Risk factors for clinically relevant postoperative pancreatic fistula after pancreatectomy: a retrospective observational study

Risk factors for clinically relevant postoperative pancreatic fistula after pancreatectomy: a retrospective observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk factors for clinically relevant postoperative pancreatic fistula after pancreatectomy: a retrospective observational study Shenghao Zhang, Hao Li, Guoliang Cao, Ying Mei, Yang Huang, Mingjie Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7047314/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common complication following pancreatectomy. However, the pathophysiological mechanisms underlying CR-POPF remain unclear. This study aimed to identify risk factors for CR-POPF after pancreatoduodenectomy or distal pancreatectomy in the hope of developing preventive strategies and improving postoperative patient management. Methods We retrospectively identified 180 patients who underwent pancreatectomy at Huzhou Central Hospital between January 2019 and August 2023. After excluding two cases that underwent total pancreatectomy, one with a history of pancreatectomy, two with missing information on the amylase level in drainage fluid, and one that underwent distal pancreatectomy with combined adrenal, ureteral, and splenic resection, 174 patients were enrolled. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for CR-POPF. Predictive performance was evaluated using ROC curves. Results Thirty-five of the 174 patients (20.1%) developed CR-POPF. Multivariate analysis revealed that a positive drainage fluid culture (P = 0.005), an elevated perioperative white blood cell (WBC) count (P = 0.06), and an elevated perioperative C-reactive protein (CRP) level (P = 0.001) were independent risk factors for CR-POPF. For pancreaticoduodenectomy, univariate analysis identified a positive drainage fluid culture (P = 0.019), lower serum calcium on postoperative day (POD) 1 (P = 0.009), elevated perioperative WBC count (P < 0.001) and CRP (P = 0.014), and a prolonged operation time (P = 0.001) to be risk factors. Multivariate analysis confirmed a serum calcium level of < 2.0 mmol/L on POD 1, a perioperative WBC count ≥ 10.5×10⁹/L, and an operation time of ≥ 352 min to be independent risk factors. For distal pancreatectomy, univariate analysis identified a lower preoperative blood glucose level (P = 0.034) as a risk factor, but no independent factors emerged in multivariate analysis. Conclusions A positive drainage fluid culture, a perioperative WBC count ≥ 10.7×10⁹/L, and a perioperative CRP ≥ 52 mg/L were independent risk factors for CR-POPF. For pancreaticoduodenectomy, serum calcium < 2.0 mmol/L on POD 1, a perioperative WBC count ≥ 10.5 ×10 9 /L, and operation time ≥ 352 min were independent risk factors for CR-POPF. An elevated WBC count on POD 5/6 had predictive value for CR-POPF. These findings underscore the importance of postoperative monitoring for intra-abdominal infections and inflammatory markers to mitigate the risk of CR-POPF. Pancreatectomy Postoperative pancreatic fistula Risk factors Infection Inflammatory markers Figures Figure 1 Figure 2 BACKGROUND Pancreatic cancer is the seventh leading cause of cancer-related deaths globally [ 1 ] , with a universally dismal 5-year survival rate [ 2 ] . Pancreatectomy remains a cornerstone of treatment for pancreatic cancer, but is associated with significant complications, including hemorrhage, gastroparesis, biliary fistula, and pancreatic fistula. Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent and complex complication, resulting in intraperitoneal abscesses and lethal hemorrhage, with reported incidence rates ranging from 3–45% between 2005 and 2016 [ 3 ] . Although adequate attention has been paid to pancreatic fistulae in recent years by optimizing surgical approaches, including conversion from open to minimally invasive surgery, use of pancreatic duct stents, and refinement of the anastomotic approach, recent analyses of the outcomes of pancreaticoduodenectomy indicate that CR-POPF persists in approximately 14.3% of cases [ 4 ] . The pathogenesis of CR-POPF remains poorly understood. One hypothesis [ 5 ] is that pancreatic ischemia and inflammation contribute to development of CR-POPF. Ischemia at the resection site may lead to activation of pancreatic enzymes (e.g., trypsin) in an acidic environment mediated by enterokinase, pepsin, or microbial activity, resulting in tissue necrosis, ductal exposure, and subsequent leakage of pancreatic fluid. At the same time, activation of NF-κB at the resection site triggers local and systemic inflammatory responses, exacerbating pancreatic injury and promoting acute pancreatitis postoperatively, both of which may synergistically drive the development of CR-POPF. Given the high incidence of CR-POPF, identifying risk factors is critical in terms of reducing morbidity and providing new clues in the search for its pathogenesis. Several studies have identified that patient variables, including age, sex, and body mass index (BMI), affect the incidence of POPF and that certain pancreatic characteristics, [ 6 ]−[ 9 ] , particularly a soft pancreas, narrow pancreatic duct, and thick pancreas, are risk factors for POPF. A pancreas with a soft texture is vulnerable to ischemia and necrosis during surgery, and pancreatic ducts with a diameter of < 3 mm are more prone to poor drainage and inflammation [ 9 ] . Of note, Walber et al. [ 10 ] found that diabetes reduces the risk of POPF. The long-term effects of chronic diabetes may cause pancreatic fibrosis, which hardens the pancreas, thereby decreasing the risk of POPF. This is in contrast to the abovementioned situation of a soft pancreas. Therefore, attempts have been made to refine surgical techniques to reduce the incidence of POPF. In distal pancreatectomy, a stapler or hand suturing is used, depending on the texture and thickness of the pancreas [ 8 ] . Kojima et al. demonstrated that Blumgart sutures are effective in pancreaticoduodenectomy because they ensure a blood supply to the pancreas and reduce the risk of POPF [ 11 ] . Moreover, there has been some research that aimed to improve pancreatic fistulae by using a polyethylene glycol-coated hemostatic patch or autologous tissue coverage [ 12 , 13 ] . This study aimed to identify risk factors for CR-POPF following pancreatectomy and to compare risk profiles between pancreaticoduodenectomy and distal pancreatectomy. METHODS Patient cohort We retrospectively identified 180 consecutive patients who underwent pancreatectomy at Huzhou Central Hospital between January 2019 and August 2023. After excluding two cases that underwent total pancreatectomy and one with a history of prior pancreatectomy, data for 177 patients were available for analysis. Definition of CR-POPF CR-POPF was defined according to the 2016 International Study Group on Pancreatic Surgery consensus guidelines [ 3 ] . Briefly, CR-POPF was diagnosed if the amylase level in drainage fluid exceeded three times the upper limit of the normal serum value on or after postoperative day (POD) 3 and required clinical intervention such as altered therapeutic management or percutaneous drainage (grade B) or resulted in severe complications requiring reoperation or causing organ failure (grade C). Grade A fistulas (biochemical leaks) and non-fistula cases were categorized as non-CR-POPF. Clinical and pathological variables Demographic, preoperative, intraoperative, and postoperative data were collected, including age, sex, BMI, smoking history, alcohol consumption, comorbidities (hypertension, diabetes), prior upper abdominal surgery, texture of the pancreas, tumor markers (carcinoembryonic antigen, carbohydrate antigen 19 − 9), preoperative and postoperative blood glucose levels, perioperative laboratory values (WBC count, C-reactive protein [CRP], serum calcium, potassium, serum amylase), preoperative use of growth inhibitors, postoperative use of nonsteroidal anti-inflammatory drugs, time until postoperative resumption of enteral nutrition, type of postoperative enteral nutrition, surgical technique (pancreaticoduodenectomy vs. distal pancreatectomy), operation time, intraoperative blood loss, anastomotic methods, stump management, use of surgical adhesives, pancreatic duct placement, and drainage fluid culture. BMI was calculated as body weight (kg) divided by the square of height (m 2 ). The pancreatic texture palpated by the surgeon was obtained from the surgical records. Perioperative leukocytes were calculated as (preoperative + leukocytes in the first 6 postoperative days)/number of days. Perioperative CRP, calcium, and potassium were calculated using the same method. Statistical analysis Categorical variables were compared between groups using the chi-squared test or Fisher’s exact test. Variables with a P-value of < 