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Invited Critique
September 1, 2005

Management of Pancreatic Fistulas After Pancreaticoduodenectomy—Invited Critique

Arch Surg. 2005;140(9):856. doi:10.1001/archsurg.140.9.856

Postoperative PF remains the Achilles’ heel of pancreaticoduodenectomy. Fortunately, many recent reports have indicated that most postoperative PFs can be managed conservatively, with good outcomes. This review from the University of California, Los Angeles, very nicely documents that postoperative PF was identified in 12.6% of patients and that postoperative PF was significantly more common when the underlying pathological diagnosis was an ampullary tumor or a benign cystic neoplasm. Patients with postoperative PF had more postoperative complications, including intra-abdominal abscess requiring drainage, wound infection, intra-abdominal bleeding, sepsis, biliary fistula, late biliary stricture, and need for reoperation. Fortunately, mortality rates and long-term survival were unaffected by the presence of a PF. Overall, 94.5% of patients had successful “conservative” management of their postoperative PF, basically relying on operatively placed drains. Numerous institutions have looked at their postoperative PF rates over the last several years. A large retrospective review done at Johns Hopkins (Baltimore, Md) and first authored by Lin et al1 evaluated 1891 patients undergoing pancreaticoduodenectomy over a 21-year period. The incidence of postoperative PF in this very large series was 11.4%, and multivariate analyses showed that the texture of the gland (namely, a soft gland commonly seen with benign disease and ampullary tumors) was highly predictive of a postoperative PF. In the Johns Hopkins series, although 30-day postoperative mortality was not different between patients with postoperative and nonpostoperative PF, the mean length of hospital stay was longer and complications such as pancreatitis, bile leakage, and intra-abdominal abscess all had a significantly higher incidence in patients with postoperative PF.