Association Between Preoperative HALP and Immediate Postoperative Outcomes

Primary outcomes

1. Morbidity- Clavién-Dindo grading :

   Time frame: 30days following the pancreaticoduodenectomy

   It is graded from grade I to V on the basis of surgical site infection, organ space infection, single or multiple organ failure, and death.

   Grade I Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions

   Grade II Requires pharmacological treatment, blood transfusions, or total parenteral nutrition

   Grade III Requires surgical, endoscopic, or radiological intervention IIIa Not under general anesthesia IIIb Under general anesthesia

   Grade IV Life-threatening complication requiring IC/ICU management IVa Single organ dysfunction IVb Multiorgan dysfunction

   Grade V Death of a patient

   PS- Higher the score worst the outcome.

2. Morbidity- Delayed Gastric Empty (DGE)

   Time frame: 30days following the pancreaticoduodenectomy

   Postoperative gastroparesis.

   Grade A DGE: If the Naso-Gastric Tube (NGT) is needed between the postoperative day (POD) -4 and 7, or if reinserted due to nausea and vomiting after removal by POD 3 and the patient is unable to tolerate a solid diet on POD 7, but starts a solid diet before POD 14.

   Grade B DGE: If the NGT is needed from POD 8-14, if reinserted after POD 7, or if the patient cannot tolerate unlimited oral intake by POD 14, but is able to resume a solid diet before POD 21.

   Grade C DGE: When nasogastric intubation cannot be discontinued or has to be reinserted after POD 14, or if the patient is unable to maintain unlimited oral intake by POD 21.

   PS- Higher the score worst the outcome.

3. Morbidity- Postoperative pancreatic fistula (POPF)

   Time frame: 30days following the pancreaticoduodenectomy

   A POPF is an abnormal communication between the pancreatic ductal epithelium and another epithelial surface containing pancreas-derived enzyme-rich fluid.

   Biochemical leak (Grade A): Pancreatic fistula often appears well and requires no intervention.

   Grade B: Pancreatic fistulas occur in patients who generally appear well, but may require parenteral nutrition or interventional fistula drainage for the fistula to heal.

   Grade C: Pancreatic fistulas, in which patients appear ill and require parenteral nutrition, interventional drainage, and potentially even re-operation for treatment.

   PS- Higher the score worst the outcome.

4. Morbidity- Post pancreatectomy Hemorrhage (PPH)

   Time frame: 30days following the pancreaticoduodenectomy

   Time of onset

   • Early hemorrhage ( 24 h after the end of the index operation)
   • Late hemorrhage ( 24 h after the end of the index operation)

   Location

   • Intraluminal
   • Extraluminal

   Severity of Hemorrhage Mild

   • Small or medium volume blood loss (from drains, nasogastric tube, or on ultrasonography, decrease in hemoglobin concentration 3 g/dl)
   • Mild clinical impairment of the patient, no therapeutic consequence, or at most the need for noninvasive treatment with volume resuscitation or blood transfusions (2-3 units packed cells within 24hrs of end of operation or 1-3 units if later than 24hrs after operation)
   • No need for reoperation or interventional angiographic embolization; endoscopic treatment of anastomotic bleeding may occur provided the other conditions apply

   Severe

   • Large volume blood loss (drop in hemoglobin level by 3g/dl)
   • Clinically significant impairment and need for blood transfusion (3 units packed cells)
   • Need for invasive treatment.

5. Mortality

   Time frame: 30days following the pancreaticoduodenectomy

   Survival within 30days.