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Multidimensional Nomogram to Predict Postoperative Pancreatic Fistula after Minimally Invasive Pancreaticoduodenectomy

  • Pancreatic Tumors
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Abstract

Background

Clinically relevant postoperative pancreatic fistula (CR-POPF) is an inherently severe risk of pancreatic resection. Previous research has proposed models that identify risk factors and predict CR-POPF, although these are rarely applicable to minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the individual risks of CR-POPF and to propose a nomogram for predicting POPF in MIPD.

Patients and Methods

We retrospectively reviewed the medical records of 429 patients who underwent MIPD. In the multivariate analysis, the Akaike information criterion stepwise logistic regression method was used to select the final model to develop the nomogram.

Results

Of 429 patients, 53 (12.4%) experienced CR-POPF. On multivariate analysis, pancreatic texture (p = 0.001), open conversion (p = 0.008), intraoperative transfusion (p = 0.011), and pathology (p = 0.048) were identified as independent predictors of CR-POPF. The nomogram was developed based on patient, pancreatic, operative, and surgeon factors by using the following four additional clinical factors as variables: American Society of Anesthesiologists class ≥ III, size of pancreatic duct, type of surgical approach, and < 40 cases of MIPD experience.

Conclusions

A multidimensional nomogram was developed to predict CR-POPF after MIPD. This nomogram and calculator can help surgeons anticipate, select, and manage critical complications.

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References

  1. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161:584–91.

    Article  PubMed  Google Scholar 

  2. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13.

    Article  PubMed  Google Scholar 

  3. Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc. 1994;8:408–10.

    Article  CAS  PubMed  Google Scholar 

  4. Nickel F, Haney CM, Kowalewski KF, et al. Laparoscopic versus open pancreaticoduodenectomy: a systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2020;271:54–66.

    Article  PubMed  Google Scholar 

  5. Palanivelu C, Senthilnathan P, Sabnis SC, et al. Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours. Br J Surg. 2017;104:1443–50.

    Article  CAS  PubMed  Google Scholar 

  6. Song KB, Kim SC, Lee W, et al. Laparoscopic pancreaticoduodenectomy for periampullary tumors: lessons learned from 500 consecutive patients in a single center. Surg Endosc. 2019. https://doi.org/10.1007/s00464-019-06913-9.

    Article  PubMed  Google Scholar 

  7. Wang M, Li D, Chen R, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial. Lancet Gastro Hepat. 2021;6:438–47.

    Article  Google Scholar 

  8. Han SH, Kang CM, Hwang HK, Yoon DS, Lee WJ. The Yonsei experience of 104 laparoscopic pancreaticoduodenectomies: a propensity score-matched analysis with open pancreaticoduodenectomy. Surg Endosc. 2019. https://doi.org/10.1007/s00464-019-06942-4.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Choi M, Hwang HK, Rho SY, Lee WJ, Kang CM. Comparing laparoscopic and open pancreaticoduodenectomy in patients with pancreatic head cancer: oncologic outcomes and inflammatory scores. J Hepatobiliary Pancreat Sci. 2020;27:124–31.

    Article  PubMed  Google Scholar 

  10. Song KB, Kim SC, Hwang DW, et al. Matched case-control analysis comparing laparoscopic and open pylorus-preserving pancreaticoduodenectomy in patients with periampullary tumors. Ann Surg. 2015;262:146–55.

    Article  PubMed  Google Scholar 

  11. Roberts KJ, Hodson J, Mehrzad H, et al. A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB. 2014;16:620–8.

    Article  PubMed  Google Scholar 

  12. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013;216:1–14.

    Article  PubMed  Google Scholar 

  13. Kantor O, Talamonti MS, Pitt HA, et al. Using the NSQIP pancreatic demonstration project to derive a modified fistula risk score for preoperative risk stratification in patients undergoing pancreaticoduodenectomy. J Am Coll Surg. 2017;224:816–25.

    Article  PubMed  Google Scholar 

  14. Choi M, Hwang HK, Lee WJ, Kang CM. Total laparoscopic pancreaticoduodenectomy in patients with periampullary tumors: a learning curve analysis. Surg Endosc. 2020. https://doi.org/10.1007/s00464-020-07684-4.

