Does Postoperative Drain Amylase Predict Pancreatic Fistula after Pancreatectomy?

University of Wisconsin School of Medicine and Public Health, Department of Surgery, Section of Surgical Oncology, Madison, WI
Journal of the American College of Surgeons (Impact Factor: 5.12). 05/2014; 218(5). DOI: 10.1016/j.jamcollsurg.2014.01.048


Previous studies suggest that after pancreatectomy, drain fluid amylase obtained on postoperative day 1 (DFA1) >5000 U/L correlates with the development of postoperative pancreatic fistula (PF).1,2 We sought to validate whether DFA1 is a clinically useful predictor of PF and to evaluate whether DFA1 correlates with PF severity.

Study Design
Using a prospective database, we reviewed records from patients having pancreatectomy between 2010 and 2012. Presence and grade of PF were determined using the consensus guidelines from the International Study Group on Pancreatic Fistula (ISGPF).1

Sixty-three patients who underwent pancreatectomy had a documented DFA1. There were 27 (43%) who developed PF: 2 (7%) were grade A, 18 grade B (67%), and 7 grade C (26%). Median DFA1 in patients with PF (4600 U/L, range 32—16,900) was significantly higher than in those without (45 U/L, range 2—5840; p <0.001). When DFA1 was analyzed at varying cutoff values, correlation of DFA1 with PF was high. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed at varying levels of DFA1. Highest sensitivity (96%) and NPV (96%) were obtained with a cutoff DFA1 of < 100 U/L. On multivariate analysis, DFA1 >100 was the only significant predictor of PF when controlling for gland texture, duct size, pathology, and neoadjuvant radiation. There was no statistically significant relationship between DFA1 and PF grade.

In patients undergoing pancreatic resection, a cutoff of DFA1 <100 resulted in high sensitivity and NPV. Early drain removal may be safe in these patients. Further studies are recommended to validate the role of DFA1 in excluding PF and assisting in management of surgical drains.

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    • "Indeed patients who presented a high risk to develop a POPF were those who had higher amylase levels of drainage fluid in the first postoperative day[52]. Predictive values for DFA1 (first postoperative day drain amylase values) are very variable in the literature, ranging from DFA1 > 90 U/L[53], DFA1 > 100 U/L[54], DFA1 350 U/L[55], to 5000 U/L[56]. "
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    ABSTRACT: The most frequent reason for performing a distal pancreatectomy is the presence of cystic or neuroendocrine tumours, in which the distal pancreatic stump is often soft and non fibrotic. This parenchymal consistence represents the main risk factor for post-operative pancreatic fistula. In order to identify the fistula and assessing its severity postoperative monitoring of amylase from intraperitoneal drains is important. From a retrospective multicentric database analysis were included 33 patients who underwent distal pancreatectomy for pancreatic neoplastic disease. Postoperative pancreatic fistula occurred in four cases. one patient had a ductal adenocarcinoma, two presented with pancreatic endocrine neoplasms and the last one had an intraductal papillary mucinous neoplasia. Two patients underwent open, the other two laparoscopic distal pancreatectomy. Postoperative pancreatic fistulas after distal pancreatectomy worsen the quality of life, prolong the post-operative stay and delay further adjuvant therapy. In patients who underwent distal pancreatectomy literature exposed some advantages deriving from the placement of abdominal drainages only in selected cases and from their early removal. Patients presenting a high risk of pancreatic fistula had higher amylase levels of drainage fluid in the first postoperative day. POPF is the most frequently complication after pancreatectomy. In our analysis DFA1 > 5000 can be considered as a predictive factor for pancreatic fistula. For this reason, the systematic measurement of amylase in drain fluid in first-postoperative day can be considered a good clinical practice. Copyright © 2015. Published by Elsevier Ltd.
    Full-text · Article · Jun 2015 · International Journal of Surgery (London, England)
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    ABSTRACT: Introduction Improvements in the ability to predict pancreatic fistula could enhance patient outcomes. Previous studies demonstrate that drain fluid amylase on postoperative day 1 (DFA1) is predictive of pancreatic fistula. We sought to assess the accuracy of DFA1 and to identify a reliable DFA1 threshold under which pancreatic fistula is ruled out. Methods Patients undergoing pancreatic resection from November 1, 2011 to December 31, 2012 were selected from the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project database. Pancreatic fistula was defined as drainage of amylase-rich fluid with drain continuation >7 days, percutaneous drainage, or reoperation for a pancreatic fluid collection. Univariate and multi-variable regression models were utilized to identify factors predictive of pancreatic fistula. Results DFA1 was recorded in 536 of 2,805 patients who underwent pancreatic resection, including pancreaticoduodenectomy (n = 380), distal pancreatectomy (n = 140), and enucleation (n = 16). Pancreatic fistula occurred in 92/536 (17.2 %) patients. DFA1, increased body mass index, small pancreatic duct size, and soft texture were associated with fistula (p
    No preview · Article · Aug 2014 · Journal of Gastrointestinal Surgery
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    ABSTRACT: To perform an unbiased assessment of first postoperative day (POD 1) drain amylase level and pancreatic fistula (PF) after pancreaticoduodenectomy (PD). Recent evidence demonstrated that drain abandonment in PD is unsafe. Early drain amylase levels have been proposed as predictors of PF after PD, allowing for selection of patients for early drain removal. Daily drain amylase levels were correlated with the development of PF in 2 independent cohorts of patients undergoing PD: training cohort (n = 126; year 2008) and validation cohort (n = 369; years 2009-2012). POD 1 drain amylase level had the highest predictive ability (concordance index: 0.911) for PF in the training cohort. An amylase level of 612 U/L or higher showed the best accuracy (86%), sensitivity (93%), and specificity (79%). Thus, a cutoff value of 600 U/L was utilized. In the validation cohort, 229 (62.1%) patients had a POD 1 drain amylase level of lower than 600 U/L, and PF developed in only 2 (0.9%) cases; whereas in patients with POD 1 drain amylase level of 600 U/L or higher (n = 140) the PF rate was 31.4% (odds ratio [OR] = 52, P < 0.0001). On multivariate analysis, POD 1 drain amylase level of lower than 600 U/L (OR = 0.0192, P < 0.0001) was a stronger predictor of the absence of PF than pancreatic gland texture (OR = 0.193, P = 0.002) and duct diameter (OR = 0.861, P = 0.835). After PD, the risk of PF is less than 1% if POD 1 drain amylase level is lower than 600 U/L. We propose that in this group, which comprise more than 60% of patients, drains should be removed on POD 1.
    No preview · Article · Jan 2015 · Annals of Surgery
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