Pancreatic fistula after pancreatectomy: Evolving definitions, preventive strategies and modern management

Table 1 The different components of previously used definitions of pancreatic fistula and the new grading system used by the International Study Group for Pancreatic Fistula (ISGPF)

Commonly used definitions used prior to the ISGPF recommendations
Output > 10 mL/d of amylase rich fluid on post-operative day 5 or for > 5 d.
Output > 10 mL/d of amylase rich fluid on post-operative day 8 or for > 8 d.
Output between 25 mL/d and 100 mL/d of amylase rich fluid after post-operative day 8 or for > 8 d.
Output > 50 mL/d of amylase rich fluid after post-operative day 11 or for > 11 d.
ISGPF Definition: “Output via an operatively placed drain (or a subsequently placed percutaneous drain) of any measurable volume of drain fluid on or after postoperative d 3, with an amylase content greater than 3 times the upper normal serum value”
Grade A	“Transient fistula”	No clinical impact	No peri-pancreatic collections on CT scan; little/no change in management	Clinically well; no sepsis; no prolongation of hospital stay; slow removal of operatively placed drains
Grade B		Clinical impact	Peri-pancreatic drains in place or repositioned to drain collections; Change in management is required	Clinically fairly well; degree of infection requiring specific treatment; prolongation of hospital stay; patients often discharged with drains in situ and observed in outpatient setting
Grade C		Severe clinical impact	Worrisome peri-pancreatic collections that require percutaneous drains; major change in management usually in ICU setting; possible re-surgery to salvage a difficult situation (completion pancreatectomy etc)	Clinically unwell; associated sepsis requiring aggressive antibiotics, octreotide and other intensive care support; major prolongation of hospital stay; associated complications and possibility of mortality

Table 2 Pancreatic anastomotic failure (PAF) as described by Strasberg et al

Definition: “Drainage of greater than 50 mL amylase-rich fluid (> 3-fold elevation above upper limit of normal in serum) per day through the drains on or after postoperative d 10, or pancreatic anastomotic disruption shown radiographically”
Grade 1	Deviation from normal postoperative course without pharmacologic, endoscopic, surgical or radiologic intervention (certain drugs allowed)
Grade 2	Pharmacologic treatment needed. Includes blood transfusions and total parenteral nutrition
Grade 3 (a/b)	Surgical, endoscopic or interventional radiologic treatment needed
	a: Not under general anesthesia	b: Under general anesthesia
Grade 4 (a/b)	Life threatening complications and organ dysfunction
	a: Single organ	b: Multi-organ
Grade 5	Death due to PAF