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Huang YL, Tian XF, Qiu YJ, Lou WH, Jung EM, Dong Y, Wang HZ, Wang WP. Preoperative ultrasound radiomics for predicting clinically relevant postoperative pancreatic fistula after pancreatectomy. Clin Hemorheol Microcirc 2024; 86:313-326. [PMID: 37927251 DOI: 10.3233/ch-231955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To evaluate the efficacy of the radiomics model based on preoperative B-mode ultrasound (BMUS) and shear wave elastography (SWE) for predicting the occurrence of clinically relevant-postoperative pancreatic fistula (CR-POPF). METHODS Patients who were scheduled to undergo pancreatectomy were prospectively enrolled and received ultrasound assessment within one week before surgery. The risk factors of POPF (grades B and grades C) were analyzed. Preoperative BMUS images, SWE values of pancreatic lesions and surrounding parenchyma were used to build preoperative prediction radiomics models. Radiomic signatures were extracted and constructed using a minimal Redundancy Maximal Relevance (mRMR) algorithm and an L1 penalized logistic regression. A combined model was built using multivariate regression which incorporated radiomics signatures and clinical data. RESULTS From January 2020 to November 2021, a total of 147 patients (85 distal pancreatectomies and 62 pancreaticoduodenectomies) were enrolled. During the three-week follow-up after pancreatectomy, the incidence rates of grade B/C POPF were 28.6% (42/147). Radiomic signatures constructed from BMUS of pancreas parenchymal regions (panRS) achieved an area under the receiver operating characteristic curve (AUC) of 0.75, accuracy of 68.7%, sensitivity of 85.7 %, and specificity of 61.9 % in preoperative noninvasive prediction of CR-POPF. The AUC of the radiomics model increased to 0.81 when panRS was used for the prediction of CR-POPF after pancreaticoduodenectomy. CONCLUSIONS Radiomics model based on ultrasound images was potentially useful for predicting CR-POPF. Patients with high-risk factors should be closely monitored when postoperation.
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Affiliation(s)
- Yun-Lin Huang
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Fan Tian
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Jie Qiu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Hui Lou
- Department of Pancreas Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ernst-Michael Jung
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Han-Zhang Wang
- Precision Health Institute, GE Healthcare China, Shanghai, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
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Ashraf Ganjouei A, Romero-Hernandez F, Wang JJ, Casey M, Frye W, Hoffman D, Hirose K, Nakakura E, Corvera C, Maker AV, Kirkwood KS, Alseidi A, Adam MA. A Machine Learning Approach to Predict Postoperative Pancreatic Fistula After Pancreaticoduodenectomy Using Only Preoperatively Known Data. Ann Surg Oncol 2023; 30:7738-7747. [PMID: 37550449 DOI: 10.1245/s10434-023-14041-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/14/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Clinically-relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) is a major postoperative complication and the primary determinant of surgical outcomes. However, the majority of current risk calculators utilize intraoperative and postoperative variables, limiting their utility in the preoperative setting. Therefore, we aimed to develop a user-friendly risk calculator to predict CR-POPF following PD using state-of-the-art machine learning (ML) algorithms and only preoperatively known variables. METHODS Adult patients undergoing elective PD for non-metastatic pancreatic cancer were identified from the ACS-NSQIP targeted pancreatectomy dataset (2014-2019). The primary endpoint was development of CR-POPF (grade B or C). Secondary endpoints included discharge to facility, 30-day mortality, and a composite of overall and significant complications. Four models (logistic regression, neural network, random forest, and XGBoost) were trained, validated and a user-friendly risk calculator was then developed. RESULTS Of the 8666 patients who underwent elective PD, 13% (n = 1160) developed CR-POPF. XGBoost was the best performing model (AUC = 0.72), and the top five preoperative variables associated with CR-POPF were non-adenocarcinoma histology, lack of neoadjuvant chemotherapy, pancreatic duct size less than 3 mm, higher BMI, and higher preoperative serum creatinine. Model performance for 30-day mortality, discharge to a facility, and overall and significant complications ranged from AUC 0.62-0.78. CONCLUSIONS In this study, we developed and validated an ML model using only preoperatively known variables to predict CR-POPF following PD. The risk calculator can be used in the preoperative setting to inform clinical decision-making and patient counseling.
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Affiliation(s)
| | | | - Jaeyun Jane Wang
- Department of Surgery, University of California, San Francisco, USA
| | - Megan Casey
- School of Medicine, University of California, San Francisco, USA
| | - Willow Frye
- School of Medicine, University of California, San Francisco, USA
| | - Daniel Hoffman
- Department of Surgery, University of California, San Francisco, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Eric Nakakura
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Carlos Corvera
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Mohamed A Adam
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA.
