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Zentralbl Chir 2018; 143(03): 259-269
DOI: 10.1055/s-0043-119896
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Komplikationsmanagement der Pankreasanastomose

Management of Complications of Pancreatic Anastomoses
Georg F. Weber
1   Chirurgische Klinik, Universitätsklinikum Erlangen, Deutschland
,
Axel Schmid
2   Radiologie, Universitätsklinikum Erlangen, Deutschland
,
Michael Uder
2   Radiologie, Universitätsklinikum Erlangen, Deutschland
,
Robert Grützmann
1   Chirurgische Klinik, Universitätsklinikum Erlangen, Deutschland
› Institutsangaben
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Publikationsverlauf

Publikationsdatum:
10. November 2017 (online)

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Zusammenfassung

Hintergrund Die Pankreasanastomose gilt als die Achillesferse der Pankreaschirurgie. Durch die Ausbildung einer postoperativen Pankreasfistel (POPF) kommt es häufig zu mittel- bis schwergradigen, teilweise lebensbedrohlichen Folgekomplikationen.

Fragestellung Möglichkeiten der Prophylaxe, Diagnostik und Therapie der POPF und der POPF-assoziierten Komplikationen im interdisziplinären Management.

Ergebnisse Aktuelle Studienergebnisse zeigen, dass je nach Einteilung der POPF in Grad A – C unterschiedliche diagnostische und therapeutische Maßnahmen die Morbidität und Mortalität senken. Je nach Zeitpunkt und Schweregrad der POPF sowie der POPF-assoziierten Komplikationen ist ein konservatives/interventionelles Management oder chirurgisches Vorgehen indiziert.

Schlussfolgerung Durch die präzise Einteilung der POPF und der POPF-assoziierten Folgekomplikationen kann durch ein gezieltes interdisziplinäres diagnostisches und therapeutisches Vorgehen die Morbidität und Mortalität nach Pankreasoperationen gesenkt werden.

Abstract

Background The pancreatic anastomosis may be the Achilles heel in pancreatic surgery. When a postoperative pancreatic fistula develops, be it mild or severe, in some cases life-threatening, POPF-associated complications can occur.

Objectives Possibilities for the prophylaxis, diagnosis and therapy of POPF and POPF-associated complications in an interdisciplinary setting.

Results Differentiated diagnostic and therapeutic management of POPF grade A – C is supported by recent studies to reduce morbidity and mortality. Depending on time and severity of POPF and POPF-associated complications, a conservative/interventional or surgical approach is indicated.

Conclusion With the precise classification of POPF and POPF-associated complications, interdisciplinary diagnostic and therapeutic management can reduce morbidity and mortality after pancreatic surgery.

Schlüsselwörter

postoperative Pankreasfistel (POPF) - Hämorrhagie - Angiografie - PTCD - Pankreaschirurgie

Key words

postoperative pancreatic fistula (POPF) - hemorrhage - angiography - PTCD - pancreas surgery
 