0.05 in univariate analysis were entered into multivariate logistic regression to identify independent risk factors. The results are reported as odds ratios (ORs) with 95% confidence intervals (CIs). Receiver-operating characteristic curves were generated to evaluate predictive performance. All statistical analyses were performed using SPSS version 24.0 (IBM Corp., Armonk, NY, USA). RESULTS After excluding two cases that were missing information on the amylase level in drainage fluid and one case that underwent distal pancreatectomy with combined adrenal, ureteral, and splenic resection, the final analysis included 174 patients. Thirty-five of these patients developed CR-POPF (20 men, 15 women), yielding an overall incidence of 20.1% (35/174). Grade B fistula occurred in 30 patients and grade C fistula in five, including one that was fatal, one that required repeat surgery, and three that progressed to organ failure. Univariate analysis for all cases that underwent pancreatectomy Patients were stratified into a CR-POPF group (n = 35) and a non-CR-POPF group (n = 139). Univariate analysis identified a positive drainage fluid culture (P = 0.005), an elevated perioperative WBC count (P = 0.06), and elevated perioperative CRP (P = 0.001) to be significant risk factors for CR-POPF. Patients with a positive drainage culture had a three-fold higher risk of CR-POPF. There were no significant associations for age, sex, diabetes, hypertension, and pancreatic texture. Multivariate analysis for all cases that underwent pancreatectomy Multivariate logistic regression confirmed a positive drainage fluid culture (OR 2.75, 95% CI 1.1–6.87), a perioperative WBC count ≥ 10.7×10 9 /L (OR 1.38, 95% CI 1.17–1.61), and a perioperative CRP ≥ 52 mg/L (OR 1.02, 95% CI 1.002–1.04) to be independent risk factors for CR-POPF. Univariate analysis for pancreaticoduodenectomy To determine whether the risk factors for clinically relevant pancreatic fistula varied according to the surgical procedure performed, the patients were divided into those who underwent pancreaticoduodenectomy (n = 101) and those who underwent pancreatic body-caudal resection (n = 69). Twenty-two (21.8%) of the 101 patients who underwent pancreaticoduodenectomy developed CR-POPF. Univariate analysis identified positive drainage culture (P = 0.019), a lower serum calcium level on POD 1 (P = 0.009), an elevated perioperative WBC count (P < 0.001) and CRP level (P = 0.014), elevated serum amylase within 3 days postoperatively (P = 0.050), and a prolonged operation time (P = 0.001) to be significant risk factors. Multivariate analysis for pancreaticoduodenectomy Independent risk factors for pancreaticoduodenectomy-related CR-POPF included a serum calcium level of < 2.0 mmol/L on POD 1 (OR 0.001, 95% CI 0.00–0.47), a perioperative WBC count of ≥ 10.5×10 9 /L (OR 1.57, 95% CI 1.21–2.03), and an operation time of ≥ 352 min (OR 1.01, 95% CI 1.001–1.012). Univariate analysis for distal pancreatectomy Twelve (17.4%) of the 69 patients who underwent distal pancreatectomy developed CR-POPF. Univariate analysis identified a lower preoperative blood glucose level (P = 0.034) to be a significant risk factor. No independent risk factors were identified in multivariate analysis. DISCUSSION CR-POPF remains a common but poorly understood complication following pancreatectomy. The incidence rates observed in this study (20.1% overall, 21.8% for pancreaticoduodenectomy, 17.4% for distal pancreatectomy) align with prior reports [ 3 – 4 , 14 – 16 , 26 , 29 ] . In our study, a positive drainage fluid culture, a perioperative WBC count of ≥ 10.7×10 9 /L, and a perioperative CRP ≥ 52 mg/L were identified to be independent risk factors for clinically relevant pancreatic fistula. We identified a positive postoperative abdominal drainage fluid culture to be a basic risk factor for clinically relevant pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy. This is in line with previous studies in which a positive postoperative abdominal drainage fluid culture after pancreaticoduodenectomy was an independent risk factor for clinically relevant pancreatic fistula [ 14 ]−[ 16 ] . Demir et al. [ 17 ] concluded that a positive abdominal drainage fluid culture would result in a higher grade of pancreatic fistula. The potential cause of abdominal infection may be linked with intraoperative contamination. Some reports have found that Enterococcus faecalis accounts for the major proportion of positive postoperative drainage fluid cultures [ 14 ],[ 20 ] and that this finding is associated with reconstruction of the gastrointestinal tract in pancreaticoduodenectomy. Therefore, previous studies have focused on the relationship between intraoperative bile and lavage cultures and postoperative abdominal infection. One study found that 32.2% of intraoperative bile cultures and drain cultures on POD 3 were positive and that the bacterial species in the two cultures showed 94.9% similarity [ 21 ] . Several studies have confirmed that a positive intraoperative peritoneal lavage culture is associated with an increased incidence of positive postoperative abdominal cultures [ 18 ]−[ 20 ] , suggesting that a positive peritoneal lavage culture can to some extent predict a positive postoperative drain culture. Meanwhile, Yasukawa et al. [ 20 ] and Matsuki et al. [ 18 ] used 10,000 mL and 6,000 mL of saline, respectively, to flush the peritoneal cavity with the aim of decreasing intraoperative contamination and found that the rate of positive peritoneal lavage fluid cultures decreased as the volume of peritoneal lavage fluid increased. D'Angelica et al. observed that use of piperacillin–tazobactam antibacterial therapy based on the susceptibility of culture-positive colonies in peritoneal lavage fluid or bile reduced the absolute risk of surgical site infection by 13.0% in comparison with cefoxitin and that the incidence of CR-POPF was lower in patients treated with piperacillin–tazobactam [ 22 ] . However, researchers have also found that the bacterial populations in positive lavage fluid cultures and organ/interstitial infections are not identical [ 19 , 20 ] , which may be related to retrograde infections or anastomotic fistulas in postoperative drains. A multicenter cohort study found that compared with early drain removal (on POD 1–3), late drain removal (after POD 4) was associated with more morbidity from CR-POPF and a higher overall complication rate [ 23 ] . However, there seem to be limited data available on the relationship between the timing of drain removal and the risk of postoperative abdominal infection. CRP is one of the proteins in plasma that increase sharply when the organism is exposed to infection or tissue damage. CRP levels usually peak about 48–72 hours after a single stimulus (e.g., surgical trauma), and decrease thereafter if there is no ongoing stimulus (e.g., a pancreatic fistula or a complication such as infection) [ 24 ] , which is in line with the peak CRP being observed at about POD 3 in this study. We found a significant difference in the CRP level between patients with CR-POPF and those without CR-POPF from POD 3 onwards; this finding was significant after pancreaticoduodenectomy, but not after distal pancreatectomy, which may reflect some of the differences between these surgical procedures. Pancreaticoduodenectomy generally requires a longer operation time with pancreatico-enteric and biliary-enteric anastomoses, which involve more complex vascular and anatomical structures and require dissection and destruction of a larger amount of tissue, resulting in more trauma. Therefore, pancreaticoduodenectomy is more likely to cause insufficient perfusion of residual pancreatic tissues (ischemia) or a localized inflammatory response, inducing acute pancreatitis postoperatively and evolving further into CR-POPF [ 25 ] , as evidenced by the significant elevation of blood amylase within 3 days after pancreaticoduodenectomy in this study. A multicenter retrospective study also identified CRP as a risk factor for clinically relevant pancreatic fistula on days 3, 5, and 7 after pancreaticoduodenectomy; all time points had early predictive value, with respective areas under the receiver-operating characteristic curve of 0.78, 0.83, and 0.85 [ 26 ] . Another meta-analysis found that the area under the curve (AUC) for CRP was > 0.80 on PODs 3–5, especially on POD 4. The sensitivity of CRP for POPF was 0.85 and the specificity was 0.69, indicating positive diagnostic value [ 27 ] . However, Solaini et al. [ 28 ] identified the CRP on POD 3 to be an early predictor of pancreatic fistula, and that its accuracy and sensitivity seemed to be improved when used alone. Partelli et al. [ 29 ] found that CR-POPF occurred in almost all patients with an amylase level of > 500 IU/L in drainage fluid on POD 1 and a CRP level of > 185 mg/L on POD 3, and proposed