Potential Utility of Intraoperative Fluid Amylase Measurement during Pancreaticoduodenectomy

Abstract

Introduction: Postoperative pancreatic fistula (POPF) is an important cause of morbidity after pancreaticoduodenectomy (PD), and may be predicted by preoperative and postoperative factors, including BMI, pancreatic duct width and first postoperative day drain fluid amylase (DFA1). We hypothesised that raised intraoperative amylase concentrations (IOAC) in intra-abdominal fluid taken adjacent to the pancreatic anastomosis may correlate with DFA1 and/or POPF. Methods: Intra-abdominal fluid samples were taken from adjacent to the pancreatic anastomosis immediately prior to abdominal closure and sent for fluid amylase analysis (IOAC) in patients undergoing PD. The relationship between IOAC and DFA1/POPF were evaluated using Pearson correlation. A cut-off value for IOAC to exclude POPF was determined by ROC analysis. Results: Data was prospectively collected for 52 patients who underwent PD between February-November 2020. All patients underwent an end-side pancreaticojejunostomy anastomosis. There was significant correlation between IOAC and DFA1 (R2 = 0.713; P<0.01). Using a cut-off value of IOAC = 260 U/L, IOAC<260 excluded a POPF with a negative predictive value of 97% (P= 0.001). 7/18 (39%) patients with IOAC≥260 developed POPF compared to only 1/34 (3%) patients with IOAC<260 (P = 0.001). Conclusion: Intraoperative detection of amylase-rich fluid adjacent to a completed pancreatic anastomosis is an early predictor of postoperative pancreatic fistula. Low risk patients with a low IOAC may be suitable for a ‘no drain’ strategy, whilst patients with a high IOAC may benefit from intraoperative mitigation strategies to reduce the incidence and/or severity of a postoperative pancreatic fistula.FP14.03ComplicationsSevere complications (CD grade>3a)5/529.6%Clavien Dindo GradesNo complications:15/5228.84%Biochemical pancreatic leak5/529.6%Grade 110/5219.2%CR-POPF (all grade C)3/525.8%Grade222/5242.30%PPH (all grade C)3/525.8%Grade 3a3/525.76%DGE (4 grade A, 1 grade B)5/529.6%Grade 3b1/521.92%In-hospital mortality1/521.9%Grade 40/5290-day mortalityCOVID-19Early cancer recurrence2/52113.8%1.9%1.9%Grade 51/521.92%ROC Curve AnalysisROCCut offSensitivitySpecificityPPVNPVAUROCCIP valueIOAC Vs DFA1>350236U/L82.4%82.9%70%90%0.9210.848 -0.9940.00IOAC Vs POPF260U/L87.5%75%38.88%97%0.9050.794 -1.0000.00 Open table in a new tab