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Zou J, Xue X, Qin L. Development of a Nomogram to Predict Clinically Relevant Postoperative Pancreatic Fistula After Pancreaticoduodenectomy on the Basis of Visceral Fat Area and Magnetic Resonance Imaging. Ann Surg Oncol 2023; 30:7712-7719. [PMID: 37530992 DOI: 10.1245/s10434-023-13943-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/27/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The aim of this study was to develop a nomogram to predict the risk of developing clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) using preoperative clinical and imaging data. METHODS The data of 205 patients were retrospectively analyzed, randomly divided into training (n = 125) and testing groups (n = 80). The patients' preoperative laboratory indicators, preoperative clinical baseline data, and preoperative imaging data [enhanced computed tomography (CT), enhanced magnetic resonance imaging (MRI)] were collected. Univariate analyses combined with multivariate logistic regression were used to identify the independent risk factors for CR-POPF. These factors were used to train and validate the model and to develop the risk nomogram. The area under the curve (AUC) was used to measure the predictive ability of the models. The integrated discrimination improvement index (IDI) and decision curve analysis (DCA) were used to assess the clinical feasibility of the nomogram in relation to five other models established in literature. RESULTS CT visceral fat area (P = 0.014), the pancreatic spleen signal ratio on T1 fat-suppressed MRI sequences (P < 0.001), and CT main pancreatic duct diameter (P = 0.001) were identified as independent prognostic factors and used to develop the model. The final nomogram achieved an AUC of 0.903. The IDI and DCA showed that the nomogram outperformed the other five CR-POPF models in the training and testing cohorts. CONCLUSION The nomogram achieved a superior predictive ability for CR-POPF following PD than other models described in literature. Clinicians can use this simple model to optimize perioperative planning according to the patient's risk of developing CR-POPF.
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Affiliation(s)
- Jiayue Zou
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Xiaofeng Xue
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Lei Qin
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
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Angrisani M, Meniconi RL, Sandini M, Colasanti M, Ferretti S, Guglielmo N, Berardi G, Mariano G, Usai S, Braga M, Gianotti L, Ettorre GM. External validation of scores predicting postoperative fistula after pancreatogastrostomy for pancreatoduodenectomy reconstruction. A single center experience. Pancreatology 2023; 23:852-857. [PMID: 37827971 DOI: 10.1016/j.pan.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent complication of pancreatic surgery and can be fatal. Selection and stratification of patients according to the risk of POPF are important for the perioperative management. Predictive metrics have been developed and validated in pancreatojejunostomy. Aim of this study is to assess whether the most used prognostic scores can be predictive of fistula following Wirsung-pancreaticogastrostomy (WPG) for pancreatoduodenectomy (PD)reconstruction. METHOD This single-center prospective observational study included 212 PDs between January 2008 and October 2022 with a standardized WPG. All component variables of the six scores were separately validated in our cohort. The overall predictive ability of the six fistula scores was measured and compared with the receiver operating characteristics curves (ROC) method and expressed by the area under the ROC-curve (AUC). Univariate and multivariate logistic regression analyses were performed considering all risk factors in the scores in order to identify variables independently correlated with POPF in the WPG. RESULTS CR-POPF occurred in 36 of 212 (17 %) patients. All scores showed poor prognostic stratification for the development of CR-POPF. The occurrence of CR-POPF was associated with nine factors: male gender (p = 0.003); BMI (kg/m2) (p = 0.005); ASA (%) (p = 0.003); Soft pancreatic texture (%) (p = 0.003), Pathology (p = 0.008); MPD (p = 0.011); EBL (mL) (p = 0.021); Preop. Bilirubin (mg/dl) (p = 0.038); Preop. Glucose (mg/dl) (p = 0.0369). Male gender (OR: 5.54, CI 1.41-21.3) and soft consistency of the remnant pancreas (OR: 3.83, CI 1.14-12.8) were the only independent prognostic factors on multivariate analysis. CONCLUSIONS Our study including exclusively pancreatogastrostomies failed to validate the most used predictive scores for POPF. We found that only male gender and soft pancreatic texture are associated with POPF. Specific predictive scores following pancreatogasgtrostomy are needed.
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Affiliation(s)
- Marco Angrisani
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy; School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy.
| | - Roberto Luca Meniconi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Marta Sandini
- Department of Medical, Surgical, and Neurologic Sciences, University of Siena, Siena, Italy
| | - Marco Colasanti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Stefano Ferretti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Nicola Guglielmo
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Giammauro Berardi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Germano Mariano
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Sofia Usai
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Marco Braga
- School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
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Pande R, Halle-Smith JM, Phelan L, Thorne T, Panikkar M, Hodson J, Roberts KJ, Arshad A, Connor S, Conlon KC, Dickson EJ, Giovinazzo F, Harrison E, de Liguori Carino N, Hore T, Knight SR, Loveday B, Magill L, Mirza D, Pandanaboyana S, Perry RJ, Pinkney T, Siriwardena AK, Satoi S, Skipworth J, Stättner S, Sutcliffe RP, Tingstedt B. External validation of postoperative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:287-298. [PMID: 34810093 DOI: 10.1016/j.hpb.2021.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/12/2021] [Accepted: 10/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation and are the most accurate. The aim of this study was to identify risk scores for POPF, and assess the clinical validity of these scores. METHODS Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models. RESULTS Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so included in the meta-analysis, (Tokyo (N=2 validation studies), Birmingham (N=5), FRS (N=19), a-FRS (N=12), m-FRS (N=3) and ua-FRS (N=3) scores). Overall predictive accuracies were similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%. CONCLUSION Most risk scores lack external validation; where this was performed, risk scores were found to have limited predictive accuracy. . Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.
