Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group

Brett L. Ecker, Matthew T. McMillan, Valentina Allegrini, Claudio Bassi, Joal D. Beane, Ross M. Beckman, Stephen W. Behrman, Euan J. Dickson, Mark P. Callery, John D. Christein, Jeffrey A. Drebin, Robert H. Hollis, Michael G. House, Nigel B. Jamieson, Ammar A. Javed, Tara S. Kent, Michael D. Kluger, Stacy J. Kowalsky, Laura Maggino, Giuseppe MalleoVicente Valero, Lavanniya K.P. Velu, Amarra A. Watkins, Christopher Wolfgang, Amer H. Zureikat, Charles M. Vollmer

Research output: Contribution to journalArticle

Abstract

OBJECTIVE: To identify a clinical fistula risk score following distal pancreatectomy. BACKGROUND: Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. METHODS: This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. RESULTS: CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001). CONCLUSIONS: From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.

Original languageEnglish (US)
Pages (from-to)143-149
Number of pages7
JournalAnnals of Surgery
Volume269
Issue number1
DOIs
StatePublished - Jan 1 2019

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Pancreatic Fistula
Pancreatectomy
Fistula
Octreotide
Epidural Anesthesia
Pancreatic Ducts
Splenectomy
Sutures
Ligation
Blood Vessels
Drainage
Retrospective Studies
Obesity
Logistic Models
Regression Analysis
Pathology
Morbidity

ASJC Scopus subject areas

  • Surgery

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Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy : Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group. / Ecker, Brett L.; McMillan, Matthew T.; Allegrini, Valentina; Bassi, Claudio; Beane, Joal D.; Beckman, Ross M.; Behrman, Stephen W.; Dickson, Euan J.; Callery, Mark P.; Christein, John D.; Drebin, Jeffrey A.; Hollis, Robert H.; House, Michael G.; Jamieson, Nigel B.; Javed, Ammar A.; Kent, Tara S.; Kluger, Michael D.; Kowalsky, Stacy J.; Maggino, Laura; Malleo, Giuseppe; Valero, Vicente; Velu, Lavanniya K.P.; Watkins, Amarra A.; Wolfgang, Christopher; Zureikat, Amer H.; Vollmer, Charles M.

In: Annals of Surgery, Vol. 269, No. 1, 01.01.2019, p. 143-149.

Research output: Contribution to journalArticle

Ecker, BL, McMillan, MT, Allegrini, V, Bassi, C, Beane, JD, Beckman, RM, Behrman, SW, Dickson, EJ, Callery, MP, Christein, JD, Drebin, JA, Hollis, RH, House, MG, Jamieson, NB, Javed, AA, Kent, TS, Kluger, MD, Kowalsky, SJ, Maggino, L, Malleo, G, Valero, V, Velu, LKP, Watkins, AA, Wolfgang, C, Zureikat, AH & Vollmer, CM 2019, 'Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group', Annals of Surgery, vol. 269, no. 1, pp. 143-149. https://doi.org/10.1097/SLA.0000000000002491
Ecker, Brett L. ; McMillan, Matthew T. ; Allegrini, Valentina ; Bassi, Claudio ; Beane, Joal D. ; Beckman, Ross M. ; Behrman, Stephen W. ; Dickson, Euan J. ; Callery, Mark P. ; Christein, John D. ; Drebin, Jeffrey A. ; Hollis, Robert H. ; House, Michael G. ; Jamieson, Nigel B. ; Javed, Ammar A. ; Kent, Tara S. ; Kluger, Michael D. ; Kowalsky, Stacy J. ; Maggino, Laura ; Malleo, Giuseppe ; Valero, Vicente ; Velu, Lavanniya K.P. ; Watkins, Amarra A. ; Wolfgang, Christopher ; Zureikat, Amer H. ; Vollmer, Charles M. / Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy : Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group. In: Annals of Surgery. 2019 ; Vol. 269, No. 1. pp. 143-149.
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title = "Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group",
abstract = "OBJECTIVE: To identify a clinical fistula risk score following distal pancreatectomy. BACKGROUND: Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. METHODS: This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. RESULTS: CR-POPF occurred following 306 (15.1{\%}) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95{\%} CI 1.05-1.82), obesity (OR 1.54, 95{\%} CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95{\%} CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95{\%} CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95{\%} CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95{\%} CI 1.25-3.17), and vascular resection (OR 2.29, 95{\%} CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95{\%} CI 1.51-3.78) but reduced fistula severity (P < 0.001). CONCLUSIONS: From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.",
author = "Ecker, {Brett L.} and McMillan, {Matthew T.} and Valentina Allegrini and Claudio Bassi and Beane, {Joal D.} and Beckman, {Ross M.} and Behrman, {Stephen W.} and Dickson, {Euan J.} and Callery, {Mark P.} and Christein, {John D.} and Drebin, {Jeffrey A.} and Hollis, {Robert H.} and House, {Michael G.} and Jamieson, {Nigel B.} and Javed, {Ammar A.} and Kent, {Tara S.} and Kluger, {Michael D.} and Kowalsky, {Stacy J.} and Laura Maggino and Giuseppe Malleo and Vicente Valero and Velu, {Lavanniya K.P.} and Watkins, {Amarra A.} and Christopher Wolfgang and Zureikat, {Amer H.} and Vollmer, {Charles M.}",
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TY - JOUR

T1 - Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy

T2 - Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group

AU - Ecker, Brett L.

AU - McMillan, Matthew T.

AU - Allegrini, Valentina

AU - Bassi, Claudio

AU - Beane, Joal D.

AU - Beckman, Ross M.

AU - Behrman, Stephen W.

AU - Dickson, Euan J.

AU - Callery, Mark P.

AU - Christein, John D.

AU - Drebin, Jeffrey A.

AU - Hollis, Robert H.

AU - House, Michael G.

AU - Jamieson, Nigel B.

AU - Javed, Ammar A.

AU - Kent, Tara S.

AU - Kluger, Michael D.

AU - Kowalsky, Stacy J.

AU - Maggino, Laura

AU - Malleo, Giuseppe

AU - Valero, Vicente

AU - Velu, Lavanniya K.P.

AU - Watkins, Amarra A.

AU - Wolfgang, Christopher

AU - Zureikat, Amer H.

AU - Vollmer, Charles M.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - OBJECTIVE: To identify a clinical fistula risk score following distal pancreatectomy. BACKGROUND: Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. METHODS: This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. RESULTS: CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001). CONCLUSIONS: From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.

AB - OBJECTIVE: To identify a clinical fistula risk score following distal pancreatectomy. BACKGROUND: Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. METHODS: This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. RESULTS: CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001). CONCLUSIONS: From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.

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