The International Study Group for Pancreatic Surgery (ISGPS) Definition and Classification of Postpancreatectomy Mortality.

Evaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center

To prospectively validate the recently established International Study Group for Pancreatic Surgery (ISGPS) pancreas classification as a parenchymal risk classification system for pancreatic fistula after pancreatoduodenectomy. Postoperative pancreatic fistula (POPF) is the major driver for complications after partial pancreatoduodenectomy (PD). Recently, the ISGPS published a pancreas classification containing the parameters of main pancreatic duct diameter and pancreatic texture to help assess the risk of POPF development after PD. From January 2020 to July 2021, 271 patients receiving elective PD were included after informed consent. The postoperative course was documented prospectively up to postoperative day 30. Among the pancreas characteristics, the main pancreatic duct and pancreatic texture were assessed intraoperatively at the pancreatic resection margin, and the pancreatic glands were assigned to one of the 4 pancreas classes according to the ISGPS (A-D). The primary endpoint was POPF according to the updated ISGPS definition. Secondary endpoints comprised other post-PD morbidity and mortality. Of 271 patients, 264 had available data according to the ISGPS pancreas classification. Of those, 78 were assigned to class A (30%), 53 to class B (20%), 50 to class C (19%) and 83 to class D (31%). POPF occurred in 54 of 271 patients (19.9%). The 30-day mortality was 7/271 (2.6%), with 6/7 having developed POPF (86%). POPF rates within the classes A, B, C, and D were 9.0%, 11.3%, 20.0%, and 37.4%, respectively ( P < 0.001). In the univariable regression analysis, only patients in pancreas class D demonstrated a significantly higher risk for POPF when compared with class A (odds ratio: 6.05; 95% CI: 2.6-15.9; P < 0.001). In the multivariable regression model, patients in class D had a significantly higher risk for POPF compared with class A (odds ratio: 3.45; 95% CI: 1.15-11.3; P = 0.032). The model comprised body mass index, surgery duration, microscopic fibrosis, and the ISGPS pancreas classification, demonstrating an area under the curve (AUC) value of ∼0.82 when tested on the PARIS data set. This prospective trial shows that the ISGPS pancreas classification is valid. Patients in risk class D are prone to POPF independently of other factors. Therefore, all future publications on pancreatic surgery should report the risk class according to the ISGPS pancreas classification to allow for a better comparison of reported cohorts.

The aim of the present study was to evaluate the clinical implications of the 2016 International Study Group for Pancreatic Surgery (ISGPS) definition and classification of postoperative pancreatic fistula (POPF) using a single high-volume institutional cohort of patients undergone pancreatic surgery. The ISGPS definition and grading system of POPF has been recently updated. Although the rationale for the changes was supported by previous studies, the effect of the new definition and classification scheme on surgical series has not been established. A total of 775 patients undergone pancreatic surgery in our institute from 2013 to 2015 were reviewed. The parameters modified in the ISGPS classification were analyzed according to postoperative outcomes. Finally the classification was validated by external clinical and economical outcomes. Applying the 2016 scheme, 17.5% of patients changed classification group compared to the 2015 system. Grade B increased from 11.5% to 22.1%, whereas grade C decreased from 15.2% to 4.6%. Biochemical leak occurred in 7% of patients, and it did not differ from the non-POPF condition in terms of surgical outcomes. Non-POPF group, grades B and C POPF differed significantly in terms of intensive care unit staying (P < 0.001), length of stay (P < 0.001), readmission rate (P < 0.001), and hospital costs (P < 0.001). The present study has confirmed the pertinence of the changes introduced in the 2016 ISGPS POPF definition and grading. This updated classification is effective in identifying three conditions that differ in terms of clinical and economic outcomes. These results suggested the reliability of the new definition and scheme in classifying POPF-related outcomes.

Outcomes of pancreatic resection: Analysis of the french national database on 6436 patients

External validation of ISGPS two-factor, four-tier classification for the prediction of pancreatic fistula after pancreaticoduodenectomy.

BackgroundPost-pancreatectomy acute pancreatitis (PPAP) is an increasingly described complication after pancreatic resection. No uniform definition criteria were present in the literature until the recent proposal of the International Study Group of Pancreatic Surgery (ISGPS). Aim of this study is to evaluate the clinical significance of the novel ISGPS definition of PPAP. MethodsPatients who underwent pancreatoduodenectomy (PD) between 2006 and 2022 were enrolled. PPAP was defined and graded according to the ISGPS criteria. ResultsAmong 520 PDs, 120 (23%)patients developed post-operative hyperamylasemia (POH), while PPAP occurred in 63(12.1%) cases. PPAP occurrence related to a higher rate of more severe complications (48–76.1%vs118–25.8%; p < 0.0001), delayed gastric emptying (DGE) (27–42.9%vd114–24.9%; p = 0.003) and post-operative pancreatic fistula (POPF) (57–90.5%vs186–40.8%; p < 0.0001). When stratified for PPAP severity, grade B and C patients more frequently developed major complications (p < 0.0001), POPF (p < 0.0001), DGE (p = 0.02) and post-operative hemorrhage (p < 0.0001) as compared to POH. At the multivariable analysis, soft pancreatic texture (p = 0.01)and a Wirsung diameter ≤3 mm (p = 0.01) were recognized as prognostic factors for PPAP onset, while a pancreatic duct ≤3 mm was the only feature significantly influencing a more severe course of PPAP (p = 0.01). ConclusionThe ISGPS classification is confirmed as a valuable method for a uniform definition and clinical course evaluation. Further studies in a prospective manner are still needed for a further confirmation.

Moving towards the New International Study Group for Pancreatic Surgery (ISGPS) definitions in pancreaticoduodenectomy: a comparison between the old and new

Systematic review of the literature on the use of sealants in pancreatic surgery

Postoperative pancreatic fistula (POPF) remains the major postoperative cause of morbidity and mortality following pancreatic surgery. Since 2005, the International Study Group of Pancreatic Fistula (ISGPF) definition and classification has been adopted worldwide allowing the comparison among different surgical approaches and mitigation strategies. Over the last 11 years, several limitations have emerged from clinical practice and in 2016 the International Study Group for Pancreatic Surgery (ISGPS) updated the POPF definition and grading system. Objectives of this review article were to summarize modifications in the updated ISGPS definition and to illustrate their clinical impact.

Reappraisal of post-pancreatectomy hemorrhage (PPH) classifications: do we need to redefine grades A and B?

Postoperative pancreatic fistula: We need to redefine grades B and C

Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)

After Distal Pancreatectomy Pancreatic Leakage from the Stump of the Pancreas May Be Due to Drain Failure or Pancreatic Ductal Back Pressure

Pancreatic fistulae after pancreatic resections for neuroendocrine tumours compared with resections for other lesions

Background: Complications in pancreatic surgery are potentially life-threating. Post-operative pancreatic fistulas (POPF) can form in pancreatic tissue after surgery and can cause peripancreatic fluid collections and infections. In addition, pancreatic fluid is corrosive and can lead to post-operative bleeding in the operative area. Clinically significant class B and C fistulas increase post-operative morbidity and can lead to prolonged hospital stay. Delaying of adjuvant therapy due to fistula formation in cancer patients can affect their prognosis. Diagnosis of pancreatic fistula can be set according to international study group of pancreatic surgery (ISGPS) criteria (Bassi et al. 2016). Previously, the use of perioperative pasireotide decreased the number of clinically relevant pancreatic fistulas (Allen et al. N Engl J Med 2014). According to Seppänen et al. (abstr. 2016) the use of pasireotide after pancreaticoduodenectomy was seen beneficial in risk patients.