Novel risk scoring system for prediction of pancreatic fistula after pancreaticoduodenectomy

Optimizing prediction models for pancreatic fistula after pancreatectomy: Current status and future perspectives

Postoperative pancreatic fistula (POPF) is a frequent complication after pancreatectomy, leading to increased morbidity and mortality. Optimizing prediction models for POPF has emerged as a critical focus in surgical research. Although over sixty models following pancreaticoduodenectomy, predominantly reliant on a variety of clinical, surgical, and radiological parameters, have been documented, their predictive accuracy remains suboptimal in external validation and across diverse populations. As models after distal pancreatectomy continue to be progressively reported, their external validation is eagerly anticipated. Conversely, POPF prediction after central pancreatectomy is in its nascent stage, warranting urgent need for further development and validation. The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance. Moreover, there is potential for the development of personalized prediction models based on patient- or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF. In the future, prospective multicenter studies and the integration of novel imaging technologies, such as artificial intelligence-based radiomics, may further refine predictive models. Addressing these issues is anticipated to revolutionize risk stratification, clinical decision-making, and postoperative management in patients undergoing pancreatectomy.

Development of a Nomogram to Predict Clinically Relevant Postoperative Pancreatic Fistula After Pancreaticoduodenectomy on the Basis of Visceral Fat Area and Magnetic Resonance Imaging

BACKGROUND

The aim of this study was to develop a nomogram to predict the risk of developing clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) using preoperative clinical and imaging data.

METHODS

The data of 205 patients were retrospectively analyzed, randomly divided into training (n = 125) and testing groups (n = 80). The patients' preoperative laboratory indicators, preoperative clinical baseline data, and preoperative imaging data [enhanced computed tomography (CT), enhanced magnetic resonance imaging (MRI)] were collected. Univariate analyses combined with multivariate logistic regression were used to identify the independent risk factors for CR-POPF. These factors were used to train and validate the model and to develop the risk nomogram. The area under the curve (AUC) was used to measure the predictive ability of the models. The integrated discrimination improvement index (IDI) and decision curve analysis (DCA) were used to assess the clinical feasibility of the nomogram in relation to five other models established in literature.

RESULTS

CT visceral fat area (P = 0.014), the pancreatic spleen signal ratio on T1 fat-suppressed MRI sequences (P < 0.001), and CT main pancreatic duct diameter (P = 0.001) were identified as independent prognostic factors and used to develop the model. The final nomogram achieved an AUC of 0.903. The IDI and DCA showed that the nomogram outperformed the other five CR-POPF models in the training and testing cohorts.

CONCLUSION

The nomogram achieved a superior predictive ability for CR-POPF following PD than other models described in literature. Clinicians can use this simple model to optimize perioperative planning according to the patient's risk of developing CR-POPF.

A novel prediction model of pancreatic fistula after pancreaticoduodenectomy using only preoperative markers

BACKGROUND

Since clinically relevant postoperative pancreatic fistula (CR-POPF) can cause intra-abdominal hemorrhage and abscesses, leading to surgery-related deaths after pancreaticoduodenectomy (PD), its preoperative prediction is important to develop strategies for surgical procedures and perioperative management. This study aimed to establish a novel prediction model for CR-POPF using preoperative markers.

METHODS

On a training set of 180 patients who underwent PD at the Yamaguchi University Hospital, a combination of CR-POPF predictors were explored using the leave-one-out method with a unique discrete Bayes classifier. This predictive model was confirmed using a validation set of 366 patients who underwent PD at the Osaka University Hospital.

RESULTS

In the training set, CR-POPF occurred in 60 (33%)　of 180 patients and 130 (36%)　of 366 patients in the validation set using selected markers. In patients with pancreatic ductal adenocarcinoma (PDAC), the main pancreatic duct (MPD) index showed the highest prognostic performance and could differentiate CR-POPF with 87% sensitivity and 81% specificity among 84 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index-based model for 130 PDAC samples were 93% and 87%, respectively. In patients with non-PDAC, the MPD index/body mass index (BMI) combination showed the highest prognostic performance and could differentiate CR-POPF with 84% sensitivity and 57% specificity among 96 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index/BMI-based model for 236 non-PDAC samples were 85% and 53%, respectively.

