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Strategies for Prevention and Treatment of Pancreatic Fistula

Published on Jan 1, 2018
· DOI :10.1007/978-3-319-62624-6_10
Priya M. Puri3
Estimated H-index: 3
(UPenn: University of Pennsylvania),
Charles M. Vollmer40
Estimated H-index: 40
(UPenn: University of Pennsylvania)
Abstract
Postoperative pancreatic fistula (POPF) is the most common complication after major pancreatic resections and is the greatest contributor to postoperative morbidity and mortality following pancreatoduodenectomy (PD). The relatively recent establishment of a standardized definition of POPF by the International Study Group of Pancreatic Fistula (ISGPF) allowed for the delineation between innocuous biochemical POPF (grade A) and clinically relevant (CR) POPF (grades B and C). This classification system subsequently enabled the identification of distinct risk factors for CR-POPF, which further led to the development of the Fistula Risk Score (FRS) – a widely validated system for the prediction of CR-POPF after PD. This system assigns quantitative values to four risk factors – soft gland texture, high-risk pathology, small duct diameter, and elevated intraoperative blood loss – which can be further segregated into four discrete risk zones. Importantly, the FRS allows for the evaluation of fistula mitigation and management strategies in a risk-adjusted setting. Prevention and early detection of CR-POPF is vital to reducing morbidity and enhancing outcomes. Accordingly, our philosophy to pancreatic fistula is “prevention as management,” in order to alleviate the occurrence and severity of CR-POPF. Important perioperative prevention and mitigation strategies include technical factors (including the type of reconstruction and anastomosis), as well as the selective utilization of both transanastomotic stents and intraperitoneal external drains, and the elimination of somatostatin analog use. Furthermore, the importance of a risk-stratified strategic method has significant merit as results of recent risk-adjusted studies justify a tailored approach to identify the optimal strategies for fistula risk mitigation in any given scenario.
  • References (118)
  • Citations (0)
References118
Newest
#1Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 12
#2Matthew T. McMillanH-Index: 17
Last. Charles M. VollmerH-Index: 40
view all 38 authors...
Objective:The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.Background:The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circ
14 CitationsSource
#1Matthew T. McMillanH-Index: 17
#2Giuseppe MalleoH-Index: 29
Last. Charles M. VollmerH-Index: 40
view all 13 authors...
Objective:This multicenter study sought to prospectively evaluate a drain management protocol for pancreatoduodenectomy (PD).Background:Recent evidence suggests value for both selective drain placement and early drain removal for PD. Both strategies have been associated with reduced rates of clinica
54 CitationsSource
#1Shailesh V. Shrikhande (ACTREC: Tata Memorial Hospital)H-Index: 30
#2Masillamany Sivasanker (ACTREC: Tata Memorial Hospital)H-Index: 2
Last. Markus W. Büchler (Heidelberg University)H-Index: 127
view all 29 authors...
Background Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreati...
38 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
Last. Charles M. VollmerH-Index: 40
view all 35 authors...
Objective:This multicenter study sought to evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) surgical risk calculator for predicting outcomes after pancreatoduodenectomy (PD) and to determine whether incorporating other factors impr
30 CitationsSource
#1Claudio BassiH-Index: 80
Last. Markus W. Büchler (Heidelberg University)H-Index: 127
view all 33 authors...
Background In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of th...
421 CitationsSource
#1Daniel E. Abbott (UW: University of Wisconsin-Madison)H-Index: 27
#2Ching-Wei David Tzeng (University of Texas MD Anderson Cancer Center)H-Index: 19
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 11 authors...
Abstract Background As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins. Methods A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analy...
3 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 12
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 12 authors...
Background Evidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted.
10 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2John D. Christein (UA: University of Alabama)H-Index: 29
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 12 authors...
Background Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden. Methods From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards...
32 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
Last. Stephen W. Behrman (UTHSC: University of Tennessee Health Science Center)H-Index: 28
view all 29 authors...
Introduction International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas (POPF) are the greatest contributor to major morbidity and mortality following pancreatoduodenectomy (PD); however, their infrequent occurrence has hindered deeper analysis. This study sought to develop a predictive algorithm, which could facilitate effective management of this challenging complication.
41 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Giuseppe Malleo (University of Verona)H-Index: 29
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 5 authors...
Abstract Background Pancreatoduodenectomy (PD) is a technically challenging operation characterized by numerous management decisions. Objective This study was designed to test the hypothesis that there is significant variation in the contemporary global practice of PD. Methods A survey with native‐language translation was distributed to members of 22 international gastrointestinal surgical societies. Practice patterns and surgical decision making for PD were assessed. Regions were categorized as...
31 CitationsSource
Cited By0
Newest
#1Maxwell T. Trudeau (UPenn: University of Pennsylvania)
#2Laura Maggino (UPenn: University of Pennsylvania)H-Index: 6
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 9 authors...
Abstract Background Intraoperative drain use for pancreatoduodenectomy (PD) has been practiced in an unconditional, binary manner (placement/no-placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically-relevant pancreatic fistula (CR-POPF). Study Design An extended experience with dynamic drain management was employed at a single institution for 400 consecutive PDs (2014-2019)...
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