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©The Author(s) 2017.
World J Gastrointest Surg. Mar 27, 2017; 9(3): 82-91
Published online Mar 27, 2017. doi: 10.4240/wjgs.v9.i3.82
Published online Mar 27, 2017. doi: 10.4240/wjgs.v9.i3.82
Table 1 Expanded Accordion Classification
| Expanded Accordion Classification (levels of severity) | |
| Mild | Requires only minor invasive procedures that can be done at the bedside physiotherapy and the following drugs are allowed: Antiemetics, antipyretics, analgesics and electrolytes |
| Moderate | Requires pharmacologic treatment with drugs other than such allowed for minor complications, for instance antibiotics |
| Blood transfusions and total parenteral nutrition are also included | |
| Severe | Invasive procedure/no GA, requires management by an endoscopic, interventional procedure or re-operation without general anesthesia |
| Severe | Invasive procedure under GA or single organ system failure requires management by an operation under general anesthesia or results in single organ system failure |
| Severe | Organ system failure and invasive procedure under GA or multisystem organ failure, such complications would normally be managed in an increased acuity setting but in some cases patients with complications of lower severity might also be admitted to an ICU |
| Deaths | Postoperative death |
Table 2 Demographic and clinical data for patients with and without complications
| Total (n = 130) | Those with complications (n = 95) | Those without complications (n = 35) | P-value | |
| Age (yr), median (range) | 26 (13-73) | 28 (13-73) | 24 (15-59) | 0.0064a |
| Mechanism of injury | ||||
| GSW | 88 (67.7%) | 63 (66.3%) | 25 (71.43%) | 0.6490c |
| Stab | 7 (5.4%) | 6 (6.3%) | 1 (2.86%) | |
| Blunt | 35 (26.9%) | 26 (27.3%) | 9 (25.71%) | |
| Hospital stay, median (range) | 8 (1-255) | 23 (1-255) | 9 (5-58) | 0.0000a |
| ICU stay | 77 (59.23%) | 68 (71.58%) | 9 (25.71%) | 0.0000b |
| Number ICU days, median (range) | 3 (0-153) | 4 (0-153) | 3 (0-7) | 0.0000a |
| RTS | ||||
| < 7.8 | 49 (37.69%) | 44 (46.32%) | 5 (14.29%) | 0.001b |
| 7.8 | 81 (62.3%) | 51 (53.68%) | 30 (85.71%) | |
| Patients shocked on admission (n, %) | 46 (35.4%) | 42 (44.21%) | 4 (11.43%) | 0.001b |
| Patients who received a blood transfusion (n, %) | 103 (79.2%) | 79 (83.16%) | 24 (68.57%) | 0.069b |
| Units of blood transfused, median units (range) | 84.5 (0-124a) | 8 (0-124) | 2 (0-28) | 0.0000a |
| Damage control surgery | 30 (23.1%) | 27 (28.42%) | 3 (8.57%) | 0.0176b |
| Pancreatic injury site | ||||
| Head and neck of pancreas | 24 (18.5%) | 20 (21.05%) | 4 (11.43%) | 0.0443c |
| Body of pancreas | 57 (43.8%) | 44 (46.32%) | 13 (37.14%) | |
| Tail of pancreas | 49 (37.7%) | 31(32.63%) | 18 (51.43%) | |
| AAST | ||||
