MIAMI BEACH – Pancreaticojejunostomy reconstruction, use of stents, and avoidance of prophylactic octreotide, especially in combination, could reduce the fistula rate associated with pancreatoduodenectomy.
Failure of the anastomosis is “of greatest concern” to surgeons performing a pancreatoduodenectomy, said Brett L. Ecker, MD, a surgical resident at the University of Pennsylvania, Philadelphia.
“There is no shortage of high-quality data to help guide the use of [fistula reduction] strategies,” he added. However, “the utility of these strategies in patients most vulnerable to fistula … has rarely been particularly explored.”
and his colleagues conducted a study with 62 surgeons at 17 institutions to compare various fistula mitigation strategies in this higher-risk population. They assessed surgical reconstruction, dunking, tissue patches, intraperitoneal drains, stents, prophylactic octreotide, and use of tissue sealants.
“Ultimately, we want to know the best way to deal with this high-stakes situation, and whether outcomes might be optimized by bundling these proactive strategies,” Dr. Ecker explained.
“We found the combination of externalized stents and PJ [pancreaticojejunostomy] reconstruction with the omission of prophylactic octreotide was associated with significant improvements in fistula that exceeded the benefit of any individual mitigation approach or any other combination of strategies,” he said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
“The mitigation of risk in real-life practice is often the result of multiple moving parts,” Dr. Ecker said. “The best outcomes [may result from] the synergistic effects of multiple strategies.”
Of the approximately 10% of patients with a Fistula Risk Score of 7-10, 152 ended up with clinically relevant postoperative pancreatic fistula (CR-POPF). “An FRS score of 7 or higher is associated with worse outcomes, including a fistula rate approaching 30%,” Dr. Ecker said. Grade B or C fistula based on International Study Group on Pancreatic Surgery criteria were considered clinically relevant. All patients had surgery from 2003 to 2016 in the retrospective, multinational study.
“This represents the only series of high-risk cases where current international standards were used to define both the risk and the outcome,” he noted.
“Almost all [of the 522] patients had a soft gland and a small duct, a median of 2 mm,” Dr. Ecker added. “High-risk pathology was common, in 86%.”
Surgeons contributing to the series were at high-volume centers and had performed more than 200 Whipple procedures in their careers. “Both institutional and surgeon volume were associated with improved fistula outcomes,” Dr. Ecker said. “We found that intraperitoneal drains were not associated with improved fistula outcomes, but that is limited by the fact that drains were rarely omitted in these cases.”
Four strategies compared
The investigators compared the outcomes of four fistula strategies among the patients considered high risk prior to surgery. When they combined pancreaticogastrostomy, prophylactic octreotide, and no stent, the CR-POPF rate was 47%. “This was associated with an alarming fistula rate approaching 50%,” Dr. Ecker said.
When surgeons combined pancreaticojejunostomy, octreotide, and no stent, the CR-POPF rate declined to 34%. Furthermore, pancreaticojejunostomy without octreotide or a stent yielded a 26% CR-POPF rate.
Ultimately, the most effective strategy to avoid clinically relevant fistula was pancreaticojejunostomy with an external stent and no octreotide.
“The use of PJ reconstruction with an external stent and omission of octreotide was associated with a fistula rate of about 13%, which was a greater than 50% risk reduction from the overall cohort,” Dr. Ecker said.
The researchers also performed propensity score matching to reduce bias associated with surgeon or patient factors. They matched 167 participants in the study with 155 controls. Dr. Ecker said, “Still, we observed that patients managed this way had significantly lower fistula rates.”
“This is an excellent paper and an important topic,” said study discussant, a general surgeon at the Mayo Clinic in Rochester, Minn.
“At our institution, we’ve used the same Fistula Risk Score and found it very helpful for a mitigation strategy in a separate protocol, and we found that reduced our leak rates as well,” Dr. Kendrick noted.
Dr. Ecker and Dr. Kendrick had no relevant disclosures.