Critical Appraisal of 232 Consecutive Distal Pancreatectomies With Emphasis on Risk Factors, Outcome, and Management of the Postoperative Pancreatic Fistula: A 21-Year Experience at a Single Institution | Gastrointestinal Surgery | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 35.175.212.130. Please contact the publisher to request reinstatement.
1.
Fernández-del Castillo  CRattner  DWWarshaw  AL Standards for pancreatic resection in the 1990s.  Arch Surg 1995;130 (3) 295- 300PubMedGoogle ScholarCrossref
2.
Büchler  MWWagner  MSchmied  BMUhl  WFriess  HZ’graggen  K Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy.  Arch Surg 2003;138 (12) 1310- 1314PubMedGoogle ScholarCrossref
3.
Birkmeyer  JDSiewers  AEFinlayson  EV  et al.  Hospital volume and surgical mortality in the United States.  N Engl J Med 2002;346 (15) 1128- 1137PubMedGoogle ScholarCrossref
4.
Balcom  JH  IVRattner  DWWarshaw  ALChang  YFernandez-del Castillo  C Ten-year experience with 733 pancreatic resections: changing indications, older patients and decreasing length of hospitalization.  Arch Surg 2001;136 (4) 391- 398PubMedGoogle ScholarCrossref
5.
Lillemoe  KDKaushal  SCameron  JLSohn  TAPitt  HAYeo  CJ Distal pancreatectomy: indications and outcomes in 235 patients.  Ann Surg 1999;229 (5) 693- 700PubMedGoogle ScholarCrossref
6.
Kleeff  JDiener  MKZ’graggen  K  et al.  Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases.  Ann Surg 2007;245 (4) 573- 582PubMedGoogle ScholarCrossref
7.
Fahy  BNFrey  CFHo  HSBeckett  LBold  RJ Morbidity, mortality, and technical factors of distal pancreatectomy.  Am J Surg 2002;183 (3) 237- 241PubMedGoogle ScholarCrossref
8.
Balzano  GZerbi  ACristallo  MCarlo  VD The unsolved problem of fistula after left pancreatectomy: the benefit of cautious drain management.  J Gastrointest Surg 2005;9 (6) 837- 842PubMedGoogle ScholarCrossref
9.
Rodríguez  JRGermes  SSPandharipande  PV  et al.  Implications and cost of pancreatic leak following distal pancreatic resection.  Arch Surg 2006;141 (4) 361- 366PubMedGoogle ScholarCrossref
10.
Dindo  DDemartines  NClavien  PA Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.  Ann Surg 2004;240 (2) 205- 213PubMedGoogle ScholarCrossref
11.
DeOliveira  MLWinter  JMSchafer  M  et al.  Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy.  Ann Surg 2006;244 (6) 931- 939PubMedGoogle ScholarCrossref
12.
Yeo  CJCameron  JLSohn  TA  et al.  Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes.  Ann Surg 1997;226 (3) 248- 260PubMedGoogle ScholarCrossref
13.
Bassi  CDervenis  CButturini  G  et al.  Postoperative pancreatic fistula: an international study group (ISGPF) definition.  Surgery 2005;138 (1) 8- 13PubMedGoogle ScholarCrossref
14.
Pratt  WBMaithel  SKVanounou  THuang  ZSCallery  MPVollmer  CM  Jr Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme.  Ann Surg 2007;245 (3) 443- 451PubMedGoogle ScholarCrossref
15.
Lin  JWCameron  JLYeo  CJRiall  TSLillemoe  KD Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula.  J Gastrointest Surg 2004;8 (8) 951- 959PubMedGoogle ScholarCrossref
16.
Brooks  ADMarcus  SGGradek  C  et al.  Decreasing length of stay after pancreaticoduodenectomy.  Arch Surg 2000;135 (7) 823- 830PubMedGoogle ScholarCrossref
17.
Suzuki  YFujino  YTanioka  Y  et al.  Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas.  Br J Surg 1999;86 (5) 608- 611PubMedGoogle ScholarCrossref
18.
Knaebel  HPDiener  MKWente  MNBuchler  MWSeiler  CM Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy.  Br J Surg 2005;92 (5) 539- 546PubMedGoogle ScholarCrossref
19.
Pratt  WMaithel  SKVanounou  TCallery  MPVollmer  CM  Jr Postoperative pancreatic fistulas are not equivalent after proximal, distal, and central pancreatectomy.  J Gastrointest Surg 2006;10 (9) 1264- 1279PubMedGoogle ScholarCrossref
20.
Bassi  CButturini  GMolinari  E  et al.  Pancreatic fistula rate after pancreatic resection: the importance of definitions.  Dig Surg 2004;21 (1) 54- 59PubMedGoogle ScholarCrossref
21.
Bilimoria  MMCormier  JNMun  YLee  JEEvans  DBPisters  PW Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation.  Br J Surg 2003;90 (2) 190- 196PubMedGoogle ScholarCrossref
22.
Pannegeon  VPessaux  PSauvanet  AVullierme  MPKianmanesh  RBelghiti  J Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment.  Arch Surg 2006;141 (11) 1071- 1076PubMedGoogle ScholarCrossref
23.
Sledzianowski  JFDuffas  JPMuscari  FSuc  BFourtanier  F Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy.  Surgery 2005;137 (2) 180- 185PubMedGoogle ScholarCrossref
24.
Li-Ling  JIrving  M Somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized trials.  Br J Surg 2001;88 (2) 190- 199PubMedGoogle ScholarCrossref
25.
Sheehan  MKBeck  KCreech  SPickleman  JAranha  GV Distal pancreatectomy: does the method of closure influence fistula formation?  Am Surg 2002;68 (3) 264- 267PubMedGoogle Scholar
26.
Takeuchi  KTsuzuki  YAndo  T  et al.  Distal pancreatectomy: is staple closure beneficial?  ANZ J Surg 2003;73 (11) 922- 925PubMedGoogle ScholarCrossref
27.
Ohwada  SOgawa  TTanahashi  Y  et al.  Fibrin glue sandwich prevents pancreatic fistula following distal pancreatectomy.  World J Surg 1998;22 (5) 494- 498PubMedGoogle ScholarCrossref
28.
Suc  BMsika  SFingerhut  A  et al. French Associations for Surgical Research, Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial.  Ann Surg 2003;237 (1) 57- 65PubMedGoogle ScholarCrossref
29.
Sugo  HMikami  YMatsumoto  FTsumura  HWatanabe  YFutagawa  S Distal pancreatectomy using the harmonic scalpel.  Surgery 2000;128 (3) 490- 491PubMedGoogle ScholarCrossref
30.
Shoup  MBrennan  MF McWhite  KLeung  DHKlimstra  DConlon  KC The value of splenic preservation with distal pancreatectomy.  Arch Surg 2002;137 (2) 164- 168PubMedGoogle ScholarCrossref
31.
Aldridge  MCWilliamson  RCN Distal pancreatectomy with and without splenectomy.  Br J Surg 1991;78 (8) 976- 979PubMedGoogle ScholarCrossref
32.
Benoist  SDugué  LSauvanet  A  et al.  Is there a role of preservation of the spleen in distal pancreatectomy?  J Am Coll Surg 1999;188 (3) 255- 260PubMedGoogle ScholarCrossref
Original Article
October 20, 2008

