Implications and management of pancreatic fistulas following pancreaticoduodenectomy

Objective: To describe the management and impact of pancreatic fistulas in a high-volume center. Design: Retrospective case series. Setting: Tertiary academic center. Patients: Five hundred eighty-one consecutive patients who underwent pancreaticoduodenectomy from January 2001 through June 2006. Main Outcome Measures: Development of a pancreatic fistula (defined as > 30 mL of amylase-rich fluid from drains on or after postoperative day 7, or discharge with surgical drains in place, regardless of amount); the need for additional interventions or total parenteral nutrition; other morbidity; and mortality. Results: Seventy-five patients (12.9%) developed a pancreatic fistula. Fistulas were managed with gradual with drawal of surgical drains. This allowed for patient discharge and eventual closure at a mean of 18 days in 38.7% of cases; these were classified as low-impact fistulas. The remaining 46 patients (61.3%) had an associated abscess, required percutaneous drainage or total parenteral nutrition, or developed bleeding; these were classified as high-impact fistulas and closed a mean of 35 days after surgery. Standard 30-day in-hospital mortality was 1.9% for all pancreaticoduodenectomies and 6.7% for those who developed a pancreatic fistula. The overall fistula-related mortality was 9.3% (7 patients), all but I of which was related to major hemorrhage. Conclusions: More than one-third of pancreatic fistulas are clinically insignificant (low impact). The remaining 60% of fistulas have a high clinical impact and nearly an 8-fold increase in overall mortality.