An Evidence-Based Approach to the Surgical Interventions for Severe Pancreatic Fistula after Pancreatoduodenectomy.

Background and objective: To assess the safety and therapeutic outcome of different surgical interventions for severe pancreatic fistula after pancreatoduodenectomy. Methods: A systematic literature search was performed in PubMed database for relevant articles published between 1990 and March 2017. Descriptive statistics were performed and data are expressed as mean. Results: Twenty-four studies involving 370 patients undergoing surgical interventions for severe pancreatic fistula after pancreatoduodenectomy were included. Rates of further relaparotomy, in-hospital mortality, and long-term endocrine insufficiency were reported for completion pancreatectomy (31.8%, 42% and 100% respectively), disconnection of anastomosis with preservation of a pancreatic remnant (25%, 21.3% and 17.8% respectively), internal or external wirsungostomy (10.4%, 14.9%, and 12.3% respectively), salvage pancreaticogastrostomy (12.5%, 0% and 25%, respectively), and simple peripancreatic drainage (30%, 47.9% and 12.5%, respectively). Conclusions: The pancreas-preserving strategy of disconnection of anastomosis with preservation of a pancreatic remnant, internal or external wirsungostomy, and salvage pancreatogastrostomy seems to be the preferred option for the treatment of severe pancreatic fistula after pancreatoduodenectomy. As completion pancreatectomy is a very aggressive treatment, it should only be reserved for specific instances in which organ-preserving resection is technically unfeasible. (C) 2017 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.