| Grade 3 | 107 (82.3%) | 74 (77.89%) | 33 (94.28%) | 0.0297c |
| Grade 4 | 4 (3.1%) | 3 (3.16%) | 1 (2.86%) | |
| Grade 5 | 19 (14.6%) | 18 (18.95%) | 1 (2.86%) | |
| Associated abdominal injuries | ||||
| Nil (isolated injury) | 14 (10.8%) | 10 (10.53%) | 4 (11.43%) | 0.8833c |
| 1 or 2 organs injured | 51 (39.2%) | 37 (38.95%) | 14 (40%) | |
| 3 or more injured | 65 (50%) | 48 (50.53%) | 17 (48.57%) | |
| Associated injured organs | ||||
| Liver | 53 (40.7%) | 40 (42.11%) | 13 (37.14%) | 0.6109 |
| Kidney | 53 (40.7%) | 34 (35.79%) | 19 (54.29%) | 0.0579 |
| Spleen | 52 (40%) | 39 (41.05%) | 13 (37.14%) | 0.6876 |
| Stomach | 49 (37.7%) | 32 (33.68%) | 17 (48.57%) | 0.1217 |
| Diaphragm | 38 (29.2%) | 28 (29.47%) | 10 (28.57%) | 0.9204 |
| Colon | 32 (24.6%) | 27 (28.42%) | 5 (14.29%) | 0.0983 |
| Duodenum | 22 (16.9%) | 20 (21.05%) | 2 (5.71%) | 0.0393a |
| Pancreatic resection type | ||||
| Pancreaticoduodenectomy | 20 (15.4%) | 19 (20%) | 1 (2.86%) | 0.0004c |
| Distal pancreatectomy and splenectomy | 95 (73%) | 70 (73.68%) | 25 (71.4%) | |
| Distal pancreatectomy with spleen preservation | 15 (11.5%) | 6 (6.32%) | 9 (25.7%) | |
| Associated vascular injuries | 24 (18.5%) | 24 (25.26%) | 0 (0%) | 0.001b |
| Patients who had a repeat laparotomy (n, %) | 58 (44.6%) | 55 (57.89%) | 3 (8.57%) | 0.0000b |
| No. of repeat laparotomies done, median (range) | 0 (1-10) | 1 (0-10) | 0 (0-1) | 0.0000a |
| Death | 19 (14.62%) | 19 (20%) | 0 (0%) | 0.004b |
Table 3 Accordion Severity Grade in 130 patients
| Accordion Severity Grade | Mild | Moderate | Severe: Invasive/no GA | Severe: Invasive/GA | Severe: Organ failure | Death | Total |
| 1 | 2 | 3 | 4 | 5 | 6 | n = 130 | |
| Surgical complications | |||||||
| Pancreatic | |||||||
| Fistula | 1 | 11 | 6 | 6a | -- | -- | 24 (18.5%) |
| Peri-pancreatic collection | -- | 3 | 4 | 1 | -- | -- | 8 (6.6%) |
| Pseudocyst | -- | -- | 1 | 1 | -- | -- | 2 (1.5%) |
| Pancreatic necrosis | 2 | 2 (1.5%) | |||||
| Intra-abdominal | |||||||
| Postoperative ileus | 2 | -- | -- | -- | -- | -- | 2 (1.5%) |
| Intra-abdominal infection | -- | 9 | 17 | 16 | -- | -- | 42 (32.3%) |
| Biliary fistula | -- | 1 | -- | 1 | -- | -- | 2 (1.5%) |
| Small bowel obstruction | -- | 1 | -- | 7 | -- | -- | 8 (6.6%) |
| Enterocutaneous fistula | -- | 9 | -- | -- | -- | -- | 9 (6.9%) |
| Anastomotic leak | -- | -- | -- | 3 | -- | -- | 3 (2.3%) |
| Abdominal compartment syndrome | -- | -- | -- | 3 | -- | -- | 3 (2.3%) |
| Wound | |||||||
| Wound infection | -- | 7 | -- | 2b | -- | -- | 9 (6.9%) |
| Wound dehiscence | -- | 1 | -- | 1 | -- | -- | 2 (1.5%) |
| Bleeding | |||||||
| Intra-abdominal | -- | 4 | -- | 6 | -- | 1 | 11 (8.5%) |
| DIC | -- | 7 | -- | -- | 6 | 5 | 18 (13.8%) |
| Non-surgical complications | |||||||
