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Surgery. 2017 Mar;161(3):584-591. doi: 10.1016/j.surg.2016.11.014. Epub 2016 Dec 28.

The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After.

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Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy.
Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy. Electronic address:
Department of Surgery, AGIA OLGA Hospital, Athens, Greece.
Mayo Clinic Department of General Surgery, Rochester, NY.
HPB Department, Southampton General Hospital, Southampton, UK.
Digestive Surgery Department, Lyon Civil Hospital, Lyon, France.
Memorial Sloan-Kettering Cancer Center, New York, NY.
Department of Surgery, Clinical Sciences Lund, Lund University, Lund, Sweden.
Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL.
Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland.
Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden.
Pancreatic Surgery Unit, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy.
Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain.
Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA.
First Department of Digestive Surgery, Hippokrateon Hospital, University of Athens, Athens, Greece; Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.
Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.
The Petz Aladar Hospital, Gyor, Hungary.
Department of Surgery, University of Colorado School of Medicine, Aurora, CO.
Department of GI and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
St. Luke's Clinic - Center For Pancreatic and Liver Diseases, Boise, ID.
Department of Surgery, Penn Medicine, The University of Pennsylvania, Philadelphia, PA.
Department of Surgery, Johns Hopkins Medicine, Baltimore, MD.
Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA.



In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of the present report is to verify the value of the International Study Group of Pancreatic Fistula definition and grading of postoperative pancreatic fistula and to update the International Study Group of Pancreatic Fistula classification in light of recent evidence that has emerged, as well as to address the lingering controversies about the original definition and grading of postoperative pancreatic fistula.


The International Study Group of Pancreatic Fistula reconvened as the International Study Group in Pancreatic Surgery in order to perform a review of the recent literature and consequently to update and revise the grading system of postoperative pancreatic fistula.


Based on the literature since 2005 investigating the validity and clinical use of the original International Study Group of Pancreatic Fistula classification, a clinically relevant postoperative pancreatic fistula is now redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. Consequently, the former "grade A postoperative pancreatic fistula" is now redefined and called a "biochemical leak," because it has no clinical importance and is no longer referred to a true pancreatic fistula. Postoperative pancreatic fistula grades B and C are confirmed but defined more strictly. In particular, grade B requires a change in the postoperative management; drains are either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures. Grade C postoperative pancreatic fistula refers to those postoperative pancreatic fistula that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula.


This new definition and grading system of postoperative pancreatic fistula should lead to a more universally consistent evaluation of operative outcomes after pancreatic operation and will allow for a better comparison of techniques used to mitigate the rate and clinical impact of a pancreatic fistula. Use of this updated classification will also allow for more precise comparisons of surgical quality between surgeons and units who perform pancreatic surgery.

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