Clinically Relevant Postoperative Pancreatic Fistula Research Articles

The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence.

Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups. Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013). The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

Prediction of clinically relevant postoperative pancreatic fistula using radiomic features and preoperative data

Clinically relevant postoperative pancreatic fistula (CR-POPF) can significantly affect the treatment course and outcome in pancreatic cancer patients. Preoperative prediction of CR-POPF can aid the surgical decision-making process and lead to better perioperative management of patients. In this retrospective study of 108 pancreatic head resection patients, we present risk models for the prediction of CR-POPF that use combinations of preoperative computed tomography (CT)-based radiomic features, mesh-based volumes of annotated intra- and peripancreatic structures and preoperative clinical data. The risk signatures were evaluated and analysed in detail by visualising feature expression maps and by comparing significant features to the established CR-POPF risk measures. Out of the risk models that were developed in this study, the combined radiomic and clinical signature performed best with an average area under receiver operating characteristic curve (AUC) of 0.86 and a balanced accuracy score of 0.76 on validation data. The following pre-operative features showed significant correlation with outcome in this signature (p < 0.05) - texture and morphology of the healthy pancreatic segment, intensity volume histogram-based feature of the pancreatic duct segment, morphology of the combined segment, and BMI. The predictions of this pre-operative signature showed strong correlation (Spearman correlation co-efficient, rho = 0.7) with the intraoperative updated alternative fistula risk score (ua-FRS), which is the clinical gold standard for intraoperative CR-POPF risk stratification. These results indicate that the proposed combined radiomic and clinical signature developed solely based on preoperatively available clinical and routine imaging data can perform on par with the current state-of-the-art intraoperative models for CR-POPF risk stratification.

Efficacy of Reinforced Stapler Versus Hand-sewn Closure of the Pancreatic Stump During Pure Laparoscopic Distal Pancreatectomy to Reduce Pancreatic Fistula.

Laparoscopic distal pancreatectomy (L-DP) is the standard procedure for treating left-sided pancreatic tumors. Stapler closure of the pancreas is the preferred method for L-DP; however, postoperative pancreatic fistula (POPF) remains a challenging problem. The present study aimed to compare the surgical outcomes of staple closure using a reinforcing stapler (RS) and transection using an ultrasonic dissector followed by hand-sewn (HS) closure in a fish-mouth manner in pure L-DP and to determine independent perioperative risk factors for clinically relevant postoperative pancreatic fistula (CR-POPF). Among the 85 patients who underwent pure L-DP between February 2011 and August 2021, 80 of whom the pancreatic stump was closed with RS (n = 59) or HS (n = 21) were retrospectively investigated. Associations between potential risk factors and POPF were assessed using univariate analysis. The factors, of which the P value was determined to be <0.1 by univariate analysis, were entered into a multivariate regression analysis to ascertain independent predictive factors. The surgery time and estimated blood loss were not significantly different between the two groups. Overall, 13 patients (16.3%) developed CR-POPF (B = 12 and C = 1). The rate of CR-POPF was lower in RS than in HS; however, the difference was not statistically significant (RS vs HS: 11.9% vs 28.9%, P = 0.092). Consistent with the results for CR-POPF, the rate of Clavien-Dindo IIIa or more postoperative complications and the length of hospital stay were also not significantly different between the two groups (RS vs HS: 10.2, 12% vs 14.3%, 14d). In the univariate analysis of risk factors for CR-POPF, the pancreatic thickness at the transection site, procedure for stump closure, and estimated blood loss were associated with a significantly higher rate of CR-POPF. The multivariate analysis revealed that the pancreatic thickness at the transection site (cutoff: 12mm) was the only independent risk factor for CR-POPF (odds ratio: 6.5l, 95% CI: 1.4-30.4, P = 0.018). The rate of CR-POPF was much lower in RS than in HS for pancreatic thickness <12mm (RS vs HS: 4.1% vs 28.6%), whereas that was rather higher in RS than in HS for pancreatic thickness ≥12mm (RS vs HS: 50% vs 28.6%). RS closure was superior to HS closure for pancreatic thickness <12mm and for prevention of CR-POPF after pure L-DP. It is necessary to seek more reliable procedures for pancreatic stump closure in patients with a pancreatic thickness of ≥12mm.

