Retrospective investigation of risk factors for pancreatic fistula development after pancreaticoduodenectomy

Table 1 Comparison of definition and grading system for postoperative pancreatic fistula

	The definition and grading system of postoperative pancreatic fistula in the 2005 ISGPF version			The ISGPS version of the definition and grading system for postoperative pancreatic fistula
Classification	A-level	B-level	C-level
Clinical manifestation	Good	Good	Poor
Special treatment	Yes	No	No
Continuous ultrasound or CT	Negative	Positive	Positive
Continuous drainage for > 3 weeks	No	No	Yes
Secondary surgery	No	No	Yes
Pancreatic fistula related death	No	No	No
Symptoms of infection	No	Yes	Yes
Sepsis	No	No	Yes
Readmission	No	Yes	Yes
Definition and classification				Biochemical leakage	B-level	C-level
On the third day after surgery, the amylase value in the drainage fluid reached more than three times the normal upper limit				Yes	Yes	Yes
Peripancreatic continuous drainage > 3 weeks				No	Yes	Yes
Changes in clinically relevant treatment measures for pancreatic fistula				No	Yes	Yes
Transcutaneous or intradermal microscopic puncture drainage				No	Yes	Yes
Angiographic intervention treatment of postoperative pancreatic fistula related bleeding				No	Yes	Yes
Secondary operation				No	No	Yes
Postoperative pancreatic fistula related symptoms of infection				No	With (without organ failure)	Yes
Postoperative pancreatic fistula related organs failure				No	No	Yes
Postoperative pancreas fistula related death				No	No	Yes

CT: Computed tomography; ISGPF: International Study Group of Pancreatic Fistula; ISGPS: International Study Group on Pancreatic Surgery.

Table 2 Clinical characteristics of the modeling and validation sets, n (%)

Index	Modeling group (n = 253)	Validation group (n = 50)	P value
Gender			0.416
Male	167 (66.0)	30 (60.0)
Female	86 (34.0)	20 (40.0)
Age (years)	61 ± 9	62 ± 7	0.686
BMI (kg/m2)	23.1 ± 2.7	22.4 ± 3.3	0.312
Alcohol consumption			0.246
Yes	48 (19.0)	13 (26.0)
No	205 (81.0)	37 (74.0)
Smoking			0.846
Yes	110 (43.5)	21 (42.0)
No	143 (56.5)	29 (58.0)
Diabetes			0.983
Yes	56 (22.1)	11 (22.0)
No	197 (77.9)	39 (78.0)
Main pancreatic duct diameter (mm)	3.8 ± 2.1	3.7 ± 2.2	0.606
Cutting edge pancreatic thickness (mm)	15.3 ± 3.5	14.7 ± 3.1	0.220
Main pancreatic duct index	0.3 ± 0.2	0.3 ± 0.2	0.885
Portal vein invasion			0.901
Yes	16 (6.3)	4 (8.0)
No	237 (93.7)	46 (92.0)
Intra-abdominal fat thickness (mm)	71.1 ± 27.2	68.3 ± 25.3	0.389
Pancreatic CT value (HU)	38.6 ± 8.3	38.1 ± 8.8	0.693
Preoperative biliary drainage			0.707
Yes	30 (11.9)	5 (10.0)
No	223 (88.1)	45 (90.0)
Preoperative laboratory examination
White blood cells	6.1 ± 1.7	5.9 ± 1.6	0.397
Platelets	232.5 ± 68.5	240.3 ± 62.8	0.316
Albumin (g/L)	39.3 ± 4.1	38.7 ± 3.8	0.662
Total bilirubin (μmol/L)	121.3 (34.1-231.4)	130.5 (39.2-190.0)	0.747
Serum amylase (IU/L)	25.0 (16.0-42.0)	26.0 (19.5-39.3)	0.737
CA19-9 (U/mL)	81.9 (34.2-273.1)	94.0 (28.5-357.5)	0.626
Pancreatic intestinal anastomosis method			0.814
Pancreatic duct jejunal mucosa vs mucosa	47 (18.6)	10 (20.0)
Pancreatic intestinal end to side insertion	206 (81.4)	40 (80.0)
Pancreatic cancer			0.684
Yes	59 (23.3)	13 (26.0)
No	194 (76.7)	37 (74.0)
Postoperative pancreatic dysfunction
ISGPF			0.517
Yes	124 (49.0)	22 (44.0)
No	129 (51.0)	28 (56.0)
ISGPS			0.987
Yes	61 (24.1)	12 (24.0)
No	192 (75.9)	38 (76.0)
Surgical related deaths			0.658
Yes	8 (3.2)	1 (2.0)
No	245 (96.8)	49 (98.0)

BMI: Body mass index; CT: Computed tomography; HU: Hounsfield unit; CA19-9: Carbohydrate antigen 19-9; ISGPF: International Study Group of Pancreatic Fistula; ISGPS: International Study Group on Pancreatic Surgery.

