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Fistula Risk Assessment for Pancreatoduodenectomy: a Call for Consensus
Matthew T. McMillan*1, Giuseppe Malleo2, Claudio Bassi2, Michael H. Sprys1, Jeffrey Drebin1, Charles M. Vollmer1
1Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 2Surgery, University of Verona, Verona, Italy
Introduction: Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most common complication following pancreatoduodenectomy (PD). Risk-adjustment enables accurate prediction, impartial evaluation, and optimal management of CR-POPFs; however, it is unclear how pancreatic surgeons perceive risk for this highly morbid complication.
Methods: A web-based survey was distributed to members of six international GI surgical societies, including the SSAT. Surgeons' understanding of CR-POPF risk was investigated based on their experience and global region of practice. CR-POPF risk factors were categorized as follows: (1) patient factors—acuity, nutrition; (2) pancreatic gland characteristics—texture, duct size; (3) intraoperative variables—anastomosis, blood loss, fluids; (4) perioperative mitigation techniques—stents, octreotide, drains; (5) institutional features—volume, multidisciplinary support.
Results: Surveys were completed by 897 surgeons worldwide. The most commonly cited contributors to CR-POPF risk were gland characteristics (91%), while patient and intraoperative factors were selected 71 and 69% of the time, respectively. Conversely, institutional features (32%) and perioperative mitigation techniques (21%) were rarely recognized. While surgeons indicated a median of three factors contribute to CR-POPF development, 66% designated gland characteristics as the most important risk factor. Surgeons who had surpassed the learning curve for PD (>60 cases) more often considered gland characteristics the most significant risk factor (72 vs. 60%, P<0.001), whereas surgeons below that threshold were more likely to consider intraoperative factors (22 vs. 16%, P=0.028) and perioperative mitigation techniques (6 vs. 3%, P=0.017). Surgeons in the upper quartile for annual PD volume (≥25 cases/year) associated gland characteristics with the highest risk for CR-POPF development (76 vs. 63%, P<0.001), while lower volume surgeons were more likely to associate patient factors with the highest degree of CR-POPF risk (11 vs. 7%, P=0.046). CR-POPF risk characterization differed greatly between global regions (Table 1). Although various impressions of what constitutes CR-POPF risk were expressed, 26% of the surgeons use a validated, objective risk metric—the Fistula Risk Score—to guide their clinical practice. Surgeons were asked to grade a series of clinical vignettes for the severity of CR-POPF risk using this tool. The results demonstrated that surgeons struggle to consistently discriminate CR-POPF risk (Table 2).
Conclusions: This international study analyzes how surgeons discern CR-POPF risk for PD. The considerable degree of variability in surgeons' perceptions of risk may have an adverse effect on the quality of risk adjustment measures in comparative studies. Consensus regarding a standardized approach to CR-POPF risk assessment is necessary.
Regional variations in the perception of the most impactful clinically-relevant postoperative pancreatic fistula (CR-POPF) risk factor
| CR-POPF Risk Factor, N (%) | Asia | North America | South America | Europe/Africa/Middle East | P-value | | Patient factors | 17 (8.2) | 33 (11.8) | 24 (19.0) | 15 (5.5) | 0.0002 | | Gland characteristics | 131 (63.0) | 199 (71.3) | 56 (44.4) | 202 (74.0) | < 0.0001 | | Intraoperative factors | 45 (21.6) | 45 (16.1) | 34 (27.0) | 43 (15.8) | 0.023 | | Perioperative mitigation techniques | 3 (1.4) | 0 (0) | 3 (2.4) | 1 (0.4) | 0.045 | | Institutional factors | 12 (5.8) | 2 (0.7) | 9 (7.1) | 12 (4.4) | 0.0005 |
Surgeons' grading of the clinically-relevant postoperative pancreatic fistula (CR-POPF) risk clinical scenarios | Clinical Scenario, N (%) | CR-POPF Risk Categorization | | Negligible | Low | Moderate | High | | Firm gland, 6 mm duct, PDAC, 350 mL EBL | *330 (37.3) | 504 (56.9) | 43 (4.9) | 8 (0.9) | | Firm gland, 4 mm duct, PDAC, 650 mL EBL | 38 (4.3) | *541 (61.0) | 284 (32.0) | 24 (2.7) | | Soft gland, 3 mm duct, cystic pathology, 350 mL EBL | 11 (1.2) | 98 (11.0) | *512 (57.7) | 266 (30.0) | | Soft gland, 2 mm duct, Ampullary cancer, 850 mL EBL | 4 (0.5) | 29 (3.3) | 177 (20.0) | *677 (76.3) |
*Correct score per the Fistula Risk Score; PDAC=pancreatic ductal adenocarcinoma; EBL=estimated intraoperative blood loss
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