Strategies for Prevention and Treatment of Pancreatic Fistula

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.