The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy.

Autor:	Trudeau MT; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania., Casciani F; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy., Ecker BL; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania., Maggino L; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy., Seykora TF; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania., Puri P; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania., McMillan MT; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania., Miller B; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania., Pratt WB; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts., Asbun HJ; Mayo Clinic, Jacksonville, Florida., Ball CG; University of Calgary, Calgary, Canada., Bassi C; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy., Behrman SW; University of Tennessee Health Science Center, Memphis, Tennessee., Berger AC; Jefferson Medical College, Philadelphia, Pennsylvania., Bloomston MP; The Ohio State University Wexner Medical Center, Columbus, Ohio., Callery MP; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts., Castillo CF; Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts., Christein JD; University of Alabama at Birmingham School of Medicine, Birmingham, Alabama., Dillhoff ME; The Ohio State University Wexner Medical Center, Columbus, Ohio., Dickson EJ; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK., Dixon E; University of Calgary, Calgary, Canada., Fisher WE; Baylor College of Medicine, Houston, Texas., House MG; Indiana University School of Medicine, Indianapolis, Indiana., Hughes SJ; University of Florida College of Medicine, Jacksonville, Florida., Kent TS; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts., Malleo G; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy., Salem RR; Yale School of Medicine, New Haven, Connecticut., Wolfgang CL; Johns Hopkins School of Medicine, Baltimore, Maryland., Zureikat AH; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania., Vollmer CM; Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
Jazyk:	angličtina
Zdroj:	Annals of surgery [Ann Surg] 2022 Feb 01; Vol. 275 (2), pp. e463-e472.
DOI:	10.1097/SLA.0000000000004068
Abstrakt:	Objective: This study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter. Background: The FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes. Methods: FRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003-2019). The FRS was used to derive 80 unique combinations of patient "scenarios." Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches. Results: The overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) - the only negligible-risk scenario (CR-POPF rate = 0.7%). The moderate-risk zone had the most scenarios (50), patients (N = 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33). Conclusion: Through this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF. Competing Interests: The authors report no conflicts of interest. (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)
Databáze:	MEDLINE
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