that a combination of these two variables may have an improved ability to predict CR-POPF. WBCs, which are responsible for recognizing and eliminating pathogens, clearing damaged cells, and regulating the immune response, represent an inflammation-related response indicator. Although previous studies have found a significant difference in the WBC count on POD 3/5 between groups with and without CR-POPF [ 26 , 29 ] , few reports have used this parameter as a predictive index for assessment of clinically relevant pancreatic fistula. In this study, the AUC for a WBC count of > 10.85 mg/dL was highest on POD 5/6 after both pancreatectomy (0.81, with a sensitivity of 0.73 and a specificity of 0.80) and pancreaticoduodenectomy (0.85, with a sensitivity of 0.76 and a specificity of 0.88). We also analyzed the relationship between the WBC count on POD 5/6 and pancreatic fistula (persistent and new-onset) after POD 3. We found an 83% incidence of POPF and a 61% incidence of CR-POPF in pancreatectomized patients with a WBC count of > 10.85 mg/dL on POD 5/6, with respective rates of 85% and 76% after pancreaticoduodenectomy and a CR-POPF rate of only 48% after distal pancreatectomy. These results suggest a closer correlation between the WBC count and pancreaticoduodenectomy and that an elevated WBC count on POD 5 has predictive significance for CR-POPF. Ma et al. identified an elevated WBC count on POD 3 as an independent risk factor with predictive value after laparoscopic pancreaticoduodenectomy [ 30 ] . Although most of the studies have found CRP and procalcitonin to have better predictive significance, both the WBC count and CRP have been identified as indicators of inflammation and often increase sequentially during postoperative management. In the present study, the WBC count and CRP level were both found to be risk factors for CR-POPF, but whether they can be used together to predict CR-POPF needs further investigation. This study had some limitations, in particular a single-center retrospective design with a limited sample size, which means that the generalizability of our findings may be limited, and the possibility of bias cannot be excluded. Further clarification of risk factors is needed in large, multicenter, high-quality randomized trials. CONCLUSIONS Positive drainage fluid culture, perioperative WBC ≥ 10.7×10 9 /L, and perioperative CRP ≥ 52 mg/L are independent risk factors for CR-POPF. Pancreaticoduodenectomy-specific risks include postoperative hypocalcemia, elevated perioperative WBC ≥ 10.5×10 9 /L, and prolonged operation time ≥ 352 min. Positive postoperative drainage fluid cultures and elevated perioperative CRP and WBC suggest that clinically relevant pancreatic fistulas may be closely related to intraoperative or postoperative infections and inflammation. An elevated WBC count on POD 5/6 demonstrates predictive value, highlighting the importance of monitoring inflammatory markers and intra-abdominal infections to optimize postoperative management. Abbreviations CR-POPF Clinically relevant postoperative pancreatic fistula WBC white blood cell count CRP C-reactive protein PD pancreaticoduodenectomy DP distal pancreatectomy POD1 postoperative day 1 BMI body mass index PPAP postoperative acute pancreatitis POPF postoperative pancreatic fistula ISGPF International Study Group on Pancreatic Surgery NSAID nonsteroidal anti-inflammatory drug Declarations Ethics approval and consent to participate This study was approved by the ethics committee of Huzhou central hospital on June 20, 2025.(Approval NO:202506020-01). Written informed consent forms about this procedure were obtained for all patients before surgery. Clinical trial number not applicable Consent for publication Not applicable. Competing interests The authors declare that they have no competing interest. Funding This work was supported by Public Welfare Application Research of Huzhou Science and Technology Bureau 2021GYB24. Author Contribution SZ and MZ designed the studies. SZ, YH and YM performed data acquisition and analysis. SZ, HL and GC performed statistical analysis and data interpretation.SZ prepared the manuscript. All authors read and approved the final manuscript. Acknowledgement We thank Susan Albrecht, PhD, from Liwen Bianji (Edanz) for editing the English text of a draft of this manuscript. Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files]. References Stoffel EM, Brand RE, Goggins M. Pancreatic Cancer: Changing Epidemiology and New Approaches to Risk Assessment, Early Detection, and Prevention. Gastroenterology. 2023;164(5):752–65. Hu JX, Zhao CF, Chen WB, Liu QC, Li QW, Lin YY, Gao F. Pancreatic cancer: A review of epidemiology, trend, and risk factors. World J Gastroenterol. 2021;27(27):4298–321. 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Tables Univariate analysis of risk factors for CR-POPF after all cases that underwent pancreatectomy Variables CR-POPF χ2 P value YES(n = 35) NO(n = 139) perioperative WBC(10 9 /L) <10.7 ≥ 10.7 11 24 80 59 7.650 0.006+ perioperative CRP(mg/L) <52 ≥ 52 10 25 82 57 10.385 0.001+ Operation time(min) <305 ≥ 305 14 21 74 65 1.96 0.162 intraoperative blood loss(ml) <246 ≥ 246 22 13 100 39 1.101 0.294 Pancreatic texture Soft 31 125 0.055 0.814 Hard 4 14 Surgical procedure PD DP 22 12 79 58 1.324 0.493 middle pancreatectomy 1 2 Surgical method Open Laparoscope 25 10 109 30 0.771 0.380 Drainage fluid culture Positive Negative 15 20 28 111 7.753 0.005+ Univariate analysis of risk factors for CR-POPF after PD Variables CR-POPF χ2 P Value YES(n = 22) NO(n = 79) Preoperative serum calcium(mmol/L) <2.2 ≥ 2.2 11 11 30 49 1.032 0.310 POD1 serum calcium(mmol/L) <2.0 ≥ 2.0 9 13 12 67 6.912 0.009+ Perioperative serum calcium(mmol/L) <2.1 ≥ 2.1 11 11 25 54 2.527 0.112 Blood amylase within POD3(U/L) <161 ≥ 161 12 10 60 19 3.851 0.050+ perioperative WBC(10 9 /L) <10.5 ≥ 10.5 5 17 51 28 12.188 0.000+ perioperative CRP(mg/L) <50 ≥ 50 6 16 45 34 6.068 0.014+ Operation time(min) <352 ≥ 352 8 14 59 20 11.315 0.001+ Pancreatic texture Soft 3 9 0.218 0.640 Hard 19 71 Drainage fluid culture Positive Negative 12 10 22 57 5.492 0.019+ Univariate analysis of risk factors for CR-POPF after DP Variables CR-POPF χ2 P Value YES(n = 12) NO(n = 57) Pancreatic texture Soft 11 51 0.000 1.000 Hard 1 6 Drainage fluid culture Positive Negative 3 9 5 52 1.210 0.271 Stump management Suture Stapling Suture and stapling 5 4 3 7 35 15 5.622 0.055 Surgical adhesives Yes No 4 8 27 30 0.789 0.374 perioperative WBC(10 9 /L) <10.5 ≥ 10.5 4 8 22 35 0.117 0.732 perioperative CRP(mg/L) <50 ≥ 50 4 8 29 28 1.223 0.269 Operation time(min) <240 ≥ 240 7 5 30 27 0.130 0.719 Intraoperative blood loss(ml) <230 ≥ 230 9 3 43 14 0.001 0.974 Drainage fluid culture Positive Negative 3 9 5 52 1.210 0.271 Comparison of WBC5/6 after different surgical procedure WBC POD5/6(109/L) CR-POPF χ2 P value YES NO PD + DP <10 ≥ 10 8 97 27 42 25.73 <0.001 PD <10 ≥ 10 4 18 59 20 23.408 <0.001 DP <10 ≥ 10 3 9 35 22 5.309 0.021 Multivariate logistic regression analysis for CR-POPF after all cases that underwent pancreatectomy β S.E. Wald P value OR CI 95% Drainage fluid culture 1.012 0.467 4.685 0.030 2.750 1.100-6.872 Perioperative WBC 0.318 0.081 15.596 0.000 1.375 1.174–1.610 Perioperative CRP 0.021 0.010 4.637 0.031 1.021 1.002–1.040 Multivariate logistic regression analysis for CR-POPF after PD β S.E. Wald P value OR CI95% POD1 serum calcium -7.343 3.357 4.784 0.029 0.001 0.000-.466 Blood amylase within POD3 0.002 0.002 0.627 0.428 1.002 0.997–1.006 Perioperative WBC 0.449 0.132 11.520 0.001 1.567 1.209–2.032 Perioperative CRP 0.015 0.016 0.819 0.365 1.015 0.983–1.047 Operation time 0.006 0.003 5.142 0.023 1.006 1.001–1.012 Drainage fluid culture 1.087 0.676 2.583 0.108 2.965 0.788–11.161 AUC, sensitivity, and specificity of postoperative WBC on postoperative days 5 or 6 AUC Sensitivity Specificity All case 0.81 0.73 0.80 PD 0.85 0.76 0.88 DP 0.762 0.73 0.76 Additional Declarations No competing interests reported. 