  • Literatur

  • 1 Bassi C, Dervenis C, Butturini G. et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8-13
    CrossrefPubMedGoogle Scholar
  • 2 Bassi C, Marchegiani G, Dervenis C. et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017; 161: 584-591
    CrossrefPubMedGoogle Scholar
  • 3 Wente MN, Shrikhande SV, Muller MW. et al. Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis. Am J Surg 2007; 193: 171-183
    CrossrefPubMedGoogle Scholar
  • 4 Hackert T, Hinz U, Pausch T. et al. Postoperative pancreatic fistula: we need to redefine grades B and C. Surgery 2016; 159: 872-877
    CrossrefPubMedGoogle Scholar
  • 5 Keck T, Wellner UF, Bahra M. et al. Pancreatogastrostomy versus pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS00000767): perioperative and long-term results of a multicenter randomized controlled trial. Ann Surg 2016; 263: 440-449
    CrossrefPubMedGoogle Scholar
  • 6 Grutzmann R, Distler M, Keck T. et al. [Pancreatic anastomosis – a video comparison of different techniques]. Zentralbl Chir 2013; 138: 24-26
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 7 Halloran CM, Platt K, Gerard A. et al. PANasta Trial; Cattell Warren versus Blumgart techniques of panreatico-jejunostomy following pancreato-duodenectomy: Study protocol for a randomized controlled trial. Trials 2016; 17: 30
    CrossrefPubMedGoogle Scholar
  • 8 Peng S, Mou Y, Cai X. et al. Binding pancreaticojejunostomy is a new technique to minimize leakage. Am J Surg 2002; 183: 283-285
    CrossrefPubMedGoogle Scholar
  • 9 Riediger H, Krueger CM, Makowiec F. et al. [Computed tomography-based planimetry of the pancreatic transection line in risk evaluation for postoperative pancreatic fistula after pancreatic head resection]. Zentralbl Chir 2016; 141: 446-453
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 10 Sandini M, Bernasconi DP, Ippolito D. et al. Preoperative computed tomography to predict and stratify the risk of severe pancreatic fistula after pancreatoduodenectomy. Medicine (Baltimore) 2015; 94: e1152
    CrossrefPubMedGoogle Scholar
  • 11 Roberts KJ, Karkhanis S, Pitchaimuthu M. et al. Comparison of preoperative CT-based imaging parameters to predict postoperative pancreatic fistula. Clin Radiol 2016; 71: 986-992
    CrossrefPubMedGoogle Scholar
  • 12 Peng YP, Zhu XL, Yin LD. et al. Risk factors of postoperative pancreatic fistula in patients after distal pancreatectomy: a systematic review and meta-analysis. Sci Rep 2017; 7: 185
    CrossrefPubMedGoogle Scholar
  • 13 Roberts KJ, Hodson J, Mehrzad H. et al. A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB (Oxford) 2014; 16: 620-628
    CrossrefPubMedGoogle Scholar
  • 14 Soreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol 2016; 51: 1147-1154
    CrossrefPubMedGoogle Scholar
  • 15 Gurusamy KS, Koti R, Fusai G. et al. Somatostatin analogues for pancreatic surgery. Cochrane Database Syst Rev 2013; (04) CD008370
    PubMedGoogle Scholar
  • 16 Allen PJ, Gonen M, Brennan MF. et al. Pasireotide for postoperative pancreatic fistula. N Engl J Med 2014; 370: 2014-2022
    CrossrefPubMedGoogle Scholar
  • 17 Welsch T, Mussle B, Distler M. et al. Cost-effectiveness comparison of prophylactic octreotide and pasireotide for prevention of fistula after pancreatic surgery. Langenbecks Arch Surg 2016; 401: 1027-1035
    CrossrefPubMedGoogle Scholar
  • 18 Ma LW, Dominguez-Rosado I, Gennarelli RL. et al. The cost of postoperative pancreatic fistula versus the cost of pasireotide: results from a prospective randomized trial. Ann Surg 2017; 265: 11-16
    CrossrefPubMedGoogle Scholar
  • 19 Connor S, Alexakis N, Garden OJ. et al. Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery. Br J Surg 2005; 92: 1059-1067
    CrossrefPubMedGoogle Scholar
  • 20 Seufferlein T, Porzner M, Becker T. et al. [S3-guideline exocrine pancreatic cancer]. Z Gastroenterol 2013; 51: 1395-1440
