The Landmark Series: Mitigation of the Postoperative Pancreatic Fistula
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CONTINUING EDUCATION– PANCREATIC TUMORS
The Landmark Series: Mitigation of the Postoperative Pancreatic Fistula George Van Buren II, MD1,2, and Charles M. Vollmer Jr., MD3 Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; 2Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX; 3Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 1
ABSTRACT Pancreatic fistula has been the defining complication and challenge of pancreatic surgery. Better awareness and mitigation of postoperative pancreatic fistulas has led to significant improvements in morbidity and mortality of pancreatic surgery. The definition and management of pancreatic fistulas has sequentially progressed over the last three decades; the literature ranges from retrospective, observational studies to prospective multicenter randomized controlled trials. The landmark literature contributions driving the perioperative management of pancreatic fistulas are detailed in this article.
Pancreatic fistula has been the defining complication and challenge since the inception of pancreatic surgery. The rates of postoperative complications after pancreatic resection remain high at 30 to 60%.1,2 The definition and management of pancreatic fistulas has become increasingly more standardized and data driven over the years. Surgeons have matured in their awareness, mitigation, and management of postoperative pancreatic fistulas (POPF) as a body of literature on this topic has grown to help pancreatic surgeons refine their practices. These insights range from retrospective, single-series reviews to randomized controlled trials (RCTs) to large meta-analyses. Following the progression of the landmark papers allows one to see how perioperative management of pancreatic surgery has
Ó Society of Surgical Oncology 2020 First Received: 21 September 2020 Accepted: 4 October 2020 C. M. Vollmer Jr., MD e-mail: [email protected]
advanced over the years. The collective data allow us to develop several principles useful for guiding patient care when this challenging problem is encountered. DEFINITION The definition of a pancreatic fistula is ‘‘an abnormal communication between the pancreatic ductal epithelium and another surface, where pancreas-derived, degradative, enzyme-rich fluid is evident.’’3 Pancreatic fistulas can occur in a variety of settings—either from pathologic disease states such as pancreatitis or from iatrogenic interventions such as surgery. The discussion here will focus on postoperative pancreatic fistula (POPF). The classification and description of POPF has varied significantly over time. The variability in terminology and definitions of pancreatic fistulas clouded the literature and limited the discussion of management of these fistulas for decades prior to the new millennium. Attempts were made to standardize the definition of a pancreatic fistula in 2005, when the International Study Group of Pancreatic Fistula (ISGPF) consensus statement was pu
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