Related Experiment Video
Updated: Aug 8, 2025
DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens
Published on: February 1, 2020
Nationwide validation of the ISGPS risk classification for postoperative pancreatic fistula after
J Annelie Suurmeijer1, Anouk M Emmen1, Bert A Bonsing2
1Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands.
Insights
The 4-tier International Study Group of Pancreatic Surgery classification for postoperative pancreatic fistula after pancreatoduodenectomy is validated. A simplified 3-tier system offers comparable predictive value, suggesting potential for improved clinical risk stratification.
Area of Science:
- Surgery
- Gastroenterology
- Oncology
Background:
- The International Study Group of Pancreatic Surgery (ISGPS) developed a 4-tier risk classification (A-D) for postoperative pancreatic fistula (POPF) grade B/C after pancreatoduodenectomy.
- This classification is based on pancreatic texture and pancreatic duct size.
Purpose of the Study:
- To validate the ISGPS 4-tier risk classification system for POPF after pancreatoduodenectomy.
- To assess the predictive value of the classification in a nationwide cohort.
Main Methods:
- A retrospective analysis of 3,900 consecutive patients undergoing pancreatoduodenectomy (2014-2021) from the Dutch Pancreatic Cancer Audit.
- Calculation of POPF grade B/C rates per risk category and assessment of model performance using area under the receiver operating curve (AUC) and calibration plots.
Main Results:
- The 4-tier system showed varying POPF grade B/C rates (3.8% to 29.6%) and significant differences in in-hospital mortality (P=.001).
- No significant difference in POPF rates was observed between risk categories B and C (12.2% vs 15.6%, P=.101).
- A simplified 3-tier classification demonstrated comparable predictive discrimination (AUC 0.697 vs 0.701, P=.077).
Conclusions:
- The ISGPS 4-tier classification is validated but the two middle categories (B and C) lack distinct predictive value.
- A simplified 3-tier classification system with similar predictive performance is proposed for future validation.
Background:
The International Study Group of Pancreatic Surgery 4-tier (ie, A-D) risk classification for postoperative pancreatic fistula grade B/C is based on pancreatic texture and pancreatic duct size: A (not-soft texture and pancreatic duct >3 mm), B (not-soft texture and pancreatic duct ≤3 mm), C (soft texture and pancreatic duct >3 mm), and D (soft texture and pancreatic duct ≤3 mm). This study aimed to validate the International Study Group of Pancreatic Surgery risk classification for postoperative pancreatic fistula after pancreatoduodenectomy.
Methods:
Consecutive patients after pancreatoduodenectomy for all indications (2014-2021) were included from the nationwide, mandatory Dutch Pancreatic Cancer Audit. The rate of postoperative pancreatic fistula grade B/C (according to the International Study Group of Pancreatic Surgery 2016 definition) was calculated per risk category. Model performance was assessed using the area under the receiver operating curve (discrimination) and calibration plots.
Results:
Overall, 3,900 patients were included in risk categories: A (n = 1,046), B (n = 498), C (n = 963), and D (n = 1,393) with corresponding postoperative pancreatic fistula grade B/C rates of 3.8%, 12.2%, 15.6%, and 29.6%. Per category, the in-hospital mortality rates were 1.3%, 3.4%, 2.9%, and 4.1%, P = .001. There was no difference in the rate of postoperative pancreatic fistula between risk categories B and C (12.2% vs 15.6%, P = .101). When simplifying the classification system to a 3-tier classification system (based on 0, 1, and 2 risk factors), the discrimination was not significantly different (area under the receiver operating curve 0.697 vs area under the receiver operating curve 0.701, P = .077).
Conclusion:
This validation of the 4-tier International Study Group of Pancreatic Surgery risk classification for postoperative pancreatic fistula after pancreatoduodenectomy confirmed its predictive value. However, as the 2 middle risk categories provide no added predictive value, a simplified 3-tier classification with comparable predictive value is proposed and should be validated in future prospective studies.
