Classification of postoperative pancreatic fistula after left pancreatectomy: international multicentre cohort study

Akseli Bonsdorff; William Yu; Jakob Kirkegård; Charles de Ponthaud; Trond Kjeseth; Poya Ghorbani; Johanna Wennerblom; Caroline Williamsson; Alexandra W Acher; Manoj Thillai; Timo Tarvainen; Aki Uutela; Jukka Sirén; Arto Kokkola; Dyre Kleive; Mushegh Sahakyan; Rolf E Hagen; Andrea Lund; Mette Fugleberg Nielsen; Richard Fristedt; Christina Biörserud; Svein Olav Bratlie; Bobby Tingstedt; Knut J Labori; Sébastien Gaujoux; Stephen J Wigmore; Julie Hallet; Ernesto Sparrelid; Ville Sallinen

doi:10.1093/bjsopen/zraf149

Classification of postoperative pancreatic fistula after left pancreatectomy: international multicentre cohort study

BJS Open. 2025 Oct 30;9(6):zraf149. doi: 10.1093/bjsopen/zraf149.

Authors

Akseli Bonsdorff¹, William Yu², Jakob Kirkegård³, Charles de Ponthaud⁴, Trond Kjeseth^{5

6}, Poya Ghorbani², Johanna Wennerblom⁷, Caroline Williamsson⁸, Alexandra W Acher⁹, Manoj Thillai¹⁰, Timo Tarvainen¹, Aki Uutela^{10

11}, Jukka Sirén¹, Arto Kokkola¹, Dyre Kleive⁵, Mushegh Sahakyan^{12

13

14}, Rolf E Hagen¹⁵, Andrea Lund³, Mette Fugleberg Nielsen³, Richard Fristedt⁸, Christina Biörserud⁷, Svein Olav Bratlie⁷, Bobby Tingstedt⁸, Knut J Labori^{5

16}, Sébastien Gaujoux⁴, Stephen J Wigmore¹⁰, Julie Hallet⁹, Ernesto Sparrelid², Ville Sallinen^{1

11}

Affiliations

¹ Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
² Division of Surgery and Oncology, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
³ Department of Surgery, Aarhus University Hospital, HPB Section and Institute for Clinical Medicine, Aarhus University, Aarhus, Denmark.
⁴ Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Sorbonne Université Paris, Paris, France.
⁵ Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
⁶ Department of Clinical Medicine, University of Bergen, Bergen, Norway.
⁷ Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
⁸ Department of Surgery, Lund University, Skåne University Hospital at Lund, Lund, Sweden.
⁹ Department of Surgery, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹⁰ Hepatobiliary and Pancreatic Unit & Edinburgh Transplant Unit, University of Edinburgh, Royal Infirmary, Edinburgh, UK.
¹¹ Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
¹² Department of Surgery, Vestre Viken Hospital Trust, Ringerike Hospital, Hønefoss, Norway.
¹³ The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
¹⁴ Department of Surgery N1, Yerevan State Medical University, Yerevan, Armenia.
¹⁵ Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway.
¹⁶ Institute of Clinical Medicine, University of Oslo, Oslo, Norway.

Abstract

Background: Postoperative pancreatic fistula (POPF) is a major complication after left pancreatectomy. The current International Study Group of Pancreatic Surgery classification has limitations, including heterogeneity in morbidity and high interobserver variability. This study aimed to assess POPF-related morbidity after left pancreatectomy and propose a refined classification system.

Methods: Patients undergoing left pancreatectomy at nine high-volume centres between January 2010 and April 2023 were included. All postoperative treatments and interventions related to POPF were collected. The Comprehensive Complication Index (CCI) was used to assess total cumulative morbidity. The International Study Group of Pancreatic Surgery B POPF was subclassified (B1 = prolonged drainage, B2 = pharmacological intervention, B3 = percutaneous intervention, B4 = endoscopic or angiographic intervention). A new POPF grading system was developed by combining subclasses with similar morbidity.

Results: Among 2284 patients, 497 (21.8%) had B (B1: 48 (2.1%), B2: 135 (5.9%), B3: 175 (7.7%), B4: 99 (4.3%)) or C (40 (1.8%)) POPF. Median (interquartile range) POPF-related CCI was 33.5 (22.6-39.7). A significant overlap existed between B and C POPF in terms of CCI. Median CCI (i.q.r.) increased with the B POPF subclasses (B1-B4), 8.7 (8.7-8.7) - 22.6 (20.9-22.6) - 33.5 (33.5-34.6) - 47.4 (39.7-52.1) (P < 0.001), but no difference between B4 POPF and C POPF was observed (median CCI 47.4 versus 50.2; P = 0.265). The refined POPF grading system consists of grades 0 (including biochemical leak and B1), A (including B2), B (including B3), and C (including B4 and C) reflecting worsening morbidity.

Conclusion: The current International Study Group of Pancreatic Surgery classification includes highly heterogeneous grade B POPF cases, ranging from minimal to severe morbidity. The refined grading system improves classification and clinical relevance by aligning POPF severity with morbidity and short-term outcomes.

Publication types

Multicenter Study

MeSH terms

Aged
Female
Humans
Male
Middle Aged
Pancreatectomy* / adverse effects
Pancreatic Fistula* / classification
Pancreatic Fistula* / epidemiology
Pancreatic Fistula* / etiology
Pancreatic Fistula* / therapy
Postoperative Complications* / classification
Postoperative Complications* / epidemiology
Postoperative Complications* / etiology
Retrospective Studies

Abstract

Publication types

MeSH terms

Grants and funding