Percutaneous Transhepatic Biliary Drainage in High-Risk Postoperative Pancreatic Fistula after
Sergio Calamia1,2, Sergio Li Petri1,2, Duilio Pagano1,2
1IRCCS ISMETT, Palermo, Italy.
Insights
Percutaneous transhepatic biliary drainage (PTBD) effectively manages high-risk postoperative pancreatic fistulas after pancreaticoduodenectomy (PD). This safe intervention promotes fistula healing and may prevent Grade C fistulas, supporting its use in selected patients.
Area of Science:
- Gastroenterology and Hepatology
- Surgical Oncology
- Interventional Radiology
Background:
- Postoperative pancreatic fistula (POPF) is a severe complication following pancreaticoduodenectomy (PD).
- High-output fistulas, infection, and anastomotic dehiscence increase POPF severity.
- Percutaneous transhepatic biliary drainage (PTBD) may aid healing by reducing intraluminal pressure and bile reflux.
Purpose of the Study:
- To evaluate the efficacy of PTBD in managing high-risk POPF after PD.
- To assess PTBD's role in reducing complications and promoting fistula resolution.
Main Methods:
- Retrospective analysis of 122 PDs performed between January 2022 and December 2024.
- Identified 17 patients with clinically relevant POPF; 8 met criteria for high-risk POPF and underwent PTBD.
- Compared outcomes between the PTBD group and 9 patients treated conservatively.
Main Results:
- PTBD achieved fistula resolution in 87.5% of high-risk patients within a median of 5 days post-procedure.
- One patient (12.5%) progressed to Grade C POPF; two required additional percutaneous drainage.
- No PTBD-related complications occurred; conservative management had lower resolution rates and higher need for further drainage.
Conclusions:
- PTBD with external bile diversion is safe and effective for high-risk POPF post-PD.
- PTBD promotes fistula healing and may prevent progression to Grade C POPF.
- Incorporating PTBD into POPF management protocols for selected patients is supported, pending larger studies.
Background And Objectives:
Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreaticoduodenectomy (PD), particularly in the presence of high-output fistulas, infection, and radiological evidence of anastomotic dehiscence. Percutaneous transhepatic biliary drainage (PTBD) with external bile diversion may promote fistula healing by reducing intraluminal pressure, microbial exposure, and bile reflux. This study aimed to evaluate the role of PTBD in high-risk POPF management after PD.
Methods:
Between January 2022 and December 2024, 122 PDs were performed at our center. Seventeen patients (13.9%) developed clinically relevant POPF. Nine were treated conservatively with antibiotics ± percutaneous drainage, while eight met criteria for high-risk POPF (very high output >400 mL/day, positive cultures, CT evidence of dehiscence) and underwent PTBD.
Results:
In the PTBD group, 7/8 patients (87.5%) achieved fistula resolution with a median of 15 days (IQR: 12-19) from surgery, but only 5 days (IQR 4-6; mean 5.4) after PTBD placement. One patient (12.5%) progressed to Grade C, and 2 (25%) required additional percutaneous drainage. No PTBD-related complications occurred, and follow-up cholangiograms confirmed the absence of bile leaks. Importantly, no biliary fistulas were observed. In the non-PTBD group, 7/9 patients achieved resolution with a median of 19 days (IQR 15-22; mean 18.0); 2 patients (22.2%) progressed to Grade C, and 5 (55.5%) required percutaneous drainage.
Conclusions:
PTBD with external bile diversion is a safe and effective tool for managing high-risk pancreatic fistulas following PD. By modifying intraluminal pressure and microbial exposure in the child's limb, PTBD significantly promotes fistula healing and may prevent progression to Grade C. Our findings support the incorporation of PTBD into POPF management protocols for selected patients. Larger prospective studies are needed to confirm these results.
