Staging and Postoperative Outcomes Using the International Study Group of Pancreatic Surgery (ISGPS) Classifications

  • T. Welsch
  • J. Weitz
Reference work entry


The International Study Group of Pancreatic Surgery (ISGPS) established consensus definitions of postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), and delayed gastric emptying (DGE) and thereby covered the major specific complications of pancreatic surgery. A threefold increase of the amylase content in abdominal wound drains compared with serum level on or after the third postoperative day defines POPF; early and late (>24 h) PPH is defined by mild and moderate bleeding according to the drop of hemoglobin or the need for transfusion requirement, and the inability to tolerate solid oral intake after the first postoperative week defines DGE. All three consensus definitions are classified into three grades: A, B, and C. These grades stratify the clinical effect (the illness of the patient and the need for intervention), associated mortality, hospital stay, and economic costs. All definitions have been validated using large cohorts of patients and show different outcome data at different centers, even when high-volume centers are compared with each other. A minor degree of equivocacy of the original definitions is also acknowledged. The clinically relevant grades are most important, and the prevalence of grade B/C complications based on the ISGPS definitions occurs at the following median rates: 12–20% (POPF), 2–11% (PPH), and 6–17% (DGE).


Pancreatic surgery Postoperative pancreatic fistula Postpancreatectomy hemorrhage Delayed gastric emptying Definition 


