A 62-year-old Indian woman undergoes total gastrectomy with D2 lymphadenectomy for T4aN3 gastric cancer. Intraoperatively, the tumour is found to directly invade the pancreatic body. The surgeon performs en bloc distal pancreatectomy and splenectomy along with total gastrectomy. Reconstruction is completed with a Roux-en-Y gastrojejunostomy. On postoperative day 5, the patient develops fever (38.5°C), tachycardia (110 bpm), and left upper quadrant pain. Drain output is serosanguinous with an amylase level of 450 U/L (normal <100 U/L). What is the most likely complication?

Explanation

## Pancreatic Fistula After En Bloc Distal Pancreatectomy **Key Point:** Pancreatic fistula is a common complication after distal pancreatectomy, particularly when performed en bloc with gastrectomy for locally invasive cancer. The elevated drain amylase, left upper quadrant pain, and fever on postoperative day 5 are classic for pancreatic fistula. ### Clinical Features of Pancreatic Fistula | Feature | Pancreatic Fistula | Anastomotic Leak | Splenic Infarction | |---------|-------------------|------------------|-------------------| | **Timing** | POD 3–7 | POD 1–3 (early) | POD 1–2 (early) | | **Drain amylase** | **Elevated (>3× serum)** | Normal or mildly elevated | Normal | | **Pain location** | Left upper quadrant | Epigastrium/left flank | Left flank | | **Fever pattern** | Persistent, low-grade | High fever, septic shock | Mild or absent | | **Peritoneal signs** | Mild | Severe (peritonitis) | Mild | **High-Yield:** Drain amylase >3 times the serum amylase is diagnostic of pancreatic fistula. In this case, drain amylase 450 U/L with serum amylase likely normal or <150 U/L confirms the diagnosis. ### Risk Factors for Pancreatic Fistula 1. **Distal pancreatectomy** — higher fistula rate than proximal resection 2. **Soft pancreatic parenchyma** — increased risk of stump leak 3. **Large pancreatic duct** — difficulty in achieving watertight closure 4. **En bloc resection** — additional tissue trauma and ischemia ### Management 1. **Conservative management (most cases):** - Keep drain in place; monitor output and amylase - NPO; IV fluids and electrolyte replacement - Broad-spectrum antibiotics if signs of infection - Octreotide (inhibits pancreatic secretion) — controversial but often used 2. **Intervention if:** - Persistent high-output fistula (>200 mL/day) after 4–6 weeks - Signs of sepsis or peritonitis - Drain becomes loculated or infected **Clinical Pearl:** Most pancreatic fistulas (>80%) resolve spontaneously with conservative management if adequately drained. Mortality is <5% with appropriate drainage and supportive care. ### Why Pancreatic Fistula Here? The patient underwent **en bloc distal pancreatectomy** for direct tumour invasion. The pancreatic stump is at high risk for leak due to: - Difficulty achieving a watertight closure on the soft distal pancreatic parenchyma - Ischemia from division of splenic vessels (which supply the pancreatic tail) - Inflammatory response from the malignancy and surgical trauma