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Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Li","suffix":""},{"id":504810226,"identity":"b461585f-0954-4b44-8d52-6893a7cab969","order_by":2,"name":"Guoliang Cao","email":"","orcid":"","institution":"Affiliated Huzhou Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Guoliang","middleName":"","lastName":"Cao","suffix":""},{"id":504810229,"identity":"06eece24-029e-4e67-8b5a-b8eca82f89b4","order_by":3,"name":"Ying Mei","email":"","orcid":"","institution":"Huzhou Central Hospital, Affiliated Hospital of Huzhou Normal University","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Mei","suffix":""},{"id":504810231,"identity":"4aa173ba-83ec-46d8-9614-0f874ca4857d","order_by":4,"name":"Yang Huang","email":"","orcid":"","institution":"Affiliated Huzhou Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Huang","suffix":""},{"id":504810236,"identity":"a40a8238-dd97-44cc-83f0-fdf83b848344","order_by":5,"name":"Mingjie Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBAC+waGBAYGAwkeNvnjBx8kVNQQ1sII1lJhI8MvwZNs8ODMMaK0AMGZNBvJGQxmkg9bmAlrYRY78EzyZ9thHoPbDWkViQ1sDPzt3Ql4tbBJJ6RJ84K03Dl47EbiDhkGiTNnN+DVwgPSwgjSciAh7UbiGTZgUOTi1yIB1AJx2IEEs4LENmbCWgyAWiR4zqTxSM5IMGMgVkuyNU+FDQ8/z5lkiYQzx3gI+sV+dk7izR8GEvZs7O0HP/6oqJHjb+/FrwUYACkSKFwCykGA/fAHIlSNglEwCkbBSAYAtYlKacQyEsgAAAAASUVORK5CYII=","orcid":"","institution":"Affiliated Huzhou Hospital, Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Mingjie","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-07-04 13:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7047314/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7047314/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90310949,"identity":"26645576-2d71-436b-bb0f-3da0f2a48eac","added_by":"auto","created_at":"2025-09-01 09:47:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":16941,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic (ROC) curves were used to evaluate WBC on postoperative days 5 or 6 after all cases that underwent pancreatectomy\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7047314/v1/c85df9bc7402a68e3e2d0493.png"},{"id":90312367,"identity":"2b8589d9-d93e-499a-8cae-9efeba99f611","added_by":"auto","created_at":"2025-09-01 09:55:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18953,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic (ROC) curves were used to evaluate WBC on postoperative days 5 or 6 after PD and DP\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7047314/v1/38488a0b9848c470ee682e5c.png"},{"id":90328074,"identity":"70484dc8-8594-4117-addd-d1a301c42c69","added_by":"auto","created_at":"2025-09-01 12:32:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1436481,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7047314/v1/2d1eeee9-ca34-4b52-9aad-538a18b73150.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factors for clinically relevant postoperative pancreatic fistula after pancreatectomy: a retrospective observational study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePancreatic cancer is the seventh leading cause of cancer-related deaths globally \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, with a universally dismal 5-year survival rate \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Pancreatectomy remains a cornerstone of treatment for pancreatic cancer, but is associated with significant complications, including hemorrhage, gastroparesis, biliary fistula, and pancreatic fistula. Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent and complex complication, resulting in intraperitoneal abscesses and lethal hemorrhage, with reported incidence rates ranging from 3–45% between 2005 and 2016 \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Although adequate attention has been paid to pancreatic fistulae in recent years by optimizing surgical approaches, including conversion from open to minimally invasive surgery, use of pancreatic duct stents, and refinement of the anastomotic approach, recent analyses of the outcomes of pancreaticoduodenectomy indicate that CR-POPF persists in approximately 14.3% of cases \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe pathogenesis of CR-POPF remains poorly understood. One hypothesis \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e is that pancreatic ischemia and inflammation contribute to development of CR-POPF. Ischemia at the resection site may lead to activation of pancreatic enzymes (e.g., trypsin) in an acidic environment mediated by enterokinase, pepsin, or microbial activity, resulting in tissue necrosis, ductal exposure, and subsequent leakage of pancreatic fluid. At the same time, activation of NF-κB at the resection site triggers local and systemic inflammatory responses, exacerbating pancreatic injury and promoting acute pancreatitis postoperatively, both of which may synergistically drive the development of CR-POPF.\u003c/p\u003e\u003cp\u003eGiven the high incidence of CR-POPF, identifying risk factors is critical in terms of reducing morbidity and providing new clues in the search for its pathogenesis. Several studies have identified that patient variables, including age, sex, and body mass index (BMI), affect the incidence of POPF and that certain pancreatic characteristics, \u003csup\u003e[\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]−[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, particularly a soft pancreas, narrow pancreatic duct, and thick pancreas, are risk factors for POPF. A pancreas with a soft texture is vulnerable to ischemia and necrosis during surgery, and pancreatic ducts with a diameter of \u0026lt; 3 mm are more prone to poor drainage and inflammation \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Of note, Walber et al. \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e found that diabetes reduces the risk of POPF. The long-term effects of chronic diabetes may cause pancreatic fibrosis, which hardens the pancreas, thereby decreasing the risk of POPF. This is in contrast to the abovementioned situation of a soft pancreas. Therefore, attempts have been made to refine surgical techniques to reduce the incidence of POPF. In distal pancreatectomy, a stapler or hand suturing is used, depending on the texture and thickness of the pancreas \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Kojima et al. demonstrated that Blumgart sutures are effective in pancreaticoduodenectomy because they ensure a blood supply to the pancreas and reduce the risk of POPF \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Moreover, there has been some research that aimed to improve pancreatic fistulae by using a polyethylene glycol-coated hemostatic patch or autologous tissue coverage \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study aimed to identify risk factors for CR-POPF following pancreatectomy and to compare risk profiles between pancreaticoduodenectomy and distal pancreatectomy.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003ePatient cohort\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe retrospectively identified 180 consecutive patients who underwent pancreatectomy at Huzhou Central Hospital between January 2019 and August 2023. After excluding two cases that underwent total pancreatectomy and one with a history of prior pancreatectomy, data for 177 patients were available for analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDefinition of CR-POPF\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCR-POPF was defined according to the 2016 International Study Group on Pancreatic Surgery consensus guidelines \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Briefly, CR-POPF was diagnosed if the amylase level in drainage fluid exceeded three times the upper limit of the normal serum value on or after postoperative day (POD) 3 and required clinical intervention such as altered therapeutic management or percutaneous drainage (grade B) or resulted in severe complications requiring reoperation or causing organ failure (grade C). Grade A fistulas (biochemical leaks) and non-fistula cases were categorized as non-CR-POPF.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical and pathological variables\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDemographic, preoperative, intraoperative, and postoperative data were collected, including age, sex, BMI, smoking history, alcohol consumption, comorbidities (hypertension, diabetes), prior upper abdominal surgery, texture of the pancreas, tumor markers (carcinoembryonic antigen, carbohydrate antigen 19 − 9), preoperative and postoperative blood glucose levels, perioperative laboratory values (WBC count, C-reactive protein [CRP], serum calcium, potassium, serum amylase), preoperative use of growth inhibitors, postoperative use of nonsteroidal anti-inflammatory drugs, time until postoperative resumption of enteral nutrition, type of postoperative enteral nutrition, surgical technique (pancreaticoduodenectomy vs. distal pancreatectomy), operation time, intraoperative blood loss, anastomotic methods, stump management, use of surgical adhesives, pancreatic duct placement, and drainage fluid culture. BMI was calculated as body weight (kg) divided by the square of height (m\u003csup\u003e2\u003c/sup\u003e). The pancreatic texture palpated by the surgeon was obtained from the surgical records. Perioperative leukocytes were calculated as (preoperative + leukocytes in the first 6 postoperative days)/number of days. Perioperative CRP, calcium, and potassium were calculated using the same method.