Fistula Definition
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7/31/2019 Fistula Definition
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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: [email protected]
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7/31/2019 Fistula Definition
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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
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1188 J Gastrointest Surg (2009) 13:11871188
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