Fistula Mitigation Strategies Research Articles

Risk factor analysis and prediction of postoperative clinically relevant pancreatic fistula after distal pancreatectomy

ObjectivePostoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) is a serious complication. In the present study, we aimed to identify the risk factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF) and establish a nomogram model for predicting CR-POPF after DP.MethodsIn total, 115 patients who underwent DP at the General Hospital of Northern Theater Command between January 2005 and December 2020 were retrospectively studied. Univariate and multivariable logistic regression analyses were used to identify the independent risk factors associated with CR-POPF. Then, a nomogram was formulated based on the results of multivariable logistic regression analysis. The predictive performance was evaluated with receiver operating characteristic (ROC) curves. Decision curve and clinical impact curve analyses were used to validate the clinical application value of the model.ResultsThe incidence of CR-POPF was 33.0% (38/115) in the present study. Multivariate logistic regression analysis identified the following variables as independent risk factors for POPF: body mass index (BMI) (OR 4.658, P = 0.004), preoperative albumin level (OR 7.934, P = 0.001), pancreatic thickness (OR 1.256, P = 0.003) and pancreatic texture (OR 3.143, P = 0.021). We created a nomogram by incorporating the above mentioned risk factors. The nomogram model showed better predictive value, with a concordance index of 0.842, sensitivity of 0.710, and specificity of 0.870 when compared to each risk factor. Decision curve and clinical impact curve analyses also indicated that the nomogram conferred a high clinical net benefit.ConclusionOur nomogram could accurately and objectively predict the risk of postoperative CR-POPF in individuals who underwent DP, which could help clinicians with early identification of patients who might develop CR-POPF and early development of a suitable fistula mitigation strategy and postoperative management.

“Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach”—a narrative review

Postoperative pancreatic fistula (POPF) is associated with a mortality of up to 25% apart from significant morbid sequelae related to abdominal sepsis and post pancreatectomy hemorrhage. Numerous strategies to curtail the risk of POPF and associated morbidity have been largely unsuccessful. The pancreaticoenteric anastomosis post pancreaticoduodenectomy in a high-risk pancreas represents a significant surgical and clinical challenge. In this narrative review, we present the strategies for early identification and comprehensive management of the high-risk pancreas as per the available literature and present a stepwise algorithmic approach of different fistula mitigation strategies in patients undergoing pancreaticoduodenectomy. Medline, PubMed, Embase, Cochrane Library, and various center-specific guidelines were searched for the pancreas, pancreatic cancer, pancreatectomy, pancreatoduodenectomy, Whipple's operation, postoperative, complications, fistula, High-risk pancreas, risk assessment, different predictors, and scoring systems for the high-risk pancreas, current and emerging concepts in the development of POPF and mitigation strategies management and treatment in various combinations. Over the years, literature has mainly addressed the technical aspects of pancreatico-enteric anastomosis; however, the impact of different technical modifications has been at the most elusive. Recent literature has focused on other aspects like remnant ischemia, locoregional inflammation, and postoperative acute pancreatitis among others, defining their evolving role in pathophysiology of POPF. Although many pre-operative risk prediction models are available; their intra-operative implications are not clear. Furthermore, the evidence available on the mitigation strategies is limited, heterogeneous, and center specific. Fistula prediction includes numerous potentiating factors in addition to the factors described in various Fistula Risk Scores. Early identification of these high-risk scenarios allows the algorithmic application of mitigation strategies. Management of the high-risk pancreas starts in the pre-operative period by early identifications of the risk factors and then continues into the intra-operative period with strategies to decrease intraoperative blood loss, precise anastomosis, and external stenting wherever feasible; goal-directed fluid therapy as well as total pancreatectomy (TP) in certain highly selected scenarios followed by early identification of complications in the postoperative period and appropriate and early management of the same. The coherent application of these mitigation strategies provides the opportunity for the best possible outcome in this complicated scenario. At present, the zero post-operative pancreatic fistulae seem unattainable, and time has come to study the strategies outside the operation theatre. Till preventive strategies become mainstream, a strategic personalized algorithmic approach may yield best outcomes.

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

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

Randomized clinical trial and meta-analysis of the impact of a fibrin sealant patch on pancreatic fistula after distal pancreatectomy: CPR trial.

BackgroundPostoperative pancreatic fistula (POPF) remains the main cause of morbidity in patients after distal pancreatectomy. The objective of this study was to investigate whether an absorbable fibrin sealant patch could prevent POPF after distal pancreatectomy.MethodsA multicentre, patient-blinded, parallel-group randomized superiority trial was performed in seven Dutch hospitals. Allocation was done using a computer-generated randomization list with a 1 : 1 allocation ratio and concealed varying permuted block sizes. Pancreatic stump closure with a fibrin patch was compared with standard treatment in patients undergoing distal pancreatectomy. The primary endpoint was the development of grade B/C POPF. A systematic review and meta-analysis was performed which combined the present findings with all available evidence.ResultsBetween October 2010 and August 2017, 247 patients were enrolled. Fifty-four patients (22.2 per cent) developed a POPF, 25 of 125 patients in the patch group versus 29 of 122 in the control group (20.0 versus 23.8 per cent; P = 0·539). No related adverse effects were observed. In the meta-analysis, no significant difference was seen between the patch and control groups (19.7 versus 22.0 per cent; odds ratio 0.89, 95 per cent c.i. 0.60 to 1.32; P = 0·556).ConclusionApplication of a fibrin patch to the pancreatic stump does not reduce the incidence of POPF in distal pancreatectomy. Future studies should focus on alternative fistula mitigation strategies, considering pancreatic neck thickness and duct size as risk factors. Trial registration number NL5876 (Netherlands Trial Registry).

Pancreatoduodenectomy at the Verona Pancreas Institute: the Evolution of Indications, Surgical Techniques, and Outcomes: A Retrospective Analysis of 3000 Consecutive Cases.

The aim of the present study was to critically reappraise the experience at our high-volume institution to obtain new insights for future directions. The indications, surgical techniques, and perioperative management of pancreatoduodenectomy (PD) have profoundly evolved over the last 20 years. All consecutive PDs performed during the last 20 years at the Verona Pancreas Institute were divided into four 5-year timeframes and retrospectively analyzed in terms of indications, intraoperative features, and surgical outcomes. Significant milestones were provided to understand practice changes using a before-after analysis method. The study population consisted of 3000 patients. The median age, ASA ≥ 3 and number of nonbenchmark cases significantly increased over time ( P < 0.005). Pancreatic cancer was the leading indication, representing 60% of patients/year in the last timeframe, 40% of whom received neoadjuvant treatment. Conversely, after the development of International Guidelines, the proportion of resected cystic neoplasms progressively and thoroughly decreased. Given the increased complexity of surgery for pancreatic cancer, the evolution of technologies, surgical techniques, and postoperative management allowed the maintenance of favorable surgical outcomes over time, with a stable 20.0% of patients with a Clavien-Dindo grade ≥ 3, an 11.7% failure to rescue and a 2.3% in-hospital mortality rate. The incidence of postoperative pancreatic fistula, hemorrhage, and delayed gastric emptying was 22.4%, 13.4%, and 12.4%, respectively. PD significantly evolved in Verona over the past 2 decades. Surgeries of greater complexity are currently performed on increasingly frailer patients, mostly for pancreatic cancer and often after neoadjuvant chemotherapy. However, the progression of all fields of pancreatic surgery, including the expanding use of postoperative pancreatic fistula mitigation strategies, has allowed satisfactory outcomes to be maintained.

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

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.

Small Bowel Skewer Technique for Pancreatic Stenting in Robotic Whipple

Use of an external pancreatic stent is a proven fistula mitigation strategy for high risk anastomoses during PD. We propose a novel technique for passing and securing an internal - external pancreatic stent from skin via small bowel limb and into pancreas during PJ to facilitate totally robotic reconstruction phase in high fistula risk situations. This will be several slides and a 3 minute video outing the process and technique to be presented in ´Tricks of the Trade´.

Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development

BackgroundPancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood. MethodsThe fistula risk score was applied to identify high-risk patients (fistula risk score 7–10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003–2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models. ResultsEight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (–49.7%) and career length (–41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35–0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22–0.74). ConclusionSurgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.

Defining the practice of distal pancreatectomy around the world

BackgroundBest management practices for distal pancreatectomy (DP) have not been conclusively defined. The aim of this study was to analyze the practice of DP worldwide and to compare surgeons' behavior with the best available evidence. MethodsA survey assessing management approaches for DP was distributed worldwide, in eight native-language translations. Regions were clustered: North-America, South/Central America, Asia/Australia, and Europe/Africa/Middle East. ResultsOverall, 721/797 (91%) responding surgeons (median age = 48; years of experience = 14) indicated their region, representing six continents and 68 nations. Use of minimally-invasive (MI) techniques is diverse–highest in North-America (p < 0.001). Laparoscopy is the most common MI approach, while robotic techniques are rarely performed outside North-America. The preferred means of pancreatic remnant closure is via stapler – more commonly applied in North-America than in Europe/Africa/Middle East. Management techniques for the remnant and other fistula mitigation strategies display significant regional variability. The use of drains is also diverse, with the biggest disparity between North-American and Asian/Australian surgeons (selective and routine drainers, respectively). ConclusionThere is wide heterogeneity in practices for DP worldwide, which is influenced by the surgeon's region of practice. Variability in practice reflects the lack of solid evidence on the benefit of any given strategy, underlining areas for improvement.

Taking Theory to Practice: Quality Improvement for Pancreaticoduodenectomy and Development and Integration of the Fistula Risk Score

Improvements in surgical outcomes are predicated on recognizing effective practices with subsequent adaptation. It is unknown whether risk assessment for pancreatic fistula (clinically relevant postoperative pancreatic fistula [CR-POPF]) after pancreaticoduodenectomy (PD) translates to improved patient outcomes at the practice level. A prospectively collected, single-surgeon career experience (2003 to 2018) of 455 consecutive pancreatectomies (303 PDs and 152 distal pancreatectomies) was examined. Analysis occurred during 4 eras of practice: learning curve for PD (n= 50); development of the Fistula Risk Score (n= 48); reactive, data-driven adjustments of anastomotic stent use (n= 94); and omission of prophylactic octreotide with adoption of selective drainage (n= 111). Observed to expected ratios of CR-POPF were calculated using a multi-institutional derivation set (5,379 PDs). After adjustment for increasing fistula risk across the 4 eras (p= 0.016), the risk-adjusted CR-POPF rate declined significantly (observed to expected ratio 1.42→1.28→1.01→0.30; p < 0.001). Literature-driven changes in fistula mitigation strategies likewise led to reductions in the overall complication burden (Postoperative Morbidity Index: 0.20→0.24→0.25→0.15; p= 0.015) and resource use (therapeutic antibiotics: p= 0.019; hospital readmission: p= 0.006; postoperative transfusion: p= 0.007). In contrast, the CR-POPF rate after distal pancreatectomy, for which no validated risk-adjustment process exists, did not vary (approximately 12%; p= 0.878). Patient outcomes for PD can be optimized by risk-adjusted evaluation and deliberate modification of practice.

Characterization and Optimal Management of High-risk Pancreatic Anastomoses During Pancreatoduodenectomy.

The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circumstances of the anastomosis. The Fistula Risk Score (FRS) identifies a distinct high-risk cohort (FRS 7 to 10) that demonstrates substantially worse clinical outcomes. The value of various fistula mitigation strategies in these particular high-stakes cases has not been previously explored. This multinational study included 5323 PDs performed by 62 surgeons at 17 institutions. Mitigation strategies, including both technique related (ie, pancreatogastrostomy reconstruction; dunking; tissue patches) and the use of adjuvant strategies (ie, intraperitoneal drains; anastomotic stents; prophylactic octreotide; tissue sealants), were evaluated using multivariable regression analysis and propensity score matching. A total of 522 (9.8%) PDs met high-risk FRS criteria, with an observed CR-POPF rate of 29.1%. Pancreatogastrostomy, prophylactic octreotide, and omission of externalized stents were each associated with an increased rate of CR-POPF (all P < 0.001). In a multivariable model accounting for patient, surgeon, and institutional characteristics, the use of external stents [odds ratio (OR) 0.45, 95% confidence interval (95% CI) 0.25-0.81] and the omission of prophylactic octreotide (OR 0.49, 95% CI 0.30-0.78) were independently associated with decreased CR-POPF occurrence. In the propensity score matched cohort, an "optimal" mitigation strategy (ie, externalized stent and no prophylactic octreotide) was associated with a reduced rate of CR-POPF (13.2% vs 33.5%, P < 0.001). The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.