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eCategorical variables were compared between groups using the chi-squared test or Fisher’s exact test. Variables with a P-value of \u0026lt; 0.05 in univariate analysis were entered into multivariate logistic regression to identify independent risk factors. The results are reported as odds ratios (ORs) with 95% confidence intervals (CIs). Receiver-operating characteristic curves were generated to evaluate predictive performance. All statistical analyses were performed using SPSS version 24.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAfter excluding two cases that were missing information on the amylase level in drainage fluid and one case that underwent distal pancreatectomy with combined adrenal, ureteral, and splenic resection, the final analysis included 174 patients. Thirty-five of these patients developed CR-POPF (20 men, 15 women), yielding an overall incidence of 20.1% (35/174). Grade B fistula occurred in 30 patients and grade C fistula in five, including one that was fatal, one that required repeat surgery, and three that progressed to organ failure.\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnivariate analysis for all cases that underwent pancreatectomy\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients were stratified into a CR-POPF group (n\u0026thinsp;=\u0026thinsp;35) and a non-CR-POPF group (n\u0026thinsp;=\u0026thinsp;139). Univariate analysis identified a positive drainage fluid culture (P\u0026thinsp;=\u0026thinsp;0.005), an elevated perioperative WBC count (P\u0026thinsp;=\u0026thinsp;0.06), and elevated perioperative CRP (P\u0026thinsp;=\u0026thinsp;0.001) to be significant risk factors for CR-POPF. Patients with a positive drainage culture had a three-fold higher risk of CR-POPF. There were no significant associations for age, sex, diabetes, hypertension, and pancreatic texture.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMultivariate analysis for all cases that underwent pancreatectomy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMultivariate logistic regression confirmed a positive drainage fluid culture (OR 2.75, 95% CI 1.1\u0026ndash;6.87), a perioperative WBC count\u0026thinsp;\u0026ge;\u0026thinsp;10.7\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L (OR 1.38, 95% CI 1.17\u0026ndash;1.61), and a perioperative CRP\u0026thinsp;\u0026ge;\u0026thinsp;52 mg/L (OR 1.02, 95% CI 1.002\u0026ndash;1.04) to be independent risk factors for CR-POPF.\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnivariate analysis for pancreaticoduodenectomy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo determine whether the risk factors for clinically relevant pancreatic fistula varied according to the surgical procedure performed, the patients were divided into those who underwent pancreaticoduodenectomy (n\u0026thinsp;=\u0026thinsp;101) and those who underwent pancreatic body-caudal resection (n\u0026thinsp;=\u0026thinsp;69). Twenty-two (21.8%) of the 101 patients who underwent pancreaticoduodenectomy developed CR-POPF. Univariate analysis identified positive drainage culture (P\u0026thinsp;=\u0026thinsp;0.019), a lower serum calcium level on POD 1 (P\u0026thinsp;=\u0026thinsp;0.009), an elevated perioperative WBC count (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and CRP level (P\u0026thinsp;=\u0026thinsp;0.014), elevated serum amylase within 3 days postoperatively (P\u0026thinsp;=\u0026thinsp;0.050), and a prolonged operation time (P\u0026thinsp;=\u0026thinsp;0.001) to be significant risk factors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMultivariate analysis for pancreaticoduodenectomy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIndependent risk factors for pancreaticoduodenectomy-related CR-POPF included a serum calcium level of \u0026lt;\u0026thinsp;2.0 mmol/L on POD 1 (OR 0.001, 95% CI 0.00\u0026ndash;0.47), a perioperative WBC count of \u0026ge;\u0026thinsp;10.5\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L (OR 1.57, 95% CI 1.21\u0026ndash;2.03), and an operation time of \u0026ge;\u0026thinsp;352 min (OR 1.01, 95% CI 1.001\u0026ndash;1.012).\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnivariate analysis for distal pancreatectomy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTwelve (17.4%) of the 69 patients who underwent distal pancreatectomy developed CR-POPF. Univariate analysis identified a lower preoperative blood glucose level (P\u0026thinsp;=\u0026thinsp;0.034) to be a significant risk factor. No independent risk factors were identified in multivariate analysis.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCR-POPF remains a common but poorly understood complication following pancreatectomy. The incidence rates observed in this study (20.1% overall, 21.8% for pancreaticoduodenectomy, 17.4% for distal pancreatectomy) align with prior reports \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. In our study, a positive drainage fluid culture, a perioperative WBC count of \u0026ge;\u0026thinsp;10.7\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L, and a perioperative CRP\u0026thinsp;\u0026ge;\u0026thinsp;52 mg/L were identified to be independent risk factors for clinically relevant pancreatic fistula.\u003c/p\u003e\u003cp\u003eWe identified a positive postoperative abdominal drainage fluid culture to be a basic risk factor for clinically relevant pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy. This is in line with previous studies in which a positive postoperative abdominal drainage fluid culture after pancreaticoduodenectomy was an independent risk factor for clinically relevant pancreatic fistula \u003csup\u003e[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u0026minus;[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Demir et al. \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e concluded that a positive abdominal drainage fluid culture would result in a higher grade of pancreatic fistula. The potential cause of abdominal infection may be linked with intraoperative contamination. Some reports have found that \u003cem\u003eEnterococcus faecalis\u003c/em\u003e accounts for the major proportion of positive postoperative drainage fluid cultures \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e],[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e and that this finding is associated with reconstruction of the gastrointestinal tract in pancreaticoduodenectomy. Therefore, previous studies have focused on the relationship between intraoperative bile and lavage cultures and postoperative abdominal infection. One study found that 32.2% of intraoperative bile cultures and drain cultures on POD 3 were positive and that the bacterial species in the two cultures showed 94.9% similarity \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Several studies have confirmed that a positive intraoperative peritoneal lavage culture is associated with an increased incidence of positive postoperative abdominal cultures \u003csup\u003e[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u0026minus;[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e, suggesting that a positive peritoneal lavage culture can to some extent predict a positive postoperative drain culture. Meanwhile, Yasukawa et al. \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e and Matsuki et al. \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e used 10,000 mL and 6,000 mL of saline, respectively, to flush the peritoneal cavity with the aim of decreasing intraoperative contamination and found that the rate of positive peritoneal lavage fluid cultures decreased as the volume of peritoneal lavage fluid increased. D'Angelica et al. observed that use of piperacillin\u0026ndash;tazobactam antibacterial therapy based on the susceptibility of culture-positive colonies in peritoneal lavage fluid or bile reduced the absolute risk of surgical site infection by 13.0% in comparison with cefoxitin and that the incidence of CR-POPF was lower in patients treated with piperacillin\u0026ndash;tazobactam \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. However, researchers have also found that the bacterial populations in positive lavage fluid cultures and organ/interstitial infections are not identical \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e, which may be related to retrograde infections or anastomotic fistulas in postoperative drains. A multicenter cohort study found that compared with early drain removal (on POD 1\u0026ndash;3), late drain removal (after POD 4) was associated with more morbidity from CR-POPF and a higher overall complication rate \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. However, there seem to be limited data available on the relationship between the timing of drain removal and the risk of postoperative abdominal infection.