Predictor Of Pancreatic Fistula Research Articles

Early postoperative fever as a predictor of pancreatic fistula after pancreaticoduodenectomy: a single-center retrospective observational study

BackgroundThe connection between early postoperative fever and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy remains unclear. This study aimed to investigate this association and assess the predictive value of early postoperative fever for CR-POPF.MethodsThis retrospective observational study included adult patients who underwent pancreaticoduodenectomy at a tertiary teaching hospital between 2007 and 2019. Patients were categorized into those with early postoperative fever (≥ 38 °C in the first 48 h after surgery) and those without early postoperative fever groups. Weighted logistic regression analysis using stabilized inverse probability of treatment weighting (sIPTW) and multivariable logistic analysis were performed. The c-statistics of the receiver operating characteristic curves were calculated to evaluate the impact on the predictive power of adding early postoperative fever to previously identified predictors of CR-POPF.ResultsOf the 1997 patients analyzed, 909 (45.1%) developed early postoperative fever. The overall incidence of CR-POPF among all the patients was 14.3%, with an incidence of 19.5% in the early postoperative fever group and 9.9% in the group without early postoperative fever. Early postoperative fever was significantly associated with a higher risk of CR-POPF after sIPTW (adjusted odds ratio [OR], 1.73; 95% confidence interval [CI], 1.34–2.22; P < 0.001) and multivariable logistic regression analysis (adjusted OR, 1.88; 95% CI, 1.42–2.49; P < 0.001). The c-statistics for the models with and without early postoperative fever were 0.76 (95% CI, 0.73–0.79) and 0.75 (95% CI, 0.72–0.78), respectively, showing a significant difference between the two (difference, 0.02; 95% CI, 0.00–0.03; DeLong’s test, P = 0.005).ConclusionsEarly postoperative fever is a significant but not highly discriminative predictor of CR-POPF after pancreaticoduodenectomy. However, its widespread occurrence limits its applicability as a predictive marker.

Prediction of Pancreatic Fistula & Puedocyst after Laparoscopic Distal Pancreatectomy Based on Cross-sectional Area of Pancreas on CT

Prediction of Pancreatic Fistula & Puedocyst after Laparoscopic Distal Pancreatectomy Based on Cross-sectional Area of Pancreas on CT

Study of C-reactive Protein as a Predictor of Pancreatic Fistula after the Whipple Procedure. Review of the Literature

Study of C-reactive Protein as a Predictor of Pancreatic Fistula after the Whipple Procedure. Review of the Literature

The usefulness of preoperative exocrine function evaluated by the 13C-trioctanoin breath test as a significant physiological predictor of pancreatic fistula after pancreaticoduodenectomy

BackgroundThe association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the 13C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF.MethodA total of 80 patients who underwent 13C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between 13C-trioctanoin absorption and PF incidence.ResultsAmong 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the 13C-trioctanoin breath test value (Aa% dose/h) increased (odd’s ratio: 1.082, 95% confidence interval: 1.007–1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53).ConclusionsFavorable preoperative fat absorption evaluated using the 13C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

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.

Prediction of pancreatic fistula after pancreatectomy by virtual touch tissue imaging and quantification (VTIQ) technology

ObjectivesThe aim of this study was to quantitatively evaluate the stiffness of pancreatic parenchyma and solid focal pancreatic lesions (FPLs) by virtual touch tissue imaging and quantification (VTIQ) technique and to investigate the potential usefulness of VTIQ method in the prediction of post-operative pancreatic fistula (POPF) after pancreatectomy. MethodsIn this prospective study, patients who scheduled to undergo pancreatectomy were initially enrolled and received VTIQ assessment within one week before surgery. VTIQ elastography (Siemens ACUSON Sequoia, 5C-1 transducer) was used to measure the shear wave velocity (SWV) value of FPLs and the body part pancreatic parenchyma. The palpation stiffness of pancreas was qualitatively evaluated during operation by surgeons. POPF was finally diagnosed and graded through a three-weeks post-operative follow-up according to international study group of pancreatic fistula (ISGPF). SWV values were compared between POPF positive and negative group. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic efficacy of SWV value in predicting POPF. ResultsFrom December 2020 to June 2021, 44 patients were finally enrolled in this study, among which, 26 patients were identified to develop POPF after pancreatectomy. The SWV value of pancreatic parenchyma in POPF positive group was significantly lower than that in POPF negative group (P = 0.001). However, there was no significant difference in palpation stiffness between the two groups (P = 0.124). Besides, neither the SWV value of FPL nor the SWV ratio between FPL to surrounding pancreatic parenchyma differ significantly between POPF positive and negative group (P > 0.05). Taking SWV value of pancreatic parenchyma >1.10 m/s as a cut-off value for predicting POPF, area under the receiver operating characteristic curve (AUROC) was 0.864 with 72.2% sensitivity, 92.3% specificity, 86.7% positive predictive value (PPV) and 82.8% negative predictive value (NPV), respectively. ConclusionsVTIQ technique might be a potential non-invasive imaging method to predict POPF before pancreatectomy in future clinical practice.

