Risk factors for pancreatic fistula following pancreaticoduodenectomy: A retrospective study in a Thai tertiary center

Table 1 Patient characteristics in postoperative pancreatic fistula and no postoperative pancreatic fistula groups

Characteristic data	No POPF (n = 91)	POPF (n = 88)	P-value	95%CI
Age, mean (SD)	60.7 (10.6)	59.1 (11.2)	0.33	58.22-61.44
BMI, median (IQR)	21.4 (20, 23.9)	23.1 (20.8, 25.5)	0.005	22.05-23.22
Albumin, median (IQR)	34.1 (31, 38.3)	34.9 (32, 37.95)	0.667	33.38-35.10
Total bilirubin, median (IQR)	4.1 (1.3, 13.2)	1.3 (0.7, 5.6)	0.002	5.01-7.16
Pancreatic duct diameter (mm), median (IQR)	3 (3, 5)	3 (2, 5)	0.048	3.44-3.99
Operative time, median (IQR)	420 (360, 540)	480 (420, 570)	0.014	448.46-486.23
Blood loss (mL), median (IQR)	1000 (600, 1500)	800 (500, 1500)	0.236	1082-1459.66
LOH day, median (IQR)	15 (12, 20)	25 (17, 39.5)	< 0.001	23.14-32.87
Gender, n (%)
Male	49 (53.8)	46 (52.3)	0.833
Female	42 (46.2)	42 (47.7)
DM, n (%)
No	64 (70.3)	69 (78.4)	0.216
Yes	27 (29.7)	19 (21.6)
Hx of cardiovascular disease, n (%)
No	82 (90.1)	64 (72.7)	0.003
Yes	9 (9.9)	24 (27.3)
PBD, n (%)
No	36 (39.6)	25 (28.4)	0.116
Yes	55 (60.4)	63 (71.6)
Pancreatic texture, n (%)1
Hard/firm	60 (68.2)	27 (31.4)	< 0.001
Soft	28 (31.8)	59 (68.6)
Type of resection, n (%)
PPPD	20 (22.0)	31 (35.2)	0.05
Classical PD	71 (78.0)	57 (64.8)
Duct to mucosa vs Invagination
Duct to mucosa	56 (61.5)	63 (71.6)	0.154
Invagination	35 (38.5)	25 (28.4)
Stent, n (%)
No	73 (80.2)	54 (61.4)	0.005
Yes	18 (19.8)	34 (38.6)
External vs Internal, n (%)
External	4 (22.2)	12 (36.4)	0.298
Internal	14 (77.8)	21 (63.6)
Malignant, n (%)
No	18 (19.8)	16 (18.2)	0.785
Yes	73 (80.2)	72 (81.8)
Final diagnosis, n (%)
CA ampulla	25 (27.5)	37 (42.1)	0.04
CA pancreas	28 (27.5)	12 (13.6)
CA duodenal	8 (8.8)	3 (3.4)
CA distal CBD	7 (7.7)	11 (12.5)
Other	26 (28.5)	25 (28.4)
Grading, n (%)
No	91 (100)	0	0
A	0	58 (65.9)
B	0	22 (25.0)
C	0	8 (9.1)
Other complications
No	86 (94.5)	66 (75.0)	< 0.001
Yes	5 (5.5)	22 (25.0)
30-d mortality, n (%)
No	91 (100)	85 (96.6)	0.117
Yes	0	3 (3.4)
Age, n (%)
< 70	73 (80.2)	73 (82.9)	0.637
≥ 70	18 (19.8)	15 (17.1)
BMI, n (%)
< 25	78 (85.7)	63 (71.6)	0.021
≥ 25	13 (14.3)	25 (28.4)
Albumin, n (%)
≥ 30	75 (82.4)	77 (87.5)	0.342
< 30	16 (17.6)	11 (12.5)
Total bilirubin, n (%)
< 3	41 (45.1)	56 (63.6)	0.013
≥ 3	50 (54.9)	32 (36.4)
Pancreatic duct diameter, n (%)
≥ 5	45 (49.4)	23 (26.1)	0.001
< 5	46 (50.6)	65 (73.9)
Operative time, n (%)
< 420	39 (42.9)	21 (23.9)	0.007
≥ 420	52 (57.1)	67 (76.1)
Blood loss, n (%)
< 1000	45 (49.5)	54 (61.4)	0.109
≥ 1000	46 (50.5)	34 (38.6)

¹n = 174 patients. Other complications: DGE, postoperative hemorrhage, chyle leakage. POPF: Postoperative pancreatic fistul; PBD: Preoperative biliary drainage; PPPD: Pylorus-preserved pancreaticoduodenectomy; PD: Pancreaticoduodenectomy; BMI: Body mass index.

