Stump Ischemia Is a Possible Risk Factor for Late‐Onset Pancreatic Fistula After Distal Pancreatectomy

BACKGROUND: This study was conducted to determine the clinical significance of pancreatic stump ischemia (PSI) in predicting late-onset pancreatic fistula (LOPF) following stapled distal pancreatectomy (DP). METHODS: A total of 165 patients who underwent stapled DP between July 2018 and March 2024 were included. PSI was defined as a non-enhancing area between the pancreatic stump and stapler line on postoperative contrast-enhanced computed tomography (CT). LOPF was diagnosed when peripancreatic fluid collection necessitated antibiotics and/or image-guided drainage after drain removal. RESULTS: LOPF developed in 19 patients (11.5%). PSI was detected in 40 patients (24.2%) and was significantly more frequent in those with LOPF (47.4% vs. 21.2%). Receiver operating characteristic curve analysis identified a PSI width of ≥ 1.9 mm as the optimal threshold LOPF prediction. The incidence of LOPF was 26.5% among 81 patients with positive PSI (≥ 1.9 mm) on contrast-enhanced CT within 90 days postoperatively. By contrast, LOPF did not develop beyond 90 days following surgery, even when PSI was present. CONCLUSION: PSI may be interpreted as a radiologic factor associated with LOPF after stapled DP. Conservative drain management and close postoperative follow-up are recommended when an ischemic band ≥ 2 mm along a stapler line is detected on early postoperative CT.