A novel nomogram for predicting the risk of major complications after pancreaticoduodenectomy in patients with obstructive jaundice

Risk stratification of postoperative pancreatic fistula and other complications following pancreatoduodenectomy. How far are we? A scoping review

PURPOSE

Pancreatoduodenectomy (PD) is a challenging procedure which is associated with high morbidity rates. This study was performed to make an overview of risk factors included in risk stratification methods both logistic regression models and models based on artificial intelligence algorithms to predict postoperative pancreatic fistula (POPF) and other complications following PD and to provide insight in the extent to which these tools were validated.

METHODS

Five databases were searched to identify relevant studies. Calculators, equations, nomograms, and artificial intelligence models that addressed POPF and other complications were included. Only PD resections were considered eligible. There was no exclusion of the minimally invasive techniques reporting PD resections. All other pancreatic resections were excluded.

RESULTS

90 studies were included. Thirty-five studies were related to POPF, thirty-five studies were related to other complications following PD and twenty studies were related to artificial intelligence predication models after PD. Among the identified risk factors, the most used factors for POPF risk stratification were the main pancreatic duct diameter (MPD) (80%) followed by pancreatic texture (51%), whereas for other complications the most used factors were age (34%) and ASA score (29.4%). Only 26% of the evaluated risk stratification tools for POPF and other complications were externally validated. This percentage was even lower for the risk models using artificial intelligence which was 20%.

CONCLUSION

The MPD was the most used factor when stratifying the risk of POPF followed by pancreatic texture. Age and ASA score were the most used factors for the stratification of other complications. Insight in clinically relevant risk factors could help surgeons in adapting their surgical strategy and shared decision-making. This study revealed that the focus of research still lies on developing new risk models rather than model validation, hampering clinical implementation of these tools for decision support.

A novel model based on clinical and computed tomography (CT) indices to predict the risk factors of postoperative major complications in patients undergoing pancreaticoduodenectomy

Background

Postoperative complications are prone to occur in patients after radical pancreaticoduodenectomy (PD). This study aimed to construct and validate a model for predicting postoperative major complications in patients after PD.

Methods

The clinical data of 360 patients who underwent PD were retrospectively collected from two centers between January 2019 and December 2023. Visceral adipose volume (VAV) and subcutaneous adipose volume (SAV) were measured using three-dimensional (3D) computed tomography (CT) reconstruction. According to the Clavien-Dindo classification system, the postoperative complications were graded. Subsequently, a predictive model was constructed based on the results of least absolute shrinkage and selection operator (LASSO) multivariate logistic regression analysis and stepwise (stepAIC) selection. The nomogram was internally validated by the training and test cohort. The discriminatory ability and clinical utility of the nomogram were evaluated by area under the receiver operating characteristic (ROC) curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

The major complications occurred in 13.3% (n = 48) of patients after PD. The nomogram revealed that high VAV/SAV, high system inflammation response index (SIRI), high triglyceride glucose-body mass index (TyG-BMI), low prognostic nutritional index (PNI) and CA199 ≥ 37 were independent risk factors for major complications. The C-index of this model was 0.854 (95%CI [0.800-0.907]), showing excellent discrimination. The calibration curve demonstrated satisfactory concordance between nomogram predictions and actual observations. The DCA curve indicated the substantial clinical utility of the nomogram.

Conclusion

The model based on clinical and CT indices demonstrates good predictive performance and clinical benefit for major complications in patients undergoing PD.

Comprehensive analysis of the association between inflammation indexes and complications in patients undergoing pancreaticoduodenectomy

Background

During clinical practice, routine blood tests are commonly performed following pancreaticoduodenectomy (PD). However, the relationship between blood cell counts, inflammation-related indices, and postoperative complications remains unclear.

Method

We conducted a retrospective study, including patients who underwent PD from October 2018 to July 2023 at the First Hospital of Chongqing Medical University, and compared baseline characteristics and clinical outcomes among different groups. Neutrophil count (NC), platelet count (PLT), lymphocyte count (LC), systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and the product of platelet count and neutrophil count (PPN) were derived from postoperative blood test results. We investigated the association between these indicators and outcomes using multivariable logistic regression and restricted cubic spline analysis. The predictive performance of these indicators was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve and decision curve analysis (DCA).

