Nationwide Outcome after Pancreatoduodenectomy in Patients at Very High Risk (ISGPS-D) for Postoperative Pancreatic Fistula
Rutger T. Theijse, Thomas F. Stoop, T. Hendriks, J. Annelie Suurmeijer, F. Jasmijn Smits, Bert A. Bonsing, Daan J. Lips, Eric R. Manusama, Erwin van der Harst, Gijs A. Patijn, Jan H. Wijsman, Mark Meerdink, Marcel den Dulk, Ronald M. van Dam, Martijn W.J. Stommel, Kees van Laarhoven, Roeland F. de Wilde, Sebastiaan Festen, Werner A. Draaisma, Koop Bosscha, Casper H.J. van Eijck, Olivier R. Busch, I. Quintus Molenaar, Bas Groot Koerkamp, Hjalmar C. van Santvoort, Marc G. Besselink, for the Dutch Pancreatic Cancer Group
Abstract
OBJECTIVE: To assess nationwide surgical outcome after pancreatoduodenectomy (PD) in patients at very high risk for postoperative pancreatic fistula (POPF), categorized as ISGPS-D. SUMMARY BACKGROUND DATA: 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. METHODS: 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. RESULTS: 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%). CONCLUSION: 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.