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Background: Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP., Methods: Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed., Results: At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001)., Conclusions: Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Grade B postoperative pancreatic fistula represents the largest fraction of postoperative pancreatic fistula. A subclassification of grade B postoperative pancreatic fistula has been recently proposed and seems to better stratify postoperative pancreatic fistula clinical and economic burden. Aim of this study was to validate, from a clinical and economic standpoint, grade B postoperative pancreatic fistula subclassification in patients submitted to pancreaticoduodenectomy., Methods: All consecutive patients who underwent pancreaticoduodenectomy and developed biochemical leak or postoperative pancreatic fistula were included. Grade B postoperative pancreatic fistula was subclassified into 3 categories (B1: persistent drainage >21 days, B2: pharmacological treatments; B3: interventional procedures). Postoperative pancreatic fistula clinical and economic burden was assessed by evaluating postoperative complications, length of hospital stay, and overall hospital costs., Results: Overall, 289 patients developed biochemical leak or postoperative pancreatic fistula. Of these, 34 had biochemical leak (12%), 25 had grade B1 postoperative pancreatic fistula (9%), 91 had grade B2 postoperative pancreatic fistula (31%), 94 had grade B3 postoperative pancreatic fistula (32%), and 45 experienced grade C postoperative pancreatic fistula (16%). The severity of postoperative complications significantly increased across biochemical leak and postoperative pancreatic fistula categories (P < .001), but it was comparable between biochemical leak and grade B1 postoperative pancreatic fistula. There was no significant difference in terms of length of hospital stay between patients with biochemical leak and those with grade B1 postoperative pancreatic fistula (P = 1.000). Overall hospital costs were similar for patients with biochemical leak and those with grade B1 postoperative pancreatic fistula (P = 1.000), whereas they significantly increased across all the other postoperative pancreatic fistula subgroups., Conclusion: A subclassification of grade B postoperative pancreatic fistula can better stratify the increasing clinical burden and economic impact of postoperative pancreatic fistula after pancreaticoduodenectomy. Grade B1 postoperative pancreatic fistula has minimal clinical and economic consequences and can be considered closer to a biochemical leak than to a grade B2 postoperative pancreatic fistula., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: A fatty infiltration of the pancreas has been traditionally regarded as the main histological risk factor for postoperative pancreatic fistula, whereas the role of the secreting acinar compartment has been poorly investigated. The aim of this study was to evaluate the role of acinar content at the pancreatic resection margin in the development of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis after pancreaticoduodenectomy., Methods: Data from 388 consecutive patients who underwent pancreaticoduodenectomy (2018-2019) were analyzed. Pancreatic section margins were histologically assessed for acinar, fibrosis, and fat content. Acinar content was categorized using median and third quartile as cut-offs. Univariate and multivariable analysis of possible predictors of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis were performed., Results: Acinar content was <60% in 166 patients (42.8%), ≥60% and ≤80% in 156 patients (40.2%), and >80% in 66 patients (17.0%). The rate of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis was significantly higher in patients with acinar content >80% (39.4% and 33.3%, respectively) as well as in those with acinar content ≥60% and ≤80% (36.5% and 35.3%, respectively), compared with patients with acinar content <60% (10.2% and 5.4%, respectively) (P < .001). Acinar content was identified as an independent predictor of clinically relevant postoperative pancreatic fistula (≥60% and ≤80%, odds ratio 2.51, P = .008; >80%, odds ratio 2.93, P = .010) and clinically relevant postoperative acute pancreatitis (≥60% and ≤80%, odds ratio 9.42, P < .001; >80%, odds ratio 10.16, P < .001)., Conclusion: An acinar content at the pancreatic resection margin ≥60% is associated to an increased risk of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis. Fat content was associated neither with clinically relevant postoperative pancreatic fistula nor with clinically relevant postoperative acute pancreatitis., (Copyright © 2021 Elsevier Inc. All rights reserved.)