Facing the surgeon's nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery (ISGPS).

BACKGROUND: Postoperative pancreatic fistulas (POPF) grade C represent a rare but feared complication following pancreaticoduodenectomy (PD). They can contribute significantly to postoperative morbidity and mortality. METHODS: We performed a retrospective chart review for all patients who had undergone pancreatic head resection between 2007 and 2016 to identify those who suffered from POPF grade C according to the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). RESULTS: A total of 722 patients underwent PD. Twenty-three patients (3.19%) developed a POPF grade C. Cardiovascular diseases, soft pancreatic texture and main pancreatic duct diameter were identified as risk factors (P < .05). Reoperation was necessary in all affected patients on postoperative day 12 ± 9 on average. Mortality was significantly associated with POPF grade C (P < .05) being present in 39.1% (9/23). CONCLUSIONS: POPF grade C after PD remains a serious complication with a high level of morbidity and mortality. Surgical treatment is the sole curative therapy and thus the treatment of choice.

Decoding Grade B Pancreatic Fistula: A Clinical and Economical Analysis and Subclassification Proposal.

OBJECTIVE: The aim of this study was to describe characteristics and management approaches for grade B pancreatic fistula (B-POPF) and investigate whether it segregates into distinct subclasses. BACKGROUND: The 2016 ISGPS refined definition of B-POPF is predicated on various postoperative management approaches, ranging from prolonged drainage to interventional procedures, but the spectrum of clinical severity within this entity is yet undefined. METHODS: Pancreatectomies performed at 2 institutions from 2007 to 2016 were reviewed to identify B-POPFs and their treatment strategies. Subclassification of B-POPFs into 3 classes was modeled after the Fistula Accordion Severity Grading System (B1: prolonged drainage only; B2: pharmacologic management; B3: interventional procedures). Clinical and economic outcomes, unique from the ISGPS definition qualifiers, were analyzed across subclasses. RESULTS: B-POPF developed in 320 of 1949 patients (16.4%), and commonly required antibiotics (70.3%), prolonged drainage (67.8%), and enteral/parenteral nutrition (54.7%). Percutaneous drainage occurred in 79 patients (24.7%), always in combination with other strategies. Management of B-POPFs was widely heterogeneous with a median of 2 approaches/patient (range 1 to 6) and 38 various strategy combinations used. Subclasses B1-3 comprised 19.1%, 52.2%, and 28.8% of B-POPFs, respectively, and were associated with progressively worse clinical and economic outcomes. These results were confirmed by multivariable analysis adjusted for clinical and operative factors. Notably, distribution of the B-POPF subclasses was influenced by institution and type of resection (P < 0.001), while clinical/demographic predictors proved elusive. CONCLUSION: B-POPF is a heterogeneous entity, where 3 distinct subclasses with increasing clinical and economic burden can be identified. This classification framework has potential implications for accurate reporting, comparative research, and performance evaluation.

Analysis of pancreatic fistula according to the International Study Group on Pancreatic Fistula classification scheme for 294 patients who underwent pancreaticoduodenectomy in a single center.

OBJECTIVES: The purposes of this study were to validate the value of the International Study Group on Pancreatic Fistula (ISGPF) classification scheme for pancreatic fistula (PF) and to identify predictive factors for clinically significant PF. METHODS: From January 2000 to December 2007, 294 consecutive patients underwent pancreaticoduodenectomy in a single medical center. Pancreatic fistula was evaluated by the ISGPF criteria and Johns Hopkins Hospital's definition (JHH). Then, logistic regression analysis was performed to identify predictive factors for PF development. Our own management strategies with PF were also discussed. RESULTS: The overall incidence of PF was 19.4% (57/294) according to the ISGPF criteria, and 8.8% (26/294) using the JHH definition. Thirty-one patients with PF classified by the ISGPF were missed by the JHH definition. By logistic regression analysis, we found that besides the lack of cardiovascular disease and malignant diseases, our single-layer continuous circular invaginated pancreaticojejunostomy was another independent factor for the lowered incidence of PF. CONCLUSIONS: The ISGPF classification scheme was accurate for evaluating PF. Single-layer continuous circular invaginated pancreaticojejunostomy may be a promising method that may have been responsible for the lower incidence of PF in this study.

A grading system can predict clinical and economic outcomes of pancreatic fistula after pancreaticoduodenectomy: results in 755 consecutive patients.

AIM: Postoperative pancreatic fistula (POPF) has a wide range of clinical and economical implications due to the difference of the associated complications and management. The aim of this study is to verify the applicability of the International Study Group of Pancreatic Fistula (ISGPF) definition and its capability to predict hospital costs. METHODS: This is a retrospective study based on prospectively collected data of 755 patients who underwent pancreaticoduodenectomy in our institution between November 1996 and October 2006. A number of 147 patients (19.5%) have developed a POPF according to ISGPF definition. RESULTS: Grade A fistula, which has no clinical impact, occurred in 19% of all cases. Grade B occurred in 70.7% and was successfully managed with conservative therapy or mini-invasive procedures. Grade C (8.8%) was associated to severe clinical complications and required invasive therapy. Pulmonary complications were statistically higher in the groups B and C rather than the group A POPFs (p < 0.005; OR 8). Patients with carcinoma of the ampullary region had a higher incidence of POPF compared to ductal cancer, with a predominance of grade A (p = 0.036). Increasing fistula grades have higher hospital costs (€11,654, €25,698, and €59,492 for grades A, B, and C, respectively; p < 0.001). CONCLUSIONS: The development of a POPF does not always determine a substantial change of the postoperative management. Clinically relevant fistulas can be treated conservatively in most cases. Higher fistula severity corresponds to increased costs. The grading system proposed by the ISGPF allows a correct stratification of the complicated patients based on the real clinical and economic impact of the POPF.

