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

• Published in: Annals of surgery Vol. 269; no. 1; pp. 143 - 149
• Main Authors: Ecker, Brett L, McMillan, Matthew T, Allegrini, Valentina, Bassi, Claudio, Beane, Joal D, Beckman, Ross M, Behrman, Stephen W, Dickson, Euan J, Callery, Mark P, Christein, John D, Drebin, Jeffrey A, Hollis, Robert H, House, Michael G, Jamieson, Nigel B, Javed, Ammar A, Kent, Tara S, Kluger, Michael D, Kowalsky, Stacy J, Maggino, Laura, Malleo, Giuseppe, Valero, Vicente, Velu, Lavanniya K P, Watkins, Amarra A, Wolfgang, Christopher L, Zureikat, Amer H, Vollmer, Charles M
• Format: Journal Article
• Language: English
• Published: United States Copyright Wolters Kluwer Health, Inc. All rights reserved 01-01-2019
• Subjects: Female; Humans; Male; Middle Aged; Morbidity - trends; Pancreatectomy - adverse effects; Pancreatectomy - methods; Pancreatic Fistula - epidemiology; Pancreatic Fistula - etiology; Pancreatic Fistula - prevention & control; Postoperative Complications - epidemiology; Postoperative Complications - etiology; Practice Guidelines as Topic; Retrospective Studies; Risk Assessment - methods; Risk Factors; Survival Rate - trends; United States - epidemiology; United States
• ISSN: 0003-4932; 1528-1140
• DOI: 10.1097/SLA.0000000000002491

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 includedage (<60 yrsOR 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-POPFmethod 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.