The International Study Group for Pancreatic Surgery (ISGPS) Definition and Classification of Postpancreatectomy Mortality

Tommaso Giuliani^{1

2}, Ajith K Siriwardena³, Charles M Vollmer⁴, Mohammed Abu Hilal^{5

6}, Mustapha Adham⁷, Savio George Barreto^{8

9}, Ugo Boggi¹⁰, Carlos Fernández-Del Castillo¹¹, Marco Del Chiaro¹², Massimo Falconi¹³, Helmut Friess¹⁴, Isabella Frigerio^{15

16}, Giuseppe Kito Fusai¹⁷, Luca Gianotti¹⁸, Brian K P Goh^{19

20}, Christopher M Halloran²¹, Werner Hartwig²², Jin He²³, Melissa E Hogg²⁴, Kuirong Jiang²⁵, Matthew H G Katz²⁶, Jörg Kleeff²⁷, Knut Jørgen Labori²⁸, Keith D Lillemoe¹¹, Sanjay Pandanaboyana²⁹, Elena Rangelova³⁰, Lilian Schwarz³¹, Alejandro Serrablo³², Faik G Uzunoglu³³, Alessandro Zerbi^{34

35}, Christos Dervenis³⁶, John P Neoptolemos³⁷, Markus W Büchler³⁸, Marc G Besselink^{39

40}, Cristina R Ferrone⁴¹, Thilo Hackert³³, Roberto Salvia⁴², Shailesh V Shrikhande⁴³, Oliver Strobel⁴⁴, Jens Werner⁴⁵, Christopher L Wolfgang⁴⁶, Giovanni Marchegiani¹; International Study Group for Pancreatic Surgery

Affiliations

¹ HPB and Transplant Surgery Unit, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy.
² Department of Surgery, Morgagni-Pierantoni Hospital, Forlí, Italy.
³ Regional HPB Surgery Unit, Manchester Royal Infirmary, University of Manchester, Manchester, UK.
⁴ Department of Surgery, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁵ University Hospital Southampton NHS Foundation Trust, Department of Surgery, Southampton, UK.
⁶ School of Medicine, The University of Jordan, Department of Surgery, Amman, Jordan.
⁷ Department of Digestive Surgery, Eduart Herriot Hospital, HCL, Lyon Sud Faculty of Medicine, UCBL1, Lyon, France.
⁸ Department of Surgery, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia.
⁹ College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, South Australia, Australia.
¹⁰ Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
¹¹ Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
¹² Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
¹³ Pancreatic Surgery Unit, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy.
¹⁴ Department of Surgery, TUM University Hospital, Rechts der Isar, Faculty of Medicine and Health, Technical University Munich, Munich, Germany.
¹⁵ HPB Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Italy.
¹⁶ Collegium Medicum, SAN University, Lodz, Poland.
¹⁷ HPB Surgery Unit, Royal Free Hospital, London, UK.
¹⁸ Unit of Pancreatic Surgery, University of Milano-Bicocca, Foundation IRCCS San Gerardo Hospital, Monza, Italy.
¹⁹ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General National Cancer Center, Singapore.
²⁰ Surgery Academic Clinical Program, Duke-National University of Singapore Medical School, Singapore.
²¹ Institute of Systems, Molecular and Integrative Biology, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.
²² Department of Surgery, Evangelisches Krankenhaus Dusseldorf, Düsseldorf, Germany.
²³ Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
²⁴ Department of Surgery, NorthShore University Health System, Evanston, IL, USA.
²⁵ Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
²⁶ Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
²⁷ Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
²⁸ Department of HPB Surgery, Oslo University Hospital, Oslo, Norway.
²⁹ Department of HPB Surgery, Freeman Hospital, Newcastle upon Tyne, UK.
³⁰ Department of Surgery at Sahlgrenska University Hospital, Department of Surgery, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg Sweden.
³¹ Department of Digestive and Oncological Surgery, Rouen University Hospital, Rouen, France.
³² Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain.
³³ Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
³⁴ IRCCS Humanitas Research Hospital, Rozzano, Italy.
³⁵ Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.
³⁶ Department of Surgery, AGIA OLGA Hospital, Athens, Greece.
³⁷ Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
³⁸ Botton-Champalimaud Pancreatic Cancer Centre, Champalimaud Foundation, Lisbon, Portugal.
³⁹ Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
⁴⁰ Cancer Center Amsterdam, the Netherlands.
⁴¹ Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
⁴² Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy.
⁴³ Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, MH, India.
⁴⁴ Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria.
⁴⁵ Department of Surgery, University Hospital, LMU Munich, Munich, Germany.
⁴⁶ Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA.

PMID: 41572457
DOI: 10.1097/SLA.0000000000007019

The International Study Group for Pancreatic Surgery (ISGPS) Definition and Classification of Postpancreatectomy Mortality

Tommaso Giuliani et al. Ann Surg. 2026.

. 2026 Jan 23.

doi: 10.1097/SLA.0000000000007019. Online ahead of print.

