Surgeon vs Pathologist for the Prediction of Pancreatic Fistula: Results from the Randomized Multicenter RECOPANC Study.

Abstract

BACKGROUND\nSurgically assessed pancreatic texture has been identified as the strongest predictor of POPF. However, texture is a subjective parameter with no proven reliability or validity. Therefore, a more objective parameter is needed. In this study, we evaluated the fibrosis level at the pancreatic neck resection margin and correlated fibrosis and all clinico-pathological parameters collected over the course of the RECOPANC study.\n\n\nSTUDY DESIGN\nThe RECOPANC trial was a multicenter randomized prospective trial of patients undergoing pancreatoduodenectomy. 261 H&E stained slides were allocated for histopathological analyses. Pancreatic fibrosis was scored from score 0 to score III (no fibrosis up to severe fibrosis) by two blinded independent pathologists. All variables possibly associated with POPF were entered into a generalized linear model for multivariable analysis.\n\n\nRESULTS\nThe fibrosis grade and pancreatic texture was scored in all 261 patients. In POPF B/C patients, 71% had a soft pancreas and fibrosis grades were distributed as follows: 48% with score 0, 28% with score I, 20% with score II and 7% with score III, respectively. Fibrosis grading showed substantial interrater reliability (kappa=0.74) and correlated positively with hard pancreatic texture (p<0.05). In univariable analysis, area under the curve (AUC) for POPF B/C prediction was higher for fibrosis grade than for pancreatic texture (0.71 vs 0.59). In multivariate analysis, the following predictors were selected: sex, surgeon volume, pancreatic texture and fibrosis grade. However, the addition of pancreatic texture only lead to an incremental improvement (AUC 0.794 vs. 0.819).\n\n\nCONCLUSION\nHistologically evaluated pancreatic fibrosis is an easily applicable and highly reproducible POPF predictor and superior to surgically evaluated pancreatic texture. Future studies might use fibrosis grade for risk stratification in pancreatoduodenectomy.