A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula

Abstract

Objective: The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). Summary Background Data: Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. Methods: A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort. Results: Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62–5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively (P < 0.001). Conclusion: For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Modified Technique for Wirsung-Pancreatogastric Anastomosis after Pancreatoduodenectomy: A Single Center Experience and Systematic Review of the Literature

“…Operative data are reported in Table 2 : the pancreatic characteristics were classified according to the ISGPS as Type A (not-soft pancreatic texture, duct size > 3 mm), Type B (not-soft, ≤3 mm), Type C (soft pancreatic texture, duct size > 3 mm) or Type D (soft, ≤3 mm) [ 31 ]. Additionally, intraoperative patients’ characteristics were classified on the basis of the Fistula Risk Score, depending on pancreatic texture, pathology, Wirsung diameter and intraoperative blood loss (see Table 3 ) [ 32 ].…”

“Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach”—a narrative review

“…This scoring system utilized a standardized national database (ACS National Surgical Quality Improvement Program) (26). Across the classifications, pancreatic duct size and texture have constantly featured in the risk score models which have led to the four-tier classification of these pancreas associated risk factors for clinically relevant POFP (CR-POPF) by the International Study Group of Pancreatic Surgery (ISGPS) in a recent systemic review of 108 relevant studies (27). Type-A included not-soft pancreas with duct diameter of >3 mm; Type B included not-soft texture and duct diameter <3 mm; Type C included soft texture and duct diameter >3 mm and Type D included soft texture and duct diameter <3 mm.…”

“…Type-A included not-soft pancreas with duct diameter of >3 mm; Type B included not-soft texture and duct diameter <3 mm; Type C included soft texture and duct diameter >3 mm and Type D included soft texture and duct diameter <3 mm. This classification was validated in more than 5,000 patients, with CR-POPF of 23.2% in Type D as compared to 3.5% in Type A (27). All these classifications are based on intra-operative parameters that are partially subjective.…”

“…These highly predictive models may aid in patient stratification and allocation to accelerated care pathways or early remnant pancreatectomies based on the risk of CR-POPF on POD-1 (28). Prediction scores have a strong potential to alter the surgeon behavior that starts in the preoperative period with patient counseling that continues in the intra-operative period and culminates into focused and directed post-operative evaluation and management that potentially minimize complications and optimizes outcomes in these high-risk scenarios (19)(20)(21)(22)(23)(24)(25)(26)(27)(28).…”

Reply to: Letter to the Editor: More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis, by Marchegiani, Giovanni et al.

“…In conclusion, as the authors have already emphasized, the most crucial factor lies with the careful patient selection. In this context, the recently published results of the International Study Group of Pancreatic Surgery (ISGPS) 7,8 could presumably contribute to an even better selection of those patients for whom TP, if applicable with IAT, should be considered instead of high-risk PD.…”