Clinical and Economic Validation of the ISGPS Definition of PPAP (ISGPS-PPAP)

Clinical and Economic Validation of the International Study Group for Pancreatic Surgery (ISGPS) Definition of Postpancreatectomy Acute Pancreatitis (PPAP)

This prospective validation study aims to investigate the incidence of PPAP after pancreaticoduodenectomy (PD) by applying the ISGPS definition and grading system, to demonstrate its clinical impact by examining associated postoperative outcomes, and to validate its applicability through an economic assessment.

Study Overview

• Status: Completed
• Conditions: Postoperative Complications; Pancreaticoduodenectomy; Postoperative Pancreatic Fistula; Postoperative Acute Pancreatitis
• Intervention / Treatment: Diagnostic test: PPAP diagnosis

Detailed Description

The study will be conducted at approximately 37 investigative sites in Europe, Asia, Oceania, and the United States. Only high volume centers for Pancreatic Surgery will be included in the study. All patients scheduled to receive elective pancreaticoduodenectomy (PD Kausch-Whipple or Longmire-Traverso) for all type of pancreatic disease (benign, malignant, or premalignant) will be enrolled. The study duration per subject will be up to 30 days after surgery or all the in-hospital lengths of stay. Preoperative care will follow institutional standards, according to each center involved. Surgical resection and reconstruction will be carried out according to the techniques adopted by each participating center. Both patients undergoing open and minimally invasive surgery can be considered eligible. Postoperative management will follow the institutional standards of each center. Serum amylase (total or the pancreatic isoform) and/or lipase activity will be systematically measured at least on postoperative days (POD) 1 and 2.Serum C-reactive protein (CRP) will be measured according to each institutional policy and reported once assessed from POD 1 to 3. Drain fluid amylase, or lipase activity will be checked according to the Institutional standards of each involved, and the values will be retrieved whether assessed from POD 1 to five. Radiological imaging will be performed in the postoperative course when clinically required, facing patients' clinical worsening, suspicious for abdominal complications.The severity of complications will be assessed according to the Clavien-Dindo (CD) classification system 32 . Readmission will be defined as a new hospital admission after discharge within 30 days from index surgery. Length of hospital stay is calculated from the day of surgery to discharge. Preoperative, intra-operative, and postoperative data will be recorded prospectively.

The estimated study duration will be 15 months. Time for data analysis must be considered negligible. Patients' follow-up will last 30 days after surgery to catch any additional morbidity even after discharge from the hospital.

• Study Type: Observational
• Enrollment (Actual): 2900

Contacts and Locations

• Study Contact: Name: Giovanni Marchegiani; Phone Number: 000458124622; Email: giovanni.marchegiani@aovr.veneto.it
• Study Contact Backup: Name: Elisa Bannone; Phone Number: 000458124622; Email: bannone.elisa@gmail.com

Study Locations

• Italy
  • Verona, Italy, 37134
    • Giovanni Marchegiani

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

• Sampling Method: Probability Sample

Study Population

All patients scheduled to receive elective pancreaticoduodenectomy (PD - Kausch-Whipple or Longmire-Traverso) for all type of pancreatic disease (benign, malignant, or premalignant) will be enrolled.

Description

Inclusion Criteria:

• Scheduled for elective PD;
• Male and females ≥ 18 years;
• Upfront or after neoadjuvant therapy surgery is allowed;
• The ability of the subject to understand the character and individual consequences of the clinical trial;
• Written informed consent.

Exclusion Criteria:

• Patients undergoing emergency surgery;
• Informed consent withdrawal;
• Inability to perform the resection for any reason;
• Total or distal pancreatectomy.

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

study population; Subgroups based on the ISGPS diagnostic criteria and the grading system of PPAP: Without PPAP or POH: Patients without POH nor imaging consistent with AP.; POH: sustained postoperative serum hyperamylasemia neither clinically relevant nor consistent imaging; PPAP: requiring the fulfilment of three criteria:POH: sustained serum hyperamylasemia greater than the institutional upper limit of normal persisting on postoperative days 1 and 2;macroscopic radiologic features of APclinically relevant complications. PPAP severity will be classified into grades B and C, with progressive clinical deterioration.