Impact of postoperative pancreatic fistula on surgical outcome--the need for a classification-driven risk management.

BACKGROUND: The International Study Group of Pancreatic Fistula (ISGPF) classification allows comparison of incidence and severity of postoperative pancreatic fistula (POPF). Its post hoc character, however, does not provide a guideline for the treatment of POPF in individual patient. We therefore studied the association of POPF type A-C on secondary surgical morbidity and mortality in patients undergoing pancreatic resection. PATIENTS AND METHODS: Between 3/2001-12/2007, 483 patients underwent pancreatic resections. POPF were classified according to the ISGPF classification. All patient data were entered in a clinical data management system prospectively. RESULTS: Patients who developed POPF had significantly more vascular but not other surgical complications than patients without POPF. Patients with POPF A had no vascular or surgical complications. Twenty one of the 29 patients with POPF C had surgical complications (17 vascular complications). Mortality attributed to surgical complications after POPF C was 5/29. A soft pancreatic consistency (OR 8.5; p < 0.008) and a high drain lipase activity on postoperative day 3 (OR 4.4; p = 0,065) were predictors for the development of POPF C. DISCUSSION: POPF C is associated with vascular complications like erosion bleeding and other surgical complications like delayed gastric emptying or pleural effusions. A soft pancreatic consistency and a high drain lipase activity on postoperative day 3 are early predictors for the development of POPF C.

Risk prediction for development of pancreatic fistula using the ISGPF classification scheme.

BACKGROUND: The International Study Group on Pancreatic Fistula (ISGPF) classification scheme has become a useful system for characterizing the clinical impact of pancreatic fistula. We sought to identify predictive factors that predispose patients to fistula, specifically those with clinical relevance (grades B/C), and to describe the clinical and economic significance of risk stratification within this framework. METHODS: Overall, 233 consecutive pancreatoduodenectomies were performed between October 2001 and March 2007 in our institution. Pancreatic fistula is defined according to the ISGPF classification scheme. Logistic regression analysis was performed to identify risk factors for pancreatic fistula development. These features were then analyzed to determine whether additive risk severity equates to worsening clinical and economic impact. RESULTS: Fistulas of any extent occurred in 60 patients, but only 31 (14%) were clinically relevant. There are no identifiable risk factors for grade A biochemical fistulas. Multivariate analysis shows that small pancreatic duct size (<3 mm); soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss (>1,000 ml) are associated with clinically relevant fistulae. An additive effect is further illustrated, in which clinical and economic outcomes progressively worsen as risk profile increases. Each additional risk factor increases the odds of developing a clinically relevant fistula by 52%. CONCLUSIONS: For pancreatoduodenectomy, small duct size; soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss are convincing risk factors for the development clinically relevant fistulae as judged by ISGPF classification. As risk profile accrues, patients suffer more complications, encounter longer hospital stays, and incur greater hospital costs. These outcomes can be predicted in the operating room through accurate delineation of high-risk glands.

Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme.

OBJECTIVE: The authors sought to validate the ISGPF classification scheme in a large cohort of patients following pancreaticoduodenectomy (PD) in a pancreaticobiliary surgical specialty unit. SUMMARY BACKGROUND DATA: Definitions of postoperative pancreatic fistula vary widely, precluding accurate comparisons of surgical techniques and experiences. The ISGPF has proposed a classification scheme for pancreatic fistula based on clinical parameters; yet it has not been rigorously tested or validated. METHODS: : Between October 2001 and 2005, 176 consecutive patients underwent PD with a single drain placed. Pancreatic fistula was defined by ISGPF criteria. Cases were divided into four categories: no fistula; biochemical fistula without clinical sequelae (grade A), fistula requiring any therapeutic intervention (grade B), and fistula with severe clinical sequelae (grade C). Clinical and economic outcomes were analyzed across all grades. RESULTS: More than two thirds of all patients had no evidence of fistula. Grade A fistulas occurred 15% of the time, grade B 12%, and grade C 3%. All measurable outcomes were equivalent between the no fistula and grade A classes. Conversely, costs, duration of stay, ICU duration, and disposition acuity progressively increased from grade A to C. Resource utilization similarly escalated by grade. CONCLUSIONS: Biochemical evidence of pancreatic fistula alone has no clinical consequence and does not result in increased resource utilization. Increasing fistula grades have negative clinical and economic impacts on patients and their healthcare resources. These findings validate the ISGPF classification scheme for pancreatic fistula.