OBJECTIVE Pancreatic fistula (PF) after distal pancreatectomy (DP) is considered a major source of morbidity. To identify factors that contribute to the risk of PF and assess its clinical significance, we reviewed 155 consecutive elective DP performed with routine placement of surgical drains. Preoperative, intraoperative, and surgical outcome variables were analyzed. Pancreatic fistula (PF) was defined by the presence of any pancreatic juice in the drain effluent. RESULTS The median length of stay was 7 days. The nonpancreatic complication rate was 25% (39/155), and postoperative mortality was 1.3% (2/155). Although PF developed in 36% of patients after DP (55/155), 83% of fistula patients (46/55) were asymptomatic, while 16% (9/55) developed intraabdominal complications (IAC) and required either percutaneous drainage (11%) or reoperation (6%, 3/55). In the absence of recognized PF, no patients required reintervention (p=0.0002 vs. PF group). Patients developing IAC had a higher risk of reintervention (p<0.0001) with a longer hospital stay (median 9 days, p<0.004) than patients in the no PF group. In the absence of IAC, patients with PF did not experience a delay in the resumption of oral intake (median 3 days) or increased median length of stay (8 days vs. 7, p=NS). The risk of PF was increased by longer operative time (p<0.005) and blood transfusion (p<0.05) but not by the estimated blood loss, need for splenectomy, performance of additional major operative procedures, or by the final pathologic diagnosis. In the presence of routine surgical drainage, 78% of postoperative morbidity was caused by nonpancreatic complications associated with preexisting medical comorbidities (p=0.02), but not postoperative PF. The technique of pancreatic transection (54% stapling vs. 46% surgical division with horizontal mattress sutures) had no effect on the risk of either PF or IAC. Neither supplemental suture ligation of the pancreatic duct nor reinforcement of the staple line with absorbable mesh significantly reduced the risk of postoperative PF. CONCLUSION In the presence of surgical drains, 83% of patients developing pancreatic fistulae after DP have a benign postoperative course. Only 6% of DP patients developed a symptomatic IAC requiring further intervention. In our series, the method for controlling the pancreatic remnant did not impact the risk of PF. Conversely, our data suggests that the risk of PF may result from perioperative factors (operative time and blood transfusion). With the utilization of routine surgical drainage, the majority of morbidity after DP is associated with preexisting comorbidities and is not directly related to pancreatic fistulae.