Early Fistulography Can Predict Whether Biochemical Leakage Develops to Clinically Relevant Postoperative Pancreatic Fistula

Background As complete prevention of postoperative pancreatic fistula (POPF) after pancreatic surgery remains difficult, many risk factors for clinically relevant POPF (CR-POPF) have been reported. However, their clinical impact could be limited because all previous reports included patients without biochemical leakage (BL) that rarely developed to CR-POPF. Therefore, a new strategy for identifying high-risk patients who develop delayed complications from patients with confirmed BL and for implementing interventions for such patients in the early postoperative period is required. This study aimed to examine the role of fistulography in predicting CR-POPF from confirmed BL. Methods Consecutive patients diagnosed with BL on postoperative day 3 after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from January 2013 to June 2015 in our institution were included. Fistulography was performed 1 week after the operation, and the associations between findings on fistulography and delayed complications associated with POPF were evaluated. Results Eighty-four (37%) of 227 patients who underwent PD and 45 (48%) of 94 patients who underwent DP were included and divided to two groups according to fistulographic findings (simple type, n = 107, 83%; cavity type, n = 22, 17%). The latter finding was associated with a greater morbidity rate (Clavien–Dindo grade ≥ 2: 36% vs 59%, p = 0.018) and a worse final POPF grade (B/C 64% vs 95%, p = 0.003). In the multivariate analysis, cavity type on fistulography was a significant predictive factor for grade B/C POPF. Conclusions Fistulography is a useful examination for identifying patients with a high risk of developing delayed complications associated with POPF.