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ISGPS POPF Grading

International Study Group on Pancreatic Surgery — Post-Operative Pancreatic Fistula (2016 Definition)

Post-operative pancreatic fistula (POPF) is defined as drain amylase >3× upper limit of normal (ULN) of serum amylase on or after postoperative day 3. This tool classifies POPF severity and guides management.

Pancreatic Surgery HPB Surgery Post-operative Complications
ISGPS POPF Grading (2016 Definition)

POPF defined as drain amylase >3× serum ULN on/after POD3

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POPF Grade
Select a grade above and confirm

ISGPS 2016 Definition

Any measurable volume of output from a surgically placed drain (or percutaneous drain placed postoperatively) with an amylase concentration more than 3-fold the upper institutional limit of normal serum amylase activity, associated with a clinically relevant development or condition related directly to the postoperative pancreatic fistula.

Grading Classification

Grade Criteria Clinical Impact Management
Biochemical Leak Drain amylase >3× ULN after POD3 None Monitor; remove drain when normalised
Grade B BL + changed management or symptoms Moderate Drain maintenance; antibiotics; octreotide; NPO
Grade C Grade B + invasive procedure or organ failure Severe Surgery or CT drainage; ICU; TPN

Clinical Application

  • The 2016 ISGPS update reclassified "Grade A POPF" as "Biochemical Leak" — it carries no clinical consequence and is no longer a true fistula.
  • Only Grade B and C are clinically relevant POPF.
  • Biochemical Leak: drain can be removed once amylase normalises; does not require dietary restriction.
  • Grade B: maintain drain; if drain has already been removed, place a new percutaneous drain under CT/USS guidance; NPO or liquid diet; octreotide 200–300 mcg SC TDS; antibiotics (co-amoxiclav or piperacillin-tazobactam) if infected.
  • Grade C: requires formal surgical or radiological intervention; anastomotic disruption may need reoperation; single-organ failure (especially respiratory) demands ICU; TPN via central line.
  • Delayed gastric emptying (DGE) and post-pancreatectomy haemorrhage (PPH) often co-occur with Grade B/C POPF.
  • Drain amylase on POD1 >5000 IU/L predicts subsequent POPF (Molinari criterion); use to guide early watchfulness.
  • Assess concurrent drain fluid culture to guide antibiotic selection in Grade B.

Management by Grade

Biochemical Leak

  • Continue drain; serial drain amylase every 2–3 days.
  • Remove drain when amylase <3× ULN.
  • Advance diet as tolerated; no dietary restriction required.

Grade B

  • Keep drain in situ (reposition if necessary under imaging guidance).
  • Soft diet or NPO depending on severity and patient tolerance.
  • Octreotide 200 mcg SC TDS; antibiotics if infected collections are present.
  • Repeat imaging (CT abdomen) at POD7–10 to assess for collections.

Grade C

  • MDT discussion; percutaneous CT-guided drainage of collections as first-line intervention.
  • If failed or anastomotic disruption suspected: laparotomy with formal drainage and possible completion pancreatectomy.
  • HDU/ICU admission; TPN via central venous catheter.
  • Vasopressors and organ support if septic shock develops.

References

  1. Bassi C, et al. (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3):584–591.
  2. Callery MP, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013.
  3. Molinari E, et al. Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula. Ann Surg. 2007.

Related Calculators

ISGPS Fistula Risk Score