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Affiliation(s)
| | | | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK.
| | - James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Liam Phelan
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Thomas Thorne
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - M Panikkar
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Ali Arshad
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital of Southampton, Tremona Rd, Southampton, SO16 6YD, UK
| | - Saxon Connor
- Department of General Surgery, Christchurch Hospital, 2 Riccarton Ave, Christchurch, 8140, New Zealand
| | - Kevin Cp Conlon
- Hepatobiliary and Pancreatic Surgery Unit, The University of Dublin, Trinity College, College Green, Dublin 2, Ireland
| | - Euan J Dickson
- Hepatobiliary and Pancreatic Surgery Unit, Glasgow Royal Infirmary, Scotland, UK
| | - Francesco Giovinazzo
- General Surgery and Liver Transplantation Unit, Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Ewen Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, EH16 4UX, UK
| | - Nicola de Liguori Carino
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK
| | - Todd Hore
- Department of General Surgery, Christchurch Hospital, 2 Riccarton Ave, Christchurch, 8140, New Zealand
| | - Stephen R Knight
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, EH16 4UX, UK
| | - Benjamin Loveday
- Hepatobiliary and Pancreatic Surgery Unit, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC, 3052, Australia
| | - Laura Magill
- Birmingham Surgical Trials Consortium (BiSTC), University of Birmingham, Birmingham, B15 2TW, UK
| | - Darius Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
| | - Rita J Perry
- Birmingham Surgical Trials Consortium (BiSTC), University of Birmingham, Birmingham, B15 2TW, UK
| | - Thomas Pinkney
- Birmingham Surgical Trials Consortium (BiSTC), University of Birmingham, Birmingham, B15 2TW, UK
| | - Ajith K Siriwardena
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK
| | - Sohei Satoi
- Division of Pancreatobiliary Surgery, Kansai Medical University, Osaka, Japan; Division of Surgical Oncology, University of Colorado Anschutz Medical,Campus, Aurora, CO, USA
| | - James Skipworth
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK
| | - Stefan Stättner
- Hepatobiliary and Pancreatic Surgery Unit, Salzkammergut Klinikum OÖG, Sweden
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Bobby Tingstedt
- Hepatobiliary and Pancreatic Surgery Unit, Lund University, Box 117, 221 00, Lund, Sweden
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Adamu M, Plodeck V, Adam C, Roehnert A, Welsch T, Weitz J, Distler M. Predicting postoperative pancreatic fistula in pancreatic head resections: which score fits all? Langenbecks Arch Surg 2021; 407:175-188. [PMID: 34370113 PMCID: PMC8847178 DOI: 10.1007/s00423-021-02290-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 07/23/2021] [Indexed: 01/08/2023]
Abstract
Purpose Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to select those who might benefit from strategies to prevent complications. The aim of this study was to validate ten prognostic scores in patients who underwent pancreatic head surgery. Methods A total of 364 patients were included in this study between September 2012 and August 2017. Ten risk scores were applied to this cohort. Univariate and multivariate analyses were performed considering all risk factors in the scores. Furthermore, the stratification of patients into risk categories was statistically tested. Results Nine of the scores (Ansorge et al., Braga et al., Callery et al., Graham et al., Kantor et al., Mungroop et al., Roberts et al., Yamamoto et al. and Wellner et al.) showed strong prognostic stratification for developing POPF (p < 0.001). There was no significant prognostic value for the Fujiwara et al. risk score. Histology, pancreatic duct diameter, intraabdominal fat thickness in computed tomography findings, body mass index, and C-reactive protein were independent prognostic factors on multivariate analysis. Conclusion Most risk scores tend to stratify patients correctly according to risk for POPF. Nevertheless, except for the fistula risk score (Callery et al.) and its alternative version (Mungroop et al.), many of the published risk scores are obscure even for the dedicated pancreatic surgeon in terms of their clinical practicability. There is a need for future studies to provide strategies for preventing POPF and managing patients with high-risk stigmata.
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Affiliation(s)
- Mariam Adamu
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Verena Plodeck
- Department of Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Claudia Adam
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Anne Roehnert
- Department of Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Juergen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
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Box EW, Deng L, Morgan DE, Xie R, Kirklin JK, Wang TN, Heslin MJ, Reddy S, Vickers S, Dudeia V, Rose JB. Preoperative anthropomorphic radiographic measurements can predict postoperative pancreatic fistula formation following pancreatoduodenectomy. Am J Surg 2020; 222:133-138. [PMID: 33390246 DOI: 10.1016/j.amjsurg.2020.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Postoperative pancreatic fistulae (POPF) are a major contributing factor to pancreatoduodenectomy-associated morbidity. Established risk calculators mostly rely on subjective or intraoperative assessments. We hypothesized that various objective preoperatively determined computed tomography (CT) measurements could predict POPF as well as validated models and allow for more informed operative consent in high-risk patients. METHODS Patients undergoing elective pancreatoduodenectomies between January 2013 and April 2018 were identified in a prospective database. Comparative statistical analyses and multivariable logistic regression models were generated to predict POPF development. Model performance was tested with receiver operating characteristics (ROC) curves. Pancreatic neck attenuation (Hounsfield units) was measured in triplicate by pancreatic protocol CT (venous phase, coronal plane) anterior to the portal vein. A pancreatic density index (PDI) was created to adjust for differences in contrast timing by dividing the mean of these measurements by the portal vein attenuation. Total areas of subcutaneous fat and skeletal muscle were calculated at the L3 vertebral level on axial CT. Pancreatic duct (PD) diameter was determined by CT. RESULTS In the study period 220 patients had elective pancreatoduodenectomies with 35 (16%) developing a POPF of any grade. Multivariable regression analysis revealed that demographics (age, sex, and race) were not associated with POPF, yet patients resected for pancreatic adenocarcinoma or chronic pancreatitis were less likely to develop a POPF (10 vs. 24%; p = 0.004). ROC curves were created using various combinations of gland texture, body mass index, skeletal muscle index, sarcopenia, PDI, PD diameter, and subcutaneous fat area indexed for height (SFI). A model replacing gland texture with SFI and PDI (AUC 0.844) had similar predictive performance as the established model (p = 0.169). CONCLUSION A combination of preoperative objective CT measurements can adequately predict POPF and is comparable to established models relying on subjective intraoperative variables. Validation in a larger dataset would allow for better preoperative stratification of high-risk patients and improve informed consent among this patient population.
