Risk Factors and Mitigation Strategies for Pancreatic Fistula after Distal Pancreatectomy: Analysis of 2,026 Resections from the International, Multi-Institution Distal Pancreatectomy Study Group

Abstract

Clinically relevant pancreatic fistula (CR-POPF) after distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. This multinational, retrospective study of 2,026 DPs involved 52 surgeons at 10 institutions (2001 to 2016). CR-POPFs were defined by International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. CR-POPF occurred in 306 (15.1%) DPs. Risk factors independently associated with fistula included: BMI 25–30 kg/m2: odds ratio (OR) 1.38, 95% CI 1.01–1.87; ≥30 kg/m2: OR 1.52, 95% CI 1.11–2.09, hypoalbuminenia (OR 1.56, 95% CI 1.03–2.44), high-risk pathology (neuroendocrine or benign: OR 1.62, 95% CI 1.23–2.14), concomitant splenectomy (OR 2.02, 95% CI 1.27–3.21), and vascular resection (OR 2.25, 95% CI 1.23–4.11). However, the model had poor predictive discrimination (c-statistic 0.635). Intraoperative drainage was more frequently utilized in cases of increased fistula risk (OR 2.11, p = 0.013). CR-POPF rates varied by method of transection (stapled: 12.7% vs handsewn: 19.1% vs energy device: 24.2%, p < 0.001); however, in a multivariable model, method of transection, suture ligation of the pancreatic duct, staple size, and the use of mesh reinforcement, tissue patches, biologic sealants, or prophylactic octreotide were not independently associated with CR-POPF. From this multi-institutional analysis of pancreatic fistula after DP, CR-POPF cannot be reliably predicted, prohibiting risk score development and effective risk-adjusted analysis of mitigation strategies or surgeon performance.