• Brett L Ecker, Matthew T McMillan, Horacio J Asbun, Chad G Ball, Claudio Bassi, Joal D Beane, Stephen W Behrman, Adam C Berger, Euan J Dickson, Mark Bloomston, Mark P Callery, John D Christein, Elijah Dixon, Jeffrey A Drebin, Castillo Carlos Fernandez-Del CF Massachusetts General Hospital, Harvard Medical School, Boston, MA., William E Fisher, Fong Zhi Ven ZV Massachusetts General Hospital, Harvard Medical School, Boston, MA., Ericka Haverick, Robert H Hollis, Michael G House, Steven J Hughes, Nigel B Jamieson, Ammar A Javed, Tara S Kent, Stacy J Kowalsky, John W Kunstman, Giuseppe Malleo, Katherine E Poruk, Ronald R Salem, Carl R Schmidt, Kevin Soares, John A Stauffer, Vicente Valero, Lavanniya K P Velu, Amarra A Watkins, Christopher L Wolfgang, Amer H Zureikat, and Charles M Vollmer.
• Departments of Surgery from University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
• Ann. Surg. 2018 Apr 1; 267 (4): 608-616.

ObjectiveThe aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.BackgroundThe 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.MethodsThis 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.ResultsA 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).ConclusionsThe 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.

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