Li Y, Zhou F, Zhu DM, Zhang ZX, Yang J, Yao J, Wei YJ, Xu YL, Li DC, Zhou J. Novel risk scoring system for prediction of pancreatic fistula after pancreaticoduodenectomy. World J Gastroenterol 2019; 25(21): 2650-2664 [PMID: 31210716 DOI: 10.3748/wjg.v25.i21.2650]
Corresponding Author of This Article
Jian Zhou, MD, Doctor, Department of General Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China. zhoujian06@suda.edu.cn
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastroenterol. Jun 7, 2019; 25(21): 2650-2664 Published online Jun 7, 2019. doi: 10.3748/wjg.v25.i21.2650
Table 1 Demographic and clinical characteristics of the study and validation groups, n (%)
Variable
Study group (n = 189)
Validation group (n = 109)
P-value
POPF
0.976
No POPF
117 (61.9)
68 (62.4)
Grade A (BL)
34 (18.0)
18 (16.5)
Grade B
32 (16.9)
20 (18.3)
Grade C
6 (3.2)
3 (2.8)
Age (yr)
61.8 ± 9.9
62.4 ± 10.3
0.650
Sex
0.284
Male
116 (61.4)
60 (55.0)
Female
73 (38.6)
49 (45.0)
Surgery
0.595
PD
98 (51.9)
60 (55.0)
PPPD
91 (48.1)
49 (45.0)
BMI (kg/m2)
22.1 ± 2.9
22.4 ± 2.9
0.431
Diabetes mellitus
0.164
Yes
31 (16.4)
25 (22.9)
No
158 (83.6)
84 (77.1)
Location of tumor
0.493
Pancreas
105 (55.6)
65 (59.6)
Non-pancreas
84 (44.4)
44 (40.4)
Pathologic type
0.834
Benign
11 (5.8)
7 (6.4)
Pancreatic myxoid cystadenoma
7 (3.7)
5 (4.6)
Pancreatic serous cystadenoma
4 (2.1)
2 (1.8)
Malignant
178 (94.2)
102 (93.6)
Pancreatic cancer
92 (48.7)
56 (51.4)
Biliary duct cancer
29 (15.3)
21 (19.3)
Ampullary cancer
33 (17.5)
16 (14.7)
Duodenal cancer
24 (12.7)
9 (8.3)
Preoperative STB (μmol/L)
111.4 ± 120.4
116.0 ± 144.9
0.767
Preoperative pre-albumin (mg/L)
141.2 ± 57.1
142.4 ± 56.8
0.861
Preoperative serum albumin (g/L)
38.4 ± 5.7
37.5 ± 4.7
0.137
Preoperative serum globulin (g/L)
26.9 ± 4.2
27.2 ± 4.9
0.606
Preoperative hemoglobin (g/L)
121.4 ± 19.9
119.9 ± 19.5
0.533
Preoperative white blood cells (109/L)
7.0 ± 8.1
6.4 ± 2.6
0.465
Preoperative platelets (109/L)
233.7 ± 78.5
237.6 ± 73.7
0.671
Pancreatic texture
0.725
Soft
81 (42.9)
49 (45.0)
Hard
108 (57.1)
60 (55.0)
Main pancreatic duct diameter (mm)
3.1 ± 1.0
3.2 ± 1.1
0.496
Biliary tract compression
23 (12.2%)
15 (13.8)
0.691
Pancreaticojejunostomy anastomosis
0.061
Duct-to-mucosa
153 (81.0)
78 (71.6)
Dunking method
36 (19.0)
31 (28.4)
Pancreatic duct stent
0.735
Internal stent
85 (45.0)
50 (45.9)
External stent
68 (36.0)
35 (32.1)
None
36 (19.0)
24 (22.0)
Vascular invasion
0.483
Yes
32 (16.9)
22 (20.2)
No
157 (83.1)
87 (79.8)
Operative time (min)
269.5 ± 70.3
255.4 ± 64.7
0.088
Estimated blood loss (mL)
320.3 ± 269.3
326.6 ± 267.5
0.846
Serum albumin POD 1 (g/L)
33.01 ± 5.4
33.4 ± 5.7
0.623
Serum globulin on POD 1 (g/L)
23.4 ± 10.9
26.1 ± 27.2
0.233
Hemoglobin on POD 1 (g/L)
112.0 ± 16.8
112.4 ± 15.8
0.849
Table 2 Demographic and clinical characteristics of the clinically relevant postoperative pancreatic fistula and non-clinically relevant postoperative pancreatic fistula groups, n (%)
Variable
non-CR-POPF (n = 237)
CR-POPF (n = 61)
P-value
Age (yr)
61.8 ± 10.1
62.2 ± 9.4
0.804
Sex
0.095
Male
135 (57.0)
41 (67.2)
Female
102 (43.0)
20 (32.8)
Surgery
0.445
PD
123 (51.9)
35 (57.4)
PPPD
114 (48.1)
26 (42.6)
BMI (kg/m2)
22.0 ± 2.9
22.5 ± 2.8
0.352
Diabetes mellitus
0.351
Yes
42 (17.7)
14 (23.0)
No
195 (82.3)
47 (77.0)
Location of tumor
0.131
Pancreas
130 (54.9)
40 (65.6)
Non-pancreas
107 (45.1)
21 (34.4)
Pathologic type
0.428
Benign
13 (5.5)
5 (8.2)
Malignant
224 (94.5)
56 (91.8)
