Original Article

J Nepal Health Res Counc 2022 Oct-Dec;20(57): 935-41

Post-operative Pancreatitis as a Predictor of Post-

operative Pancreatic Fistula in Patients Following
Pancreaticoduodenectomy
Nirajan Subedi,1 Bikal Ghimire,2 Prasan B S Kansakar,2 Ramesh S Bhandari,3 Paleswan J Lakhey,3 Yogendra
P Singh2
1
Department of Surgical Gastroenterology, National Academy of Medical Sciences- Bir hospital, 2Department
of General Surgery, TUTH, MMC,IOM, 3Department of Surgical Gastroenterology, TUTH,MMC,IOM.

ABSTRACT

Background: Postoperative pancreatic fistula remains the single most important determinant of morbidity and
mortality following pancreaticoduodenectomy. A new entity was proposed by Saxon Connor “Post-Operative
pancreatitis”, which is defined by raised serum amylase more than the upper limit of institutional serum amylase
value on Post-Operative day 0 or 1. There has been shown to be an association between postoperative pancreatitis and
postoperative pancreatic fistula. We have conducted this study to see the incidence of postoperative pancreatitis and its
association with postoperative pancreatic fistula.
Methods: This was a prospective observational study. All patients undergoing pancreaticoduodenectomy at a tertiary
care center for one and a half years were included. A cut-off value of serum amylase 80U/L was used to make a
diagnosis of postoperative pancreatitis. The patients were followed up for one month. Pancreas specific complications
were defined according to the definition given by the International Study Group of Pancreatic Surgery.
Results: A total of 49 pancreaticoduodenectomies were done in the given period. The incidence of postoperative
pancreatitis was 31(63.3%) and postoperative pancreatic fistula was 19(38.8%). Postoperative pancreatic fistula
was seen in 19(61.2%) of patients having postoperative pancreatitis (P<0.001). Post-operative pancreatitis was also
significantly associated with post pancreatectomy hemorrhage, increased hospital stay, and mortality. In multivariate
analysis, preoperative endoscopic biliary drainage and increased serum amylase on the first postoperative day came out
to be an independent predictor of postoperative pancreatic fistula.
Conclusions: Post-operative Pancreatitis was associated with an increased incidence of Post-operative pancreatic
fistula and other postoperative complications like Post pancreatectomy hemorrhage and mortality.
Keywords: Pancreaticoduodenectomy; postoperative pancreatitis; postoperative pancreatic fistula; post
pancreatectomy haemorrhage

INTRODUCTION proposed by Connors, according to this hypothesis-

there are ischemic changes in pancreatic remnant that
Pancreaticoduodenectomy(PD) is one of the complex eventually lead to the pancreatitis of the pancreatic
surgery of the gastrointestinal tract with a high remnant, and the POPF is the sequelae of the POP.4 For
complication rate.1 Pancreaticoduodenectomy is diagnosing POP a raised serum amylase level more than
associated with high morbidity of around 40-60% even institutional normal serum amylase level on the day zero
at high volume center.2 Post-operative pancreatic and the first post-operative day was proposed.4
fistula(POPF) is one of the most common complications
following PD and attributes for most of the post- Some retrospective studies have shown association
operative morbidities. Post-operative pancreatic fistula between POP and POPF,5,6 but another study did not
causes abdominal collection, abscess formation and show any association.7 Hence In the light of conflicting
hemorrhage.3 evidences, lack of prospective studies and no study in
this topic in our country this study was conducted.
The novel concept post-operative pancreatitis has been
Correspondence: Dr Nirajan Subedi, Department of Surgical Gastroenterology,
National Academy of Medical Sciences- Bir hospital, Mahaboudha, Kathmandu,
Nepal. Email: [email protected], Phone: +9779851037212.

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 Post-operative Pancreatitis as a Predictor of Post-operative Pancreatic Fistula in Patients

METHODS The quantitative continuous data (Age, Body mass index,

Preoperative albumin, Intraoperative blood loss, Opera-
A prospective observational study was done between tive time, Serum amylase)were expressed as mean ± SD,
June 2019 to February 2021 after ethical clearance The categorical data(Sex, Preoperative biliary drainage,
from the Institutional review committee, Institute of pancreas texture, type of PJ and all the postoperative
Medicine, Tribhuvan University, Kathmandu, Nepal. The complications) were expressed in number (percentage)
study was done at the Department of GI and general . Patients were divided into two groups on the basis of
surgery, Tribhuvan university teaching hospital(TUTH), development of POP, development of POPF and Mortal-
Kathmandu, Nepal. All the patients with age more than ity. The difference between two quantitative continuous
18 years that had undergone PD in the study period were data were compared using the Student t-Test as a para-
included, those patients who had mortality before the metric test and Mann–Whitney U-Test as a nonparametric
third postoperative day and who refused to participate test, categorical date were compared using the χ 2 test
in the study were excluded. (parametric test) or Fisher’s exact test (nonparametric
test). The predictive value of the S. Amylase for pre-
All preoperative assessments were done, preoperative dicting POPF was assessed using a receiver operating
biliary drainage was done in those patients who characteristic (ROC) curve analysis. Variables with a sig-
were in cholangitis or nutritionally unfit, by either nificant impact on POPF and mortality as determined by
percutaneous transhepatic biliary drainage(PTBD) or univariate analysis were analysed in multivariate logis-
endoscopic retrograde cholangiopancreatography(ERCP) tic regression analysis to examine the relationship. The
and stenting. Classical PD was done which included P-value < 0.05 was taken as statistically significant. All
removal of the gall bladder with CBD, antrectomy, data were analysed using SPSS (version 23.0).
excision of head of the pancreas and duodenum
and 10 cm of jejunum.8 Pancreatojejunostomy(PJ) RESULTS
was done in all the patients and the anastomotic
technique depended on the surgeon’s preference, A total of 49 consecutive PDs were done in the study
either a dunking PJ or duct to mucosa PJ was done. period. The mean age of the patients was 53.67 ±
An end to side Hepaticojejunostomy(HJ), retro colic 11.2 years and the male: female ratio was almost
gastrojejunostomy, and a Braun’s jejunojejunostomy similar(25:24). More than half(n=25, 51%) of the
was routinely performed. patients had preoperative biliary drainage, ERCP
stenting in eight(16.3%) cases, and PTBD in 17 (34.6%)
All patients received prophylactic antibiotics and cases. The mean duration between drainage and surgery
octreotide intraoperatively and for three days was 25± 20.54 days. The mean BMI of the patients was
postoperatively, further continuation of octreotide 19.96± 2.44 Kg/m2 with mean albumin of 34.49± 6.6
dependent on surgeon discretion. Two drains were g/L. The mean duration of surgery was 428.98±106.28
placed, one at the PJ site and another at the HJ site. mins and mean blood loss was 545.92± 341.84ml.
Most(n=42,85.7%) of the patients had a soft pancreas
Serum amylase was checked four hours following surgery and only seven(14.3%) patients had firm pancreas,
and on the morning of the first POD. Drain fluid amylase the mean diameter of the main pancreatic duct was
was checked on the third POD and subsequently as 3.35±1.37mm. Ampullary carcinoma(n=31,63.3%) was
per treating physician discretion. Pancreas specific the most common final histopathology, followed by distal
complications like POPF9, postpancreatectomy cholangiocarcinoma in ten(20.4%) patients, carcinoma
haemorrhage(PPH) , Delayed gastric emptying(DGE)11,
10
head of the pancreas was present in only three(6.1%)
Chyle leak12 were defined according to that given by the patients, chronic pancreatitis in two(4.1%) and other
international study group of pancreatic surgery(ISGPS). diagnosis in three(6.1%) patients.
Bile leak was defined as that given by International
study group of liver surgery.13 Other complications were The mean serum amylase on POD0 was 179.55 U/ml with
graded according to Clavien Dindo(CD).14 Patients were a range of 10-1100 U/ml and the mean serum amylase
followed up to 30 days following surgery. on POD1 was 215.47 with a range of 10-1377 U/ml.
Out of 49 patients, 31(63.2%) developed POP. Among
The General objective of the study was to assess POP as all preoperative and intraoperative parameters, the
a predictor of POPF and the secondary objectives were mean MPD diameter was smaller(3.03± 1.01 vs 3.89±
to look for the incidence of POP and the association of 1.74mm, p=0.034) in those patients who developed
POP with other postoperative morbidities and mortality. POP. Rest other parameters like age, sex, preoperative
biliary drainage, type of biliary drainage, preoperative

