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Implications and Management of Pancreatic Fistula Following Pancreaticoduodenectomy: The MGH Experience
Gregory Veillette, Ismael Dominguez, Cristina Ferrone, Sarah P Thayer, Deborah McGrath, Andrew L Warshaw, Carlos Fernandez-del Castillo
MGH, Boston, MA
Objective: To describe the management and impact of pancreatic fistula in a high volume center
Design: Retrospective case series
Setting: Tertiary academic center
Patients: 585 consecutive patients who underwent pancreaticoduodenectomy from January 2001 through June 2006
Main Outcome Measure: Development of pancreatic fistula (defined as drain output greater than 30cc/day of amylase-rich fluid after post-operative day 7), the need for additional interventions or total parenteral nutrition, other morbidity and mortality
Results: Pancreatic fistula occurred in 67/585 patients (11.4%). Fistulas were managed with gradual withdrawal of surgical drains. This allowed for patient discharge, outpatient follow-up and eventual closure at a mean of 19 days in 46% of cases. These were classified as ‘low-impact’ fistulas. The remaining 36 patients (54%) had an associated abscess, required percutaneous drainage or total parenteral nutrition, or developed bleeding. These were classified as ‘high-impact’ fistulas, and closed an average of 32 days after surgery. Only two patients with pancreatic fistula (3%) required re-operation, both for bleeding pseudoaneurysms. Overall mortality for patients with pancreatic fistula was 4.5% (3/67), and not significantly different from those without fistula (2.1%). Mortality was from hemorrhage (2) and sepsis (1).
Conclusions: Nearly half of pancreatic fistulas after pancreaticoduodenectomy are clinically insignificant, requiring no further intervention other than drain management. The remaining fistulas occur in 6.1% of patients who undergo pancreaticoduodenectomy. These have a significant impact in the patients’ post-operative course, but rarely require re-operation.
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