• Sylvia Timme, Gian Kayser, Martin Werner, Stanislav Litkevych, Ambrus Gabor Màlyi, Tobias Keck, Peter Bronsert, Ulrich Friedrich Wellner, Ekaterina Petrova, Kim C Honselmann, and RECOPANC Review Group.
• Institute for Pathology, University of Freiburg Medical Center, Freiburg im Breisgau, Germany; Core Facility for Histopathology and Digital Pathology, University of Freiburg Medical Center, Freiburg im Breisgau, Germany; Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
• J. Am. Coll. Surg. 2021 Jun 1; 232 (6): 935-945.e2.

BackgroundSurgically assessed pancreatic texture has been identified as the strongest predictor of postoperative pancreatic fistula. However, texture is a subjective parameter with no proven reliability or validity. Therefore, a more objective parameter is needed. In this study, we evaluated the fibrosis level at the pancreatic neck resection margin and correlated fibrosis and all clinico-pathologic parameters collected over the course of the Pancreatogastrostomy vs Pancreatojejunostomy for RECOnstruction (RECOPANC) study.Study DesignThe RECOPANC trial was a multicenter randomized prospective trial of patients undergoing pancreatoduodenectomy. There were 261 hematoxylin and eosin-stained slides allocated for histopathologic analyses. Pancreatic fibrosis was scored from 0 to III (no fibrosis up to severe fibrosis) by 2 blinded independent pathologists. All variables possibly associated with POPF were entered into a generalized linear model for multivariable analysis.ResultsThe fibrosis grade and pancreatic texture were scored in all 261 patients. In POPF B/C (postoperative pancreatic fistula grade B or C) patients, 71% had a soft pancreas, and fibrosis grades were distributed as follows: 48% with score 0, 28% with score I, 20% with score II, and 7% with score III, respectively. Fibrosis grading showed substantial inter-rater reliability (kappa = 0.74) and correlated positively with hard pancreatic texture (p < 0.05). In univariable analysis, area under the curve (AUC) for POPF B/C prediction was higher for fibrosis grade than for pancreatic texture (0.71 vs 0.59). In multivariate analysis, the following predictors were selected: sex, surgeon volume, pancreatic texture, and fibrosis grade. However, the addition of pancreatic texture only led to an incremental improvement (AUC 0.794 vs 0.819).ConclusionsHistologically evaluated pancreatic fibrosis is an easily applicable and highly reproducible POPF predictor and superior to surgically evaluated pancreatic texture. Future studies might use fibrosis grade for risk stratification in pancreatoduodenectomy.Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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