Somatostatin Analogues for the Prevention of Pancreatic Fistula after Open Pancreatoduodenectomy: A Nationwide Analysis

Abstract

Purpose: Somatostatin analogues (SA) are varyingly used to try to prevent development of a pancreatic postoperative fistula (POPF) after pancreatoduodenectomy. Some centers do not use SA, some use it only in high-risk patients, and others in all patients. The aim of this study was to evaluate the effect of different protocols for SA use on the incidence of POPF after pancreatoduodenectomy in the Netherlands. Method: The Dutch Pancreatic Cancer Audit (DPCA) is a national, mandatory audit that registers all patients after pancreatoduodenectomy. Consecutive patients undergoing elective open pancreatoduodenectomy for all indications were included from the DPCA (2014-2017). Patients were divided into six groups depending on the SA protocol: no SA, octreotide, lanreotide, pasireotide, octreotide only in high risk patients, and lanreotide only in high risk patients. Primary endpoint was POPF (grade B and C). The updated alternative Fistula Risk Score (uaFRS) was used to analyze the occurrence of clinically relevant POPF across various risk scenarios (low-intermediate risk (<20%) and high risk (≥20%)). Results: Overall, 1992 patients were included with a POPF rate of 13.1%. POPF occurred less often when octreotide was administered in high risk patients only (9.4%) or if a lanreotide protocol was used (10.0%) compared to other protocols (varying from 12.7-19.1%, p=0.001). Sub-analysis in 577 patients (56.7%) with a high uaFRS showed a significantly lower rate of POPF when treated with lanreotide (10.0%) compared to the other protocols (varying from 18.9%-27.4%) (p=<0.001). In the 440 patients (43.3%) with a low-intermediate uaFRS the rate of POPF did not differ significantly between the six protocols. Multivariate regression analysis, controlling for male sex, BMI, soft pancreatic tissue, a pancreatic duct smaller than 3mm, ASA score III/IV, neuroendocrine tumor pathology, demonstrated lanreotide to be significantly associated with a low OR for POPF (OR 0.387, 95% CI 0.180-0.834) compared to no SA use. Conclusion: This nationwide retrospective study suggests that the use of lanreotide in patients undergoing pancreatoduodenectomy is beneficial in reducing the rate of POPF. However, perioperative mortality is unaffected. Since SA appear not to be beneficial in low-intermediate risk patients, the use of lanreotide may be reserved for patients at high risk of POPF.