CONCLUSION

We developed a novel prediction model for pancreatic fistulas after PD using only preoperative markers. The MPD index and MPD index/BMI combination will be useful for CR-POPF assessment in PDAC and non-PDAC samples, respectively.

Prevalence of Malnutrition and the Value of Predicting Pancreatic Fistula in Patients with Laparoscopic Pancreatoduodenectomy

Background: Pancreatoduodenectomy is a standard surgical procedure for periampullary tumors. With recent improvements in perioperative management, postoperative mortality has decreased significantly in recent years; however, postoperative pancreatic fistula (POPF) is still one of the most prevalent and dangerous complications. The purpose of this study was to analyze the prevalence of malnutrition and the value of predicting POPF in patients with laparoscopic pancreatoduodenectomy (LPD). Methods: We retrospectively analyzed the perioperative data of 747 patients undergoing LPD in the Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, China. Simultaneously, we analyzed the prevalence rate of malnutrition with three different nutritional assessment scores and explored the independent risk variables for POPF to identify potential predictive value. Results: Malnutrition was observed in 20.1% of patients with the prognostic nutritional index (PNI), 85.0% of patients with the controlling nutritional status (CONUT) score, and 73.1% of patients with the NRI score. Univariate and multivariate analyses all showed that the risk factors for POPF were pancreatic texture, pancreatic duct diameter, abdominal infection, body mass index (BMI), nomogram-revised risk index (NRI), and PNI. The receiver operating characteristic curve indicated that the BMI/PNI ratio was capable of predicting the occurrence of clinical POPF following LPD, with an area under the curve of 0.708. Conclusions: Compared with no malnourished patients, malnutrition is associated with a higher risk of POPF among patients with LPD. In addition, the BMI/PNI ratio has some predictive value in the development of POPF following LPD.

A Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis analysis to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy: A systematic review

BACKGROUND

Postoperative pancreatic fistula is a frequent and potentially lethal complication after pancreatoduodenectomy. Several models have been developed to predict postoperative pancreatic fistula risk. This study was performed to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist that provides guidelines on reporting prediction models to enhance transparency and to help in the decision-making regarding the implementation of the appropriate risk models into clinical practice.

METHODS

Studies that described prediction models to predict postoperative pancreatic fistula after pancreatoduodenectomy were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The TRIPOD checklist was used to evaluate the adherence rate. The area under the curve and other performance measures were extracted if reported. A quadrant matrix chart is created to plot the area under the curve against TRIPOD adherence rate to find models with a combination of above-average TRIPOD adherence and area under the curve.

RESULTS

In total, 52 predictive models were included (23 development, 15 external validation, 4 incremental value, and 10 development and external validation). No risk model achieved 100% adherence to the TRIPOD. The mean adherence rate was 65%. Most authors failed to report on missing data and actions to blind assessment of predictors. Thirteen models had an above-average performance for TRIPOD checklist adherence and area under the curve.

CONCLUSION

Although the average TRIPOD adherence rate for postoperative pancreatic fistula models after pancreatoduodenectomy was 65%, higher compared to other published models, it does not meet TRIPOD standards for transparency. This study identified 13 models that performed above average in TRIPOD adherence and area under the curve, which could be the appropriate models to be used in clinical practice.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

OBJECTIVE

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA

Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS

A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS

Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION

For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Development of a Pancreatic Fistula Prediction Model After Pancreaticoduodenectomy Based on a Decision Tree and Random Forest Algorithm

BACKGROUND

The incidence of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is high. We sought to develop a POPF prediction model based on a decision tree (DT) and random forest (RF) algorithm after PD and to explore its clinical value.