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Affiliation(s)
- E W Box
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - L Deng
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - D E Morgan
- Department of Radiology, University of Alabama at Birmingham, 500 22nd Street South, Birmingham, AL, 35233, USA
| | - R Xie
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - J K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - T N Wang
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - M J Heslin
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - S Reddy
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - S Vickers
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - V Dudeia
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA
| | - J B Rose
- Department of Surgery, University of Alabama at Birmingham, Boshell Diabetes Building #618, 1808 7th Ave. S, Birmingham, AL, 35233, USA.
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Vanbrugghe C, Birnbaum DJ, Boucekine M, Ewald J, Marchese U, Guilbaud T, Berdah SV, Moutardier V. Prospective study on predictability of complications by pancreatic surgeons. Langenbecks Arch Surg 2020; 405:155-163. [PMID: 32285190 DOI: 10.1007/s00423-020-01866-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/20/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE We evaluated the intuition of expert pancreatic surgeons, in predicting the associated risk of pancreatic resection and compared this "intuition" to actual operative follow-up. The objective was to avoid major complications following pancreatic resection, which remains a challenge. METHODS From January 2015 to February 2018, all patients who were 18 years old or more undergoing a pancreatic resection (pancreaticoduodenectomy [PD], distal pancreatectomy [DP], or central pancreatectomy [CP]) for pancreatic lesions were included. Preoperatively and postoperatively, all surgeons completed a form assessing the expected potential occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF: grade B or C), postoperative hemorrhage, and length of stay. RESULTS Preoperative intuition was assessed for 101 patients for 52 PD, 44 DP, and 5 CP cases. Overall mortality and morbidity rates were 6.9% (n = 7) and 67.3% (n = 68), respectively, and 38 patients (37.6%) developed a POPF, including 27 (26.7%) CR-POPF. Concordance between preoperative intuition of CR-POPF occurrence and reality was minimal, with a Cohen's kappa coefficient (κ) of 0.175 (P value = 0.009), and the same result was obtained between postoperative intuition and reality (κ = 0.351; P < 0.001). When the pancreatic parenchyma was hard, surgeons predicted the absence of CR-POPF with a negative predictive value of 91.3%. However, they were not able to predict the occurrence of CR-POPF when the pancreas was soft (positive predictive value 48%). CONCLUSIONS This study assessed for the first time the surgeon's intuition in pancreatic surgery, and demonstrated that pancreatic surgeons cannot accurately assess outcomes except when the pancreatic parenchyma is hard.
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Affiliation(s)
- Charles Vanbrugghe
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Mohamed Boucekine
- EA 3279 - Self-perceived Health Assessment Research Unit, Aix-Marseille University, 13005, Marseille, France
| | - Jacques Ewald
- Department of Digestive Surgery and Oncology, Institut Paoli Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Ugo Marchese
- Department of Digestive Surgery and Oncology, Institut Paoli Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Théophile Guilbaud
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Stéphane Victor Berdah
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Vincent Moutardier
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
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Zettervall SL, Ju T, Holzmacher JL, Huysman B, Werba G, Sidawy A, Lin P, Vaziri K. Arterial, but Not Venous, Reconstruction Increases 30-Day Morbidity and Mortality in Pancreaticoduodenectomy. J Gastrointest Surg 2020; 24:578-584. [PMID: 30945084 DOI: 10.1007/s11605-019-04211-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure. METHODS A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction. RESULTS A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P < 0.01), those with arterial reconstruction had higher rates of pulmonary disease (11.5% vs. 4.5%, P = 0.02), and neoadjuvant chemotherapy was more common in both venous (34% vs 12%, P < 0.01) and arterial reconstruction (21% vs 12%, P = 0.04). In multivariable analysis, there was no increase in morbidity or mortality following venous reconstruction. However, arterial reconstruction was associated with increased 30-day mortality with an odds ratio (OR): 6.7, 95%; confidence interval (CI): 1.8-25. Morbidity was increased as represented with return to the operating room (OR: 4.5, 95%; CI: 1.5-15), pancreatic fistula (OR: 4.4, 95%; CI: 1.7-11), and reintubation (OR: 3.9, 95%; CI: 1.1-14). CONCLUSIONS Venous reconstruction during pancreaticoduodenectomy does not increase perioperative morbidity or mortality and should be considered for patients previously considered to be unresectable or those where R0 resection would otherwise not be possible due to venous involvement. Careful consideration should be made prior to arterial reconstruction given the significant increase in perioperative complications and death within 30 days.