Factors predicting 30-day mortality after pancreaticoduodenectomy-the impact of elevated aspartate aminotransferase.

High preoperative bilirubin levels and cholangitis are associated with poor peri-operative outcomes following pancreaticoduodenectomy (PD). However, the impact of deranged preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels on immediate postoperative outcomes is relatively unexplored. We hypothesized that deranged AST and ALT lead to worse postoperative outcomes after PD. The aim of this study was to assess the factors contributing to postoperative mortality (POM) following PD, and to study the impact of deranged aminotransferases. This is a retrospective analysis of 562 patients. Risk factors for POM were computed using a multivariate logistic regression model. The rate of POM was 3.9%. On univariate analysis, the American Society of Anaesthesiologists grades, diabetes mellitus, cardiac comorbidity, preoperative biliary stenting, elevated serum bilirubin, AST, elevated serum creatinine, clinically relevant pancreatic fistula (CRPF), and grade B+C post-pancreatectomy hemorrhage (PPH) were associated with 30-day mortality. On multivariate analysis, preoperative elevated AST was independently predictive of 30-day POM (OR = 6.141, 95%CI 2.060-18.305, p = 0.001). Other factors independently predictive of POM were elevated serum creatinine, preoperative biliary stenting, CRPF and grade B and C PPH. The ratio of AST/ALT > 0.89 was associated with 8 times increased odds of POM. Elevated preoperative AST emerged as a predictor of 30-day POM after PD, with an 8-times increased odds of death with an AST/ALT ratio > 0.89.

Application of a sectional U-shaped reinforcement combined with penetrating pancreaticojejunostomy (U-PPJ) for soft pancreas in laparoscopic pancreatic surgery.

Laparoscopic techniques have been widely used in pancreatic surgery, such as laparoscopic pancreaticoduodenectomy (LPD) and laparoscopic central pancreatectomy (LCP). Laparoscopic pancreaticojejunostomy (LPJ) is a common procedure for LPD and LCP, and is also the most critical. The quality of LPJ is associated with the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). Although LPJ technology has been greatly improved, CR-POPF cannot be completely avoided especially to soft pancreas, which is an important reason for the high risk of laparoscopic pancreatic surgery. To date, there is a lack of standard LPJ approaches. Here, we report a U-shaped suture reinforcement for soft pancreatic section combined with penetrating pancreaticojejunostomy (PPJ) technique, called U-PPJ. Twenty-three patients with soft pancreas who underwent laparoscopic pancreatic surgery adopting U-PPJ method between 2017 and 2022 were enrolled (LPD = 19, LCP = 4). Preoperative, intraoperative and postoperative indexes were collected and analyzed. The results showed that all patients treated with U-PPJ were discharged without drainage tube or a small amount of exudate in the drainage tube does not require clinical treatment, but only needs to be removed after 2 days of observation. The average operation time was 417.35min. The intraoperative blood loss was 171.74ml. The pancreatic duct diameter was 3.41mm. The average postoperative hospitalization days were 11.83days. The average postoperative drainage tube removal time was 13.26days. The incidence of postoperative B-grade pancreatic fistula was 4.3%, and no C-grade pancreatic fistula occurred. In our experience, U-PPJ can be completed by a skilled surgeon in less than 20min. U-PPJ is safe, reliable, convenient and has a low incidence of CR-POPF in soft pancreas, which is worthy of clinical application. It also provides more options for laparoscopic pancreatic surgery. Since this is a retrospective study with a small number of cases, more prospective multicenter studies are needed to further verify its safety and efficacy.

