The Effects of Different Treatments on Postoperative Pancreatic Fistula (POPF)*

Pancreatoduodenectomy (PD), the most challenging operation in general surgery, plays an important role in pancreatic head tumors and ampulla neoplasms [1]. With the improvement of surgical techniques and the introduction of a more effective predictive risk scoring system in recent years, the postoperative mortality rate for PD dropped from 25% to less than 5%, but the postoperative morbidity rate still remains at a high level, even up to 60% [2–4]. POPF affects between 13% and 41% of patients who undergo PD. Once it occurs, it always results in prolonged duration of hospital stays and substantial resource utilization. Furthermore, the original illness will be exacerbated, even leading to death [5].

According to the new consensus published in “The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After”, the definition of POPF is more strict. POPF is classified according to three grades of severity: BL (biochemical leak), grade B POPF and grade C POPF. BL has no clinical impact and does not require any special treatment as long as it does not transition into CR-POPF (a clinically relevant postoperative pancreatic fistula including grade B POPF and grade C POPF). CR-POPF is redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, which is associated with a clinically relevant condition related directly to the postoperative pancreatic fistula [6]. CR-POPF occurs in 12% patients who undergo PD, and the mortality rate is up to 39%. Nevertheless, a consensus on the optimal treatment strategy for CR-POPF is lacking [7]. In clinical practice, the majority of POPF can be cured spontaneously with conservative therapy, and minimally invasive treatment is becoming mainstream for those whose condition cannot be resolved with conservative therapy. Relapalarotomy is necessary only when uncontrolled sepsis and multi-organ failure occur or when percutaneous or endoscopic drainage is inadequate [4]. The minimally invasive procedures have two main routes that have been demonstrated to be both effective and safe. The first is the percutaneous route, which is a well-documented standard treatment for POPF. Some studies have shown that more than 85% patients can manage successfully with the percutaneous route [5]. The other is the transgastric route, which is utilized to drain those collections that are positioned in the lesser sac and cannot be reached by the percutaneous route [2]. Many studies have shown that the treatment success (79–100%) is similar between the two techniques [5]. Though the minimally invasive procedures have been gradually accepted, some studies still report a relaparotomy rate varying from 15% to 50%, implying some hesitation to treat POPF with a minimally invasive approach [7]. Therefore, a novel treatment should be introduced to those for whom percutaneous or endoscopic drainage is inadequate.

In recent years, percutaneous or transgastric catheter drainage was followed by percutaneous or transgastric debridement or necrosectomy, if needed, has gradually been accepted as standard treatment for infected pancreatic necrosis (IPN), showing more advantages than open necrosectomy (ON) [7,8]. While there are a number of reports regarding the effects of percutaneous endoscopic necrosectomy (PEN) on IPN [7], little was known about the application of PEN to CR-POPF until Jian Li and his colleagues conducted a retrospective cohort study at the Fujian Medical University evaluating the efficacy of PEN combined with percutaneous catheter drainage (PCD) and irrigation versus PCD for the treatment of CR-POPF after PD. A total of 34 patients were enrolled in the study. The combination therapy group, which received PEN combined with PCD and irrigation, contained 12 patients, and the other 22 patients were in the PCD group, which received PCD only. The authors concluded that the combination therapy group had a markedly lower rate of postoperative delayed severe intra-abdominal hemorrage. This was the first original study to evaluate PEN combined with PCD and irrigation, and it can provide reference for the treatment of the POPF.

Unfortunately, this study had some drawbacks. It was a single-center restrospective study and the sample size was small, both of which limit the reliability of the conclusion. However, in addition to its effects on IPN, there are reasons to believe that PEN combined with PCD and irrigation is a safe and effective treatment for CR-POPF after PD. Though PEN is gradually being used to treat POPF, more randomized controlled trials are needed to verify the conclusion of Jian Li et al.’s study.

Declaration of interest

No potential conflict of interest was reported by the author(s).