Postoperative Pancreatic Fistula: A Surgeon’s Nightmare! An Insight with a Detailed Literature Review

  • Prasad Seetharam Kasturba Medical College, Manipal University. Manipal, India
  • Gabriel Sunil Rodrigues Kasturba Medical College, Manipal University. Manipal, India
Keywords: complications, Fistula, Pancreatectomy, Pancreaticoduodenectomy, Postoperative Period


Context Postoperative fistula formation is an important complication following pancreatic resections. Objective A large volume of literature without uniform conclusions is available regarding various controversies about postoperative pancreatic fistulae. The term postoperative pancreatic fistula includes fistula resulting from any surgery involving pancreas, most commonly pancreaticoduodenectomy and distal pancreatectomy. In this review, we have tried to present a comprehensive account of postoperative pancreatic fistula with particular emphasis on important controversies clouding the subject. Methods We performed MEDLINE literature search for relevant articles using the key words pancreas, pancreatic cancer, pancreatectomy, pancreatoduodenectomy, Whipple’s operation, postoperative, complications, fistula, management and treatment in various combinations with the Boolean operators AND, OR and NOT. Conclusions Postoperative pancreatic fistula is a troublesome complication of pancreaticoduodenectomy. Although the risk factors for postoperative pancreatic fistula have been extensively described, none of the methods recommended for preventing postoperative pancreatic fistula have been conclusively proved to be effective. While endoscopic treatment and percutaneous treatment form important aspects of treatment of postoperative pancreatic fistula, surgery may be required for select cases.

Image: Management of postoperative pancreatic fistula.


Download data is not yet available.


Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J. et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138:8-13. [PMID: 16003309]

DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA. Assessment of complications after pancreatic surgery. A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006; 244:931-7. [[PMID: 17122618]

Zinner MJ, Baker RR, Cameron JL. Pancreatic cutaneous fistulas. Surg Gynecol Obstet 1974; 138:710-2. [PMID: 4823372]

Alexakis N, Sutton R, Neoptolemos JP. Surgical treatment of pancreatic fistula. Dig Surg 2004; 21:262-4. [PMID: 15308865]

Böttger TC, Junginger T. Factors influencing morbidity and mortality after pancreaticoduodenectomy: critical analysis of 221 resections. World J Surg 1999; 23:164-72. [PMID: 9880426]

Cullen J, Surr M, Ilstrup D. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance and management. Am J Surg 1994; 168:295-8. [PMID: 7524375]

van Berge Henegouwen MI, De Wit LT, Van Gulik TM, Obertop H, Gouma DJ. Incidence, risk factors and treatment of pancreatic leakage after a pancreatoduodenectomy: drainage versus resection of pancreatic remnant. J Am Coll Surg 1997; 185:18-24. [PMID: 9208956]

Büchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z'Graggen K. Pancreatic fistula after pancreatic head resection. Br J Surg 2000; 87:883-9. [PMID: 10931023]

Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, Lillemoe KD, Pitt HA. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995; 222:580-8. [PMID: 7574936]

Büchler M, Friess H, Klempa I, Hermanek P, Sulkowski U, Becker H, Schafmayer A, Baca I, Lorenz D, Meister R, et al. Role of octreotide in prevention of post operative complications following pancreatic resection. Am J Surg 1992; 163:125-30. [PMID: 1733360]

Pederzoli P, Bassi C, Falconi M, Camboni MG. Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Br J Surg 1994; 81:265-9. [PMID: 8156354]

Suzuki Y, Kuroda Y, Morita A, Pujino Y, Ykawamura T, Saitoh Y. Fibrin glue sealing for the prevention of pancreatic fistula following distal pancreatectomy. Arch Surg 1995; 130:952-5. [PMID: 7661678]

Lowy AM, Lee JE, Pisters PW, Davidson BS, Fenoglio CJ, Stanford P, Jinnah R, Evans DB.Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 1997; 226:632-41. [PMID: 9389397]

Matsusue S, Takeda H, Nakamura Y, Nishimura S, Koizumi S. A prospective analysis of the factors influencing pancreaticojejunostomy performed using a single method, in 100 consecutive pancreaticoduodenectomies. Surg Today 1998; 28:719-26. [PMID: 9697265]