Clinical impact of lactate on postoperative pancreatic fistula after pancreaticoduodenectomy: A single-center retrospective study of 1,043 patients

Background/objectivesSeveral hemodynamic markers have been studied to predict postoperative complication which is a risk factor for poor quality of life and prognosis. The aim of this study was to determine whether postoperative lactate clearance could affect clinical outcome based on complications in one surgical patient group. MethodsWe retrospectively reviewed data from all patients who underwent pancreaticoduodenectomy (PD) at Samsung Medical Center from January 2015 to December 2019. Differences in baseline characteristics of patients, intraoperative outcome, and postoperative outcome were evaluated according to the presence or absence of clinically relevant postoperative pancreatic fistula (CR-POPF). ResultsAmong a total of 1107 patients, 1043 patients were tested for arterial lactate levels immediately after surgery, and the day after surgery. Immediately postoperative hyperlactatemia (lactate ≥2.0 mmol/L) was not related to CR-POPF (P = 0.269). However, immediately postoperative hyperlactatemia with a negative lactic clearance on postoperative day (POD) 1 was related to CR-POPF (P = 0.003). In multivariate analyses, non-pancreatic cancer (hazard ratio (HR): 2.545, P < 0.001), soft pancreatic texture (HR: 1.884, P < 0.001), and postoperative hyperlactatemia with negative lactate clearance on POD 1 (HR: 1.805, P = 0.008) were independent risk factors for CR-POPF. ConclusionsHyperlactatemia with negative lactate clearance after PD, one of the high-risk surgeries requiring postoperative ICU care, is a risk factor for CR-POPF. In case of immediately postoperative hyperlactatemia after PD, lactate clearance with serial lactate level follow-up can be used for achieving the hemodynamic goal to prevent CR-POPF.

The visceral pancreatic neck anterior distance may be an effective parameter to predict post-pancreaticoduodenectomy clinically relevant postoperative pancreatic fistula

BackgroundThe clinically relevant postoperative pancreatic fistula (CR-POPF) is significantly correlated with a high post-pancreaticoduodenectomy (PD) mortality rate. Several studies have reported an association between visceral obesity and CR-POPF. Nevertheless, there are many technical difficulties and controversies in the measurement of visceral fat. The aim of this research was to determine whether the visceral pancreatic neck anterior distance (V-PNAD) was a credible predictor for CR-POPF. MethodsWe retrospectively analyzed the data of 216 patients who underwent PD in our center between January 2016 and August 2021. The correlation of patients’ demographic information, imaging variables, and intraoperative data with CR-POPF was assessed. Furthermore, areas under the receiver operating characteristic curves for six distances (abdominal thickness, visceral thickness, abdominal width, visceral width, abdominal PNAD, V-PNAD) were used to identify the best imaging distance to predict POPF. ResultsIn the multivariate logistic analysis, V-PNAD (P < 0.01) was the most significant risk factor for CR-POPF after PD. Males with a V-PNAD >3.97 cm or females with a V-PNAD >3.66 cm were included into the high-risk group. The high-risk group had a higher prevalence of CR-POPF (6.5% vs. 45.1%, P < 0.001), intraperitoneal infection (1.9% vs. 23.9%, P < 0.001), pulmonary infection (3.7% vs. 14.1%, P = 0.012), pleural effusion (17.8% vs. 33.8%, P = 0.014), and ascites (22.4% vs. 40.8%, P = 0.009) than the low-risk group. ConclusionOf all imaging distances, V-PNAD may be the most effective predictor of CR-POPF. Moreover, high-risk patients (males, V-PNAD >3.97 cm; females, V-PNAD >3.66 cm) have a high incidence of CR-POPF and poor short-term post-PD prognosis. Therefore, surgeons should perform PD carefully and take adequate preventive measures to reduce the incidence of pancreatic fistula when the patient has a high V-PNAD.

Risk factor analysis and prediction of postoperative clinically relevant pancreatic fistula after distal pancreatectomy

ObjectivePostoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) is a serious complication. In the present study, we aimed to identify the risk factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF) and establish a nomogram model for predicting CR-POPF after DP.MethodsIn total, 115 patients who underwent DP at the General Hospital of Northern Theater Command between January 2005 and December 2020 were retrospectively studied. Univariate and multivariable logistic regression analyses were used to identify the independent risk factors associated with CR-POPF. Then, a nomogram was formulated based on the results of multivariable logistic regression analysis. The predictive performance was evaluated with receiver operating characteristic (ROC) curves. Decision curve and clinical impact curve analyses were used to validate the clinical application value of the model.ResultsThe incidence of CR-POPF was 33.0% (38/115) in the present study. Multivariate logistic regression analysis identified the following variables as independent risk factors for POPF: body mass index (BMI) (OR 4.658, P = 0.004), preoperative albumin level (OR 7.934, P = 0.001), pancreatic thickness (OR 1.256, P = 0.003) and pancreatic texture (OR 3.143, P = 0.021). We created a nomogram by incorporating the above mentioned risk factors. The nomogram model showed better predictive value, with a concordance index of 0.842, sensitivity of 0.710, and specificity of 0.870 when compared to each risk factor. Decision curve and clinical impact curve analyses also indicated that the nomogram conferred a high clinical net benefit.ConclusionOur nomogram could accurately and objectively predict the risk of postoperative CR-POPF in individuals who underwent DP, which could help clinicians with early identification of patients who might develop CR-POPF and early development of a suitable fistula mitigation strategy and postoperative management.

Adjusting Drain Fluid Amylase for Drain Volume Does Not Improve Pancreatic Fistula Prediction

IntroductionDrain fluid amylase (DFA) levels have been used to predict clinically relevant postoperative pancreatic fistula (CR-POPF) and guide postoperative drain management. Optimal DFA cutoff thresholds vary between studies, thereby prompting investigation of an alternative assessment technique. As DFA measurements could, in theory, be distorted by variations in ascites fluid production, we hypothesized that adjusting DFA for volume corrected drain fluid amylase (vDFA) would improve CR-POPF predictive models. MethodsA single-institution retrospective cohort study of patients, who underwent pancreatoduodenectomies (PD) and distal pancreatectomies (DP) between 2013 and 2019, was performed. DFAs and vDFAs were measured on postoperative day (POD) 3. Clinicopathologic variables were compared between cohorts by univariable and multivariable analyses and Receiver operating characteristic (ROC) curves. ResultsPatients developing a CR-POPF were more likely to be male and have elevated DFA, vDFA, and body mass index (BMI). vDFA use did not contribute to a superior CR-POPF predictive model compared to DFA–a finding consistent on subanalysis of surgery type PD versus DP. In CR-POPF predictive models, DFA, vDFA, and male sex significantly improved CR-POPF predictive models when considering both surgery subtypes, while only DFA and vDFA significantly improved models when cohorts were segregated by surgery type. ConclusionsPostoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability.

Hypertension Requiring Medication Use: a Silent Predictor of Poor Outcomes After Pancreaticoduodenectomy

BackgroundAlthough hypertension requiring medication (HTNm) is a well-known cardiovascular comorbidity, its association with postoperative outcomes is understudied. This study aimed to evaluate whether preoperative HTNm is independently associated with specific complications after pancreaticoduodenectomy. Study DesignAdults undergoing elective pancreaticoduodenectomy were included from the 2014–2019 NSQIP-targeted pancreatectomy dataset. Multivariable regression models compared outcomes between patients with and without HTNm. Endpoints included significant complications, any complication, unplanned readmissions, length of stay (LOS), clinically relevant postoperative pancreatic fistula (CR-POPF), and cardiovascular and renal complications. A subgroup analysis excluded patients with diabetes, heart failure, chronic obstructive pulmonary disease, estimated glomerular filtration rate from serum creatinine (eGFRCr) < 60 ml/min per 1.73 m2, bleeding disorder, or steroid use. ResultsAmong 14,806 patients, 52% had HTNm. HTNm was more common among older male patients with obesity, diabetes, congestive heart failure, chronic obstructive pulmonary disease, functional dependency, hard pancreatic glands, and cancer. After adjusting for demographics, preoperative comorbidities, and laboratory values, HTNm was independently associated with higher odds of significant complications (aOR 1.12, p = 0.020), any complication (aOR 1.11, p = 0.030), cardiovascular (aOR 1.78, p = 0.002) and renal (aOR 1.60, p = 0.020) complications, and unplanned readmissions (aOR 1.14, p = 0.040). In a subgroup analysis of patients without major preoperative comorbidity, HTNm remained associated with higher odds of significant complications (aOR 1.14, p = 0.030) and cardiovascular complications (aOR 1.76, p = 0.033). ConclusionsHTNm is independently associated with cardiovascular and renal complications after pancreaticoduodenectomy and may need to be considered in preoperative risk stratification. Future studies are necessary to explore associations among underlying hypertension, specific antihypertensive medications, and postoperative outcomes to investigate potential risk mitigation strategies.

