Evaluation of a recently described risk classification scheme for pancreatic fistulae development after pancreaticoduodenectomy without routine post-operative drainage.
BACKGROUND
Post-operative pancreatic fistula (POPF) formation occurs frequently after a pancreaticoduodenectomy (PD). Recently, a 10-point Fistula Risk Score (FRS) evaluating the likelihood of clinically relevant POPF (CR-POPF) development has been described and validated. This scheme has yet to be evaluated in PD patients managed without intra-operative drain placement.


METHODS
Among patients undergoing PD at an academic centre since 2003, a retrospective analysis calculating FRS and its correlation with CR-POPF development was evaluated by logistic regression. Secondary analysis examined presentation and management of CR-POPF in undrained PD patients.


RESULTS
FRS was calculated for 265 patients; 97.7% were managed without operative drains. The overall incidence of CR-POPF was 7.9%. Logistic regression revealed a 1.6-fold increase in CR-POPF risk per 1-point increase in FRS [95% confidence interval (CI) 1.2-2.0]. The negative predictive value in patients with FRS <3 was 100%, whereas the positive predictive value of FRS >6 was 16.7%. The median time to CR-POPF diagnosis was 18 days [interquartile range (IQR) 13-23]; 70.0% required readmission and 10.0% required a laparotomy.


CONCLUSIONS
Among patients without operative drainage, CR-POPF often has delayed presentations but most are managed non-operatively. The predictive value of high-risk FRS appears limited; conversely, a low-risk FRS accurately predicts the absence of CR-POPF and seems an appropriate metric for guiding care.
Department of Surgery, Section of Surgical Oncology, Yale University School of Medicine, New Haven, CT, USA.
John W
JW
Kunstman
Eric
E
Kuo
Annabelle L
AL
Fonseca
Ronald R
RR
Salem
D000046:Academic Medical Centers; D016009:Chi-Square Distribution; D003237:Connecticut / Q000453:epidemiology; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D010359:Patient Readmission; D011237:Predictive Value of Tests; D012086:Reoperation; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome