5 Things You Should Know About Complications After Pancreatectomy

According to the International Study Group of Pancreatic Surgery (ISGPS), there are 4 main complications that should be taken into account whenever pancreatic surgery is performed.

1) Postoperative pancreatic fistula (POPF)

Definition: exit through drainage of any volume of measurable liquid with an amylase level > 3 times the upper limit of normal serum amylase, associated or not with relevant clinical repercussion directly related to POPF.

Incidence: 10-15% in pancreatoduodenectomy, 10-30% in distal pancreatectomy and 30% in tumor enucleation.

Classification according to its severity: · Biochemical leak (formerly “Grade A”): by definition, it has no clinical relevance. · Grade B: it comes with clinical repercussion but without organ failure. · Grade C: characterized by one of these three scenarios: a need for reoperation, the presence of one or multiple organ failure and/or mortality attributable to the PF.

2) Bile leakage (BL)

Definition: bilirubin concentration in the drain fluid at least 3 times the serum bilirubin concentration on or after postoperative day 3, or as the need for radiological intervention or surgical reintervention as a result of biliary collections or biliary peritonitis.

Classification according to its impact on patients’ clinical management: Grade A: it has little or no impact on patients' clinical management. Grade B: it requires active therapeutic intervention but is manageable without relaparotomy. Grade C: those cases in which relaparotomy is required.

BL has an incidence of 0.8-4% of all hepaticojejunostomies performed in the context of pancreatoduodenectomy. In most cases they are clinically well tolerated and have good prognosis with conservative management and drainage.

The initial management usually consists of interventional radiology, by stent dilation or placement. Another option when the previous ones fail is re-hepaticojejunostomy.

3) Postpancreatectomy hemorrhage (PPH)

It is one of the most serious and feared complications in pancreatic surgery because it is potentially the most lethal one, especially if not diagnosed and treated immediately. According to the ISGPS 2007 consensus, it can be defined by 3 parameters: · Onset: early (≤24h after the end of the index operation) or late (>24h). · Location: intraluminal or extraluminal. · Severity: mild (Hb loss of <3 g/dL and without clinical repercussions) or severe (Hb loss of ≥3 mg/dL and/or clinical repercussion). Classification:

GradeOnsetLocationSeverityAEarlyIntra/extraluminalMildB1EarlyIntra/extraluminalSevereB2LateIntra/extraluminalMildCLateIntra/extraluminalSevere

An abdominal CT scan with arterial contrast should be performed immediately once hemorrhage is suspected.

Usually, early postpancreatectomy hemorrhage is the result of inadequate intraoperative hemostasis, so it typically needs immediate reintervention. On the other hand, late postpancreatectomy hemorrhage usually comes from a pseudoaneurysm rupture, originated from an inflammatory process (i.e. POPF, intestinal ulceration…). Treatment is performed with endovascular coil embolization or covered stent placement.

4) Delayed gastric emptying (DGE)

Definition: functional gastroparesis without any mechanical obstruction. It is the most common complication after pancreatic surgery. Its definition and severity is based in these features: · Permanence of the nasogastric tube beyond POD 4. · Inability to start oral intake from POD 7. · Presence of nausea and vomiting. · Need to use prokinetic drugs.

Classification:

DGE GradeNasogastric tube requiredDays of oral intoleranceVomiting/gastric distensionUse of prokineticsA4-7 days or reinsertion > POD 37+/-+/-B8-14 days or reinsertion > POD 714++C>14 days or reinsertion > POD 1421++

DGE clinical management: · Total parenteral nutrition if the patient is expected to remain ≥7 days without oral intake. · Keep the nasogastric tube in intermittent aspiration. · Prokinetic drugs:     · Metoclopramide IV 10 mg every 8 hours.     · Erythromycin IV 250 mg every 6 hours.     · Domperidone PO 10 mg every 8 hours before meals.