Options and Limitations in Applying the Fistula Classification by the International Study Group for Pancreatic Fistula

Background: Because of its retrospective character, the classification system of the International Study Group of Pancreatic Fistula (ISGPF) lacks prognostic capacity regarding fistula-related complications. This study aimed to evaluate the options and limitations of the ISGPF classification system and to identify risk factors with respect to clinical decision making. Methods: Between 1992 and 2009, 1966 patients underwent surgery of the pancreas. All patient data were entered into a prospective clinical data management system. Results: After surgery, 276 patients (14%) developed postoperative pancreatic fistula (POPF). ISGPF type A fistula was seen in 69 patients (25%), type B in 110 (39.9%), and type C in 97 (34.1%). Solely due to their death, 16 patients had to be classified as type C fistula, even though they suffered only type A or B. Compared to genuine C fistulas, we were not able to detect any significant predictors, which may allow to distinguish the development in their further clinical course. The level of drainage amylase is of no use, whereas univariate analysis identified underlying disease, type of operation, and high levels of serum amylase or bilirubin on the day of onset of POPF to be prognostic parameters for reoperation. Multivariate analysis found elevated serum C-reactive protein to be an independent factor for increased in-hospital mortality. Conclusions: The ISGPF classification system has its limitations in clinical decision making, because it does not adequately describe a large subgroup of patients. To improve clinical decision making about management of patients, it is crucial that the ISGPF classification system is merged with newer clinical data.