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Meta-Analysis
. 2023 Mar 1;277(3):e597-e608.
doi: 10.1097/SLA.0000000000004855. Epub 2021 Mar 12.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

Fabian Schuh  1 , André L Mihaljevic  1   2 , Pascal Probst  1 , Maxwell T Trudeau  3 , Philip C Müller  4 , Giovanni Marchegiani  5 , Marc G Besselink  6 , Faik Uzunoglu  7 , Jakob R Izbicki  7 , Massimo Falconi  8 , Carlos Fernandez-Del Castillo  9 , Mustapha Adham  10 , Kaspar Z'graggen  4 , Helmut Friess  11 , Jens Werner  12 , Jürgen Weitz  13 , Oliver Strobel  1 , Thilo Hackert  1 , Dejan Radenkovic  14 , Dezso Kelemen  15 , Christopher Wolfgang  16 , Y I Miao  17 , Shailesh V Shrikhande  18 , Keith D Lillemoe  19 , Christos Dervenis  20 , Claudio Bassi  5 , John P Neoptolemos  1 , Markus K Diener  1   2 , Charles M Vollmer Jr  3 , Markus W Büchler  1
Affiliations
Meta-Analysis

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

Fabian Schuh et al. Ann Surg. .

Abstract

Objective: The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

Summary background data: Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

Methods: A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

Results: Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

Conclusion: For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

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Conflict of interest statement

The authors report no conflicts of interest.

Figures

Figure 1
Figure 1
PRISMA flow chart.
Figure 2
Figure 2
Meta-analysis of pancreatic texture (soft vs not-soft) and clinically relevant postoperative pancreatic fistula, defined as POPF B or C according to the ISGPS.
Figure 3
Figure 3
Meta-analysis of main pancreatic duct size and clinically relevant postoperative pancreatic fistula, defined as POPF B or C according to the ISGPS.
Figure 4
Figure 4
Risk of bias of the included studies according to QUADAS-2 analysis.
Figure 5
Figure 5
Funnel Plot for publications investigating the association between main pancreatic duct size and postoperative pancreatic fistula.
Figure 6
Figure 6
ISGPS consensus classification on risk of POPF based on pancreatic texture and main pancreatic duct size The category “soft” also includes brittle or friable tissue. The category “not-soft” contains any pancreatic texture (eg, hard, firm, or sclerotic) other than “soft, brittle or friable”.
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