Abstract
Background
Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. Recently, early drain removal has been recommended as a means of preventing POPF. The present study sought to determine how to distinguish clinical POPF from non-clinical POPF in the early postoperative period after PD to aid in early drain removal.
Methods
From March 2002 through December 2010, 176 patients underwent PD and were enrolled in this study to examine factors predictive of clinical POPF after PD. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline, and grade B/C POPF was defined as clinical POPF.
Results
Grade A POPF occurred in 39 (22.2 %) patients, grade B in 19 (10.8 %) patients, and grade C in 11 (6.3 %) patients. Clinical POPF (grade B/C) occurred in 17.1 % of patients. Multivariate analysis revealed male gender and body mass index (BMI) ≥22.5 kg/m2 to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the combination of drain amylase ≥750 IU/L, C-reactive protein (CRP) ≥20 mg/dL, and body temperature ≥37.5 °C on postoperative day 3 could effectively distinguish clinical POPF from non-clinical POPF. Sensitivity, specificity, and accuracy were 84.6, 98.2, and 95.7 %, respectively.
Conclusions
Male gender and BMI ≥22.5 were the independent preoperative predictive risk factors for POPF. We assume that when amylase is <750 IU/L, serum CRP is <20 mg/dL, and body temperature is <37.5 °C the drain can safely be removed, even if POPF is indicated.
Similar content being viewed by others
References
Tani M, Kawai M, Hirono S et al (2012) Use of omentum or falciform ligament does not decrease complications after pancreaticoduodenectomy: nationwide survey of the Japanese Society of Pancreatic Surgery. Surgery 151:183–191
Lai EC, Lau SH, Lau WT (2009) Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 144:1074–1080
Pratt WB, Callery MP, Vollmer CM Jr (2008) Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg 32:419–428. doi:10.1007/s00268-007-9388-5
Motoi F, Egawa S, Rikiyama T et al (2012) Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg 99:524–531
Pessaux P, Sauvanet A, Mariette C et al (2011) External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg 253:879–885
Poon RT, Fan ST, Lo CM et al (2007) External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg 246:425–433
McKay A, Mackenzie S, Sutherland FR et al (2006) Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy. Br J Surg 93:929–936
Oussoultzoglou E, Bachellier P, Bigourdan JM et al (2004) Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg 139:327–335
Suc B, Msika S, Piccinini M et al (2004) Octreotide in the prevention of intra-abdominal complication following elective pancreatic resection: a prospective, multicenter randomized controlled trial. Arch Surg 139:288–294
Choi SB, Lee JS, Kim WB et al (2012) Efficacy of the omental roll-up technique in pancreaticojejunosomy as a strategy to prevent pancreatic fistula after pancreaticoduodenectomy. Arch Surg 147:145–150
Kawai M, Tani M, Terasawa H et al (2006) Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg 244:1–7
Bassi C, Molinari E, Malleo G et al (2010) Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg 252:207–214
Diener MK, Tadjalli-Mehr K, Wente MN et al (2011) Risk-benefit assessment of closed intra-abdominal drains after pancreatic surgery: a systematic review and meta-analysis assessing the current state of evidence. Langenbecks Arch Surg 396:41–52
Balzano G, Zerbi A, Braga M et al (2008) Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 95:1387–1393
Bassi C, Dervenis C, Butturini G et al (2005) Postoperative pancreatic fistula: an International Study Group (ISGPF) definition. Surgery 138:8–13
Hiyoshi M, Chijiiwa K, Ohuchida J et al (2012) Comparative study of gastric emptying and nutritional status after pylorus-preserving vs. subtotal stomach-preserving pancreaticoduodenectomy. Hepatogastroenterology 59:1018–1022
