[Pancreatic fistula - definition, risk factors and treatment options]

Pancreatic fistula is a common complication after pancreatic resections. Its incidence oscillates between 10 and 30%. The differences in the incidence cited in the studies are due to the various fistula definitions. According to ISGPF, pancreatic fistula is an output -via an operatively placed drain (or a subsequently placed percutaneous drain) - of any measurable volume of drain fluid on or after postoperative day 3, with an amylase content higher than 3 times the upper normal serum value. The fistula is then classified according to the clinical impact in grades A, B, and C. There are known three risk factor categories for the development of pancreatic fistula: the risk related to the pancreatic disease, to the patient, and to the surgical procedure. Most of the risk factors for the development of pancreatic fistula cannot be influenced either prior to or during the surgery. There are two basic options for the prevention of pancreatic fistula: pharmacological intervention (administration of somatostatin and its analogues) and technical modifications of the pancreatic remnant treatment. However, the routine administration of somatostatin and its analogues is not advisable in all pancreatic surgical procedures. In high risk cases the selective administration is preferred. The second option is modification of pancreatic remnant treatment. Most of the studies dealing with various modifications of the pancreatic remnant treatment were retrospective with lower level of evidence. There were only a few properly designed randomized trials, and most of them did not prove benefit of one method over another. It has been shown that the results depend on the experience of a given surgical department, and above all on the experience of an individual surgeon who performs the pancreatic resection. The therapy of pancreatic fistula is based on the clinical severity. Conservative approach is warranted in most patients. In cases when reoperation is required, there are two basic strategies: surgical drainage of the collections, and completion of total pancreatectomy. Total pancreatectomy was preferred in the past, however, this procedure is technically very demanding with mortality up to 80 per cent. Nowadays, most of the authors prefer surgical drainage; this procedure is technically less demanding, has lower mortality, the endocrine function of pancreas is protected, and the patients usually need no further interventions.