Toward defining grade C pancreatic fistula following pancreaticoduodenectomy: Incidence, risk factors, management and outcome

Background: In 2005 the International Study Group for Pancreatic Fistula (ISGPF) created a definition and grading system for pancreatic fistulae (PF) in which grade C denotes the most severe and potentially life-threatening type. Factors and outcomes associated with grade C fistulae have been ill defined. Methods: Systematic searches of PubMed and EMBASE were conducted by two independent reviewers utilizing the keywords 'pancreaticoduodenectomy' (PD) and 'pancreatic fistula'. Inclusion criteria were: (i) a sample of ≥100 patients; (ii) consecutive accrual of all pathologies, and (iii) use of the ISGPF definition and grading system. Quality appraisal and data extraction were performed using pilot-tested templates. Results: Fourteen articles describing a total of 2706 PDs met the study entrance criteria. Pancreatic fistulae occurred in 479 patients (18%) and included 71 grade C PF that were directly responsible for 25 deaths (35% mortality rate). Only two studies analysed risk factors; these found soft pancreatic texture and histology other than adenocarcinoma to be the most common risk factors. Ten studies reported management strategies and indicated that 51% of patients required reoperation. Conclusions: Grade C PF: (i) accounts for 15% of fistulae following PD and has an associated mortality rate of 35%; (ii) occurs most commonly in pathology associated with a soft remnant, and (iii) requires reoperation in approximately one half of patients. The published literature incompletely describes grade C PF.