METHODS

The case data of 257 patients who underwent PD in a tertiary general hospital from 2013 to 2021 were retrospectively collected in China. The RF model was used to select features by ranking the importance of variables, and both algorithms were used to build the prediction model after automatic adjustment of parameters by setting the respective hyperparameter intervals and resampling as a 10-fold cross-validation method, etc. The prediction model's performance was assessed by the receiver operating characteristic curve (ROC) and the area under curve (AUC).

RESULTS

Postoperative pancreatic fistula occurred in 56 cases (56/257, 21.8%). The DT model had an AUC of .743 and an accuracy of .840, while the RF model had an AUC of .977 and an accuracy of .883. The DT plot visualized the process of inferring the risk of pancreatic fistula from the DT model on independent individuals. The top 10 important variables were selected for ranking in the RF variable importance ranking.

CONCLUSION

This study successfully developed a DT and RF algorithm for the POPF prediction model, which can be used as a reference for clinical health care professionals to optimize treatment strategies to reduce the incidence of POPF.

Intraoperative conditions of patients undergoing pancreatoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a severe complication following pancreatoduodenectomy (PD). Previous research in colorectal surgery demonstrated suboptimal intraoperative conditions to be related with an increased risk of anastomotic leakage. Aim of this study was to evaluate the intraoperative condition of patients undergoing PD by both assessing whether these known intraoperative modifiable risk factors in colorectal surgery are also present during PD and by measuring compliance to intraoperative ERAS guidelines. Secondly, to determine the relation of these factors with POPF.

MATERIALS AND METHODS

This prospective single center study included patients undergoing PD from 2016 to 2020. Parameters regarding the patient's general condition, local perfusion, oxygenation, surgical factors and ERAS elements were measured with a checklist intraoperatively, before the creation of the pancreatojejunal anastomosis. Uni- and multivariable logistic regression analyses were performed.

RESULTS

83 patients were included. POPF occurred in 27.7% (9.0% grade B, 10.0% grade C). Patients with POPF significantly had more other postoperative complications compared to patients without POPF (100% vs. 76.2%, p = 0.017). A suboptimal intraoperative condition was observed in 89.2%. Overall compliance to the intraoperative ERAS guideline was 0%. In univariable analysis, soft pancreatic tissue, pancreatic duct <3 mm, tumor location and intraoperative vasopressor administration were significantly associated with POPF. In multivariable analysis, only soft pancreatic tissue was independently associated with POPF (OR 13.627; 95% CI 1.656-112.157, p = 0.015).

CONCLUSION

Awareness amongst surgeons and anesthesiologists should be created. The influence of these intraoperative factors on POPF should be further evaluated in future, larger studies.

Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review

Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.

Risk factors of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common and troublesome complication after pancreatoduodenectomy (PD). We conducted a systematic review and meta-analysis to identify the risk factors of CR-POPF after PD.

METHODS

We searched PubMed, EMBASE, and Cochrane Library databases for studies related to risk factors of CR-POPF after PD. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were extracted from the included studies, then a meta-analysis was conducted. If necessary, sensitivity analysis would be performed by changing the effect model or excluding 1 study at a time. Publication bias was assessed by funnel plot and Begg test and Egger test.

RESULTS

A total of 27 studies with 24,740 patients were included, and CR-POPF occurred in 3843 patients (incidence = 17%, 95% CI: 16%-19%). Male (OR = 1.56, 95% CI: 1.42-1.70), body mass index >25 kg/m2 (OR = 1.98, 95% CI: 1.23-3.18), pancreatic duct diameter <3 mm (OR = 1.87, 95% CI: 1.66-2.12), soft pancreatic texture (OR = 3.49, 95% CI: 2.61-4.67), and blood transfusion (OR = 3.10, 95% CI: 2.01-4.77) can significantly increase the risk of CR-POPF. Pancreatic adenocarcinoma (OR = 0.54, 95% CI: 0.47-0.61), vascular resection (OR = 0.57, 95% CI: 0.39-0.83), and preoperative chemoradiotherapy (OR = 0.68, 95% CI: 0.57-0.81) can significantly decrease the factor of CR-POPF. Diabetes mellitus was not statistically associated with CR-POPF (OR = 0.66, 95% CI: 0.40-1.08). However, the analysis of body mass index, pancreatic texture, and diabetes mellitus had a high heterogeneity, then sensitivity analysis was performed, and the result after sensitivity analysis showed diabetes mellitus can significantly decrease the risk of CR-POPF. There was no significant publication bias in this meta-analysis.

