• Maxwell T Trudeau, Fabio Casciani, Brett L Ecker, Laura Maggino, Thomas F Seykora, Priya Puri, Matthew T McMillan, Benjamin Miller, Wande B Pratt, Horacio J Asbun, Chad G Ball, Claudio Bassi, Stephen W Behrman, Adam C Berger, Mark P Bloomston, Mark P Callery, CastilloCarlos Fernandez-DelCFMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts., John D Christein, Mary E Dillhoff, Euan J Dickson, Elijah Dixon, William E Fisher, Michael G House, Steven J Hughes, Tara S Kent, Giuseppe Malleo, Ronald R Salem, Christopher L Wolfgang, Amer H Zureikat, Charles M Vollmer, and on the behalf of the Pancreas Fistula Study Group.
• Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
• Ann. Surg. 2022 Feb 1; 275 (2): e463e472e463-e472.

ObjectiveThis study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter.BackgroundThe FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes.MethodsFRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003-2019). The FRS was used to derive 80 unique combinations of patient "scenarios." Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches.ResultsThe overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) - the only negligible-risk scenario (CR-POPF rate = 0.7%). The moderate-risk zone had the most scenarios (50), patients (N = 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33).ConclusionThrough this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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