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Identification of an Optimal Cut-off for Drain Fluid Amylase on Postoperative Day 1 for Predicting Clinically Relevant Fistula After Distal Pancreatectomy

A Multi-institutional Analysis and External Validation

Maggino, Laura, MD*; Malleo, Giuseppe, MD, PhD*; Bassi, Claudio, MD*; Allegrini, Valentina, MD*; Beane, Joal D., MD; Beckman, Ross M., MD; Chen, Bofeng, BA*; Dickson, Euan J., MD§; Drebin, Jeffrey A., MD, PhD*,||; Ecker, Brett L., MD*; Fraker, Douglas L., MD*; House, Michael G., MD; Jamieson, Nigel B., MD, PhD§; Javed, Ammar A., MD; Kowalsky, Stacy J., MD; Lee, Major K., MD, PhD*; McMillan, Matthew T., BA*; Roses, Robert E., MD*; Salvia, Roberto, MD*; Valero, Vicente III, MD, MHS; Velu, Lavanniya K. P., MD§; Wolfgang, Christopher L., MD, PhD; Zureikat, Amer H., MD; Vollmer, Charles M. Jr, MD*

doi: 10.1097/SLA.0000000000002532

Objective: The aim of this study was to investigate the relationship between drain fluid amylase value on the first postoperative day (DFA1) and clinically relevant fistula (CR-POPF) after distal pancreatectomy (DP), and to identify the cut-off of DFA1 that optimizes CR-POPF prediction.

Background: DFA1 is a well-recognized predictor of CR-POPF after pancreatoduodenectomy, but its role in DP is largely unexplored.

Methods: DFA1 levels were correlated with CR-POPF in 2 independent multi-institutional sets of DP patients: developmental (n = 338; years 2012 to 2017) and validation cohort (n = 166; years 2006 to 2016). Cut-off choice was based on Youden index calculation, and its ability to predict CR-POPF occurrence was tested in a multivariable regression model adjusted for clinical, demographic, operative, and pathological variables.

Results: In the developmental set, median DFA1 was 1745 U/L and the CR-POPF rate was 21.9%. DFA1 correlated with CR-POPF with an area under the curve of 0.737 (P < 0.001). A DFA1 of 2000 U/L had the highest Youden index, with 74.3% sensitivity and 62.1% specificity. Patients in the validation cohort displayed different demographic and operative characteristics, lower values of DFA1 (784.5 U/L, P < 0.001), and reduced CR-POPF rate (10.2%, P < 0.001). However, a DFA1 of 2000 U/L had the highest Youden index in this cohort as well, with 64.7% sensitivity and 75.8% specificity. At multivariable analysis, DFA1 ≥2000 U/L was the only factor significantly associated with CR-POPF in both cohorts.

Conclusion: A DFA1 of 2000 U/L optimizes CR-POPF prediction after DP. These results provide the substrate to define best practices and improve outcomes for patients receiving DP.

*Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

Department of Surgery, University of Verona, The Pancreas Institute, Verona, Italy

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN

§Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD

Department of Surgery, West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK

||Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA Memorial Sloan Kettering Cancer Center, New York, NY.

Reprints: Charles M. Vollmer, Jr, MD, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104. E-mail:

Conception/design (LM, GM, CMV); data acquisition (LM, VA, JB, RMB, NBJ, AAJ, SK, VV, LKPV); data interpretation (all authors); manuscript drafting (LM, CMV); critical revisions (all authors); final approval (all authors).

The authors did not receive any funding for this study.

The authors declare no conflict of interests.

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