Tricks of the Senior Surgeon

■ Patience, adequate drainage, and complete pre- or intraoperative imaging is paramount for definition of the fistula and associated ductal anatomy; should marked disease remain in the duct, an alternative procedure, e.g., resection or lateral pancreaticojejunostomy, might be a better choice.

■ One goal of fistula drainage is to preserve pancreatic endocrine and exocrine function. If the fistula arises from the tail of the pancreas, resection of the distal pancreas may be the best option if minimal loss of functional pancreatic tissue is anticipated.

■ Spontaneous closure of the pancreatic fistula can be aided with a somatostatin analogue; success may be predictable based on radiographic evaluation. Fistulae that arise from a divided duct will not resolve.

■ Closure of fistulae that radiographically connect to the GI tract may be facilitated by transpapillary pancreatic stents and by ensuring that strictures and obstructing calculi are addressed.

■ Internal drainage of the fistulous tract into the stomach is not suggested; rather a defunctionalized Roux limb of jejunum is preferred when resection is not the best option.

■ Sew to the pancreatic parenchyma at the point of origin of fistula and not to the fistulous tract; the parenchyma is usually thickened and scarred.

■ If internal drainage is not possible (high operative risk or anatomic considerations), chronic external drainage is the best option.

■ Amylase-rich fluid in the drain signifies breakdown of the anastomosis; management is considerably easier if a stent is placed across anastomosis at operation. The anastomosis can be evaluated radiographically; as the output decreases, the stent is converted from closed suction to passive drainage and then advanced

■ Early intra-abdominal hemorrhage is best treated by reoperation and direct vessel ligation. Late hemorrhage may be a sentinel bleed from a pseudoa-neurysm; immediate angiography and vessel embolization are indicated.

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