\u003c/p\u003e\u003cp\u003eCRP is one of the proteins in plasma that increase sharply when the organism is exposed to infection or tissue damage. CRP levels usually peak about 48\u0026ndash;72 hours after a single stimulus (e.g., surgical trauma), and decrease thereafter if there is no ongoing stimulus (e.g., a pancreatic fistula or a complication such as infection) \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e, which is in line with the peak CRP being observed at about POD 3 in this study. We found a significant difference in the CRP level between patients with CR-POPF and those without CR-POPF from POD 3 onwards; this finding was significant after pancreaticoduodenectomy, but not after distal pancreatectomy, which may reflect some of the differences between these surgical procedures. Pancreaticoduodenectomy generally requires a longer operation time with pancreatico-enteric and biliary-enteric anastomoses, which involve more complex vascular and anatomical structures and require dissection and destruction of a larger amount of tissue, resulting in more trauma. Therefore, pancreaticoduodenectomy is more likely to cause insufficient perfusion of residual pancreatic tissues (ischemia) or a localized inflammatory response, inducing acute pancreatitis postoperatively and evolving further into CR-POPF \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e, as evidenced by the significant elevation of blood amylase within 3 days after pancreaticoduodenectomy in this study. A multicenter retrospective study also identified CRP as a risk factor for clinically relevant pancreatic fistula on days 3, 5, and 7 after pancreaticoduodenectomy; all time points had early predictive value, with respective areas under the receiver-operating characteristic curve of 0.78, 0.83, and 0.85 \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Another meta-analysis found that the area under the curve (AUC) for CRP was \u0026gt;\u0026thinsp;0.80 on PODs 3\u0026ndash;5, especially on POD 4. The sensitivity of CRP for POPF was 0.85 and the specificity was 0.69, indicating positive diagnostic value \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. However, Solaini et al. \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e identified the CRP on POD 3 to be an early predictor of pancreatic fistula, and that its accuracy and sensitivity seemed to be improved when used alone. Partelli et al. \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e found that CR-POPF occurred in almost all patients with an amylase level of \u0026gt;\u0026thinsp;500 IU/L in drainage fluid on POD 1 and a CRP level of \u0026gt;\u0026thinsp;185 mg/L on POD 3, and proposed that a combination of these two variables may have an improved ability to predict CR-POPF.\u003c/p\u003e\u003cp\u003eWBCs, which are responsible for recognizing and eliminating pathogens, clearing damaged cells, and regulating the immune response, represent an inflammation-related response indicator. Although previous studies have found a significant difference in the WBC count on POD 3/5 between groups with and without CR-POPF \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e, few reports have used this parameter as a predictive index for assessment of clinically relevant pancreatic fistula. In this study, the AUC for a WBC count of \u0026gt;\u0026thinsp;10.85 mg/dL was highest on POD 5/6 after both pancreatectomy (0.81, with a sensitivity of 0.73 and a specificity of 0.80) and pancreaticoduodenectomy (0.85, with a sensitivity of 0.76 and a specificity of 0.88). We also analyzed the relationship between the WBC count on POD 5/6 and pancreatic fistula (persistent and new-onset) after POD 3. We found an 83% incidence of POPF and a 61% incidence of CR-POPF in pancreatectomized patients with a WBC count of \u0026gt;\u0026thinsp;10.85 mg/dL on POD 5/6, with respective rates of 85% and 76% after pancreaticoduodenectomy and a CR-POPF rate of only 48% after distal pancreatectomy. These results suggest a closer correlation between the WBC count and pancreaticoduodenectomy and that an elevated WBC count on POD 5 has predictive significance for CR-POPF. Ma et al. identified an elevated WBC count on POD 3 as an independent risk factor with predictive value after laparoscopic pancreaticoduodenectomy \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Although most of the studies have found CRP and procalcitonin to have better predictive significance, both the WBC count and CRP have been identified as indicators of inflammation and often increase sequentially during postoperative management. In the present study, the WBC count and CRP level were both found to be risk factors for CR-POPF, but whether they can be used together to predict CR-POPF needs further investigation.\u003c/p\u003e\u003cp\u003eThis study had some limitations, in particular a single-center retrospective design with a limited sample size, which means that the generalizability of our findings may be limited, and the possibility of bias cannot be excluded. Further clarification of risk factors is needed in large, multicenter, high-quality randomized trials.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003ePositive drainage fluid culture, perioperative WBC\u0026thinsp;\u0026ge;\u0026thinsp;10.7\u0026times;10\u003csup\u003e9\u003c/sup\u003e /L, and perioperative CRP\u0026thinsp;\u0026ge;\u0026thinsp;52 mg/L are independent risk factors for CR-POPF. Pancreaticoduodenectomy-specific risks include postoperative hypocalcemia, elevated perioperative WBC\u0026thinsp;\u0026ge;\u0026thinsp;10.5\u0026times;10\u003csup\u003e9\u003c/sup\u003e /L, and prolonged operation time\u0026thinsp;\u0026ge;\u0026thinsp;352 min. Positive postoperative drainage fluid cultures and elevated perioperative CRP and WBC suggest that clinically relevant pancreatic fistulas may be closely related to intraoperative or postoperative infections and inflammation. An elevated WBC count on POD 5/6 demonstrates predictive value, highlighting the importance of monitoring inflammatory markers and intra-abdominal infections to optimize postoperative management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCR-POPF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eClinically relevant postoperative pancreatic fistula\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ewhite blood cell count\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eC-reactive protein\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epancreaticoduodenectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edistal pancreatectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePOD1\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epostoperative day 1\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebody mass index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epostoperative acute pancreatitis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePOPF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epostoperative pancreatic fistula\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eISGPF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Study Group on Pancreatic Surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSAID\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003enonsteroidal anti-inflammatory drug\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003e This study was approved by the ethics committee of Huzhou central hospital on June 20, 2025.(Approval NO:202506020-01). Written informed consent forms about this procedure were obtained for all patients before surgery.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003enot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent for publication\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by Public Welfare Application Research of Huzhou Science and Technology Bureau 2021GYB24.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSZ and MZ designed the studies. SZ, YH and YM performed data acquisition and analysis. SZ, HL and GC performed statistical analysis and data interpretation.SZ prepared the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank Susan Albrecht, PhD, from Liwen Bianji (Edanz) for editing the English text of a draft of this manuscript.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStoffel EM, Brand RE, Goggins M. Pancreatic Cancer: Changing Epidemiology and New Approaches to Risk Assessment, Early Detection, and Prevention. Gastroenterology. 2023;164(5):752\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHu JX, Zhao CF, Chen WB, Liu QC, Li QW, Lin YY, Gao F. Pancreatic cancer: A review of epidemiology, trend, and risk factors. 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Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy: A Randomized Clinical Trial. JAMA. 2023;329(18):1579\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLinnemann RJA, Patijn GA, van Rijssen LB, Besselink MG, Mungroop TH, de Hingh IH, Kazemier G, Festen S, de Jong KP, van Eijck CHJ, Scheepers JJG, van der Kolk M, Dulk MD, Bosscha K, Busch OR, Boerma D, van der Harst E, Nieuwenhuijs VB. Dutch Pancreatic Cancer Group. The role of abdominal drainage in pancreatic resection - A multicenter validation study for early drain removal. Pancreatology. 