7/31/2019 Fistula Definition

1/2

SSAT/SAGES JOINT SYMPOSIUM

Defining, Controlling, and Treating a Pancreatic Fistula

David Mahvi

Received: 7 January 2009 /Accepted: 6 March 2009 /Published online: 31 March 2009# 2009 The Society for Surgery of the Alimentary Tract

Keywords Pancreatic fistula diagnosis .

Pancreatic fistula treatment

The Achilles heel of pancreatic surgery is the pancreas.

After resection of the pancreatic head, the residual pancreas

must be drained into the gastrointestinal tract. This

connection is among the most tenuous in surgery. Hundreds

if not thousands of publications have been devoted to

pancreatic surgical technique based on the hope that some

technical innovation will prevent this complication. To

summarize this vast literature: as long as an experienced

pancreatic surgeon performs the procedure, no method of

anastomosis is less likely to result in a pancreatic leak than

another. This review will focus on complications ofpancreatoduodenectomy. The treatment of a postoperative

leak or fistula after distal pancreatectomy is less of a

clinical issue but can be diagnosed and treated using similar

methods. The diagnosis of a leak will first be defined and

then the treatment of both an acute leak and a chronic

controlled fistula will be discussed. The difference between

a leak and a fistula is control and chronicity. When a leak is

controlled and persists, it becomes a fistula. Though leak

and fistula are different aspects of the same disease process,

the treatment of an acute leak is very different than the

treatment of a chronic fistula.

The pancreatic anastomosis will leak 15% to 25% of thetime.1 The consequences of a leak have improved over

time, but the leak rate has not changed. A leak, thus, cannot

be avoided and is best anticipated both by the surgeon and

the patient. The failure to recognize this common compli-

cation of pancreatic resection leads to delay in treatment

and the potential of a fatal outcome. Any change in the

clinical course of a patient after pancreatic resection should

raise the thought of a pancreatic leak.

The Diagnosis of a Leak The literature is difficult to interpret

without some standardized method of reporting. Two expert

groups have approached the task of defining a leak. They eachdeveloped both a biochemical and a clinical definition. The

general theme of both consensus statements is similar. When

amylase-rich fluid is detected in a drain, it may represent a

leak; but in the early postoperative period, the amylase content

of a drain can vary. Sarr and coauthors recommended that in

addition to amylase rich fluid (they defined amylase rich as

five times the normal serum level), the drainage should occur

five or more days post-resection, and the drain volume should

be greater than 30 cm3/day.1 Three years later, a second group

(the International Study Group for Pancreatic Fistula

(ISGPF)) suggested a slightly different definition of leak.2

The ISGPF included many members of the first group

including Dr. Sarr. The definition of a leak was liberalized by

the second group. Their rationale was that the stringent

definitions proposed by the original group missed some

clinically relevant leaks. The concentration of amylase in the

fluid was changed from five- to threefold greater than the

serum level. The requirement for 30 cm3/day was omitted, and

the timing was altered to 3 days post-resection rather than

5 days. These efforts resulted in a clinically meaningful method

to compare complication rates after pancreatic resection.

J Gastrointest Surg (2009) 13:11871188

DOI 10.1007/s11605-009-0867-x

This paper was originally presented as part of the SSAT/SAGES Joint

Symposium entitled, The Gastrointestinal Anastomosis: Evidence vs.

Tradition; The Pancreatic Anastomosis: The Danger of a Leak, at the

SSAT 49th Annual Meeting, May 2008, in San Diego, CA, USA. The

other articles presented in this symposium were Adams DB, Which

Anastomotic Technique is Better? and Schulick RD, Stents, Glue,

Etc.: Is Anything Proven to Help Prevent Leaks/Fistulae?

D. Mahvi (*)

Feinberg School of Medicine, Northwestern University,

Chicago, IL, USA

e-mail: dmahvi@nmh.org

7/31/2019 Fistula Definition

2/2

The impact of a biochemical leak on an individual

patient varies and has no relationship to the biochemical

parameters which define a leak. Clinical classification

systems have been validated that stratify patients into

groups based on the systemic impact of the leak and the

need for further therapy.3,4 A grade 1 leak had no clinical

sequel. A grade 2 leak necessitated percutaneous drain

placement for intra-abdominal abscess, resulted in delayed

gastric emptying, or required hospital readmission. A grade

3 leak required reoperation or resulted in death. The Sarr

classification system and the ISGPF classification system

were equally good at detecting grade 3 leaks. The ISGPF

criteria demonstrated a higher total leak rate than the Sarr

criteria (27% vs. 14%), but the majority of the leaks noted

with the less stringent ISGPF system were grade 1. As a

means to contrast disparate reports, the ISGPF definitions

will detect more leaks but miss very few clinically relevant

leaks and, thus, has become the standard.

The Treatment of a Leak The treatment of a leak is

dependent on the clinical grade and thus the systemic

impact of the leak. A grade 1 leak requires no treatment.

The patient with a grade 1 leak should be offered a normal

diet and discharged with the drain in place. Octreotide has

no role in the patient with a grade 1 leak. A grade 3 leak is

rare (9% of leaks) and requires urgent control of sepsis in a

desperately ill patient. The treatment of a grade 2 leak is the

art rather than the science of pancreatic surgery. This is a

rare event with a variable presentation and no real data

comparing treatments. The key elements of therapy are

aggressive drainage of intra-abdominal fluid collections and

adequate nutritional support.

