Nationwide validation of the ISGPS risk classification for postoperative pancreatic fistula after pancreatoduodenectomy: “Less is more”

Suurmeijer, J Annelie; Emmen, Anouk M.L.H.; Bonsing, Bert A.; Busch, Olivier R.; Daams, Freek; Eijck, Casper H. van; Hingh, Ignace H. J. T. de; Mackay, Tara M; Mieog, J. Sven D.; Molenaar, I. Quintus; Stommel, Martijn W J; Meijer, Vincent E de; Santvoort, Hjalmar C. van; Koerkamp, B. Groot; Besselink, Marc G.

doi:10.1016/j.surg.2023.01.004

Cited by 9 publications

(5 citation statements)

References 31 publications

(25 reference statements)

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“…A recent nationwide validation of the ISGPS risk classification for POPF showed how 37% of the 3900 included patients were allocated into B and C categories, with no significant difference in POPF risk between the two. 14 Similarly, in the present study, more than one-third (according to ISGPS) and up to 80% (according to FRS) of patients were categorized in the middle ground of moderate risk according to macroscopic features. Based on histopathologic scoring, it was possible to selectively dichotomize them into 2 definite groups, with either low-risk or high-risk.…”

Section: Discussionsupporting

confidence: 65%

“…12 However, the surgeon's evaluation of macroscopic pancreatic features remains by definition subjective and may not always be conclusive, as most patients fall into "intermediate" risk categories (ie, FRS 3-6; ISGPS class B-C). 7,13,14 Despite expressing a definite area of the entire spectrum of risk stratification, an "intermediate" risk represents a gray area in which surgeons are challenged whether to adopt mitigation strategies. Moreover, there is no consistency regarding what measures should be adopted as the gold standard in these cases, as most evidence relies either on low-risk or high-risk categories.…”

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confidence: 99%

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et al. 2023

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Background: Pancreatic acinar content (Ac) has been associated with pancreas-specific complications after pancreatoduodenectomy. The aim of this study was to improve the prediction ability of intraoperative risk stratification by integrating the pancreatic acinar score. Methods: A training and validation cohort underwent pancreatoduodenectomy with a subsequent histologic assessment of pancreatic section margins for Ac, fibrosis (Fc), and fat. Intraoperative risk stratification (pancreatic texture, duct diameter) and pancreas-specific complications (postoperative hyperamylasemia [POH], postpancreatectomy acute pancreatitis [PPAP], pancreatic fistula [POPF]) were classified according to ISGPS definitions. Results: In the validation cohort (n = 373), the association of pancreasspecific complications with higher Ac and lower Fc was replicated (all P < 0.001). In the entire cohort (n = 761), the ISGPS classification allocated 275 (36%) patients into intermediate-risk classes B (POH 32%/ PPAP 3%/POPF 17%) and C (POH 36%/PPAP 9%/POPF 33%). Using the acinar score (Ac ≥ 60% and/or Fc ≤ 10%), intermediate-risk patients could be dichotomized into a low-risk (POH 5%/PPAP 1%/POPF 6%) and a high-risk (POH 51%/PPAP 9%/POPF 38%) group (all P < 0.001). The acinar score AUC for POPF prediction was 0.70 in the ISGPS intermediate-risk classes. Overall, 239 (31%) patients were relocated into the high-risk group from lower ISGPS risk classes using the acinar score. Conclusions: The risk of pancreas-specific complications appears to be dichotomous-either high or low-according to the acinar score, a tool to better target the application of mitigation strategies in cases of intermediate macroscopic features.