2019;19(6):888\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVigushin DM, Pepys MB, Hawkins PN. Metabolic and scintigraphic studies of radioiodinated human C-reactive protein in health and disease. J Clin Invest. 1993;91:1351\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChui JN, Sahni S, Samra JS, Mittal A. Postoperative pancreatitis and pancreatic fistulae: a review of current evidence. HPB (Oxford). 2023;25(9):1011\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Dongen JC, Smits FJ, van Santvoort HC, Molenaar IQ, Busch OR, Besselink MG, Aziz MH, Groot Koerkamp B, van Eijck CHJ. Dutch Pancreatic Cancer Group. C-reactive protein is superior to white blood cell count for early detection of complications after pancreatoduodenectomy: a retrospective multicenter cohort study. HPB (Oxford). 2020;22(10):1504\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen G, Yi H, Zhang J. Diagnostic value of C-reactive protein and procalcitonin for postoperative pancreatic fistula following pancreatoduodenectomy: a systematic review and meta-analysis. Gland Surg. 2021;10(12):3252\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSolaini L, Atmaja BT, Watt J, Arumugam P, Hutchins RR, Abraham AT, Bhattacharya S, Kocher HM. Limited utility of inflammatory markers in the early detection of postoperative inflammatory complications after pancreatic resection: Cohort study and meta-analyses. Int J Surg. 2015;17:41\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePartelli S, Pecorelli N, Muffatti F, Belfiori G, Crippa S, Piazzai F, Castoldi R, Marmorale C, Balzano G, Falconi M. Early Postoperative Prediction of Clinically Relevant Pancreatic Fistula after Pancreaticoduodenectomy: usefulness of C-reactive Protein. HPB (Oxford). 2017;19(7):580\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMa J, Jiang P, Ji B, Song Y, Liu Y. Post-operative procalcitonin and C-reactive protein predict pancreatic fistula after laparoscopic pancreatoduodenectomy. BMC Surg. 2021;21(1):171.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cb\u003eUnivariate analysis of risk factors for CR-POPF after all cases that underwent pancreatectomy\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCR-POPF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eχ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYES(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNO(n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eperioperative WBC(10\u003c/b\u003e\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;10.7\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.650\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.006+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eperioperative CRP(mg/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;52\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82\u003c/p\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.385\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOperation time(min)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;305\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;305\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.162\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eintraoperative blood loss(ml)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;246\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.294\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePancreatic texture\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSoft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.814\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHard\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePD\u003c/p\u003e\u003cp\u003eDP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79\u003c/p\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.324\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.493\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emiddle pancreatectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical method\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOpen\u003c/p\u003e\u003cp\u003eLaparoscope\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e109\u003c/p\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.771\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.380\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrainage fluid culture\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePositive\u003c/p\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.753\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.005+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnivariate analysis of risk factors for CR-POPF after PD\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCR-POPF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eχ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYES(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNO(n\u0026thinsp;=\u0026thinsp;79)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePreoperative serum calcium(mmol/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;2.2\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.032\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.310\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePOD1 serum calcium(mmol/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;2.0\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.912\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.009+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerioperative serum calcium(mmol/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;2.1\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.527\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBlood amylase within POD3(U/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;161\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.851\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.050+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eperioperative WBC(10\u003c/b\u003e\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;10.5\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.188\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eperioperative CRP(mg/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;50\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.014+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOperation time(min)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;352\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.315\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePancreatic texture\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSoft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.640\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHard\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrainage fluid culture\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePositive\u003c/p\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.492\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.019+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnivariate analysis of risk factors for CR-POPF after DP\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCR-POPF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eχ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYES(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNO(n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePancreatic texture\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSoft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHard\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrainage fluid culture\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePositive\u003c/p\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.271\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStump management\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSuture\u003c/p\u003e\u003cp\u003eStapling\u003c/p\u003e\u003cp\u003eSuture and stapling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003cp\u003e4\u003c/p\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003cp\u003e35\u003c/p\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.622\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical adhesives\u003c/b\u003e\u003c/p\u003e\u003cp\u003eYes\u003c/p\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.789\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.374\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eperioperative WBC(10\u003c/b\u003e\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;10.5\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.732\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eperioperative CRP(mg/L)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;50\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.269\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOperation