title: Implications and management of pancreatic fistulas following pancreaticoduodenectomy: the Massachusetts General Hospital experience.
abstract: OBJECTIVE
  To describe the management and impact of pancreatic fistulas in a high-volume center.
  
  
  METHODS
  Retrospective case series.
  
  
  METHODS
  Tertiary academic center.
  
  
  METHODS
  Five hundred eighty-one consecutive patients who underwent pancreaticoduodenectomy from January 2001 through June 2006.
  
  
  METHODS
  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 withdrawal 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 1 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.
authors.affiliation: Department of Surgery, Massachusetts General Hospital, 15 Parkman St, Wang Ambulatory Care Center 460, Boston, MA 02114, USA.
authors.forename: Gregory
authors.initials: G
authors.lastname: Veillette
authors.forename: Ismael
authors.initials: I
authors.lastname: Dominguez
authors.forename: Cristina
authors.initials: C
authors.lastname: Ferrone
authors.forename: Sarah P
authors.initials: SP
authors.lastname: Thayer
authors.forename: Deborah
authors.initials: D
authors.lastname: McGrath
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Warshaw
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernández-del Castillo
mesh_terms: D000368:Aged; D015331:Cohort Studies; D004322:Drainage; D005260:Female; D017052:Hospital Mortality; D006769:Hospitals, General; D006801:Humans; D007902:Length of Stay; D008297:Male; D008404:Massachusetts; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000209:etiology* / Q000401:mortality / Q000628:therapy*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D010288:Parenteral Nutrition; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome