Perioperative risk factors associated with prolonged postoperative hospital stay in patients with severe complications after highly advanced hepatobiliary-pancreatic surgery: A single-center retrospective study

Perioperative risk factors associated with prolonged postoperative hospital stay in patients with severe complications after highly advanced hepatobiliary-pancreatic surgery: A single-center retrospective 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 Perioperative risk factors associated with prolonged postoperative hospital stay in patients with severe complications after highly advanced hepatobiliary-pancreatic surgery: A single-center retrospective study Masahiro Fukada, Takeshi Horaguchi, Itaru Yasufuku, Yuta Sato, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4191634/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 Postoperative length of hospital stay (PLOS) is an important indicator of surgical quality, particularly because postoperative complications are closely related to PLOS. Prolonged PLOS (PPLOS) increases treatment costs and delays the transition from surgery to adjuvant chemotherapy. PPLOS may also have an unfavorable impact on long-term prognosis. However, the risk factors for PPLOS, particularly after highly advanced hepatobiliary-pancreatic surgery (HBPS), have not been adequately investigated. In this study, we aimed to identify the perioperative risk factors for PPLOS following highly advanced HBPS. Methods In this single-center retrospective study, we included 737 patients who underwent highly advanced HBPS at Gifu University Hospital, Japan, between 2010 and 2023. Of these, 190 patients with severe postoperative complications (Clavien–Dindo classification grades ≥Ⅲ) were evaluated for perioperative risk factors for PPLOS using uni- and multivariate analyses. Results The median PLOS of patients with severe postoperative complications was 40 days, and 97 patients had a PPLOS. Univariate analysis indicated that pancreatic surgery, open surgery, clinically relevant postoperative pancreatic fistulas (CR-POPF), postoperative respiratory failure (PORF), and C-reactive protein levels > 15 mg/dL on postoperative day 3 significantly correlated with PPLOS. Multivariate analysis showed that open surgery (odds ratio [OR], 14193908; 95% confidence interval [CI], 2.06–; p = 0.01), CR-POPF (OR, 2.49; 95% CI, 1.10–5.77; p = 0.03), and PORF (OR, 5.74; 95% CI, 1.29–40.48; p = 0.02) were independent risk factors for PPLOS. Conclusions After highly advanced HBPS, the PLOS was significantly prolonged with the presence and severity of postoperative complications, regardless of the type of surgery. In cases with severe postoperative complications, open surgery, CR-POPF, and PORF may be risk factors for PPLOS. This study underlines the need for proficient minimally invasive surgery and appropriate perioperative management to avoid severe POPF and PORF, leading to a shorter PLOS after highly advanced HBPS. prolonged postoperative length of stay highly advanced hepatobiliary-pancreatic surgery perioperative risk factors Figures Figure 1 Figure 2 BACKGROUND Postoperative length of hospital stay (PLOS) is the core of many quality improvement initiatives as it can reflect the quality of care delivered to patients and is associated with healthcare costs. Especially in surgical patients, PLOS is one of the most important outcomes for assessing the quality of surgery and perioperative management; thus, a short PLOS is the primary goal of enhanced recovery after surgery (ERAS) [ 1 ]. Previous studies have reported that multiple factors are associated with PLOS after gastroenterological surgery, including age, smoking habits, American Society of Anesthesiologists (ASA) status, preoperative anemia, preoperative nutritional status, comorbidities, surgical approach, operative time, intraoperative blood loss, blood transfusion, and postoperative complications [ 2 – 9 ]. Among these factors, the incidence of postoperative complications, particularly severe complications requiring intensive treatment with invasive procedures, directly impacts the PLOS. Highly advanced hepatobiliary-pancreatic surgery (HBPS) induces severe complications more likely than general gastroenterological surgery, leading to prolonged PLOS (PPLOS). Furthermore, according to the National Comprehensive Cancer Network Clinical Guidelines in Oncology version 1.2024 [ 10 ], adjuvant treatment should be administered to patients who have adequately recovered from surgery; ideally, treatment should be initiated within 12 weeks. A contributing factor to delayed adjuvant treatment is PPLOS, which is consequently associated with worse outcomes [ 11 – 13 ]. However, the risk factors for PPLOS, particularly after HBPS, have not been adequately investigated. Therefore, in this study, we aimed to identify perioperative (pre-, intra-, and postoperative) risk factors to predict PPLOS in patients with severe postoperative complications after highly advanced HBPS. METHODS This single-center retrospective study included 737 patients who underwent highly advanced HBPS at the Department of Gastroenterological Surgery, Gifu University Hospital, between January 2010 and December 2023. Gifu University Hospital is a Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS)-certified training institution. All highly advanced HBPS procedures were performed by experienced board-certified JSHBPS-qualified surgeons. The study was conducted in accordance with the World Medical Association Declaration of Helsinki and was approved by the Ethics Committee of Gifu University (approval number: 2023-018). The need for informed consent was waived in view of the retrospective nature of the study. Definition of PPLOS and severe postoperative complications The main outcome of this study was PPLOS in patients with severe postoperative complications after highly advanced HBPS. PPLOS was defined as PLOS longer than the median value. According to this definition, patients were divided into two groups: those with and without PPLOS. A severe postoperative complication was defined as a grade ≥Ⅲ Clavien–Dindo (CD) classification after the surgical procedure. Pre-, intra-, and postoperative variables Pre-, intra-, and postoperative variables were included in the analysis. Preoperative variables were patient background, including age, sex, body mass index (BMI), ASA physical status classification, smoking habits, a past history of abdominal surgery, and preoperative chemotherapy; prognostic indices, including prognostic nutritional index (PNI), controlling nutritional status (CONUT), modified Glasgow prognostic score (GPS), and systemic immune inflammation index (SII); and patient comorbidity (Charlson risk index, and type of comorbidity). The intraoperative variables included the type of surgery (hepatobiliary or pancreatic surgery/open or minimally invasive [laparoscopic and robotic] surgery, MIS), operation time, blood loss, and blood transfusion. The postoperative variables were onset time of postoperative complications, postoperative complications (pancreatic fistula, bile leakage, liver failure, respiratory failure, postoperative bleeding, intra-abdominal abscess, and reoperation), postoperative mortality, and blood tests on postoperative day (POD) 1 and 3 (white blood cell count, C-reactive protein (CRP), and albumin levels). Highly advanced HBPS Highly advanced HBPSs include hepatobiliary surgeries, such as hepatic trisegmentectomy, hemihepatectomy, hepatic sectionectomy (except lateral sectionectomy), hepatic segmentectomy (except S4), hepatectomy (S4a + S5 resection or hemihepatectomy) with extrahepatic bile duct resection, extrahepatic bile duct resection for congenital biliary dilatation, and hepato-pancreatectomy, in addition to pancreatic surgeries, such as total pancreatectomy, pancreaticoduodenectomy (PD), distal pancreatectomy (DP) with lymph node dissection, and middle pancreatectomy. Statistical analysis Continuous and categorical variables are presented as median (range) values and frequencies (percentages), respectively. The Fisher’s exact test was used to compare categorical variables between the PPLOS and non-PPLOS groups. The Mann–Whitney U test was used for continuous variables. The Steel–Dwass test was used to assess the correlation between the presence and severity of postoperative complications and PLOS. The Youden's index was used to determine the optimal cut-off value for calculating the specificities and sensitivities of the receiver operating characteristic curve analysis. Variables with a p-value < 0.1 in univariate analysis were introduced into the multivariate logistic regression model. Statistical significance was set at a two-sided p-value < 0.05. All statistical analyses were performed using JMP software (SAS Institute Inc., Cary, NC, USA). RESULTS At least one postoperative complication occurred in 367 (49.8%) patients. According to the CD grading system, 43 (5.8%) patients with grade I complications recovered without any treatment, 134 (18.2%) with grade II complications required antibiotic therapy, 168 (22.8%) with grade III complications needed radiologic intervention or reoperation, and 13 (1.8%) with grade IV complications and 9 (1.2%) with grade V complications died in the hospital. In total, 190 (25.8%) patients who experienced at least one postoperative severe complication, with grades ≥ III, were evaluated for risk factors associated PPLOS in our study (Fig. 1 ). PLOS of all patients and those with and without postoperative complications according to the highly advanced HBPS type Table 1 summarizes the PLOS of all patients and those with and without postoperative complications according to the highly advanced HBPS type. The median PLOS in total patients was 20 days (range 5–162): 13 days (range 5–46) in those without any postoperative complications, 24 days (range 8–59) in those with non-severe postoperative complications (CD grade <Ⅲ), and 40 days (range 9–162) in those with severe postoperative complications (CD grade ≥Ⅲ). PLOS was significantly prolonged depending on the presence and severity of postoperative complications (p < 0.0001). Table 1 PLOS of all cases and cases with and without postoperative complications according to highly advanced HBPS type All cases No complication cases Cases without SC (CD grade <Ⅲ) Cases with SC (CD grade ≧Ⅲ) n PLOS (days) n PLOS (days) n PLOS (days) n PLOS (days) Hepatobiliary surgeries 370 14 [5-162] 230 12 [ 5 – 34 ] 68 19 [8–58] 72 35 [9-162] ▪hepatic trisegmentectomy ▪hemihepatectomy ▪hepatic sectionectomy ▪hepatic segmentectomy ▪hepatectomy with extrahepatic bile duct resection 8 125 116 60 36 21 [ 11 – 46 ] 14 [5-162] 13 [6-107] 12 [ 8 – 43 ] 27 [9–78] 4 82 76 45 13 14 [ 11 – 22 ] 12 [ 5 – 25 ] 12 [ 6 – 25 ] 12 [ 8 – 23 ] 22 [ 9 – 31 ] 0 25 19 9 9 - 18 [13–58] 21 [ 8 – 35 ] 13 [ 8 – 15 ] 24 [ 14 – 40 ] 4 18 21 6 14 31 [ 20 – 46 ] 40 [9-162] 33 [11–107] 23 [ 12 – 43 ] 34 [17–78] ▪ extrahepatic bile duct resection for congenital biliary dilatation 14 13 [8–52] 9 11 [ 8 – 23 ] 3 24 [ 18 – 24 ] 2 47 418 − 52] ▪ hepato-pancreatectomy 11 40 [9-109] 1 34 [-] 3 40 [ 26 – 46 ] 7 51 [9-109] Pancreatic surgeries 367 27 [10–150] 140 18 [ 10 – 46 ] 109 27 [12–59] 118 42 [12–150] ▪total pancreatectomy ▪pancreatico duodectomy ▪distal pancreatectomy with lymph node dissection ▪middle pancreatectomy 18 269 76 4 15 [10–93] 29 [10–150] 14 [10–93] 34 [26–59] 12 85 42 1 14 [ 10 – 21 ] 22 [ 10 – 46 ] 14 [ 10 – 21 ] 27 [-] 2 90 16 1 36 [ 34 – 37 ] 29 [13–59] 14 [ 12 – 29 ] 26 [-] 4 94 18 2 36 [23–93] 43 [15–150] 42 [12–93] 50 [40–59] Total 737 20 [5-162] 370 13 [ 5 – 46 ] 177 24 [8–59] 190 40 [9-162] PLOS: postoperative length of stay SC: severe complicatons