Table 3 Univariate analysis results of risk factors related to postoperative pancreatic fistula after pancreaticoduodenectomy (2005 International Study Group of Pancreatic Fistula edition)

Index	Postoperative pancreatic fistula in PD patients		Statistical value	P value
	Yes	No
Main pancreatic duct diameter			χ2 = 31.641	< 0.001
≤ 3 mm	88	46
> 3 mm	36	83
Main pancreatic duct index			χ2 = 52.777	< 0.001
≤ 0.25	101	47
> 0.25	23	82
Portal vein invasion			χ2 = 6.259	0.012
Yes	3	13
No	121	116
Intra-abdominal fat thickness			χ2 = 7.665	0.006
≤ 65 mm	43	67
> 65 mm	81	62
Preoperative biliary drainage			χ2 = 5.999	0.014
Yes	21	9
No	103	120
Pancreatic cancer			χ2 = 5.544	0.019
Yes	21	38
No	103	91
Cutting edge pancreatic thickness (mm)	16.5 ± 3.7	15.0 ± 3.8	t = 2.055	0.032
Pancreatic CT value (HU)	36.3 ± 6.4	41.1 ± 9.6	t = -3.224	0.002
Gender			χ2 = 0.572	0.449
Male	79	88
Female	45	41
Drinking alcohol			χ2 = 1.242	0.265
Yes	27	21
No	97	108
Smoking			χ2 = 0.00	0.974
Yes	54	56
No	70	73
Diabetes			χ2 = 0.549	0.459
Yes	25	31
No	99	98
Pancreatic intestinal anastomosis method			χ2 = 1.703	0.192
Pancreatic duct jejunal mucosa vs mucosa	19	28
Pancreatic intestinal end to side insertion	105	101
Age (years)	61 ± 9	61 ± 7	f = -0.259	0.796
BMI (kg/m2)	23.0 ± 3.1	23.2 ± 2.8	t = -0.372	0.626
Preoperative laboratory examination
White blood cells	6.1 ± 1.9	6.0 ± 1.6	t = 0.773	0.441
Platelets	230.4 ± 69.6	235.0 ± 64.1	t = -0.892	0.374
Albumin (g/L)	39.4 ± 4.2	38.9 ± 4.1	t = 0.757	0.450
Total bilirubin (μmol/L)	124.8 (55.6-249.3)	117.8 (37.0-219.1)	U = -1.093	0.275
CA19-9 (U/mL)	73.3 (29.4-222.6)	96.2 (42.0-370.1)	U = -1.069	0.285
Serum amylase (IU/L)	23.0 (17.0-34.0)	31.5 (17.3-60.0)	U = -2.099	0.036

PD: Pancreaticoduodenectomy; CT: Computed tomography; HU: Hounsfield unit; BMI: Body mass index; CA19-9: Carbohydrate antigen 19-9.

Table 4 Univariate analysis results of risk factors related to postoperative pancreatic fistula after pancreaticoduodenectomy (International Study Group on Pancreatic Surgery)

Index	Postoperative pancreatic fistula after PD surgery		Statistical value	P value
	Yes	No
Main pancreatic duct diameter			χ2 = 5.391	0.020
≤ 3 mm	39	90
> 3 mm	22	102
Main pancreatic duct index			χ2 = 11.39	0.001
≤ 0.25	47	101
> 0.25	14	91
Intra-abdominal fat thickness			χ2 = 8.899	0.003
≤ 65 mm	16	92
> 65 mm	45	100
Cutting edge pancreatic thickness (mm)	17.0 ± 4.2	14.5 ± 3.6	t = 2.665	0.009
Pancreatic CT value (HU)	36.2 ± 7.3	39.7 ± 8.8	t = -2.835	0.004
Portal vein invasion			χ2 = 0.672	0.412
Yes	2	14
No	59	178
Preoperative biliary drainage			χ2 = 2.933	0.087
Yes	11	19
No	50	173
Pancreatic cancer			χ2 = 1.721	0.190
Yes	18	41
No	43	151
Gender			χ2 = 0.720	0.396
Male	43	124
Female	18	68
Drinking alcohol			χ2 = 0.286	0.593
Yes	13	35
No	48	157
Smoking			χ2 = 0.020	0.887
Yes	27	83
No	34	109
Diabetes			χ2 = 0.283	0.595
Yes	12	44
No	49	148
Pancreatic intestinal anastomosis method			χ2 = 2.680	0.102
Pancreatic duct jejunal mucosa vs mucosa	7	40
Pancreatic intestinal end to side insertion	54	152
Age (years)	6 ± 8	60 ± 10	t = 1.246	0.215
BMI (kg/m2)	22.9 ± 4.3	23.3 ± 2.1	t = -0.738	0.534
Preoperative laboratory examination
White blood cells	6.2 ± 2.3	6.0 ± 1.7	t = 0.474	0.673
Platelets	230.9 ± 67.9	237.8 ± 73.2	t = -0.523	0.602
Albumin (g/L)	39.2 ± 4.3	39.0 ± 4.0	t = 0.303	0.762
Total bilirubin (μmol/L)	127.1 (50.0-231.4)	121.5 (32.9-216.6)	U = -0.882	0.378
CA19-9 (U/mL)	97.4 (34.5-314.4)	80.9 (27.3-344.3)	U = -0.498	0.618
Serum amylase (IU/L)	24.0 (17.0-33.8)	30.0 (17.0-58.0)	U = -1.818	0.069

PD: Pancreaticoduodenectomy; CT: Computed tomography; HU: Hounsfield unit; BMI: Body mass index; CA19-9: Carbohydrate antigen 19-9.