Nationwide Outcome after Pancreatoduodenectomy in Patients at very High Risk (ISGPS-D) for Postoperative Pancreatic Fistula

• Published in: Annals of surgery
• Main Authors: Theijse, Rutger T, Stoop, Thomas F, Hendriks, Tessa E, Suurmeijer, J Annelie, Smits, F Jasmijn, Bonsing, Bert A, Lips, Daan J, Manusama, Eric, van der Harst, Erwin, Patijn, Gijs A, Wijsman, Jan H, Meerdink, Mark, den Dulk, Marcel, van Dam, Ronald, Stommel, Martijn W J, van Laarhoven, Kees, de Wilde, Roeland F, Festen, Sebastiaan, Draaisma, Werner A, Bosscha, Koop, van Eijck, Casper H J, Busch, Olivier R, Molenaar, I Quintus, Groot Koerkamp, Bas, van Santvoort, Hjalmar C, Besselink, Marc G
• Format: Journal Article
• Language: English
• Published: United States 11-12-2023
• ISSN: 0003-4932; 1528-1140; 1528-1140
• DOI: 10.1097/SLA.0000000000006174

To assess nationwide surgical outcome after pancreatoduodenectomy (PD) in patients at very high risk for postoperative pancreatic fistula (POPF), categorized as ISGPS-D.
Morbidity and mortality after ISGPS-D PD is perceived so high that a recent randomized trial advocated prophylactic total pancreatectomy (TP) as alternative aiming to lower this risk. However, current outcomes of ISGPS-D PD remain unknown as large nationwide series are lacking.
Nationwide retrospective analysis including consecutive patients undergoing ISGPS-D PD (i.e., soft texture and pancreatic duct ≤3 mm), using the mandatory Dutch Pancreatic Cancer Audit (2014-2021). Primary outcome was in-hospital mortality and secondary outcomes included major morbidity (i.e., Clavien-Dindo grade ≥IIIa) and POPF (ISGPS grade B/C). The use of prophylactic TP to avoid POPF during the study period was assessed.
Overall, 1402 patients were included. In-hospital mortality was 4.1% (n=57), which decreased to 3.7% (n=20/536) in the last 2 years. Major morbidity occurred in 642 patients (45.9%) and POPF in 410 (30.0%), which corresponded with failure to rescue in 8.9% (n=57/642). Patients with POPF had increased rates of major morbidity (88.0% vs. 28.3%; P<0.001) and mortality (6.3% vs. 3.5%; P=0.016), compared to patients without POPF. Among 190 patients undergoing TP, prophylactic TP to prevent POPF was performed in 4 (2.1%).
This nationwide series found a 4.1% in-hospital mortality after ISGPS-D PD with 45.9% major morbidity, leaving little room for improvement through prophylactic TP. Nevertheless, given the outcomes in 30% of patients who develop POPF, future randomized trials should aim to prevent and mitigate POPF in this high-risk category.