CD: clavien-dindo classification A significantly longer PLOS due to postoperative complications was found in both hepatobiliary and pancreatic surgeries (p < 0.0001) (Fig. 2 ). Characteristics of patients with PPLOS Table 2 summarizes the characteristics of the patients with PPLOS. Patients in the PPLOS group had significantly higher BMI (p = 0.016); higher rates of pancreatic surgery (p = 0.04), open surgery (p = 0.016), and clinically relevant postoperative pancreatic fistula (CR-POPF) (p < 0.001); and higher CRP level on POD 3 (p < 0.001) than those in the non-PPLOS group. Table 2 Comparison of patient characteristics between patients with and without PPLOS PPLOS group (n = 97) Non-PPLOS group (n = 93) p -value Age (years) 71 [30–89] 70 [24–85] 0.92 Sex Male: 69 (71.1%) Female: 28 (28.9%) Male: 60 (64.5%) Female: 33 (35.5%) 0.33 BMI (kg/m 2 ) 22.6 [16.7–30.1] 21.4 [14.8–29.2] 0.016* ASA 1: 13 (13.4%) 2: 73 (75.3%) 3: 11 (11.3%) 1: 12 (12.9%) 2: 69 (74.2%) 3: 12 (12.9%) 0.95 Smoking habits 54 (61.4%) 52 (65.0%) 0.63 Brinkman index 420 [0-2000] 245 [0-2700] 0.93 Past abdominal surgery 39 (40.2%) 43 (46.2%) 0.40 Preoperative chemotherapy 15 (15.5%) 22 (23.7%) 0.15 PNI✝ 40.0 [15.0–50.0] 40.0 [27.0–54.0] 0.33 CONUTS Normal:37 (39.0%) Mild:49 (51.6%) Moderate:6 (6.3%) Severe:3 (3.1%) Normal:29 (31.2%) Mild:58 (62.4%) Moderate:6 (6.4%) Severe:0 (0.0%) 0.12 Modified GPS 0: 73 (75.3%) 1: 17 (17.5%) 2: 7 (7.2%) 0: 62 (66.7%) 1: 22 (23.7%) 2: 9 (9.7%) 0.43 SII§ 465 [65-5616] 428 [95-12357] 0.82 Charlson comorbidity index 2 [0–9] 2 [0–10] 0.64 History of malignancy 32 (33.0%) 29 (31.2%) 0.79 Heart-related comorbidity 19 (19.6%) 15 (16.1%) 0.53 Respiratory-related Comorbidity 17 (17.5%) 14 (15.1%) 0.64 Liver-related Comorbidity 12 (12.4%) 17 (18.3%) 0.26 Cerebrovascular-related Comorbidity 7 (7.2%) 9 (9.7%) 0.54 Diabetes mellitus 33 (34.0%) 29 (31.2%) 0.68 Chronic renal dysfunction 7 (7.2%) 5 (5.4%) 0.60 Type of surgery Hepatobiliary: 30 (30.9%) Pancreatic: 67 (69.1%) Hepatobiliary: 42 (45.2%) Pancreatic: 51 (54.8%) 0.04* Open: 97 (100.0%) MIS: 0 (0.0%) Open: 89 (95.7%) MIS: 4 (4.3%) 0.016* Operation time (min) 425 [176–8880] 429 [161–949] 0.36 Blood loss (ml) 690 [55-21800] 780 [0-12000] 0.33 Blood transfusion 26 (26.8%) 26 (28.0%) 0.87 Date of complication diagnosis (POD) 7 [0–34] 7 [0–25] 0.53 Clinically relevant pancreatic fistula 56 (57.7%) 29 (31.2%) < 0.001*** Bile leakage 14 (14.4%) 16 (17.2%) 0.60 Liver failure 4 (4.1%) 2 (2.2%) 0.43 Respiratory failure 8 (8.3%) 2 (2.2%) 0.06 Postoperative bleeding 17 (17.5%) 11 (11.8%) 0.27 Intraabdominal abscess 30 (30.9%) 18 (19.4%) 0.07 Re-operation 6 (6.2%) 8 (8.6%) 0.52 Postoperative mortality 5 (5.2%) 5 (5.4%) 1.00 White blood cell on POD1 (×10 3 µl) 9.08 [2.40-30.24] 9.36 [2.85–22.39] 0.27 C-reactive protein on POD1 (mg/dl) 8.16 [0.27–14.64] 6.25 [0.75–17.36] 0.09 Albumin on POD1 (g/dl) 2.8 [1.7–3.8] 2.7 [2.0-3.6] 0.20 White blood cell on POD3 (×10 3 µl) 9.62 [2.88–41.36] 8.75 [3.18–19.69] 0.42 C-reactive protein on POD3 (mg/dl) 17.30 [0.88–30.98] 13.13 [1.31–32.72] < 0.001*** Albumin on POD3 (g/dl) 2.8 [2.0-3.7] 2.8 [1.9–3.7] 0.82 PPLOS: prolonged postoperative length of hospital stay BMI: body mass index ASA: American Society of Anesthesiologists physical status classification CONUTS: Controlling Nutritional Status Score GPS: Glasgow Prognostic Score MIS: minimally invasive surgery POD: postoperative day ✝: Prognostic nutritional index = 10×albumin(g/dl) + 0.005× the absolute lymphocyte count §:Systemic Inflammation Index = the absolute platelet count × the absolute neutrophil count / the absolute lymphocyte count *: p < 0.05 **: p < 0.01 ***: p < 0.001 Uni- and multivariate analyses to predict PPLOS in patients with severe postoperative complications after highly advanced HBPS In the univariate analysis, PPLOS in patients with severe postoperative complications after highly advanced HBPS was significantly associated with pancreatic surgery (p = 0.04), open surgery (p = 0.02), CR-POPF (p < 0.001), postoperative respiratory failure (PORF) (p 15 mg/dL on POD 3 (p < 0.001). In addition to these five factors, two possible predictive factors (p 24 kg/m 2 (p = 0.09) and intra-abdominal abscesses (p = 0.07). Finally, three predictive factors were identified; open surgery (odds ratio [OR], 14193908; 95% confidence interval [CI] 2.06–; p = 0.01), CR-POPF (OR, 2.49;95% CI, 1.1–-5.77; p = 0.03), and PORF (OR, 5.74, 95% CI, 1.29–40.48; p = 0.02) (Table 3 ). Table 3 Uni- and multivariate analysis of prediction for PPLOS after highly advanced HBPS n Univariate Multivariate OR 95%CI p-value OR 95%CI p -value Age (years) > 75 24 < 24 49 141 1.74 1 0.90–3.43 0.09 1.68 1 0.82–3.54 0.16 ASA 3 1/2 23 167 0.86 1 0.36–2.08 0.74 Smoking Yes No 106 62 0.86 1 0.45–1.60 0.63 Past abdominal surgery Yes No 82 108 0.78 1 0.44–1.39 0.40 Preoperative-chemotherapy Yes No 37 153 0.59 1 0.28–1.22 0.15 PNI✝ > 40 5 437 < 437 96 93 1.432 1 0.74–2.34 0.35 Charlson comorbidity index 2+ 0/1 98 92 0.91 1 0.52–1.62 0.76 History of malignancy Yes No 61 129 1.09 1 0.59-2.00 0.79 Heart-related comorbidity Yes No 34 156 1.27 1 0.60–2.70 0.53 Respiratory-related Comorbidity Yes No 31 159 1.20 1 0.55–2.63 0.64 Liver-related Comorbidity Yes No 29 161 0.63 1 0.28–1.40 0.26 Cerebrovascular-related Comorbidity Yes No 16 174 0.73 1 0.25–2.03 0.54 Diabetes mellitus Yes No 62 128 1.14 1 0.62–2.10 0.68 Chronic renal dysfunction Yes No 12 178 1.37 1 0.42–4.78 0.60 Type of surgery Pancreas Hepatobiliary 118 72 1.84 1 1.02–3.35 0.04* 0.90 1 0.40-2.00 0.80 Type of surgery Open MIS 186 4 11863408 1 1.74- 0.02* 14193908 1 2.06- 0.01* Operative time (min) > 540 1600 7 < 7 75 114 1.41 1 0.79–2.55 0.25 Clinically relevant pancreatic fistula Yes No 85 105 3.01 1 1.67–5.52 < 0.001*** 2.49 1 1.10–5.77 0.03* Bile leakage Yes No 30 160 0.81 1 0.37–1.78 0.60 Liver failure Yes No 6 184 2.00 1 0.37–14.36 0.43 Respiratory failure Yes No 10 180 4.09 1 0.99–27.59 < 0.05* 5.74 1 1.29–40.48 0.02* Postoperative bleeding Yes No 28 162 1.58 1 0.71–3.68 0.27 Intraabdominal abscess Yes No 48 142 1.87 1 0.96–3.70 0.07 1.74 1 0.85–3.63 0.13 Re-operation Yes No 14 176 0.70 1 0.22–2.20 0.52 Postoperative mortality Yes No 9 181 0.96 1 0.26–3.55 0.95 White blood cell on POD3 (×10 3 µl) > 10000 15 < 15 99 91 2.68 1 1.50–4.86 2.8 < 2.8 78 112 0.78 1 0.56–1.139 0.41 PPLOS: prolonged postoperative length of hospital stay OR: odds ratio 95%CI: 95% confidence interval BMI: body mass index ASA: American Society of Anesthesiologists physical status classification CONUTS: Controlling Nutritional Status Score GPS: Glasgow Prognostic Score MIS: minimally invasive surgery POD: postoperative day ✝: Prognostic nutritional index = 10×albumin(g/dl) + 0.005× the absolute lymphocyte count §:Systemic Inflammation Index = the absolute platelet count × the absolute neutrophil count / the absolute lymphocyte count *: p < 0.05 **: p < 0.01 ***: p < 0.001 DISCUSSION In this study, we aimed to identify the perioperative risk factors for PPLOS following highly advanced HBPS. Our results revealed some significant correlations between PLOS and postoperative complications after highly advanced HBPS: i) the incidence of postoperative complications significantly prolonged PLOS, ii) PLOS was significantly prolonged as postoperative complications became more severe, and iii) these significant correlations were observed in both hepatobiliary and pancreatic surgeries. We found that open surgery, CR-POPF, and PORF were independent risk factors for PPLOS in patients with severe postoperative complications after highly advanced HBPS. However, no significant correlation was observed between PPLOS and operative mortality. We previously reported a study on predictive factors for postoperative mortality after advanced HBPS, in which comorbid liver disease, intraoperative blood loss, intraoperative blood transfusion, postoperative bleeding, and postoperative organ failure were significantly correlated [ 14 ]. We hypothesized that there are many similarities between the risk factors for PPLOS and postoperative mortality; however, this was not always the case. Previous large-scale database studies have reported similar results [ 15 ]; therefore, efforts to shorten PLOS, which is different from avoiding postoperative mortality, may be required. One of the most important initiatives for shortening PLOS is ERAS. ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes and has been shown to be effective in reducing PLOS. ERAS guidelines for pancreaticoduodenectomy and liver surgeries were reported in 2012 and 2016, respectively [ 16 , 17 ]. The key ERAS items identified were preoperative education and counseling, minimum fasting and administration of carbohydrate drinks before surgery, perioperative nutrition, avoidance of bowel preparation, epidural analgesia, intravenous fluid restriction, a minimally invasive approach, prevention of hypothermia, early removal of urinary catheters and abdominal drains, thromboembolic prophylaxis, antibiotic prophylaxis, early oral intake, early mobilization, early commencement of oral analgesia, and prevention of postoperative nausea and vomiting. A systematic review and meta-analysis by Noba et al. reported on the clinical benefits of ERAS in pancreatic and liver surgeries [ 18 , 19 ]. In pancreatic surgery, the PLOS was reduced by 3.15 days, and hospital costs were significantly lower in the ERAS group than in the standard care group without increasing postoperative mortality, readmission, and reoperation [ 18 ]. Similarly, in liver surgery, PLOS was reduced by 2.2 days, and hospital costs were significantly lower in the ERAS group without increasing postoperative mortality and readmission rates [ 19 ]. In our institution, many items were also implemented, such as early oral intake and mobilization but not preoperative carbohydrate drinks, avoidance of bowel preparation, and early removal of abdominal drains. It is thus possible that increased ERAS efforts could lead to a reduction in PPLOS. First, in our present study, pancreatic surgery, particularly for CR-POPF, was shown to be significantly correlated with PPLOS. Traditionally, pancreatic surgery is associated with a high complication rate. Complications tend to remain very high, ranging from 40 to 60%, despite surgical techniques and improvements in perioperative care management [ 20 – 22 ]. Among the postoperative complications after pancreatic surgery, CR-POPF and delayed gastric emptying (DGE) have been identified as more severe complications that require further radiological or surgical intervention and are the primary causes of PPLOS [ 23 ]. Some meta-analyses have reported that ERAS markedly reduces the incidence of DGE but does not influence CR-POPF [ 18 , 24 ]. Veillette et al. retrospectively analyzed 581 patients who underwent PD, and found that patients with CR-POPF had a significantly longer PLOS (23.6 days vs 8.7 days, p < 0.001) [ 25 ]. In another international, multicenter, retrospective study including 1,089 patients who underwent DP according to the International Study Group in Pancreatic Surgery definition, the median PLOS increased from 7 days in patients with no POPF or grade A POPF to 9 days in those with grade B POPF. This number increased to 29 days in patients with grade C POPF [ 26 ]. Another problem is the negative impact of CR-POPF on patient costs and initiation of adjuvant chemotherapy due to PPLOS. We previously reported that CR-POPF not only prolongs PLOS but also delays the initiation of adjuvant chemotherapy for pancreatic cancer (65 days vs 40 days, p < 0.001) [ 27 – 29 ]. Jajja et al. found that patients with CR-POPF incur 2.4 times the overall median cost of PD, and the most significant contribution to cost was the postoperative