Prediction and consequences of postoperative pancreatitis after pancreaticoduodenectomy

Abstract

Background Recent studies have suggested postoperative acute pancreatitis (POAP) as a serious complication after pancreaticoduodenectomy (PD) and have speculated on its possible role in the pathogenesis of postoperative pancreatic fistula (POPF). This study aimed to assess the impact of POAP on post-PD outcomes and fistula risk score (FRS) performance in predicting POAP. Methods All PDs at Helsinki University Hospital between 2013 and 2020 were analysed. POAP was defined as a plasma amylase activity greater than the normal upper limit on postoperative day (POD) 1 and stratified as clinically relevant (CR)-POAP once C-reactive protein (CRP) reached or exceeded 180 mg/l, and non-CR-POAP once CRP was less than 180 mg/l on POD 2. The Comprehensive Complication Index (CCI) was used to assess total postoperative morbidity. Different FRSs were assessed using receiver operating characteristic curves. Results Of the 508 patients included, POAP occurred in 202 (39.8 per cent) patients, of whom 91 (17.9 per cent) had CR-POAP. The incidence of CR-POPF was 12.6 per cent (64 patients). Patients with non-CR-POAP had a similar morbidity to patients with no POAP (median CCI score 24.2 versus 22.6; P = 0.142), while CCI score was significantly higher (37.2) in patients with CR-POAP (P < 0.001). CR-POAP was associated with increased rates of CR-POPF, delayed gastric emptying, haemorrhage, and bile leak, while non-CR-POAP was associated only with CR-POPF. Ninety-day mortality was 1.6 per cent, 0.9 per cent, and 3.3 per cent in patients with no-POAP, non-CR-POAP, and CR-POAP, respectively. Updated alternative FRS showed the best performance in predicting CR-POAP (area under the curve 0.834). Conclusion CR-POAP was associated with a higher CCI score, suggesting CR-POAP as a distinct entity from non-CR-POAP. FRSs can be used to assess the risk of CR-POAP.

Prediction of postoperative pancreatic fistula and pancreatitis after pancreatoduodenectomy or distal pancreatectomy: A review

“…68 However, there is a growing body of evidence for factors associated with POAP. 9,69 POAP and POPF seem to share the majority of identified risk factors with pancreatic texture, high BMI, narrow duct, operative complexity, non-malignant histology, and male sex predisposing for POAP. 8,9…”

“…No prediction models for POAP or PPAP exist to date, but one study demonstrated that POPF prediction models could be used to predict clinically relevant POAP (elevated amylase and C-reactive protein over 180 mg/l on second postoperative day), with ua-FRS performing the best with an AUROC of 0.83. 9…”

“…Recent studies have noted postoperative acute pancreatitis (POAP) to possibly have clinical relevance after pancreatic resections. [8][9][10][11] First proposed in 2016 by Connor, 12 it was defined as an alteration in early serum or plasma amylase levels, with subsequent rise in C-reactive protein denoting a more severe form of POAP. POAP has been speculated to drive the formation of POPF, but studies have also demonstrated it to be independently associated with postoperative morbidity.…”

Bacterial content of the human pancreatic duct: An observational study

“…The pathophysiology behind pancreatic fistula formation is still not understood. Persistent leakage from the main pancreatic duct or from side branches, a high amount of acinar cells at the transection plane [ 2 ], postoperative pancreatitis [ 3 ], or dysfunction of the Sphincter of Oddi [ 4 ], are considered the probable underlying mechanisms.…”

Postoperative acute pancreatitis after pancreatoduodenectomy: the importance of considering modifiers when validating a definition

“…Bonsdorff et al present a retrospective series of 614 patients who underwent pancreatoduodenectomy between 2013 and 2020 at Helsinki University Hospital. 1 The aim of this study was two-fold, first to reconfirm the impact of clinically relevant POAP (CR-POAP) on early outcomes following PD but also to assess the utility of presently used fistula risk scores in predicting CR-POAP. It is acknowledged that the definition of CR-POAP remains an area of evolution 2 , 3 and for this study the authors elected to use the initial definition proposed by my previous work (serum amylase above upper limit of normal day 0–1 and C-reactive protein (CRP) more than180 mg/dl day 1–2) 2 .…”