Postpancreatectomy Acute Pancreatitis (PPAP)

Abstract

Objective:The ISGPS aimed to develop a universally accepted definition for PPAP for standardized reporting and outcome comparison.Background: :PPAP is an increasingly recognized complication after partial pancreatic resections, but its incidence and clinical impact, and even its existence are variable because an internationally accepted consensus definition and grading system are lacking.Methods:The ISGPS developed a consensus definition and grading of PPAP with its members after an evidence review and after a series of discussions and multiple revisions from April 2020 to May 2021.Results:We defined PPAP as an acute inflammatory condition of the pancreatic remnant beginning within the first 3 postoperative days after a partial pancreatic resection. The diagnosis requires (1) a sustained postoperative serum hyperamylasemia (POH) greater than the institutional upper limit of normal for at least the first 48 hours postoperatively, (2) associated with clinically relevant features, and (3) radiologic alterations consistent with PPAP. Three different PPAP grades were defined based on the clinical impact: (1) grade postoperative hyperamylasemia, biochemical changes only; (2) grade B, mild or moderate complications; and (3) grade C, severe life-threatening complications.Discussions:The present definition and grading scale of PPAP, based on biochemical, radiologic, and clinical criteria, are instrumental for a better understanding of PPAP and the spectrum of postoperative complications related to this emerging entity. The current terminology will serve as a reference point for standard assessment and lend itself to developing specific treatments and prevention strategies.

Incidence and risk factors of postoperative acute pancreatitis after pancreaticoduodenectomy: a systematic review and meta-analysis

“…Regardless of the diagnostic criteria, the high incidence of POAP deserves the attention of surgeons. In particular, the activation of pancreatic enzymes after POAP may lead to prolonged healing time or even non-healing of the pancreatic-intestinal anastomoses, resulting in postoperative pancreatic fistulas (POPFs), localized fluid accumulation in the abdominal cavity, infections, and even serious systemic complications ( 8 , 9 , 14 , 35 , 36 ). Some POAP may include acute necrotizing pancreatitis, which may pose serious hazards and even require secondary surgery for total pancreatectomy ( 10 ).…”

“…The Connor criteria ( 9 ), Atlanta definitions ( 13 ), and International Study Group for Pancreatic Surgery (ISGPS) definition ( 8 ) have been commonly used for diagnosing POAP. The Connor criteria defines POAP as the presence of urinary trypsinogen-2 levels higher than 50 µg/l or serum amylase levels higher than the normal upper limit on postoperative days (PODs) 0 or 1 ( 9 ).…”

“…The ISGPS defines POAP as an acute inflammatory response in the remnant pancreas early after partial pancreatectomy and serum amylase activity consistently above the normal upper limit for at least 48 h postoperatively, in addition to the presence of radiologic features and disease-related management changes ( 8 ). Finally, the Atlanta POAP classification and definition requires the presence of two of the following three features: abdominal pain consistent with acute pancreatitis; serum lipase or amylase activity at least three times higher than the normal upper limit; and radiologic features of acute pancreatitis ( 13 ).…”

“…The equally severe post-ERCP pancreatitis can also lead to local or systemic complications and even organ failure. The local acute inflammation of the pancreas may slow down the healing of pancreato-enteric anastomoses and residual pancreatic necroses, resulting in pancreatic fistulas, infections, and the need for secondary interventions (8)(9)(10).…”

Effects of Pancreatic Surgery : Quality of Life, Cost-effectiveness and Postoperative Results

“…The definition implies a sustained increase in serum amylase for at least 48 hours postoperatively together with radiological features of pancreatitis and a clinically relevant change in management. As with POPF, the clinically relevant grades are B and C, 93 as outlined in Table 3. One recent Swedish singlecentre study retrospectively investigated the rates of sustained hyperamylasaemia among 1078 patients who had undergone PD during a period of 13 years.…”