Postoperative pancreatic fistula after pancreatic cancer surgery: Past and present of ISGPS classification

Postoperative pancreatic fistula (POPF) is a frequent and consequential complication after cancer-related pancreatic resections. Even in high-volume centers, reported incidence after pancreatoduodenectomy ranges from ~5% to 30% (1–3), and distal pancreatectomy historically reaches 30–40% in some series (2). POPF prolongs hospitalization and drives secondary problems—abscess, sepsis, hemorrhage, and delayed gastric emptying—despite overall perioperative mortality falling below 5% in specialized units (4,5). Although Grade C events are uncommon (<5%), they carry a grave prognosis, with postoperative mortality reported up to 20–30% when organ failure or erosive bleeding occurs (4,6).

Before 2005, heterogeneous, center-specific criteria produced wide variation in reported fistula rates and impeded benchmarking (4). The International Study Group on Pancreatic Fistula (ISGPF) addressed this by proposing the first consensus definition and severity grading in 2005: any drain output on/after postoperative day 3 with amylase >3× the upper normal serum level constituted a POPF, stratified into Grades A–C by clinical impact (4). Broad adoption standardized reporting (4,7), yet accumulating experience exposed limitations and ambiguities, prompting critical reassessment by the community (5,8).