[Pancreatic fistula after pancreaticoduodenectomy: risk factors and treatment].
OBJECTIVE
Operative mortality rates after pancreaticoduodenectomy (PD) have decreased dramatically over the past 3 decades and recent series have reported no mortality. Nevertheless pancreatic leakage remains the major cause of morbidity with incidences varying between 6-16%. The aim of the study is to analyze the main etiopatogenetic factors and the treatment of this complication in the literature and, retrospectively, in own experience.


METHODS
At the Clinical Surgery of the University of Genoa, from 1991 to 1995, and then at the General Surgery Department of the Hospitals of Bordighera and Imperia, between 1995 and 2003, 30 PD were completed; there were 20 males (66.6%) and 10 females (33.3%), the average age being 64.6 years (range 50-81). Indications for surgery were pancreatic head adenocarcinoma (70%), ampullary adenocarcinoma (16.6%), duodenal adenocarcinoma (6.6%) and chronic pancreatitis (6.6%).The personal method of reconstruction after PD consisting of a double Roux-en-Y on the same jejunal loop without interruption of the mesentery and a third anatomical Roux-en-Y to reconstitute the alimentary tract. The gastric stump was anastomosed with the jejunum as a Billroth II-type reconstruction in older patients.


RESULTS
The mean hospital stay was 15 days (range 10-40), the operative time 397 min (range 295-500) and transfusion of red blood cells 0.2 (range 0-3). The incidence of perioperative mortality was 0; pancreaticojejunostomy leakage occurred in 3 patients (10%); one of this died 48 days after surgery for bleeding.


CONCLUSIONS
the level of pancreatic fibrosis and diameter of main pancreatic duct are the more important risk factors for complications after PD. Nowadays pancreaticojejunostomy remains the standard technique; pancreaticogastrostomy, occlusion of the pancreatic duct and two-stage pancreaticojejunostomy must be reserved to selected cases. The majority of pancreatic fistulas are uncomplicated and heal with conservative treatment. The skills of the interventional radiology team provide expert management of these complications, speeding recovery times and minimizing morbidity. If surgical re-exploration is necessary, an early completion pancreatectomy may maximize survival.
Struttura Complessa di Chirurgia Generale, Dipartimento Chirurgico di Imperia, ASL 1 Imperiese, Imperia, Italy.
M
M
Abete
V
V
Ronchetti
A
A
Casano
G
G
Pescio
D000368:Aged; D000369:Aged, 80 and over; D000713:Anastomosis, Roux-en-Y; D004322:Drainage; D005260:Female; D005763:Gastroenterostomy; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D010182:Pancreatic Diseases / Q000601:surgery*; D010185:Pancreatic Fistula / Q000209:etiology* / Q000628:therapy; D010190:Pancreatic Neoplasms / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000209:etiology* / Q000628:therapy; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome