Impact of dynamic risk stratification for postoperative pancreatic fistula using serum pancreatic amylase on the day after pancreatoduodenectomy.

Abstract

An appropriate combination of various biomarkers, including serum pancreatic amylase, drain amylase, and C-reactive protein levels, is pivotal for assessing the dynamic changes in patient status after pancreatoduodenectomy. This study aimed to establish a dynamic risk stratification for clinically relevant postoperative pancreatic fistula using clinically applicable parameters on postoperative days 1 to 3. Data from 234 patients who underwent pancreatoduodenectomy were analyzed. Multivariate analyses were conducted using biomarkers available on postoperative days 1 to 3. Clinically relevant postoperative pancreatic fistula, grade C postoperative pancreatic fistula, and postpancreatectomy hemorrhage were observed in 56 (24%), 12 (5%), and 24 (10%) patients, respectively. Although the prognostic value of drain amylase and C-reactive protein improved over time, serum pancreatic amylase levels on postoperative days 1 and 2 were equally predictive of clinically relevant postoperative pancreatic fistula. Patients with high levels of serum pancreatic amylase had significantly high fistula risk scores. Multivariate analysis revealed that serum pancreatic amylase ≥75 U/L and drain amylase ≥2,000 U/L on postoperative day 1 were independent risk factors (odds ratio: 18.0 and 3.45, respectively). Adding C-reactive protein on postoperative day 2 to the stratification on postoperative day 1 improved the diagnostic accuracy (odds ratio: 3.19). Finally, risk assessment on postoperative day 3, using serum pancreatic amylase ≥75 U/L on postoperative day 1, drain amylase ≥5,000 U/L on postoperative day 3, and C-reactive protein ≥22 mg/L on postoperative day 3, identified 75% of patients at highest risk for clinically relevant postoperative pancreatic fistula (odds ratio: 19.7, 5.41, and 5.01, respectively), with an accuracy of 87%. Dynamic risk stratification using serum pancreatic amylase on postoperative day 1 gradually increased the accuracy of identifying high-risk patients from postoperative days 1 to 3. Using suitable biomarkers, including those at each perioperative stage, can facilitate the early identification of high-risk patients.