Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy

Brett L. Ecker(University of Pennsylvania), Matthew T. McMillan(University of Pennsylvania), Valentina Allegrini(University of Verona), Claudio Bassi(University of Verona), Joal D. Beane(Indiana University School of Medicine), Ross M. Beckman(Johns Hopkins University), Stephen W. Behrman(University of Tennessee Health Science Center), Euan J. Dickson(Glasgow Royal Infirmary), Mark P. Callery(Beth Israel Deaconess Medical Center), John D. Christein(University of Alabama at Birmingham), Jeffrey A. Drebin(Memorial Sloan Kettering Cancer Center), Robert H. Hollis(NewYork–Presbyterian Hospital), Michael G. House(Indiana University School of Medicine), Nigel B. Jamieson(Glasgow Royal Infirmary), Ammar A. Javed(Johns Hopkins University), Tara S. Kent(Beth Israel Deaconess Medical Center), Michael D. Kluger(NewYork–Presbyterian Hospital), Stacy J. Kowalsky(University of Tennessee Health Science Center), Laura Maggino(University of Verona), Giuseppe Malleo(University of Verona), Vicente Valero(Johns Hopkins University), Lavanniya K. P. Velu(Glasgow Royal Infirmary), Amarra A. Watkins(Beth Israel Deaconess Medical Center), Christopher L. Wolfgang(Johns Hopkins University), Amer H. Zureikat(University of Tennessee Health Science Center), Charles M. Vollmer(University of Pennsylvania)
Annals of Surgery
August 29, 2017
10.1097/sla.0000000000002491
Cited by 212Open Access
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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.

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