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