pancreatic bed, resection area, liver, anastomosis region, severed vessels, pseudoaneurysm - Combined:
Pseudoaneurysm → tryptic erosion of the vessel wall by pancreatic secretions with the formation of a perivascular hematoma, which can either decompress intra-abdominally (extraluminal) or connect to the GI tract, e.g., via an insufficient anastomosis (intraluminal).
- Severity
- Mild:
Minor to moderate blood loss, Hb drop < 3 g/dl, only slight impairment of the patient → no surgical intervention required, endoscopy and volume/RBC substitution sufficient (1-3 RBC) - Severe:
Severe blood loss, Hb drop > 3 g/dl
Severe impairment of the patient (tachycardia, hypotension, oliguria, shock), substitution → 3 RBC required
Invasive measures indicated: angiography with coiling or stenting, re-laparotomy
An algorithm for the management of late bleeding after pancreatic procedures can be found here: Late Bleeding
Gastric Emptying Disorder
→ Exclusion of intra-abdominal formation → symptomatic
- Leave or reinsert the gastric tube
- Prokinetics
- Parenteral nutrition