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 Post-operative Pancreatitis as a Predictor of Post-operative Pancreatic Fistula in Patients

albumin, BMI, operative duration, blood loss, pancreas whereas the negative predictive value was 100%. As POP
texture were similar as shown in Table 1. was determined by serum amylase on POD 0 and POD 1,
we plotted the ROC curve of serum amylase levels and
On comparing patient with POP and without POP; its association with POPF, the AUC for POD 0 and POD 1
POPF rate was 19(61.2%) vs 0(p<0.001), PPH rate was .785 and .881 respectively(Figure1).
was 12(24.5%) vs 2(4.1%)(p=0.039), Mortality rate was
10(20.4%) vs 0(p=0.07), CD≥IIIA complications rate was As POP is functional on serum amylase on POD0/1,
18(36.7%) vs 2(4.1%) (p=0.001) respectively . Rest other initially in multivariate analysis only POP and ERCP were
postoperative events like DGE, Chyle leak, bile leak and included, but POP had a very high odds ratio, hence it
hospital stay were similar as shown in the table 1. was dropped. Due to the multicollinearity of POD 0, it
was excluded from the model. Hence, serum amylase
Out of 31 patients that developed POP, 19(61.2%, on POD 1 and ERCP were included in the multivariate
p<0.001) developed POPF. The Sensitivity of POP to analysis. High serum amylase on POD1 and preoperative
diagnose POPF was 100%, Specificity of 60%. The positive ERCP were independent predictors of POPF(Table 2).
predictive value of POP for diagnosing POPF was 61.3%,
Table 1. Comparing preoperative and intraoperative parameters between the two groups who developed and did
not develop Post Operative Pancreatitis. (α: Fisher exact test, β: Student’s T-test, rest other parameters: Chi-
square test.)
Parameters POP(Present)N=31 POP(Absent)N=18 P-Value
Age β
52.52±10.80 55.67±11.89 0.866
Sex(M: F) 17:14 8:10 0.685
Yes 18(58.1%) 7(38.9%)
Preoperative Biliary drainage 0.196
No 13(41.9%) 11(61.1%)
ERCPα 7(22.6%) 1(5.6%) 0.229
PTBD 10(32.3%) 6(33.3%) 0.938
BMI(Kg/m 2)β
20±2.5 19.37±2.26 0.176
Pre-operative Albumin(g/l) β
35.19±6.64 33.38±6.64 0.335
Operative time(mins) β 434.52±109.14 419.44±103.55 0.637
Intra-operative blood loss β
569.35±397.21 505.56±220.88 0.534
Soft 28(90.3%) 14(77.8%)
Consistency of pancreasα 0.226
Firm 3(9.7%) 4(22.2%)
Main pancreatic duct diameter(mm) 3.03±1.01 3.89±1.74 0.034
Dunking 28(66.7%) 14(33.3%)
PJα 0.398
DTM 3(42.9%) 4(57.1%)
POPF 19(61.2%) 0 <0.001
PPH 12(24.5%) 2(4.1%) 0.039
DGE α
0 1(2.0%) 0.185
Chyle leak α
1(2.0%) 18(36.7%) 0.441
Bile leakα 5(10.2%) 2(2.0%) 0.276
Hospital stay(In days) β
21±14.57 18±12.39 0.186
Mortality α
10(20.4%) 0 0.007
CD≥IIIA 18(36.7%) 2(4.1%) 0.001

Table 2. Univariate and multivariate analysis of different preoperative, intra-operative and post-operative
predictors of POPF. (α: Fisher exact test, β: Student’s T-test, rest other parameters: Chi-square test.)
POPF univariate analysis Multivariate analysis
Yes(n=19) No(n=30) P-value O.R C.I P-value
Age(in years) β 54.42±10.80 53.20±11.59 0.714
Sex 10:9 15:15 0.545

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 Post-operative Pancreatitis as a Predictor of Post-operative Pancreatic Fistula in Patients

Preoperative biliary Yes 12(63.2%) 13(43.3%)

0.145
drainage No 7(36.8%) 17(56.7%)
ERCPα 7(36.8%) 1(3.3%) 0.004 17.164 1.592-185.02 0.019
PTBD 5(26.3%) 11(36.7%) 0.541
BMI(kg/m ) 2 β
20.8±2.43 19.46±2.32 0.053
Pre-Operative Albumin(mmol/l) β 35.32±6.74 33.97±6.63 0.494
Operative time(min) β
448.42±98.56 416.67±110.74 0.313
Intraoperative blood loss(ml) β
610.53±473.92 505±222.58 0.297
Soft 18(94.7%) 24(80%)
Pancreas consistencyα 0.155
Firm 1(5.3%) 6(20%)
Dunking 17(89.5%) 25(83.3%)
PJα 0.691
DTM 2(10.5%) 5(16.7%)
S.A POD0(U/ml) β 297.42±323.10 104.9±103.22 0.004
S.A POD1(U/ml) β
387.63±366.67 106.43±117.697 <0.001 1.009 1.003-1.015 0.019
POP 19(100%) 12(40%) <0.001