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 21 Ecker BL, McMillan MT, Asbun HJ. et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg 2017; DOI: 10.1097/SLA.0000000000002327. [Epub ahead of print]
    PubMedGoogle Scholar
  • 22 Wang S, Wang X, Dai H. et al. The effect of intraoperative fluid volume administration on pancreatic fistulas after pancreaticoduodenectomy. J Invest Surg 2014; 27: 88-94
    CrossrefPubMedGoogle Scholar
  • 23 Weinberg L, Wong D, Karalapillai D. et al. The impact of fluid intervention on complications and length of hospital stay after pancreaticoduodenectomy (Whippleʼs procedure). BMC Anesthesiol 2014; 14: 35
    CrossrefPubMedGoogle Scholar
  • 24 Machado MC, Machado MA. Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: five years of experience with zero mortality. Eur J Surg Oncol 2016; 42: 1584-1590
    CrossrefPubMedGoogle Scholar
  • 25 Klaiber U, Probst P, Knebel P. et al. Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy. Br J Surg 2015; 102: 331-340
    CrossrefPubMedGoogle Scholar
  • 26 Xiong JJ, Altaf K, Mukherjee R. et al. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. Br J Surg 2012; 99: 1050-1061
    CrossrefPubMedGoogle Scholar
  • 27 Van BG, Bloomston M, Hughes SJ. et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg 2014; 259: 605-612
    CrossrefPubMedGoogle Scholar
  • 28 Conlon KC, Labow D, Leung D. et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg 2001; 234: 487-493
    CrossrefPubMedGoogle Scholar
  • 29 Correa-Gallego C, Brennan MF, DʼAngelica M. et al. Operative drainage following pancreatic resection: analysis of 1122 patients resected over 5 years at a single institution. Ann Surg 2013; 258: 1051-1058
    CrossrefPubMedGoogle Scholar
  • 30 Witzigmann H, Diener MK, Kienkotter S. et al. No need for routine drainage after pancreatic head resection: the dual-center, randomized, controlled PANDRA trial (ISRCTN04937707). Ann Surg 2016; 264: 528-537
    CrossrefPubMedGoogle Scholar
  • 31 McMillan MT, Malleo G, Bassi C. et al. Multicenter, prospective trial of selective drain management for pancreatoduodenectomy using risk stratification. Ann Surg 2017; 265: 1209-1218
    CrossrefPubMedGoogle Scholar
  • 32 McMillan MT, Malleo G, Bassi C. et al. Drain management after pancreatoduodenectomy: reappraisal of a prospective randomized trial using risk stratification. J Am Coll Surg 2015; 221: 798-809
    CrossrefPubMedGoogle Scholar
  • 33 Ven Fong Z, Correa-Gallego C, Ferrone CR. et al. Early drain removal – the middle ground between the drain versus no drain debate in patients undergoing pancreaticoduodenectomy: a prospective validation study. Ann Surg 2015; 262: 378-383
    CrossrefPubMedGoogle Scholar
  • 34 Wente MN, Veit JA, Bassi C. et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142: 20-25
    CrossrefPubMedGoogle Scholar
  • 35 Grutzmann R, Ruckert F, Hippe-Davies N. et al. Evaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center. Surgery 2012; 151: 612-620
    CrossrefPubMedGoogle Scholar
  • 36 Balzano G, Pecorelli N, Piemonti L. et al. Relaparotomy for a pancreatic fistula after a pancreaticoduodenectomy: a comparison of different surgical strategies. HPB (Oxford) 2014; 16: 40-45
    CrossrefPubMedGoogle Scholar
  • 37 Correa-Gallego C, Brennan MF, DʼAngelica MI. et al. Contemporary experience with postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006 and 2011. J Am Coll Surg 2012; 215: 616-621
    CrossrefPubMedGoogle Scholar
  • 38 Ding X, Zhu J, Zhu M. et al. Therapeutic management of hemorrhage from visceral artery pseudoaneurysms after pancreatic surgery. J Gastrointest Surg 2011; 15: 1417-1425
    CrossrefPubMedGoogle Scholar
  • 39 Yekebas EF, Wolfram L, Cataldegirmen G. et al. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 2007; 246: 269-280
    CrossrefPubMedGoogle Scholar
  • 40 Limongelli P, Khorsandi SE, Pai M. et al. Management of delayed postoperative hemorrhage after pancreaticoduodenectomy: a meta-analysis. Arch Surg 2008; 143: 1001-1007
    CrossrefPubMedGoogle Scholar
