Pancreatic fistula following pancreaticoduodenectomy : risk assessment and early diagnosis

Pancreaticoduodenectomy (PD), a complex surgical procedure for resecting tumors of the pancreatic head, distal bile duct or periampullary region, is associated with a considerable morbidity. Postoperative pancreatic fistula (POPF), the main contributor, is caused by leakage from the pancreatico-enteric anastomosis and ranges from 15 to 26%. If not controlled promptly, POPF may lead to a complex postoperative course with septic or hemorrhagic complications, organ failure and increased mortality. Although multiple approaches to decrease POPF rates have been reported, an effective preventive strategy has not been found. The aims of this thesis were to study the contributing factors and early diagnostic markers of clinically relevant POPF, and to formulate predictive models that may facilitate clinical management of patients undergoing PD. In study I, a prospective observational cohort study on 48 non-consecutive PD patients 2007-10, local metabolite changes and protease activation in the proximity of the pancreaticojejunostomy (PJ) were measured by microdialysis to investigate the pathophysiology of POPF. In patients subsequently developing POPF, high glycerol and lactate/pyruvate (LP) ratio levels, low glucose concentrations and presence of trypsinogen activation peptides were observed before any POPF symptoms appeared. The fact that glycerol level peaks preceded the elevations in LP ratios suggested that the early glycerol release in POPF patients was not initiated by local ischemia. In study II, a prospective observational cohort study on 110 non-consecutive PD patients 2008-10, the predictive impact of a standardized intraoperative assessment of pancreatic consistency (PC) and pancreatic duct diameter (PDD) on the development of POPF was investigated. Combining both characteristics in a composite classification, the risk for POPF or fluid collections could be stratified as ‘high’ (softer PC and smaller PDD, incidence of associated morbidity 51%), ‘intermediate’ (softer PC or smaller PDD, 26%) or ‘low’ (no risk ...