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Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment.

HYPOTHESIS
Predictive factors of pancreatic fistula (PF) and the value of conservative management of PF following distal pancreatectomy (DP) are poorly known.


DESIGN
Case series.


SETTING
A university hospital referral center.


PATIENTS
From 1991 to 2003, 175 patients underwent DP with routine drainage of the pancreatic stump and postoperative repeated measures in drainage fluid. Pancreatic fistula was defined as an amylase level in surgical drainage fluid more than 5-fold the serum level after postoperative day 5, or amylase-rich fluid collection. Computed tomographic scan was only done for suspicion of abdominal collection. Conservative management of PF included percutaneous drainage of abdominal collection and total parenteral nutrition or maintaining oral feeding in some patients with low-volume PF.


INTERVENTION
Conservative management of PF after DP.


MAIN OUTCOME MEASURES
Incidence of PF according to indication, concomitant splenectomy, additional procedure, texture of parenchyma, location of transection (neck vs body), and technique of stump suture (stapler vs hand sewn), including elective ligation of the main duct, transfusions, and prophylactic use of octreotide.


RESULTS
There was no mortality. Forty patients (23%) developed PF, which was symptomatic in 25 patients (63%); computed tomographic scan identified an abdominal collection in 26 (65%). Multivariate analysis identified 2 predictive factors for PF: no elective ligation of the main pancreatic duct (odds ratio, 2.2 [95% confidence interval, 1.0-4.7]) and transection at the body (odds ratio, 2.1 [95% confidence interval, 1.1-5.5]). If none or both predictive factors were present, the observed rate of PF was 16% and 63%, respectively. Pancreatic fistula was managed conservatively in 38 patients (95%), including percutaneous drainage in 16, and by reoperation in 2.


CONCLUSIONS
Pancreatic fistula following DP is more frequent in cases of pancreatic division at the body level and no elective ligation of the main duct. Routine drainage of the pancreatic stump does not prevent postoperative abdominal collections. Conservative management of PF is successful in 95% of cases.