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The Value of Postoperative Measurement of Amylase in Abdominal Drainage Fluid After Pancreatic Surgery

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The Value of Postoperative Measurement of Amylase in Abdominal Drainage Fluid After Pancreatic Surgery IJHPD 201 2;2:31 –37. Safi et al. 31 www.ijhpd.com ORIGINAL ARTICLE OPEN ACCESS The value of postoperative measurement of amylase in abdominal drainage fluid after pancreatic surgery F Safi, S Bakathir, M Taha, T Lange, H El Salhat, F Branicki ABSTRACT serum amylase (≥100 IU/l) was found in 20/52 (38%) patients following pancreatic surgery. Introduction: Clinical symptoms accompanied The elevated amylase levels returned to normal by a continuous increase of amylase within four days. Abdominal drainage fluid concentration in abdominal drainage fluid and amylase values were found increased in 19/47 change in color of drainage fluid may indicate (40%) of patients. All elevated levels returned to the presence of fistula or leakage. Aims: To normal by the tenth post­operative day. The investigate the clinical relevance and utility of color of abdominal drainage fluid was sero­ post­operative (PO) monitoring of amylase and sanguinous in all cases. No clinical pancreatic lipase estimations in the serum and abdominal fistula or anastomotic leakage was evident (0/55 drainage fluid following pancreatic surgery. patients), all patients were discharged home. Methods: Seventy patients (37 males, 33 Conclusion: Documentation of transient females) who underwent duodenum­preserving elevation of serum amylase and abdominal pancreatic head resection [n = 12 (GI)], pylorus drainage fluid amylase levels did not appear to preserving Whipple’s procedure [n = 39 (GII)], be of clinical significance. segmental resection of the body of the pancreas [n = 4 (GIII)] and pancreas tail/body resection Keywords: Pancreatic anastomosis, Leakage, [n = 15] were enrolled in the study prospectively. Fluid amylase level. In G I, II and III (n = 55) duct mucosa anastomosis with the remnant of distal pancreas ********* was fashioned. The serum amylase and lipase levels and levels of amylase in drainage fluid Safi F, Bakathir S, Taha M, Lange T, Salhat HE, Branicki were measured pre­operatively and from PO day F. The value of postoperative measurement of amylase 1, until removal of the drain. Only 32 patients in abdominal drainage fluid after pancreatic surgery. received subcutaneous octreotide, 100 µg three International Journal of Hepathobiliary and Pancreatic times daily for five days. Results: Elevation of Diseases 2012;2:31–37. Article ID: 100009IJHPDFS2012 1 F Safi, 2S Bakathir, 3M Taha, 4T Lange, 2H El Salhat, 1 F Branicki Affiliations: 1 Department of Surgery, United Arab Emirates University; 2Department of Surgery, Tawam Hospital, Al ********* Ain, UAE; 3Department of Internal Medicine (Division Gastroenterology), Tawam Hospital, Al Ain, UAE; 4Weimer doi:10.5348/ijhpd­2012­9­OA­7 Hospital, Germany. Corresponding Author: Dr. Farouk Safi, Professor Department of Surgery, Faculty of Medicine & Health Sciences, United Arab Emirates University, P.O. Box 1 7666, Al Ain, United Arab Emirates; Email: INTRODUCTION [email protected] The three fundamental techniques for reconstruction to enable pancreatic exocrine secretion after proximal Received: 27 December 2011 pancreas resection are end to side pancreatico­ Accepted: 03 April 201 2 Published: 08 November 201 2 jejunostomy, end to side pancreatico­gastrostomy and end to end invaginating anastomosis. IJHPD – International Journal of Hepatobiliary and Pancreatic Diseases, Vol. 2, 201 2. ISSN – [2230 - 901 2] IJHPD 201 2;2:31 –37. Safi et al. 32 www.ijhpd.com The mortality rate after pancreatic resection has drainage fluid postoperatively or during deteriorating decreased to less than 5% but reported morbidity clinical status of the patient are essential for the remains high [1]. Even today, following resection, diagnosis of anastomotic failure, 3) to follow up the morbidity ranges from 6–57%. Fistula rate after patients with high abdominal drainage/serum amylase resection is 0–20% with a morbidity of 0–13% [1]. The levels in order to document whether the patient main cause of serious morbidity and mortality is developed surgical complications in the form of postoperative anastomotic leakage due to intra­ anastomotic or stump failure and, 4) to evaluate the peritoneal release of enterokinases and activation of value of octerotide in reducing failures. pancreatic enzymes that lead to sepsis and hemorrhagic complications. Failure of the remnant proximal pancreatic duct closure after left sided pancreatic MATERIALS AND METHODS resection causes milder complications as compared to anastomotic failure of an entero­entero anastomosis but A prospective study was conducted which included it can result in fistula formation or an intra­abdominal all patients undergoing pylorus preserving