Defining the practice of distal pancreatectomy around the world

Background: Despite considerable efforts, best management practices for distal pancreatectomy (DP) have not been conclusively defined. Surgeons' choices are therefore often based on their backgrounds or surgical dogma, possibly leading to substantial variation in the practice of DP. Methods: A survey assessing experience and management approaches for DP was distributed worldwide, in 8 native-language translations, through 56 surgical societies (including AHPBA and IHPBA). To evaluate global variance, regions were clustered: North America, South/Central America, Asia/Australia, and Europe/Africa. Results: 797 surgeons from 68 nations responded (median age = 47; years of experience = 14; fellowship trained = 62%). Most were HPB surgeons (61%) – greatest in Asia/Australia (76%, p < .001) – with only 7% practicing pancreas surgery exclusively. Median annual and career volumes were 6 and 46 DPs, respectively, with major regional variations (p < .001). Experience with minimally invasive (MI) techniques was also diverse – highest in North America (p < .001). Laparoscopy was the most common MI approach (85%), while robotics was rarely performed outside the US/Canada. The preferred means of pancreatic remnant closure was via stapler (65%) – more commonly applied in North America than in Europe/Africa (81% vs 53%, p < .001). Management techniques for the remnant (hand-sewing, duct ligation, use of meshes/biological sealants/autologous patches, performance of an anastomosis) and other fistula mitigation strategies (e.g. stents, octreotide, antibiotics) displayed significant regional variability. In particular, there were stark differences in practice between North and South America (Table). Conclusion: Globally, there is wide regional variability in the practice of DP. Many of these choices are not evidence-based, precluding equipoise in management and, possibly, optimized outcomes.Tabled 1Variable n(%) or median (IQR)North America n = 182South/Central America n = 109p-valueExperienceYears of experience10.0(4.0–21.5)15.0 (6.0–25.0)0.012Fellowship-trained143 (78.6)73 (67.0)0.040Distal pancreatectomy annual volume10.0 (5.0–20.0)5.0 (3.0–8.0)<0.001Distal pancreatectomy career volume60.0 (30.0–165.0)30(11.3–60.0)<0.001Career total number of minimally invasive distal pancreatectomies25.0 (5.0–70.0)8.0 (2.0–18.0)<0.001Operative techniquePerformance of minimally invasive Distal Pancreatectomy0.080 Never – occasionally46 (25.4)38 (34.9) Sometimes58 (32.0)23 (21.1) Frequently – always77 (42.5)43 (44.0)Preferred minimally invasive technique<0.001 Laparoscopic105 (65.2)93 (98.9) Robot-assisted27 (16.8)0 Combined29 (18.0)1(1.1)Approach to pancreatic dissection0.032 Median to lateral117(64.3)67 (61.5) Lateral to median39 (21.4)35 (32.1) No specific approach26 (14.3)7 (6.4)Preferred means of pancreatic transection<0.001 Scalpel2(1.1)16(14.7) Electrocautery19 (10.5)5 (4.6) Stapled transection149 (82.3)78 (71.6) Energy devices8(4.4)8 (7.3) Other3(1.7)2(1.8)Preferred means of remnant closure0.005 Hand-sewn closure28 (15.4)35 (32.1) Stapled closure147 (80.8)71 (65.1) Energy devices3(1.6)0 Other4(2.2)3 (2.8)Management of the pancreatic remnantManagement of the pancreatic remnant<0.001 Same technique every time81 (44.5)77 (70.6) Variable depending on the case101 (55.5)32 (29.4)Primary hand-sewn closure of a non-stapled transection line0.004 Never – occasionally136 (78.2)65 (67.7) Sometimes19 (10.9)6 (6.3) Frequently – always19 (10.9)25 (26.0)Selective suture ligation of the main pancreatic duct0.001 Never – occasionally134 (77.5)54 (56.8) Sometimes18 (10.4)13 (13.7) Frequently – always21 (12.1)28 (29.5)Over-sew a staple-line transection with additional suture0.026 Never – occasionally131 (74.0)59 (58.4) Sometimes23 (13.0)20(19.8) Frequently – always23 (13.0)22 (21.8)Synthetic mesh on the remnant0.098 Never – occasionally148 (85.1)85 (92.4) Sometimes7(4.0)4 (4.3) Frequently – always19 (10.9)5 (5.4)Biological sealant on the remnant0.018 Never – occasionally142 (80.7)84 (90.3) Sometimes17 (9.7)4 (4.3) Frequently – always17(9.7)5 (5.4)Autologous tissue patch on the remnant0.007 Never – occasionally126 (72.4)81 (89.0) Sometimes20 (11.5)3 (3.3) Frequently – always28 (16.1)7 (7 7)Pancreatico-jejunal anastomosis/ pancreatogastrostomy0.015 Never – occasionally172 (98.3)83 (92.2) Sometimes2(1.1)7 (7.8) Frequently – always1 (0.6)0Fistula mitigation strategiesProphylactic trans-papillary pancreatic stent0.007 Never – occasionally179 (99.4)92 (92.9) Sometimes1 (0.6)5 (5.1) Frequently – always02(2.0)Intraoperatively placed, externalized drains0.014 Never – occasionally26(14.3)6 (5.5) Sometimes13 (7.1)3 (2.8) Frequently – always143 (78.6)100 (91.7)Prophylactic somatostatin analogue0.689 Never – occasionally147 (32.1)84 (80.0) Sometimes17(9.5)9 (8.6) Frequently – always15 (8.4)12 (11.4)Postoperative antibiotics specifically for fistula prophylaxis<0.001 Never – occasionally167 (92.8)69 (65.1) Sometimes6(3.3)8 (7.5) Frequently – always7(3.9)29(27.4) Open table in a new tab

