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Christopher B Nahm,1–3 Saxon J Connor,4 Jaswinder S Samra,1,2,5 Anubhav Mittal1,2,5 1Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia; 2Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia; 3Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, Australia; 4Department of Surgery, Christchurch Hospital, Christchurch, New Zealand; 5Australian Pancreatic Centre, Sydney, Australia Abstract: Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF. Keywords: postoperative pancreatic fistula, postoperative pancreatitis, distal pancreatectomy, pancreaticoduodenectomy

Pancreatitis occurs in approximately 4% of patients treated with the thiopurines azathioprine or mercaptopurine. Its development is unpredictable and almost always leads to drug withdrawal. We identified patients with inflammatory bowel disease (IBD) who had developed pancreatitis within 3 months of starting these drugs from 168 sites around the world. After detailed case adjudication, we performed a genome-wide association study on 172 cases and 2,035 controls with IBD. We identified strong evidence of association within the class II HLA region, with the most significant association identified at rs2647087 (odds ratio 2.59, 95% confidence interval 2.07-3.26, P = 2 x 10(-16)). We replicated these findings in an independent set of 78 cases and 472 controls with IBD matched for drug exposure. Fine mapping of the H LA region identified association with the HLA-DQA1*02:01-HLA-DRB1*07:01 haplotype. Patients heterozygous at rs2647087 have a 9% risk of developing pancreatitis after administration of a thiopurine, whereas homozygotes have a 17% risk.

The various players in a health care encounter all hold different perspectives on what constitutes service quality. Findings from this preliminary investigation show that doctors in a multispecialty clinic rated patient expectations of reliability, responsiveness, assurance, and empathy lower than did administrators, patient-contact personnel, and, most significantly, the patients themselves. Health care marketers need to educate doctors on the importance patients place on certain issues and how to address them.