Predictive Value of Body Composition Parameters for Postoperative Complications in Patients Who Received Pancreaticoduodenectomy

Introduction: Sarcopenia and visceral obesity have been identified as risk factors for postoperative complications following hepatobiliary and colon surgery. However, the correlation between body composition parameters and morbidity following pancreatectomy remains unclear. This study aimed to assess the predictive value of body composition parameters measured from preoperative CT images for postoperative complications following pancreaticoduodenectomy (PD). Methods: A retrospective study of patients who underwent PD between January 2018 and January 2021 was performed. Areas of subcutaneous adipose tissue, visceral adipose tissue, total abdominal muscle area, and mean muscle radio-attenuation were measured from preoperative CT images. Postoperative complications were categorized according to the Clavien-Dindo classification, and comprehensive complication index (CCI) scores were calculated. Logistic regression analysis was performed to identify factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF) and high CCI score (≥26.2). Results: From the data collected on 129 study patients, sarcopenia, visceral obesity, and myosteatosis were detected in 47 (36.4%), 38 (29.4%), and 50 (38.7%) patients, respectively. CR-POPF developed in 51 (39.5%) patients, the overall median CCI score was 30.8 (22.6–36.2), and high CCI scores were identified in 70 (54.3%) patients. Multivariate analysis indicated sarcopenia and visceral obesity were independent risk variables for CR-POPF. Preoperative sarcopenia, visceral obesity, age, preoperative biliary drainage, and a positive culture of postoperative drainage were predictors of high CCI scores. Conclusion: Sarcopenia and visceral obesity were significant predictors of CR-POPF and high CCI score. Preoperative body composition assessment by CT images may help identify high-risk patients who undergo PD.

CAR viability: Predictive marker for fistula after whipple?

Background: Clinically-relevant postoperative pancreatic fistula (CR-POPF) is a relatively common and feared complication after pancreaticoduodenectomy. Currently, postoperative day (POD) 1 drain is the most accurate predictor of the future development of a CR-POPF. This is problematic as up to 41% of pancreatic surgeons report not regularly leaving intraperitoneal drains after pancreaticoduodenectomy. C-reactive protein-to-albumin ratio (CAR) is a novel inflammatory marker thought to be increased in CR-POPF. This study aims to assess this viability CAR to identify patients with CR-POPF after pancreaticoduodenectomy compared to the current standard.

Is it time to "POP" the pancreatic fistula risk score?

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common complication after pancreatoduodenectomy and is associated with significant mortality. The Fistula Risk Score (FRS), incorporating pancreatic duct size, parenchymal texture, blood loss, and at-risk pathology, is a validated tool for predicting CR-POPF. Postoperative pancreatitis (POP), reflecting parenchymal injury or ischemia, has been described in up to 40% of patients after pancreatoduodenectomy, but its association with POPF remains unclear. The aim of this study was to examine the relationships between POP, FRS, and CR-POPF.

Association of postoperative opioid use with pancreatic fistula rates after distal pancreatectomy

Background: The rate of clinically relevant postoperative pancreatic fistula (CR-POPF) after distal pancreatectomy ranges from 15-35% in the literature. Many risk factors have been reported with no consensus on their predictive value. Prior studies have observed an association between increased postoperative opioid use and fistula formation, secondary to increased sphincter of Oddi tone that leads to impaired emptying and increased pancreatic duct pressure. Our group has implemented perioperative care pathways, with each iteration increasingly using non-opioid medication bundles and reducing administered opioids. The aim of this study was to determine the association between perioperative variables, including early postoperative opioid use, and CR-POPF.

