Can We Predict Development of Post-pancreatoduodenectomy Pancreatic Fistula?

[Abstract] [Objective] : Pancreatic fistula (PF) occurs often after pancreatoduodenectomy (PD) and can lead to further, serious complications. To clarify important predictors of early post-PD PF, we compared clinical variables between patients in whom no or low-grade PF (no fistula or PF-A) developed and patients in whom PF-B or PF-C developed. [Patients and Methods] : Included were 54 patients (39 men and 15 women ; mean age, 68.7+-10.4 years) who underwent PD at our hospital between July 2011 and July 2016. We divided the patients between those in whom no PF or PF-A developed and those in whom PF-B or PF-C developed. We performed between-group comparisons of clinical factors, including especially body mass index ; operation time ; intraoperative blood loss volume ; and C-reactive protein (CRP) concentrations, drain amylase (D-AMY) levels, and procalcitonin (PCT) levels on postoperative days (PODs) 1 and 4. We also compared clinical variables betwen the 2 groups of patients and performed an ROC analysis of laboratory factors shown to be significant by univariate and multiple regression analyses. [Results] : Significant between-group differences were found in overall complications, infectious complications, length of the hospital stay, pancreatic vs. non-pancreatic disorders, relative pancreatic stiffness (hard/soft), size of the pancreatic duct tube, and the CRP concentration on POD 4. Multiple regression analysis showed pancreatic disease (vs. non-pancreatic disease) to be significantly related to occurrence of PF-B. ROC analysis of CRP revealed a POD 4 concentration of 10.9 mg/mL to be predictive of post-PD PF. ROC analysis of the D-AMY levels on PODs 1 and 4, which were also found to be significant, showed levels of 2,257 U/L and 405 U/L, respectively, to be predictors of PF. [Conclusion] : PF is the most challenging early post-PD complication. The predictive factor PF-B was the only non-pancreatic disease in multivariate analysis. It appears that post-PD PF can indeed be predicted and that a CRP concentration of 10.9 mg/mL by POD 4 should be considered a signal for drain removal.