A Simple Classification Of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula

  • Fabian Schuh (Shared first author)
  • André L Mihaljevic (Shared first author)
  • Pascal Probst
  • Maxwell T Trudeau
  • Philip C Müller
  • Giovanni Marchegiani
  • Marc G Besselink
  • Faik Uzunoglu
  • Jakob R Izbicki
  • Massimo Falconi
  • Carlos Fernandez-Del Castillo
  • Mustapha Adham
  • Kaspar Z'graggen
  • Helmut Friess
  • Jens Werner
  • Jürgen Weitz
  • Oliver Strobel
  • Thilo Hackert
  • Dejan Radenkovic
  • Dezső Kelemen
  • Christopher Wolfgang
  • Y I Miao
  • Shailesh V Shrikhande
  • Keith D Lillemoe
  • Christos Dervenis
  • Claudio Bassi
  • John P Neoptolemos
  • Markus K Diener
  • Charles M Vollmer
  • Markus W Büchler

Abstract

OBJECTIVE: The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA: Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS: A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS: Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION: For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Bibliographical data

Original languageEnglish
ISSN0003-4932
DOIs
Publication statusPublished - 01.03.2023
PubMed 33914473