The Treatment of a Fistula A subset of patients with a leak

will ultimately develop a chronic fistula. There is broad

consensus that early operative intervention results in poor

outcome in patients with fistula. Most of these fistulas will

close spontaneously with observation alone, but at some

point, there is little hope that a fistula will close. Precisely

when a chronic fistula will not resolve is unknown. We

have not noted healing of a fistula that persists for more

than 2 months after the resolution of sepsis despite gravity

(rather than suction) drainage. A fistulogram with water

soluble contrast will both secure the diagnosis and confirm

that an enteric (non-pancreatic) fistula is not present.

A leak persists because the resistance to flow in the fistula

is less than the resistance to flow in the pancreaticenteric

anastomosis. Treatment has focused on methods to decrease

flow (such as octreotide), increase resistance (drain removal or

fibrin glue), or convert the fistula tract to an enteric

anastomosis. Several groups have evaluated octreotide to treat

fistula after pancreatoduodenectomy. The key endpoint in

these studies was resolution of the fistula. The general

consensus was that a decrease in fistula output with octreotide

had no impact on fistula resolution. We do not use octreotide

in the treatment of pancreatic leaks or fistulas.

Methods to increase resistance in the fistula tract, in

contrast, have been successful (though in small series).

Over time, the resistance to flow will increase in the fistula.

The removal (or advancement out) of a long-standing drain

increases the resistance in the fistula tract both by removal

of the stenting effect of the drain and by the fibrosis of the

drain tract. We have removed long standing drains in four

patients without subsequent cutaneous fistula formation.

Fibrin glue injected into the fistula tract after drain removal

has also resulted in fistula resolution, especially in the

patient group with low output fistulas.5

Late operative intervention has also been successful in a

small selected series.6

In this report, a Roux limb of jejunum

was anastomosed to the fibrotic fistula tract. This resulted in

resolution of the fistula in all the treated patients.

Summary Pancreatic leak after pancreatoduodenectomy

occurs in 1425 % of cases. The current grading systems for

both biochemical and clinical leak effectively identify signif-

icant leaks and allow comparison between clinical studies.

When a chronic fistula develops, observation is the initial

treatment in all patients and fails in only a small subset.

Octreotide does not aid in the resolution of a fistula. The

options for treatment of a persistent chronic fistula include

removal of the drain and injection of the fistula tract with fibrin

glue or fistula tractenteric anastomosis. All of these options

have resulted in fistula closure in the majority of patients.

References

1. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic

fistula: an international study group (ISGPF) definition. Surgery

2005;138:813. doi:10.1016/j.surg.2005.05.001.

2. Reid-Lombardo KM, Farnell MB, Crippa S, Barnett M, Maupin G,

Bassi C, Traverso LW. Pancreatic anastomotic leak study group,

Pancreatic anastomotic leakage after pancreaticoduodenectomy in

1,507 patients: a report from the pancreatic anastomotic leak study

group. J Gastrointest Surg 2007;11(11):14511458. doi:10.1007/

s11605-007-0270-4.

3. DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron

JL, Yeo CJ, Clavien PA. Assessment of complications after pancreaticsurgery: A novel grading system applied to 633 patients undergoing

pancreaticoduodenectomy. Ann Surg 2006;244(6):931937.

4. Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer

CM Jr. Clinical and economic validation of the International Study

Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg

2007;245:443451. doi:10.1097/01.sla.0000251708.70219.d2 .

5. Cothren CC, McIntyre RC Jr, Johnson S, Stiegmann GV. Management

of low-output pancreatic fistulas with fibrin glue. Am J Surg 2004;188

(1):8991. doi:10.1016/j.amjsurg.2003.10.027 .

6. Nair RR, Lowy AM, McIntyre B, Sussman JJ, Matthews JB, Syed

AA. Fistulojejunostomy for the management of refractory pancre-

atic fistula. Surgery 142:636642. doi:10.1016/j.surg.2007.07.019.

1188 J Gastrointest Surg (2009) 13:11871188

http://dx.doi.org/10.1016/j.surg.2005.05.001http://dx.doi.org/10.1007/s11605-007-0270-4http://dx.doi.org/10.1007/s11605-007-0270-4http://dx.doi.org/10.1097/01.sla.0000251708.70219.d2http://dx.doi.org/10.1097/01.sla.0000251708.70219.d2http://dx.doi.org/10.1016/j.amjsurg.2003.10.027http://dx.doi.org/10.1016/j.amjsurg.2003.10.027http://dx.doi.org/10.1016/j.surg.2007.07.019http://dx.doi.org/10.1016/j.surg.2007.07.019http://dx.doi.org/10.1016/j.amjsurg.2003.10.027http://dx.doi.org/10.1097/01.sla.0000251708.70219.d2http://dx.doi.org/10.1007/s11605-007-0270-4http://dx.doi.org/10.1007/s11605-007-0270-4http://dx.doi.org/10.1016/j.surg.2005.05.001