Fistula risk-based use of external pancreatic drainage and modified Blumgart anastomosis minimize the postoperative fistula risk in high-risk patients

Abstract

Background: Fistula risk scores are barely used for decision-making and are not validated for different surgical techniques. We studied the use of modified Blumgart anastomosis associated to a selective external pancreatic duct drainage in high-risk duodenopancreatectomy patients. Methods: 64 consecutive patients from a prospectively maintained database were included and distributed into 3 groups according to the risk score developed by Callery et al. and the selective use of external pancreatic drainage as follows: Group 1: Negligible/low risk + anastomotic stent (n=32), Group 2: Intermediate/high risk + anastomotic stent (n=19) and Group 3: Intermediate/high risk + external pancreatic drain (n=13). Results: The applied risk score kept its fistula predictive value for patients with modified Blumgart anastomosis (p<0,001). There were significantly less clinically relevant fistulas (7,7% vs 47,7%, p<0,001) in Group 3 compared to Group 2, and these were less severe according to the Clavien-Dindo complication scale. Among the intermediate/high-risk patients, Group 3 had shorter median postoperative length of stay (14 vs 19 days) and lower clinically relevant complication rate than Group 2 (15,4% vs 47,4%). Conclusion: Selective external pancreatic drainage in intermediate/high-risk patients associated to a modified Blumgart anastomosis mitigates the fistula risk after duodenopancreatectomy. Fistula risk scores should be used for decision-making purposes in the perioperative period.