Yeh TS, Jan YY, Jeng LB, Hwang TL, Wang CS, Chen SC, Chao TC, Chen MF. Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy-multivariate analysis of perioperative risk factors. J Surg Res 1997; 67:119-25. [PMID: 9073557]

Bartoli FG, Arnone GB, Ravera G, Bachi V. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature. Anticancer Res 1991; 11:1831-48. [PMID: 1685076]

Yeo CJ, Cameron JL, Lillemoe KD, Sauter PK, Coleman J, Sohn TA, Campbell KA, Choti MA. Does prophylactic octreotide decrease the rate of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo controlled trial. Ann Surg 2000; 232:419-29. [PMID: 10973392]

Al-Sharaf K, Ihse I, Dawiskiba S, Andrèn-Sandberg A. Characteristics of the gland remnant predict complications after subtotal pancreatectomy. Dig Surg 1997;14:101-4. [PMID: 172522]

Sato N, Yamaguchi K, Chijiiwa K, Tanaka M. Risk analysis of pancreatic fistula after pancreatic head resection. Arch Surg 1998;133:1094-8. [PMID: 9790207]

Hamanaka Y, Nishihara K, Hamasaki T, Kawabata A, Yamamoto S, Tsurumi M, Ueno T, Suzuki T. Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size and leakage. Surgery 1996; 119:281-7. [PMID: 8619183]

Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995; 221:635-45. [PMID: ]

Ishikawa O, Ohigashi H, Imaoka S, Teshima T, Inoue T, Sasaki Y, Iwanaga T, Nakaizumi A.Concomitant benefit of preoperative irradiation in preventing pancreatic fistula formation after pancreatoduodenectomy. Arch Surg 1991; 126: 885-9. [PMID: 1854249]

Yang YM, Tian XD, Zhuang Y, Wang WM, Wan YL, Huang YT. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol 2005; 11:2456-61. [PMID: 15832417]

Sikora SS, Posner MC. Management of pancreatic stump following pancreatico duodenectomy. Br J Surg 1995; 82:1590-7. [PMID: 8548218]

Marczell AP, Stierer M. Partial pancreaticoduodenectomy (Whipple procedure) for pancreatic malignancy: occlusion of a non-anastomosed pancreatic stump with fibrin sealant. HPB Surg 1992; 5:251-9. [PMID: 1356420]

Di Carlo V, Chiesa R, Pontiroli AE, Carlucci M, Staudacher C, Zerbi A, Cristallo M, Braga M, Pozza G. Pancreatoduodenectomy with occlusion of the residual stump with Neoprene injection. World J Surg 1989; 13:105-10. [PMID: 2543144]

Grace PA, Pitt HA, Tompkins RK, DenBesten L, Longmire WP Jr. Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg 1986; 151:141-9. [PMID: 3946745]

Matsumoto Y, Fujii H, Miura K, Inoue S, Sekikawa T, Aoyama H, et al. Successful pancreatojejunal anastomosis for pancreaticoduodenectomy. Surg Gynecol Obstet 1992; 175:555-62. [PMID: 1360173]

Howard JM. Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection. J Am Coll Surg 1997; 184: 454-7. [PMID: 9145064]

Hosotani R, Doi R, Imamura M. Duct-to-mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy. World J Surg 2002; 26:99-104. [PMID: 11898041]

Tsuji M, Kimura H, Konishi K, Yabushita K, Maeda K, Kuroda Y. Management of continuous anastomosis of pancreatic duct and jejunal mucosa after pancreaticoduodenectomy: historical study of 300 patients. Surgery 1998; 123:617-21. [PMID: 9626311]

Hwang TL, Jan YY, Chen MF. Secural pancreaticojejunal anastomosis for the pancreaticoduodenectomy. Hepatogastroenterology 1996; 43:275-7. [PMID: 8682478]

Batignani G, Fratini G, Zuckermann M, Bianchini E, Tonelli F. Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2005; 4:450-5. [PMID: 16109535]

Waugh JM, Clagett OT. Resection of the duodenum and head of the pancreas for carcinoma: an analysis of thirty cases. Surgery 1946; 20:224-32. [PMID: 20994806]

