Annals of Surgical Oncology | 2021
Mitigation of the Postoperative Pancreatic Fistula After Pancreatoduodenectomy: Can We do Something Better?
Abstract
Dear Editor, We read with great interest the article by van Buren and Vollmer entitled ‘The Landmark Series: Mitigation of the Postoperative Pancreatic Fistula’. The authors have reported in detail the landmark literature contributions driving the perioperative management of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) and distal pancreatectomy. The landmark analysis performed by the authors included the following five components of the fistula mitigation strategy: risk factors for POPF, surgical technique, intraperitoneal drain placement (and early removal), octreotide/somatostatin analogs, and pancreatic stents. Unfortunately, a sixth very important component of the fistula mitigation strategy was inexplicably omitted by the authors: POPF management to mitigate the evolution to clinically relevant POPF (CRPOPF) and POPF-related mortality. The actual choice is between the ‘standard’ treatment, performed by almost 90% of centers, and some modality of ‘draining-tract-targeted’ management. The ‘standard’ treatment relies on maintaining drains in situ, or slowly removing them, with drain fluid amylase (DFA) multiple measurements until resolution. Any further treatment is started only after a computed tomography (CT) documented, possibly infected, fluid collection is found. Non-surgical options (percutaneous and/or endoscopic and/ or endovascular treatment) are the first choice whenever possible, followed by surgical treatment in the event of failure. In a recent literature review of PDs performed between 1990 and 2018 by centers performing at least 10 PDs/year and reporting more than 100 PDs, the POPFrelated mortality rate stayed almost unchanged during the entire period, with a little but significant increase (from around 1–1.2%) during the last 3 years of the study. Therefore, it is difficult to consider POPF ‘standard’ treatment as a candidate to be included among the mitigation strategies. The ‘draining-tract-targeted’ management of POPF is started earlier than the ‘standard’ treatment, usually around the seventh postoperative day, and uses the drain tract to study the shape of the fistula by fistulography and to drain it adequately. According to Faccioli et al. 3 and Tomimaru et al., the mean healing time of a PF after PD can be predicted according to fistulography imaging. This information could be very important both for in-hospital POPF management and for discharging the patient at home with the drain still in place to prevent unexpected complications. Although ‘draining-tract-targeted’ management was performed in three different ways 5–7 by the authors of the study, a significant improvement was found, according to the pooled analysis, in grade C POPFs, the POPF-related mortality rate, reoperations, and completion pancreatectomies when compared with the ‘standard’ treatment. A significant improvement in completion pancreatectomies was also found with meta-analysis. Furthermore, the use of ‘draining-tract-targeted’ management of POPFs does not Sergio Pedrazzoli: Retired, former full Professor of Surgery of the University of Padua.