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Affiliation(s)
- Sara L Zettervall
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Tammy Ju
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA.
| | - Jeremy L Holzmacher
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Bridget Huysman
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Gregor Werba
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Anton Sidawy
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Paul Lin
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
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10
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Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation. Ann Surg 2020; 269:937-943. [PMID: 29240007 DOI: 10.1097/sla.0000000000002620] [Citation(s) in RCA: 258] [Impact Index Per Article: 51.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this study was to develop an alternative fistula risk score (a-FRS) for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, without blood loss as a predictor. BACKGROUND Blood loss, one of the predictors of the original-FRS, was not a significant factor during 2 recent external validations. METHODS The a-FRS was developed in 2 databases: the Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B/C POPF according to the 2005 International Study Group on Pancreatic Surgery (ISGPS) definition. The score was externally validated in 2 independent databases (University Hospital of Verona and University Hospital of Pennsylvania), using both 2005 and 2016 ISGPS definitions. The a-FRS was also compared with the original-FRS. RESULTS For model design, 1924 patients were included of whom 12% developed POPF. Three predictors were strongly associated with POPF: soft pancreatic texture [odds ratio (OR) 2.58, 95% confidence interval (95% CI) 1.80-3.69], small pancreatic duct diameter (per mm increase, OR: 0.68, 95% CI: 0.61-0.76), and high body mass index (BMI) (per kg/m increase, OR: 1.07, 95% CI: 1.04-1.11). Discrimination was adequate with an area under curve (AUC) of 0.75 (95% CI: 0.71-0.78) after internal validation, and 0.78 (0.74-0.82) after external validation. The predictive capacity of a-FRS was comparable with the original-FRS, both for the 2005 definition (AUC 0.78 vs 0.75, P = 0.03), and 2016 definition (AUC 0.72 vs 0.70, P = 0.05). CONCLUSION The a-FRS predicts POPF after pancreatoduodenectomy based on 3 easily available variables (pancreatic texture, duct diameter, BMI) without blood loss and pathology, and was successfully validated for both the 2005 and 2016 POPF definition. The online calculator is available at www.pancreascalculator.com.
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11
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You Y, Han IW, Choi DW, Heo JS, Ryu Y, Park DJ, Choi SH, Han S. Nomogram for predicting postoperative pancreatic fistula. HPB (Oxford) 2019; 21:1436-1445. [PMID: 30982739 DOI: 10.1016/j.hpb.2019.03.351] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/26/2019] [Accepted: 03/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies analyzed risk factors for postoperative pancreatic fistula (POPF) and developed risk prediction tool using scoring system. However, no study has built a nomogram based on individual risk factors. This study aimed to evaluate individual risks of POPF and propose a nomogram for predicting POPF. METHODS From 2007 to 2016, medical records of 1771 patients undergoing pancreaticoduodenctomy were reviewed retrospectively. Variables with p < 0.05 in multivariate logistic regression analysis were included in the nomogram. Internal performance validation was executed using a repeated cross validation method. RESULTS Of 1771 patients, 222 (12.5%) experienced POPF. In multivariable analysis, sex (p = 0.004), body mass index (BMI) (p < 0.001), ASA score (p = 0.039), preoperative albumin (p = 0.035), pancreatic duct diameter (p = 0.002), and location of tumor (p < 0.001) were identified as independent predictors for POPF. Based on these six variables, a POPF nomogram was developed. The area under the curve (AUC) estimated from the receiver operating characteristic (ROC) graph was 0.709 in the train set and 0.652 in the test set. CONCLUSIONS A POPF nomogram was developed. This nomogram may be useful for selecting patients who need more intensified therapy and establishing customized treatment strategy.
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Affiliation(s)
- Yunghun You
- Department of Surgery, Konkuk University Choongju Hospital, Konkuk University School of Medicine, 6, Gwangmyeong 1-gil, Chungju-si, Chungcheongbuk-do, 27376, South Korea
| | - In W Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Dong W Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jin S Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Youngju Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Dae J Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Seong H Choi
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158, Paryong-ro, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, 51353, South Korea
| | - Sunjong Han
- Department of Surgery, Seoul National University College of Medicine, Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
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12
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Li Y, Zhou F, Zhu DM, Zhang ZX, Yang J, Yao J, Wei YJ, Xu YL, Li DC, Zhou J. Novel risk scoring system for prediction of pancreatic fistula after pancreaticoduodenectomy. World J Gastroenterol 2019; 25:2650-2664. [PMID: 31210716 PMCID: PMC6558436 DOI: 10.3748/wjg.v25.i21.2650] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/24/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The available prediction models for clinically relevant postoperative pancreatic fistula (CR-POPF) do not incorporate both preoperative and intraoperative variables.
AIM To construct a new risk scoring system for CR-POPF that includes both preoperative and intraoperative factors.