time(min)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;240\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.719\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative blood loss(ml)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;230\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;230\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.974\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrainage fluid culture\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePositive\u003c/p\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.271\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eComparison of WBC5/6 after different surgical procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWBC POD5/6(109/L)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCR-POPF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eχ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNO\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePD\u0026thinsp;+\u0026thinsp;DP\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;10\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePD\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;10\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.408\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDP\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;10\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.309\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMultivariate logistic regression analysis for CR-POPF after all cases that underwent pancreatectomy\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eS.E.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWald\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCI 95%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrainage fluid culture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.467\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.685\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.750\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.100-6.872\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerioperative WBC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.318\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.596\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.174\u0026ndash;1.610\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerioperative CRP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.637\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.002\u0026ndash;1.040\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMultivariate logistic regression analysis for CR-POPF after PD\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabf\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eS.E.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWald\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCI95%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePOD1 serum calcium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-7.343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.357\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.784\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000-.466\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood amylase within POD3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.627\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.428\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.997\u0026ndash;1.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerioperative WBC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.449\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.520\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.567\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.209\u0026ndash;2.032\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerioperative CRP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.819\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.983\u0026ndash;1.047\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.001\u0026ndash;1.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrainage fluid culture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.087\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.676\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.583\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.965\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.788\u0026ndash;11.161\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAUC, sensitivity, and specificity of postoperative WBC on postoperative days 5 or 6\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv 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colname=\"c1\"\u003e\u003cp\u003eAll case\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.762\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pancreatectomy, Postoperative pancreatic fistula, Risk factors, Infection, Inflammatory markers","lastPublishedDoi":"10.21203/rs.3.rs-7047314/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7047314/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eClinically relevant postoperative pancreatic fistula (CR-POPF) is a common complication following pancreatectomy. However, the pathophysiological mechanisms underlying CR-POPF remain unclear. This study aimed to identify risk factors for CR-POPF after pancreatoduodenectomy or distal pancreatectomy in the hope of developing preventive strategies and improving postoperative patient management.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively identified 180 patients who underwent pancreatectomy at Huzhou Central Hospital between January 2019 and August 2023. After excluding two cases that underwent total pancreatectomy, one with a history of pancreatectomy, two with missing information on the amylase level in drainage fluid, and one that underwent distal pancreatectomy with combined adrenal, ureteral, and splenic resection, 174 patients were enrolled. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for CR-POPF. Predictive performance was evaluated using ROC curves.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThirty-five of the 174 patients (20.1%) developed CR-POPF. Multivariate analysis revealed that a positive drainage fluid culture (P\u0026thinsp;=\u0026thinsp;0.005), an elevated perioperative white blood cell (WBC) count (P\u0026thinsp;=\u0026thinsp;0.06), and an elevated perioperative C-reactive protein (CRP) level (P\u0026thinsp;=\u0026thinsp;0.001) were independent risk factors for CR-POPF. For pancreaticoduodenectomy, univariate analysis identified a positive drainage fluid culture (P\u0026thinsp;=\u0026thinsp;0.019), lower serum calcium on postoperative day (POD) 1 (P\u0026thinsp;=\u0026thinsp;0.009), elevated perioperative WBC count (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and CRP (P\u0026thinsp;=\u0026thinsp;0.014), and a prolonged operation time (P\u0026thinsp;=\u0026thinsp;0.001) to be risk factors. Multivariate analysis confirmed a serum calcium level of \u0026lt;\u0026thinsp;2.0 mmol/L on POD 1, a perioperative WBC count\u0026thinsp;\u0026ge;\u0026thinsp;10.5\u0026times;10⁹/L, and an operation time of \u0026ge;\u0026thinsp;352 min to be independent risk factors. For distal pancreatectomy, univariate analysis identified a lower preoperative blood glucose level (P\u0026thinsp;=\u0026thinsp;0.034) as a risk factor, but no independent factors emerged in multivariate analysis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eA positive drainage fluid culture, a perioperative WBC count\u0026thinsp;\u0026ge;\u0026thinsp;10.7\u0026times;10⁹/L, and a perioperative CRP\u0026thinsp;\u0026ge;\u0026thinsp;52 mg/L were independent risk factors for CR-POPF. For pancreaticoduodenectomy, serum calcium\u0026thinsp;\u0026lt;\u0026thinsp;2.0 mmol/L on POD 1, a perioperative WBC count\u0026thinsp;\u0026ge;\u0026thinsp;10.5 \u0026times;10\u003csup\u003e9\u003c/sup\u003e/L, and operation time\u0026thinsp;\u0026ge;\u0026thinsp;352 min were independent risk factors for CR-POPF. An elevated WBC count on POD 5/6 had predictive value for CR-POPF. These findings underscore the importance of postoperative monitoring for intra-abdominal infections and inflammatory markers to mitigate the risk of CR-POPF.\u003c/p\u003e","manuscriptTitle":"Risk factors for clinically relevant postoperative pancreatic fistula after pancreatectomy: a retrospective observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 09:47:26","doi":"10.21203/rs.3.rs-7047314/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb24290a-1651-421a-bcb9-dfbdb4d40a0d","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T12:23:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 09:47:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7047314","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7047314","identity":"rs-7047314","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}