title: Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy.
abstract: BACKGROUND
  The morbidity rate after pancreaticoduodenectomy remains high (20-50 per cent) and postoperative pancreatic fistula (POPF) is a major underlying factor. POPF has been reported to be associated with pancreatic consistency (PC) and pancreatic duct diameter (PDD). The aim was to quantify the risk of pancreaticojejunostomy-associated morbidity (PJAM) by means of a structured intraoperative assessment of both characteristics.
  
  
  METHODS
  This single-centre prospective observational study included pancreaticoduodenectomies performed between 2008 and 2010 with a standardized duct-to-mucosa end-to-side pancreaticojejunostomy. PC and PDD were assessed during surgery and classified into four grades each (from very hard to very soft, and from larger than 4 mm to smaller than 2 mm, respectively). PJAM was defined as POPF (grade B or C in International Study Group on Pancreatic Fistula classification) or symptomatic peripancreatic collection of either abscess or fluid. PJAM of at least Clavien grade IIIb was considered severe.
  
  
  RESULTS
  PJAM and POPF were observed in 24 (21·8 per cent) and 17 (15·5 per cent) of 110 patients respectively. Softer PC and smaller PDD were risk factors for POPF (both P < 0·001), symptomatic peripancreatic collections (P = 0·071 and P = 0·015) and PJAM (both P < 0·001). Combining consistency and duct characteristics in a composite classification the PJAM risk was stratified as 'high' (both risk factors, PJAM incidence 51 per cent), 'intermediate' (softer PC or smaller PDD, PJAM 26 per cent) or 'low' (no risk factors, PJAM 2 per cent). Severe PJAM was observed only in patients with smaller PDD.
  
  
  CONCLUSIONS
  A high-risk pancreatic gland had a 25-fold higher risk of PJAM after pancreaticoduodenectomy than a low-risk gland. This simple classification can contribute to more individualized patient management and allow stratification of study cohorts with homogeneous POPF risk.
authors.affiliation: Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden. christoph.ansorge@karolinska.se
authors.forename: C
authors.initials: C
authors.lastname: Ansorge
authors.forename: L
authors.initials: L
authors.lastname: Strömmer
authors.forename: Å
authors.initials: Å
authors.lastname: Andrén-Sandberg
authors.forename: L
authors.initials: L
authors.lastname: Lundell
authors.forename: M K
authors.initials: MK
authors.lastname: Herrington
authors.forename: R
authors.initials: R
authors.lastname: Segersvärd
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery; D005260:Female; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000473:pathology*; D010185:Pancreatic Fistula / Q000517:prevention & control*; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000379:methods*; D050500:Pancreatitis, Chronic / Q000473:pathology / Q000601:surgery; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control*; D011446:Prospective Studies; D018570:Risk Assessment