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XXII Congresso Nazionale S.I.FI.PA.C. Padova, Aprile 2009

XXII Congresso Nazionale S.I.FI.PA.C. Padova, Aprile 2009. GESTIONE DEL MONCONE PANCREATICO: TRATTAMENTO DELLE FISTOLE. Prof. Claudio Bassi MD, FRCS Dipartimento di Scienze Chirurgiche Università di Verona. XXII Congresso Nazionale S.I.FI.PA.C. Padova, Aprile 2009.

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XXII Congresso Nazionale S.I.FI.PA.C. Padova, Aprile 2009

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  1. XXII Congresso Nazionale S.I.FI.PA.C.Padova, Aprile 2009 GESTIONE DEL MONCONE PANCREATICO:TRATTAMENTO DELLE FISTOLE. Prof. Claudio Bassi MD, FRCS Dipartimento di Scienze Chirurgiche Università di Verona

  2. XXII Congresso Nazionale S.I.FI.PA.C.Padova, Aprile 2009 GESTIONE DEL MONCONE PANCREATICO:TRATTAMENTO DELLE FISTOLE. CONCLUSIONE Il Sig. Moderatore ha ragione!

  3. POST – OPERATIVE PANCREATIC FISTULA: CONSENSUS DEFINITION(and grading!!!)Surgery 2005;138:8

  4. Grade A Fistulas Modified by Pratt et al. from Bassi C et al. Surgery 2005; 138: 8-13.

  5. Grade B Fistulas Modified by Pratt et al. fromBassi C et al. Surgery 2005; 138: 8-13.

  6. Grade C Fistulas Modified by Pratt et al. from Bassi C et al. Surgery 2005; 138: 8-13.

  7. “sinister appearance? … no!”take it out as soon as possible!! Kawai M et al. Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection. Prospective study for 104 consecutive patients. Ann Surg. 2006;244:1–7.

  8. “sinister appearance? …yes!”look to amylase content!Radiological support!

  9. “sinister appearance? …yes!”look to amylase and bacteria!Radiological support!

  10. CT scan: a determinant role in the algorithm management of POPF!

  11. Dalla teoria alla pratica … • 1996 – 2008: 1075 DCP • 4 decessi (0.4%) – 33 reinterventi (3.5%) • 182 POPF (17%) • 39 Grado A (21.2%) • 124 Grado B (68.3%) • 19 Grado C (10.5%) • 143 fistole con impatto clinico (13.3%) … e tutti hanno fatto una CT … ma non solo !!!

  12. Perchè non solo la CT ??? Role of fistulography in characterizing pancreatic fistula after pancreaticoduodenectomy: back to the future? Faccioli N, Molinari E, Hermans JJ, Comai A, D’Onofrio M, Bassi C, Pozzi Mucelli R. Radiology (submitted)

  13. Role of fistulography in characterizingpancreatic fistula afterpancreaticoduodenectomy: back to thefuture? • Eighty-four consecutive fistulographies were executed for clinical suspicion of PF after PD (mean time after surgery 11 days, range 6–20). to determine: • the position of the tip of the drainage catheter • the presence or absence of a communication with jejunal loop or stomach, of fistulous tract, of fluid collections, of communication with the main pancreatic duct, and with the biliary tree. • two groups were statistically analyzed depending on presence or absence of fistulous tract.

  14. Pancreatic fistula!

  15. POPF

  16. POPF

  17. Fistula due to decubitus of the drainagein PJ in PG

  18. Role of fistulography in characterizingpancreatic fistula afterpancreaticoduodenectomy: back to thefuture?

  19. Role of fistulography: back to the future?useful by identifying erosion or migration of the drain and for interventional radiologically guided drain management!

  20. Role of fistulography in characterizingpancreatic fistula afterpancreaticoduodenectomy: back to thefuture? In 49/84 (58.3%) the clinical suspect of PF was confirmed by the execution of fistulography. In the other 35/84 (41.7%) patients fistulography demonstrated a fistula due to decubitus of the drainage catheter. None of the 84 patients required surgical reoperations! All survived with conservative treatment (Rx guide drain management, TPN/EN, Antisecretive and Antibiotics)

  21. Postoperative Pancreatic FistulasPreventing Severe Complications and Reducing Reoperationand Mortality RateSergio Pedrazzoli, MD, FACS,* et al.(Ann Surg 2009;249: 97–104) • An early aggressive treatment based on interventional radiology was applied. The drain’s track and/or percutaneous approach was used to insert catheters into the peripancreatic fluid collection or abscess. The position of catheters was verified at least once a week. • The main results are zero mortality, zero completion pancreatectomies, and a 4.2% reoperation rate for 70/445 consecutive POPFs. • The best way to prevent severe complications from a POPF is to obtain a perfect drainage without stasis and consequent infection of the pancreatic juice. • Early interventional radiology aimed to capture pancreatic juice as close to its origin as possible may prevent reoperative surgery in most of our patients. Furthermore, using the surgical drain as an access route minimized the need of a percutaneous procedure.

  22. XXII Congresso Nazionale S.I.FI.PA.C.Padova, Aprile 2009 GESTIONE DEL MONCONE PANCREATICO:TRATTAMENTO DELLE FISTOLE. CONCLUSIONE Il Sig. Moderatore ha ragione!

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