Decision-Making and Practice Habits from International Expert Surgeons Regarding Operative Techniques and Mitigation Strategies to Reduce Pancreatic Fistula Following Pancreatoduodenectomy

Abstract

Background: Employment of pancreatic fistula mitigation strategies during pancreatoduodenectomy (PD) offers numerous decision-making points. Notably, 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. Their thought-processes and practice regarding pancreatico-enteric anastomotic technique and fistula mitigation strategy employment were explored. Results: 60 surgeons from 22 countries 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. Trans-anastomotic stents are always placed by few experts (17%), with the internal type preferred. Prophylactic somatostatin-analogues are infrequently employed (never: 57%). 45% selectively employ transperitoneal drainage, but not one absolutely omits drains. There is no conformity regarding drain number, type or system. When considering such approaches collectively, two-thirds declare 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%), prophylactic Somatostatin (20%) and externalized stents (18%). Total pancreatectomy is opted by just 10%, while a PG (rather than PJ) by only 5%. Facing a challenging scenario where the pancreatic tissue is easily disrupted in a soft parenchyma with a <1mm duct, most specialists would perform a new anastomosis after cutting back the pancreas (42%), whereas others directly perform a dunking/invagination PJ (27%). Constructing a PG (12%) or a total pancreatectomy (10%) are both rarely considered. Other additive approaches employed in such a situation are stents (58%), additional drain placement and Somatostatin-analogue administration (37%) and jejunal/gastrostomy tubes (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. These insights indicate that approaches to pancreatico-enteric reconstruction are variable, and optimal, absolute solutions for high-risk anastomoses are still unresolved.Tabled 1EP02E-028Mitigation Strategy Employment (n = 60)NeverOccasionally (1-25%)Sometimes (26-75%)Frequently (76-99%)AlwaysPancreatico-jejunostomy (PJ)-2 (3.3)1 (1.7)24 (40.0)33 (55.0)Duct-to-mucosa PJ6 (10.0)4 (6.7)2 (3.3)29 (48.3)19 (31.7)Dunking/invagination PJ17 (28.3)33 (55.0)3 (5.0)3 (5.0)4 (6.7)Pancreatico-gastrostomy (PG)35 (58.3)23 (38.3)-2 (3.3)-No reconstruction (e.g. duct occlusion)51 (85.0)9 (15.0)---Externalized trans-anastomotic stent36 (60.0)16 (26.7)4 (6.7)-4 (6.7)Internal trans-anastomotic stent26 (43.3)13 (21.7)6 (10.0)9 (15.0)6 (10.0)Isolated Roux-en-Y jejunal limb47 (78.3)11 (18.3)-1 (1.7)1 (1.7)Biological sealants (e.g. fibrin glue)52 (86.7)6 (10.0)1 (1.7)-1 (1.7)Autologous tissue patches43 (71.7)4 (6.7)1 (1.7)8 (13.3)4 (6.7)Prophylactic Somatostatin-analogues34 (56.7)15 (25.0)5 (8.3)3 (5.0)3 (5.0)External drain placement-6 (10.0)8 (13.3)13 (21.7)33 (55.0) Open table in a new tab Tabled 1EP02E-028 Table. Pancreatic fistula mitigation strategy employment by 60 expert pancreatic surgeons (top) and adaptation to their standard practice in the case of perceived increase risk of fistula (bottom).Adaptation to their standard practice in the case of perceived increase risk of fistula.I place more drains than usual.16 (26.7)I administer prophylactic Somatostatin-analogues.12 (20.0)I use a trans-anastomotic externalized stent (rather than no stent).11 (18.3)I drain the anastomosis in this particular case, although I usually don’t drain.10 (16.7)I use a trans-anastomotic internal stent (rather than no stent).8 (13.3)I perform an invaginating/dunking anastomosis (rather than duct-to-mucosa).6 (10.0)I instead perform a total pancreatectomy to avoid any risk of fistula.6 (10.0)I place a naso-jejunal /jejunostomy/gastrostomy tube.6 (10.0)I use an autologous tissue patch.5 (8.3)I use a biological sealant.4 (6.7)I perform a pancreatico-gastrostomy (rather than a pancreatico-jejunostomy).3 (5.0)I apply a Roux-en-Y reconstruction (rather than a single pancreatico-biliary jejunal limb).3 (5.0)Other (Afferent loop decompression; end-to-end binding PJ; hydrocortisone administration).4 (6.7)Grey emphasis reflects dominant practices. Open table in a new tab