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

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.

[1]  Quan P. Ly,et al.  A Prospective Randomized Multicenter Trial of Distal Pancreatectomy With and Without Routine Intraperitoneal Drainage , 2017, Annals of surgery.

[2]  C. Bassi,et al.  Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification , 2017, Annals of surgery.

[3]  M. Büchler,et al.  Sphincter of Oddi botulinum toxin injection to prevent pancreatic fistula after distal pancreatectomy , 2017, Surgery.

[4]  T. Ohtsuka,et al.  Attempts to prevent postoperative pancreatic fistula after distal pancreatectomy , 2017, Surgery Today.

[5]  D. Gouma,et al.  The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After , 2017, Surgery.

[6]  D. Fraker,et al.  Externalized Stents for Pancreatoduodenectomy Provide Value Only in High-Risk Scenarios , 2016, Journal of Gastrointestinal Surgery.

[7]  Jin‐Young Jang,et al.  Optimal stapler cartridge selection according to the thickness of the pancreas in distal pancreatectomy , 2016, Medicine.

[8]  Ammara A Watkins,et al.  Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy. , 2016, Surgery.

[9]  C. Ko,et al.  Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time: Evaluation of Hospital Cohorts With up to 8 Years of Participation , 2016, Annals of surgery.

[10]  D. Fraker,et al.  Drain Management after Pancreatoduodenectomy: Reappraisal of a Prospective Randomized Trial Using Risk Stratification. , 2015, Journal of the American College of Surgeons.

[11]  K. Lillemoe,et al.  Does Pancreatic Stump Closure Method Influence Distal Pancreatectomy Outcomes? , 2015, Journal of Gastrointestinal Surgery.

[12]  T. Kent,et al.  Prophylactic octreotide for pancreatoduodenectomy: more harm than good? , 2014, HPB : the official journal of the International Hepato Pancreato Biliary Association.

[13]  H. Pitt,et al.  Defining the post-operative morbidity index for distal pancreatectomy. , 2014, HPB : the official journal of the International Hepato Pancreato Biliary Association.

[14]  C. Vollmer,et al.  Predictive factors for pancreatic fistula following pancreatectomy , 2014, Langenbeck's Archives of Surgery.

[15]  M. Gönen,et al.  Pasireotide for postoperative pancreatic fistula. , 2014, The New England journal of medicine.

[16]  T. Ohtsuka,et al.  Prediction of Pancreatic Fistula by Preoperatively Assessable Factors; Retrospective Review of Unified Operations by Single Surgeon. , 2014, Hepato-gastroenterology.

[17]  H. Yamaue,et al.  Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy. , 2013, American journal of surgery.

[18]  K. Gurusamy,et al.  Somatostatin analogues for pancreatic surgery. , 2013, The Cochrane database of systematic reviews.

[19]  M. Büchler,et al.  Decrease in clinically relevant pancreatic fistula by coverage of the pancreatic remnant after distal pancreatectomy. , 2012, Surgery.

[20]  M. Porembka,et al.  Mesh Reinforcement of Pancreatic Transection Decreases Incidence of Pancreatic Occlusion Failure for Left Pancreatectomy: A Single-Blinded, Randomized Controlled Trial , 2012, Annals of surgery.

[21]  U. Arnelo,et al.  The Effect of Prophylactic Transpapillary Pancreatic Stent Insertion on Clinically Significant Leak Rate Following Distal Pancreatectomy: Results of a Prospective Controlled Clinical Trial , 2012, Annals of surgery.

[22]  L. Traverso,et al.  After Distal Pancreatectomy Pancreatic Leakage from the Stump of the Pancreas May Be Due to Drain Failure or Pancreatic Ductal Back Pressure , 2012, Journal of Gastrointestinal Surgery.

[23]  B. Hall,et al.  Postoperative morbidity index: a quantitative measure of severity of postoperative complications. , 2011, Journal of the American College of Surgeons.

[24]  J. Kleeff,et al.  Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial , 2011, The Lancet.

[25]  Y. Takeda,et al.  A Thick Pancreas Is a Risk Factor for Pancreatic Fistula after a Distal Pancreatectomy: Selection of the Closure Technique according to the Thickness , 2011, Digestive Surgery.

[26]  M. Porembka,et al.  Quantitative weighting of postoperative complications based on the accordion severity grading system: demonstration of potential impact using the american college of surgeons national surgical quality improvement program. , 2010, Journal of the American College of Surgeons.

[27]  K. Trinkaus,et al.  The effect of mesh reinforcement of a stapled transection line on the rate of pancreatic occlusion failure after distal pancreatectomy: review of a single institution's experience. , 2009, HPB : the official journal of the International Hepato Pancreato Biliary Association.

[28]  K. Soo,et al.  Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution. , 2008, Archives of surgery.

[29]  D. Rattner,et al.  Pancreatic Fistula Rates After 462 Distal Pancreatectomies: Staplers Do Not Decrease Fistula Rates , 2008, Journal of Gastrointestinal Surgery.

[30]  M. Callery,et al.  Risk Prediction for Development of Pancreatic Fistula Using the ISGPF Classification Scheme , 2008, World Journal of Surgery.

[31]  M. Sierzega,et al.  Nutritional status affects the rate of pancreatic fistula after distal pancreatectomy: a multivariate analysis of 132 patients. , 2007, Journal of the American College of Surgeons.

[32]  H. Friess,et al.  Distal Pancreatectomy: Risk Factors for Surgical Failure in 302 Consecutive Cases , 2007, Annals of surgery.

[33]  S. Maithel,et al.  Clinical and Economic Validation of the International Study Group of Pancreatic Fistula (ISGPF) Classification Scheme , 2007, Annals of surgery.

[34]  G. Balzano,et al.  The unsolved problem of fistula after left pancreatectomy: The benefit of cautious drain management , 2005, Journal of Gastrointestinal Surgery.

[35]  D. Klimstra,et al.  The value of splenic preservation with distal pancreatectomy. , 2002, Archives of surgery.

[36]  T. Kent,et al.  A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. , 2013, Journal of the American College of Surgeons.

[37]  T. Hyslop,et al.  A Dual-Institution Randomized Controlled Trial of Remnant Closure after Distal Pancreatectomy: Does the Addition of a Falciform Patch and Fibrin Glue Improve Outcomes? , 2012, Journal of Gastrointestinal Surgery.

[38]  J. Yamamoto,et al.  Risk Factors for Clinical Pancreatic Fistula After Distal Pancreatectomy: Analysis of Consecutive 100 Patients , 2009, World Journal of Surgery.