METHODS This was a retrospective study of patients who underwent pancreaticoduodenectomy (PD) or pylorus-preserving PD (PPPD) between January 2011 and December 2016 at the First Affiliated Hospital of Soochow University. Patients were divided into a study (01/2011 to 12/2014) or validation (01/2015 to 12/2016) group according to the time of admission. POPF severity was classified into three grades: Biochemical leak (grade A) and CR-POPF (grades B and C). Logistic regression was used to create a predictive scoring system.
RESULTS Preoperative serum albumin ≥ 35 g/L [P = 0.032, odds ratio (OR) = 0.92, 95% confidence interval (CI): 0.85-0.99], hard pancreatic texture (P = 0.004, OR = 0.25, 95%CI: 0.10-0.64), pancreatic duct diameter ≥ 3 mm (P = 0.029, OR = 0.50, 95%CI: 0.27-0.93), and intraoperative blood loss ≥ 500 mL (P = 0.006, OR = 1.002, 95%CI: 1.001-1.003) were independently associated with CR-POPF. We established a 10-point risk scoring system to predict CR-POPF. The area under the curve was 0.821 (95%CI: 0.736-0.905) and the cut-off value was 3.5. Including drain amylase levels improved the predictive power of the model.
CONCLUSION This study established a 10-point scoring system to predict CR-POPF after PD/PPPD using preoperative and intraoperative parameters. Ultimately, this system could be used to distinguish between high- and low-risk populations in order to facilitate timely interventions after PD.
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Affiliation(s)
- Ye Li
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
- Pancreatic Disease Research Centre, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Fang Zhou
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Dong-Ming Zhu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
- Pancreatic Disease Research Centre, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Zi-Xiang Zhang
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
- Pancreatic Disease Research Centre, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Jian Yang
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
- Pancreatic Disease Research Centre, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Jun Yao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Yi-Jun Wei
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Ya-Ling Xu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
- Pancreatic Disease Research Centre, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Dei-Chun Li
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
- Pancreatic Disease Research Centre, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Jian Zhou
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
- Pancreatic Disease Research Centre, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
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Daniel F, Tamim H, Hosni M, Ibrahim F, Mailhac A, Jamali F. Validation of day 1 drain fluid amylase level for prediction of clinically relevant fistula after distal pancreatectomy using the NSQIP database. Surgery 2019; 165:315-322. [DOI: 10.1016/j.surg.2018.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/11/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022]
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Yagnik V, Patel A. Evaluation of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy. FORMOSAN JOURNAL OF SURGERY 2019. [DOI: 10.4103/fjs.fjs_118_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Zhang W, Cai W, He B, Xiang N, Fang C, Jia F. A radiomics-based formula for the preoperative prediction of postoperative pancreatic fistula in patients with pancreaticoduodenectomy. Cancer Manag Res 2018; 10:6469-6478. [PMID: 30568506 PMCID: PMC6276820 DOI: 10.2147/cmar.s185865] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The objective of the study was to develop and validate a radiomics-based formula for the preoperative prediction of postoperative pancreatic fistula (POPF) in patients undergoing pancreaticoduodenectomy (PD). MATERIALS AND METHODS A total of 117 consecutive patients who underwent PD were enrolled in this retrospective study. Radiomics features were extracted from portal venous phase computed tomography of the above patients. The least absolute shrinkage and selection operator logistic regression was used to construct a formula of Rad-score calculation. Then the performance of the formula was assessed with standard pancreatic Fistula Risk Score. RESULTS The Rad-score could predict POPF with an area under the curve (AUC) of 0.8248 in the training cohort and of 0.7609 in the validation cohort. Patients who had experienced POPF generally had a statistically higher Rad-score than those who had not experienced POPF in both cohorts. The AUC of the Rad-score was statistically higher than the Fistula Risk Score for predicting POPF in both the training and validation cohort. CONCLUSION A novel radiomics-based formula was developed and validated for predicting POPF in patients who underwent PD, which provides a new method for identifying POPF risks and may help to improve informed decision-making in the prevention of POPF at low cost.