Machine learning predicts pancreatic fistula after whipple using only preoperative data

Background: Clinically-relevant postoperative pancreatic fistula (CR-POPF) following Whipple is a major complication and the primary determinant of surgical outcomes. Many risk calculators have been developed to identify patients at higher risk of developing CR-POPF. However, most of these published tools utilize intraoperative and postoperative variables, limiting their utility in the preoperative setting. We aimed to create a risk calculator for CR-POPF following Whipple using only preoperative variables.

Fistula risk score as a predictor of successful early discharge after pancreaticoduodenectomy

Background: Introduction: Enhanced recovery after surgery (ERAS) protocols have decreased length of stay (LOS), reduced hospital costs, and improved care following pancreaticoduodenectomy (PD). However, patients at high risk for complications may not be appropriate candidates for early discharge. The Fistula Risk Score (FRS) accurately predicts subsequent clinically relevant postoperative pancreatic fistula (CR-POPF). We hypothesized that low FRS would be associated with success to discharge by post-operative day (POD) 3.

Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

IntroductionConflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC). MethodsAll patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan–Meier survival analysis. ResultsOf the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC. ConclusionsObesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.

Comparative outcomes of extended distal pancreatectomy and distal pancreatectomy

Patients with locally advanced pancreatic body/tail tumors, gastric cancer, or colon cancer often have contiguous organ involvement requiring extensive pancreatic resection. This study was performed to compare surgical complications and the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between distal pancreatectomy (DP) with extended organ resection and standard DP. In total, 128 patients who underwent DP from January 2012 to January 2021 were retrospectively reviewed. Extended DP was defined according to the International Study Group of Pancreatic Surgery definition. Of the 128 patients, 62 (48.4%) underwent extended DP and 66 (51.6%) underwent DP. Blood loss was greater (p<0.001), the incidence of major complications was higher (p=0.032), and the hospital stay was longer (p=0.002) in the extended DP group than in the DP group. There were no differences in the incidence of CR-POPF, the readmission rate, or the need for postoperative intervention drainage. Univariate and multivariate analyses showed that extended DP was not a risk factor for CR-POPF or major complications. Extended DP can be performed with comparable CR-POPF occurrence and mortality but increased morbidity when compared with standard DP.

Nomogram predicts CR-POPF in open central pancreatectomy patients with benign or low-grade malignant pancreatic neoplasms.

Central pancreatectomy (CP) is a standard surgical procedure for benign and low-grade malignant pancreatic neoplasms in the body and neck of the pancreas. Higher incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) after CP than after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has been reported, but no nomogram for prediction of CR-POPF after open CP has been previously established. Patients undergoing open CP for benign or low-grade malignant pancreatic neoplasms in the department of Hepatobiliary and Pancreatic (HBP) surgery of Shanghai Changhai Hospital affiliated to Naval Medical University between January 01, 2009 and December 31,2020 were enrolled. Pre-, intra- and post-operative parameters were analyzed retrospectively. A total of 194 patients, including 60 men and 134 women, were enrolled with median age of 52 years (21~85 years). 84 patients (43.3%) were overweight (BMI>23.0 Kg/m2) and 14 (7.2%) were obese (BMI>28.0 Kg/m2). Pathological diagnoses ranged from serous cystic neoplasm (32.5%), solid pseudopapillary neoplasm (22.2%), pancreatic neuroendocrine tumor (20.1%), intraductal papillary mucinous neoplasm (18.0%) to mucinous cystic neoplasm (5.2%). All patients had soft pancreatic texture. Main pancreatic duct diameters were ≤0.3cm for 158 patients (81.4%) and were ≥0.5cm in only 12 patients (6.2%). A stapler (57.7%) or hand-sewn closure (42.3%) were used to close the pancreatic remnant. The pancreatic anastomosis techniques used were duct to mucosa pancreaticojejunostomy (PJ)-interrupted suture (47.4%), duct to mucosa PJ-continuous suture (43.3%), duct to mucosa "HO" half-purse binding PJ (5.2%) and invaginating pancreaticogastrostomy (4.1%). Post-surgical incidences of CR-POPF of 45.9%, surgical site infection of 28.9%, postpancreatectomy hemorrhage of 7.7% and delayed gastric emptying of 2.1% were found. Obesity and pancreatic anastomosis technique were independent risk factors of CR-POPF, with a concordance index of 0.675 and an Area Under the Curve of 0.678. This novel nomogram constructed according to obesity and pancreatic anastomosis technique showed moderate predictive performance of CR-POPF after open CP.