ward stay. They also reported a significant increase in costs associated with the grade of CR-POPF [ 30 ]. Preoperative risk assessment of CR-POPF development in each patient, intraoperative patronizing procedure of the pancreas, and early postoperative diagnosis and intervention for CR-POPF may contribute to reducing PPLOS by avoiding severe POPF. Second, in the present study, MIS was significantly correlated with PPLOS. Currently, MIS is increasingly providing benefits as an alternative approach for patients needing elective surgery, including less postoperative pain, fewer early complications, faster recovery times, less stress on the immune system, smaller incisions, and shortened PLOS [ 31 , 32 ]. The technological advantages of imaging, instrumentation cameras, and robotics allow MIS to have more expensive applications and demonstrate medical and financial advantages for most surgical cases [ 33 ]. Vlădescu et al. showed that the MIS significantly reduces PLOS, with a potential positive influence on the national healthcare budget, based on an analysis of the Romanian national database. They found that the PLOS for MIS decreased annually at a significantly faster rate as compared to the PLOS for open surgery (0.085 days/year vs. 0.05 days/year, p < 0.05), and the gap between the two gradually increased in favor of MIS (from 1.6 days in 2008 to 2.06 days) [ 34 ]. However, they found that the most pronounced shortening of PLOS after MIS for gallbladder surgery (by 7.95 days), gastric surgery (by 5.64 days), and incisional hernia surgery (by 4.33 days), but did not evaluate it in highly advanced HBPS. A systematic review and meta-analysis of propensity score-matched studies comparing the surgical outcomes of MIS vs. open surgery for hepatocellular carcinoma revealed that the PLOS was significantly shorter and the incidence of severe complications was significantly lower in MIS than in open surgery [ 35 ]. In contrast, regarding the comparison of surgical outcomes between MIS and open surgery in PD, which is the most frequent type of highly advanced pancreatic surgery, the results vary [ 36 – 40 ]. This discrepancy may stem from patient selection bias, differences in surgical indications, and learning curves. In our study, the fact that we performed MIS more aggressively during liver surgery than during pancreatic surgery may have influenced our results. However, as the analysis in this study was limited to patients with severe postoperative complications after highly advanced HBPS, MIS may have contributed to a shorter PLOS. Finally, in the present study, PORF significantly correlated with PPLOS. Postoperative pulmonary complications, including hypoxemia, pneumonia, atelectasis, and PORF are more common than cardiovascular complications following surgery [ 41 , 42 ]. These complications have high incidence, ranging from 6 to 80%, and are a leading cause of poor surgical outcomes [ 43 ]. Furthermore, postoperative pulmonary complications are more likely to occur after upper abdominal surgery, including HBPS [ 44 ]. Studies estimate that nearly one million postoperative pulmonary complications occur annually in the United States, resulting in 46,200 deaths and 480,000 additional hospital days [ 45 ]. In our previous study, PORF was identified as a significant risk factor for postoperative mortality [ 14 ]. Effective prevention of PORF is strongly associated with shorter hospital stays and decreased mortality. Postoperative factors, including respiratory support, breathing training, and physical therapy, are increasingly affecting the incidence of PORF. Postoperative diaphragmatic dysfunction is the pathophysiological basis of PORF. In contrast, preoperative inspiratory training reportedly reduces the incidence of PORF after major abdominal surgeries [ 46 ]. At our institution, preoperative respiratory training is routinely introduced for thoracic surgery, including esophageal surgery, and the introduction of a highly advanced HBPS may lead to reduced PPLOS. This study has some limitations. First, this single-center retrospective study may have resulted in selection bias and multiplicity issues in the statistical analysis. A multicenter study with a larger number of patients is required to obtain more accurate results. However, multicenter studies may be affected by differences in discharge criteria at each institution. Therefore, our study on PPLOS at a single institution with a well-developed medical environment and uniform surgical indications may be of particular value. Second, this study included all patients with highly advanced HBPS who underwent hepatobiliary and pancreatic surgeries. Each type of surgery may be associated with different risk factors of PPLOS. This limitation should be considered when evaluating the results. Conclusions PLOS after highly advanced HBPS was significantly prolonged with the presence and severity of postoperative complications, regardless of the type of surgery. In cases with severe postoperative complications, open surgery, CR-POPF, and PORF may be risk factors for PPLOS. Proficient MIS and appropriate perioperative management to avoid severe CR-POPF and PORF may lead to a shorter PLOS after highly advanced HBPS. Abbreviations PLOS postoperative length of stay ERAS enhanced recovery after surgery ASA American Society of Anesthesiologists HBPS hepatobiliary-pancreatic surgery NCCN National Comprehensive Cancer Network CD Clavien–Dindo PNI prognostic nutritional index CONUT controlling nutritional status GPS Glasgow prognostic score SII systemic immune inflammation index POD postoperative day CRP C-reactive protein JSHBPS Japanese Society of Hepato-Biliary-Pancreatic Surgery OR odds ratio CI confidence interval,PD,pancreaticoduodenectomy POPF postoperative pancreatic fistula PORF postoperative respiratory failure DGE delayed gastric emptying PD pancreaticoduodenectomy DP distal pancreatectomy MIS minimally invasive surgery. Declarations Ethics approval and consent to participate: This study was conducted in accordance with the World Medical Association Declaration of Helsinki and approved by the Ethics Committee of Gifu University (approval number '2023-018'). This retrospective study did not include any potentially identifiable patient data; therefore, the need for informed consent was waived by the Ethics Committee of Gifu University. This retrospective study was approved by the Institutional Review Board. Consent for publication: Not applicable Availability of data and materials: The datasets used in this study are available from the corresponding author upon request. Competing interests: The authors declare that they have no competing interests. Funding : Not applicable Authors’ contributions: MF conceived the study concept, planned the study design as the principal investigator, interpreted the results, and drafted the manuscript. NM revised the manuscript, added intellectual content, and provided critical advice. MF, TH, IY, YS, JYT, SK, YT, KM, and NM obtained the data, provided critical comments to improve the manuscript, and approved its final submission. All authors read and approved the final manuscript. Acknowledgments: The authors thank the medical staff of the Department of Gastroenterological Surgery at Gifu University Hospital for their participation in this study. We could not have completed this study without their diligence or support. We would also like to thank Editage (www.editage.jp) for English language editing. References Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–8. 10.1007/s001090000086 . Schiphorst AH, Verweij NM, Pronk A, Borel Rinkes IH, Hamaker ME. Non-surgical complications after laparoscopic and open surgery for colorectal cancer—a systematic review of randomised controlled trials. 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Tempero MA, Malafa MP, Al-Hawary M, Behrman SW, Benson AB, Cardin DB, et al. Pancreatic Adenocarcinoma, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2021;19:439–57. 10.6004/jnccn.2021.0017 . Des Guetz G, Nicolas P, Perret GY, Morere JF, Uzzan B. Does delaying adjuvant chemotherapy after curative surgery for colorectal cancer impair survival? A meta-analysis. Eur J Cancer. 2010;46:1049–55. 10.1016/j.ejca.2010.01.020 . Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335–42. 10.1001/jama.2011.749 . Malietzis G, Mughal A, Currie AC, Anyamene N, Kennedy RH, Athanasiou T, et al. Factors implicated for delay of adjuvant chemotherapy in colorectal cancer: a meta-analysis of observational studies. Ann Surg Oncol. 2015;22:3793–802. 10.1245/s10434-015-4479-2 . Fukada M, Murase K, Higashi T, Yasufuku I, Sato Y, Tajima JY, et al. Perioperative predictive factors of failure to rescue following highly advanced hepatobiliary-pancreatic surgery: a single-institution retrospective study. World J Surg Oncol. 2023;21:365. 10.1186/s12957-023-03257-6 . Silber JH, Rosenbaum PR, Williams SV, Ross RN, Schwartz JS. The relationship between choice of outcome measure and hospital rank in general surgical procedures: implications for quality assessment. Int J Qual Health Care. 1997;9:193–200. 10.1093/intqhc/9.3.193 . Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced recovery after surgery (ERAS®) society recommendations. Clin Nutr. 2012;31:817–30. 10.1016/j.clnu.2012.08.011 . Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CH, et al. Guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg. 2016;40:2425–40. 10.1007/s00268-016-3700-1 . Noba L, Rodgers S, Doi L, Chandler C, Hariharan D, Yip V. Costs and clinical benefits of enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy: an updated systematic review and meta-analysis. J Cancer Res Clin Oncol. 2023;149:6639–60. 10.1007/s00432-022-04508-x . Noba L, Rodgers S, Chandler C, Balfour A, Hariharan D, Yip VS. Enhanced recovery after surgery (ERAS) reduces hospital costs and improve clinical outcomes in liver surgery: a systematic review and meta-analysis. J Gastrointest Surg. 2020;24:918–32. 10.1007/s11605-019-04499-0 . Gooiker GA, Lemmens VE, Besselink MG, Busch OR, Bonsing BA, Molenaar IQ, et al. Impact of centralization of pancreatic cancer surgery on resection rates and survival. Br J Surg. 2014;101:1000–5. https://doi.org/10.1002/bjs. 9468 . Lermite E, Sommacale D, Piardi T, Arnaud JP, Sauvanet A, Dejong CH et al. Complications after pancreatic resection: diagnosis, prevention and management. Clin Res Hepatol Gastroenterol. 2013;37:230–9. https://doi.org/10. 1016/j. clinre. 2013. 01. 003. Kunstman JW, Goldman DA, Gönen M, Balachandran VP, D'Angelica MI, Kingham TP et al. Outcomes after pancreatectomy with routine pasireotide use. J Am Coll Surg 228:161–e702. 10.1016/j.jamcollsurg.2018.10.018 . Zhang XY, Zhang XZ, Lu FY, Zhang Q, Chen W, Ma T, et al. Factors associated with failure of enhanced recovery after surgery program in patients undergoing pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int. 2020;19:51–7. 10.1016/j.hbpd.2019.09.006 . Wang XY, Cai JP, Huang CS, Huang XT, Yin XY. Impact of enhanced recovery after surgery protocol on pancreaticoduodenectomy: a meta-analysis of non-randomized and randomized controlled trials. HPB (Oxford). 2020;22(10):1373–83. 10.1016/j.hpb.2020.07.001 . Veillette G, Dominguez I, Ferrone C, Thayer SP, McGrath D, Warshaw AL, et al. Implications and management of pancreatic fistulas following pancreaticoduodenectomy: the Massachusetts General Hospital experience. Arch Surg. 2008;143:476–81. 10.1001/archsurg.143.5.476 . van Hilst J, de Pastena M, de Rooij T, Alseidi A, Busch OR, van Dieren S, et al. Clinical impact of the updated international postoperative pancreatic fistula definition in distal pancreatectomy. HPB (Oxford). 2018;20:1044–50. 