Several explanatory questions:

Level of amylase in the drain? Distribution of IPMN in the residual pancreas?

Clarification - Whipple not Wipple

Dear Yonka

please tell us the drain secretion is bile stain or not? if you have bile and pancreas together , it is very dangerous and cause digestion of retroperitoneal tissue.

if you have not bile leakage and only pancreas fistula ,watch and wait and start para enteral nutrition and proper antibiotics only.

good luck

Dear Yonka

i recommend to read this paper

Send to

Scand J Gastroenterol. 2016 May 23:1-8. [Epub ahead of print]

Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review.

Søreide K1,2, Labori KJ3.

Author information

Abstract

BACKGROUND:

Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.

METHODS:

A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.

RESULTS:

A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.

CONCLUSIONS:

Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.

A practical classification of pancreatic fistula was published from the pancreatic study group in "Surgery". If you have only a small amount of fluid in the drains and it contains only pancreatic enzyma a watch and wait strategy under clinical observation is an option.

If the amount of fluid increases and contains bile and pancreatic enzyma and the pat. develops signs of sepsis, re-operation with creating an external pancreatic fistula and separating the bile duct anastomosis from the pancreatic on may be the procedure of choice.

The so called salvage pancreatectomy may be an option, too, but there is a high mortality.

 Thanks for the fast answers to everybody. Some adds:

@Prof Kostov – negative resection margin was obtained by frozen section, drain amylase was 10 times greater than serum, and thank you for the correction- it is my age to blame

@Prof Mahmoodzadeh- no there is no bile in either pancreatic or abdominal drains- the CBD was very thin so the bile anastomosis was Kehr protected. Thanks for the article- very intersting and practical

@Prof Becker – thank you for the very practical advices. The work of Prof Bassi is my preferred reading these days

Clinical picture is the cornerstone. 

Bowel movement, no sepsis = grade A fistula. Nothing per os, Ocreotide, antibiotics. 

CT scan = undrained collections - intervention radiology.

Progressive sepsis, unavailability of dedicated radiologist = relaparotomy.

Please take into account timely completion of pancreatectomy, which maybe a lifesaving procedure. 

We have been used for years a recnstruction technique after pancreaticoduodenectomy  using a isolated jejunum loop for pancreatic anastomosis with great success  By using  this technique  when we have a pancreatic fistula  it is allways a isolated pancreatic fistula See our article recently published

Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: Five years of experience with zero mortality.

Machado MC, Machado MA.

Eur J Surg Oncol. 2016 May 29. pii: S0748-7983(16)30174-3. doi: 10.1016/j.ejso.2016.05.023. [Epub ahead of print]

PMID:

27266408

Free Article

In your case I would  recommend watching wait bvt I would start  oral feeding if the patient does not have delay gastric emptying problem

IPMN of main duct  and doing whipple  procedure looks odd.

If it is just elevated amylase , do not worry. It might just resolve. 

ak pujahari

Some update: on 6th day the drains drain nothing so they are removed. The patient has bowel movements and is eating. On 9th day we discharged him with Kehr and pancreatic drain to be removed in outpatient settings. Pathological report : Segmental main duct IPMN with moderate grade dysplasia and negative resection margins. LN- negative. I would like to thank everybody for fast and useful answers.

Dear Dr Yonko

Thanks for your update.

Good Luck

Dear Dr. Yonko;

in my opinion as long as there is no collection on radiology, good general condition of the patient, albumin level kept more than 35 and no sepsis, you can continue conservative treatment in the form of NPO, TPN, octreotides and follow up of drain and patients' vital data. With these measure I think this fistula will heal. Good luck

In cases of pancreatic fistula grade A  there is no need for parenteral nutrition   if the patient does not have  delay gastric empty There is also  no need for octreotide administration