Risk Factors and Mitigation Strategies for Pancreatic Fistula after Distal Pancreatectomy: Analysis of 2,026 Resections from the International, Multi-Institution Distal Pancreatectomy Study Group

Abstract

INTRODUCTION:Post-hepatectomy liver insufficiency (PHLI) is a significant cause of morbidity and mortality after liver resection. Quantitative imaging analysis using CT scans measures variations in pixel intensity related to perfusion. The objective of this study was to create a predictive model for PHLI using quantitative imaging features of the future liver remnant (FLR) from preoperative CT scans. METHODS:From 5 high-volume academic centers, patients were retrospectively identified who developed PHLI after major hepatectomy and were matched to control patients without PHLI (by extent of resection, chemotherapy, age [AE5 years], and sex). Quantitative imaging features were extracted from the FLR in the preoperative CT scan, and the most discriminatory features were included in naïve-Bayes classifier to predict PHLI. The study cohort was split into 70-30 training and test sets. RESULTS:From 2000 to 2015, 74 patients with PHLI and 74 matched controls were identified. The most common indications for surgery were colorectal liver metastases (79/148, 53%), hepatocellular carcinoma (54/148, 37%), and cholangiocarcinoma (13/148, 9%). The most frequently performed resections were right hemihepatectomy (108/148, 73%) and right trisectionectomy (25/148, 24%). The median percentage remnant liver volume (%RLV) of patients with PHLI was 38.0% (interquartile range [IQR] 30.1% to 43.2%), compared with 41.6% (IQR 33.9% to 49.9%) in control patients (p ¼ 0.036). The quantitative imaging prediction model for PHLI had an area under the curve (AUC) of 0.709 and 0.746 in the training and test sets, respectively. The combination model of imaging features and %RLV achieved the highest AUC (Table). Table. Model AUC Training Test Imaging features 0.709 0.746 %RLV 0.616 0.569 Imaging features and %RLV 0.727 0.746 CONCLUSIONS:Quantitative imaging features can independently predict PHLI and are a promising preoperative risk stratification tool.

Pancreatic neck thickness: A possible key to stump closure technique selection after distal pancreatectomy

“…Therefore, association between a lower risk of POPF with transection through the neck of the pancreas, in our opinion, results from the coincidence of a small parenchyma thickness at the neck of the pancreas. This could also explain the lower rate of POPF observed after distal pancreatectomies due to pancreatic cancer -with mandatory transection of the pancreas through the neck, as reported by Ecker et al [16].…”

“…There were no significant differences between patients' demographics between the groups, except for the male-to-female ratio. As sex does not exert a confounding influence on stump closure selection or outcomes [16], propensity matching was not performed. Even if procedures with stapled pancreatic stump tended to have shorter operative time than procedures using a hand-sewn closing technique (median time 180 versus 210 min., p = 0.037), other perioperative variables did not differ among stump closure groups.…”

Risk factors for pancreatic fistula following distal pancreatectomy: a retrospective study of 211 consecutive patients

“…Our work also demonstrates that POPF clearly affects the short-term prognosis of the patients (Table 4). However, the strides in both risk prediction and prevention measures of POFP for DP have fallen behind when compared to that of fistula following pancreaticoduodenectomy [11]. The primary reason for this is that surgical complications associated with a pancreatic fistula in a DP are less complicated due to the absence of a biliary and enteric anastomosis, which did not attract enough attention from the physician, and the fact that pancreatic body and tail lesions occur less frequently than pancreatic head lesions also played a role in it [10,12].…”

“…The increased pressure in the main pancreatic duct [13] and the necrosis of the pancreatic stump [6,14] were thought of as two factors for pancreatic fistula formation after DP. Several studies have emphasized the management of the pancreatic remnant after DP, such as the closure techniques, including pancreatico-intestinal anastomosis [5,6], stapler and suture [4,[14][15][16][17], main pancreatic duct ligation [4,14,18,19], biologic glues [20,21], mesh reinforcement [3,22] and pancreatic duct stent [23][24][25]. However, the optimal management of the pancreatic stump following DP has still not been established [4, 6, 14-16, 18, 26].…”

Clinical impact of developing better practices at the institutional level on surgical outcomes after distal pancreatectomy in 1515 patients: Domestic audit of the Japanese Society of Pancreatic Surgery

“…The international multi‐institutional distal pancreatectomy study group analyzed data from 2026 patients who underwent DP. Although they failed to predict CR‐POPF occurrence reliably, seven risk factors (age, body mass index [BMI], serum albumin level, pathology, epidural use, splenectomy, and vascular resection) were identified . They suggested the existence of two possibilities: (i) fistula after distal pancreatectomy is a stochastic process that cannot be predicted; or (ii) despite the extensive data accrual by each collaborating institution, important risk factors were not accounted for.…”