Table 2 Univariate and multivariate logistic regression analysis of postoperative pancreatic fistula risk factors

Variable	Univariate OR (95%CI)	Univariate P-value	Multivariate OR (95%CI)	Multivariate P-value
Age (yr)
< 70
≥ 70	0.833 (0.39-1.78)	0.637
Body mass index (kg/cm2)
< 25
≥ 25	2.381 (1.13-5.03)	0.023	2.081 (0.86-5.03)	0.104
Albumin
≥ 30
< 30	0.669 (0.29-1.54)	0.344
Total bilirubin
< 3
≥ 3	0.468 (0.26-0.85)	0.013	1.455 (0.38-5.55)	0.583
Pancreatic duct diameter
≥ 5 mm
< 5 mm	2.765 (1.47-5.18)	0.002	3.148 (0.81-12.27)	0.098
Operative time
< 420 min
≥ 420 min	2.393 (1.26-4.55)	0.008	1.355 (0.59-3.07)	0.465
Blood loss
< 1000
≥ 1000	0.616 (0.34-1.12)	0.11
Gender
Male
Female	1.065 (0.59-1.92)	0.833
DM
No
Yes	0.653 (0.33-1.29)	0.218
Hx of cardiovascular disease
No
Yes	3.417 (1.48-7.86)	0.004	2.612 (0.96-7.08)	0.059
Preop biliary stent (no)
No
Yes	1.649 (0.88-3.08)	0.117
Pancreatic texture
Hard/firm
Soft	4.682 (2.47-8.87)	< 0.001	3.598 (1.77-7.32)	< 0.001
Type of resection
Pylorus-preserved pancreaticoduodenectomy
Pancreaticoduodenectomy	0.518 (0.27-1.00)	0.051	0.807 (0.37-1.78)	0.597
Duct to mucosa
Invagination	0.635 (0.34-1.19)	0.156
Stent (no)
No
Yes	2.553 (1.31-4.99)	0.006	1.272 (0.52-3.09)	0.595
External
Internal	0.500 (0.13-1.87)	0.303
Malignant (no)
No
Yes	1.109 (0.52-2.34)	0.785
Final diagnosis (CA ampulla)
CA pancreas	0.324 (0.14-0.76)	0.01	0.439 (0.16-1.19)	0.105
CA duodenal	0.253 (0.06-1.05)	0.058	0.533 (0.11-2.59)	0.435
CA distal CBD	1.062 (0.36-3.11)	0.913	1.188 (0.33-4.29)	0.793
Other	0.650 (0.31-1.37)	0.258	0.543 (0.22-1.35)	0.189

Table 3 Relationships between patient characteristics, operative outcome and postoperative pancreatic fistula grade