CONCLUSIONS

The current review assessed the effects of different factors on CR-POPF. This can provide a basis for the prevention and management of CR-POPF. Effective interventions targeting the above risk factors should be investigated in future studies for decreasing the occurrence of CR-POPF.

The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data

BACKGROUND

The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck.

METHODS

The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film.

RESULTS

Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF.

CONCLUSION

Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.

External validation of postoperative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis

BACKGROUND

Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation and are the most accurate. The aim of this study was to identify risk scores for POPF, and assess the clinical validity of these scores.

METHODS

Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models.

RESULTS

Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so included in the meta-analysis, (Tokyo (N=2 validation studies), Birmingham (N=5), FRS (N=19), a-FRS (N=12), m-FRS (N=3) and ua-FRS (N=3) scores). Overall predictive accuracies were similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%.

CONCLUSION

Most risk scores lack external validation; where this was performed, risk scores were found to have limited predictive accuracy. . Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.

Higher cumulative fluid follows a pancreaticoduodenectomy as a single modifiable factor for post-operative pancreatic fistula: Risk factor analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the major complications after pancreaticoduodenectomy. There have been many studies into the risk factors determining POPF. Some studies have reported a higher peri-operative fluid balance associated with POPF, however, the pertinent findings remain controversial. The aims of this study were to determine risk factors of clinically relevant-post operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and an association between peri-operative fluid balance and the incidence of CR-POPF.

MATERIALS AND METHODS

This is a retrospective cohort study included all adult patients who underwent an elective open pancreaticoduodenectomy in our center from 2005 to 2018. Patients who did not have POPF related data were excluded from study. We divided patients into CR-POPF and no CR-POPF group. Peri-operative data including amount and type of fluid were compared between two groups. Logistic regression analysis was used to identify the independent risk factors of CR-POPF.

RESULTS

There were 223 pancreaticoduodenectomies done in our center during that period. The incidence of CR-POPF was 15.2 %. Patients in CR-POPF group had significant higher BMI, higher serum globulin level, smaller pancreatic duct diameter and higher cumulative fluid balance per body weight (FBPBW) at post-operative day 3. Multivariable analysis showed BMI >23 kg/m², diagnosis other than pancreatic duct adenocarcinoma or chronic pancreatitis and higher cumulative FBPBW at post-operative day 3 were the independent risk factors for CR-POPF.

CONCLUSIONS

Post-operative fluid balance was the post-operative modifiable risk factor to reduce CR-POPF. Higher positive post-operative fluid balance should be avoided especially in higher CR-POPF risk patients.

Comprehensive Diagnostic Nomogram for Predicting Clinically Relevant Postoperative Pancreatic Fistula After Pancreatoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a severe and challenging complication of pancreaticoduodenectomy (PD). This study aimed to establish a novel postoperative nomogram-based diagnostic model for the early detection of CR-POPF in patients subjected to PD.

METHODS

Consecutive patients who underwent PD in Zhongshan Hospital, Fudan University from December 2018 to October 2020 were retrospectively enrolled. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for CR-POPF. Then, a novel predictive nomogram was established accordingly.

RESULTS

Among the consecutive 176 patients who underwent PD, 37 (21.1%) patients developed CR-POPF. Through univariate and multivariate analyses, the drain amylase (P = 0.002), serum creatinine (P = 0.009), and serum C reactive protein (P = 0.045) at postoperative day 1 (POD1) as well as the neutrophil count (P = 0.025) and temperature (P = 0.025) at POD3 were identified as independent risk factors for CR-POPF. Based on this, a novel predictive nomogram containing these factors was constructed to predict the probability of CR-POPF after PD. The formulated nomogram showed better performance to detect CR-POPF after PD with a sensitivity of 0.784, specificity of 0.770, positive predictive value of 0.475, and negative predictive value of 0.930 when compared to other predictors. In addition, the predictive value of the nomogram was assessed by a concordance index of 0.814 (95% CI, 0.736-0.892), which was significantly higher than indicators alone. This was further validated and depicted by decision curve analysis and clinical impact curve.

