Decoding Grade B Pancreatic Fistula

Maggino, Laura; Malleo, Giuseppe; Bassi, Claudio; Allegrini, Valentina; McMillan, Matthew T.; Borin, Alex; Chen, Bofeng; Drebin, Jeffrey A.; Ecker, Brett L.; Fraker, Douglas L.; Lee, Major K.; Paiella, Salvatore; Roses, Robert E.; Salvia, Roberto; Vollmer, Charles M.

doi:10.1097/sla.0000000000002673

Cited by 59 publications

(41 citation statements)

References 29 publications

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“…Despite the treatment escalation, for instance, the same patient initially treated with simple antibiotics, then with artificial nutrition and eventually with several procedures of ID placement requiring several controls with cross-sectional imaging will always be included in the grade B POPF category. Another large series has retrospectively applied the new definition of POPF19 revealing how at least three different subcategories of patients coexist within grade B POPFs: those experiencing only a prolonged time (more than 3 weeks) with the drain kept in place; those that in addition need antibiotics, artificial nutrition or somatostatin analogues, and those that in addition need interventional procedures like ID or angiography to manage episodes of bleeding. Indeed, these sub-classification of grade B POPF seems to be particularly relevant as hospital costs related to the burden of treatment progressively increase by 36%, 146%, and 189% respectively compared to costs for the management of patients without POPF 19.…”

Section: Validation and Issues Related To 2016 Definition And Gradingmentioning

confidence: 99%

“…Another large series has retrospectively applied the new definition of POPF19 revealing how at least three different subcategories of patients coexist within grade B POPFs: those experiencing only a prolonged time (more than 3 weeks) with the drain kept in place; those that in addition need antibiotics, artificial nutrition or somatostatin analogues, and those that in addition need interventional procedures like ID or angiography to manage episodes of bleeding. Indeed, these sub-classification of grade B POPF seems to be particularly relevant as hospital costs related to the burden of treatment progressively increase by 36%, 146%, and 189% respectively compared to costs for the management of patients without POPF 19. This substantial heterogeneity of clinical pictures and management could ideally prevent the development of appropriate prevention and treatment strategies.…”

Section: Validation and Issues Related To 2016 Definition And Gradingmentioning

confidence: 99%

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Current Definition of and Controversial Issues Regarding Postoperative Pancreatic Fistulas

2019

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The International Study Group for Pancreatic Fistula (ISGPF) made the first attempt to standardize the outcome measure of fistulas in the field of pancreatic surgery by publishing the definition and classification of postoperative pancreatic fistulas (POPFs) in 2005. POPFs were determined by any measurable volume of fluid output via an operatively placed drain with amylase activity greater than three times the upper normal serum value. Taking into account more than 10 years of reported experience worldwide, the updated definition published in 2016 by the reconvened International Study Group for Pancreatic Surgery (ISGPS) attempted to overcome the limits of the previous classification. The crucial concept of POPF clinical significance was introduced by eliminating grade A from the fistula scenario. The wider use of interventional procedures has also made it necessary to recode grade C POPFs, which now have clearer boundaries, toward the worst end of the severity scale. Grade B still represents the most prevalent and heterogeneous category of POPFs, both in terms of clinical burden and management. In the near future, further efforts will be required to better stratify grade B POPFs to standardize treatment strategies and compare outcomes among institutions.

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Section: Validation and Issues Related To 2016 Definition And Gradingmentioning

confidence: 99%

Section: Validation and Issues Related To 2016 Definition And Gradingmentioning

confidence: 99%

Current Definition of and Controversial Issues Regarding Postoperative Pancreatic Fistulas

2019

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“…We estimated postoperative pancreatic fistulas according to ISGPS reassessment of 2016-2017. [9][10][11][12] Pancreatic fistulas were estimated There were significantly less pancreatic fistulas in the OP group in our study. Delayed gastric emptyings were not presented in this group either.…”

Section: Morbidity Ratementioning

confidence: 42%

Organ‐preserving procedures as an option for treatment of patients with pancreatic neuroendocrine tumours

et al. 2021

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Objective Pancreatic neuroendocrine tumour (pNET) is a rare type of tumour with different malignant potential. Nowadays there is no universal approach for treatment of small and benign‐looking pNETs throughout the world. Methods There were 137 patients with pNETs surgically treated in our department between 2007 and 2017. Most of them were female ‐ 96 cases with median age 42 years old. Organ‐preserving procedures (OP) were performed in 44 (32%) cases and were compared with standard procedures 93 (68%) cases. Results Main intraoperative characteristics were comparable in groups. There was significantly less estimated blood loss volume in the OP group: less than 1 dL. Postoperative length of stay and drainage placement time were less in the OP group. There were less pancreatic fistulas and no delayed gastric empties in the OP group. 90‐day postoperative mortality rate was the same in both groups: four cases of severe postoperative pancreatitis with acute respiratory distress syndrome. Conclusion As the “wait‐and‐see” policy can be not useful due to uncontrolled disease progression, choice of organ‐preserving treatment first can become the first line of decision taking in small benign pNETs. Our experience shows that organ‐preserving treatment is more comfortable for the surgeon and for the patient. However, it is not the universal position. The long‐term survival data still has to be estimated.

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“…The modern incidence of clinically significant pancreatic fistulae as defined by the International Study Group of Pancreatic Surgery is variable and dependent on numerous factors and patient characteristics. Rates in the literature range from 5% to greater than 30% [13][14][15][16][17]. Utilizing organ-space surgical infection as a surrogate may underestimate the true incidence of pancreatic fistula but is nonetheless a useful metric to consider.…”

Section: Discussionmentioning

confidence: 99%

Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients

et al. 2020

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Background: While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. Methods: ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DPdistal pancreatectomy, PDpancreaticoduodenectomy, or TP-total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. Results: Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%). Conclusion: Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.

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Decoding Grade B Pancreatic Fistula

Abstract: 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.

Cited by 59 publications

References 29 publications

Current Definition of and Controversial Issues Regarding Postoperative Pancreatic Fistulas

Current Definition of and Controversial Issues Regarding Postoperative Pancreatic Fistulas

Organ‐preserving procedures as an option for treatment of patients with pancreatic neuroendocrine tumours

Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients

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