Pancreatogastrostomy as a salvage procedure to treat severe postoperative pancreatic fistula after pancreatoduodenectomy.

HYPOTHESIS Postoperative pancreatic fistula (POPF) is one of the most severe surgical complications of pancreatoduodenectomy (PD) with pancreaticojejunostomy (PJ) reconstruction. Recently, POPF has been classified as grade A, B, or C. Relaparotomy is mandatory for POPF associated with sepsis or hemorrhage (grade C). Peripancreatic drainage and completion pancreatectomy are the procedures most commonly used, but associated morbidity and mortality remain high. We hypothesized that the results of pancreatogastrostomy (PG) for treatment of grade C POPF following PD with PJ in the rare patients for whom relaparotomy is necessary would be similar to the results in a historical series of similar patients who underwent completion pancreatectomy. DESIGN Case series. SETTING Academic research. PATIENTS Between June 1, 1988, and June 30, 2005, 403 patients underwent PD (85 with PJ and 318 with PG). During the same period, 12 patients were treated for grade C POPF, which occurred only after PD with PJ. INTERVENTIONS All 12 patients with grade C POPF required relaparotomy. Eight patients underwent completion pancreatectomy (group A), and 4 patients underwent salvage telescoped PG with preservation of the pancreatic remnant (group B). MAIN OUTCOME MEASURES Postoperative mortality and morbidity. RESULTS Mortality was 50% (4 of 8 patients) in group A and 0% (0 of 4 patients) in group B. Specific and general complications and the length of hospital stay were similar in both groups. One patient in group B developed grade B POPF, which was managed nonsurgically. Postoperative diabetes mellitus occurred in all patients in group A and in 1 patient in group B. CONCLUSION In selected patients, salvage PG can be considered a safe and efficient alternative to completion pancreatectomy for the treatment of grade C POPF after PD with PJ.