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Postoperative Pancreatic Fistulas Are Not Equivalent After Proximal, Distal, and Central Pancreatectomy
Wande Pratt, Shishir Maithel, Tsafrir Vanounou, Mark P. Callery, Charles M. Vollmer; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

Background: Some still believe that postoperative pancreatic fistulas (POPF) following distal (DP) and central pancreatectomy (CP) behave similarly to those following pancreaticoduodenectomy (PD). To date, this has not been validated either clinically or economically. Methods: 227 consecutive pancreatic resections from 10/01 to 10/05 (166 PD; 56 DP; 5 CP) were evaluated according to the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. POPF was defined as any measurable drainage on or after POD 3 with an amylase content >3x serum value. Outcomes were divided into 4 grades: no fistula (NF), biochemical fistula without clinical sequelae (A), fistula requiring any therapeutic intervention (B), or fistula with severe clinical sequelae (C). Grades B and C are considered clinically relevant (CR-POPF) based on worsening morbidity, increased LOS, readmission, and increased costs/resource utilization. Clinical and economic outcomes were compared—grade for grade—across the 3 resection types. Results: Fistulas of any extent (Grades A to C) occurred in one-third of all patients. Two-thirds had NF. Overall, there were 15 readmissions (7%), 8 reoperations (4%), and no deaths attributable to POPF. Outcomes for NF and A patients were identical, though Grade A POPF was more common in DP. For each resection type, LOS and costs progressively increased with Grades B and C. However, the negative impact of a CR-POPF (Table) varied between resection types. Rates for ICU admission and rehab placement were higher among PD patients. TPN and antibiotic use were similar, but percutaneous drainage was utilized more often for DP. Grade B POPF was more severe after DP, as indicated by increased LOS, readmissions, and total cost. Although reoperation rates for Grade C POPF were equivalent, intervals to reoperation were substantially longer following DP and CP. Conclusion: When classified according to ISGPF criteria, clinically-relevant pancreatic fistulas behave differently depending on type of pancreatectomy. This translates into variable severity that guides management decisions, which ultimately dictate clinical outcomes and economic impact.
Clinically-relevant POPF after pancreatic resection


Proximal Resections n=166

Distal Resections n=56

Central Resections n=5

# POPF/LOS/costs (median) Grade B Grade C

21 / 12d /$24,283 6 / 35d / $119,083

6/16d/ $25,313 2 / 22d / $43,313

3 / 11d / $34,644 1 / 20d / $57,737

ICU admission (% CR-POPF)

5 (19%)

0 (0%)

1 (25%)

Rehab (% CR-POPF)

13 (48%)

0 (0%)

0 (0%)

Percutaneous drainage (% CR-POPF)

4 (15%)

4 (50%)

1 (25%)

Readmission for Grade B POPF (%)

5 (24%)

6 (100%)

1 (33%)

Intervals to reoperation (median)




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