The Fistula Risk Score Catalog

Abstract

This study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter. Background: The FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes. Methods: FRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019). The FRS was used to derive 80 unique combinations of patient ''scenarios.'' Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches.Results: The overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) -the only negligible-risk scenario (CR-POPF rate ¼ 0.7%). The moderate-risk zone had the most scenarios (50), patients (N ¼ 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33). Conclusion: Through this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF.

Impact of timing and duration of postoperative delirium: a retrospective observational study

“…We have previously proposed fistula risk "scenarios" defined as a collection of the 4 FRS elements. 46 Given the definition of high-risk PDs being those 7 FRS points, cases in which blood loss was minimal (400 mL, 0 FRS points) can only be comprised of a soft gland (2 FRS points) with a diminutive duct (4 FRS points) and nonprotective pathology (1 FRS point), representing the most perilous scenario for CR-POPF development a surgeon can encounter (Scenario #70). 46 Subsequently, this study confirms that escalating blood loss from this baseline biologic starting point accentuates bad outcomes even further.…”

Effect of postoperative non-steroidal anti-inflammatory drugs on anastomotic leakage after pancreaticoduodenectomy

“…However, our results were obtained from the leading institution in South Korea in this field, with a large hospital volume [32]. During the study period, the incidence rate of clinically relevant anastomotic leakage in our institution was lower than in other institutions [3]. Therefore, the effect of surgeons' experience on This article is protected by copyright of Korean Journal of Anesthesiology.…”

“…However, it was still difficult to conclude the safety of using ketorolac for PD due to their wide CI, including substantial adverse effects (any ketorolac, OR 1.99, 95% CI 0.93-4.26, P = 0.08), but the authors supported the safety of using ketorolac for PD, noting that the incidence of CR-POPF remained stable despite the great increase in the use of ketorolac at their institution. However, the improvement in surgical treatment and accumulated surgeon's experience could have offset the harmful effect of ketorolac on ALs [3].…”

“…Therefore, center-specific factors and the ethnic uniformity of the cohort limit the generalizability of our findings. Third, we could not consider the effect of surgeons' experience, such as surgical skills, on the occurrence of POPF [3,31]. However, our results were obtained from the leading institution in South Korea in this field, with a large hospital volume [32].…”

“…Such anastomoses are the most problematic sites following PD, and anastomotic leakages (ALs) from these sites are important contributors to postoperative morbidity, prolonged hospitalization, and mortality after PD [1,2]. Thus, several efforts have been made to identify their risk factors [3][4][5].…”