Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy

Background: The morbidity rate after pancreaticoduodenectomy remains high (2050 per cent) and postoperative pancreatic fistula (POPF) is a major underlying factor. POPF has been reported to be associated with pancreatic consistency (PC) and pancreatic duct diameter (PDD). The aim was to quantify the risk of pancreaticojejunostomy-associated morbidity (PJAM) by means of a structured intraoperative assessment of both characteristics. Methods: This single-centre prospective observational study included pancreaticoduodenectomies performed between 2008 and 2010 with a standardized duct-to-mucosa end-to-side pancreaticojejunostomy. PC and PDD were assessed during surgery and classified into four grades each (from very hard to very soft, and from larger than 4 mm to smaller than 2 mm, respectively). PJAM was defined as POPF (grade B or C in International Study Group on Pancreatic Fistula classification) or symptomatic peripancreatic collection of either abscess or fluid. PJAM of at least Clavien grade IIIb was considered severe. Results: PJAM and POPF were observed in 24 (21.8 per cent) and 17 (15.5 per cent) of 110 patients respectively. Softer PC and smaller PDD were risk factors for POPF (both P < 0.001), symptomatic peripancreatic collections (P = 0.071 and P = 0.015) and PJAM (both P < 0.001). Combining consistency and duct characteristics in a composite classification the PJAM risk was stratified as high (both risk factors, PJAM incidence 51 per cent), intermediate (softer PC or smaller PDD, PJAM 26 per cent) or low (no risk factors, PJAM 2 per cent). Severe PJAM was observed only in patients with smaller PDD. Conclusion: A high-risk pancreatic gland had a 25-fold higher risk of PJAM after pancreaticoduoden- ectomy than a low-risk gland. This simple classification can contribute to more individualized patient management and allow stratification of study cohorts with homogeneous POPF risk. Copyright (c) 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.