Result

A total of 232 patients were included in this study. Multivariate logistic regression and restricted cubic spline analysis showed that all indicators, except for PLT, were associated with clinical postoperative pancreatic fistula (POPF). SII, NLR, and NC were linked to surgical site infection (SSI), while SII, NLR, and PLR were correlated with CD3 complication. PLT levels were related to postoperative hemorrhage. SII (AUC: 0.729), NLR (AUC: 0.713), and NC (AUC: 0.706) effectively predicted clinical POPF.

Conclusion

In patients undergoing PD, postoperative inflammation-related indices and blood cell counts are associated with various complications. NLR and PLT can serve as primary indicators post-surgery for monitoring complications.

Five-year follow-up after pancreatoduodenectomy performed for malignancy: A single-centre study

Backgrounds/Aims

The aim of this study was to describe short- and long-term outcomes of patients who underwent pancreatoduodenectomy (PD) at a typical United Kingdom hepatopancreatobiliary unit.

Methods

A retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA), or distal cholangiocarcinoma (CC) from September 1st, 2006 to May 31st, 2015 was carried out. The following information was obtained: demographics, comorbidities, preoperative investigations, neoadjuvant treatment, operative details, postoperative management, complications, adjuvant treatment, five-year recurrence, and five-year survival. Effects of selected preoperative variables on short- and long-term outcomes were investigated.

Results

Of 271 included patients, 57.9% had PDAC, 25.8% had AA, and 16.2% had CC. In total, 67.9% experienced morbidity and 17.3% developed a Clavien-Dindo grade ≥ III complication. The 90-day mortality was 3.3%. Clinically-relevant postoperative pancreatic fistula, bile leak, gastrojejunal leak, postpancreatectomy haemorrhage and delayed gastric emptying affected 8.1%, 4.1%, 0.0%, 9.2%, and 19.9% of patients, respectively. American Society of Anesthesiologists grade III-VI correlated with overall morbidity (p = 0.002) and major morbidity (p = 0.009), but not 90-day mortality or five-year survival. The same pattern was observed in patients with a preoperative serum bilirubin > 29 μmol/L and/or a neutrophil/lymphocyte ratio > 3.1. Five-year cancer recurrence and five-year survival were 68.3% and 22.5%, respectively. PDAC patients had higher five-year recurrence but lower five-year survival rates (both p = 0.001).

Conclusions

In our series, the majority of patients experienced a complication. However, few patients experienced major morbidity. Surgical risk factors did not affect five-year survival.

Development and validation of a nomogram for predicting post-operative abdominal infection in patients undergoing pancreaticoduodenectomy

AIM

The aim of this retrospective study is to develop and validate a predictive nomogram for predicting the risk of post-operative abdominal infection (PAI) in patients undergoing pancreaticoduodenectomy (PD).

METHODS

A total of 360 patients who underwent PD were enrolled into this research and randomly divided into the development and validation group. The clinical data of patients were statistically compared and the nomogram was constructed based on the results of multivariate logistic regression analysis and stepwise (stepAIC) selection. The nomogram was internally and crossly validated by the development and validation cohort. The discriminatory ability of the nomogram was estimated by AUC (Area Under the receiver operating characteristic Curve), calibration curve and decision curve analysis.

RESULTS

After PD, post-operative abdominal infection occurred in 33.89% (n = 122) of patients. The nomogram showed that preoperative biliary drainage and C-reactive protein (CRP), direct bilirubin (DB), alkaline phosphatase (AKP) levels on the 3rd postoperative day (POD3) were independent prognostic factors for abdominal infection after PD. The internal and cross validation of Receiver Operating Characteristic (ROC) curve was statistically significant (AUC = 0.723 and 0.786, respectively). The calibration curves showed good agreement between nomogram predictions and actual observations. The decision curves showed that the nomogram was of great clinical value.

CONCLUSION

A nomogram based on perioperative risk factors such as preoperative biliary drainage, CRP, DB and AKP could simply and accurately predict the risk degree of PAI in patients undergoing PD.