After distal pancreatectomy pancreatic leakage from the stump of the pancreas may be due to drain failure or pancreatic ductal back pressure.

Hypothesis: The method to lower postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) involves controlling risk factors for leakage from the pancreatic stump.
Goal: The aim of this study was to identify controllable risk factors for POPF.
Methods: In order to promote homogeneity, we used a single surgeon case series and then calculated POPF with a public web-based tool based on the severity classification system of the International Study Group of Pancreatic Surgery (ISGPS). A total of 223 consecutive cases of DPs were reviewed. DP involved the same hand-sewn fish-mouth closure of the pancreatic stump. All received postoperative epidural anesthesia. Logistic regression analysis identified risk factors for clinically relevant POPF (grade B/C).
Results: Mortality was zero. ISGPS gradings were: no POPF 53%, grade A = 32%, B = 13.9%, and C = 0.9%. The clinical-relevant POPF (B/C) rate was 14.8% of which 24% represented surgical drain failure due to lack of patency and/or misplaced from their original location. Preoperative endoscopic ablation and/or stenting of Wirsung's duct was a significant risk factor to lower grade B/C leak (3%). Multivariate analysis identified two controllable risk factors-intraoperative blood loss >1,000 ml and those who did not undergo preoperative endoscopic interventions of Wirsung's duct. In the group with presumed intact pancreatic sphincters (no endoscopic intervention, n = 177), the use of postoperative intravenous opioids (with epidural failure) was a risk factor for B/C leak (34%). These findings suggest that increased back pressure in the pancreatic duct has a role in promoting pancreatic stump leakage.
Conclusions: Using the ISGPS definition and its web-based tool, the incidence of clinically relevant leakage was 14.8% in 223 cases of DP. Opportunities to lower this rate are improving our surgical drain technology, limiting intraoperative blood loss, and avoiding postoperative intravenous narcotics with epidural analgesia.