Different types of pancreatico-enteric anastomosis.

The pancreatico-enteric anastomosis has widely been regarded as the 'Achilles heel' of the modern day, single-stage, pancreatoduodenectomy (PD). A review of the literature was carried out to address the evolution of the pancreatico-enteric anastomosis following PD, the spectrum of anastomoses performed around the world, and finally present the current evidence in support of each anastomosis. Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the most common forms of pancreatico-enteric reconstruction following PD. There is no difference in postoperative pancreatic fistula (POPF) rates between PG and PJ, as well as individual variations, except in a high-risk anastomosis where performance of a PJ may be preferred. The routine use of glue, trans-anastomotic stents or omental wrapping is of no proven benefit. Externalised trans-anastomotic stents may have a role in mitigating the risk of a clinically relevant POPF in high-risk anastomoses. Pancreatico-enteric anastomosis is an important component of reconstruction following PD even though it is fraught with the risk of development of a POPF. Adherence to the tenets of anastomotic reconstruction and performance of a safe and reproducible anastomosis with a low clinically-relevant POPF rate remain the mainstay of achieving the best outcomes. Appropriate selection and opportune use of fistula mitigation strategies may help provide optimal outcomes when faced with the need to perform a high-risk pancreatico-enteric anastomosis.

The influence of fellowship training on the practice of pancreatoduodenectomy

BackgroundThere has been a proliferation of gastrointestinal surgical fellowships; however, little is known regarding their association with surgical volume and management approaches. MethodsSurveys were distributed to members of GI surgical societies. Responses were evaluated to define relationships between fellowship training and surgical practice with pancreatoduodenectomy (PD). ResultsSurveys were completed by 889 surgeons, 84.1% of whom had completed fellowship training. Fellowship completion was associated with a primarily HPB or surgical oncology-focused practice (p < 0.001), and greater median annual PD volume (p = 0.030). Transplant and HPB fellowship-trained respondents were more likely to have high-volume (≥20) annual practice (p = 0.005 and 0.029, respectively). Regarding putative fistula mitigation strategies, HPB-trained surgeons were more likely to use stents, biologic sealants, and autologous tissue patches (p = 0.007, <0.001 and 0.001, respectively). Surgical oncology trainees reported greater autologous patch use (p = 0.003). HPB fellowship-trained surgeons were less likely to routinely use intraperitoneal drainage (p = 0.036) but more likely to utilize early (POD ≤ 3) drain amylase values to guide removal (p < 0.001). Finally, HPB fellowship-trained surgeons were more likely to use the Fistula Risk Score in their practice (29 vs. 21%, p = 0.008). ConclusionFellowship training correlated with significant differences in surgeon experience, operative approach, and use of available fistula mitigation strategies for PD.

Externalized Stents for Pancreatoduodenectomy Provide Value Only in High-Risk Scenarios

BackgroundEvidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted. MethodsFrom 2001 to 2015, PDs were performed at three institutions, with externalized stents placed at the surgeon’s discretion. The Fistula Risk Score (FRS) and the Modified Accordion Severity Grading System were used to analyze occurrence and severity of clinically relevant postoperative pancreatic fistula (CR-POPF) across various risk scenarios. ResultsOf 729 PDs, externalized stents were placed during 129 (17.7 %). Overall, CR-POPFs occurred in 77 (10.6 %) patients. The median FRS of patients who received externalized stents was significantly higher compared with patients who did not (6 vs. 3, p < 0.0001). Patients with negligible, low, or moderate CR-POPF risk (FRS 0–6) did not demonstrate improved outcomes with externalized stents; however, among high-risk patients (FRS 7–10), stents were associated with significantly reduced rates of CR-POPF (14.0 vs. 36.4 %, p = 0.031), severe complications (p = 0.039), and hospital stay (p = 0.014) compared with no stents. The average complication burden of CR-POPF was significantly lower for patients with externalized stents (p = 0.035). ConclusionThis multicenter study, the largest comparative analysis of externalized trans-anastomotic stents versus no stent for PD, demonstrates a risk-stratified benefit to externalized stents.

The Value of Drains as a Fistula Mitigation Strategy for Pancreatoduodenectomy: Something for Everyone? Results of a Randomized Prospective Multi-institutional Study

BackgroundA recent randomized, controlled trial investigating intraperitoneal drain use during pancreatoduodenectomy (PD) had a primary goal of assessing overall morbidity. It was terminated early with findings that routine elimination of drains in PD increases mortality and the severity and frequency of overall complications. Here, we provide a follow-up analysis of drain value in reference to clinically relevant postoperative pancreatic fistula (CR-POPF). MethodsNine institutions performed 137 PDs, with patients randomized to intraperitoneal drainage (N = 68) or no drainage (N = 69). The Fistula Risk Score (FRS), a 10-point scale derived from four validated risk factors for CR-POPF, facilitated risk adjustment between treatment groups. ResultsThere was no difference in fistula risk between the two cohorts. Overall, CR-POPF rates were higher in the no drain group compared to the drain group (20.3 vs. 13.2 %; p = 0.269). Patients with negligible/low FRS risk had higher rates of CR-POPF when drains were used (14.8 vs. 4.0 %; p = 0.352). Conversely, there were significantly fewer CR-POPFs (12.2 vs. 29.5 %; p = 0.050) when drains were used with moderate/high risk patients. Lastly, moderate/high risk patients who suffered a CR-POPF had reduced 90-day mortality (22.2 vs. 42.9 %) when a drain was used. ConclusionThe results of this analysis suggest that drains diminish the rate and severity of CR-POPF in patients with moderate/high risk, but they could possibly be avoided in the roughly one third of patients with negligible/low risk.

459 The Value of Drains as a Fistula Mitigation Strategy for Pancreatoduodenectomy: Something for Everyone? Results of a Randomized Prospective Multi-Institutional Study

459 The Value of Drains as a Fistula Mitigation Strategy for Pancreatoduodenectomy: Something for Everyone? Results of a Randomized Prospective Multi-Institutional Study