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IMPROVING FISTULA RATES FOR PANCREATODUODENECTOMY BY TARGETING THE MOST CLINICALLY IMPACTFUL RISK SCENARIOS WITH OPTIMAL MITIGATION
Max Judish
*, Charles Vollmer
Surgery, University of Pennsylvania, Bryn Mawr, PA
IntroductionPancreatic Fistula (POPF) is among the most consequential complications following pancreatoduodenectomy (PD), an operation with numerous decision points. The Fistula Risk Score (FRS) Catalog defines 80 distinct risk profiles (Scenarios) based upon all possible combinations of the four FRS factors (texture, pathology, duct size, EBL). Importantly, it establishes expected, unique outcomes for each scenario and indicates that Scenario occurrence and POPF rates do not necessarily correlate. In fact, most fistulas arise in Moderate FRS risk cases. Improvement the global fistula rate will require decreasing POPF rates in those scenarios that produce the bulk of fistulas—through application of the most effective, tailored mitigation.
MethodsComplete data on POPF, FRS, and mitigation used were acquired for 7110 PDs performed from 2000-2024 within an 18-institution, multinational collaborative representing 83 surgeons. From the FRS Catalog, the most clinically impactful scenarios were deemed those with the greatest contribution to the crude POPF total (a construct of frequency of a scenario’s occurrence and its POPF rate). For each scenario, optimal outcomes were determined from observed application of various mitigation approaches, i.e. drains, trans-anastomotic stents, octreotide, PG vs. PJ, sealants, and the additive effect of early drain removal (POD ?4).
ResultsThe ten most clinically impactful scenarios were 20, 31, 33, 43, 44, 47, 59, 60 (Moderate FRS Zone), and 69, 70 (High Risk). They comprised 33.3% of the series (n=2365) and 50.7% of POPFs (n=544). The fistula rate among these "impactful" scenarios was 23.0%, versus 11.1% all others (p<0.001), and they naturally were more risky (median FRS 5 [IQR 4-6] vs. FRS 3 [IQR 1-4], p<0.001).
Application rates of mitigation for these "impactful" scenarios were: drains=96.7%, stents=47.8%, octreotide=26.2%, PG=4.0%, and sealants=4.1%. Early drain removal was employed in just 34.7%. The best combination(s) of mitigation strategies was discerned for each of these scenarios. While varying between scenarios, best mitigation consisted of drain application with early removal +/- stent placement (Table). Three scenarios (47, 60, 70) seem best served by a mitigation package that differs from the best approach previously established for that case’s broad risk zone.
If the optimal mitigation approach was adopted for all of the patients in these ten impactful scenarios, it would result in dropping the median POPF rate of the series from 15.1% to 8.3%—eliminating 45% of POPFs, overall.
ConclusionThis expansive, experiential study offers a path forward as to how surgeons can make a substantial impact on driving down so-far stubborn fistula rates. This practical application of risk assessment relies on recognition of these impactful scenarios in the operating room, paired with tailored and effective mitigation.
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