Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)

Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition.

Mortality associated with pancreaticoduodenectomy (PD) has decreased dramatically to less than 5% over the past 2 decades in high-volume centers,1–6 but persistent high morbidity rates have remained an important concern for patients, healthcare providers, and payers. While mortality is an objective and easily quantifiable outcome parameter, morbidity is only poorly defined, and this shortcoming has severely hampered conclusive comparisons among centers and within the same institution over time.7–9 Similarly, the identification of risk factors related to specific complications has been difficult.

Recognizing this deficiency, there has been several recent attempts to define specific complications related to PD such as pancreatic fistula, either by individual groups10–14 or through consensus statements from a few experts.15 Although important, these definitions have focused only on one specific complication (pancreatic fistula), and typically lack a severity grading system. For example, when a pancreatic fistula is defined as the persistent drainage of amylase-rich fluid during the postoperative course or as radiologic evidence of pancreatic anastomotic disruption, no distinction is made between the minimal criteria and more severe manifestation leading to reoperation or even death. An attempt was recently made by a group of experts in pancreas surgery to grade pancreatic fistula by severity,15 but the grading system is complex, includes multiple subjective criteria, and is not applicable to other types of complications. Therefore, there is persistent need for the availability of a reproducible, simple, and widely acceptable system to grade all complications following PD.

A previously reported grading system7–9 was recently revisited and validated in a large cohort of patients undergoing general surgery. An international survey confirmed the simplicity and reproducibility of the new grading system.16 This classification was recently adopted by the International Transplantation Society17 to prospectively monitor the outcome of living liver donors. A key feature facilitating the use of the grading system is that it mostly relies on the therapies used to correct negative events. This is crucial to minimize down grading of complications as even nursing notes can be used to secure appropriate grading in retrospective analyses. Another attractive aspect of the new classification is that it considers the patient perspective through a strong emphasis on long lasting disability. Such a grading system can be adapted to any complication as long as the minimal criteria to define each specific complication are well described and widely accepted.

We adapted this novel classification of complications by severity16 to a large cohort of patients, who underwent a PD at Johns Hopkins Hospital, a high-volume center with the availability of a comprehensive database. We used the well-established Johns Hopkins definitions for pancreatic fistula and delayed gastric emptying (DGE),18,19 and stratified them according to severity criteria. Of importance, the John Hopkins definition of pancreatic fistula is consistent with a recent consensus statements.15

The primary aims of the study were to evaluate the feasibility of grading each recorded complication in the database according to the novel classification system, to present specific complications by severity, and to identify risk factors. A secondary aim was to test the novel classification system in comparing the incidence and severity of one type of complication, pancreatic fistula, with a previous series of patients in the same institution. Finally, an attempt was made to evaluate the impact of complications on long-term survival.

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Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy.

PDAC is an aggressive disease and early infiltrates peripancreatic tissues and adjacent organs, and gives distant metastasis and peritoneal involvement, making often surgical resection impossible. About 80% of PDACs are inoperable at the time of diagnosis. However, even if radiologically resectable, some PDAC microscopically involves the resection margins (pancreatic, retroperitoneal, or biliary, the retroperitoneal being the most important because it cannot be evaluated intraoperatorially) resulting in a nonradical excision. Local aggressiveness consists in the invasion of contiguous structures and organs (spleen, stomach, left adrenal gland, colon, and peritoneum), whereas distant metastases can occur in liver, lungs, adrenals, kidneys, bones, brain, and skin.

Pathology and Genetics

Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS).

The Lymph Node Ratio is the Strongest Prognostic Factor after Resection of Pancreatic Cancer

Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection

Background Postoperative morbidity is high after pancreatic head resections. Data about risk factors are controversial. The aim of this study was to evaluate risk factors for complications after pancreatic head resection and to assess whether the complication rate changed during the study period. Methods Data of 301 patients undergoing pancreatic head resection were recorded prospectively. Risk factors were assessed by multivariate analysis. The first and second part of the study period were compared. Results Mortality was 3%. Overall and surgery-related complications occurred in 42% and 28%, respectively. Independent risk factors for postoperative morbidity were impaired renal function (odds ratio [OR] 2.7), absence of preoperative biliary drainage (OR 1.9), and resection of other organs (OR 3.2). Complication rate, duration of surgery, amount of blood transfused, and length of hospital stay decreased during the study period. Conclusions Increasing hospital experience decreased complication rates. Patients with risk factors should be considered for transferal to specialized centers.

Hartwig Riediger

Papers

The Lymph Node Ratio is the Strongest Prognostic Factor after Resection of Pancreatic Cancer

Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection

Risk factors for complications after pancreatic head resection

Long-term Outcome After Resection for Chronic Pancreatitis in 224 Patients

Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications