Postoperative pancreatic fistula after gastrectomy for gastric cancer

Abstract

Postoperative pancreatic fistula is one of the most severe complications after gastric cancer surgery, and can cause critical patient conditions leading to surgery-related death. Fortunately, the incidence of postoperative pancreatic fistula after gastrectomy seems to be decreasing with changes in operative procedures. The rate was reported at about 30% after open gastrectomy with Appleby's method in 1997, but lately has improved below 1% for robotic gastrectomy in 2019. For the diagnosis of postoperative pancreatic fistula, drain amylase concentration has been demonstrated to be beneficial and some reports have proposed the optimal cut-off values of drain amylase to predict major postoperative pancreatic fistula. There have been many reports identifying risk factors for postoperative pancreatic fistula, including overweight patients, pancreatic anatomy, blunt trauma from compression of the pancreas, and thermal injuries caused by the continuous use of energy devices. And importantly, laparoscopic gastrectomy has been shown to be more often associated with postoperative pancreatic fistula than open gastrectomy in the prospective national clinical database in Japan. Hence, further sophistication of surgical techniques to reduce pancreas compression would have great promise in reducing postoperative pancreatic fistula after laparoscopic gastrectomy.

Keywords: gastrectomy; gastric cancer; pancreatic fistula.

Figure 1

Incidence of postoperative pancreatic fistula after gastrectomy. ⁹ , ¹³ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁹ , ²⁹ , ³⁴ Green bars indicate prospective studies, and dark blue bar indicates a retrospective study. The rate of postoperative pancreatic fistula incidence was reported as 30% after open gastrectomy (OG) with pancreaticosplenectomy in 1997, ¹³ but lately has improved to below 1% with robotic gastrectomies (RGs) in 2019. ³² TG, total gastrectomy; RCT, randomized controlled trials; DG, distal gastrectomy; LDG, laparoscopic distal gastrectomy; ODG, open distal gastrectomy

Figure 2

Fluorescent imaging of the pancreas by a chymotrypsin probe. Gross appearance in natural color (A). Image obtained through light‐blocking glasses 2 minutes after administration of the chymotrypsin probe (B). The black dotted line in (A) indicates the borders of the pancreas. The white arrow in (B) indicates ascites containing pancreatic juice. These figures were cited from Ida et al (2018) ⁵⁵

Figure 3

‘Hit and Away’ technique. In the ‘‘Hit’’ phase, surgeons perform three activations with the tip of the ultrasonic scalpel after the tissues and vessels are clamped in a block. After three activations, the ultrasonic scalpel is immediately released. These figures were cited from Irino et al (2016) ⁵⁷