Surgical Management of Severe Pancreatic Fistula after Pancreatoduodenectomy: Indications, Timing, and Perioperative Outcomes of Rescue Pancreatectomy

Abstract

Introduction: Rescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. In-depth literature is scarce and hard to interpret. Method: Retrospective single-center study from all consecutive patients (2008-2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity (i.e. Clavien-Dindo grade ≥IIIa) and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤11 versus >11 days). Results: From 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Postpancreatectomy hemorrhage (PPH) grade B or C occurred in 21% (11/53) and 62% (33/53). Percutaneous drainage for intra-abdominal collection, minimally invasive PPH management, and relaparotomy was performed in 66%, 30%, and 49%. Most patients developed single- (19/53, 36%) or multi- (17/53, 32%) organ failure. Rescue pancreatectomy was performed in 39 patients (74%), preceded by minimally invasive intervention(s) or relaparotomy in 21/39 (54%) and 11/39 (28%). Mortality in the overall population and after rescue pancreatectomy was 30% and 23%. Timing for rescue pancreatectomy did not change over time: 11 days (IQR 8-14) [2008-2012] versus 14 days (IQR 7-33) [2013-2016] versus 8 days (IQR 6-11) [2017-2020] (p=0.140). Mortality after early rescue pancreatectomy (3/22, 14%) was lower compared to late rescue pancreatectomy (6/17, 35%), although not significant (p=0.142). Conclusions: Rescue pancreatectomy for severe POPF is associated with high mortality, but may be more favourable in an early stage to avoid further clinical deterioration in vulnerable patients.