Risk factors affecting clinically relevant pancreatic fistula after pancreaticoduodenectomy

Introduction and Aim: Pancreaticoduodenectomy (PD) is the main surgical procedure for the curative treatment of periampullary pathologies. Despite the visibly increasing advances in perioperative management over the last decade; Morbidity rates after PD still remain high. The most bothersome complication that increases the early and long-term morbidity after PD is postoperative pancreatic fistula (POPF) and is classified as biochemical leak (BL) and clinically relevant Grade B/C pancreatic fistula (CR - POPF) according to clinical severity. Numerous risk factors have been identified so far, including preoperative malnutrition, associated with the occurrence of CR-POPF after PD. However, there is limited information on the relationship between as an indicator of preoperative immune-nutritional status, preoperative prognostic nutritional index (PNI) value ([serum albumin g/dl x 10] + [total lymphocyte count x 0.05]) and CR-POPF occurrences. In this study, we aimed to investigate the clinicopathological factors associated with CR-POPF formations, focusing especially on the preoperative PNI value in a cohort undergoing PD due to different periampullary pathologies. Materials and Methods: A total of 152 patients who underwent PD between January 2018 and February 2023 in Ondokuz Mayıs University Faculty of Medicine, Department of General Surgery were included in this retrospective study. We recorded POPF occurrences as BL and CR-POPF according to the International Study Group of Pancreatic Fistula categorization. The cohort was divided according to the development of CR-POPF and postoperative findings including demographic, preoperative, intraoperative and final pathology were compared with univariant analysis. Parameters with statistical significance (p < 0.1) were evaluated by multivariant binary logistic regression analysis. While the primary endpoint of the study was CR-POPF, the secondary endpoint was Grade 3-4 (severe postoperative complications) according to the Clavien-Dindo classification. Results: Of the 152 patients who underwent PD, 68 (44.7%) were female, and the median age was 66 (29-87). 26 (17.1%) patients with an American Society of Anesthesiologists (ASA) score of ≥ 3 and 78 (51.3%) who underwent preoperative biliary drainage were enrolled. 13.1% (n = 20) of the cohort experienced CR-POPF. In univariant analysis, soft pancreatic remnant tissue (OR [odds ratio], 0.291; 95% CI [confidence interval], 0.092-0.917; p = 0.035), pathological diagnosis other than pancreatic head ductal adenorcinoma (OR, 2.577; 95% CI, 0.886 -7.502; p = 0.082), PNI value (OR, 0.909; 95% CI, 0.829-0.997; p = 0.043), and postoperative serum CRP level (OR, 1.007; 95% CI, 1.0- 1.014; p = 0.035) was statistically significant. In multivariant analysis, soft pancreatic remnant tissue and PNI were determined as independent risk factors for the development of CR-POPF, respectively (OR, 0.255; 95% CI, 0.076-0.852; p = 0.026 and OR, 0.890; 95% CI, 0.808-0.980; p = 0.018). Results: Of the 152 patients who underwent PD, 68 (44.7%) were female, and the median age was 66 (29-87). 26 (17.1%) patients with an ASA score of ≥ 3 and 78 (51.3%) who underwent preoperative biliary drainage were enrolled. 13.1% (n = 20) of the cohort experienced CR-POPF. In univariant analysis, soft pancreatic remnant tissue (OR [odds ratio], 0.291; 95% CI [confidence interval], 0.092-0.917; p = 0.035), pathological diagnosis other than pancreatic head ductal adenorcinoma (OR, 2.577; 95% CI, 0.886 -7.502; p = 0.082), PNI value (OR, 0.909; 95% CI, 0.829-0.997; p = 0.043), and postoperative serum CRP level (OR, 1.007; 95% CI, 1.0- 1.014; p = 0.035) was statistically significant. In multivariant analysis, soft pancreatic remnant tissue and PNI were determined as independent risk factors for the development of CR-POPF, respectively (OR, 0.255; 95% CI, 0.076-0.852; p = 0.026 and OR, 0.890; 95% CI, 0.808-0.980; p = 0.018). Conclusions: In this study, soft pancreatic remanant tissue and low preoperative PNI were independent risk factors for the development of CR-POPF in patients undergoing PD. The advantage of determining the preoperative PNI level in patients scheduled for PD is that it may contribute to CR-POPF risk stratification and perioperative patient management, in addition to other prognostic factors. Keywords: Pancreatic fistula, prognostic nutritional index, CRP, Whipple