The Influence of Intraoperative Blood Loss on Fistula Development Following Pancreatoduodenectomy

Published on Nov 12, 2020in Annals of Surgery10.13
· DOI :10.1097/SLA.0000000000004549
Maxwell T. Trudeau3
Estimated H-index: 3
(UPenn: University of Pennsylvania),
Fabio Casciani2
Estimated H-index: 2
(UPenn: University of Pennsylvania)
+ 22 AuthorsCharles M. Vollmer67
Estimated H-index: 67
(UPenn: University of Pennsylvania)
Sources
Abstract
OBJECTIVE To investigate the role of intraoperative EBL on development of CR-POPF after pancreatoduodenectomy (PD). BACKGROUND Minimizing EBL has been shown to decrease transfusions and provide better perioperative outcomes in PD. EBL is also felt to be influential on CR-POPF development. METHODS This study consists of 5534 PDs from a 17-institution collaborative (2003-2018). EBL was progressively categorized (≤150 mL; 151-400 mL; 401-1,000 mL; >1,000 mL). Impact of additive EBL was assessed using 20 3-factor fistula risk score (FRS) scenarios reflective of endogenous CR-POPF risk. RESULTS CR-POPF developed in 13.6% of patients (N = 753) and median EBL was 400 mL (interquartile range 250-600 mL). CR-POPF and Grade C POPF were associated with elevated EBL (median 350 vs 400 mL, P = 0.002; 372 vs 500 mL, P 400 mL was associated with increased CR-POPF occurrence in 13/20 endogenous risk scenarios. Moreover, 8 of 10 scenarios predicated on a soft gland demonstrated increased CR-POPF incidence. Hypothetical projections demonstrate significant reductions in CR-POPF can be obtained with 1-, 2-, and 3-point decreases in FRS points attributed to EBL risk (12.2%, 17.4%, and 20.0%; P < 0.001). This is especially pronounced in high-risk (FRS7-10) patients, who demonstrate up to a 31% reduction (P < 0.001). Surgeons in the lowest-quartile of median EBL demonstrated CR-POPF rates less than half those in the upper-quartile (7.9% vs 18.8%; P < 0.001). CONCLUSION EBL independently contributes significant biological risk to CR-POPF. Substantial reductions in CR-POPF occurrence are projected and obtainable by minimizing EBL. Decreased individual surgeon EBL is associated with improvements in CR-POPF.
📖 Papers frequently viewed together
70 Citations
72 Citations
25 Citations
References0
Newest
Cited By5
Newest
#1Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
Source
#1Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 2
#2Maxwell T. Trudeau (UPenn: University of Pennsylvania)H-Index: 3
Last. Ronald R. SalemH-Index: 29
view all 55 authors...
Abstract Background The association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored. Methods In total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003–2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated ...
Source
#1Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 2
#2Claudio Bassi (University of Verona)H-Index: 110
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 3 authors...
Abstract Background Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indica...
4 CitationsSource
#1Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 2
#2Maxwell T. Trudeau (UPenn: University of Pennsylvania)H-Index: 3
Last. John W. KunstmanH-Index: 18
view all 55 authors...
Abstract Background Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood. Methods The fistula risk score was applied to identify high-risk patients (fistula risk score 7–10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003–2020). For each case, surgeon pancreatoduodenectomy career volume and years...
4 CitationsSource
Source