A deep pancreas is a novel predictor of pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct

BackgroundWe investigated the risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct. MethodsWe investigated a total of 354 patients who underwent pancreaticoduodenectomy. The diameter of the main pancreatic duct, the shortest distance from the body surface to the pancreas (the pancreatic depth), and the computed tomography attenuation index (the difference between the pancreatic and splenic computed tomography attenuation) were measured in preoperative computed tomography. ResultsOne hundred eighty-one (51.1%) patients had a nondilated main pancreatic duct, and 50 (27.6%) of the 181 patients with a nondilated main pancreatic duct developed a clinically relevant postoperative pancreatic fistula. Univariate analyses revealed that the calculated body mass index (≥21.8 kg/m2) (P = .004), deep pancreas (pancreatic depth ≥51.2 mm) (P = .001), and low computed tomography attenuation index (≤–3.8 Hounsfield units) (P = .02) were significant risk factors for clinically relevant postoperative pancreatic fistula. The multivariate logistic regression analysis revealed that deep pancreas (odds ratio 2.370; 95% confidence interval 1.0019–5.590; P = .049) was an independent risk factor for clinically relevant postoperative pancreatic fistula. Among patients with a nondilated main pancreatic duct, deep pancreas (in comparison to patients without deep pancreas) was associated with male sex (72.7% vs 54.9%; P = .016), higher body mass index (22.5 kg/m2 vs 19.6 kg/m2; P < .001), a history of diabetes mellitus (24.5% vs 8.5%; P = .006), a lower computed tomography attenuation index (–9.6 Hounsfield units vs –4.6 Hounsfield units; P = .007), a longer operative time (454 minutes vs 420 minutes; P = .007), and a higher volume of intraoperative blood loss (723 mL vs 500 mL; P < .001), respectively. ConclusionDeep pancreas may be an important parameter associated with significant risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.

Post operative acute pancreatitis (POAP) is a major predictor of pancreatic fistula after distal pancreatectomy

Post operative acute pancreatitis (POAP) is a major predictor of pancreatic fistula after distal pancreatectomy

The Late Phase/Early Phase Ratio of Pancreatic CT Values as a Novel Predictor of Pancreatic Fistula after Distal Pancreatectomy.

Post-operative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy (DP). In this retrospective study, we reviewed the data from patients who underwent DP between 2008 and 2019 in our institute to determine whether the late phase/early phase ratio (L/E ratio) by preoperative computed tomography (CT) scan in the pancreas could predict POPF occurrence after DP. We examined the relationship between preoperative or intraoperative factors and the occurrence of POPF after DP using statistical methods in 23 males and 21 females with a mean age of 73. The mean L/E ratio was significantly lower in the POPF group than the non-POPF group (p=0.035). The L/E ratio had moderate diagnostic accuracy, with a calculated optimal cutoff value of 0.77. In univariate analysis, a significant association was noted between POPF and stump thickness ≥ 16.9, body mass index ≥ 27.5, and L/E ratio ≤ 0.77. In the multivariate analysis, the L/E ratio (odds ratio, 5.96; p=0.036) was an independent risk factor for POPF. Our findings suggest that the pancreatic L/E ratio may predict the occurrence of POPF after DP. This measure may be useful in preoperative risk stratification, patient counseling, and perioperative patient management, improving clinical outcomes after DP.

