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

Rutger T Theijse; Thomas F Stoop; Tessa E Hendriks; J Annelie Suurmeijer; F Jasmijn Smits; Bert A Bonsing; Daan J Lips; Eric Manusama; Erwin van der Harst; Gijs A Patijn; Jan H Wijsman; Mark Meerdink; Marcel den Dulk; Ronald 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; Dutch Pancreatic Cancer Group

doi:10.1097/SLA.0000000000006174

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

Ann Surg. 2023 Dec 11. doi: 10.1097/SLA.0000000000006174. Online ahead of print.

Authors

Rutger T Theijse^{1

2}, Thomas F Stoop^{1

2

3}, Tessa E Hendriks^{1

2

4}, J Annelie Suurmeijer^{1

2}, F Jasmijn Smits⁵, Bert A Bonsing⁴, Daan J Lips⁶, Eric Manusama⁷, Erwin van der Harst⁸, Gijs A Patijn⁹, Jan H Wijsman¹⁰, Mark Meerdink¹¹, Marcel den Dulk^{12

13

14}, Ronald van Dam^{12

13}, Martijn W J Stommel¹⁵, Kees van Laarhoven¹⁵, Roeland F de Wilde¹⁶, Sebastiaan Festen¹⁷, Werner A Draaisma¹⁸, Koop Bosscha¹⁸, Casper H J van Eijck¹⁶, Olivier R Busch^{1

2}, I Quintus Molenaar⁵, Bas Groot Koerkamp¹⁶, Hjalmar C van Santvoort⁵, Marc G Besselink^{1

2}; Dutch Pancreatic Cancer Group

Affiliations

¹ Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands.
² Cancer Center Amsterdam, Amsterdam, the Netherlands.
³ Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA.
⁴ Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
⁵ Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands.
⁶ Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands.
⁷ Department of Surgery, Medisch Centrum Leeuwarden, the Netherlands.
⁸ Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands.
⁹ Department of Surgery, Isala Clinics, Zwolle, the Netherlands.
¹⁰ Department of Surgery, Amphia Hospital, Breda, the Netherlands.
¹¹ Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands.
¹² Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
¹³ Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany.
¹⁴ NUTRIM-School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
¹⁵ Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
¹⁶ Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.
¹⁷ Department of Surgery, OLVG Oost, Amsterdam, the Netherlands.
¹⁸ Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands.

PMID: 38073575
DOI: 10.1097/SLA.0000000000006174

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.