Independent Predictor Of Postoperative Pancreatic Fistula Research Articles

Pancreatojejunostomy: standing on the shoulders of giants. A single centre retrospective analysis.

Gaining experience in pancreatic surgery could be demanding especially when minimally invasive approach is used. Pancreatojejunostomy (PJ) is one of the most critical steps during pancreatoduodenectomy (PD). Our aim was to investigate the impact of a surgeon's experience in performing PJ, especially in a subgroup of patients undergoing laparoscopic PD (LPD). Data of consecutive patients undergoing PD from 2017 to 2022 were prospectively collected and retrospectively analyzed. Patients were divided into two groups: M group included patients in which PJ was performed by an experienced surgeon, D group included those receiving PJ by a less experienced one. The groups were compared in terms of postoperative outcomes. 187 patients were selected (157 in group M and 30 in group D). The cohorts differed in terms of median age (68 vs 74years, p = 0.016), and previous abdominal surgery (41.4% vs 66.7%, p = 0.011), while no difference was found regarding risk of postoperative pancreatic fistula (POPF). The groups did not differ in terms of surgical outcomes. POPF rate was 15.9% and 10% in the M and D group (p = 0.578), respectively. Among patients undergoing laparoscopic PJ POPF rate was 16.0% and 17.7% in the M and D group (p = 0.867), respectively, without difference. No difference was found in terms of POPF in patients undergoing PD independently from the surgeon who performed the PJ, even during LPD. Moderate/high FRS, BMI > 30kg/m2 and male sex, but not the surgeon who performed the PJ anastomosis, were independent predictors of POPF.

Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort.

To evaluate the performance of published fistula risk models by external validation, and to identify independent risk factors for postoperative pancreatic fistula (POPF). Multiple risk models have been developed to predict POPF after pancreatoduodenectomy. External validation in high-quality prospective cohorts is, however, lacking or only performed for individual models. A post hoc analysis of data from the stepped-wedge cluster cluster-randomized Care After Pancreatic Resection According to an Algorithm for Early Detection and Minimally Invasive Management of Pancreatic Fistula versus Current Practice (PORSCH) trial was performed. Included were all patients undergoing pancreatoduodenectomy in the Netherlands (January 2018-November 2019). Risk models on POPF were identified by a systematic literature search. Model performance was evaluated by calculating the area under the receiver operating curves (AUC) and calibration plots. Multivariable logistic regression was performed to identify independent risk factors associated with clinically relevant POPF. Overall, 1358 patients undergoing pancreatoduodenectomy were included, of whom 341 patients (25%) developed clinically relevant POPF. Fourteen risk models for POPF were evaluated, with AUCs ranging from 0.62 to 0.70. The updated alternative fistula risk score had an AUC of 0.70 (95% confidence intervals [CI]: 0.69-0.72). The alternative fistula risk score demonstrated an AUC of 0.70 (95% CI: 0.689-0.71), whilst an AUC of 0.70 (95% CI: 0.699-0.71) was also found for the model by Petrova and colleagues. Soft pancreatic texture, pathology other than pancreatic ductal adenocarcinoma or chronic pancreatitis, small pancreatic duct diameter, higher body mass index, minimally invasive resection and male sex were identified as independent predictors of POPF. Published risk models predicting clinically relevant POPF after pancreatoduodenectomy have a moderate predictive accuracy. Their clinical applicability to identify high-risk patients and guide treatment strategies is therefore questionable.

Impact of pancreatic fat infiltration on postoperative pancreatic fistula occurrence in patients undergoing invagination pancreaticojejunostomy

BackgroundNo studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination pancreaticojejunostomy (IV-PJ). MethodsThe medical records of patients with a soft pancreas who underwent pancreatoduodenectomy followed by IV-PJ were reviewed . The pancreatic fat ratio on computed tomography (CT) images (I-PFR) was determined using preoperative CT and verified by histologic examination. The relationship between the I-PFR and POPF occurrence was determined. Patients were classified into 2 groups based on I-PFR value (fatty and non-fatty pancreas). Postoperative outcomes were compared between the two groups, and specifically among patients who developed POPF. ResultsOf 221 patients, POPF occurred in 67 (30.3%). I-PFR was positively correlated with histologic-calculated fat ratio (ρ = 0.517, p < 0.001). This index was shown to be an independent predictor of POPF. Based on an I-PFR cut-off value of 3.2%, 92 patients were classified in the fatty pancreas group. Subgroup analysis of the patients who developed POPF showed that incidence of abscess formation and hemorrhage tended to be higher in patients with fatty pancreas than in those with non-fatty pancreas. ConclusionsPancreatic fat infiltration is highly associated with POPF and possibly causes subsequent serious complications in patients undergoing IV-PJ.