Possibility of computer tomography with contrast enhancement in evaluation of the structure of the pancreas and prediction of pancreatic fistula in pancreas resection

One of the most common complications after pancreatic resections is an external pancreatic fistula. The main risk factor for pancreatic fistula is the “soft” structure of the pancreas. The aim of the study is to determine the possibility of computed tomography with contrast enhancement at the preoperative period in an objective assessment of the structure of the pancreas with pancreatoduodenal resections and prediction of pancreatic fistula in the postoperative period. Retrospectively, 102 patients were selected. Patients were divided into 2 groups depending on the structure of the pancreas according to computed tomography at the preoperative period. According to the data of preoperative CT with contrast enhancement, the structure of the pancreas was evaluated; density characteristics in native, arterial, venous, delayed phases (HU); pancreatic duct diameter. Group 1 included 37 patients with a “soft” pancreas. 65 patients with a “solid” pancreas were in group 2. In group 1, in 16 cases (43%), a clinically significant PF was formed in the postoperative period; in 21 cases (57%), the postoperative period proceeded uncomplicated. In group 2, in 5 cases (8%), the postoperative period was complicated by clinically significant PF; in 60 cases (92%), the postoperative period was uncomplicated. The development of clinically significant PF positively correlates with the “soft” pancreas (r = 0.374, p&lt;0.001), the density of pancreas of the native phase (r = 0.179, p = 0.099), the density of pancreas in the arterial phase (r = 0.208, p =0.054). Negatively correlates with the “solid” pancreas (r = -0.274, p&lt;0.001) and the pancreatic duct diameter (r = -0.339, p = 0.001). The “soft” pancreas positively correlates with the density pancreas in the native phase (r = 0,559, p&lt;0,001) and the density pancreas in the arterial phase (r = 0,710, p&lt;0,001) and negatively correlates with the pancreatic duct diameter (r = - 0,534, p&lt;0,001) and the density pancreas in the excretory phase (r = -0,409, p&lt;0,001). Using computed tomography with contrast enhancement at the preoperative period, an objective assessment of the pancreatic structure is possible due to its density characteristics in the native and arterial phases of the scan to highlight a high-risk group for the development of clinically significant PF.

Albumin difference as a new predictor of pancreatic fistula following distal pancreatectomy: a retrospective study of 211 consecutive patients.

The level of albumin declines after surgery, and whether the difference between preoperative and postoperative albumin levels on postoperative day 1 has an effect on the development of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) is unclear. Our aim was to evaluate the effect of albumin difference on POPF. A retrospective analysis of consecutive patients who had undergone DP between January 2016 and October 2018 at a single institution was conducted. Patient demographic data and perioperative data were analysed using univariate and multivariate models. Pancreatic fistula was defined by the 2016 International Study Group of Pancreatic Surgery criteria. All patients were followed for up to 90days. A total of 211 consecutive patients were identified. The POPF rate was 15.64%, and no 90-day mortality was observed. Five predictors were independently associated with POPF: albumin difference (OR 6.60, 95% CI 2.36-18.45, P < 0.001), pancreatic texture (OR 4.15, 95% CI 1.62-10.63, P = 0.003), operative time (OR 3.13, 95% CI 1.19-8.24, P = 0.021), intraoperative fluid transfusion (OR 4.85, 95% CI 1.70-13.79, P = 0.003), and cardiovascular disease (OR 5.38, 95% CI 1.99-14.55, P = 0.001). Although DP can be performed with a low rate of mortality, POPF remains a common complication. Albumin difference is a new, accessible predictor for POPF following DP.

Risk Factors of Pancreatic Fistula in Distal Pancreatectomy Patients.

