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Invited Commentary
June 2017

“Step-Up Approach” for the Treatment of Postoperative Severe Pancreatic Fistula: Is It Really Possible and Useful?

Author Affiliations
  • 1Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
JAMA Surg. 2017;152(6):548-549. doi:10.1001/jamasurg.2016.5710

Postoperative pancreatic fistula (POPF) remains the Achilles heel after pancreaticoduodenectomy and primary cause of operation-related death. At this time, there are no surgical techniques or specific medical treatments that can overcome the problem of POPF. Therefore, the correct approach to treatment of severe POPF is crucial to reduce the mortality and morbidity after pancreatic surgery. Smits and coauthors1 suggest that percutaneous catheter drainage as the first interventional procedure for “relevant” POPF could improve clinical outcomes, compared with the use of relaparotomy. Even though this therapeutic approach to severe POPF is interesting, the data presented by the authors should be critically analyzed. The definition of “severe” POPF comprises what ISGPF2 regards as types B and C fistulae. These categories include the wide range of patients in whom the fistula would resolve by leaving the operative drains in place longer, without further intervention, in patients with systemic inflammatory response syndrome, sepsis, and organ failure in whom completion pancreatectomy could be the only chance for rescue. In the Smits et al1 study, the group that underwent relaparotomy seems to have a higher comorbidity burden, higher American Society of Anesthesiologists class, more severe systemic inflammatory response syndrome, and a higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score before intervention compared with the primary catheter drainage group. Moreover, the use of the APACHE II score as a means for stratification of the patients in the matching subgroups is debatable. Although a relevant prognostic score for the severity of acute pancreatitis, the APACHE II scale has not been proven to accurately correlate with POPF-related morbidity after pancreatic surgery, as do most of the other widely used physiologic prognostic scores (eg, POSSUM, Apgar).3,4 In addition, Gueroult et al5 note that severely ill patients with postoperative peritonitis due to POPF who would require relaparotomy would generally have a mean APACHE II score of 18.6, which is significantly higher than the less than 9 and greater than 12 cutoff levels used in the Smits et al study. Finally, relaparotomy as the first intervention included solely open drainage in just half of the patients. The reason why open surgery was primarily needed, such as inability to access a peripancreatic collection by interventional radiology, personal preference of the surgeon, or patients’ deterioration, was not clarified. Clearly, the first 2 options should not be an indication for relaparotomy for most patients; instead, relaparotomy should probably be reserved for patients with severe POPF requiring completion pancreatectomy.

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