Postoperative Serum Hyperamylasemia Adds Sequential Value to the Fistula Risk Score in Predicting Pancreatic Fistula after Pancreatoduodenectomy.

To evaluate whether postoperative serum hyperamylasemia (POH), with drain fluid amylase (DFA) and C-reactive protein (CRP), improves the Fistula Risk Score (FRS) accuracy in assessing the risk of a postoperative pancreatic fistula (POPF). The FRS predicts POPF occurrence using intraoperative predictors with good accuracy but intrinsic limits. Outcomes of patients who underwent pancreaticoduodenectomies between 2016 and 2021 were evaluated across FRS-risk zones and POH occurrence. POH consists of serum amylase activity greater than the upper limit of normal (52 U/l), persisting within the first 48 hours postoperatively (postoperative day -POD- 1 and 2). Out of 905 pancreaticoduodenectomies, some FRS elements, namely soft pancreatic texture (odds ratio (OR) 11.6), pancreatic duct diameter (OR 0.80), high-risk pathologic diagnosis (OR 1.54), but not higher blood loss (OR 0.99), were associated with POH. POH was an independent predictor of POPF, which occurred in 46.8% of POH cases ( P <0.001). Once POH occurs, POPF incidence rises from 3.8% to 42.9%, 22.9% to 41.7%, and 48.9% to 59.2% in patients intraoperatively classified at low, moderate and high FRS risk, respectively. The predictive ability of multivariable models adding POD 1 drain fluid amylase, POD 1-2 POH and POD 3 C-reactive protein to the FRS showed progressively and significantly higher accuracy (AUC FRS=0.82, AUC FRS-DFA=0.85, AUC FRS-DFA-POH=0.87, AUC FRS-DFA-POH-CRP=0.90, DeLong always P <0.05). POPF risk assessment should follow a dynamic process. The stepwise retrieval of early, postoperative biological markers improves clinical risk stratification by increasing the granularity of POPF risk estimates and affords a possible therapeutic window before the actual morbidity of POPF occurs.

The value of drain fluid amylase as a predictor of postoperative pancreatic fistula after pancreaticogastrostomy.

Drain fluid amylase is commonly used as a predictor of pancreatic fistula after pancreaticoduodenectomy (PD). This study aimed to determine the ideal cut-off value of drain fluid amylase on postoperative day 1 (DFA1) for predicting pancreatic fistula after pancreaticogastrostomy (PG). Prospective data of 272 consecutive patients undergoing PG between 2010 and 2020 was collected and analysed to determine the postoperative pancreatic fistula (POPF) risk factors. The incidence of POPF was 143 cases (52.6%). The median DFA1 in patients with POPF was significantly higher than that of patients with NO-POPF (5483 versus 311, P < 0.001). DFA1 correlated with POPF in the area under the curve (AUC) of 0.84 (P < 0.001). When DFA1 was 2300 U/L, Youden index was the highest, with a sensitivity of 72.7% and a specificity of 82.9%. Logistic regression analysis showed that DFA1 ≥ 2300 U/L was an independent predictor of POPF (P < 0.001; OR: 12.855; 95% CI: 7.019-23.544). The AUC of DFA1 and clinically relevant postoperative pancreatic fistula (CR-POPF) was 0.674 (P < 0.001). DFA1 ≥ 2300 U/L can be used as an independent predictor of POPF after PG. DFA1 ≥ 3000 U/L can predict the occurrence of CR-POPF, when DFA1 ≥ 3000 U/L, the patients should be observed closely active for complications.