Characteristic data	POPF (grading)		P-value	95%CI
	A (n = 58)	B + C (n = 30)
Age, mean (SD)	59.2 (11.3)	58.8 (11.4)	0.874	56.67-61.46
BMI, median (IQR)	23.1 (20.4, 25.1)	23.1 (21.1, 26.5)	0.805	22.62-24.45
Albumin, median (IQR)	34.7 (32, 38)	35.4 (32, 37.9)	0.603	33.38-35.58
Total bilirubin, median (IQR)	0.9 (2, 5)	3.3 (1.2, 12)	0.01	3.44-6.66
Pancreatic duct diameter (mm), median (IQR)	3 (2, 5)	3 (2, 4)	0.175	3.07-3.79
Operative time, median (IQR)	480 (420, 600)	480 (360, 540)	0.49	462.22-511.75
Blood loss (mL), median (IQR)	800 (500, 1500)	900 (600, 1500)	0.071	985.10-1616.95
LOH day, median (IQR)	21 (14, 30)	42.5 (30, 60)	< 0.001	28.14-46.32
Gender, n (%)
Male	34 (58.6)	12 (40.0)	0.097
Female	24 (41.4)	18 (60.0)
DM, n (%)
No	45 (77.6)	24 (80.0)	0.794
Yes	13 (22.4)	6 (20.0)
Hx of cardiovascular disease, n (%)
No	42 (72.4)	22 (73.3)	0.927
Yes	16 (27.6)	8 (26.7)
PBD, n (%)
No	20 (34.5)	5 (16.7)	0.079
Yes	38 (65.5)	25 (83.3)
Pancreatic texture, n (%)
Hard/Firm	20 (35.1)	7 (24.1)	0.301
Soft	37 (64.9)	22 (75.9)
Type of resection, n (%)
PPPD	24 (41.4)	7 (23.3)	0.093
PD	34 (58.6)	23 (76.7)
Duct, n (%)
Duct to mucosa	46 (79.3)	17 (56.7)	0.026
Invagination	12 (20.7)	13 (43.3)
Stent, n (%)
No	32 (55.2)	22 (73.3)	0.097
Yes	26 (44.8)	8 (26.7)
External vs Internal, n (%)
External	8 (32.0)	4 (50.0)	0.42
Internal	14 (68.0)	4 (50.0)
Malignant, n (%)
No	12 (20.7)	4 (13.3)	0.396
Yes	46 (79.3)	26 (86.7)
Final diagnosis, n (%)
CA ampulla	23 (39.6)	14 (46.7)	0.33
CA pancreas	8 (13.8)	4 (13.3)
CA duodenal	3 (5.2)	0
CA distal CBD	5 (8.6)	6 (20.0)
Other	19 (32.8)	6 (20.0)
Age, n (%)
< 70	47 (81.0)	26 (86.7)	0.505
≥ 70	11 (19.0)	4 (13.3)
BMI, n (%)
< 25	42 (71.4)	21 (70.0)	0.812
≥ 25	16 (27.6)	9 (30.0)
Albumin, n (%)
≥ 30	50 (86.2)	27 (90.0)	0.743
< 30	8 (13.8)	3 (10.0)
Total bilirubin, n (%)
< 3	43 (74.1)	13 (43.3)	0.004
≥ 3	15 (28.9)	17 (56.7)
Pancreatic duct diameter, n (%)
≥ 5	12 (20.7)	11 (36.7)	0.106
< 5	46 (79.3)	19 (63.3)
Operative time, n (%)
< 420	12 (20.7)	9 (30.0)	0.331
≥ 420	46 (79.3)	21 (70.0)
Blood loss, n (%)
< 1000	37 (63.8)	17 (56.7)	0.515
≥ 1000	21 (36.2)	13 (43.3)

POPF: Postoperative pancreatic fistul; PBD: Preoperative biliary drainage; PPPD: Pylorus-preserved pancreaticoduodenectomy; PD: Pancreaticoduodenectomy; BMI: Body mass index.

Table 4 Univariate and multivariate logistic regression analysis of risk factors for clinically relevant-postoperative pancreatic fistula

Variable	Univariate OR (95%CI)	Univariate P-value	Multivariate OR (95%CI)	Multivariate P-value
Age (yr)
< 70
≥ 70	0.657 (0.19-2.27)	0.507
BMI (kg/cm2)
< 25
≥ 25	1.125 (0.43-2.96)	0.812
Albumin
≥ 30
< 30	0.694 (0.17-2.84)	0.611
Total bilirubin
< 3
≥ 3	3.749 (1.48-9.51)	0.005	4.506 (1.54-13.15)	0.006
Pancreatic duct diameter (mm)
≥ 5
< 5	0.451 (0.17-1.20)	0.11
Operative time (min)
< 420
≥ 420	0.609 (0.22-1.66)	0.334
Blood loss
< 1000
≥ 1000	1.347 (0.55-3.31)	0.516
Gender
Male
Female	2.125 (0.86-5.22)	0.1
DM
No
Yes	0.865 (0.29-2.56)	0.794
Hx of cardiovascular disease
No
Yes	0.954 (0.35-2.58)	0.927
Preop biliary stent (no)
No
Yes	2.631 (0.87-7.92)	0.085	2.24 (0.67-7.49)	0.191
Pancreatic texture
Hard/firm
Soft
Type of resection
PPPD
PD	2.319 (0.86-6.27)		1.787 (0.54-5.92)	0.342
Duct to mucosa
Invagination	2.931 (1.12-7.67)	0.028	2.837 (0.89-9.08)	0.079
Stent (no)
No
Yes	0.447 (0.17-1.17)	0.101
External
Internal	0.471 (0.09-2.38)	0.362
Malignant (no)
No
Yes	1.695 (0.50-5.80)	0.4
Final diagnosis (CA ampulla)
CA pancreas	0.821 (0.21-3.24)	0.779
CA duodenal	-	-	-	-
CA distal CBD	1.971 (0.51-7.68)	0.328
Other	0.519 (0.17-1.61)	0.256

POPF: Postoperative pancreatic fistul; PBD: Preoperative biliary drainage; PPPD: Pylorus-preserved pancreaticoduodenectomy; PD: Pancreaticoduodenectomy; BMI: Body mass index.