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• W2751484828 abstract "Background: Postoperative pancreatic fistula (POPF) is regarded as the most serious complication after pancreaticoduodenectomy (PD). We sought to identify factors which may predict its occurrence and evaluate the effect of POPF on outcomes following PD. Methods: Patients who underwent PD at our institution from January 2009 to December 2012 were enrolled in this study. For patients operated before July 2011, the details were collected retrospectively. Medical/surgical records, histopathological specimen's reports and computerised hospital information system (HIS) were analysed and the details were entered in a standard protocol format. POPF was defined as per ISGPF criteria. We performed a risk factor analysis for POPF after PD in 95 patients enrolled in our study with focus on preoperative clinical and blood parameters, perioperative parameters and histopathological parameters that might serve to predict POPF. We also analysed the value of intraoperative subjective prediction for POPF occurrence by the surgeon. Analysis of outcomes, including treatment cost of POPF after PD was also done. Results: There were 67 males and 28 females with a mean age of 57±12 (range 16-77) years. Preoperative biliary stenting was done in 44 (46.3%) patients. Classical Whipple's and pylorus preserving PD were performed in 91 (95.8%) and 4 (4.2%) patients, respectively. Isolated loop and single loop reconstruction was done in 67 (70.5%) and 28 (29.5%) patients, respectively. Dunking, end-to-side duct-to-mucosa and binding pancreaticojejunal anastomoses (PJ) were done in 77 (81.1%), 15 (15.8%) and 3 (3.2%) patients, respectively. An external stent was placed in PJ and hepaticojejunostomy in 76 (80%) and 42 (44.2%) patients, respectively. The mean operative time was 427±91.7 (range 255-790) minutes. Median intraoperative blood loss was 400 (IQR 250-500) ml. Intraoperative Blood/FFP transfusion was done in 39 (41.1%) patients. A single drain was placed near the PJ site in all patients. Histopathological diagnosis of the operative specimen was adenocarcinoma - 77 (81%), neuroendocrine carcinoma - 7 (7.7%), cystic neoplasm of pancreas - 3 (3.1%), gastrointestinal stromal tumour - 1 (1.1%), leiomyosarcoma - 1 (1.1%), chronic pancreatitis - 1 (1.1%), AV malformation - 1 (1.1%) and miscellaneous - 4 (4.2%). Anatomical site of lesion was periampullary - 64 (67.4%), head of pancreas - 23 (24.2%), common bile duct (CBD) - 3 (3.2%), duodenum only - 3 (3.2%) and stomach + duodenum - 2 (2.1%). The tumour was well, moderately and poorly differentiated in 19 (20%), 50 (52.6%) and 6 (6.3%) patients, respectively. Lymph nodes and surgical resection margins were positive in 36 (37.9%) and 8 (8.4%) patients, respectively. Postoperatively Octreotide was given in 58 (61.1%) patients. POPF (as per ISGPF definition) developed in 35 (36.8%) patients, of which grade A, B and C POPF were 12 (12.6%), 17 (17.9%) and 6 (6.3%), respectively. In patients with POPF, mortality was seen in only 3 (8.6%) patients. Specific complications in these patients with POPF were delayed gastric emptying - 7 (20%), sepsis - 8 (22.9%), haemorrhage - 6 (17.1%), reoperation - nil. The median postoperative hospital stay and ICU stay in patients with POPF were 13 (IQR 11-18) days and 3 (IQR 1-4) days, respectively. The median treatment cost in patients with POPF was Rs.5,01,374 (IQR Rs. 2,87,353- Rs.5,84,396). On univariate analysis of preoperative, perioperative and histopathological factors between POPF and non POPF group, serum amylase value on post-operative day (POD)-3 ( p = 0.012) and POD-5 ( p = 0.017) along with CBD resection margin positive for tumour ( p = 0.047) showed significant positive correlation with occurrence of POPF. But multivariate analysis (multiple logistic regression) on above factors demonstrated serum amylase value at POD-3 to be the only independent predictor of POPF ( p = 0.039, odds ratio [OR] 1.014, 95% confidence interval [CI] 1.001-1.028). On receiver operating characteristics (ROC) analysis, the area under the curve (AUC) was 0.728 (95% Cl: 0.571-0.885, p = 0.004). A serum amylase value on POD-3 of ≥ 60 IU/L demonstrated to predict POPF with a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 61.1%, 83.3%, 73.3%, 74.1% and 73.8%, respectively. A drain amylase value of ≥ 666 IU/L on POD-3 was proposed as the cut-off level to predict clinically relevant high impact fistula (grade B and C) by ROC curve (AUC = 0.585, 95% Cl: 0.363-0.807, p < 0.001). The sensitivity, specificity, PPV, NPV and accuracy of this cut-off value was 62.5%, 91.5%, 71.4%, 87.8% and 84.1%, respectively. The subjective intraoperative prediction by the surgeon at the time surgery of risk of POPF did not showed any correlation with actual POPF occurrence ( p = 0.157). On univariate analysis of outcomes between POPF and non POPF group, postoperative hospital stay ( p = 0.004) and treatment cost ( p = 0.011) were found to increase significantly in POPF group. All other outcomes were equivalent between the two groups. Postoperative hospital stay ( p = 0.002), ICU stay ( p = 0.005) and treatment cost ( p = 0.014) also progressively increased from grade A to C. Conclusions: Our study demonstrated that serum amylase value on POD-3 is an independent predictor of POPF. Drain amylase value of ≥ 666 IU/L on POD-3 is significant predictor of clinically relevant high impact fistula (grade B and C). Increasing POPF grades have negative clinical and economic impact on patients and their healthcare resources." @default.
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• W2751484828 date "2013-08-31" @default.
• W2751484828 modified "2023-09-27" @default.
• W2751484828 title "DOES A DRAIN AMYLASE < 666 IU/L ON THE THIRD POST-OPERATIVE DAY EFFECTIVELY PREDICTS THE ABSENCE OF A HIGH-IMPACT POSTOPERATIVE PANCREATIC FISTULA FOLLOWING PANCREATICODUODENECTOMY?" @default.
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