Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy.
BACKGROUND
Pancreatic fistula (PF), which is a major complication of pancreaticoduodenectomy (PD), can be treated conservatively or by reoperation. The aim of this study was to evaluate conservative management of PF, which was attempted whenever possible as a first-intention treatment in a large series of PD.


METHODS
From 1990 to 2000, 242 patients underwent PD with pancreaticogastrostomy. PF was observed in 31 (13%) and was defined by an amylase-rich surgical drainage fluid (above fivefold serum amylase) after postoperative day 5, or by presence on CT scan of a fluid collection located close to the anastomosis or containing amylase-rich fluid, or by operative findings in case of reoperation. Conservative management included total parenteral nutrition, nasogastric suction, imaging-guided percutaneous drainage of collection when necessary, and somatostatin or its analogues.


RESULTS
PF was symptomatic in 20 patients (65%). Amylase level on surgical drainage fluid was elevated in 23 patients (74%). Four patients (13%), including two with hemorrhage and two with intraabdominal collection not accessible by percutaneous approach, were not considered for conservative management and underwent early reoperation. Conservative management was successful in the 27 patients (100%) in whom it was attempted, including the 10 who required percutaneous drainage. The only death (3%) occurred after massive hemorrhage complicating misdiagnosed PF. Mean hospital stay was 36 +/- 12 days (range 18 to 71) after successful conservative management.


CONCLUSIONS
Conservative management of PF complicating PD is feasible and successful in above 85% of patients.
Department of Digestive Surgery, Hopital Beaujon, AP-HP, University Paris VII, Clichy, France.
Nicolas
N
Munoz-Bongrand
Alain
A
Sauvanet
Alban
A
Denys
Annie
A
Sibert
Valérie
V
Vilgrain
Jacques
J
Belghiti
D000681:Amylases / Q000032:analysis; D005774:Gastrostomy; D006470:Hemorrhage / Q000150:complications; D006801:Humans; D007902:Length of Stay; D010179:Pancreas / Q000601:surgery*; D010185:Pancreatic Fistula / Q000209:etiology / Q000628:therapy*; D016577:Pancreaticoduodenectomy; D010288:Parenteral Nutrition; D012086:Reoperation; D013004:Somatostatin / Q000627:therapeutic use; D013396:Suction
D013004:Somatostatin; D000681:Amylases