Post-operative pancreatitis as a predictor of post-operative pancreatic fistula in patients following pancreaticoduodenectomy

Introduction: Post-Operative Pancreatic Fistula(POPF) remains the challenge following Pancreaticoduodenectomy(PD). Recently Post Operatve Pancreatitis(POP) has been defined which has been shown to be independent predictor of POPF in retrospective studies. Method: We Performed a prospective study where Serum Amylase of more than 80U/L on POD0 or POD1 was defined as POP following PD. The end point of the study was to see incidence of POP and its relation with POPF. Result: There were total 23 PDs. Most of the Patients had final diagnosis of ampullary carcinoma(52%). The incidence of POP and POPF was 56.5% and 60.9%. 84.6% patient who had POP developed POPF(P= 0.008). There was total seven Post Pancreatectomy Hemorrhage, two delayed gastric emptying, one chyle leak and four Mortality. However no statistical correlation could be made between POP and other pancreas specific complications and mortality. Conclusion: Though the sample size is less but POP seems to predict POPF in Patient following PDs in our study. Keywords: POP- Post Operative Pancreatitis, POPF- Post Operative Pancreatic Fistula, PD- Pancreaticoduodenctomy.

Redefining the Role of Drain Amylase Value for a Risk-Based Drain Management after Pancreaticoduodenectomy: Early Drain Removal Still Is Beneficial

BackgroundThe application of postoperative pancreatic fistula (POPF) risk stratification and mitigation strategies requires an update of the protocol for an early drain removal after pancreaticoduodenectomy (PD). The aim of the study is to highlight the unreliability of a single drain fluid amylase (DFA) cutoff-based protocol in the setting of a risk-based drain management. MethodsThe role of postoperative day one (POD1) DFA in predicting POPF was explored in the setting of both selective drain placement and early drain removal protocols. Receiver operating characteristics (ROC) curves were used to assess the POPF diagnostic performance in terms of negative predictive value (NPV) of several POD1 DFA cutoffs in different clinical scenarios according to POPF risk and mitigation strategies. ResultsThe areas under the curve (AUCs) for POD1-DFA were 0.815 for intermediate risk and pancreaticojejunostomy (PJ) (best cutoff 1000 IU/L, NPV 92.9%), 0.712 for intermediate risk and PJ with external stent (best cutoff 1000 IU/L, NPV 88.8%), and 0.574 for high risk and external stent (best cutoff 250 IU/L, NPV 93.7%). Independent predictors of POPF were body mass index, pancreatic texture, and early drain removal, whereas POD1 DFA was not. ConclusionIn the era of risk stratification and mitigation strategies, selective early drain removal still is associated with a reduced rate of POPF. However, a single protocol based on POD1-DFA is not suitable for all clinical scenarios after PD.

Postoperative Acute Pancreatitis Following Pancreaticoduodenectomy: A Determinant of Fistula Potentially Driven by the Intraoperative Fluid Management.

The aim of the study is to characterize postoperative acute pancreatitis (POAP). A standardized definition of POAP after pancreaticoduodenectomy (PD) has been recently proposed, but specific studies are lacking. The patients were extracted from the prospective database of The Pancreas Institute of Verona. POAP was defined as an elevation of the serum pancreatic amylase levels above the upper limit of normal (52 U/L) on postoperative day (POD) 0 or 1. The endpoints included defining the incidence and predictors of POAP and investigating the association of POAP with postoperative pancreatic fistula (POPF). The study population consisted of 292 patients who underwent PD. The POAP and POPF rates were 55.8% and 22.3%, respectively. POAP was an independent predictor of POPF (OR 3.8), with a 92% sensitivity and 53.7% specificity (AUC 0.79). Preoperative exocrine insufficiency (OR 0.39), neoadjuvant therapy (OR 0.29) additional resection of the pancreatic stump margin (OR 0.25), soft pancreatic texture (OR 4.38), and Main Pancreatic Duct (MPD) diameter ≤3 mm (OR 2.86) were independent predictors of POAP. In high-risk patients, an intraoperative fluid administration of ≤3 ml/kg/h was associated with an increased incidence of POAP (24.6 vs. 0%, P = 0.04) and POPF (27.6 vs. 11.4%, P = 0.05). This study represents the first clinical application of the only available definition of POAP as a specific complication of pancreatic surgery. POAP is associated with an increased occurrence of POPF and overall morbidity and could potentially be avoided through a specific intraoperative fluid regimen in high-risk pancreas.