10.1016/j.hpb.2018.05.003 . Fukada M, Murase K, Higashi T, Yokoi R, Tanaka Y, Okumura N, et al. Early predictive factors for postoperative pancreatic fistula after distal pancreatectomy for pancreatic cancer. Cancer Diagn Progn. 2022;2:452–61. 10.21873/cdp.10128 . Fukada M, Murase K, Higashi T, Fujibayashi S, Kuno M, Yasufuku I, et al. The pancreas-to-muscle signal intensity ratio on T 1 -weighted MRI as a predictive biomarker for postoperative pancreatic fistula after distal pancreatectomy: a single-center retrospective study. World J Surg Oncol. 2022;20:250. 10.1186/s12957-022-02718-8 . Fukada M, Murase K, Higashi T, Yasufuku I, Sato Y, Tajima JY, et al. Drain fluid and serum amylase concentration ratio is the most reliable indicator for predicting postoperative pancreatic fistula after distal pancreatectomy. BMC Surg. 2023;23:87. 10.1186/s12893-023-01980-1 . Jajja MR, Mustansir F, Nadeem SO, Lovasik BP, Blair CM, Sarmiento JM. Counting the cost: financial implications of complications following pancreaticoduodenectomy. HPB (Oxford). 2022;24:1177–85. 10.1016/j.hpb.2021.12.012 . Mohiuddin K, Swanson SJ. Maximizing the benefit of minimally invasive surgery. J Surg Oncol. 2013;108:315–9. 10.1002/jso.23398 . Chakravartty S, Sarma DR, Noor M, Panagiotopoulos S, Patel AG. Laparoscopy has a therapeutic role in the management of abdominal trauma: A matched-pair analysis. Int J Surg. 2017;44:21–5. 10.1016/j.ijsu.2017.05.035 . Tonutti M, Elson DS, Yang GZ, Darzi AW, Sodergren MH. The role of technology in minimally invasive surgery: state of the art, recent developments and future directions. Postgrad Med J. 2017;93:159–67. 10.1136/postgradmedj-2016-134311 . Vlădescu C, Copăescu C. The Use of Minimal Invasive Surgery versus Open Approach in Hospitalized Cases. Chirurgia (Bucur). 2021;116(eCollection):1–13. 10.21614/chirurgia.116.eC.2422 . Wang Q, Li HJ, Dai XM, Xiang ZQ, Zhu Z. Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: systematic review and meta-analysis of propensity-score matched studies. Int J Surg. 2022;105:106821. 10.1016/j.ijsu.2022.106821 . Shi Y, Jin J, Qiu W, Weng Y, Wang J, Zhao S, et al. Short-term outcomes after robot-assisted vs open pancreaticoduodenectomy after the learning curve. JAMA Surg. 2020;155:389–94. 10.1001/jamasurg.2020.0021 . Zureikat AH, Postlewait LM, Liu Y, Gillespie TW, Weber SM, Abbott DE, et al. A multi-institutional comparison of perioperative outcomes of robotic and open pancreaticoduodenectomy. Ann Surg. 2016;264:640–9. 10.1097/SLA.0000000000001869 . Adam MA, Choudhury K, Dinan MA, Reed SD, Scheri RP, Blazer DG, et al. Minimally invasive versus open pancreaticoduodenectomy for cancer: practice patterns and short-term outcomes among 7061 patients. Ann Surg. 2015;262:372–7. 10.1097/SLA.0000000000001055 . Doula C, Kostakis ID, Damaskos C, Machairas N, Vardakostas DV, Feretis T, et al. Comparison between minimally invasive and open pancreaticoduodenectomy: a systematic review. Surg Laparosc Endosc Percutan Tech. 2016;26:6–16. 10.1097/SLE.0000000000000228 . Guo W, Ye X, Li J, Lu S, Wang M, Wang Z, et al. Comparison of surgical outcomes among open, laparoscopic, and robotic pancreatoduodenectomy: a single-center retrospective study. BMC Surg. 2022;22:348. 10.1186/s12893-022-01797-4 . Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med. 1995;10:671–8. 10.1007/BF02602761 . Khan NA, Quan H, Bugar JM, Lemaire JB, Brant R, Ghali WA. Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med. 2006;21:177–80. 10.1111/j.1525-1497.2006.00319.x . Serpa Neto A, Hemmes SN, Barbas CS, Beiderlinden M, Fernandez-Bustamante A, Futier E, et al. Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: a systematic review and meta-analysis. Lancet Respir Med. 2014;2:1007–15. 10.1016/S2213-2600(14)70228-0 . Karalapillai D, Weinberg L, Peyton P, Ellard L, Hu R, Pearce B, et al. Effect of intraoperative low tidal volume vs conventional tidal volume on postoperative pulmonary complications in patients undergoing major surgery: A randomized clinical trial. JAMA. 2020;324:848–58. 10.1001/jama.2020.12866 . Shander A, Fleisher LA, Barie PS, Bigatello LM, Sladen RN, Watson CB. Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies. Crit Care Med. 2011;39:2163–72. 10.1097/CCM.0b013e31821f0522 . Katsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev. 2015;2015:CD010356. 10.1002/14651858.CD010356.pub2 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4191634","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":286047878,"identity":"94829598-2abf-4697-8c2e-f232440ffefa","order_by":0,"name":"Masahiro Fukada","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Fukada","suffix":""},{"id":286047879,"identity":"afbe0f7d-5f5d-4ae8-8d24-e3b40b3f1cc9","order_by":1,"name":"Takeshi Horaguchi","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takeshi","middleName":"","lastName":"Horaguchi","suffix":""},{"id":286047880,"identity":"88a0fcaf-cad5-47ad-8c39-c9b237b5be8e","order_by":2,"name":"Itaru Yasufuku","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Itaru","middleName":"","lastName":"Yasufuku","suffix":""},{"id":286047881,"identity":"2791252b-1639-40bb-8d73-a029a9e71f10","order_by":3,"name":"Yuta Sato","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuta","middleName":"","lastName":"Sato","suffix":""},{"id":286047882,"identity":"794c0b52-bc4a-435a-93b1-0b933dc4c73b","order_by":4,"name":"Jesse Yu Tajima","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jesse","middleName":"Yu","lastName":"Tajima","suffix":""},{"id":286047883,"identity":"1d243a74-2afa-4cc4-9faf-2bb36d032022","order_by":5,"name":"Shigeru Kiyama","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shigeru","middleName":"","lastName":"Kiyama","suffix":""},{"id":286047884,"identity":"7006278a-c94b-4a7a-9ac7-64c549f9e6ae","order_by":6,"name":"Yoshihiro Tanaka","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yoshihiro","middleName":"","lastName":"Tanaka","suffix":""},{"id":286047885,"identity":"5c719421-2655-4b4f-bc8b-32b37a90659e","order_by":7,"name":"Katsutoshi Murase","email":"","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Katsutoshi","middleName":"","lastName":"Murase","suffix":""},{"id":286047887,"identity":"9c020372-5502-4b9e-bb4e-13672f5b5ca3","order_by":8,"name":"Nobuhisa Matsuhashi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYFACHgZmBgMGBvtm/o+PwQLMzA3EaTFgZzA2ZgCxmBmJ0QIEBvwMZtJgLQwEtJiz9x6TLiiokzdnZkirLqj4E83fDtTyo2IbTi2WPefSpGcYHDbc2cxw7PaMMwa5Mw4zNjD2nLmNU4vBjRwzaR6DA4wNhxnbbvO2GeQCGQ3MQDYhLXX2DYeZ2YpBWuYTqYU5ccNhNjZmkJYNBLWcOZdszWNwOHlmMw+zNM8Z49yNQC0H8frleO/B2zx/6mz7+c8wfuapkMudd/7wwQc/KnBrwQ4OkKh+FIyCUTAKRgEaAAD/EVKLBNbE7wAAAABJRU5ErkJggg==","orcid":"","institution":"Gifu University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Nobuhisa","middleName":"","lastName":"Matsuhashi","suffix":""}],"badges":[],"createdAt":"2024-03-30 09:47:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4191634/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4191634/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54107993,"identity":"1645d602-bff2-4c03-a1ee-b031483ff40d","added_by":"auto","created_at":"2024-04-04 17:33:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45537,"visible":true,"origin":"","legend":"\u003cp\u003eExclusion criteria used in the study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4191634/v1/17a9a27eca25ab1ff5101cc0.png"},{"id":54107994,"identity":"88e17e6a-c0c3-4cfa-9e24-0a6e63789e8d","added_by":"auto","created_at":"2024-04-04 17:33:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":99235,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation of PLOS with the presence and severity of postoperative complications following highly advanced HBPS\u003c/p\u003e\n\u003cp\u003ePLOS, postoperative length of stay; HBPS, hepatobiliary-pancreatic surgery\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4191634/v1/9a9c8520155c1e7478c9f03e.png"},{"id":54216293,"identity":"be37ccb5-8187-47e1-9eee-3e85c189aab0","added_by":"auto","created_at":"2024-04-06 15:01:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":709439,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4191634/v1/aae13475-3a1c-40a7-9247-d5d95ce88e06.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative risk factors associated with prolonged postoperative hospital stay in patients with severe complications after highly advanced hepatobiliary-pancreatic surgery: A single-center retrospective study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePostoperative length of hospital stay (PLOS) is the core of many quality improvement initiatives as it can reflect the quality of care delivered to patients and is associated with healthcare costs. Especially in surgical patients, PLOS is one of the most important outcomes for assessing the quality of surgery and perioperative management; thus, a short PLOS is the primary goal of enhanced recovery after surgery (ERAS) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies have reported that multiple factors are associated with PLOS after gastroenterological surgery, including age, smoking habits, American Society of Anesthesiologists (ASA) status, preoperative anemia, preoperative nutritional status, comorbidities, surgical approach, operative time, intraoperative blood loss, blood transfusion, and postoperative complications [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Among these factors, the incidence of postoperative complications, particularly severe complications requiring intensive treatment with invasive procedures, directly impacts the PLOS. Highly advanced hepatobiliary-pancreatic surgery (HBPS) induces severe complications more likely than general gastroenterological surgery, leading to prolonged PLOS (PPLOS).\u003c/p\u003e \u003cp\u003eFurthermore, according to the National Comprehensive Cancer Network Clinical Guidelines in Oncology version 1.2024 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], adjuvant treatment should be administered to patients who have adequately recovered from surgery; ideally, treatment should be initiated within 12 weeks. A contributing factor to delayed adjuvant treatment is PPLOS, which is consequently associated with worse outcomes [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the risk factors for PPLOS, particularly after HBPS, have not been adequately investigated. Therefore, in this study, we aimed to identify perioperative (pre-, intra-, and postoperative) risk factors to predict PPLOS in patients with severe postoperative complications after highly advanced HBPS.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis single-center retrospective study included 737 patients who underwent highly advanced HBPS at the Department of Gastroenterological Surgery, Gifu University Hospital, between January 2010 and December 2023. Gifu University Hospital is a Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS)-certified training institution. All highly advanced HBPS procedures were performed by experienced board-certified JSHBPS-qualified surgeons.\u003c/p\u003e \u003cp\u003e The study was conducted in accordance with the World Medical Association Declaration of Helsinki and was approved by the Ethics Committee of Gifu University (approval number: 2023-018). The need for informed consent was waived in view of the retrospective nature of the study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDefinition of PPLOS and severe postoperative complications\u003c/h2\u003e \u003cp\u003eThe main outcome of this study was PPLOS in patients with severe postoperative complications after highly advanced HBPS. PPLOS was defined as PLOS longer than the median value. According to this definition, patients were divided into two groups: those with and without PPLOS.