title: Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors.
abstract: BACKGROUND
  Pancreatic fistula (PF) is one of the most common postoperative complications of pancreatoduodenectomy (PD). A recent International Study Group on Pancreatic Fistula (ISGPF) definition grades the severity of PF according to the clinical impact on the patient's hospital course. Although PF is generally treated conservatively (grade A), some cases may require interventional procedures (grade B) or may be life-threatening and necessitate emergency reoperation (grade C). The aim of the present study was to evaluate the incidence of postoperative grade C PF after PD and to assess the prognosis and risk factors for this life-threatening condition.
  
  
  METHODS
  Between January 2000 and December 2006, 680 consecutive patients underwent PD in 5 digestive surgery departments in the northwest region of France (Lille, Amiens, Rouen, and Caen). PF was defined as drain output of any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity (ISGPF guidelines). To identify possible risk factors for grade C PF, we reviewed the records of 111 (16.3%) patients with postoperative PF and compared grade C cases with grade A+B cases.
  
  
  RESULTS
  The median age was 59 years (range 22-87). The male-to-female ratio was 1.6:1. Fifty-six (50.4%) PDs were performed via pancreaticogastrostomy and 55 via pancreaticojejunostomy. Overall mortality was 2% (n = 14). Grade C PF was observed in 36 (32%) patients, of whom 17 (47%) had sepsis due to an abdominal collection, 16 (44%) had postoperative bleeding, 10 (27.7%) had bleeding associated with abdominal collection, and 3 (9%) had multi-organ failure due to other causes. Of these 36 patients, 35 (97%) underwent reoperation. The mortality rate in grade C PF patients was 38.8%. The major causes of death were sepsis (n = 6) and recurrent bleeding after reoperation (n = 5). Grade C PF increased the duration of postoperative hospitalization (46 vs 29 days, P < .001). Univariate analysis showed that peroperative soft pancreatic parenchyma, peroperative blood transfusion, and postoperative bleeding were significant risk factors for grade C PF, with P values of .011, .003, and .001, respectively. No risk factors for grade C PF were identified in a multivariate analysis. The sensibility, specificity, positive predictive value, and negative predictive value of the presence of the 3 risk factors for grade C PF were 13.89%, 100%, 100%, and 70.75%, respectively.
  
  
  CONCLUSIONS
  Sixteen percent of patients had PF after PD. Among them, 30% had grade C PF, with a mortality rate of about 40%. Achievement of a 100% predictive positive value for grade C PF after PD in individuals with 3 discriminant risk factors (peroperative soft pancreatic parenchyma, peroperative transfusion, and postoperative bleeding) is a first step towards the identification of high-risk patients who should be managed differently from other patients with PF during or after PD.
authors.affiliation: Federation of Digestive Diseases, Amiens North Hospital, University of Picardy Medical Centre, Amiens, France.
authors.forename: David
authors.initials: D
authors.lastname: Fuks
authors.forename: Guillaume
authors.initials: G
authors.lastname: Piessen
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Huet
authors.forename: Marion
authors.initials: M
authors.lastname: Tavernier
authors.forename: Philippe
authors.initials: P
authors.lastname: Zerbib
authors.forename: Francis
authors.initials: F
authors.lastname: Michot
authors.forename: Michel
authors.initials: M
authors.lastname: Scotte
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Triboulet
authors.forename: Christophe
authors.initials: C
authors.lastname: Mariette
authors.forename: Laurence
authors.initials: L
authors.lastname: Chiche
authors.forename: Ephraïm
authors.initials: E
authors.lastname: Salame
authors.forename: Philippe
authors.initials: P
authors.lastname: Segol
authors.forename: François-René
authors.initials: FR
authors.lastname: Pruvot
authors.forename: François
authors.initials: F
authors.lastname: Mauvais
authors.forename: Horace
authors.initials: H
authors.lastname: Roman
authors.forename: Pierre
authors.initials: P
authors.lastname: Verhaeghe
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Regimbeau
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004630:Emergencies; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000453:epidemiology* / Q000209:etiology*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011379:Prognosis; D012307:Risk Factors; D055815:Young Adult