• Suguru Yamashita, Takeaki Ishizawa, Kazuhiro Mori, Kazuteru Monden, Yugo Kuriki, Mako Kamiya, Junichi Kaneko, Nobuhisa Akamatsu, Junichi Arita, Yoshihiro Sakamoto, Kiyoshi Hasegawa, Yasuteru Urano, and Norihiro Kokudo.
• *Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan †Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan ‡Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan §Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan ¶PRESTO, Japan and Science and Technology Agency, Saitama, Japan ||AMED-CREST, Japan Agency for Medical Research and Development, Tokyo, Japan.
• Ann. Surg. 2017 Nov 13.

ObjectiveTo assess the predictive value of chymotrypsin activity in pancreatic juice on clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatic resection, since pancreatic peptidases rather than glycolytic enzymes play a pivotal role in causing tissue damage due to pancreatic leakage.BackgroundThe risk of CR-POPF has been estimated based on amylase level in abdominal drainage fluid.MethodsEighty-one consecutive patients underwent pancreatoduodenectomy, and postoperative pancreatic juice and drainage fluids were collected for 14 days. The chymotrypsin activity and fluid amylase level in these fluids were measured, and their susceptibility to the elapsed postoperative time and circadian rhythm were evaluated. The predictive value for the development of CR-POPF was compared between assessment of pancreatic chymotrypsin activity versus fluid amylase level.ResultsNo significant differences in the daily pancreatic chymotrypsin activity were observed, whereas the amylase level in pancreatic juice was susceptible to the postoperative interval and circadian rhythm. CR-POPF developed in 19 patients (23%). Assessment of pancreatic chymotrypsin activity on the first postoperative day predicted CR-POPF with a sensitivity/specificity of 84/87% (area under the curve, 0.855; cut-off value, 0.5 arbitrary units), which was better than measurement of fluid amylase level. Independent predictors of CR-POPF were the day-1 pancreatic chymotrypsin activity (≥0.5 arbitrary units, P < 0.001) and the main pancreatic duct index (<0.25, P = 0.039).ConclusionsAssessment of pancreatic chymotrypsin activity may allow for more rapid and accurate prediction of CR-POPF than use of conventional diagnostic criteria based on fluid amylase level, enabling individualized surgical procedures and postoperative drain management.

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