Authors

Affiliations

¹ HPB and Transplant Surgery Unit, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy.
² Department of Surgery, Morgagni-Pierantoni Hospital, Forlí, Italy.
³ Regional HPB Surgery Unit, Manchester Royal Infirmary, University of Manchester, Manchester, UK.
⁴ Department of Surgery, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁵ University Hospital Southampton NHS Foundation Trust, Department of Surgery, Southampton, UK.
⁶ School of Medicine, The University of Jordan, Department of Surgery, Amman, Jordan.
⁷ Department of Digestive Surgery, Eduart Herriot Hospital, HCL, Lyon Sud Faculty of Medicine, UCBL1, Lyon, France.
⁸ Department of Surgery, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia.
⁹ College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, South Australia, Australia.
¹⁰ Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
¹¹ Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
¹² Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
¹³ Pancreatic Surgery Unit, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy.
¹⁴ Department of Surgery, TUM University Hospital, Rechts der Isar, Faculty of Medicine and Health, Technical University Munich, Munich, Germany.
¹⁵ HPB Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Italy.
¹⁶ Collegium Medicum, SAN University, Lodz, Poland.
¹⁷ HPB Surgery Unit, Royal Free Hospital, London, UK.
¹⁸ Unit of Pancreatic Surgery, University of Milano-Bicocca, Foundation IRCCS San Gerardo Hospital, Monza, Italy.
¹⁹ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General National Cancer Center, Singapore.
²⁰ Surgery Academic Clinical Program, Duke-National University of Singapore Medical School, Singapore.
²¹ Institute of Systems, Molecular and Integrative Biology, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.
²² Department of Surgery, Evangelisches Krankenhaus Dusseldorf, Düsseldorf, Germany.
²³ Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
²⁴ Department of Surgery, NorthShore University Health System, Evanston, IL, USA.
²⁵ Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
²⁶ Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
²⁷ Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
²⁸ Department of HPB Surgery, Oslo University Hospital, Oslo, Norway.
²⁹ Department of HPB Surgery, Freeman Hospital, Newcastle upon Tyne, UK.
³⁰ Department of Surgery at Sahlgrenska University Hospital, Department of Surgery, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg Sweden.
³¹ Department of Digestive and Oncological Surgery, Rouen University Hospital, Rouen, France.
³² Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain.
³³ Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
³⁴ IRCCS Humanitas Research Hospital, Rozzano, Italy.
³⁵ Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.
³⁶ Department of Surgery, AGIA OLGA Hospital, Athens, Greece.
³⁷ Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
³⁸ Botton-Champalimaud Pancreatic Cancer Centre, Champalimaud Foundation, Lisbon, Portugal.
³⁹ Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
⁴⁰ Cancer Center Amsterdam, the Netherlands.
⁴¹ Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
⁴² Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy.
⁴³ Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, MH, India.
⁴⁴ Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria.
⁴⁵ Department of Surgery, University Hospital, LMU Munich, Munich, Germany.
⁴⁶ Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA.

PMID: 41572457
DOI: 10.1097/SLA.0000000000007019

Abstract

Objective: The International Study Group of Pancreatic Surgery (ISGPS) aimed to uniform the definition and classification of mortality following pancreatic resections, to guide strategies for reducing preventable deaths and standardize reporting.

Background: Reported rates of mortality after pancreatic surgery vary widely depending on patient comorbidities, case mix, and institutional expertise and resources. Conventional reporting lacks granularity and fails to capture the mechanisms leading to death. A standardized classification rooted in causal analysis may provide a more meaningful framework to appraise outcomes and design targeted interventions.

Methods: A systematic review of the literature, focusing on mortality rates, causes of death, and existing classification systems after pancreatectomy was conducted. A consensus definition and tripartite classification were developed through iterative discussions, revisions, and final approval by the ISGPS board members.

Results: Postpancreatectomy mortality (PPM) was defined as death occurring within 90 days of any pancreatic resection, directly or indirectly attributable to a surgical complication and retrospectively linked to it through root-cause analysis. Three categories were established: PPM 1, vascular/technical complexity-related mortality (15-30%); PPM 2, pancreatectomy-specific complication-related deaths, mainly due to postoperative pancreatic fistula (POPF) and secondary systemic deterioration (45-65%); and PPM 3, cardiopulmonary and cerebrovascular deaths (10-25%). Each category reflects distinct mechanisms, timing of onset, intervention windows, and opportunities for rescue.

Discussion: The proposed ISGPS classification of mortality enables the development of targeted strategies to reduce potentially preventable deaths and provides a more robust framework for the appraisal and benchmarking of surgical outcomes. Prospective validation is warranted to standardize this newly defined quality metric, ensuring its consistent use in future reporting and ultimately enhancing surgical quality and patient safety on a global scale.

Keywords: definition; international study group for pancreatic surgery; postpancreatectomy mortality.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest and Source of Funding: The authors declare no conflicts of interest. No funding from the National Institutes of Health (NIH), Wellcome Trust, Howard Hughes Medical Institute (HHMI), or any other organizations was received for this work.

LinkOut - more resources

Full Text Sources
- Ovid Technologies, Inc.
- Wolters Kluwer

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

The International Study Group for Pancreatic Surgery (ISGPS) Definition and Classification of Postpancreatectomy Mortality

Affiliations

The International Study Group for Pancreatic Surgery (ISGPS) Definition and Classification of Postpancreatectomy Mortality

Authors

Affiliations

Abstract

Conflict of interest statement

LinkOut - more resources

Full Text Sources