“The whole is greater than the sum of its parts” - a combined strategy to reduce post-operative pancreatic fistula after pancreaticoduodenectomy

Abstract

Presenter: Maddy Lemke MD, MSc | Western University Background: Post-operative pancreatic fistula (POPF) remains a common complication following pancreaticoduodenectomy (PD), with rates of clinically relevant (CR) POPF of 10-15%. This risk is higher in subgroups of patients, which can be predicted by the fistula risk score. Multiple methods have been employed to reduce risk of POPF following PD, including draining the surgical site, use of medications, and anastomotic techniques. In addition, research in other areas has shown the effect of combining best treatments can together offer greater benefit. This study aims to examine the rates of POPF and peri-operative morbidity for high risk patients undergoing PD where the following strategies have been employed: 1. External pancreatic stent 2. Peri-operative hydrocortisone, with first dose given intra-operatively followed by 100 mg IV q8h for 24h for three days (9 doses) 3. Inner invaginating layer 4. Blumgart outer layer Methods: Patients undergoing PD between January and December 2020 were abstracted from a single institution prospectively collected retrospective database (London Health Sciences Centre, London, Ontario). Information on pre-operative characteristics, peri-operative interventions to reduce POPF, and post-operative outcomes were collected. Patients undergoing all four strategies to reduce POPF outlined above were included in the final study. Patients were selected to undergo such interventions at surgeon discretion when suspected to have an elevated risk of CR-POPF. The following outcomes were reported: CR-POPF, surgical site infection, percutaneous drain insertion, post-operative complication (Clavien-Dindo Grade III or higher) within 30 days, length of stay, re-admission with 30 days and re-operation within 30 days. All outcomes were reported as median with interquartile range (IQR) or frequencies with percentages. Results: A total of 14 patients underwent all four interventions. The median age was 64 (IQR 57-69) and body mass index 30 (IQR 23-32). The medial fistula risk score was 6 (IQR 7-9). Four patients were high risk according to the fistula risk score, six intermediate and four low risk. One patient (7.1%) experienced a CR-POPF; this patient had a high fistula risk score. For comparison, the weighted average of the expected CR-POPF rate is 15.4% and the rate at this institution in July 2020 was 13%. Patient outcomes are described in Table 1. Conclusion: Interventions to decrease the rate of CR-POPF following PD are important but challenging. A combined approach of utilizing and studying multiple effective strategies shows promise in reducing CR-POPF rate for patients with elevated risk of CR-POPF. Further research is required to demonstrate an improved rate of CR-POPF in these patients when compared to similar controls.