Ketorolac use may increase risk of postoperative pancreatic fistula after pancreaticoduodenectomy

BackgroundKetorolac (Toradol), a commonly used nonselective nonsteroidal anti-inflammatory drug (NSAID) in the postoperative period, has been associated with increased risk of anastomotic leak after colon resection. The effect of postoperative NSAID and ketorolac use on postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is unknown. MethodsRetrospective review of consecutive PDs at a high-volume pancreas center from 2012 to 2015. POPF was identified and graded using International Study Group on Pancreatic Fistula criteria. Demographics, operative variables and 30-d postoperative NSAID use, dosage, and timing (early = postoperative day [POD] 0-5, late > POD 5) were collected. Univariate and multivariate logistic regressions were used to identify predictors of POPF. ResultsFour hundred twenty-three PDs were analyzed (mean age 66 y, 47% female), and 60% received NSAIDs postoperatively. Ketorolac (median POD 0-5 cumulative dose = 90 mg, interquartile range 60-165) was used in 35.7% (n = 151). POPF occurred in 90 patients (21.3%). Early (POD 0-5) ketorolac use was associated with increased POPF, especially grade A (odds ratio [OR] 2.16, P = 0.036). Each 25 mg incremental increase in ketorolac use was associated with a 10% increase in the incidence of POPF (OR 1.10, P = 0.021), whereas a cumulative dose of >150 mg was associated with a 44% increased risk of POPF (OR 1.44, 95% confidence interval 1.03-2.01, P = 0.035). A multivariate regression model identified estimated blood loss, soft gland, pancreatic duct diameter, body mass index, and cumulative ketorolac dose >150 mg as independent predictors of POPF (P < 0.0001, pseudo R2 = 0.149). ConclusionsIncreasing doses of ketorolac in the early postoperative period are associated with increased risk of POPF, whereas a cumulative dose of >150 mg is an independent predictor of POPF after PD.

A comparative study of risk factors for pancreatic fistula after pancreatoduodenectomy or distal pancreatectomy

BackgroundEvidence associates various biometric and histological variables such as steatosis and absence of fibrosis as risk factors for post-operative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Following distal pancreatectomy (DP), the association between these factors and POPF is less clear. This study of patients, drawn from the same background population, undergoing PD or DP at a single centre is a comparative study of the risk factors for POPF after these two operations. MethodsAssociations between POPF and patient characteristics, pre-operative blood tests, data from pre-operative computed tomography (CT) imaging, assessment of histological steatosis and fibrosis were explored. Results26/107 (24%) and 26/90 (29%) patients developed POPF after PD and DP respectively. Absence of fibrosis was associated with POPF (p < 0.001) after PD and its presence correlated with pancreatic duct width (p < 0.001). Steatosis was not associated with POPF (p = 0.910). Multivariable analysis showed pancreatic duct width (p = 0.016) and fibrosis (p = 0.025) to be independent predictors of POPF after PD. The only variable associated with POPF after DP was underlying pathology (p = 0.005). ConclusionPancreatic duct width is the most important variable related to POPF after PD and is correlated with fibrosis. Steatosis was not related to POPF. In contrast, after DP POPF appears to be related to the underlying disease.

The anatomical location of the pancreas is associated with the incidence of pancreatic fistula after laparoscopic gastrectomy.