HPB P12 Pancreatoduodenectomy for confirmed malignancy: A complication profile from the Recurrence After Whipple's (RAW) study

Abstract Background Pancreatoduodenectomy (PD) is recommended in fit patients with resectable cancer affecting the pancreatic head or periampullary region. This operation can provide a cure in some patients but it remains high-risk. Although perioperative mortality rates have fallen below 2.0% in high-volume centres, complications still affect up to 50% of cases. Due to the nature of the resection and the subsequent anastomoses required, a number of general and procedure-specific complications may occur. Whilst a number of smaller studies have reported on procedure-specific outcomes, no large recent studies have aimed to put together a comprehensive complication profile. This international multicentre retrospective study aimed to calculate the incidence and severity of all PD complications in a cohort of patients with confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA) or cholangiocarcinoma (CC). Methods Patients were included if they underwent PD for histologically-confirmed PDAC, AA or CC at one of 28 participating units between 01/06/2012 and 31/05/2015. This end date was selected so that five-year follow-up data was available for all patients. Data was collected on the following complications: clinically relevant postoperative pancreatic fistula (CR-POPF), bile leak, gastrojejunal leak, postpancreatectomy haemorrhage (PPH), delayed gastric emptying (DGE), acute kidney injury (AKI), cardiac arrythmia, chest infection, cholangitis, chyle leak, Clostridium difficile infection, ileus, intra-abdominal collection, liver abscess, myocardial infarction (MI), pancreatic necrosis, pancreatitis, portal vein (PV)/superior mesenteric vein (SMV) thrombosis, sepsis of unknown origin, splenic vein thrombosis, surgical site infection (SSI), urinary tract infection (UTI), deep vein thrombosis (DVT), and pulmonary embolism (PE). Other complications could be entered by the data collector in free text. CR-POPF, bile leak, gastrojejunal leak, PPH and DGE were defined and categorised using internationally agreed definitions. All other complications were diagnosed based on predefined clinical and/or radiological criteria. All complications were graded using the Clavien-Dindo (CD) classification. When comparing patients who developed at least one complication to those who developed no complications, medians were compared using the Mann-Whitney U test. Other comparisons were made using Fisher's exact test. Results The analysis included 1,465 patients. Median age was 67 years and 44.2% were female. In total, 49.1% of patients experienced at least one complication; 25.4% of these were CD grade I, 48.5% were grade II, 17.1% were grade III, 5.7% were grade IV and 3.2% were grade V. CR-POPF affected 7.1% of cases (grade B: 81, grade C: 23), bile leak affected 2.7% (grade A: 13, grade B: 17, grade C: 10) and gastrojejunal leak affected 1.7% (grade A: 5, grade B: 8, grade C: 7). PPH was reported in 5.6% of cases (grade A: 17, grade B: 39, grade C: 26) and 11.3% developed DGE (grade A: 73, grade B, 58, grade C: 35). Seventy-seven patients (5.2%) had an unplanned return to theatre and 90-day mortality was 3.6%. The most common cause of death was PPH, followed by POPF, intra-abdominal sepsis and renal failure. Patients who experienced morbidity were significantly more likely to be female (41.3% vs 46.9%, p=0.03) or have a preoperative cardiovascular (49.3% vs 33.7%, p&amp;lt;0.0001) or respiratory co-morbidity (13.6% vs 8.3%, p=0.001). They were also less commonly ASA grade I or II (62.9% vs 70.0%, p=0.005). Conclusions In our international multicentre study of patients who underwent PD for confirmed malignancy, overall morbidity was 49.1% and perioperative mortality was 3.6%. Whilst minor complications were common, severe complications were rare. The incidences of CR-POPF, bile leak, gastrojejunal leak, and PPH were 7.1%, 2.7%, 1.4% and 5.6%, respectively. The most common cause of death was PPH. It is important that surgeons who perform PD have a sound understanding of its complication profile. This will allow them to evaluate their own performance when auditing and guide the consenting process.