Table 3. Univariate and multivariate analysis of different preoperative, intra-operative and post-operative
predictors of mortality. (α: Fisher exact test, β: Student’s T-test, rest other parameters: Chi-square test.)
Mortality (Univariate analysis) Multivariate analysis
Yes(n=10) No(n=39) P-value O.R C.I P value
Age(yrs) β
57±11.36 52.82±11.14 0.297
Sex(M: F) α
5:5 20:19 1.000
Preoperative
Yes 6(60%) 19(48.7%)
Biliary drainageα 0.725
No 4(40%) 20(51.3%)
ERCPα 3(30%) 5(12.8%) 0.197
PTBD α
3(30%) 14(33.3%) 1.00
BMI β
20.20±3.36 19.9±2.19 0.766
Preoperative Albumin(mmol/L) β 32.30±7.07 35.0519.9± 0.246
Operative Time(min) β
478.00±105.28 416.41±104.16 0.103
Blood loss(ml) β
800.00±545.18 480.77±236.63 0.007 1.005 1.00-1.01 0.041
Pancreas textureα Soft 10(1005) 32(82.1%)
0.179
Firm 0 7(17.9%)
Main Pancreatic duct diameterβ 3.00±1.15 3.44±1.42 0.0378
PJα Dunking 10(23.8%) 32(82.1%)
0.319
DTM 0 7(17.9%)
S.A POD0β 294.30±323.77 150.13±119.36 0.082
S.A POD1β 356.50±372.17 179.31±243.06 0.073
POP α
10(100%) 21(53.8%) 0.008
POPF α
8(80%) 11(28.2%) 0.008
PPHα 9(90%) 5(12.8%) <0.001 49.14 1.85-1299.90 0.02
Bile leak α
6(60%) 2(5.1%) 0.012
DGE α
0 1(2.6%) 0.796
Chyle leakα 0 1(2.6%) 0.796
Rexploration α
6(60%) 0 <0.001

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 Post-operative Pancreatitis as a Predictor of Post-operative Pancreatic Fistula in Patients

diagnosis is pancreatic ductal adenocarcinoma, 5-7,17

therefore most of the pancreas we operate on have
soft consistency(85.7%). The mean MPD diameter in our
patients is 3.35±1.37mm. Small duct and soft pancreas
are already proven risk factors for POPF.18 This might be
one explanation for the higher POPF rate(38.2%) in our
study compared to other studies. One new thing found
in our study was ERCP with stenting as a risk factor of
POPF.

Higher intraoperative blood loss and PPH were

independent predictors of mortality in this study.
Figure 1. Showing ROC curves to assess the relationship Similarly, in another study done in our center showed
between postoperative serum amylase values and that PPH with higher intra-operative blood loss was
POPF. significantly associated with mortality.19 There was a
high mortality rate in our study compared to the previous
DISCUSSION study done in our center.20

