Risk factors and prevention of pancreatic fistula after laparoscopic gastrectomy for gastric cancer

Table 1 Incidence of pancreatic fistula after gastric cancer surgery

Ref.	Year	Incidence %	Patient total	Surgical approach	Study type
Hiki et al[3]	2018	2.2	1067	LDG for GC	Multicenter prospective randomized controlled trial
		1.0	1067	ODG for GC
Inaki et al[30]	2015	3.4	86	LG for AGC	Multicenter prospective randomized controlled trial
Nakauchi et al[31]	2016	13	92	TLTG for AGC	Single-center retrospective study
Yu et al[32]	2013	0.4	490	LDG/LPG for GC	Single-center retrospective study
		1.7	236	ODG/OPG for GC
		3.8	79	LTG for GC
		22.2	86	OTG for GC
Lee et al[33]	2019	1.9	526	LDG for AGC	Multicenter prospective randomized controlled trial
		0.6	524	ODG for AGC
Hu et al[36]	2016	0.4	519	LDG + D2 for AGC	Multicenter prospective randomized controlled trial
		0.0	520	ODG + D2 for AGC
Obama et al[38]	2011	7.2	138	LG for GC	Single-center retrospective study
		2.1	95	OG for GC
Ojima et al[46]	2019	4.7	639	LG for GC	Single-center retrospective study
		0.0	20	RG for GC
Ye et al[47]	2020	2.8	285	LDG for AGC	Single-center retrospective study
		0.4	285	RDG for AGC

AGC: Advanced gastric cancer; D2: Lymph node dissection; GC: Gastric cancer; LDG: Laparoscopic distal gastrectomy; LG: Laparoscopic gastrectomy; LPG: Laparoscopic proximal gastrectomy; LTG: Laparoscopic total gastrectomy; ODG: Open distal gastrectomy; OG: Open gastrectomy; OPG: Open proximal gastrectomy; OTG: Open total gastrectomy; RDG: Robotic distal gastrectomy; RG: Robotic gastrectomy; TLTG: Totally laparoscopic total gastrectomy.

Table 2 Key parameters for postoperative pancreatic fistula grading[2]

Grade	A	B	C
Clinical conditions	Well	Often well	Appearing/bad
Specific treatment1	No	Yes/no	Yes
US/CT (if obtained)	Negative	Negative/positive	Positive
Persistent drainage > 3 weeks2	No	Usually yes	Yes
Reoperation	No	No	Yes
Death related to POPF	No	No	Possibly yes
Possibly yes	No	Yes	Yes
Sepsis	No	No	Yes
Readmission	No	Yes/no	Yes/no

¹Partial (peripheral) or total parenteral nutrition, antibiotics, enteral nutrition, somatostatin analogs, and/or minimal invasive drainage.

²With or without a drain in situ.

CT: Computed tomographic scan; POPF: Postoperative pancreatic fistula; US: Ultrasonography.

Table 3 Revised 2016 International Study Group of Pancreatic Surgery classification and grading of postoperative pancreatic fistula: Checklist for clinical use[55]

Event	BL	Grade B POPF1	Grade C POPF1
Increased amylase activity > 3 times upper limit institutional normal serum value	Yes	Yes	Yes
Persisting peripancreatic drainage > 3 weeks	No	Yes	Yes
Clinically relevant change in management of POPF2	No	Yes	Yes
POPF percutaneous or endoscopic specific interventions for collections	No	Yes	Yes
Angiographic procedures for POPF related bleeding	No	Yes	Yes
Reoperation for POPF	No	No	Yes
Signs of infection related to POPF	No	Yes, without organ failure	Yes, with organ failure
POPF related organ failure3	No	No	Yes
POPF-related death	No	No	Yes

¹A clinically relevant postoperative pancreatic fistula is defined as a drain output of any measurable volume of fluid with an amylase level greater than 3 times the upper Institutional normal serum amylase level, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula.

²Suggests prolongation of hospital or intensive care unit stay, including use of therapeutic agents specifically employed for fistula management or its consequences (of these: somatostatin analogs, total parenteral nutrition/total enteral nutrition, blood product transfusion, or other medications).

³Postoperative organ failure is defined as the need for re-intubation, hemodialysis, and/or inotropic agents > 24 h for respiratory, renal, or cardiac insufficiency, respectively.

BL: Biochemical leak; POPF: Postoperative pancreatic fistula.

Table 4 Clavien-Dindo classification[56]

Grades	Definition
I	Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions. Allowed therapeutic regimens are: Drugs as antiemetics, antipyretics, analgesics, diuretics and electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside
II	Requiring pharmacological treatment with drugs other than such allowed for Grade I complications. Blood transfusions and total parenteral nutrition are also included
III	Requiring surgical, endoscopic, or radiological intervention
IIIa	Intervention not under general anesthesia
IIIb	Intervention under general anesthesia
IV	Life-threatening complication (including CNS complications: Brain hemorrhage, ischemic stroke, subarachnoid bleeding, but excluding transient ischemic attacks) requiring IC/ICU management
IVa	Single organ dysfunction (including dialysis)
IVb	Multi-organ dysfunction
V	Death of the patient
Suffix “d”	If the patient suffers from a complication at the time of discharge, the suffix ‘d’ (for ‘disability’) is added to the respective grade of complication. This label indicates the need for a follow-up to fully evaluate the complication

CNS: Central nervous system; IC: Intermediate care; ICU: Intensive care unit.