• Annals of surgery · Nov 2022

    The Influence of Intraoperative Blood Loss on Fistula Development Following Pancreatoduodenectomy.

    • Maxwell T Trudeau, Fabio Casciani, Laura Maggino, Thomas F Seykora, 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 Pancreas Fistula Study Group.
    • University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
    • Ann. Surg. 2022 Nov 1; 276 (5): e527-e535.

    ObjectiveTo investigate the role of intraoperative estimated blood loss (EBL) on development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD).BackgroundMinimizing 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.MethodsThis study consists of 5534 PDs from a 17-institution collaborative (2003-2018). EBL was progressively categorized (≤150mL; 151-400mL; 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.ResultsCR-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 < 0.001, respectively). Progressive EBL cohorts displayed incremental CR-POPF rates (8.5%, 13.4%, 15.2%, 16.9%; P < 0.001). EBL >400mL 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).ConclusionEBL 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.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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