Introduction Benign and malignant lesions of the pancreas located at the body and tail of the pancreas are managed by the standard procedure of distal pancreatectomy (DP). The mortality associated with this procedure is reported as less than 5% in high-volume centers. The major proportion of morbidity is comprised of pancreatic fistula with a reported incidence of 5% to 60%. The most considered risk factors associated with pancreatic fistula formation are soft pancreatic texture, diameter of the pancreatic duct <3 mm, intraoperative blood loss >1000 ml and surgical techniques. Among all these factors, the modifiable factor is the surgical technique. Several surgical techniques have been developed and modified for closure of the pancreatic remnant in the recent past in order to minimize the risk of pancreatic fistula and other complications. The main objective of the study is to analyze the factors associated with formation of pancreatic fistula after distal pancreatectomy. Patients and Methods We performed a single-center retrospective study at Aga Khan University Hospital from January 2004 till December 2015. The perioperative and postoperative data of 131 patients who underwent pancreatic resection were recorded by using ICD 9 coding. 45 patients underwent distal pancreatectomy, out of which 38 were included in the study based on inclusion criteria. Variables were grouped into demographics, indications, operative details, and postoperative course. Statistical analysis software (SPSS) was used for analysis. Quantitative variables were presented as mean with standard deviation or median with interquartile range depending on the distribution of data. Study endpoints for the risk factor analysis were surgical morbidity and development of pancreatic fistula. Univariate logistic regressions were performed associated with study endpoints. P value less than 0.05 was considered significant. Results Postoperative pancreatic fistula was the most common perioperative morbidity. The significant associated risk factor for pancreatic fistula was multivisceral resection as compared to spleen-preserving distal pancreatectomy (P value 0.039). However, the technique of stump closure when opted for suture techniques was seen to be associated with a higher occurrence of postoperative pancreatic fistula. The mortality rate was 2.6%. Conclusion Postoperative pancreatic fistula is the most common complication seen after distal pancreatectomy in our series. Multivisceral resection is associated with a high incidence of pancreatic fistula and is a statistical significant predictor of pancreatic fistula.

Prediction of Pancreatic Fistula After Distal Pancreatectomy: Is It Necessary to Place Prophylactic Drain?

Background The aim of this study was to determine the predictive factors for pancreatic fistula (PF) after distal pancreatectomy (DP) among preoperative and intraoperative parameters, and to clarify the patients who did not require drain placement. Methods Between July 2009 and April 2017, a total of 102 consecutive patients underwent DP at Hyogo College of Medicine. Preoperative and intraoperative data were collected, and the predictors of PF after DP were identified. PF was identified in 35 patients (34%). In the multivariate analysis, 3 factors [body mass index (BMI) ≥22.4, contiguous organ resection, and pancreatic thickness ≥11 mm] were found to be independent predictors of PF (odds ratio, 5.7; 95% confidence interval, 1.9–17; P = 0.002 odds ratio, 6.7; 95% confidence interval, 1.6–28; P = 0.009; odds ratio, 11.6; 95% confidence interval, 3.7–36; P &amp;lt; 0.001, respectively). Results A scoring scale for the prediction of PF was developed. BMI ≥22.4 (score: 1), contiguous organ resection (score: 1), and pancreatic thickness ≥11 mm (score: 2) were included in the scoring scale. Patients with a score of 0 never developed PF, whereas PF occurred in all patients with a score of 4. Conclusions BMI ≥22.4, contiguous organ resection, and pancreatic thickness ≥11 mm were predictive factors for PF after DP. No patients with BMI &amp;lt;22.4, no contiguous organ resection, and a pancreatic thickness of &amp;lt;11 mm developed PF after DP, indicating that such patients may not require drain placement.

The value of post-operative measurement of day one drain fluid amylase, serum amylase and serum CRP as predictor of pancreatic fistula in pancreatic surgery

The value of post-operative measurement of day one drain fluid amylase, serum amylase and serum CRP as predictor of pancreatic fistula in pancreatic surgery

The clinical value of C-reactive protein and procalcitonin in early prediction of pancreatic fistula after pancreaticoduodenectomy