In our study post-operative pancreatitis was significantly The DGE rate was very low in our study, seen in only one
associated with POPF and other postoperative case(2.3%) compared to 13.01% and 30.5% in western
complications . The incidence of POP in our study was literature. One of the reasons behind DGE is said to
63.2% and is similar to other studies where the incidence be intra-abdominal collection secondary to POPF.18 In
ranges between41%-63.4%. Similar to other studies, our study, despite the POPF rate being such high as ~
we observed a statistically significant association 32%, the DGE rate is very low. We perform a Braun’s
between POP and POPF, PPH, CD>IIIA complications, and jejunojejunostomy regularly at our centre and our
mortality.5,6 The AUC of POD1 serum amylase was 88.1 patients have a lower BMI which might be the reason for
for diagnosing POPF, which is a very good discrimination such low DGE.21,22
capacity and the negative predictive value for POP for
POPF is very high, it was similar to a review of 292 Various authors have used other additional parameters
patients who underwent PD in Verona, Italy in 2018.5 along with serum amylase for better characterization of
Hence, by the morning of the first POD, we can identify POP. Measurement of CRP on POD 25,7, CECT abdomen23
those patients who are at high risk of developing POPF. or trend of Serum amylase from POD0-3.24 The addition
of these parameters has increased the predictivity rate
Out of the different parameters in our study, those of POPF.
patients developing POP had smaller main Pancreatic
duct(MPD) than those who did not. Smaller MPD is a There are very few studies regarding the management
proven risk factor for POPF. It is seen that small MPD is of POP. In a study, it was shown that in patients at high
seen in cases other than Carcinoma Head of Pancreas risk for POP, near-zero fluid management was associated
or chronic pancreatitis like ampullary carcinoma, distal with a higher rate of POP (24.6 vs. 0%, P < 0.01) and
cholangiocarcinoma, duodenal adenocarcinoma, in these POPF (27.6 vs. 11.4%, P 1⁄4 0.05) than liberal fluid
pathologies the acinar cell density is high. In our cohort management.5 In an RCT where ulinastatin( a trypsin
of patient the common pathology is ampullary carcinoma inhibitor) and placebo were compared, ulinastatin
. Nahm et. al studied the acinar cell density of the decreased the incidence of POP and decreased the drain
pancreatic stump and found that the increase in acinar amylase level on POD 2-3 significantly but the study was
cell density in the pancreatic stump was significantly not powered enough to detect the change in the POPF
associated with POP.15 In another retrospective study, rates.25
it was shown that smaller MPD, normal bilirubin, high-
Recently, ISGPS has tried to define Post-pancreatectomy
risk pathology, female sex, and robotic surgery was
acute pancreatitis(PPAP) as an acute inflammatory
associated with developing POP.16
condition of the pancreatic remnant beginning within
The most common histopathology in our study was the first three postoperative days following a partial
ampullary carcinoma which is different to the literature pancreatic resection. The diagnosis requires (1) a
published from the West, where the most common sustained postoperative serum hyperamylasemia (POH)
greater than the institutional upper limit of normal for

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 Post-operative Pancreatitis as a Predictor of Post-operative Pancreatic Fistula in Patients

at least the first 48 hours postoperatively; (2) associated 5. Bannone E, Andrianello S, Marchegiani G, Masini G,
with clinically relevant features; and (3) radiologic Malleo G, Bassi C et al. Postoperative Acute Pancreatitis
alterations consistent with PPAP. Three different PPAP Following Pancreaticoduodenectomy: A Determinant
grades were defined based on the clinical impact: (1) of Fistula Potentially Driven by the Intraoperative Fluid
grade POH, biochemical changes only; (2) grade B, mild Management. Ann Surg. 2018;268(5):815-822.[Article]
or moderate complications; and (3) grade C, severe life-
6. Chen H, Wang W, Ying X, Deng X, Peng C, Cheng D et
threatening complications.26
al. Predictive factors for postoperative pancreatitis after
pancreaticoduodenectomy: A single-center retrospective
There are a few drawbacks of our study, first is the
analysis of 1465 patients. Pancreatology. 2020;20(2):211-
observational bias: in our study, the complications rates
216.[Article]
were higher than our previous studies,21,27 which might
have increased the predictability of POP. The second, 7. Birgin E, Reeg A, Téoule P, Rahbari NN, Post S,
is lacking of use of other additional parameters, as Reissfelder C et al. Early postoperative pancreatitis
previously mentioned, we could have added CECT following pancreaticoduodenectomy: what is clinically
abdomen to look for features of acute pancreatitis relevant postoperative pancreatitis?. HPB (Oxford).
in the patients who had postoperative CT for any 2019;21(8):972-980.[Article]
complications. Third is that we could have taken a
8. He J, Ahuja N, Makary MA, Cameron JL, Eckhauser
biopsy from the pancreas in the reexplored patients,
FE, Choti MA et al. 2564 resected periampullary
which could have given a histopathological evidence of
adenocarcinomas at a single institution: trends over three
pancreatitis. Nevertheless, this study has increased our
decades. HPB (Oxford). 2014;16(1):83-90.[Article]
interest in this new entity. The Recent definition given
by ISGPS will help in better characterization in future 9. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal
studies.26 M, Adham M, et al. The 2016 update of the International
Study Group (ISGPS) definition and grading of
CONCLUSIONS postoperative pancreatic fistula: 11 Years After. Surgery.
2017;161(3):584-591.[Article]
Post-operative Pancreatitis was associated with an
10. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A,
increased incidence of Post-operative pancreatic
Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH):
fistula and other postoperative complications like Post
an International Study Group of Pancreatic Surgery
pancreatectomy hemorrhage and mortality.
(ISGPS) definition. Surgery. 2007;142(1):20-25.[Article]
CONFLICT OF INTEREST 11. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma
The authors declare no conflict of interest DJ, Izbicki JR, et al. Delayed gastric emptying (DGE)
after pancreatic surgery: a suggested definition by
the International Study Group of Pancreatic Surgery
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