\u003c/p\u003e \u003cp\u003eA severe postoperative complication was defined as a grade \u0026ge;Ⅲ Clavien\u0026ndash;Dindo (CD) classification after the surgical procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePre-, intra-, and postoperative variables\u003c/h2\u003e \u003cp\u003ePre-, intra-, and postoperative variables were included in the analysis. Preoperative variables were patient background, including age, sex, body mass index (BMI), ASA physical status classification, smoking habits, a past history of abdominal surgery, and preoperative chemotherapy; prognostic indices, including prognostic nutritional index (PNI), controlling nutritional status (CONUT), modified Glasgow prognostic score (GPS), and systemic immune inflammation index (SII); and patient comorbidity (Charlson risk index, and type of comorbidity). The intraoperative variables included the type of surgery (hepatobiliary or pancreatic surgery/open or minimally invasive [laparoscopic and robotic] surgery, MIS), operation time, blood loss, and blood transfusion. The postoperative variables were onset time of postoperative complications, postoperative complications (pancreatic fistula, bile leakage, liver failure, respiratory failure, postoperative bleeding, intra-abdominal abscess, and reoperation), postoperative mortality, and blood tests on postoperative day (POD) 1 and 3 (white blood cell count, C-reactive protein (CRP), and albumin levels).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eHighly advanced HBPS\u003c/h2\u003e \u003cp\u003eHighly advanced HBPSs include hepatobiliary surgeries, such as hepatic trisegmentectomy, hemihepatectomy, hepatic sectionectomy (except lateral sectionectomy), hepatic segmentectomy (except S4), hepatectomy (S4a\u0026thinsp;+\u0026thinsp;S5 resection or hemihepatectomy) with extrahepatic bile duct resection, extrahepatic bile duct resection for congenital biliary dilatation, and hepato-pancreatectomy, in addition to pancreatic surgeries, such as total pancreatectomy, pancreaticoduodenectomy (PD), distal pancreatectomy (DP) with lymph node dissection, and middle pancreatectomy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous and categorical variables are presented as median (range) values and frequencies (percentages), respectively. The Fisher\u0026rsquo;s exact test was used to compare categorical variables between the PPLOS and non-PPLOS groups. The Mann\u0026ndash;Whitney U test was used for continuous variables. The Steel\u0026ndash;Dwass test was used to assess the correlation between the presence and severity of postoperative complications and PLOS. The Youden's index was used to determine the optimal cut-off value for calculating the specificities and sensitivities of the receiver operating characteristic curve analysis. Variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in univariate analysis were introduced into the multivariate logistic regression model. Statistical significance was set at a two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were performed using JMP software (SAS Institute Inc., Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAt least one postoperative complication occurred in 367 (49.8%) patients. According to the CD grading system, 43 (5.8%) patients with grade I complications recovered without any treatment, 134 (18.2%) with grade II complications required antibiotic therapy, 168 (22.8%) with grade III complications needed radiologic intervention or reoperation, and 13 (1.8%) with grade IV complications and 9 (1.2%) with grade V complications died in the hospital. In total, 190 (25.8%) patients who experienced at least one postoperative severe complication, with grades\u0026thinsp;\u0026ge;\u0026thinsp;III, were evaluated for risk factors associated PPLOS in our study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePLOS of all patients and those with and without postoperative complications according to the highly advanced HBPS type\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the PLOS of all patients and those with and without postoperative complications according to the highly advanced HBPS type. The median PLOS in total patients was 20 days (range 5\u0026ndash;162): 13 days (range 5\u0026ndash;46) in those without any postoperative complications, 24 days (range 8\u0026ndash;59) in those with non-severe postoperative complications (CD grade \u0026lt;Ⅲ), and 40 days (range 9\u0026ndash;162) in those with severe postoperative complications (CD grade \u0026ge;Ⅲ). PLOS was significantly prolonged depending on the presence and severity of postoperative complications (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePLOS of all cases and cases with and without postoperative complications according to highly advanced HBPS type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\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=\"left\" 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=\"left\" 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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAll cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eNo complication cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eCases without SC\u003c/p\u003e \u003cp\u003e(CD grade \u0026lt;Ⅲ)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eCases with SC\u003c/p\u003e \u003cp\u003e(CD grade ≧Ⅲ)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePLOS (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePLOS (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePLOS (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePLOS (days)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatobiliary surgeries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 [5-162]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19 [8\u0026ndash;58]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e35 [9-162]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e▪hepatic trisegmentectomy\u003c/p\u003e \u003cp\u003e▪hemihepatectomy\u003c/p\u003e \u003cp\u003e▪hepatic sectionectomy\u003c/p\u003e \u003cp\u003e▪hepatic segmentectomy\u003c/p\u003e \u003cp\u003e▪hepatectomy with extrahepatic bile duct resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e125\u003c/p\u003e \u003cp\u003e116\u003c/p\u003e \u003cp\u003e60\u003c/p\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 [\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e14 [5-162]\u003c/p\u003e \u003cp\u003e13 [6-107]\u003c/p\u003e \u003cp\u003e12 [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e27 [9\u0026ndash;78]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e82\u003c/p\u003e \u003cp\u003e76\u003c/p\u003e \u003cp\u003e45\u003c/p\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 [\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e12 [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e12 [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e12 [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e22 [\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e19\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e18 [13\u0026ndash;58]\u003c/p\u003e \u003cp\u003e21 [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e13 [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e24 [\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e31 [\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e40 [9-162]\u003c/p\u003e \u003cp\u003e33 [11\u0026ndash;107]\u003c/p\u003e \u003cp\u003e23 [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e34 [17\u0026ndash;78]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e▪ extrahepatic bile duct resection for congenital biliary dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 [8\u0026ndash;52]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 [\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e47 418\u0026thinsp;\u0026minus;\u0026thinsp;52]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e▪ hepato-pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 [9-109]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 [-]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40 [\u003cspan additionalcitationids=\"CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e51 [9-109]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreatic surgeries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 [10\u0026ndash;150]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27 [12\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e42 [12\u0026ndash;150]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e▪total pancreatectomy\u003c/p\u003e \u003cp\u003e▪pancreatico duodectomy\u003c/p\u003e \u003cp\u003e▪distal pancreatectomy with lymph node dissection\u003c/p\u003e \u003cp\u003e▪middle pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e269\u003c/p\u003e \u003cp\u003e76\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 [10\u0026ndash;93]\u003c/p\u003e \u003cp\u003e29 [10\u0026ndash;150]\u003c/p\u003e \u003cp\u003e14 [10\u0026ndash;93]\u003c/p\u003e \u003cp\u003e34 [26\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e85\u003c/p\u003e \u003cp\u003e42\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e22 [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e14 [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e27 [-]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e90\u003c/p\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36 [\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e29 [13\u0026ndash;59]\u003c/p\u003e \u003cp\u003e14 [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e26 [-]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e94\u003c/p\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e36 [23\u0026ndash;93]\u003c/p\u003e \u003cp\u003e43 [15\u0026ndash;150]\u003c/p\u003e \u003cp\u003e42 [12\u0026ndash;93]\u003c/p\u003e \u003cp\u003e50 [40\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 [5-162]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 [8\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e40 [9-162]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003ePLOS: postoperative length of stay\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eSC: severe complicatons\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eCD: clavien-dindo classification\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA significantly longer PLOS due to postoperative complications was found in both hepatobiliary and pancreatic surgeries (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of patients with PPLOS\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the characteristics of the patients with PPLOS. Patients in the PPLOS group had significantly higher BMI (p\u0026thinsp;=\u0026thinsp;0.016); higher rates of pancreatic surgery (p\u0026thinsp;=\u0026thinsp;0.04), open surgery (p\u0026thinsp;=\u0026thinsp;0.016), and clinically relevant postoperative pancreatic fistula (CR-POPF) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and higher CRP level on POD 3 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than those in the non-PPLOS group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patient characteristics between patients with and without PPLOS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\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\u003ePPLOS group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-PPLOS group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 [30\u0026ndash;89]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 [24\u0026ndash;85]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale: 69 (71.1%)\u003c/p\u003e \u003cp\u003eFemale: 28 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale: 60 (64.5%)\u003c/p\u003e \u003cp\u003eFemale: 33 (35.