Plasma apolipoprotein A2 isoforms predict the development of pancreatic fistula following distal pancreatectomy

BACKGROUND Postoperative pancreatic fistula (POPF) is a major complication of distal pancreatectomy (DP). Although anatomical and surgical risk factors are known, the relationship between preoperative pancreatic exocrine function and POPF remains unclear. Plasma apolipoprotein A2 isoforms (apoA2-i) hold promise as potential biomarkers of pancreatic exocrine function. AIM To examine the association between incidence of POPF following DP and preoperative apoA2-i. METHODS This retrospective cohort study included 51 patients who underwent DP at Nippon Medical School Hospital between November 2021 and December 2024. Preoperative plasma apoA2-i (ATQ/ATQ and AT/AT) levels were measured using an enzyme-linked immunosorbent assay. The primary outcome was the occurrence of POPF, classified as grade BL or grade B/C according to the 2016 International Study Group of Pancreatic Surgery criteria. RESULTS Preoperative apoA2-AT/AT levels were significantly higher in patients who developed POPF (n = 30) than in those who did not (n = 21) (P < 0.001). Receiver operating characteristic curve analysis yielded an area under the curve of 0.802 [95% confidence interval (CI): 0.681-0.924] for predicting POPF. The optimal cutoff value calculated by Youden’s index was 58.17 μg/mL. Plasma apoA2-AT/AT levels ≥ 58.17 μg/mL were significantly associated with POPF (P < 0.001) and remained an independent risk factor for POPF following DP in both univariate (odds ratio = 55.7; 95%CI: 6.58-7319.4; P < 0.001) and multivariate (odds ratio = 163.9; 95%CI: 10.50-35710.29; P < 0.001) logistic regression analyses. CONCLUSION Preoperative measurement of apoA2-i may serve as a useful predictor of POPF following DP. These findings support its use for preoperative risk stratification and individualized perioperative management.