Kapur BM. Pancreaticogastrostomy in pancreaticoduodenal resection for ampullary carcinoma: experience in thirty-one cases. Surgery 1986; 100:489-93. [PMID: 3738768]

Morris DM, Ford RS. Pancreaticogastrostomy: preferred reconstruction for Whipple resection. J Surg Res 1993; 54:122-5. [PMID: 8479169]

Ramesh H, Thomas PG. Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy. Aust N Z J Surg 1990; 60:973-6. [PMID: 2268215]

McKay A, Mackenzie S, Sutherland FR, Bathe OF, Doig C, Dort J, Vollmer CM Jr, Dixon E. Meta-analysis of pancreaticojejunostomy versus pancreatico gastrostomy after pancreaticoduodenectomy. Br J Surg 2006; 93:929-36. [PMID: 16845693]

Wente MN, Shrikhande SV, Müller MW, Diener MK, Seiler CM, Friess H, Büchler MW. Pancreaticojejunostomy versus pancreatico gastrostomy: systematic review and meta-analysis. Am J Surg 2007; 193:171-83. [PMID: 17236843]

Klempa J, Schwedes U, Usadel KH. Verhutung von postoperativen pancreatitischen komplikationen nach duodenopankreatetomie durch somatostatin. Chitrurg 1979; 50:429-32. [PMID: 477469]

Montorsi M, Zago M, Mosca F, Capussotti L, Zotti E, Ribotta G, Fegiz G, Fissi S, Roviaro G, Peracchia A, et al. Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery 1995; 117:26-31. [PMID: 7809832]

Friess H, Beger HG, Sulkowski U, Becker H, Hofbauer B, Dennler HJ, Büchler MW. Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis. Br J Surg 1995; 82:1270-3. [PMID: 7552016]

Lowy AM, Lee JE, Pisters PW, Davidson BS, Fenoglio CJ, Stanford P, Jinnah R, Evans DB. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 1997; 226: 632-41. [PMID: 9389397]

Poon RT, Lo SH, Fong D, Fan ST, Wong J. Prevention of pancreatic leakage after pancreaticoduodenectomy. Am J Surg 2002; 183:42-52. [PMID: 11869701]

Gouillat C, Chipponi J, Baulieux J, Partensky C, Saric J, Gayet B. Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy. Br J Surg 2001; 88:1456-62. [PMID: 11683740]

Sarr MG; Pancreatic Surgery Group. The potent somatostatin analogue vapreotide does not decrease pancreas specific complications after elective pancreatectomy: a prospective, multicenter, double-blinded, randomized, placebo controlled trial. J Am Coll Surg 2003; 196:556-65. [PMID: 12691930]

Suc B, Msika S, Piccinini M, Fourtanier G, Hay JM, Flamant Y, Fingerhut A, et al. French Associations for Surgical Research. Octreotide in the prevention of intra abdominal complications following elective pancreatic resection. A prospective, multicenter randomized controlled trial. Arch Surg 2004; 139:288-94. [PMID: 15006886]

Allen PJ, Gönen M, Brennan MF, Bucknor AA, Robinson LM, et al. Pasireotide for PostoperativePancreatic Fistula. N Engl J Med 2014; 370:2014-22. [PMID: 25162895]

Biehl T, Traverso LW. Is stenting necessary for a successful pancreatic anastomosis? Am J Surg 1992; 163:530-2. [PMID: 1575313]

Yoshimi F, Ono H, Asato Y, Ohta T, Koizumi S, Amemiya R, Hasegawa H. Internal stenting of the hepatojejunostomy and pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy to promote earlier discharge from the hospital. Surg Today 1996; 26:665-7. [PMID: 8855507]

Shibuya T, Uchiyama K, Imai S, Shibuya J, Shoji T. Improvement of pancreaticojejunostomy in pancreaticoduodenectomy. Int Surg 1995; 80:57-60. [PMID: 7657494]

Hamanaka Y, Suzuki T. Total pancreatic duct drainage for leakproof pancreatojejunostomy. Surgery 1994; 115:22-6. [PMID: 8284756]

Mok KT, Wang BW, Liu SI. Management of pancreatic remnant with strategies according to the size of the pancreatic duct after pancreaticoduodenectomy. Br J Surg 1999; 86:1018-9. [PMID: 10460636]