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.6 [16.7\u0026ndash;30.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4 [14.8\u0026ndash;29.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1: 13 (13.4%)\u003c/p\u003e \u003cp\u003e2: 73 (75.3%)\u003c/p\u003e \u003cp\u003e3: 11 (11.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1: 12 (12.9%)\u003c/p\u003e \u003cp\u003e2: 69 (74.2%)\u003c/p\u003e \u003cp\u003e3: 12 (12.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking habits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (61.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (65.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrinkman index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e420 [0-2000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e245 [0-2700]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast abdominal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (40.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (46.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (15.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (23.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI✝\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.0 [15.0\u0026ndash;50.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0 [27.0\u0026ndash;54.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCONUTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal:37 (39.0%)\u003c/p\u003e \u003cp\u003eMild:49 (51.6%)\u003c/p\u003e \u003cp\u003eModerate:6 (6.3%)\u003c/p\u003e \u003cp\u003eSevere:3 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal:29 (31.2%)\u003c/p\u003e \u003cp\u003eMild:58 (62.4%)\u003c/p\u003e \u003cp\u003eModerate:6 (6.4%)\u003c/p\u003e \u003cp\u003eSevere:0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified GPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0: 73 (75.3%)\u003c/p\u003e \u003cp\u003e1: 17 (17.5%)\u003c/p\u003e \u003cp\u003e2: 7 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0: 62 (66.7%)\u003c/p\u003e \u003cp\u003e1: 22 (23.7%)\u003c/p\u003e \u003cp\u003e2: 9 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSII\u0026sect;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e465 [65-5616]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e428 [95-12357]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlson comorbidity index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 [0\u0026ndash;9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 [0\u0026ndash;10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of malignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (33.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (31.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart-related comorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (19.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory-related\u003c/p\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (15.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver-related\u003c/p\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (12.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (18.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular-related\u003c/p\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (34.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (31.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic renal dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHepatobiliary: 30 (30.9%)\u003c/p\u003e \u003cp\u003ePancreatic: 67 (69.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHepatobiliary: 42 (45.2%)\u003c/p\u003e \u003cp\u003ePancreatic: 51 (54.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen: 97 (100.0%)\u003c/p\u003e \u003cp\u003eMIS: 0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen: 89 (95.7%)\u003c/p\u003e \u003cp\u003eMIS: 4 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e425 [176\u0026ndash;8880]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e429 [161\u0026ndash;949]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e690 [55-21800]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e780 [0-12000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (26.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate of complication diagnosis (POD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 [0\u0026ndash;34]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 [0\u0026ndash;25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinically relevant pancreatic fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (57.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (31.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBile leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (14.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraabdominal abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (30.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (19.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite blood cell on POD1 (\u0026times;10\u003csup\u003e3\u003c/sup\u003e\u0026micro;l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.08 [2.40-30.24]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.36 [2.85\u0026ndash;22.39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-reactive protein on POD1 (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.16 [0.27\u0026ndash;14.64]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.25 [0.75\u0026ndash;17.36]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin on POD1 (g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8 [1.7\u0026ndash;3.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7 [2.0-3.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite blood cell on POD3 (\u0026times;10\u003csup\u003e3\u003c/sup\u003e\u0026micro;l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.62 [2.88\u0026ndash;41.36]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.75 [3.18\u0026ndash;19.69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-reactive protein on POD3 (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.30 [0.88\u0026ndash;30.98]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.13 [1.31\u0026ndash;32.72]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin on POD3 (g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8 [2.0-3.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 [1.9\u0026ndash;3.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePPLOS: prolonged postoperative length of hospital stay\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI: body mass index\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eASA: American Society of Anesthesiologists physical status classification\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCONUTS: Controlling Nutritional Status Score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eGPS: Glasgow Prognostic Score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMIS: minimally invasive surgery\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePOD: postoperative day\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e✝: Prognostic nutritional index\u0026thinsp;=\u0026thinsp;10\u0026times;albumin(g/dl)\u0026thinsp;+\u0026thinsp;0.005\u0026times; the absolute lymphocyte count\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026sect;:Systemic Inflammation Index\u0026thinsp;=\u0026thinsp;the absolute platelet count \u0026times; the absolute neutrophil count / the absolute lymphocyte count\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 **: p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 ***: p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eUni- and multivariate analyses to predict PPLOS in patients with severe postoperative complications after highly advanced HBPS\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the univariate analysis, PPLOS in patients with severe postoperative complications after highly advanced HBPS was significantly associated with pancreatic surgery (p\u0026thinsp;=\u0026thinsp;0.04), open surgery (p\u0026thinsp;=\u0026thinsp;0.02), CR-POPF (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), postoperative respiratory failure (PORF) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and CRP\u0026thinsp;\u0026gt;\u0026thinsp;15 mg/dL on POD 3 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition to these five factors, two possible predictive factors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.1) were introduced into the multivariate logistic regression model: BMI\u0026thinsp;\u0026gt;\u0026thinsp;24 kg/m\u003csup\u003e2\u003c/sup\u003e (p\u0026thinsp;=\u0026thinsp;0.09) and intra-abdominal abscesses (p\u0026thinsp;=\u0026thinsp;0.07).\u003c/p\u003e \u003cp\u003eFinally, three predictive factors were identified; open surgery (odds ratio [OR], 14193908; 95% confidence interval [CI] 2.06\u0026ndash;; p\u0026thinsp;=\u0026thinsp;0.01), CR-POPF (OR, 2.49;95% CI, 1.1\u0026ndash;-5.77; p\u0026thinsp;=\u0026thinsp;0.03), and PORF (OR, 5.74, 95% CI, 1.29\u0026ndash;40.48; p\u0026thinsp;=\u0026thinsp;0.02) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUni- and multivariate analysis of prediction for PPLOS after highly advanced HBPS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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=\"left\" 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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;75\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.41\u0026ndash;1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u0026ndash;2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;24\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.90\u0026ndash;3.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.82\u0026ndash;3.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.36\u0026ndash;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.45\u0026ndash;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast abdominal surgery\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.44\u0026ndash;1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative-chemotherapy\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u0026ndash;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI✝\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.48\u0026ndash;1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCONUTS\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.52\u0026ndash;4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified GPS\u003c/p\u003e \u003cp\u003e1/2\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.35\u0026ndash;1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSII\u0026sect;\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;437\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.432\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u0026ndash;2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlson comorbidity index\u003c/p\u003e \u003cp\u003e2+\u003c/p\u003e \u003cp\u003e0/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.52\u0026ndash;1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of malignancy\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.59-2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart-related comorbidity\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.60\u0026ndash;2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory-related\u003c/p\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.55\u0026ndash;2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver-related\u003c/p\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u0026ndash;1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular-related\u003c/p\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u0026ndash;2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u0026ndash;2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic renal dysfunction\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.37\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u0026ndash;4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003cp\u003ePancreas\u003c/p\u003e \u003cp\u003eHepatobiliary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.02\u0026ndash;3.