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Invited Critique
November 1, 2006

Pancreatic Fistula After Distal Pancreatectomy—Invited Critique

Arch Surg. 2006;141(11):1076. doi:10.1001/archsurg.141.11.1076

Although fistula after pancreatic resection has become less life threatening, it remains a challenge to prevent and treat. This complication is at least as common after DP as after Whipple resection. This 13-year audit by Pannegeon et al of 175 patients who underwent DP, despite its suboptimal retrospective, uncontrolled study design, is sufficiently large to address possible risk factors. Pannegeon et al confirm published findings that direct pancreatic duct suture and transection at the pancreatic neck are associated with lower rates of fistula. As with Whipple resection, somatostatin analog administration after DP did not decrease the rate of fistula and was of limited value in its treatment. An underemphasized observation in this study (but one that is well known to experienced surgeons) is that fistula after DP tends to present late, typically days after resumption of an oral diet. This has important implications for American practice, which encourages ever-shorter lengths of stay. Presentation of fistula after DP may be subtle and not evident until outpatient convalescence; thus, the surgeon (and the office staff who may field initial calls) must still remain vigilant after hospital discharge. Total parenteral nutrition was used primarily in this series to manage PF; however, oral nutrition is often simpler, safer, and cheaper. This study also illustrates the dubious value of closed-suction drainage in early diagnosis or treatment of fistula. Half of the fistulae presented after removal of an “amylase-negative” drain, and 25% of percutaneous interventions were required with drains still in place, drains that failed to drain the very fluid for which they were prophylactically placed. Moreover, the rate of infected aspirate was strikingly high, given that leaks after DP initially consist of uncontaminated, inactivated pancreatic fluid because there is no enteric anastomosis. Despite accumulating evidence against the practice, it is difficult to dispel the continuing surgical myth of routine drainage after pancreatic resection.

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