and grading!!!

XXII Congresso Nazionale S.I.FI.PA.C.
Padova, Aprile 2009
GESTIONE DEL MONCONE
PANCREATICO:
TRATTAMENTO DELLE
FISTOLE.
Prof. Claudio Bassi MD, FRCS
Dipartimento di Scienze Chirurgiche
Università di Verona
XXII Congresso Nazionale S.I.FI.PA.C.
Padova, Aprile 2009
GESTIONE DEL MONCONE
PANCREATICO:TRATTAMENTO DELLE FISTOLE.
CONCLUSIONE
Il Sig. Moderatore
ha ragione!
POST – OPERATIVE
PANCREATIC FISTULA:
CONSENSUS
DEFINITION
(and grading!!!)
Surgery 2005;138:8
Grade A Fistulas
10 Criteria are utilized to establish each grade
Elevated Drain Amylase
Readmission
Persistent Drainage
Critical Condition
Signs of Infection
Re-operation
Diagnostic Imaging
Sepsis
Specific Treatments
Death
Modified by Pratt et al. from Bassi C et al. Surgery 2005; 138: 8-13.
Grade B Fistulas
10 Criteria are utilized to establish each grade
Elevated Drain Amylase
Readmission
Persistent Drainage
Critical Condition
Signs of Infection
Re-operation
Diagnostic Imaging
Sepsis
Specific Treatments
Death
Modified by Pratt et al. from Bassi C et al. Surgery 2005; 138: 8-13.
Grade C Fistulas
10 Criteria are utilized to establish each grade
Elevated Drain Amylase
Readmission
Persistent Drainage
Critical Condition
Signs of Infection
Re-operation
Diagnostic Imaging
Sepsis
Specific Treatments
Death
Modified by Pratt et al. from Bassi C et al. Surgery 2005; 138: 8-13.
“sinister appearance? … no!”
take it out as soon as possible!!
Kawai M et al. Early removal of
prophylactic drains reduces the risk of
intra-abdominal infections in patients
with
pancreatic
head
resection.
Prospective study for 104 consecutive
patients.
Ann Surg. 2006;244:1–7.
“sinister appearance? …yes!”
look to amylase content!
Radiological support!
“sinister appearance? …yes!”
look to amylase and bacteria!
Radiological support!
CT scan: a determinant role in the
algorithm management of POPF!
Dalla teoria alla pratica …
•
•
•
•
•
•
•
1996 – 2008: 1075 DCP
4 decessi (0.4%) – 33 reinterventi (3.5%)
182 POPF (17%)
39 Grado A (21.2%)
124 Grado B (68.3%)
19 Grado C (10.5%)
143 fistole con impatto clinico (13.3%) … e
tutti hanno fatto una CT … ma non solo !!!
Perchè non solo la CT ???
Role of fistulography in characterizing
pancreatic fistula after
pancreaticoduodenectomy: back to the
future?
Faccioli N, Molinari E, Hermans JJ, Comai A, D’Onofrio
M, Bassi C, Pozzi Mucelli R.
Radiology (submitted)
Role of fistulography in characterizing
pancreatic fistula after
pancreaticoduodenectomy: back to the
future?
• Eighty-four
consecutive
fistulographies
were
executed for clinical suspicion of PF after PD (mean
time after surgery 11 days, range 6–20).
to determine:
• the position of the tip of the drainage catheter
• the presence or absence of a communication with
jejunal loop or stomach, of fistulous tract, of fluid
collections, of communication with the main
pancreatic duct, and with the biliary tree.
• two groups were statistically analyzed depending on
presence or absence of fistulous tract.
Pancreatic fistula!
POPF
POPF
Fistula due to decubitus of the drainage
in PJ
in PG
Role of fistulography in characterizing
pancreatic fistula after
pancreaticoduodenectomy: back to the
future?
Parameter
Pancreatic
Fistula
%
Fistulous tract
41/49
Fluid collection
30/49
Fistula by
drainage
catheter
decubitus
%
p
83.7 0 / 35
0
<0.00
1
61.2 10/35
28.6 0.004
Main pancreatic duct 11/49
visualization
22.5 7/49
20.0 n.s
Biliary
visualization
tree 21/49
42.8 15/35
42.8 n.s
Mean
dd
execution
fistulography
(SD) 11 (8.1)
/
/
11 (5.4)
n.s.
Role of fistulography: back to the future?
useful by identifying erosion or migration of the
drain and for interventional radiologically guided
drain management!
Role of fistulography in characterizing
pancreatic fistula after
pancreaticoduodenectomy: back to the
future?
•
In 49/84 (58.3%) the clinical suspect of
PF was confirmed by the execution of
fistulography.
In the other 35/84 (41.7%) patients
fistulography demonstrated a fistula due
to decubitus of the drainage catheter.
None of the 84 patients required surgical
reoperations!
All survived with conservative treatment
(Rx guide drain management, TPN/EN,
Antisecretive and Antibiotics)
Postoperative Pancreatic Fistulas
Preventing Severe Complications and Reducing Reoperation
and Mortality Rate
Sergio Pedrazzoli, MD, FACS,* et al.
(Ann Surg 2009;249: 97–104)
• An early aggressive treatment based on interventional
radiology was applied. The drain’s track and/or percutaneous
approach was used to insert catheters into the peripancreatic
fluid collection or abscess. The position of catheters was
verified at least once a week.
• The main results are zero mortality, zero completion
pancreatectomies, and a 4.2% reoperation rate for 70/445
consecutive POPFs.
• The best way to prevent severe complications from a POPF is
to obtain a perfect drainage without stasis and consequent
infection of the pancreatic juice.
• Early interventional radiology aimed to capture pancreatic juice
as close to its origin as possible may prevent reoperative
surgery in most of our patients. Furthermore, using the surgical
drain as an access route minimized the need of a percutaneous
procedure.
XXII Congresso Nazionale S.I.FI.PA.C.
Padova, Aprile 2009
GESTIONE DEL MONCONE
PANCREATICO:TRATTAMENTO DELLE FISTOLE.
CONCLUSIONE
Il Sig. Moderatore
ha ragione!