    Article  PubMed  Google Scholar 

  15. Chan KS, Wang ZK, Syn N, Goh BKP. Learning curve of laparoscopic and robotic pancreas resections: a systematic review. Surgery. 2021. https://doi.org/10.1016/j.surg.2020.11.046.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Navarro JG, Kang CM. Pitfalls for laparoscopic pancreaticoduodenectomy: need for a stepwise approach. Ann Gastroenterol Surg. 2019;3:254–68.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kim H, Park SY, Park Y, et al. Assessment of learning curve and oncologic feasibility of robotic pancreaticoduodenectomy: a propensity score-based comparison with open approach. J Hepatobiliary Pancreat Sci. 2022;29:649–58.

    Article  PubMed  Google Scholar 

  18. Pande R, Halle-Smith JM, Phelan L, et al. External validation of postoperative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis. HPB. 2021. https://doi.org/10.1016/j.hpb.2021.10.006.

    Article  PubMed  Google Scholar 

  19. Mungroop TH, Klompmaker S, Wellner UF, et al. Updated alternative fistula risk score (ua-frs) to include minimally invasive pancreatoduodenectomy: pan-European validation. Ann Surg. 2021;273:334–40.

    Article  PubMed  Google Scholar 

  20. Mungroop TH, van Rijssen LB, van Klaveren D, et al. Alternative fistula risk score for pancreatoduodenectomy (a-FRS): design and international external validation. Ann Surg. 2019;269:937–43.

    Article  PubMed  Google Scholar 

  21. Shinde RS, Acharya R, Chaudhari VA, et al. External validation and comparison of the original, alternative and updated-alternative fistula risk scores for the prediction of postoperative pancreatic fistula after pancreatoduodenectomy. Pancreatology. 2020;20:751–6.

    Article  PubMed  Google Scholar 

  22. Trudeau MT, Casciani F, Maggino L, et al. The influence of intraoperative blood loss on fistula development following pancreatoduodenectomy. Ann Surg. 2020. https://doi.org/10.1097/sla.0000000000004549.

    Article  PubMed  Google Scholar 

  23. You Y, Han IW, Choi DW, et al. Nomogram for predicting postoperative pancreatic fistula. HPB. 2019;21:1436–45.

    Article  PubMed  Google Scholar 

  24. Connie LCK, Hong SS, Kang I, et al. Adverse impact of intraoperative conversion on the postoperative course following laparoscopic pancreaticoduodenectomy. Yonsei Med J. 2021;62:836–42.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Kim H, Choi SH, Jang JY, Choi M, Lee JH, Kang CM. Multicenter comparison of totally laparoscopic and totally robotic pancreaticoduodenectomy: propensity score and learning curve-matching analyses. J Hepatobiliary Pancreat Sci. 2021. https://doi.org/10.1002/jhbp.1078.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Mohamed A, Nicolais L, Fitzgerald TL. Revisiting the pancreatic fistula risk score: clinical nomogram accurately assesses risk. Am Surg. 2021. https://doi.org/10.1177/00031348211047471.31348211047471.

    Article  PubMed  Google Scholar 

  27. Bansal SS, Hodson J, Khalil K, et al. Distinct risk factors for early and late blood transfusion following pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int. 2018;17:349–57.

    Article  PubMed  Google Scholar 

  28. Choi M, Rho SY, Kim SH, Hwang HK, Lee WJ, Kang CM. Total laparoscopic versus robotic-assisted laparoscopic pancreaticoduodenectomy: Which one is better? Surg Endosc. 2022. https://doi.org/10.1007/s00464-022-09347-y.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Navarro JG, Hwang HS, Kim JS, Lee WJ, Kang CM. Revo-i assisted minimally invasive pancreaticoduodenectomy: how i do It. Ann Robot Innov Surg. 2021;2:7–14.

    Article  Google Scholar 

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Authors and Affiliations

Authors

Contributions

MC acquired the data and drafted the manuscript. HY and JYJ acquired the data. JHL and RYH analyzed and interpreted the data. SHC and JHL revised the manuscript and agreed with the manuscript’s results and conclusions. CMK supervised the study and gave final approval to the manuscript.

Corresponding authors

Correspondence to Sung Hoon Choi MD or Chang Moo Kang MD, PhD.

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The authors declare no conflicts of interest for this article.

Ethical approval

Asan Medical Center, S2020-1498-0001. Severance Hospital, 0201-05-039. CHA Bundang Medical Center, 2021-0002-001.

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Choi, M., Lee, J.H., Roh, Y.H. et al. Multidimensional Nomogram to Predict Postoperative Pancreatic Fistula after Minimally Invasive Pancreaticoduodenectomy. Ann Surg Oncol 30, 5083–5090 (2023). https://doi.org/10.1245/s10434-023-13360-3

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  • DOI: https://doi.org/10.1245/s10434-023-13360-3

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