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.40-2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003cp\u003eOpen\u003c/p\u003e \u003cp\u003eMIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e186\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11863408\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.74-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14193908\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.06-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;540\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.56\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.81\u0026ndash;3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1600\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.55\u0026ndash;2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.50\u0026ndash;1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate of complication diagnosis (POD)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;7\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u0026ndash;2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinically relevant pancreatic fistula\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.01\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.67\u0026ndash;5.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.49\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.10\u0026ndash;5.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBile leakage\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver failure\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;14.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory failure\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.09\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.99\u0026ndash;27.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.74\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.29\u0026ndash;40.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative bleeding\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.71\u0026ndash;3.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraabdominal abscess\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.87\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.96\u0026ndash;3.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.85\u0026ndash;3.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-operation\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.22\u0026ndash;2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative mortality\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u0026ndash;3.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite blood cell on POD3 (\u0026times;10\u003csup\u003e3\u003c/sup\u003e\u0026micro;l)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10000\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.81\u0026ndash;2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-reactive protein on POD3 (mg/dl)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e99\u003c/p\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.68\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.50\u0026ndash;4.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.75\u0026ndash;3.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin on POD3 (g/dl)\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2.8\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.56\u0026ndash;1.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003ePPLOS: prolonged postoperative length of hospital stay\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eOR: odds ratio\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e95%CI: 95% confidence interval\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eBMI: body mass index\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eASA: American Society of Anesthesiologists physical status classification\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eCONUTS: Controlling Nutritional Status Score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eGPS: Glasgow Prognostic Score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eMIS: minimally invasive surgery\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003ePOD: postoperative day\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e✝: Prognostic nutritional index\u0026thinsp;=\u0026thinsp;10\u0026times;albumin(g/dl)\u0026thinsp;+\u0026thinsp;0.005\u0026times; the absolute lymphocyte count\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u0026sect;:Systemic Inflammation Index\u0026thinsp;=\u0026thinsp;the absolute platelet count \u0026times; the absolute neutrophil count / the absolute lymphocyte count\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 **: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01 ***: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, we aimed to identify the perioperative risk factors for PPLOS following highly advanced HBPS. Our results revealed some significant correlations between PLOS and postoperative complications after highly advanced HBPS: i) the incidence of postoperative complications significantly prolonged PLOS, ii) PLOS was significantly prolonged as postoperative complications became more severe, and iii) these significant correlations were observed in both hepatobiliary and pancreatic surgeries.\u003c/p\u003e \u003cp\u003eWe found that open surgery, CR-POPF, and PORF were independent risk factors for PPLOS in patients with severe postoperative complications after highly advanced HBPS. However, no significant correlation was observed between PPLOS and operative mortality. We previously reported a study on predictive factors for postoperative mortality after advanced HBPS, in which comorbid liver disease, intraoperative blood loss, intraoperative blood transfusion, postoperative bleeding, and postoperative organ failure were significantly correlated [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We hypothesized that there are many similarities between the risk factors for PPLOS and postoperative mortality; however, this was not always the case. Previous large-scale database studies have reported similar results [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]; therefore, efforts to shorten PLOS, which is different from avoiding postoperative mortality, may be required.\u003c/p\u003e \u003cp\u003eOne of the most important initiatives for shortening PLOS is ERAS. ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes and has been shown to be effective in reducing PLOS. ERAS guidelines for pancreaticoduodenectomy and liver surgeries were reported in 2012 and 2016, respectively [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The key ERAS items identified were preoperative education and counseling, minimum fasting and administration of carbohydrate drinks before surgery, perioperative nutrition, avoidance of bowel preparation, epidural analgesia, intravenous fluid restriction, a minimally invasive approach, prevention of hypothermia, early removal of urinary catheters and abdominal drains, thromboembolic prophylaxis, antibiotic prophylaxis, early oral intake, early mobilization, early commencement of oral analgesia, and prevention of postoperative nausea and vomiting. A systematic review and meta-analysis by Noba et al. reported on the clinical benefits of ERAS in pancreatic and liver surgeries [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In pancreatic surgery, the PLOS was reduced by 3.15 days, and hospital costs were significantly lower in the ERAS group than in the standard care group without increasing postoperative mortality, readmission, and reoperation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, in liver surgery, PLOS was reduced by 2.2 days, and hospital costs were significantly lower in the ERAS group without increasing postoperative mortality and readmission rates [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our institution, many items were also implemented, such as early oral intake and mobilization but not preoperative carbohydrate drinks, avoidance of bowel preparation, and early removal of abdominal drains. It is thus possible that increased ERAS efforts could lead to a reduction in PPLOS.\u003c/p\u003e \u003cp\u003eFirst, in our present study, pancreatic surgery, particularly for CR-POPF, was shown to be significantly correlated with PPLOS. Traditionally, pancreatic surgery is associated with a high complication rate. Complications tend to remain very high, ranging from 40 to 60%, despite surgical techniques and improvements in perioperative care management [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Among the postoperative complications after pancreatic surgery, CR-POPF and delayed gastric emptying (DGE) have been identified as more severe complications that require further radiological or surgical intervention and are the primary causes of PPLOS [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Some meta-analyses have reported that ERAS markedly reduces the incidence of DGE but does not influence CR-POPF [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Veillette et al. retrospectively analyzed 581 patients who underwent PD, and found that patients with CR-POPF had a significantly longer PLOS (23.6 days vs 8.7 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In another international, multicenter, retrospective study including 1,089 patients who underwent DP according to the International Study Group in Pancreatic Surgery definition, the median PLOS increased from 7 days in patients with no POPF or grade A POPF to 9 days in those with grade B POPF. This number increased to 29 days in patients with grade C POPF [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Another problem is the negative impact of CR-POPF on patient costs and initiation of adjuvant chemotherapy due to PPLOS. We previously reported that CR-POPF not only prolongs PLOS but also delays the initiation of adjuvant chemotherapy for pancreatic cancer (65 days vs 40 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Jajja et al. found that patients with CR-POPF incur 2.4 times the overall median cost of PD, and the most significant contribution to cost was the postoperative ward stay. They also reported a significant increase in costs associated with the grade of CR-POPF [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Preoperative risk assessment of CR-POPF development in each patient, intraoperative patronizing procedure of the pancreas, and early postoperative diagnosis and intervention for CR-POPF may contribute to reducing PPLOS by avoiding severe POPF.