Objective To study the relationship of early postoperative CRP and PCT with pancreatic fistula after pancreaticoduodenectomy (PD); to study whether the combination of CRP and PCT can be used as an early predictor of pancreatic fistula; and to determine the optimal cut-off values of CRP and PCT for early diagnosis of pancreatic fistula after PD. Methods Postoperative pancreatic fistula and other complications were recorded in 82 patients after PD carried out at the Anshan Iron and Steel Group General Hospital from January 2013 to May 2017. PCT and CRP were measured on the 1st to the 5th postoperative day (POD). CRP and PCT were compared between the pancreatic fistula group and the non-complication group on pancreatic fistula prediction. The sensitivity, specificity, and combined sensitivity, combined specificity, negative predictive value, positive predictive value and optimal cut-off value were calculated. Results 56 patients developed postoperative complications, including 17 patients with pancreatic fistula, and 39 patients with non-pancreatic fistula. The postoperative CRP and PCT were correlated with postoperative pancreatic fistula and with other complications. The higher the CRP and PCT, the higher the risk of postoperative pancreatic fistula. The ROC curves suggested that CRP and PCT had a high predictive value for pancreatic fistula, especially on POD 2. The optimal cut-off value of CRP was 189.05 mg/L, the sensitivity was 94.1%, the specificity was 81.5%, the positive predictive value was 94.7%, and the negative predictive value was 24.4%. The optimal cut-off value of PCT was 0.89 mg/dl, the sensitivity was 88.2%, the specificity was 84.6%, the positive predictive value was 91.3%, and the negative predictive value was 20.5%. The sensitivity and specificity of combined CRP with PCT on POD 2 in predicting pancreatic fistula after operations were 100% and 69.1%, respectively. Conclusion Combined CRP and PCT had a high early predictive rate in the identification of pancreatic fistula after PD. Key words: Pancreaticoduodenectomy; Postoperative pancreatic fistula; C-reactive protein; Procalcitonin; Predictor

Prediction of pancreatic fistula after pancreatoduodenectomy by preoperative dynamic CT and fecal elastase-1 levels.

ObjectiveTo validate preoperative dynamic CT and fecal elastase-1 level in predicting the development of pancreatic fistulae after pancreatoduodenectomy.Materials and methodsFor 146 consecutive patients, CT attenuation values of the nontumorous pancreatic parenchyma were retrospectively measured on precontrast, arterial and equilibrium phase images for calculation of enhancement ratios. CT enhancement ratios and preoperative fecal elastase-1 levels were correlated with the development of pancreatic fistulae using independent t-test, logistic regression models, ROC analysis, Youden method and tree analysis.ResultsThe mean value of enhancement ratio on equilibrium phase was significantly higher (p = 0.001) in the patients without pancreatic fistula (n = 107; 2.26±3.63) than in the patients with pancreatic fistula (n = 39; 1.04±0.51); in the logistic regression analyses, it was significant predictor for the development of pancreatic fistulae (odds ratio = 0.243, p = 0.002). The mean preoperative fecal elastase-1 levels were higher (odds ratio = 1.003, p = 0.034) in the pancreatic fistula patients than other patients, but there were no significant differences in the areas under the curve between the prediction values of CT enhancement ratios and fecal elastase-1 combined and those of CT enhancement ratios alone (P = 0.897, p = 0.917) on ROC curve analysis. Tree analysis revealed that the CT enhancement ratio was more powerful predictor of pancreatic fistula than fecal elastase-1 levels.ConclusionThe preoperative CT enhancement ratio of pancreas acquired at equilibrium phase regardless of combination with fecal elastase-1 levels might be a useful predictor of the risk of developing a pancreatic fistula following pancreatoduodenectomy.

Prediction of Pancreatic Fistula After Distal Pancreatectomy Based on Cross-Sectional Images.

Postoperative pancreatic fistula (POPF) is one of the most common and clinically relevant complications after distal pancreatectomy (DP), occurring in 5-40% of patients. Determining risk factors for this complication may aid in its prevention. This study sought to predict the development of POPF after DP preoperatively and objectively based on radiologic findings. This study included 60 patients who underwent DP using a stapler for pancreatic division between June 2011 and January 2013. Fatty infiltration, apparent diffusion coefficients (ADC) on preoperative MRI, pathologic fat, and fibrosis were measured. Pancreatic thickness and cross-sectional area of the pancreas stump on CT scan were also measured. Mean patient age was 60.5years, 26 patients (46.3%) had pancreatic cancer and 20 (33.3%) underwent laparoscopic surgery. Clinically relevant POPF was observed in 12 patients (20.0%). Linear regression analysis showed a significant correlation between fat quantification on MRI and pathologic fat (pathologic fat=1.978×MR fat -6.393, p<0.001, R 2=0.777). Univariate analysis showed that ≤8% fat on MRI (p=0.040), ≤5% pathologic fat (p=0.002), ADC≤1.3×10-3mm2/s (p=0.020), thicker pancreas (p=0.007), and wider cross-sectional area of the pancreas (p=0.013) were significantly associated with clinically relevant POPF after DP. Multivariate analysis revealed that pancreas thickness >17.6mm [odds ratio (OR) 6.532, p=0.064] and cross-sectional area >377mm2 (OR 12.676, p=0.052) were marginally related to clinically relevant POPF. Pancreatic thickness and cross-sectional area of the transected surface of the pancreas are marginally significant risk factors for POPF development after DP. Measuring pancreatic thickness and cross-sectional area can be a promising tool for the preoperative prediction of POPF.

