Classification and endoscopic management of pancreatic fistulas

Table 1 International Study Group of Pancreatic Surgery grading of postoperative pancreatic fistula

Grade	Required biochemical criterion	Clinical criteria	Clinical implication
Biochemical leak	Drain fluid amylase activity > 3 times the upper limit of the institutional normal serum amylase value on or after postoperative day 3	No clinically relevant change in management; drains may remain for observation for up to 3 weeks; no POPF-related intervention, organ failure, or death	Not considered clinically relevant POPF; usually requires observation or routine drain care
Grade B POPF	Fulfills the biochemical criterion above	Requires a clinically relevant change in management, such as persistent drainage > 3 weeks, percutaneous or endoscopic drainage, angiographic intervention for bleeding, or infection without organ failure	Clinically relevant POPF requiring active management
Grade C POPF	Fulfills the biochemical criterion above and represents severe clinically relevant POPF	Associated with reoperation, organ failure, or death	Severe POPF requiring urgent multidisciplinary rescue, intensive care, and/or surgery

Management changes and adverse events should be postoperative pancreatic fistula-related. Grade B and grade C are clinically relevant postoperative pancreatic fistulas, whereas biochemical leak is not considered a true pancreatic fistula. POPF: Postoperative pancreatic fistula.