  1. 1.
    Harnoss JC, Ulrich AB, Harnoss JM, Diener MK, Büchler MW, Welsch T. Use and results of consensus definitions in pancreatic surgery: a systematic review. Surgery. 2014;155(1):47–57.CrossRefGoogle Scholar
  2. 2.
    Hartwig W, Hackert T, Hinz U, Hassenpflug M, Strobel O, Büchler MW, Werner J. Multivisceral resection for pancreatic malignancies: risk-analysis and long-term outcome. Ann Surg. 2009;250(1):81–7.CrossRefGoogle Scholar
  3. 3.
    Bassi C, Butturini G, Molinari E, Mascetta G, Salvia R, Falconi M, et al. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg. 2004;21(1):54–9.CrossRefGoogle Scholar
  4. 4.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13.CrossRefGoogle Scholar
  5. 5.
    Hackert T, Hinz U, Pausch T, Fesenbeck I, Strobel O, Schneider L, et al. Postoperative pancreatic fistula: we need to redefine grades B and C. Surgery. 2016;159(3):872–7.CrossRefGoogle Scholar
  6. 6.
    Daskalaki D, Butturini G, Molinari E, Crippa S, Pederzoli P, Bassi C. A grading system can predict clinical and economic outcomes of pancreatic fistula after pancreaticoduodenectomy: results in 755 consecutive patients. Langenbeck’s Arch Surg. 2011;396(1):91–8.CrossRefGoogle Scholar
  7. 7.
    Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM. Clinical and economic validation of the international study group of pancreatic fistula (ISGPF) classification scheme. Ann Surg. 2007;245(3):443–51.CrossRefGoogle Scholar
  8. 8.
    Welsch T, Müssle B, Distler M, Knoth H, Weitz J, Häckl D. Cost-effectiveness comparison of prophylactic octreotide and pasireotide for prevention of fistula after pancreatic surgery. Langenbeck’s Arch Surg. 2016;401:1027–35.CrossRefGoogle Scholar
  9. 9.
    Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet. 2011;377(9776):1514–22.CrossRefGoogle Scholar
  10. 10.
    Keck T, Wellner UF, Bahra M, Klein F, Sick O, Niedergethmann M, et al. Pancreaticogastrostomy versus pancreatojejunostomy for reconstruction after pancreatoduodenectomy (RECOPANC, DRKS 00000767): perioperative and long-term results of a multicenter randomized controlled trial. Ann Surg. 2015;263(3):440–9.CrossRefGoogle Scholar
  11. 11.
    Gurusamy KS, Koti R, Fusai G, Davidson BR. Somatostatin analogues for pancreatic surgery. Cochrane Database Syst Rev. 2013;4:CD008370.Google Scholar
  12. 12.
    Allen PJ, Gönen M, Brennan MF, Bucknor AA, Robinson LM, Pappas MM, et al. Pasireotide for postoperative pancreatic fistula. N Engl J Med. 2014;370(21):2014–22.CrossRefGoogle Scholar
  13. 13.
    Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition. Surgery. 2007;142(1):20–5.CrossRefGoogle Scholar
  14. 14.
    Welsch T, Eisele H, Zschäbitz S, Hinz U, Büchler MW, Wente MN. Critical appraisal of the international study group of pancreatic surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy. Langenbeck’s Arch Surg. 2011;396(6):783–91.CrossRefGoogle Scholar
  15. 15.
    Grützmann R, Rückert F, Hippe-Davies N, Distler M, Saeger HD. Evaluation of the international study group of pancreatic surgery definition of post-pancreatectomy hemorrhage in a high-volume center. Surgery. 2012;151(4):612–20.CrossRefGoogle Scholar
  16. 16.
    Tol JA, Busch OR, van Delden OM, van Lienden KP, van Gulik TM, Gouma DJ. Shifting role of operative and nonoperative interventions in managing complications after pancreatoduodenectomy: what is the preferred intervention? Surgery. 2014;156(3):622–31.CrossRefGoogle Scholar
  17. 17.
    Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the international study group of pancreatic surgery (ISGPS). Surgery. 2007;142(5):761–8.CrossRefGoogle Scholar
  18. 18.
    Welsch T, Borm M, Degrate L, Hinz U, Büchler MW, Wente MN. Evaluation of the international study group of pancreatic surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centre. Br J Surg. 2010;97(7):1043–50.CrossRefGoogle Scholar
  19. 19.
    Eisenberg JD, Rosato EL, Lavu H, Yeo CJ, Winter JM. Delayed gastric emptying after pancreaticoduodenectomy: an analysis of risk factors and cost. J Gastrointest Surg. 2015;19(9):1572–80.CrossRefGoogle Scholar
  20. 20.
    Sahora K, Morales-Oyarvide V, Thayer SP, Ferrone CR, Warshaw AL, Lillemoe KD, Fernández-Del CC. The effect of antecolic versus retrocolic reconstruction on delayed gastric emptying after classic non-pylorus-preserving pancreaticoduodenectomy. Am J Surg. 2015;209(6):1028–35.CrossRefGoogle Scholar
  21. 21.
    Su AP, Cao SS, Zhang Y, Zhang ZD, Hu WM, Tian BL. Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta-analysis. World J Gastroenterol. 2012;18(43):6315–23.CrossRefGoogle Scholar
  22. 22.
    Hackert T, Bruckner T, Dörr-Harim C, Diener MK, Knebel P, Hartwig W, et al. Pylorus resection or pylorus preservation in partial pancreaticoduodenectomy (PROPP study): study protocol for a randomized controlled trial. Trials. 2013;14:44.CrossRefGoogle Scholar
  23. 23.
    Hackert T, Hinz U, Hartwig W, Strobel O, Fritz S, Schneider L, et al. Pylorus resection in partial pancreaticoduodenectomy: impact on delayed gastric emptying. Am J Surg. 2013;206(3):296–9.CrossRefGoogle Scholar
  24. 24.
    Kawai M, Tani M, Hirono S, Miyazawa M, Shimizu A, Uchiyama K, Yamaue H. Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy: a prospective, randomized, controlled trial of pylorus-resecting versus pylorus-preserving pancreatoduodenectomy. Ann Surg. 2011;253(3):495–501.CrossRefGoogle Scholar
  25. 25.
    de Rooij T, Lu MZ, Steen MW, Gerhards MF, Dijkgraaf MG, Busch OR, et al. Minimally invasive versus open pancreatoduodenectomy: systematic review and meta-analysis of comparative cohort and registry studies. Ann Surg. 2016;10Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Visceral, Thoracic and Vascular SurgeryUniversity Hospital Carl Gustav Carus, Technische Universität DresdenDresdenGermany

Section editors and affiliations

  • James L. Abbruzzese
    • 1
  • Raul A. Urrutia
    • 2
  • John Neoptolemos
    • 3
  • Markus W. Büchler
    • 4
  1. 1.Duke University Medical CenterDurhamUSA
  2. 2.Mayo Clinic Cancer CenterMayo ClinicRochesterUSA
  3. 3.Division of Surgery and OncologyUniversity of LiverpoolLiverpoolUK
  4. 4.Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelbergGermany

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