\u003c/p\u003e \u003cp\u003eSecond, in the present study, MIS was significantly correlated with PPLOS. Currently, MIS is increasingly providing benefits as an alternative approach for patients needing elective surgery, including less postoperative pain, fewer early complications, faster recovery times, less stress on the immune system, smaller incisions, and shortened PLOS [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The technological advantages of imaging, instrumentation cameras, and robotics allow MIS to have more expensive applications and demonstrate medical and financial advantages for most surgical cases [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Vlădescu et al. showed that the MIS significantly reduces PLOS, with a potential positive influence on the national healthcare budget, based on an analysis of the Romanian national database. They found that the PLOS for MIS decreased annually at a significantly faster rate as compared to the PLOS for open surgery (0.085 days/year vs. 0.05 days/year, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the gap between the two gradually increased in favor of MIS (from 1.6 days in 2008 to 2.06 days) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, they found that the most pronounced shortening of PLOS after MIS for gallbladder surgery (by 7.95 days), gastric surgery (by 5.64 days), and incisional hernia surgery (by 4.33 days), but did not evaluate it in highly advanced HBPS. A systematic review and meta-analysis of propensity score-matched studies comparing the surgical outcomes of MIS vs. open surgery for hepatocellular carcinoma revealed that the PLOS was significantly shorter and the incidence of severe complications was significantly lower in MIS than in open surgery [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In contrast, regarding the comparison of surgical outcomes between MIS and open surgery in PD, which is the most frequent type of highly advanced pancreatic surgery, the results vary [\u003cspan additionalcitationids=\"CR37 CR38 CR39\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This discrepancy may stem from patient selection bias, differences in surgical indications, and learning curves.\u003c/p\u003e \u003cp\u003eIn our study, the fact that we performed MIS more aggressively during liver surgery than during pancreatic surgery may have influenced our results. However, as the analysis in this study was limited to patients with severe postoperative complications after highly advanced HBPS, MIS may have contributed to a shorter PLOS.\u003c/p\u003e \u003cp\u003eFinally, in the present study, PORF significantly correlated with PPLOS. Postoperative pulmonary complications, including hypoxemia, pneumonia, atelectasis, and PORF are more common than cardiovascular complications following surgery [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. These complications have high incidence, ranging from 6 to 80%, and are a leading cause of poor surgical outcomes [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Furthermore, postoperative pulmonary complications are more likely to occur after upper abdominal surgery, including HBPS [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Studies estimate that nearly one million postoperative pulmonary complications occur annually in the United States, resulting in 46,200 deaths and 480,000 additional hospital days [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In our previous study, PORF was identified as a significant risk factor for postoperative mortality [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Effective prevention of PORF is strongly associated with shorter hospital stays and decreased mortality. Postoperative factors, including respiratory support, breathing training, and physical therapy, are increasingly affecting the incidence of PORF. Postoperative diaphragmatic dysfunction is the pathophysiological basis of PORF. In contrast, preoperative inspiratory training reportedly reduces the incidence of PORF after major abdominal surgeries [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. At our institution, preoperative respiratory training is routinely introduced for thoracic surgery, including esophageal surgery, and the introduction of a highly advanced HBPS may lead to reduced PPLOS.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, this single-center retrospective study may have resulted in selection bias and multiplicity issues in the statistical analysis. A multicenter study with a larger number of patients is required to obtain more accurate results. However, multicenter studies may be affected by differences in discharge criteria at each institution. Therefore, our study on PPLOS at a single institution with a well-developed medical environment and uniform surgical indications may be of particular value. Second, this study included all patients with highly advanced HBPS who underwent hepatobiliary and pancreatic surgeries. Each type of surgery may be associated with different risk factors of PPLOS. This limitation should be considered when evaluating the results.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePLOS after highly advanced HBPS was significantly prolonged with the presence and severity of postoperative complications, regardless of the type of surgery. In cases with severe postoperative complications, open surgery, CR-POPF, and PORF may be risk factors for PPLOS. Proficient MIS and appropriate perioperative management to avoid severe CR-POPF and PORF may lead to a shorter PLOS after highly advanced HBPS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epostoperative length of stay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eenhanced recovery after surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehepatobiliary-pancreatic surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCCN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Comprehensive Cancer Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClavien\u0026ndash;Dindo\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePNI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprognostic nutritional index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCONUT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econtrolling nutritional status\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGlasgow prognostic score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSII\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esystemic immune inflammation index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epostoperative day\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\"\u003eJSHBPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJapanese Society of Hepato-Biliary-Pancreatic Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eodds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econfidence interval,PD,pancreaticoduodenectomy\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\"\u003ePORF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epostoperative respiratory failure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDGE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edelayed gastric emptying\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\"\u003eMIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eminimally invasive surgery.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was conducted in accordance with the World Medical Association Declaration of Helsinki and approved by the Ethics Committee of Gifu University (approval number \u0026apos;2023-018\u0026apos;). This retrospective study did not include any potentially identifiable patient data; therefore, the need for informed consent was waived by the Ethics Committee of Gifu University. This retrospective study was approved by the Institutional Review Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used in this study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eMF conceived the study concept, planned the study design as the principal investigator, interpreted the results, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eNM revised the manuscript, added intellectual content, and provided critical advice. MF, TH, IY, YS, JYT, SK, YT, KM, and NM obtained the data, provided critical comments to improve the manuscript, and approved its final submission. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors thank the medical staff of the Department of Gastroenterological Surgery at Gifu University Hospital for their participation in this study. We could not have completed this study without their diligence or support. We would also like to thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLjungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. 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Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev. 2015;2015:CD010356. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD010356.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD010356.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"prolonged, postoperative length of stay, highly advanced hepatobiliary-pancreatic surgery, perioperative risk factors","lastPublishedDoi":"10.21203/rs.3.rs-4191634/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4191634/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostoperative length of hospital stay (PLOS) is an important indicator of surgical quality, particularly because postoperative complications are closely related to PLOS. Prolonged PLOS (PPLOS) increases treatment costs and delays the transition from surgery to adjuvant chemotherapy. PPLOS may also have an unfavorable impact on long-term prognosis. However, the risk factors for PPLOS, particularly after highly advanced hepatobiliary-pancreatic surgery (HBPS), have not been adequately investigated. In this study, we aimed to identify the perioperative risk factors for PPLOS following highly advanced HBPS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this single-center retrospective study, we included 737 patients who underwent highly advanced HBPS at Gifu University Hospital, Japan, between 2010 and 2023. Of these, 190 patients with severe postoperative complications (Clavien\u0026ndash;Dindo classification grades \u0026ge;Ⅲ) were evaluated for perioperative risk factors for PPLOS using uni- and multivariate analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe median PLOS of patients with severe postoperative complications was 40 days, and 97 patients had a PPLOS. Univariate analysis indicated that pancreatic surgery, open surgery, clinically relevant postoperative pancreatic fistulas (CR-POPF), postoperative respiratory failure (PORF), and C-reactive protein levels\u0026thinsp;\u0026gt;\u0026thinsp;15 mg/dL on postoperative day 3 significantly correlated with PPLOS. Multivariate analysis showed that open surgery (odds ratio [OR], 14193908; 95% confidence interval [CI], 2.06\u0026ndash;; p\u0026thinsp;=\u0026thinsp;0.01), CR-POPF (OR, 2.49; 95% CI, 1.10\u0026ndash;5.77; p\u0026thinsp;=\u0026thinsp;0.03), and PORF (OR, 5.74; 95% CI, 1.29\u0026ndash;40.48; p\u0026thinsp;=\u0026thinsp;0.02) were independent risk factors for PPLOS.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAfter highly advanced HBPS, the PLOS was significantly prolonged with the presence and severity of postoperative complications, regardless of the type of surgery. In cases with severe postoperative complications, open surgery, CR-POPF, and PORF may be risk factors for PPLOS. This study underlines the need for proficient minimally invasive surgery and appropriate perioperative management to avoid severe POPF and PORF, leading to a shorter PLOS after highly advanced HBPS.\u003c/p\u003e","manuscriptTitle":"Perioperative risk factors associated with prolonged postoperative hospital stay in patients with severe complications after highly advanced hepatobiliary-pancreatic surgery: A single-center retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-04 17:33:12","doi":"10.21203/rs.3.rs-4191634/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":"93556b5b-70ec-4669-b508-1b2ce5085b90","owner":[],"postedDate":"April 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-27T15:14:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-04 17:33:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4191634","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4191634","identity":"rs-4191634","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}