Preoperative STB (μmol/L)
106.0 ± 120.0
132.8 ± 120.9
0.221
Preoperative pre-albumin (mg/L)
143.1 ± 56.2
133.7 ± 60.7
0.364
Preoperative serum albumin (g/L)
39.1 ± 5.4
35.9 ± 6.3
0.002
Preoperative serum globulin (g/L)
26.9 ± 4.3
27.2 ± 3.3
0.675
Preoperative hemoglobin (g/L)
122.1 ± 18.3
118.6 ± 25.2
0.339
Preoperative white blood cells (109/L)
7.0 ± 8.9
6.7 ± 2.1
0.833
Preoperative platelets (109/L)
236.3 ± 83.5
223.2 ± 54.1
0.358
Pancreatic texture
< 0.001
Soft
80 (33.8)
50 (82.0)
Hard
157 (66.2)
11 (18.0)
Main pancreatic duct diameter (mm)
3.2 ± 1.0
2.6±0.7
0.001
Biliary tract compression
31 (13.1)
7 (11.5)
0.738
Pancreaticojejunostomy anastomosis
0.201
Duct-to-mucosa
180 (75.9)
51 (83.6)
Dunking method
57 (24.1)
10 (16.4)
Pancreatic duct stent
0.052
Internal stent
99 (41.8)
36 (59.0)
External stent
88 (37.1)
15 (24.6)
None
50 (21.1)
10 (16.4)
Vascular invasion
0.272
Yes
40 (16.9)
14 (23.0)
No
197 (83.1)
47 (77.0)
Operative time (min)
267.9 ± 68.7
275.9 ± 76.9
0.531
Estimated blood loss (mL)
287.4 ± 229.3
451.3 ± 365.1
0.001
Serum albumin POD 1 (g/L)
33.03 ± 5.2
32.9 ± 5.9
0.918
Serum globulin on POD 1 (g/L)
23.5 ± 11.9
23.0 ± 4.9
0.832
Hemoglobin on POD 1 (g/L)
111.2 ± 17.3
114.9 ± 14.3
0.236
Table 3 Univariate and multivariate analyses of predictive factors for clinically relevant pancreatic fistula in the study group (n = 189)
Factor
Univariate analysis
Multivariate analysis
OR
95%CI
P-value
OR
95%CI
P-value
Patient characteristics
Age (≥ 65 yr/< 65 yr)
1.07
0.52-2.21
0.848
Sex (male/female)
0.58
0.27-1.14
0.107
BMI (≥ 24/< 24 kg/m2)
0.99
0.44-2.22
0.983
Diabetes mellitus (yes/no)
0.73
0.26-2.04
0.546
Preoperative status
Location of tumor (pancreas/non-pancreas)
0.66
0.32-1.35
0.256
Preoperative STB (≥ 22 μmol/L vs < 22 μmol/L)
1.07
0.50-2.30
0.857
Preoperative pre-albumin (≥ 170 mg/L vs < 170 mg/L)
0.84
0.38-1.88
0.672
Preoperative serum albumin (≥ 35 g/L vs < 35 g/L)
0.19
0.09-0.40
< 0.001
0.92
0.85-0.99
0.032
Preoperative serum globulin (≥ 22 g/L vs < 22 g/L)
Table 4 Risk scoring system for clinical relevant pancreatic fistula
Risk factor
Points contributed
Texture of pancreas (3 points)
Hard
0 points
Soft
3 points
Main pancreatic duct diameter (2 points)
≥ 3 mm
0 points
< 3 mm
2 points
Preoperative serum albumin (2 points)
≥ 35 g/L
0 points
30-35 g/L
1 point
< 30 g/L
2 points
Estimated blood loss (3 points)
< 500 mL
0 points
500-1000 mL
1 point
≥ 1000 mL
3 points
Sun score
10 points
High-risk score
4-10 points
Low-risk score
0-3 points
Table 5 Correlation between risk score and postoperative pancreatic fistula
Study group (n = 189)
Validation group (n = 109)
All (n = 298)
Risk score
Risk score
Risk score
POPF grade
Low
High
Low
High
Low
High
No POPF
97
20
60
8
157
28
Grade A (BL)
18
16
11
7
29
23
Grade B
7
25
5
15
12
40
Grade C
0
6
0
3
0
9
CR-POPF rate
5.7%
46.3%
6.6%
54.6%
6.1%
49.0%
r = 0.542
r = 0.586
r = 0.557
P < 0.001
P < 0.001
P < 0.001
Table 6 Relationship between postoperative drain amylase levels and clinically relevant postoperative pancreatic fistula
Low risk group
High risk group
P-value
AUC
Cut-off value
P-value
AUC
Cut-off value
POD 1
> 0.05
--
--
0.001
0.850
921.7 U/L
POD 3
0.003
0.859
4021.5 U/L
0.05
--
--
POD 5
0.042
0.748
4533.5 U/L
0.05
--
--
Citation: Li Y, Zhou F, Zhu DM, Zhang ZX, Yang J, Yao J, Wei YJ, Xu YL, Li DC, Zhou J. Novel risk scoring system for prediction of pancreatic fistula after pancreaticoduodenectomy. World J Gastroenterol 2019; 25(21): 2650-2664