Postoperative pancreatic fistula (POPF) is one of the major complications after laparoscopic gastrectomy (LG). We investigated the impact of the anatomical location of the pancreas, especially in relation to the suprapancreatic lymph nodes, on the incidence of POPF after LG. We retrospectively reviewed the preoperative computed tomography (CT) images of 246 patients who underwent LG with the suprapancreatic lymph node dissection between November 2008 and November 2015. The length between the levels of the pancreatic body surface and the root of the common hepatic artery (LPC) was measured on a CT image with an axial view. A receiver operating characteristics (ROC) curve analysis was performed to determine the cutoff LPC value. A multivariate analysis was performed to determine the predictive factors for POPF. POPF occurred in 11 patients (4.5%). The median LPC was significantly longer in the patients with POPF than in those without (26mm vs. 21mm, p=0.026). The ROC curve analysis revealed that the optimal cutoff LPC value for predicting POPF was 25mm. The POPF rate was significantly higher in the long LPC group than in the short LPC group (10 vs. 1.3%, p=0.002). A multivariate analysis demonstrated that a long LPC (p=0.018) and dissection of the lymph nodes along the distal splenic artery (p=0.042) were independent predictors of POPF. The amylase level in the drainage fluid on postoperative day 1 was significantly higher in the long LPC group than in the short LPC group. The LPC is a simple and reliable predictor of POPF after LG. Surgeons should take the anatomical location of the pancreas into consideration when performing LG with suprapancreatic lymph node dissection.

Acoustic Radiation Force Impulse Imaging of the Pancreas for Estimation of Pathologic Fibrosis and Risk of Postoperative Pancreatic Fistula

We sought to evaluate whether pancreatic elasticity, measured using acoustic radiation force impulse (ARFI) imaging, can determine the degree of pancreatic fibrosis and risk of pancreatic fistula (PF) in patients undergoing pancreatic resection. Although soft pancreatic texture is a reliable predictor of postoperative PF, noninvasive, quantitative methods of assessing pancreatic hardness have not been established. Shear wave velocity (SWV) of the pancreas was preoperatively measured by ARFI imaging in 62 patients undergoing pancreatic resection. Correlations of SWV with pathologic degree of fibrosis in the resected pancreas, exocrine function of the remnant pancreas, and the incidence of postoperative PF were determined. The SWV was positively correlated with the degree of pancreatic fibrosis (Spearman's rank correlation coefficient [ρ]= 0.660, p < 0.001) and inversely correlated with postoperative amylase concentrations and daily output of pancreatic juice. The incidence of postoperative PF was significantly higher in the 32 patients with soft (SWV < 1.54 m/s) than in the 30 with hard (SWV ≥ 1.54 m/s) pancreata (63% vs 17%, p < 0.001). Multivariate analysis showed that a soft pancreas (SWV < 1.54 m/s) was an independent predictor of postoperative PF (odds ratio 38.3; 95% CI 5.82 to 445; p= 0.001). Pancreatic elasticity on preoperative ARFI imaging accurately reflected the pathologic degree of fibrosis and exocrine function of the pancreas, enabling surgeons to adopt appropriate surgical procedures according to the risk of postoperative PF in each patient undergoing pancreatic resection.

Estimated pancreatic parenchymal remnant volume accurately predicts clinically relevant pancreatic fistula after pancreatoduodenectomy

Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) leads to prolonged hospitalization and potentially fatal complications. We sought to determine whether estimated pancreatic parenchymal remnant volume (EPPRV) on preoperative computed tomography (CT) predicts clinically relevant POPF. This retrospective study included 246 patients who underwent PD between 2008 and 2013. Pancreatic thickness, pancreatic width, and main pancreatic duct (MPD) diameter at the estimated transection line in addition to estimated whole pancreatic remnant volume (EWPRV) were measured on preoperative CT images. MPD volume was subtracted from EWPRV to determine EPPRV. The predictive ability of preoperative CT parameters for POPF was evaluated. EPPRV was an independent predictor of POPF and had a stronger association with POPF than EWPRV. Receiver operating characteristic curve analysis showed that EPPRV had the greatest area under the curve (0.885) for predicting POPF. EPPRV ≥25.5cm(3) was the best cutoff value for predicting POPF, with a high negative predictive value (0.934) and low likelihood ratio of a negative result (0.235). Multivariate analysis including the preoperative CT parameters and well-known risk factors for POPF showed that EPPRV ≥25.5cm(3) had the greatest odds ratio for POPF. EPPRV was correlated with pancreatic juice volume. Patients with EPPRV ≥25.5cm(3) had a greater drainage fluid amylase concentration and greater duration of drainage tube placement than those with EPPRV <25.5cm(3). EPPRV from preoperative CT was highly predictive of POPF and may help in development of management for POPF after PD.