proximal fluid collection [1]. pancreaticoduodenectomy (PD), duodenum preserving The failure in the integrity of an anastomosis pancreas head resection (DPPHR), segmental resection between the remnant pancreas and the gastrointestinal of the pancreas with anastomosis (SR) and distal tract can result in a fistula with leakage of pancreatic pancreatectomy (DP) by the same surgeon between secretions outside the abdominal cavity. This may occur January 2000 ­ July 2011. Data collected included without significantly affecting the general condition of patient demographics, type of operation carried out, the patient or it may prolong in­hospital treatment or hospital mortality, morbidity, and the need for lead to discharge of the patient with the fistula until reoperation and readmission. spontaneous closure occurs. Failure of anastomotic Instructions were given to nurses and residents integrity may well give rise to intra­abdominal fluid regarding the need to measure the serum and collections, sepsis, hemorrhage, peritonitis and death. abdominal drainage fluid amylase and lipase Strasberg et al. classified pancreatic anastomotic failure concentrations daily starting from the first postoperative into five grades depending on the clinical course day and to inject octereotide subcutaneously in a dosage following this complication. Pancreatic anastomotic of 3x100 µg; 3x200 µg or 3x300 µg for variable periods. failure grade I requires normal post­operative therapy All patients who underwent pancreatic resection and without any need for additional treatment; in grade II anastomosis had two drains (without suction), one there is need for pharmacological support; grade III placed in a sub­hepatic location, the second adjacent to requires interventional therapy; grade IV requires the pancreatic anastomosis. A single abdominal drain surgical and intensive care treatment and grade V is was used for patients undergoing DP and was placed death [2]. adjacent to the pancreatic stump. The decision to The International Study Group for Pancreatic Fistula remove the drains was dependent on the levels of Definition reviewed several previous scores/definitions amylase recorded postoperatively, the color of the of pancreas anastomotic failure on the basis of two abdominal fluid and the general clinical condition of the parameters; 1) daily output in ml, 2) and amylase patient. The upper limit of the reference range of concentration in the drained abdominal fluid, and 3) the amylase in our laboratory was 100 IU/L. duration of the fistula. Suspicion of and diagnosis of Surgical technique: Pancreaticojejunostomosis fistula depends on monitoring the output of the was performed by the same surgeon (FS) in all patients abdominal drainage system, the concentration of as follows. A retro­colic jejunal limb was brought amylase in drainage fluid more than three times the through a window in the transverse colon, an end to side serum concentration after third post­operative day, pancreatico­jejunal anastomosis was fashioned in two color of the fluid, general condition of the patient, and layers; a duct to mucosa anastomosis was made using radiologic documentation. The Group also proposed an PDS® 5/0 or 6/0 interrupted sutures; all knots were A, B or C clinical grading system: a) well patient, b) placed outside the lumen. The second layer involved a often well, and c) appearing ill [1]. pancreas parenchyma­seromuscular interrupted sutures Theoretically, the drainage fluid should be rich in using 4/0 PDS®. This technique was performed amylase when pancreatic fluid leaks from the pancreatic regardless of the diameter of the pancreatic duct. stump and anastomotic failure. Therefore, ‘amylase rich’ Following distal pancreatectomy, the pancreatic duct drainage has been one of the most popular definitions of was closed separately using prolene® 4/0 U shaped pancreatic duct leakage used in the literature [3]. The sutures, followed by parenchyma­parenchyma suturing purpose of are study was: 1) to investigate the value of using interrupted prolene® 4/0 sutures. measurement of amylase concentration in serum and abdominal drainage fluid in diagnosing anastomotic or stump failure after pancreatic surgery and to determine RESULTS if a correlation exists between the dynamics of post­ operative changes in amylase concentration in drainage Results are summarized in table 1–4. The tables fluid with clinical outcome, 2) identify whether high show the number of patients with serum amylase values concentrations of amylase in the serum or in abdominal of more than 100 IU/L. There was missing data for IJHPD – International Journal of Hepatobiliary and Pancreatic Diseases, Vol. 2, 201 2. ISSN – [2230 - 901 2] IJHPD 201 2;2:31 –37. Safi et al. 33 www.ijhpd.com amylase drainage fluid later in the post­operative course considering the color of the fluid, normalizing or when drains had been removed or no
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