Evaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center

doi:10.1016/j.surg.2011.09.039

Surgery

Volume 151, Issue 4, April 2012, Pages 612-620

https://doi.org/10.1016/j.surg.2011.09.039 Get rights and content

Background

Although postpancreatectomy hemorrhage (PPH) is observed infrequently after pancreatic surgery, it remains a serious complication with a high rate of mortality. Recently, the International Study Group of Pancreatic Surgery (ISGPS) issued a new definition for PPH. To evaluate and validate this new definition, we analyzed data retrospectively from our center.

Methods

Data from 945 patients who underwent pancreatic surgery in our department between October 1993 and December 2009 were identified retrospectively from our prospective database with regard to the occurrences of PPH. We graded the hemorrhages recorded in our database according to the ISGPS consensus definition. We assessed the clinical course, morbidity, mortality, and duration of hospital stay for patients with grade B and C PPHs in comparison with patients who underwent pancreatic resections without hemorrhage.

Results

Grade B PPH after pancreatic surgery occurred in 16 patients (1.7%), and grade C PPH occurred in 38 patients (4.0%). Mortality was significantly increased in PPH grades B and C compared with control patients (25.9% vs 2.0%; P < .001) and contributed to nearly one-half of the mortality in the present series. Morbidity was also increased in patients with grade B (76.5%) and C (94.6%) PPH compared with control patients (59.6%; P < .001). Grade B and C PPH correlated significantly with the incidence of grade C postoperative pancreatic fistula (14.8% vs 1.9%), grade C delayed gastric emptying (18.5% vs 4.0%), and wound infection (38.9% vs 13.5%) compared with control patients.

Conclusion

This is the first clinical evaluation of the ISGPS PPH definition. Our data indicate that the new definition correlates well with morbidity, mortality, and duration of hospital stay. The definition, therefore, seems suitable for clinical and scientific applications.

Section snippets

Patients and data collection

Patients who underwent pancreatic surgery between October 1993 and December 2009 in the Department of General, Thoracic and Vascular Surgery in the Carl Gustav Carus University Hospital, Dresden, were entered into a prospective electronic database. The database and medical records for each patient were analysed retrospectively. Patients were contacted by mail or by telephone and asked to participate in our survey. The survey data were complemented by the clinical notes of their physicians and

Patient cohort

From October 1993 to December 2009, 945 patients underwent pancreatic surgery in our department. The patient group consisted of 544 men (57.6%) and 401 women (42.4%) and had a mean age of 57.9 (±12.9) years. The following procedures were performed in these patients: the classic pancreatoduodenectomy (PD) (262 patients, 27.6%), pylorus-preserving pancreatoduodenectomy (476 patients, 50.4%), total pancreatectomy (13 patients, 1.4%), a left resection (151 patients, 16.0%), central pancreatectomy

Discussion

The use of different and nonstandardized definitions of PPH after pancreatic surgery⁵ have increased the difficulty in comparing the results from clinical trials. The need for an internationally accepted consensus definition of postoperative haemorrhage led to the suggested definition compiled by the ISGPS in 2007.⁵

The present study is the largest retrospective study to analyze PPH in a high-volume center. Our results show that the ISGPS consensus definition appears to be suitable for both

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Cited by (117)

Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies
2023, Pancreatology
This study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center.
This retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage.
Of 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups.
Standardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.
Management of postoperative pancreatic fistula after pancreaticoduodenectomy
2023, Journal of Visceral Surgery
A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.
A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading
2022, HPB
Morbidity and mortality from post-pancreatectomy haemorrhage (PPH) remains high. The International Study Group of Pancreatic Surgery (ISGPS) published guidelines to standardise definitions of PPH severity, management and reporting. This study aimed to i) identify the number of studies reporting PPH using ISGPS guidelines (Grade A, B or C) and ii) describe treatment modality success by grade.
A systematic literature review was performed, identifying studies reporting PPH by ISGPS Grade and their subsequent management.
Of 62 studies reporting on PPH management, 17 (27.4%) stratified by ISGPS guidelines and included 608 incidences of PPH: 48 Grade A, 274 Grade B (62 early, 166 late, 46 unspecified) and 286 Grade C.
96% of Grade A PPH were treated conservatively. Of 62 early Grade B, 54.8% were managed conservatively and 37.1% surgically. Late Grade B were managed non-operatively in 25.3% (42/166), with successful endoscopy in 90.9% (10/11) and angiography in 90.3% (28/31). In Grade C, endoscopic treatment was successful in 64.4% (29/45) and angiography in 90.8% (108/119). Surgical intervention was required in 43.5% early Grade B, 7.8% late Grade B and 33.2% Grade C.
PPH grading is underreported and despite guidelines, inconsistencies remain when using definitions and reporting of outcomes.
AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery
2022, HPB
Citation Excerpt :
In a series of more than 2000 patients from Verona, 6.8% had PPH, whereas a large German series describes a similar PPH rate of 5.9%.106,107 Other studies corroborate this range (6–8%) as a good estimate of PPH after pancreatectomy.102,108–111 The mortality associated with PPH is grade-dependent but significant ranging from 22% to 47%.110,112
Major abdominal surgery and malignancy lead to a hypercoagulable state, with a risk of venous thromboembolism (VTE) of approximately 3% after pancreatic surgery. No guidelines exist to assist surgeons in managing VTE prophylaxis or anticoagulation in patients undergoing elective pancreatic surgery for malignancy or premalignant lesions. A systematic review specific to VTE prophylaxis and anticoagulation after resectional pancreatic surgery is herein provided.
Six topic areas are reviewed: pre- and perioperative VTE prophylaxis, early postoperative VTE prophylaxis, extended outpatient VTE prophylaxis, management of chronic anticoagulation, anti-coagulation after vascular reconstruction, and treatment of VTE. A Medline and PubMED search was completed with systematic medical literature review for each topic. Level of evidence was graded and strength of recommendation ranked according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system for practice guidelines.
Levels of evidence and strength of recommendations are presented.
While strong data exist to guide management of chronic anticoagulation and treatment of VTE, data for anticoagulation after reconstruction is inconclusive and support for perioperative chemoprophylaxis with pancreatic surgery is similarly limited. The risk of post-pancreatectomy hemorrhage often exceeds that of thrombosis. The role of universal chemoprophylaxis must therefore be examined critically, particularly in the preoperative setting.
An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: A prospective observational study
2021, Asian Journal of Surgery
Citation Excerpt :
Since postoperative intra-abdominal complications such as POPF, anastomotic leakage, bleeding, ileus, fluid collection, or abscess formation are major causes of DGE, we defined DGE associated with those complications as secondary DGE, whereas DGE without any intra-abdominal complications was defined as primary DGE. PPH was defined and graded according to ISGPS.22 Grades B and C POPF, DGE and PPH were defined as clinically relevant surgical complications.
Postoperative pancreatic fistula (POPF) leads to life-threatening complications after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) often adopted as a reconstruction technique after PD to prevent POPF. Delayed gastric emptying (DGE) following PD is the most common complication that compromises the quality of life. Subtotal stomach-preserving PD (SSPPD) preserves the pooling ability of the stomach and minimize the occurrence of DGE. This study aimed to describe our PG technique following SSPPD and evaluate the perioperative outcomes.
The study included patients who underwent PG following SSPPD from August 2013 to July 2020 at our institution. An invaginated PG was performed by one-layer eight interrupted sutures with a lost stent. Patients’ demographics and perioperative outcomes were documented.
This technique was applied in 72 patients with a median age of 75 years. The median operative time was 342 min. The clinically relevant POPF, DGE and post-pancreatectomy hemorrhage was 4 (5.6%), 5 (6.9%), and 10 (13.9%), respectively. Although the drain fluid amylase concentration on postoperative day 3 was significantly higher in clinically relevant POPF (CR-POPF) positive group (median, 2006 U/L vs. 74 U/L in CR-POPF negative group, p = 0.002), none of the risk factors including disease pathology, pancreatic duct diameter, texture of pancreas and excessive blood loss were significantly associated with CR-POPF. Other morbidity ≥ Clavien-Dindo classification II occurred in 29 patients (40.3%). The 90-days operative mortality was two (2.8%).
This novel method of one-layer invaginated PG following SSPPD is safe and dependable procedure with acceptable morbidity and mortality.
Incidence, timing and risk factors of venous thromboembolic events in patients with pancreatic cancer
2021, Thrombosis Research
Pancreatic cancer is associated with a high risk of venous thromboembolism (VTE). However, comprehensive data on incidence, timing and relevant determinants of VTE in this particular population are scarce. Current study assesses incidence, timing and predictors of VTE in pancreatic cancer through different phases of disease.
All pancreatic cancer patients treated in our tertiary referral center between 2013 through 2017 were studied. Occurrence of VTE was evaluated from diagnosis through end of follow-up or death. Relevant determinants of VTE were identified in logistic regression models. Hazard ratios were calculated to evaluate impact of VTE on overall survival.
In total, 361 patients were followed for a median period of 43 months; 64 were diagnosed with VTE (18%). Most were tumor related thrombosis (59%), incidental (75%) and occurred after anti-cancer treatment had been stopped (80%), only 1.6% occurred during remission phase. Stage IV pancreatic cancer was a predictor for VTE (hazard ratio (HR) 2.46, 95% confidence interval (CI) 0.9–6.8). Biliary drainage (HR 0.52, 95%CI 0.28–0.98) and tumor resection (HR 0.45, 95%CI 0.45–1.83) were protective factors. VTE was not associated with worse survival (HR 1.3; 95% CI 0.97–1.74).
VTE in pancreatic cancer is disease-stage dependent, with 80% occurring in advanced phases of disease when patients no longer receive active treatment. We speculate that this is the main reason for the absence of a survival effect of VTE in our cohort. These practice-based findings should be taken into account when considering wide-spread introduction of primary thromboprophylaxis in patients with pancreatic cancer.

View all citing articles on Scopus

: Robert Grützmann and Felix Rückert contributed equally to this work.

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Surgical Outcome ResearchEvaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center

Background

Methods

Results

Conclusion

Section snippets

Patients and data collection

Patient cohort

Discussion

The challenge of pancreatic anastomosis

Langenbecks Arch Surg

Complications of pancreatic surgery

HPB (Oxford)

Postoperative pancreatic fistula: an international study group (ISGPF) definition

Surgery

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

Surgery

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

Surgery

Evaluation of the International Study Group of Pancreatic Surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centre

Br J Surg

Surgical Outcome Research
Evaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center