2. • 64 yrs female diagnosed with Ca head pancreas,
underwent PPPD with PJ, HJ, antecolic DJ & FJT
• NGT was removed on POD 1, Oral sips were allowed
on POD 2; Abdominal drain output was ~ 10 -15 ml,
serous, till POD 4
• POD 5 drain out put ~ 40 ml/day, clear, increased to ~
70 ml/day, slightly turbid by day 10
• What is the next step?
3. • Fluid amylase
• CECT Abdomen
• Total count
• Diagnosis?
• What next?
4. POPF Management Algorithm
Diagnosis by accepted definition
CT – no collection CT small collection/ no air local sepsis
No sepsis not tolerating orals systemic sepsis
Tolerating orals CT- AF level
no pain
no fever/ TC normal s/o sepsis Re - operation
Allow /ct orals NPO IV Antibiotics options?
TPN/EN CT guided pigtail
Delay drain removal Octreotide
Usually stops<3 wks
Grade A PF Grade B PF Grade C PF
5. Risk factors for POPF
• Surgeon factors
- high volume specialized
- standardised meticulous technique
• Patient factors
- Pancreas Anastomosis Score
- Cardiovascular disease
- Site of malignancy
- Type of Anastomosis?? (PJ vs PG)
- Preop chemoradiotherapy
- Reoperative PD
• Role of prophylactic Octreotide ??
6. Suggested reading
• Lowy AM et al, 1997: Prospective randomised trial of octreotide
to prevent pancreatic fistula after pancreaticoduodenectomy for
malignant disease. Ann Surg 226:632-641.
• Yeo CJ etal, 2000: Does prophylactic octreotide decrease the
rate of pancreatic fistula and other complications after
pancreaticoduodenectomy; results of a prospective,
randomised placebo- controlled trial. Ann Surg 232:419-429.
• Yeo CJ etal, 1995b: A prospective randomsed trial of
pancreaticojejnosomy and pancreaticogastrostomy after
pancreaticoduodenectomy. Ann Surg 222:580-588.
• Claudio Bassi et al, 2005 : Reconstruction by
pancreaticojejunostomy versus pancreaticogastrostomy
following pancreatectomy. Ann Surg 242(6):767-771.
• Bassi et al, 2005. Post operative fistula: An international study
group (ISGPF) definition. Surgery July138(1): 8-13.
7. • This patient had intolerance to fluids orally,
vomited, and required reinsertion of NGT for 2
days; Managed with NPO, erythromycin and
jejunostomy feeds
• On POD 14, drain was blood tinged, which
cleared by evening; no hematemesis/ malena;
pt was hemodynamically stable
What is the next step?
9. Management of Post Pancreatic Hemorrhage
Early(< 24hrs) Delayed (usu.1-3wks)
Sentinel overt
Only drain drain+intraluminal
pt stable= endoscpy Selective stable Unst
angio
+ve -ve embol/
DJA stentg
P. stump rebleed
REOPERATE STRATEGIES?
10. Suggested Reading
• Wente MN et al; Postpancreatic hemorrhage: an International
study Group of Pancreatic Surgeons Definition. Surgery 2007
July; 142(1):20-5
• Management of delayed pancreatic hemorrhage after
pancreaticoduodenectomy: a meta-analysis. Arch Surg 2008
Oct;143(10):1001-7.
• Jagad RB et al. Postoperative hemorrhage after major
pancreatobiliary surgery: an update. Hepatogastroenterology
2008 Mar-Apr; 55(82-83):729-37.
• Blan T et al. Hemorrhage After Pancreaticoduodenectomy;
when is Surgery still Indicated? Am J Surg 2007 July;
194(1):10-2.
• Yekebas EF et al. Post Pancreatectomy Hemorrhage:
diagnosis and Treatment: an analysis of 1669 consecutive
pancreatic resections. Ann Surg 2007 Aug; 246(2):269-80.
12. Suggested Reading
• Horstmann O et al, 2004: Pylorus Preservation has no impact
on Delayed Gastric Emptying after Pancreatic head Resection.
Pancreas 28:69-74
• Alternative reconstruction after Pancreaticoduodenectomy.
WJS Oncol 2008 Jan; 28: 6-9
• Delayed Gastric Emptying after Pancreatic Surgery: a
suggested definition by ISGPS. Surgery 2007
• Lytras D et al. Therapeutic Strategies for management of
delayed gastric emptying after pancreatic resection. Arch Surg
2007 Jan:392(1)
• Halloran CM et al, 2002: Complications of pancreatic cancer
resection. Dig Surg 19:138-46.