| Respiratory | |||||||
| Pleural effusion | 9 | 2 | -- | -- | -- | -- | 11 (8.5%) |
| Atelectasis | 2 | -- | -- | -- | -- | 2 (1.5%) | |
| Pneumonia | -- | 14 | -- | -- | -- | -- | 14 (10.7%) |
| Respiratory failure | -- | -- | -- | 10 | 6 | 9 | 25 (19.2%) |
| Renal | |||||||
| Renal failure | -- | -- | -- | 8 | 10 | 1 | 19 (14.6%) |
| Intra-abdominal urine leak | -- | -- | -- | 1 | -- | -- | 1 (0.8%) |
| Systemic sepsis | -- | 12 | -- | -- | 4 | 3 | 19 (14.6%) |
| Other | 1c | 1d | -- | -- | -- | -- | 2 (1.5%) |
| Total | 15 (6.3%) | 82 (34.5%) | 28 (11.8%) | 68 (28.6%) | 26 (10.9%) | 19 (8.0%) | 238 |
Table 4 Outcome according to type of pancreatic resection performed
| Pancreaticoduodenectomy (n = 20) | Distal pancreatectomy and splenectomy (n = 95) | Distal pancreatectomy with spleen preservation (n = 15) | P-value1 | |
| No. of patients with any complication | 19 (95%) | 70 (73.7%) | 6 (40%) | 0.0014 |
| Complications non-surgical | 15 (75%) | 58 (61.1%) | 2 (13.3%) | 0.0006 |
| Complications surgical (Other) | 12 (60%) | 37 (38.9%) | 4 (26.7%) | 0.1111 |
| Complications pancreatic | 3 (15%) | 25 (26.3%) | 5 (33.3%) | 0.4339 |
| Days in hospital, median (range) | 22 (3-94) | 17 (1-255) | 15 (5-58) | 0.1797 |
| ICU admissions | 19 (95%) | 55 (57.9%) | 3 (20%) | 0.0001 |
| Days in ICU, median (range) | 4 (1-20) | 7 (1-153) | 7, 9, 16 respectively | 0.0099 |
| Outcome died | 4 (20%) | 14 (14.7%) | 1 (6.7%) | 0.5445 |
Table 5 Logistic regression analysis of risk factors for developing complications
| Risk factor | Univariate logistic regression | Multivariate logistic regression | ||||
| Odds ratio | 95%CI | P-value | Odds ratio | 95%CI | P-value | |
| Age median, range | 0.9 | 0.58-1.43 | 0.699 | 0.9 | 0.82-0.99 | 0.031 |
| Mechanism of injury | 0.9 | 0.89-0.98 | 0.017 | 0.4 | 0.12-1.39 | 0.155 |
| RTS (< 7.8) | 5.1 | 1.85-14.5 | 0.002 | 10.8 | 0.15-788 | 0.277 |
| No. of patients shocked on admission | 6.1 | 2.0-18.8 | 0.001 | 0.5 | 0.00-30.2 | 0.728 |
| No. of patients who received a blood transfusion | 2.3 | 0.93-5.53 | 0.073 | 0.5 | 0.00-3.64 | 0.486 |
| Damage control surgery | 1.6 | 1.18-2.2 | 0.030 | 1.36 | 0.68-2.69 | 0.373 |
| Pancreatic injury site | 1.8 | 0.99-3.15 | 0.050 | 2.4 | 0.57-100 | 0.231 |
| AAST | 0.5 | 0.23-0.92 | 0.028 | 3.8 | 0.67-21.9 | 0.131 |
| Pancreatic resection type | 4.8 | 1.91-12.0 | 0.001 | 65.7 | 3.13-1381 | 0.007 |
| Associated abdominal injuries | 1.1 | 0.32-3.7 | 0.883 | 12.9 | 0.39-423 | 0.152 |
- Citation: Krige JE, Jonas E, Thomson SR, Kotze UK, Setshedi M, Navsaria PH, Nicol AJ. Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification. World J Gastrointest Surg 2017; 9(3): 82-91
- URL: https://www.wjgnet.com/1948-9366/full/v9/i3/82.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v9.i3.82