Prediction of pancreatic fistula and fibrosis in patients undergoing pancreatic resections using differential pancreatic enhancement pattern on multiphasic computed tomography (MPCT) scan: a prospective study

Prediction of pancreatic fistula and fibrosis in patients undergoing pancreatic resections using differential pancreatic enhancement pattern on multiphasic computed tomography (MPCT) scan: a prospective study

Meta-analysis of drain amylase content on postoperative day 1 as a predictor of pancreatic fistula following pancreatic resection.

Drain amylase content in the days immediately after major pancreatic resection has been investigated previously as a predictor of postoperative pancreatic fistula (POPF). Its accuracy, however, has not been determined conclusively. The purpose of this study was to evaluate the accuracy of drain amylase content on the first day after major pancreatic resection in predicting the occurrence of POPF. A literature search of the MEDLINE, Embase and Scopus(®) databases to 13 May 2015 was performed to identify studies evaluating the accuracy of drain amylase values on day 1 after surgery in predicting the occurrence of POPF. The area under the hierarchical summary receiver operating characteristic (ROC) curve (AUChSROC ) was calculated as an index of accuracy, and pooled estimates of accuracy indices (sensitivity and specificity) were calculated at different cut-off levels. Subgroup and meta-regression analyses were performed to test the robustness of the results. Thirteen studies involving 4416 patients were included. The AUChSROC was 0·89 (95 per cent c.i. 0·86 to 0·92) for clinically significant POPF and 0·88 (0·85 to 0·90) for POPF of any grade. Pooled estimates of sensitivity and specificity were calculated for the different cut-offs: 90-100 units/l (0·96 and 0·54 respectively), 350 units/l (0·91 and 0·84) and 5000 units/l (0·59 and 0·91). Accuracy was independent of the type of operation, type of anastomosis performed and octreotide administration. Evaluation of drain amylase content on the first day after surgery is highly accurate in predicting POPF following major pancreatic resection. It may allow early drain removal and institution of an enhanced recovery pathway.

Early Drain Removal--The Middle Ground Between the Drain Versus No Drain Debate in Patients Undergoing Pancreaticoduodenectomy: A Prospective Validation Study.

To perform an unbiased assessment of first postoperative day (POD 1) drain amylase level and pancreatic fistula (PF) after pancreaticoduodenectomy (PD). Recent evidence demonstrated that drain abandonment in PD is unsafe. Early drain amylase levels have been proposed as predictors of PF after PD, allowing for selection of patients for early drain removal. Daily drain amylase levels were correlated with the development of PF in 2 independent cohorts of patients undergoing PD: training cohort (n = 126; year 2008) and validation cohort (n = 369; years 2009-2012). POD 1 drain amylase level had the highest predictive ability (concordance index: 0.911) for PF in the training cohort. An amylase level of 612 U/L or higher showed the best accuracy (86%), sensitivity (93%), and specificity (79%). Thus, a cutoff value of 600 U/L was utilized. In the validation cohort, 229 (62.1%) patients had a POD 1 drain amylase level of lower than 600 U/L, and PF developed in only 2 (0.9%) cases; whereas in patients with POD 1 drain amylase level of 600 U/L or higher (n = 140) the PF rate was 31.4% (odds ratio [OR] = 52, P < 0.0001). On multivariate analysis, POD 1 drain amylase level of lower than 600 U/L (OR = 0.0192, P < 0.0001) was a stronger predictor of the absence of PF than pancreatic gland texture (OR = 0.193, P = 0.002) and duct diameter (OR = 0.861, P = 0.835). After PD, the risk of PF is less than 1% if POD 1 drain amylase level is lower than 600 U/L. We propose that in this group, which comprise more than 60% of patients, drains should be removed on POD 1.