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Affiliation(s)
- Wenyu Zhang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China,
- Research Lab for Medical Imaging and Digital Surgery, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, People's Republic of China,
| | - Wei Cai
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China,
- Research Lab for Medical Imaging and Digital Surgery, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, People's Republic of China,
| | - Baochun He
- Research Lab for Medical Imaging and Digital Surgery, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, People's Republic of China,
- Shenzhen Key Laboratory of Minimally Invasive Surgical Robotics and System, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, People's Republic of China,
| | - Nan Xiang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China,
| | - Chihua Fang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China,
| | - Fucang Jia
- Research Lab for Medical Imaging and Digital Surgery, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, People's Republic of China,
- Shenzhen Key Laboratory of Minimally Invasive Surgical Robotics and System, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, People's Republic of China,
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16
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Zettervall SL, Ju T, Holzmacher JL, Rivas L, Lin PP, Vaziri K. Neoadjuvant Radiation Is Associated with Fistula Formation Following Pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:1026-1033. [PMID: 29500685 DOI: 10.1007/s11605-018-3725-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative pancreatic fistulas remain a significant source of morbidity following pancreatic surgery. Few studies have evaluated the effect of neoadjuvant chemotherapy and radiation on this adverse outcome. This study aims to evaluate the effects of neoadjuvant therapy on 30-day morbidity and mortality following pancreaticoduodenectomy. STUDY DESIGN A retrospective analysis was performed utilizing the targeted pancreas module of the National Surgical Quality Improvement Project (NSQIP) from 2014 to 2015 for patients undergoing pancreaticoduodenectomy with pancreaticojejunal reconstruction. A fistula was defined according to the NSQIP definition. Patient demographics, operative variables, and 30-day outcomes were compared between those who received no neoadjuvant therapy, chemoradiation, chemotherapy alone, and radiation alone. Univariate analysis was completed using chi-square, Fisher exact test, Student's t test, and Mann-Whitney U test where appropriate. Independent predictors of fistula formation were established using multivariable regression. A P value < 0.05 was considered significant. RESULTS Three thousand one hundred fourteen patients were included of which 559 patients (18%) developed a pancreatic fistula. Two thousand six hundred thirty-five (85%) patients did not undergo neoadjuvant therapy, 207 (6.6%) had chemoradiation, 256 (8.2%) had chemotherapy alone, and 16 (0.5%) had radiation alone. Patients who developed a fistula had increased 30-day mortality (4.9 vs. 1.7%, P < .001) and major morbidities. Following multivariable analysis, neoadjuvant radiation (OR 2.1, 95% CI 1.0-4.5) was associated with increased fistula formation while neoadjuvant chemotherapy (OR 0.5, 95% CI 0.3-0.9) was protective. CONCLUSION Neoadjuvant chemotherapy provides protection against the development of pancreatic fistulas while neoadjuvant radiation potentiates formation likely due to their effects on the texture of the pancreatic gland. Given the morbidity of pancreatic fistula formation, these factors should be considered in neoadjuvant regimens.
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Affiliation(s)
- Sara L Zettervall
- Department of Surgery, George Washington University, 2150 Pennsylvania Ave, Suite 6B, Washington, DC, 20037, USA
| | - Tammy Ju
- Department of Surgery, George Washington University, 2150 Pennsylvania Ave, Suite 6B, Washington, DC, 20037, USA.
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17
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Kirks RC, Cochran A, Barnes TE, Murphy K, Baker EH, Martinie JB, Iannitti DA, Vrochides D. Developing and validating a center-specific preoperative prediction calculator for risk of pancreaticoduodenectomy. Am J Surg 2018. [PMID: 29519551 DOI: 10.1016/j.amjsurg.2018.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) Surgical Risk Calculator predicts postoperative risk based on preoperative variables. The ACS model was compared to an institution-specific risk calculator for pancreaticoduodenectomy (PD). METHODS Observed outcomes were compared with those predicted by the ACS and institutional models. Receiver operating characteristic (ROC) analysis evaluated the models' predictive ability. Institutional models were evaluated with retrospective and prospective internal validation. RESULTS Brier scores indicate equivalent aggregate predictive ability. ROC values for the institutional model (ROC: 0.675-0.881, P < 0.01) indicate superior individual event occurrence prediction (ACS ROC: 0.404-0.749, P < 0.01-0.860). Institutional models' accuracy was upheld in retrospective (ROC: 0.765-0.912) and prospective (ROC: 0.882-0.974) internal validation. CONCLUSIONS Identifying higher-risk patients allows for individualized care. While ACS and institutional models accurately predict average complication occurrence, the institutional models are superior at predicting individualized outcomes. Predictive metrics specific to PD center volume may more accurately predict outcomes.
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Affiliation(s)
- Russell C Kirks
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - T Ellis Barnes
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith Murphy
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Grendar J, Jutric Z, Leal JN, Ball CG, Bertens K, Dixon E, Hammill CW, Kastenberg Z, Newell PH, Rocha F, Visser B, Wolf RF, Hansen PD. Validation of Fistula Risk Score calculator in diverse North American HPB practices. HPB (Oxford) 2017; 19:508-514. [PMID: 28233672 DOI: 10.1016/j.hpb.2017.01.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 01/09/2017] [Accepted: 01/21/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fistula Risk Score (FRS) is a previously developed tool to assess the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD). METHODS Prospectively collected databases from 4 university affiliated and non-affiliated HPB centers in United States and Canada were used. The influence of individual baseline characteristics, FRS and FRS group on CR-POPF was assessed in univariate and multivariate analyses. FRS calculator performance was assessed using a C-statistic. RESULTS 444 patients were identified. Pathology, soft pancreas texture and pancreatic duct size were associated with CR-POPF rates (p < 0.001 for each); EBL was not (p = 0.067). The negligible risk group consisted of 50 (11.3%) patients, low risk of 118 (26.6%), moderate 234 (52.7%) and high risk group of 42 (9.5%) patients. The overall rate of CR-POPF was 20%. Of the patients in the negligible risk group, 2% developed CR-POPF, 13.6% of the low risk, 23.1% moderate and 42.9% in the high risk group (p < 0.001). Overall C-statistic was 0.719. CONCLUSION FRS is robust and able to stratify the risk of developing CR-POPF following PD in diverse North American academic and non-academic institutions. The FRS should be used in research and to guide clinical management of patients post PD in these institutions.
