Preliminary Remarks:
The primary causes of postoperative morbidity and mortality following pancreatic head resection are anastomotic leakage and pancreatic fistula, due to associated sepsis and bleeding. Residual pancreatitis, erosive hemorrhage, atony, and gastric emptying disorders are frequently accompanying phenomena of anastomotic insufficiency.
Erosive hemorrhage, in which the visceral vascular wall is digested by pancreatic juice, represents a life-threatening and highly acute condition requiring immediate intervention.
Pancreatic Anastomotic Insufficiency (4–20%)
The risk depends on the firmness of the pancreatic resection surface.
Diagnostic Approach:
If anastomotic leakage of the pancreaticojejunostomy is suspected (pancreatic secretion via drains, unexplained fever, elevated CRP, leukocytosis, associated pancreatitis, and atony):
➡ Immediate contrast-enhanced abdominal CT
Management:
• Localized, small leakage with mild clinical course → Conservative management with continued drainage; if an accompanying abscess is present → Interventional drainage
• Extensive leakage → Relaparotomy
• Well-perfused pancreatic remnant with favorable local conditions → Suture reinforcement or re-anastomosis
• Severe inflammatory reaction, advanced residual pancreatitis with hypoperfusion and/or local necrosis → Completion pancreatectomy
Pancreatic Fistula
Particularly in cases of very soft pancreatic parenchyma (e.g., benign cystic neoplasms), there is an increased risk of postoperative pancreatitis and/or fistula formation.
Definition and Classification of Postoperative Pancreatic Fistula (POPF) – ISGPF Criteria (2005)
According to the International Study Group for Pancreatic Fistula (ISGPF), a postoperative pancreatic fistula is defined as:
➡ Drainage fluid amylase concentration ≥3 times the serum amylase level on or after postoperative day 3
Clinical Classification (Grade A–C):
• Grade A:
• Clinically silent, persistent drainage of pancreatic fluid.
• No intra-abdominal fluid collection (CT).
• No therapeutic intervention required.
• Grade B:
• Clinically stable patient, peripancreatic fluid collection (CT) not completely drained via existing drainage.
• Management: Antibiotics, oral fasting, continued drainage; if necessary, image-guided drainage (ultrasound or CT-guided).
• Prolonged hospital stay expected.
• Grade C:
• Clinically unstable patient (sepsis).
• Requires ICU admission, interventional drainage, or relaparotomy.
• Frequent bleeding complications, significantly increased mortality.
Drainage Management:
If the target drainage is still in place:
- Leave the drain in place and ensure secure fixation.
- Consider parenteral nutrition.
- If infection is present → Microbiological swab + Empirical antibiotic therapy based on intraoperative bile culture; adjust antibiotics as needed.
If the target drainage has already been removed:
- CT-guided drainage placement or transgastric drainage
- Microbiological swab collection
Further Steps for Persistent Grade B/C Pancreatic Fistula:
• CT angiography → To rule out a pseudoaneurysm, which may result from inflammatory vascular erosion due to the fistula.
• If a pseudoaneurysm is present:
• Endovascular embolization or covered stent placement (angiographic intervention).
• As a last resort → Relaparotomy.
An algorithm for the management of pancreatic fistula can be found here: Pancreatic Fistula
Postoperative Hemorrhage (PPH – Postpancreatectomy Hemorrhage; Definition and Classification by ISGPS) (2–10%)
Erosive hemorrhage, in which the visceral vascular wall is digested by pancreatic juice, represents a life-threatening and highly acute condition requiring immediate intervention.
The specificity of postoperative bleeding after partial pancreatic resection compared to hemorrhage following other surgical procedures lies in the multiple variations regarding cause, timing, location, and severity.
• Early extraluminal bleeding is often caused by insufficient intraoperative hemostasis.
• Late extraluminal bleeding usually develops due to vascular erosion or pseudoaneurysm formation.
• A major risk factor for late bleeding is postoperative pancreatic fistula.
• Additional associations exist with bile leakage, intra-abdominal abscess, and sepsis.
Onset of Bleeding
• Early: < 24 h postoperatively
• Late: > 24 h postoperatively
Location of Bleeding
1. Intraluminal (Primary into the intestinal lumen):
• Stress ulcer
• Anastomotic site
• Resected pancreatic surface
• Pseudoaneurysm
2. Extraluminal/Intra-abdominal (Primary into the peritoneal cavity):
• Pancreatic bed
• Resection site
• Liver
• Anastomotic region
• Ligated vessels
• Pseudoaneurysm
Key point: A common site of bleeding is at the gastroduodenal artery (GDA) stump.
➡ Ideal treatment (if hemodynamic stability allows): Interventional coiling.
3. Combined:
• Pseudoaneurysm → Trypsin-induced vascular erosion by pancreatic secretions, leading to a perivascular hematoma that may rupture either:
• Extraluminally into the abdominal cavity.
• Intraluminally into the gastrointestinal tract (e.g., via an insufficient anastomosis).
Severity of Bleeding
Mild:
• Small to moderate blood loss
• Hemoglobin drop <3 g/dL
• Only minor impairment of the patient
• No surgical intervention required
• Management:
• Endoscopy
• Interventional radiology (e.g., embolization)
• Volume replacement / transfusion (1–3 units of packed red blood cells – PRBCs)
Severe:
• Significant blood loss, Hb drop >3 g/dL
• Severe clinical impairment (tachycardia, hypotension, oliguria, shock)
• Transfusion requirement: ≥3 PRBCs
• Invasive intervention required:
• If patient is stable: Angiography with coiling or stenting
• If patient is unstable: Emergency relaparotomy
An algorithm for the management of delayed postoperative hemorrhage after pancreatic surgery can be found here: Delayed Hemorrhage
Delayed Gastric Emptying (DGE) (8–20%)
➡ First, rule out intra-abdominal obstruction
➡ Symptomatic treatment:
• Maintain or replace the nasogastric tube
• Prokinetic agents
• Parenteral nutrition
Postoperative Pancreatitis
• Risk factors: Very fragile, soft pancreatic parenchyma, or intraoperative pressure trauma.
• Management: Conservative treatment.
Biliodigestive Anastomotic Insufficiency (BDA) (2–6%)
• Often ischemic in origin.
• Prevention:
• Transection proximal to the cystic duct
• Avoid coagulation near the hepatic duct (to prevent thermal injury).
Management:
• Massive early postoperative bile leakage via drains
• Surgical revision required: Consider placement of a T-tube or new anastomosis.
• Stable patient without peritonitis signs, late-onset insufficiency with lower secretion volume:
• Leave the target drain in place and monitor drainage output.
• Further diagnostics: CT, possibly MRCP.
An algorithm for the management of biliary fistulas can be found here: Biliary Fistula
Insufficiency of the Duodenojejunostomy
Important:
• MRCP or CT with water-soluble contrast cannot reliably exclude leakage from a small bowel anastomosis.
• Decisive factors:
• Clinical assessment of the patient
• Presence of pain with local or generalized peritonitis signs
• Drainage characteristics
• Sepsis indicators (elevated infection markers in laboratory tests)
➡ Even in cases of inconclusive diagnostics, an early decision for relaparotomy should be made!
