Conservative treatment of postoperative pancreatic fistulas
Sergio Pedrazzoli1, Claudio Pasquali1, Cosimo Sperti1, Sabrina Scappin1, Guido Liessi2; 1Medical and Surgical Sciences, IV Surgical Clinic, PADOVA, Italy; 2Department of Radiology, Castelfranco Veneto Hospital, Castelfranco Veneto, Italy
Background. Pancreatic fistula is a feared complication after pancreatic surgery. Surgical treatment and mortality rate decreased during recent years, but the mortality risk from a major pancreatic fistula is up to 28% due to retroperitoneal sepsis and hemorrhage (1). Aim. Retrospective evaluation of the incidence of pancreatic fistula, and of the results of treatment, of patients who underwent pancreatic surgery. Methods. From January 1994 and August 2005, 307 patients underwent pancreatic surgery for benign, borderline or malignant diseases. Nine total pancreatectomies were excluded living a total of 298 patients. The output and amylase concentration of abdominal drains were determined during the postoperative period. Drains were removed within 8 days whenever possible. A pancreatic fistula was diagnosed on the basis of drainage of more than 50 ml of amylase-rich fluid (>5000 IU)/day. Once diagnosed, the drain was exchanged under fluoroscopic control; a pig-tail catheter was also inserted trough the fistula in the intestinal lumen whenever possible. A control contrast injection under fluoroscopy was performed once or twice a week, and the drains exchanged whenever needed. Aim of the treatment was to create a straight external fistula that then closed immediately after removing the drain. Results: Out of 298 patients: 119 underwent surgery for pancreatic or periampullary cancers, 66 for endocrine pancreatic tumors, 45 for cystic tumor of the pancreas, 14 for IPMN; 42 for chronic pancreatitis, 11 for pseudocyst post SAP, one for thesaurismosis. A pancreatic fistula was diagnosed in 45 patients (15.1%). The fistula rate was 8.8% (10/114) after pancreatoduodenectomy, 9.6% (8/83) after left pancreatectomy, 46.1% (12/26) after central pancreatectomy, 47% (8/17) after DPPHR, 17.2% (5/29) after enucleation, 6.6% (1/15) after pancreatico-jejunostomy, 20% (1/5) after subtotal pancreatectomy, 0% after cystojejunostomy (0/9). All but one underwent conservative treatment. A patient in dialysis for renal insufficiency developed abrupt generalized peritonitis 8 days after PD. She underwent surgical treatment aimed to recreate the condition of a guided external fistula as for the other patients. All fistulas closed spontaneously after a mean of 25 days (range 4-60). No patient died of pancreatic fistula. Conclusion. An early and intensive interventional radiology treatment of external pancreatic fistulas can avoid severe complications that usually need surgical treatment and, in some cases, a high risk completion pancreatectomy. 1) Alexakis N, Sutton R, Neoptolemos JP. Surgical treatment of pancreatic fistula. Review. Dig Surg 2004;21:262-74.
Back to 2006 Program and Abstracts