title: Toward defining grade C pancreatic fistula following pancreaticoduodenectomy: incidence, risk factors, management and outcome.
abstract: BACKGROUND
  In 2005 the International Study Group for Pancreatic Fistula (ISGPF) created a definition and grading system for pancreatic fistulae (PF) in which grade C denotes the most severe and potentially life-threatening type. Factors and outcomes associated with grade C fistulae have been ill defined.
  
  
  METHODS
  Systematic searches of PubMed and EMBASE were conducted by two independent reviewers utilizing the keywords 'pancreaticoduodenectomy' (PD) and 'pancreatic fistula'. Inclusion criteria were: (i) a sample of ≥100 patients; (ii) consecutive accrual of all pathologies, and (iii) use of the ISGPF definition and grading system. Quality appraisal and data extraction were performed using pilot-tested templates.
  
  
  RESULTS
  Fourteen articles describing a total of 2706 PDs met the study entrance criteria. Pancreatic fistulae occurred in 479 patients (18%) and included 71 grade C PF that were directly responsible for 25 deaths (35% mortality rate). Only two studies analysed risk factors; these found soft pancreatic texture and histology other than adenocarcinoma to be the most common risk factors. Ten studies reported management strategies and indicated that 51% of patients required reoperation.
  
  
  CONCLUSIONS
  Grade C PF: (i) accounts for 15% of fistulae following PD and has an associated mortality rate of 35%; (ii) occurs most commonly in pathology associated with a soft remnant, and (iii) requires reoperation in approximately one half of patients. The published literature incompletely describes grade C PF.
authors.affiliation: Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Jason W
authors.initials: JW
authors.lastname: Denbo
authors.forename: W Shannon
authors.initials: WS
authors.lastname: Orr
authors.forename: Ben L
authors.initials: BL
authors.lastname: Zarzaur
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Behrman
mesh_terms: D006801:Humans; D015994:Incidence; D010185:Pancreatic Fistula / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome