The Gray Zone Between Postpancreaticoduodenectomy Collections and Pancreatic Fistula

Objectives: Despite the International Study Group for Pancreatic Fistulae (ISGPF) definition, there exist reports of postoperative collections of uncertain etiology. There is a recent report questioning the ISGPF criteria's ability to accurately predict pancreatic anastomotic failure and outlining new criteria. We decided to validate both proposed criteria based on our experience. Methods: Between January 2003 and November 2007, we retrospectively analyzed patients with postpancreaticoduodenectomy collections at the Tata Memorial Hospital. Results: Of 149 patients evaluated, 17 (11.4%) had intra-abdominal collections, 9 had early collections (with abdominal drains in situ, ie, <= 7 days postoperative), whereas 8 had delayed collections (after removal of drains, ie, 97 days postoperative). Early collections were attributed to pancreatic anastomotic leaks (n = 5; confirmed by ISGPF guidelines), biliary leaks (n = 3), or chyle leaks (n = 1). In patients with "delayed" collections of unclear etiology (normal drain amylase levels on days 3 and 7), 5 had normal amylase levels in the aspirated/pigtailed collections, whereas 3 had drain amylase content more than 3 times the normal, indicating postoperative pancreatic fistulae. Conclusion: Assessment of amylase levels in delayed collections (despite initial amylase levels being normal) may aid in uncovering previously undrained, or newly formed, pancreatic anastomotic leaks. This will likely reduce reported rates of uncertain postoperative collections while providing more precise (perhaps higher) rates of postoperative pancreatic fistulae.