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Affiliation(s)
- Jan Grendar
- Providence Portland Medical Center, Portland, OR, USA
| | - Zeljka Jutric
- Providence Portland Medical Center, Portland, OR, USA
| | - Julie N Leal
- Stanford Medical Center, Stanford University, Stanford, CA, USA
| | - Chad G Ball
- Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | | | - Elijah Dixon
- Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | | | | | | | | | - Brendan Visser
- Stanford Medical Center, Stanford University, Stanford, CA, USA
| | - Ronald F Wolf
- Providence Portland Medical Center, Portland, OR, USA
| | - Paul D Hansen
- Providence Portland Medical Center, Portland, OR, USA.
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Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore) 2017; 96:e6858. [PMID: 28489778 PMCID: PMC5428612 DOI: 10.1097/md.0000000000006858] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is one of the most technically demanding operations challenging surgeons, and a postoperative pancreatic fistula (POPF) can complicate an otherwise uneventful postoperative (PO) course. This review examined the methods and procedures used to prevent postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). METHODS A comprehensive systematic search of the literature was performed using PubMed (Medline), Embase, Web of science, and the Cochrane databases for studies published between January 1, 1990 and December 31, 2015. English language articles involving at least 100 patients undergoing PDs carried out in centers performing at least 10 PDs/y were screened for data regarding the Grade of any POPFs according to the definition of the International Study Group on Pancreatic Fistula (ISGPF) and the overall rate of PO mortality related to POPF. RESULTS We reviewed 7119 references through the major databases, and an additional 841 studies were identified by cross-checking the bibliographies of the full-text articles retrieved. After excluding 7379 out of 7960 studies, because they did not meet the eligibility criteria, the full texts of 581 articles were examined; 96 studies were excluded at this point, because they concerned partially or totally duplicate data that had already been reported. The remaining 485 articles were screened carefully for POPF-related mortality and POPF Grades as defined by the ISGPF. Of the 485 articles, 208 reported the POPF-related PO mortality rate and 162 the Grades (A, B, and C) of POPFs in 60,739 and 54,232 patients, respectively. The POPF-related mortality rates after pancreatojejunostomy and pancreatogastrostomy were similar but were less (0.5% vs. 1%; P = .014) when an externally draining, trans-anastomotic stent was placed intraoperatively. The incidence of the different Grades of POPF Grade was quite variable, but Grade C POPFs were associated with a PO mortality rate of 25.7% (range 0-100%). CONCLUSIONS The POPF-related mortality rate has remained at approximately 1% over the past 25 years. Only externally draining, trans-anastomotic stents decreased the POPF-related mortality rate. However, adequately designed venting drains were never tested in randomized controlled trials (RCTs).
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Abbott DE, Tzeng CWD, McMillan MT, Callery MP, Kent TS, Christein JD, Behrman SW, Schauer DP, Hanseman DJ, Eckman MH, Vollmer CM. Pancreas fistula risk prediction: implications for hospital costs and payments. HPB (Oxford) 2017; 19:140-146. [PMID: 27884544 DOI: 10.1016/j.hpb.2016.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/13/2016] [Accepted: 10/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins. METHODS A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analytic model detailed POPF risk and post-operative sequelae, and their relationship with hospital cost and payment. RESULTS Per-patient hospital cost for negligible-risk patients was $37,855. Low-, moderate-, and high- risk patients had incrementally higher hospital costs of $38,125 ($270; 0.7% above negligible-risk), $41,128 ($3273; +8.6%), and $41,983 ($3858; +10.9%), respectively. Similarly, hospital payment for negligible-risk patients was $42,685/patient, with incrementally higher payments for low-risk ($43,265; +1.4%), moderate-risk ($45,439; +6.5%) and high-risk ($46,564; +9.1%) patients. The lowest 30-day readmission rates - with highest net profit - were found for negligible/low-risk patients (10.5%/11.1%), respectively, compared with readmission rates of moderate/high-risk patients (15%/15.7%). CONCLUSION Financial outcomes following PD can be predicted using the FRS. Such prediction may help hospitals and payers plan for resource allocation and payment matched to patient risk, while providing a benchmark for quality improvement initiatives.
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Vallance AE, Young AL, Macutkiewicz C, Roberts KJ, Smith AM. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB (Oxford) 2015; 17:1040-8. [PMID: 26456948 PMCID: PMC4605344 DOI: 10.1111/hpb.12503] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A post-operative pancreatic fistula (POPF) is a major cause of morbidity and mortality after a pancreaticoduodenectomy (PD). This systematic review aimed to identify all scoring systems to predict POPF after a PD, consider their clinical applicability and assess the study quality. METHOD An electronic search was performed of Medline (1946-2014) and EMBASE (1996-2014) databases. Results were screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and quality assessed according to the QUIPS (quality in prognostic studies) tool. RESULTS Six eligible scoring systems were identified. Five studies used the International Study Group on Pancreatic Fistula (ISGPF) definition. The proposed scores feature between two and five variables and of the 16 total variables, the majority (12) featured in only one score. Three scores could be fully completed pre-operatively whereas 1 score included intra-operative and two studies post-operative variables. Four scores were internally validated and of these, two scores have been subject to subsequent multicentre review. The median QUIPS score was 38 out of 50 (range 16-50). CONCLUSION These scores show potential in calculating the individualized patient risk of POPF. There is, however, much variation in current scoring systems and further validation in large multicentre cohorts is now needed.
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Affiliation(s)
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation TrustBirmingham, UK
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