• Kjetil Søreide, Andrew J Healey, Damian J Mole, and Rowan W Parks.
• Clinical Surgery, University of Edinburgh, UK; Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK; Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway; Gastrointestinal Translational Research Unit, Laboratory for Molecular Biology, Stavanger University Hospital, Stavanger, Norway. Electronic address: ksoreide@mac.com.
• HPB (Oxford). 2019 Dec 1; 21 (12): 1621-1631.

BackgroundThe most hazardous complication to pancreatic surgery is the development of a post-operative pancreatic fistula (POPF). Appropriate understanding of the underlying pathophysiology, risk factors and perioperative mechanisms may allow for better management and use of preventive measures.MethodsSystematic literature search using the English PubMed literature up to April 2019, with emphasis on the past 5 years.ResultsSeveral risk scores have been developed but none are perfect in predicting POPF risk. A conceptual framework of factors that contribute to the pathophysiology of pancreatic fistulae is still developing but incomplete. Recognized factors include those related to the patient, the pathology and the perioperative care. Interventions such as use of drains, stents and various drugs to mediate risk is still debated. Emerging data suggest that both the microbiome and the inflammation in the post-operative phase may play important roles in risk for POPF. Available risk scores allow for stratification of risk and mitigation strategies tailored to reduce this. However, accurate estimation of risk remains a challenge and mechanisms are only partially understood.ConclusionsThe pathophysiology of POPF remains poorly understood. Current models only partially explain risks or associated mechanisms. Novel areas of investigation need to be explored for better prediction.Copyright © 2019 International Hepato-Pancreato-Biliary Association Inc. All rights reserved.

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