Kakita A, Yoshida M, Takahashi T (2001) History of pancreaticojejunostomy in pancreaticoduodenectomy: development of a more reliable anastomosis technique. J Hepatobiliary Pancreat Surg 8:230–237
Chijiiwa K, Imamura N, Ohuchida J et al (2009) Prospective randomized controlled study of gastric emptying assessed by (13)C-acetate breath test after pylorus-preserving pancreaticoduodenectomy: comparison between antecolic and vertical retrocolic duodenojejunostomy. J Hepatobiliary Pancreat Surg 16:49–55
Kawai M, Kondo S, Yamaue H et al (2011) Predictive risk factors for clinically relevant pancreatic fistula analyzed in 1,239 patients with pancreaticoduodenectomy: multicenter data collection as a project study of pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. J Hepatobiliary Pancreat Sci 18:601–608
Kawai M, Tani M, Hirono S et al (2009) How do we predict the clinically relevant pancreatic fistula after pancreaticoduodenectomy?—an analysis in 244 consecutive patients. World J Surg 33:2670–2678. doi:10.1007/s00268-009-0220-2
Kurahara H, Shinchi H, Maemura K et al (2011) Indicators of complications and drain removal after pancreatoduodenectomy. J Surg Res 170:e211–e216
Sutcliffe RP, Battula N, Haque A et al (2012) Utility of drain fluid amylase measurement on the first postoperative day after pancreaticoduodenectomy. World J Surg 36:879–883. doi:10.1007/s00268-012-1460-0
Molinari E, Bassi C, Salvia R et al (2007) Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients. Ann Surg 246:281–287
Yamamoto Y, Sakamoto Y, Nara S et al (2011) A preoperative predictive scoring system for postoperative pancreatic fistula after pancreaticoduodenectomy. World J Surg 35:2747–2755. doi:10.1007/s00268-011-1253-x
Laaninen M, Bläuer M, Vasama K et al (2012) The risk for immediate postoperative complications after pancreaticoduodenectomy is increased by high frequency of acinar cells and decreased by prevalent fibrosis of the cut edge of pancreas. Pancreas 41:957–961
Gaujoux S, Cortes A, Couvelard A et al (2010) Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery 148:15–23
Shimoda M, Katoh M, Yukihiro I et al (2012) Body mass index is a risk factor of pancreatic fistula after pancreaticoduodenectomy. Am Surg 78:190–194
Warschkow R, Beutner U, Steffen T et al (2012) Safe and early discharge after colorectal surgery due to C-reactive protein: a diagnostic meta-analysis of 1,832 patients. Ann Surg 256:245–250
Ortega-Deballon P, Radais F, Facy O et al (2010) C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World J Surg 34:808–814. doi:10.1007/s00268-009-0367-x
Woeste G, Müller C, Bechstein WO et al (2010) Increased serum levels of C-reactive protein precede anastomotic leakage in colorectal surgery. World J Surg 34:140–146. doi:10.1007/s00268-009-0304-z
Murakami Y, Uemura K, Hayasidani Y et al (2008) A soft pancreatic remnant is associated with increased drain fluid pancreatic amylase and serum CRP levels following pancreatoduodenectomy. J Gastrointest Surg 12:51–56
Welsch T, Frommhold K, Hinz U et al (2008) Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications. Surgery 143:20–28
Wente MN, Veit JA, Bassi C et al (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142:20–25
Yekebas EF, Wolfram L, Cataldegirmen G et al (2007) Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 246:269–280
Fujii Y, Shimada H, Endo I et al (2007) Management of massive hemorrhage after pancreatobiliary surgery: does embolotherapy contribute to successful outcome? J Gastrointest Surg 11:432–438
Acknowledgments
This study was supported in part by a Grant-in-Aid for Scientific Research to K.C. (No. 20591635) from the Ministry of Education, Culture, Sports, Science and Technology in Japan.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Hiyoshi, M., Chijiiwa, K., Fujii, Y. et al. Usefulness of Drain Amylase, Serum C-Reactive Protein Levels and Body Temperature to Predict Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. World J Surg 37, 2436–2442 (2013). https://doi.org/10.1007/s00268-013-2149-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-013-2149-8