J Gastrointest Surg (2009) 13:11871188 DOI 10.

1007/s11605-009-0867-x

SSAT/SAGES JOINT SYMPOSIUM

Defining, Controlling, and Treating a Pancreatic Fistula

David Mahvi

Received: 7 January 2009 / Accepted: 6 March 2009 / Published online: 31 March 2009 # 2009 The Society for Surgery of the Alimentary Tract

Keywords Pancreatic fistula diagnosis . Pancreatic fistula treatment

The Achilles heel of pancreatic surgery is the pancreas. After resection of the pancreatic head, the residual pancreas must be drained into the gastrointestinal tract. This connection is among the most tenuous in surgery. Hundreds if not thousands of publications have been devoted to pancreatic surgical technique based on the hope that some technical innovation will prevent this complication. To summarize this vast literature: as long as an experienced pancreatic surgeon performs the procedure, no method of anastomosis is less likely to result in a pancreatic leak than another. This review will focus on complications of pancreatoduodenectomy. The treatment of a postoperative leak or fistula after distal pancreatectomy is less of a clinical issue but can be diagnosed and treated using similar methods. The diagnosis of a leak will first be defined and then the treatment of both an acute leak and a chronic controlled fistula will be discussed. The difference between a leak and a fistula is control and chronicity. When a leak is controlled and persists, it becomes a fistula. Though leak and fistula are different aspects of the same disease process,

the treatment of an acute leak is very different than the treatment of a chronic fistula. The pancreatic anastomosis will leak 15% to 25% of the time.1 The consequences of a leak have improved over time, but the leak rate has not changed. A leak, thus, cannot be avoided and is best anticipated both by the surgeon and the patient. The failure to recognize this common complication of pancreatic resection leads to delay in treatment and the potential of a fatal outcome. Any change in the clinical course of a patient after pancreatic resection should raise the thought of a pancreatic leak. The Diagnosis of a Leak The literature is difficult to interpret without some standardized method of reporting. Two expert groups have approached the task of defining a leak. They each developed both a biochemical and a clinical definition. The general theme of both consensus statements is similar. When amylase-rich fluid is detected in a drain, it may represent a leak; but in the early postoperative period, the amylase content of a drain can vary. Sarr and coauthors recommended that in addition to amylase rich fluid (they defined amylase rich as five times the normal serum level), the drainage should occur five or more days post-resection, and the drain volume should be greater than 30 cm3/day.1 Three years later, a second group (the International Study Group for Pancreatic Fistula (ISGPF)) suggested a slightly different definition of leak.2 The ISGPF included many members of the first group including Dr. Sarr. The definition of a leak was liberalized by the second group. Their rationale was that the stringent definitions proposed by the original group missed some clinically relevant leaks. The concentration of amylase in the fluid was changed from five- to threefold greater than the serum level. The requirement for 30 cm3/day was omitted, and the timing was altered to 3 days post-resection rather than 5 days. These efforts resulted in a clinically meaningful method to compare complication rates after pancreatic resection.

This paper was originally presented as part of the SSAT/SAGES Joint Symposium entitled, The Gastrointestinal Anastomosis: Evidence vs. Tradition; The Pancreatic Anastomosis: The Danger of a Leak, at the SSAT 49th Annual Meeting, May 2008, in San Diego, CA, USA. The other articles presented in this symposium were Adams DB, Which Anastomotic Technique is Better? and Schulick RD, Stents, Glue, Etc.: Is Anything Proven to Help Prevent Leaks/Fistulae? D. Mahvi (*) Feinberg School of Medicine, Northwestern University, Chicago, IL, USA e-mail: dmahvi@nmh.org

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The impact of a biochemical leak on an individual patient varies and has no relationship to the biochemical parameters which define a leak. Clinical classification systems have been validated that stratify patients into groups based on the systemic impact of the leak and the need for further therapy.3,4 A grade 1 leak had no clinical sequel. A grade 2 leak necessitated percutaneous drain placement for intra-abdominal abscess, resulted in delayed gastric emptying, or required hospital readmission. A grade 3 leak required reoperation or resulted in death. The Sarr classification system and the ISGPF classification system were equally good at detecting grade 3 leaks. The ISGPF criteria demonstrated a higher total leak rate than the Sarr criteria (27% vs. 14%), but the majority of the leaks noted with the less stringent ISGPF system were grade 1. As a means to contrast disparate reports, the ISGPF definitions will detect more leaks but miss very few clinically relevant leaks and, thus, has become the standard. The Treatment of a Leak The treatment of a leak is dependent on the clinical grade and thus the systemic impact of the leak. A grade 1 leak requires no treatment. The patient with a grade 1 leak should be offered a normal diet and discharged with the drain in place. Octreotide has no role in the patient with a grade 1 leak. A grade 3 leak is rare (9% of leaks) and requires urgent control of sepsis in a desperately ill patient. The treatment of a grade 2 leak is the art rather than the science of pancreatic surgery. This is a rare event with a variable presentation and no real data comparing treatments. The key elements of therapy are aggressive drainage of intra-abdominal fluid collections and adequate nutritional support. The Treatment of a Fistula A subset of patients with a leak will ultimately develop a chronic fistula. There is broad consensus that early operative intervention results in poor outcome in patients with fistula. Most of these fistulas will close spontaneously with observation alone, but at some point, there is little hope that a fistula will close. Precisely when a chronic fistula will not resolve is unknown. We have not noted healing of a fistula that persists for more than 2 months after the resolution of sepsis despite gravity (rather than suction) drainage. A fistulogram with water soluble contrast will both secure the diagnosis and confirm that an enteric (non-pancreatic) fistula is not present. A leak persists because the resistance to flow in the fistula is less than the resistance to flow in the pancreaticenteric anastomosis. Treatment has focused on methods to decrease flow (such as octreotide), increase resistance (drain removal or fibrin glue), or convert the fistula tract to an enteric anastomosis. Several groups have evaluated octreotide to treat fistula after pancreatoduodenectomy. The key endpoint in these studies was resolution of the fistula. The general

consensus was that a decrease in fistula output with octreotide had no impact on fistula resolution. We do not use octreotide in the treatment of pancreatic leaks or fistulas. Methods to increase resistance in the fistula tract, in contrast, have been successful (though in small series). Over time, the resistance to flow will increase in the fistula. The removal (or advancement out) of a long-standing drain increases the resistance in the fistula tract both by removal of the stenting effect of the drain and by the fibrosis of the drain tract. We have removed long standing drains in four patients without subsequent cutaneous fistula formation. Fibrin glue injected into the fistula tract after drain removal has also resulted in fistula resolution, especially in the patient group with low output fistulas.5 Late operative intervention has also been successful in a small selected series.6 In this report, a Roux limb of jejunum was anastomosed to the fibrotic fistula tract. This resulted in resolution of the fistula in all the treated patients. Summary Pancreatic leak after pancreatoduodenectomy occurs in 1425 % of cases. The current grading systems for both biochemical and clinical leak effectively identify significant leaks and allow comparison between clinical studies. When a chronic fistula develops, observation is the initial treatment in all patients and fails in only a small subset. Octreotide does not aid in the resolution of a fistula. The options for treatment of a persistent chronic fistula include removal of the drain and injection of the fistula tract with fibrin glue or fistula tractenteric anastomosis. All of these options have resulted in fistula closure in the majority of patients.

References
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