  • 41 Gwon DI, Ko GY, Sung KB. et al. Endovascular management of extrahepatic artery hemorrhage after pancreatobiliary surgery: clinical features and outcomes of transcatheter arterial embolization and stent-graft placement. AJR Am J Roentgenol 2011; 196: W627-W634
    CrossrefPubMedGoogle Scholar
  • 42 Hassold N, Wolfschmidt F, Dierks A. et al. Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization. J Vasc Surg 2016; 64: 1373-1383
    CrossrefPubMedGoogle Scholar
  • 43 Boufi M, Hashemi AA, Azghari A. et al. Endovascular management of severe bleeding after major abdominal surgery. Ann Vasc Surg 2013; 27: 1098-1104
    CrossrefPubMedGoogle Scholar
  • 44 Lim SJ, Park KB, Hyun DH. et al. Stent graft placement for postsurgical hemorrhage from the hepatic artery: clinical outcome and CT findings. J Vasc Interv Radiol 2014; 25: 1539-1548
    CrossrefPubMedGoogle Scholar
  • 45 Fujii Y, Shimada H, Endo I. et al. Management of massive arterial hemorrhage after pancreatobiliary surgery: does embolotherapy contribute to successful outcome. J Gastrointest Surg 2007; 11: 432-438
    CrossrefPubMedGoogle Scholar
  • 46 Khalsa BS, Imagawa DK, Chen JI. et al. Evolution in the treatment of delayed postpancreatectomy hemorrhage: surgery to interventional radiology. Pancreas 2015; 44: 953-958
    CrossrefPubMedGoogle Scholar
  • 47 Hur S, Yoon CJ, Kang SG. et al. Transcatheter arterial embolization of gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy: safety and efficacy of two embolization techniques. J Vasc Interv Radiol 2011; 22: 294-301
    CrossrefPubMedGoogle Scholar
  • 48 Miura F, Asano T, Amano H. et al. Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology. J Hepatobiliary Pancreat Surg 2009; 16: 56-63
    CrossrefPubMedGoogle Scholar
  • 49 Wente MN, Bassi C, Dervenis C. et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142: 761-768
    CrossrefPubMedGoogle Scholar
  • 50 Janot MS, Belyaev O, Kersting S. et al. Indications and early outcomes for total pancreatectomy at a high-volume pancreas center. HPB Surg 2010; 2010 Epub 2010 Jun 23 DOI: 10.1155/2010/686702. (PMID: pii:686702)
    PubMedGoogle Scholar
  • 51 Balzano G, Piemonti L. Autologous islet transplantation in patients requiring pancreatectomy for neoplasm. Curr Diab Rep 2014; 14: 512
    CrossrefPubMedGoogle Scholar
  • 52 Balzano G, Maffi P, Nano R. et al. Autologous islet transplantation in patients requiring pancreatectomy: a broader spectrum of indications beyond chronic pancreatitis. Am J Transplant 2016; 16: 1812-1826
    CrossrefPubMedGoogle Scholar
  • 53 Funaki B, Zaleski GX, Straus CA. et al. Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts. AJR Am J Roentgenol 1999; 173: 1541-1544
    CrossrefPubMedGoogle Scholar
  • 54 Kuhn JP, Busemann A, Lerch MM. et al. Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts. AJR Am J Roentgenol 2010; 195: 851-857
    CrossrefPubMedGoogle Scholar
  • 55 de Jong EA, Moelker A, Leertouwer T. et al. Percutaneous transhepatic biliary drainage in patients with postsurgical bile leakage and nondilated intrahepatic bile ducts. Dig Surg 2013; 30: 444-450
    CrossrefPubMedGoogle Scholar
  • 56 Stampfl U, Hackert T, Radeleff B. et al. Percutaneous management of postoperative bile leaks after upper gastrointestinal surgery. Cardiovasc Intervent Radiol 2011; 34: 808-815
    CrossrefPubMedGoogle Scholar
  • 57 Cozzi G, Severini A, Civelli E. et al. Percutaneous transhepatic biliary drainage in the management of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts. Cardiovasc Intervent Radiol 2006; 29: 380-388
    CrossrefPubMedGoogle Scholar
  • 58 Nimptsch U, Krautz C, Weber GF. et al. Nationwide in-hospital mortality following pancreatic surgery in Germany is higher than anticipated. Ann Surg 2016; 264: 1082-1090
    CrossrefPubMedGoogle Scholar
  • 59 Krautz C, Nimptsch U, Weber GF. et al. Effect of hospital volume on in-hospital morbidity and mortality following pancreatic surgery in Germany. Ann Surg 2017; DOI: 10.1097/SLA.0000000000002248.
    PubMedGoogle Scholar