Roder JD, Stein HJ, Böttcher KA, Busch R, Heidecke CD, Siewert JR. Stented versus nonstented pancreaticojejunostomy after pancreaticoduodenectomy: a prospective study. Ann Surg 1999; 229:41-8. [PMID: 9923798]

Okamoto A, Tsuruta K. Fistulation method: simple and safe pancreaticojejunostomy after pancreatoduodenectomy. Surgery 2000; 127:433-8. [PMID: 10776435]

Braasch JW. Pancreaticoduodenal resection. Curr Probl Surg 1988; 25:321-63. [PMID: 3391042]

Keck H, Steffen R, Neuhaus P. Protection of pancreatic and biliary anastomosis after partial duodenopancreatectomy by external drainage. Surg Gynecol Obstet 1992; 174;329-31. [PMID: 1348151]

Kingsnorth AN. Safety and function of isolated Roux loop pancreaticojejunostomy after Whipple’s pancreaticoduodenectomy. Ann R Coll Surg Engl 1994; 76:175-9. [PMID: 7912489]

Papadimitriou JD, Fotopoulos AC, Smyrniotis B, Prahalias AA, Kostopanagiotou G, Papadimitriou LJ. Subtotal pancreatoduodenectomy: use of a defunctionalized loop for pancreatic stump drainage. Arch Surg 1999; 134:135-9. [PMID: 10025450]

Strasberg SM, McNevin MS. Results of a technique of pancreaticojejunostomy that optimizes the blood supply to the pancreas. J Am Coll Surg 1998; 187:591-6. [PMID: 9849731]

Kram HB, Clark SR, Ocampo HP, Yamaguchi MA, Shoemaker WC. Fibrin glue sealing of pancreatic injuries, resections and anastomoses. Am J Surg 1991; 161: 479-81. [PMID: 2035768]

D'Andrea AA, Costantino V, Sperti C, Pedrazzoli S. Human fibrin sealant in pancreatic surgery: it is useful in preventing fistulas? A prospective randomized study. Ital J Gastroenterol 1994; 26:283-6. [PMID: 7949264]

Lillemoe KD, Cameron JL, Kim MP, Campbell KA, Sauter PK, Coleman JA, Yeo CJ. Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2004; 8:766-72. [PMID: 15531229]

Suc B, Msika S, Fingerhut A, Fourtanier G, Hay JM, Holmières F, Sastre B, Fagniez PL; And the French Associations for Surgical Research. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra abdominal complications after pancreatic resection. Ann Surg 2003; 237:57-65. [PMID: 12496531]

Moriura S, Kimura A, Ikeda S, Iwatsuka Y, Ikezawa T, Naiki K. Closure of distal pancreatic stump with a seromuscular flap. Surg Today 1995; 25:992-4. [PMID: 8640031]

Suzuki Y, Fujino Y, Tanioka Y, Hori Y, Ueda T, Takeyama Y, Tominaga M, Ku Y, Yamamoto YM, Kuroda Y. Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non fibrotic pancreas. Br J Surg 1999; 86:608-11. [PMID: 10361178]

Zhang H, Zhu F, Shen M, Shi CJ et al. Systematic review and meta-analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy. Br J Surg 2015; 102:4-15. [PMID: 25388952]

Grant JP, Davey-McCrae J, Snyder PJ. Effect of enteral nutrition on human pancreatic secretions. JPEN J Parenter Enteral Nutr 1987; 11:302-4. [PMID: 3110448]

Bivins BA, Bell RM, Rapp RP, Toedebusch WH. Pancreatic exocrine response to parenteral nutrition. JPEN J Parenter Enteral Nutr 1984; 8:34-6. [PMID: 6321813]

Bodoky G, Harsanyi L, Pap A, Tihanyi T, Flautner L. Effect of enteral nutrition on exocrine pancreatic function. Am J Surg 1991; 161:144-8. [PMID: 1702939]

Duerksen DR, Bector S, Yaffe C, Parry DM. Does jejunal feeding with a polymeric immune-enhancing formula increase pancreatic exocrine output as compared with TPN? A case report. Nutrition 2000; 16:47-9. [PMID: 10674235]

