Increased postoperative pancreatic fistula rate after distal pancreatectomy compared with pancreatoduodenectomy is attributable to a difference in acinar scores

Abstract

Background Postoperative pancreatic fistula (POPF) is a potentially lethal complication of pancreatic surgery. POPF rate is consistently higher after distal pancreatectomy (DP) compared with pancreatoduodenectomy (PD). The acinar score of the remnant pancreas is associated with postoperative pancreatitis and POPF. This study aimed to: (i) confirm the difference in POPF rate after DP vs PD; (ii) confirm the association between acinar score and POPF; and (iii) evaluate the difference in acinar scores between DP and PD. Methods Patients undergoing DP or PD at a single institution from 2011 to 2017 were included. Hematoxylin and eosin‐stained slides of the pancreatic resection margin were evaluated for all patients and scored for acinar cell density. Clinicopathological data were retrieved from a prospectively maintained database. Results Two hundred and ninety‐four patients were included in the analysis (206 PD, 88 DP). The POPF rate was significantly higher after DP than PD (20.4% vs 11.2%, P = .043). Acinar score >50 was independently associated with the development of POPF (OR 6.457, P = .003). DP was associated with a higher median acinar score than PD (65 vs 50, P < .001). Conclusion The POPF rate is significantly higher after DP compared with PD and is attributable to a higher acinar score of the pancreatic resection margin.

Comparing the distal pancreatectomy fistula risk score (D‐FRS) and DISPAIR‐FRS for predicting pancreatic fistula after distal pancreatectomy

“…In this study, PT at pancreatic neck and at transection site were significant factor in univariate analyses ( P = 0.008 and P = 0.007, respectively) and were obviously higher in the POPF group than in the non‐POPF group (PT at pancreatic neck[median]: 15.18 versus 12.75 mm; PT at transection site[median]: 15.69 versus 13.55 mm), though it was not significant in the multivariate analyses, which may be attributed to the relatively small sample size of our cohort. A softer pancreas is often characterized by more acinar cells in the resection surface with stronger exocrine function, which may contribute to POPF 18,19 . However, pancreatic texture was a subjective factor determined by surgeon intraoperatively and lack objective accuracy, 20 resulting in its controversial role in the prediction of POPF in current and previous studies 3,21 .…”

“…A softer pancreas is often characterized by more acinar cells in the resection surface with stronger exocrine function, which may contribute to POPF. 18,19 However, pancreatic texture was a subjective factor determined by surgeon intraoperatively and lack objective accuracy, 20 resulting in its controversial role in the prediction of POPF in current and previous studies. 3,21 A higher BMI was an indicator of a softer pancreas and higher pancreatic thickness, which is highly related with visceral obesity and sarcopenia.…”

Prediction of postoperative pancreatic fistula and pancreatitis after pancreatoduodenectomy or distal pancreatectomy: A review

“…48,49 One study also demonstrated the higher rate of POPF after DP compared to PD to be attributable to higher median acinar cell count at resection margin. 50…”

“…48,49 One study also demonstrated the higher rate of POPF after DP compared to PD to be attributable to higher median acinar cell count at resection margin. 50 Especially for DP's, preoperative computed tomography (CT) scan measurements could provide an avenue for objective preoperative POPF risk assessment. A few small-scale studies have reported pancreatic thickness to be associated with POPF after DP.…”

Construction of a pancreatojejunostomy with an external stent: A technical description

“…[7][8][9][10][11] At the Royal North Shore Hospital in Sydney, we have adopted the use of external pancreatic stents for high-risk pancreatic anastomoses, based on a high Fistula Risk Score (FRS) or a high acinar score on frozen section, both of which have been correlated with a higher risk of POPF. 12,13 Here, we describe our technique using a fine bore infant feeding tube and a closed suction drainage system.…”