Diagnostic test: PPAP diagnosis; Serum amylase (total or the pancreatic isoform) and/or lipase activity will be systematically measured at least on postoperative days 1 and 2. A CT with pancreas protocol iv contrast infusion will be performed in the postoperative course when clinically required, facing patients' clinical worsening, suspicious of abdominal complications.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The incidence of PPAP	The incidence of PPAP after pancreaticoduodenectomy (PD) by applying the ISGPS definition and grading system.	30 postoperative days
The incidence of unplanned ICU admissions and hospital readmission in the PPAP group compared to the non-PPAP one.	Only an unplanned need for intensive care will be defined as intensive care unit (ICU) stay. Readmission will be defined as a new hospital admission after discharge within 30 days from index surgery.	30 postoperative days
The difference in length of hospital stay between the PPAP and the non-PPAP group	Length of hospital stay is calculated from the day of surgery to discharge.	up to hospital discharge, an average of 30 postoperative days
The difference in hospital costs among the different grades of severity according to the ISGPS grading system22: no PPAP or POH, POH, PPAP grade B, and PPAP grade C groups.	Total hospital costs will comprise the cost of the index admission and every surgery-related readmission within 30 days from the index surgery. Costs will be inflation-adjusted using the standardized national consumer price index and normalized to adjust the variability inherent to different health systems and institutions.	30 postoperative days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Correlation between postoperative serum amylase/serum lipase activity (U/L) and radiologic feature consistent with PPAP retrieved at postoperative imaging.	Serum amylase and/or lipase activity will be systematically measured on postoperative days (POD) 1 and 2. Radiological imaging will be performed in the postoperative course when clinically required, facing the patient's clinical worsening, and suspicious of abdominal complications.	30 postoperative days
Incidence and descriptive analysis of radiological features consistent with PAPP at postoperative imaging retrieved at different time points.	The radiologic evaluation will include the pancreas enlargement, pancreas enhancement, pancreatic necrosis and percentage, peripancreatic collections, characteristics, and their location, haemorrhage and pseudoaneurysm, ascites, thrombosis, main pancreatic duct diameter (mm), POD imaging (days).	30 postoperative days
Incidence and severity of postoperative morbidity.	Postoperative morbidity will be defined according to ISGPS definitions of postoperative pancreatic fistula, delayed gastric emptying, post-pancreatectomy hemorrhage, and chyle leak. Bile leakage as defined by ISGLS. Acute kidney injury will be determined according to 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The severity of complications will be assessed according to the Clavien-Dindo classification system.	30 postoperative days
Incidence of postoperative mortality.	Mortality will be defined as postoperative death recorded out to the point of 30-days postoperatively. Beyond these time limits, the mortality, possibly related to PPAP, will be considered and discussed in each case.	30 postoperative days

Collaborators and Investigators

• Sponsor: Azienda Ospedaliera Universitaria Integrata Verona
• Collaborators: University of Colorado, Denver; The First Affiliated Hospital with Nanjing Medical University; Massachusetts General Hospital; Mayo Clinic; Hospices Civils de Lyon; Lund University; Medical University of Vienna; New York University; Catholic University of the Sacred Heart; Ludwig-Maximilians - University of Munich; Heidelberg University; Royal Free Hospital NHS Foundation Trust; Amsterdam UMC, location VUmc; Thomas Jefferson University; Technical University of Munich; University of Liverpool; University of Manchester; Universitätsklinikum Hamburg-Eppendorf; Kyoto University, Graduate School of Medicine; Tata Memorial Hospital; University of Dublin, Trinity College; San Gerardo Hospital; Indiana University Health; Flinders Medical Centre; Hospital Miguel Servet; UnitedHealth Group; Humanitas Hospital, Italy; Christchurch Hospital; Kyushu University; University of Graz; Scientific Institute San Raffaele; Petz Aladar County Teaching Hospital
• Investigators: Principal Investigator: Giovanni Marchegiani, Azienda Ospedaliera Universitaria Integrata Di Verona

