Analysis of Risk Factors Associated with Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy: Experience from a Tertiary Care Center

Abstract

Background: Pancreaticoduodenectomy (PD) remains the standard surgical procedure for malignant and selected benign lesions involving the pancreatic head and periampullary region. Although advances in surgical techniques and perioperative care have substantially reduced postoperative mortality, morbidity remains high. Postoperative pancreatic fistula (POPF) is one of the most common and clinically significant complications following PD and is associated with prolonged hospitalization, increased healthcare costs, and mortality. This study aimed to identify risk factors associated with POPF following pancreaticoduodenectomy in a tertiary-care center. Methods: This prospective observational study was conducted in the Department of Hepatobiliary Surgery, National Institute of Gastroenterology and Hospital, Dhaka, Bangladesh, from January 2025 to December 2025. Fifty consecutive patients who underwent pancreaticoduodenectomy were included. Patients were categorized into two groups: Group A (without POPF) and Group B (with POPF). Demographic, clinical, laboratory, operative, and postoperative variables were analyzed. Risk factors associated with POPF were evaluated using univariate and multivariate logistic regression analyses. A p-value of less than 0.05 was considered statistically significant. Results: Among the 50 patients included, 42 (84.0%) did not develop POPF, whereas 8 (16.0%) developed POPF. Clinically relevant POPF (Grade B/C) occurred in 6 patients (12.0%). The mean age of the study population was 53.4 ± 8.6 years, and most patients were male. Periampullary carcinoma was the most common indication for surgery (70.0%). Patients who developed POPF had significantly lower serum albumin levels (2.9 ± 0.4 vs. 3.6 ± 0.5 g/dL, p=0.002), a higher prevalence of pancreatic duct diameter <3 mm (75.0% vs. 11.9%, p=0.001), and a greater frequency of soft pancreatic texture (62.5% vs. 9.5%, p=0.001). Operative time, intraoperative blood transfusion, postoperative hospital stay, and mortality were significantly higher in the POPF group. Grade B fistula was the most common subtype (62.5%). On multivariate analysis, soft pancreatic texture (OR 4.81, 95% CI 2.12–9.74; p=0.001), pancreatic duct diameter <3 mm (OR 3.72, 95% CI 1.89–7.45; p=0.001), serum albumin <3 g/dL (OR 2.97, 95% CI 1.54–5.84; p=0.001), and type of pancreatojejunostomy (OR 2.41, 95% CI 1.38–4.62; p=0.001) were identified as independent predictors of POPF. Conclusion: The incidence of POPF following pancreaticoduodenectomy was 16.0%, while clinically relevant POPF occurred in 12.0% of patients. Soft pancreatic texture, pancreatic duct diameter <3 mm, low preoperative serum albumin level, and the type of pancreatojejunostomy were identified as independent predictors of POPF. Careful preoperative optimization and appropriate reconstruction techniques may reduce the occurrence of POPF. Larger multicenter studies are required to validate these findings.