Decision-making and practice habits from international expert surgeons regarding operative techniques and mitigation strategies to reduce pancreatic fistula following pancreatoduodenectomy

Abstract

Presenter: Fabio Casciani MD | University of Pennsylvania Background: Employment of pancreatic fistula mitigation strategies during pancreatoduodenectomy (PD) offers numerous decision-making points. Particularly, despite ample retrospective studies and RCTs, no consensus exists concerning optimal anastomotic techniques and use of adjuncts for risk mitigation. Methods: A questionnaire was sent to a select panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their thought-processes and practice regarding pancreatico-enteric anastomotic technique and fistula mitigation strategy employment were explored through checkbox questions, free-text responses, and situational clinical vignettes. Results: 60 surgeons from 22 countries, encompassing 73,304 career pancreatic resections (median pancreatectomy/PD volume: 1200/705, median career duration: 22 years), contributed. When asked to report their usual fistula mitigation strategy employment, 55% always use PJ, whereas PG is never adopted by 58%. (Table) Concerning PJ technique, 80% use duct-to-mucosa reconstruction frequently/always (≥75% of the time) - more often by Cattel-Warren technique rather than Blumgart (45 vs. 33%). Trans-anastomotic stents are always placed by few experts (17%), with the internal type preferred. Roux-en-Y limb reconstruction, biological sealants and tissue patches are exceedingly rarely applied. Similarly, prophylactic somatostatin-analogues are infrequently employed (never: 57%; selectively: 38%). Lastly, 45% of authorities selectively employ transperitoneal drainage rather than routinely, but not one absolutely omits drains. However, there is no conformity regarding drain number, type or system. When considering such approaches collectively, the most prevalent “bundle” chosen (47%) is the combination of PJ, no stent, external drainage and omission of Somatostatin-analogue, with two-thirds declaring to be flexible -rather than rigid- in their fistula risk mitigation approaches. In the case of perceived increased fistula risk, the most frequent adjuncts chosen are placement of additional drains (27%), the use of prophylactic Somatostatin (20%), and externalized stents (18%). (Table, bottom) Conversely, total pancreatectomy is opted by just 10%, while a PG (rather than PJ) by only 5%. This was confirmed throughout clinical vignettes depicting stepwise increasing risk scenarios: the use of dunking/invaginating PJ, stents, drains and Somatostatin-analogues increased accordingly (+146%, +94%, +39% and +380%, respectively). Conversely, the employment of PG reconstruction and Roux limb orientation remained uncommon (≈6%). Finally, facing a challenging scenario where the pancreatic tissue is easily disrupted when placing stitches in a soft, thick parenchyma with an eccentric < 1mm duct, most specialists would perform a new anastomosis after cutting back the pancreas (42%), whereas others directly perform a dunking/invagination PJ (27%). Again, constructing a PG (12%) or converting to a total pancreatectomy (10%) are both rarely considered. Other, additive mitigation strategies employed in such a challenging situation are: stents (58%), additional drain placement and Somatostatin-analogue administration (37% each), autologous tissue patches (23%) and jejunal/gastrostomy tubes to optimize nutrition (20%). Conclusion: A tension between a rigid versus a flexible approach to fistula risk mitigation during PD is tangible among experts. Most vary their practice according to perceived, advanced risk, with dunking/invaginating PJ (rather than PG), stents, drains and Somatostatin-analogues each being modestly advocated in such circumstances. These insights indicate that approaches to pancreatico-enteric reconstruction are variable, and optimal, absolute solutions for high-risk anastomoses are still unresolved.