Publications and helpful links

General Publications

• Marchegiani G, Barreto SG, Bannone E, Sarr M, Vollmer CM, Connor S, Falconi M, Besselink MG, Salvia R, Wolfgang CL, Zyromski NJ, Yeo CJ, Adham M, Siriwardena AK, Takaori K, Hilal MA, Loos M, Probst P, Hackert T, Strobel O, Busch ORC, Lillemoe KD, Miao Y, Halloran CM, Werner J, Friess H, Izbicki JR, Bockhorn M, Vashist YK, Conlon K, Passas I, Gianotti L, Del Chiaro M, Schulick RD, Montorsi M, Olah A, Fusai GK, Serrablo A, Zerbi A, Fingerhut A, Andersson R, Padbury R, Dervenis C, Neoptolemos JP, Bassi C, Buchler MW, Shrikhande SV; International Study Group for Pancreatic Surgery. Postpancreatectomy Acute Pancreatitis (PPAP): Definition and Grading From the International Study Group for Pancreatic Surgery (ISGPS). Ann Surg. 2022 Apr 1;275(4):663-672. doi: 10.1097/SLA.0000000000005226.
• Bannone E, Andrianello S, Marchegiani G, Masini G, Malleo G, Bassi C, Salvia R. Postoperative Acute Pancreatitis Following Pancreaticoduodenectomy: A Determinant of Fistula Potentially Driven by the Intraoperative Fluid Management. Ann Surg. 2018 Nov;268(5):815-822. doi: 10.1097/SLA.0000000000002900.
• Loos M, Strobel O, Dietrich M, Mehrabi A, Ramouz A, Al-Saeedi M, Muller-Stich BP, Diener MK, Schneider M, Berchtold C, Feisst M, Hinz U, Mayer P, Giannakis A, Schneider D, Weigand MA, Buchler MW, Hackert T. Hyperamylasemia and acute pancreatitis after pancreatoduodenectomy: Two different entities. Surgery. 2021 Feb;169(2):369-376. doi: 10.1016/j.surg.2020.07.050. Epub 2020 Sep 25.
• Chen H, Wang W, Ying X, Deng X, Peng C, Cheng D, Shen B. Predictive factors for postoperative pancreatitis after pancreaticoduodenectomy: A single-center retrospective analysis of 1465 patients. Pancreatology. 2020 Mar;20(2):211-216. doi: 10.1016/j.pan.2019.11.014. Epub 2019 Nov 27.
• Partelli S, Tamburrino D, Andreasi V, Mazzocato S, Crippa S, Perretti E, Belfiori G, Marmorale C, Balzano G, Falconi M. Implications of increased serum amylase after pancreaticoduodenectomy: toward a better definition of clinically relevant postoperative acute pancreatitis. HPB (Oxford). 2020 Nov;22(11):1645-1653. doi: 10.1016/j.hpb.2020.03.010. Epub 2020 Apr 11.

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2022
• Primary Completion (Actual): September 30, 2023
• Study Completion (Actual): January 12, 2024

Study Registration Dates

• First Submitted: October 19, 2022
• First Submitted That Met QC Criteria: January 10, 2023
• First Posted (Actual): January 11, 2023

Study Record Updates

• Last Update Posted (Actual): January 16, 2024
• Last Update Submitted That Met QC Criteria: January 12, 2024
• Last Verified: January 1, 2024

More Information

Terms related to this study

• Keywords: pancreatitis; postoperative complications; pancreatic fistula; hyperamylasemia; pancreatoduodenectomy
• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Pathological Conditions, Anatomical; Pancreatic Diseases; Digestive System Fistula; Fistula; Postoperative Complications; Pancreatitis; Pancreatic Fistula
• Other Study ID Numbers: 3822CESC

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No