Pathologic Assessment of Pancreatic Fibrosis for Objective Prediction of Pancreatic Fistula and Management of Prophylactic Drain Removal After Pancreaticoduodenectomy.

Background: Soft pancreatic texture is a commonly accepted risk factor associated with pancreatic fistula (PF) after pancreaticoduodenectomy (PD). However, its evaluation is subjective and its predictive value is limited. The present study was performed to establish intraoperative PF prediction parameter: the pathological assessment of pancreatic fibrosis, which was an objective evaluation that was strongly related to pancreatic consistency.

Methods: Based on the results of a retrospective investigation on grades of pancreatic fibrosis and PF occurrence in 51 consecutive patients, an algorithm for intraoperative selection of early prophylactic drain removal was established. Prophylactic drains of patients with pancreatic fibrosis ≥ 30 % in the frozen section of pancreatic stump were removed on postoperative day (POD) 4. As CRP ≥ 10 mg/dL on POD 4 was a strong risk factor for PF in patients with fibrosis <30 %, the drains of these patients were maintained.

Results: The algorithm was applied to 26 consecutive patients. Prophylactic drains were removed in 14 patients and retained in 12 patients on POD 4. No PF was observed in patients with pancreatic fibrosis ≥ 30 % (n = 8). Among six patients with fibrosis <30 %, CRP <10 mg/dL, and without infection in the drain fluid, only two developed grade A PF. All nine patients with pancreatic fibrosis <30 % and CRP ≥ 10 mg/dL developed grade B PF. No grade C PF was observed in any group.

Conclusions: The pathological evaluation of pancreatic fibrosis could objectively predict PF occurrence. Intraoperative assessment of pancreatic fibrosis could be applied to tailor postoperative drain management after PD.