Despite its suboptimal retrospective design, the article by Veillette and colleagues1 in the May issue of the Archives illustrating the clinical importance and updated management of pancreatic fistulas after pancreaticoduodenectomy provides critical information for practicing surgeons. The patient data were prospectively collected in a high-volume hospital, where about 106 pancreaticoduodenectomies are performed annually. In their study, a pancreatic fistula was identified when there was continuous external drainage for 7 days or an intraabdominal collection of amylase-rich fluid. The authors divided pancreatic fistulas into low-impact fistulas, which could usually be treated on an outpatient basis with favorable consequences (n = 26), and high-impact fistulas, which resulted in major morbidity and/or mortality despite rigorous intervention (n = 46). High-impact fistulas were divided into overt (n = 33) and occult (n = 13) fistulas. Occult fistulas were defined as those that were not manifest in the first postoperative week but subsequently resulted in fistula-related major morbidity. High-impact pancreatic fistula–related mortality was 15.2%, 8-fold greater than overall mortality. Unlike previous studies that reported 30-day mortality after pancreaticoduodenectomy as a measure of quality of surgical care, the authors delineated all deaths associated with pancreatic fistulas beyond the traditional but questionable hallmark, relating the clinical importance of this complication. Of note is that only 2 of the 7 deaths occurred within the 30 days after surgery.
Fujita T. Clinically Significant Pancreatic Fistulas. Arch Surg. 2008;143(11):1132. doi:10.1001/archsurg.143.11.1132-a