Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy

doi:10.1016/j.surg.2015.10.028

Surgery

Volume 159, Issue 4, April 2016, Pages 1013-1022

Presented at the Society of University Surgeons/9th Annual Academic Surgical Congress, San Diego, CA, February 6, 2014.

https://doi.org/10.1016/j.surg.2015.10.028 Get rights and content

Background

Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden.

Methods

From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C). ACB values were derived from fistula severity scores based on the Modified Accordion Severity Grading. The ACB of POPFs was compared between PD and DP.

Results

POPFs were more common after DP compared with PD (34.5 vs 27.2%; P < .001); however, the incidence of any complication was greater after PD (64.9 vs 53.2%; P < .001). When POPFs occurred, they were more likely to be the highest-graded complication after DP compared with PD (65.1 vs 51.6%; P < .001). ACB significantly varied between PDs and DPs for grade C POPFs (0.804 vs 0.611; P < .001). POPFs accounted for 31.2% of the overall complication burden after DP compared with 17.5% of the burden after PD. ACB differed significantly across both institutions and surgeons in terms of POPFs, nonfistulous complications, and overall complications (all P < .05).

Conclusion

Although POPFs occur less frequently after PD, they are associated with a greater complication burden compared with DP. ACB varies significantly between health care providers, suggesting the need for risk-adjusted comparisons of complication severity. Using ACB to evaluate a distinct morbidity has the potential to aid in assessing the impact of procedure-specific complications.

Section snippets

Patient population and data collection

This study was approved by the Institutional Review Board at the University of Pennsylvania. Records for consecutive patients who received PD or DP for all indications between 2001 and 2014 were reviewed from prospectively collected databases at 4 high-volume pancreatic surgical practices. Postoperative complications were recorded by clinical research associates and complication grading was assigned by, or under the supervision of, attending surgeons familiar with complication severity scoring.⁸

PD versus DP: Demographic, operative, and pathologic characteristics

Fourteen surgeons performed 2,370 pancreatic resections, of which 1,533 (64.7%) were PD and 837 (35.3%) DP. Numerous differences existed between the PD and DP cohorts in terms of demographic and operative characteristics. Patients undergoing DP were more likely female (59.4 vs 50.6%; P < .0001) and obese (33.5 vs 22.5%; P < .0001), whereas PD patients were significantly older (median, 64 [IQR 56–72] vs 60 [IQR 49–69] years; P < .0001). A greater proportion of PD patients had pancreatic ductal

Discussion

This study demonstrates that, although the overall incidence of ISGPF POPFs is higher after DP compared with PD, the ACB of POPFs is typically greater after PD. Furthermore, POPFs are more likely the highest graded complication after DP, and they contribute to a greater proportion of overall complication burden after this procedure (31.4 vs 17.5%). Applying the concept of burden to the outcomes of health care providers revealed that ACB varied between institutions and surgeons for both PD and

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Contemporary Outcomes of Grade-C Postoperative Pancreatic Fistula in a Nationwide Database
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Grade-C postoperative pancreatic fistulas (POPFs) are dreaded complications following pancreaticoduodenectomy. The aim of this study was to quantify the incidence and risk factors associated with grade C POPF in a national database.
The National Surgical Quality Improvement Program targeted user files were queried for patients who underwent elective pancreaticoduodenectomy (2014-2020). Outcomes were compared between clinically relevant (CR) grade B POPF and grade C POPF.
Twenty-six thousand five hundred fifty-two patients were included, of which 90.1% (n = 23,714) had No CR POPF, 8.7% (n = 2287) suffered grade B POPF, and 1.2% (n = 327) suffered grade C POPF. There was no change in the rate Grade-C fistula overtime (m = 0.06, P = 0.63), while the rate of Grade-B fistula significantly increased (m = +1.40, P < 0.01). Fistula Risk Scores were similar between grade B and C POPFs (high risk: 34.9% versus 31.2%, P = 0.21). Associated morbidity was increased with grade C POPF, including delayed gastric emptying, organ space infections, wound dehiscence, respiratory complications, renal complications, myocardial infarction, and bleeding. On multivariate logistic regression, diabetes mellitus (odds ratio: 1.41 95% confidence interval: 1.06-1.87, P = 0.02) was associated with grade C POPF.
This study represents the largest contemporary series evaluating grade C POPFs. Of those suffering CR POPF, the presence of diabetes mellitus was associated with grade C POPF. While modern management has led to grade C POPF in 1% of cases, they remain associated with alarmingly high morbidity and mortality, requiring further mitigation strategies to improve outcomes.
External validation of fistula risk scores for postoperative pancreatic fistula after distal pancreatectomy
2023, Surgery (United States)
Fistula risk scores such as distal fistula risk scores and DISPAIR have been recently developed to assess the risk of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. This study aimed to validate these models externally using a large-scale Chinese cohort.
The study enrolled adult patients who underwent distal pancreatectomy at a high-volume single center between January 2011 and December 2021. The clinically relevant postoperative pancreatic fistula was defined as grade B/C, according to the 2016 International Study Group of Pancreatic Surgery. Model performance was evaluated using the area under the curve.
Among 653 eligible patients, 126 (19.3%) suffered from clinically relevant postoperative pancreatic fistulas. Independent predictors for clinically relevant postoperative pancreatic fistulas included body mass index, diabetes mellitus, pancreatic thickness at both neck and transection sites, main pancreatic duct diameter, and soft pancreas. Clinically relevant postoperative pancreatic fistula risk increased with increasing score severity. All 3 prediction models showed acceptable discrimination, with area under the curve values of preoperative distal fistula risk score at 0.723 (95% confidence interval 0.687–0.757), intraoperative distal fistula risk score at 0.737 (95% confidence interval 0.701–0.770), and DISPAIR at 0.721 (95% confidence interval 0.685–0.755). No significant differences were found among them.
Distal fistula risk scores and DISPAIR are useful tools for predicting clinically relevant postoperative pancreatic fistula after distal pancreatectomy, highlighting their importance in guiding surgical approach decisions and mitigating strategies against this complication in clinical practice.
Postoperative pancreatitis and pancreatic fistulae: a review of current evidence
2023, HPB
Postoperative pancreatic fistula (POPF) represents one of the most severe complications following pancreatic surgery. Despite being a leading cause of morbidity and mortality, its pathophysiology is poorly understood. In recent years, there has been growing evidence to support the role of postoperative or post-pancreatectomy acute pancreatitis (PPAP) in the development of POPF. This article reviews the contemporary literature on POPF pathophysiology, risk factors, and prevention strategies.
A literature search was conducted using electronic databases, including Ovid Medline, EMBASE, and Cochrane Library, to retrieve relevant literature published between 2005 and 2023. A narrative review was planned from the outset.
A total of 104 studies fulfilled criteria for inclusion. Forty-three studies reported on technical factors predisposing to POPF, including resection and reconstruction technique and adjuncts for anastomotic reinforcement. Thirty-four studies reported on POPF pathophysiology. There is compelling evidence to suggest that PPAP plays a critical role in the development of POPF. The acinar component of the remnant pancreas should be regarded as an intrinsic risk factor; meanwhile, operative stress, remnant hypoperfusion, and inflammation represent common mechanisms for acinar cell injury.
The evidence base for PPAP and POPF is evolving. Future POPF prevention strategies should look beyond anastomotic reinforcement and target underlying mechanisms of PPAP development.
Adjusting Drain Fluid Amylase for Drain Volume Does Not Improve Pancreatic Fistula Prediction
2023, Journal of Surgical Research
Drain 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.
A 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.
Patients 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.
Postoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability.
Impact of spleen preservation on the incidence of postoperative pancreatic fistula after distal pancreatectomy: Is less more?
2022, Pancreatology
Postoperative pancreatic fistula (POPF) remains a major complication after distal pancreatectomy (DP) with a significant impact on patients’ quality of life. There is limited evidence that preservation of the spleen reduces the risk of POPF. Therefore, we aimed to investigate the impact of splenectomy on perioperative outcome.
Data from patients who underwent DP for malignant and benign disease at our institution between 2004 and 2021 were reviewed. Patients were grouped according to spleen preservation (SP-DP) and splenectomy (DPS). Intraoperative parameters and postoperative outcomes were compared between groups. Univariable and multivariable analyses were used to investigate factors that influence the occurrence of clinically relevant (cr)POPF.
A total of 199 patients were included, of whom 61 (30.7%) patients underwent SP-DP. Patients who underwent SP-DP had a significantly lower rate of crPOPF (p = 0.022), shorter hospital stay (p = 0.003), and less readmissions (p = 0.012). On multivariate analysis, obesity (OR 2.88, p = 0.021), benign lesions (OR 2.35, p = 0.018), postoperative acute pancreatitis (OR 2.53, p = 0.028), and splenectomy (OR 2.83, p = 0.011) were independent risk factors associated with the onset of crPOPF.
Preservation of the spleen reduces the risk of crPOPF in patients undergoing distal pancreatectomy for benign and malignant disease.
Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes?
2022, HPB
The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1).
Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1.
POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84–14.73]) and C (68.0%, OR 10.50 [3.77–29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039).
POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.

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PancreasComparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy

Background

Methods

Results

Conclusion

Section snippets

Patient population and data collection

PD versus DP: Demographic, operative, and pathologic characteristics

Discussion

J Am Coll Surg

J Am Coll Surg

HPB

HPB

Surgery

Surgery

Am J Surg

J Gastrointest Surg

Am J Surg

J Gastrointest Surg

Am J Surg

J Am Coll Surg

Pancreas
Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy