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Ann Surg. 2019 Jan;269(1):143-149. doi: 10.1097/SLA.0000000000002491.

Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group.

Author information

1
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
2
Department of Surgery, University of Verona, Pancreas Institute, Verona, Italy.
3
Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
4
Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
5
Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
6
Department of Surgery, West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.
7
Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
8
Department of Surgery, University of Alabama School of Medicine, Birmingham, AL.
9
Department of Surgery, Memorial Sloane Kettering Cancer Center, New York, NY.
10
Department of Surgery, New York-Presbyterian Hospital, Columbia University, New York, NY.
11
Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Abstract

OBJECTIVE:

To identify a clinical fistula risk score following distal pancreatectomy.

BACKGROUND:

Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive.

METHODS:

This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution.

RESULTS:

CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001).

CONCLUSIONS:

From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.

PMID:
28857813
DOI:
10.1097/SLA.0000000000002491
[Indexed for MEDLINE]

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