Madiba TE, Haffejee AA, Singh B, Reddy R. Nutritional support in the management of external pancreatic fistulas. S Afr J Surg 1995; 33:81-4. [PMID: 8545731]

Kassell B, Kay J. Zymogens of proteolytic enzymes. Science 1973; 180:1022-7. [PMID: 4574732]

Pederzoli P, Bassi C, Falconi M, Albrigo R, Vantini I, Micciolo R. Conservative treatment of external pancreatic fistulas with parenteral nutrition alone or in combination with intravenous infusion of somatostatin, glucagon or calcitonin. Surg Gynecol Obstet 1986; 163:428-32. [PMID: 2877505]

Sheiman RG, Chan R, Matthews JB. Percutaneous treatment of a pancreatic fistula after pancreaticoduodenectomy. J Vasc Interv Radiol 2001; 12:524-6. [PMID: 11287543]

Wadström J, Gannedahl G, Wahlberg J, Frödin L. Persistent pancreatic fistula after pancreas transplantation treated with fibrin glue and octreotide. Transplant Proc 1995; 27:3491-2. [PMID: 8540064]

Buecker A, Keulers P, Guenther RW. Successful closure and embolization of a fistula between the pancreatic duct and a pseudocyst using ethibloc. Cardiovasc Intervent Radiol 1997; 20:394-6. [PMID: 9271654]

Cope C, Tuite C, Burke DR, Long WB. Percutaneous management of chronic pancreatic duct strictures and external fistulas with long term results. J Vasc Interv Radiol 2001; 12:104-10. [PMID: 11200342]

Howard TJ, Stonerock CE, Sarkar J, Lehman GA, Sherman S, Wiebke EA, Madura JA, Broadie TA. Contemporary treatment strategies for external pancreatic fistulas. Surgery 1998; 124:627-33. [PMID: 9780981]

Lipsett PA, Cameron JL. Internal pancreatic fistula. Am J Surg 1992; 163:216-20. [PMID: 1739176]

Saeed Z, Ramirez F, Hepps KS. Endoscopic stent placement for internal and external pancreatic fistulas. Gastroenterology 1993; 105:1213-7. [PMID: 8405869]

Kozarek RA, Ball TJ, Patterson DJ, Raltz SL, Traverso LW, Ryan JA, Thirlby RC. Transpapillary stenting for pancreaticocutaneous fistulas. J Gastrointest Surg 1997; 1:357-1. [PMID: 9834370]

Boerma D, Rauws EA, van Gulik TM, Huibregtse K, Obertop H, Gouma DJ. Endoscopic stent placement for pancreaticocutaneous fistula after surgical drainage of the pancreas. Br J Surg 2000; 87:1506-9. [PMID: 11091237]

Costamagna G, Mutignani M, Ingrosso M, Vamvakousis V, Alevras P, Manta R, Perri V. Endoscopic treatment of postsurgical external pancreatic fistulas. Endoscopy 2001; 33:317-22. [PMID: 11315892]

Corachan M. Sur le traitment des fistules pancreatiques. La Presse Medicale 1928; 88:1394-7. [PMID: 10827321]

Bassi C, Butturini G, Salvia R, Contro C, Valerio A, Falconi M, Pederzoli P. A single institution experience with fistulojejunostomy for external pancreatic fistulas. Am J Surg 2000; 179:203-6. [PMID: 8689156]

Farley DR, Schwall G, Trede M. Completion pancreatectomy for complications after pancreaticoduodenectomy. Br J Surg 1996; 83:176-9. [PMID: 1350387]

Smith CD, Sarr MG, vanHeerden JA. Completion pancreatectomy following pancreaticoduodenectomy: clinical experience. World J Surg 1992; 16:521-4. [PMID: 1350387]

Tamijmarane A, Ahmed I, Bhati CS, Mirza DF, Mayer AD, Buckels JA, et al. Role of completion pancreatectomy as a damage control option for post-pancreatic surgical complications. Dig Surg 2006; 23:229-234. [PMID: 16943670]

Management of postoperative pancreatic fistula
How to Cite
SeetharamP., & RodriguesG. (2015). Postoperative Pancreatic Fistula: A Surgeon’s Nightmare! An Insight with a Detailed Literature Review. JOP. Journal of the Pancreas, 16(2), 115-124.