CONCLUSION

This study established a diagnostic nomogram of postoperative objective parameters that can predict the development of CR-POPF after PD with a good discriminative ability and predictive accuracy.

Predictive nomogram for postoperative pancreatic fistula following pancreaticoduodenectomy: a retrospective study

BACKGROUND

Postoperative pancreatic fistula (POPF) represents the most common complication following pancreaticoduodenectomy (PD). Predictive models are needed to select patients with a high risk of POPF. This study was aimed to establish an effective predictive nomogram for POPF following PD.

METHODS

Consecutive patients who had undergone PD between January 2016 and May 2020 at a single institution were analysed retrospectively. A predictive nomogram was established based on a training cohort, and Lasso regression and multivariable logistic regression analysis were used to evaluate predictors. The predictive abilities of the predicting model were assessed for internal validation by the area under the receiver operating characteristic curve (AUC) and calibration plot using bootstrap resampling. The performance of the nomogram was compared with that of the currently used a-FRS model.

RESULTS

A total of 459 patients were divided into a training cohort (n = 302) and a validation cohort (n = 157). No significant difference was observed between the two groups with respect to clinicopathological characteristics. The POPF rate was 16.56%. The risk factors of POPF POPF were albumin difference, drain amylase value on postoperative day 1, pancreas texture, and BMI, which were all selected into a nomogram. Nomogram application revealed good discrimination (AUC = 0.87, 95% CI: 0.81-0.94, P <  0.001) as well as calibration abilities in the validation cohort. The predictive value of the nomogram was better than that of the a-FRS model (AUC: 0.87 vs 0.62, P <  0.001).

CONCLUSIONS

This predictive nomogram could be used to evaluate the individual risk of POPF in patients following PD, and albumin difference is a new, accessible predictor of POPF after PD.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Register ( ChiCTR2000034435 ).

Risk Factors and a New Prediction Model for Pancreatic Fistula After Pancreaticoduodenectomy

Aim

In order to find the risk factors of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) according to the latest definition and grading system of International Study Group of Pancreatic Surgery (ISGPS) (version 2016) and propose a nomogram for predicting POPF.

Methods

We conducted a retrospective analysis of 232 successive cases of PD performed at our hospital by the same operator from August 2012 to June 2020. POPF was diagnosed in accordance with the latest definition of pancreatic fistula from the ISGPS. The risk factors of POPF were analyzed by univariate and multivariate logistic regression analysis. A nomogram model to predict the risk of POPF was constructed based on significant factors.

Results

There were 18 cases of POPF, accounting for 7.8% of the total. Among them, 17 cases were classified into ISGPF grade B and 1 case was classified into ISGPF grade C. In addition, 35 cases were classified into biochemical leak. Univariate and multivariate analysis showed that hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Based on significant factors, a nomogram is plotted to predict the risk of POPF. The C-index of this nomogram to assess prediction accuracy was 0.916 (P < 0.001) indicating good prediction performance.

Conclusion

Hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Meanwhile, a nomogram for predicting POPF with good test performance and discriminatory capacity was constituted.

Dynamic prediction for clinically relevant pancreatic fistula: a novel prediction model for laparoscopic pancreaticoduodenectomy

Background

With the recent emerge of dynamic prediction model on the use of diabetes, cardiovascular diseases and renal failure, and its advantage of providing timely predicted results according to the fluctuation of the condition of the patients, we aim to develop a dynamic prediction model with its corresponding risk assessment chart for clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy by combining baseline factors and postoperative time-relevant drainage fluid amylase level and C-reactive protein-to-albumin ratio.