Critical Appraisal of 232 Consecutive Distal Pancreatectomies With Emphasis on Risk Factors, Outcome, and Management of the Postoperative Pancreatic Fistula: A 21-Year Experience at a Single Institution

Author Affiliations

Author Affiliations: Department of Surgery, Singapore General Hospital (Drs Goh, Tan, Chung, Ong, Chan, Chow, Soo, Wong, and Ooi), Department of Surgical Oncology, National Cancer Centre (Drs Tan, Chung, Cheow, Ong, Chan, Chow, Soo, Wong, and Ooi), and Duke-National University of Singapore Graduate Medical School (Drs Chow, Soo, and Ooi), Singapore.

Arch Surg. 2008;143(10):956-965. doi:10.1001/archsurg.143.10.956
Abstract

Objective  To critically analyze a large single-institution experience with distal pancreatectomy (DP), with particular attention to the risk factors, outcome, and management of the postoperative pancreatic fistula (PF).

Design  Retrospective study.

Setting  Tertiary referral center.

Patients  A total of 232 consecutive patients with pancreatic or extrapancreatic disease necessitating DP over 21 years.

Interventions  Twenty-one patients underwent spleen-preserving DP, 117 underwent DP with splenectomy, and 94 underwent DP with multiorgan resection.

Main Outcome Measures  The perioperative and postoperative data of patients who underwent DP were analyzed. This included factors associated with postoperative morbidity with particular attention to the PF (defined by the International Study Group of Pancreatic Fistula) and changing trends in operative and perioperative data during the study period.

Results  The overall operative morbidity and mortality were 47% (107 patients) and 3% (7 patients), respectively. During the study period, the rates of resection increased from 3 cases to 23 per year, and increasingly these were performed for smaller and incidental lesions. The morbidity rate remained unchanged, but there was a decline in postoperative stay and the need for care in the intensive care unit. Pancreatic fistulas occurred in 72 patients (31%); 41 (18%) were grade A, 13 (6%) grade B, and 18 (8%) grade C. Increased weight, higher American Society of Anesthesiologists score, blood loss greater than 1 L, increased operation time, decreased albumin level, and sutured closure of the stump without main duct ligation were associated with a postoperative PF on univariate analysis. A DP with splenectomy was associated with a higher incidence of grade B or C PF and non–PF-related complications. Ninety-two percent of PFs were successfully managed nonoperatively. Clinical outcomes correlated well with PF grading, as evidenced by the progressive increase in outcome measures such as postoperative stay, readmissions, reoperations, radiologic interventions, and non–PF-related complications from grade A to C PFs.

Conclusions  Pancreatic fistula is the most common complication after DP and its incidence varies depending on the definition applied. Several risk factors for developing a PF were identified. Splenic preservation after DP is safe. The grade of a PF correlates well with clinical outcomes, and most PFs may be managed nonoperatively.

×