Preoperative risk evaluation for pancreatic fistula after pancreaticoduodenectomy

Abstract

Background Pancreatic fistula remains common, with limited ability to risk stratify patients preoperatively. The objective of this study was to identify risk factors for clinically‐relevant postoperative pancreatic fistula (CR‐POPF) that are routinely available in the preoperative setting. Methods Preoperatively available variables for all pancreaticoduodenectomies from 2014‐2017 were examined using a national clinical registry. The cohort was separated into risk factor identification and internal validation subgroups. Results Among 15 033 pancreaticoduodenectomies, the CR‐POPF rate was 16.7%. CR‐POPF was more likely in patients that were male (odds ratio [OR], 1.51), obese (body mass index [BMI] > 30, OR, 1.97), had minimal preoperative weight loss (OR, 1.25), had a nondilated pancreatic duct (OR, 1.81), did not have diabetes, (OR, 1.80), did not receive neoadjuvant therapy (OR, 1.78), had no evidence of biliary obstruction (OR, 1.18), or had nonadenocarcinoma pathology (OR, 1.96; all P < 0.01). Patients with three or fewer risk factors had a CR‐POPF rate of 7.1%, while those with six or more risk factors had a CR‐POPF rate of 26.3% (P < 0.001). Conclusion Preoperative CR‐POPF risk evaluation could be a useful tool in patient counseling and surgical planning, and risk may allow for more well‐informed decisions regarding perioperative management, including enhanced recovery protocols and use of somatostatin analogs.

Predictive Factors for Postoperative Pancreatic Fistula—A Swedish Nationwide Register‐Based Study

“…Despite advantages in surgical technique, perioperative care, centralization and introduction of enhanced recovery programme, the incidence of POPF remains unaltered [ 9 ]. The incidence of POPF of 10% in this Swedish study is in concordance with or even below international figures, 11.1–16.7% [ 18 – 20 ].…”

“…Most of the findings in this study are not controversial and support previously published papers. Presence of diabetes and a preoperative biliary drainage are features described earlier related to a reduced risk of POPF [ 20 , 21 ] as well as tumour location and its correlation to POPF [ 4 , 18 , 22 ]. These are parameters associated with inflammation of the parenchyma or obstruction of the pancreatic duct, leading to pancreatic firmness.…”

“…Obese patients have an increased risk of overall complications after PD, and several studies have shown an increased risk for POPF specifically [ 2 , 20 , 21 , 26 ]. Here, median BMI was higher for the group with POPF, and higher BMI was independently correlated with POPF.…”

Usefulness of the abdominal fat area-based risk score for postoperative pancreatic fistula after pancreatoduodenectomy

“…However, the results were inconsistent. Some papers have demonstrated results that con icted with our outcomes 17,30,31 , while others suggested that DM was associated with neither negative nor positive predictors of POPF 32,33 . The various proportions of patients with type 2 DM in the studies might explain this 34 .…”

“…Generally, visceral fat is a major factor in uencing the technical di culty during abdominal surgery. It has been shown in several studies [15][16][17] that obese patients are associated with a higher rate of complications such as wound infection, anastomotic stula, and longer hospital stay. Recently, it was reported that a high amount of visceral fat was associated with a signi cantly higher rate of overall complications and pancreatic stula development after PD 15,18 .…”