Methods

We collected data of 251 patients undergoing LPD at West China Hospital of Sichuan University from January 2016 to April 2019. We extracted preoperative and intraoperative baseline factors and time-window of postoperative drainage fluid amylase and C-reactive protein-to-albumin ratio relevant to clinically relevant pancreatic fistula by performing univariate and multivariate analyses, developing a time-relevant logistic model with the evaluation of its discrimination ability. We also established a risk assessment chart in each time-point.

Results

The proportion of the patients who developed clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy was 7.6% (19/251); preoperative albumin and creatine levels, as well as drainage fluid amylase and C-reactive protein-to-albumin ratio on postoperative days 2, 3, and 5, were the independent risk factors for clinically relevant postoperative pancreatic fistula. The cut-off points of the prediction value of each time-relevant logistic model were 14.0% (sensitivity: 81.9%, specificity: 86.5%), 8.3% (sensitivity: 85.7%, specificity: 79.1%), and 7.4% (sensitivity: 76.9%, specificity: 85.9%) on postoperative days 2, 3, and 5, respectively, the area under the receiver operating characteristic curve was 0.866 (95% CI 0.737–0.996), 0.896 (95% CI 0.814–0.978), and 0.888 (95% CI 0.806–0.971), respectively.

Conclusions

The dynamic prediction model for clinically relevant postoperative pancreatic fistula has a good to very good discriminative ability and predictive accuracy. Patients whose predictive values were above 14.0%, 8.3%, and 7.5% on postoperative days 2, 3, and 5 would be very likely to develop clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy.

[Predictors of external pancreatic fistulae after pancreatic resection]

Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.

Impact of enhanced recovery after surgery protocol on pancreaticoduodenectomy: a meta-analysis of non-randomized and randomized controlled trials

BACKGROUND

Enhanced recovery after surgery (ERAS) has been widely applied in many surgical specialties. However, with respect to the impact of ERAS on pancreaticoduodenectomy (PD), there still exist some controversies.

METHODS

Literature search was performed in PubMed, Web of Science and the Cochrane Library from January, 1990 to July, 2019. A meta-analysis was performed using fixed-effects or random-effects models.

RESULTS

Twenty-two studies containing 4147 patients were identified. The entire pooled data showed that ERAS significantly reduced overall and minor morbidity (RR: 0.80, 95% CI: 0.72-0.88, p < 0.001; RR: 0.78, 95% CI: 0.69-0.88, p < 0.001, respectively), but didn't affect major morbidity (RR: 0.97, 95% CI: 0.84-1.13, p = 0.72). ERAS markedly reduced the incidences of delayed gastric emptying (DGE) (RR: 0.69, 95% CI: 0.55-0.88, p = 0.002), incisional infection (RR: 0.75, 95% CI: 0.60-0.94, p = 0.01) and intra-abdominal infection (RR: 0.79, 95% CI: 0.63-1.00, p = 0.05), but didn't influence clinically-relevant postoperative pancreatic fistula (CR-POPF) (RR: 0.86, 95% CI: 0.73-1.01, p = 0.07). Shorter length of stay (LOS) (WMD: -5.07, 95% CI: -6.71 to -3.43, p < 0.001) was noted in ERAS group, without increasing 30-day readmission (RR: 1.03, 95% CI: 0.86-1.24, p = 0.71) and mortality (RR: 0.70, 95% CI: 0.41-1.21, p = 0.20).

CONCLUSION

ERAS significantly reduced overall and minor morbidity, incidences of DGE, incisional and intra-abdominal infections, and shortened LOS in PD, without increasing 30-day readmission and mortality. However, more large-scale randomized controlled trials are still needed to confirm the findings.

Risk factors and preventive measures for postoperative pancreatic fistula after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD), which can lead to slow recovery, deterioration, and even reoperation and death. At present, the mortality rate after PD has decreased, but the incidence of POPF is still high. Therefore, exploring the risk factors and prevention strategies for pancreatic fistula has become a hot research topic in pancreatic surgery. This paper summarizes the nature, risk factors, and preventive measures for POPF.