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Section: Discussionsupporting

confidence: 65%

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confidence: 99%

Either High or low Risk

et al. 2023

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“…In the present study, the pooled rate of POPF grade B/C was 40%, which is higher than the 23% rate in patients who underwent PD in the presence of the International Study Group of Pancreatic Surgery (ISGPS) type D high-risk features (i.e., soft pancreatic tissue + main pancreatic duct size ≤3 mm). 43 , 44 This also explains the high rate of rescue pancreatectomies (11%) in comparison to the median of 2% in 6186 patients who underwent PD in high-volume centers. 7 A worldwide variety exists regarding prevention and management strategies of POPF.…”

Section: Discussionmentioning

confidence: 99%

Systematic review and Meta-analysis of the Role of total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula

et al. 2023

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Objective: Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula (POPF). Summary Background Data: TP is mentioned as an alternative to PD in patients at high risk for POPF, but a systematic review is lacking. Methods: Systematic review and meta-analyses using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published up to October 2022, comparing elective single-stage TP for any indication versus PD in patients at high risk for POPF. The primary endpoint was short-term mortality. Secondary endpoints were major morbidity (i.e., Clavien-Dindo grade ≥ IIIa) on the short-term and quality of life. Results: After screening 1212 unique records, five studies with 707 patients (334 TP and 373 high-risk PD) met the eligibility criteria, comprising one randomized controlled trial and four observational studies. The 90-day mortality after TP and PD did not differ (6.3% vs. 6.2%; RR = 1.04 ). Major morbidity rate was lower after TP compared to PD (26.7% vs. 38.3%; RR = 0.65 [95%CI 0.48-0.89]), but no significance was seen in matched/randomized studies (29.0% vs. 36.9%; RR = 0.73 [95%CI 0.48-1.10]). Two studies investigated quality of life (EORTC QLQ-C30) at a median of 30-52 months, demonstrating comparable global health status after TP and PD (77% [ ± 15] vs. 76% [ ± 20]; P = 0.857). Conclusions: This systematic review and meta-analysis found no reduction in short-term mortality and major morbidity after TP as compared to PD in patients at high risk for POPF. However, if TP is used as a bailout procedure, the comparable long-term quality of life is reassuring.

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“…Interestingly, the study by Harris and coworkers published in 2023 found statistically significantly increased rates of small Wirsung duct size and soft pancreatic texture in patients with PD and concurrent colectomies compared with the group of patients with standard PD [27]. This might explain, at least in part, the higher rates of clinically relevant POPF in the group of patients with PD and associated colectomies because small Wirsung duct size and soft pancreas are essential predictors of POPF formation after PD, widely used in recently proposed risk scores for POPF formation after PD [86,87]. Unfortunately, the study mentioned above [27] has no data about treating distal pancreatic stumps after PD.…”

Section: Complications Of Pd With Concurrent Colectomiesmentioning

confidence: 98%

Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes

Dumitrascu

2023

JCM

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Multi-visceral resections for colon and pancreatic cancer (PDAC) are feasible, safe, and justified for early and late outcomes. However, the use of pancreaticoduodenectomy (PD) with concurrent colectomies is highly debatable in terms of morbidity and oncological benefits. Based on current literature data, this review assesses the early and long-term outcomes of PD with colectomies. The association represents a challenging but feasible option for a few patients with PDAC or locally advanced right colon cancer when negative resection margins are anticipated because long-term survival can be achieved. Concurrent colectomies during PD should be cautiously approached because they may significantly increase complication rates, including severe ones. Thus, patients should be fit enough to overcome potential severe complications. Patients with PD and colectomies can be classified as borderline resectable, considering the high risk of developing postoperative complications. Carefully selecting patients suitable for PD with concurrent colectomies is paramount to mitigate the potentially severe complications of the two surgical procedures and maximize the oncological benefits. These procedures should be performed at high-volume centers with extensive experience in pancreatectomies and colectomies, and each patient situation should be assessed using a multimodal approach, including high-quality imaging and neoadjuvant therapies, in a multidisciplinary team discussion.

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Nationwide validation of the ISGPS risk classification for postoperative pancreatic fistula after pancreatoduodenectomy: “Less is more”

Cited by 9 publications

References 31 publications

Either High or low Risk

Either High or low Risk

Systematic review and Meta-analysis of the Role of total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula

Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes

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