Prevention of post-operative pancreatic fistula (POPF) after pancreatectomy: Results of a RAND/UCLA appropriateness expert panel

Abstract

Background: While a large body of literature has addressed techniques and approaches to prevent POPF, available studies have often yielded conflicting results. There is lack of evidence-informed clinical guidelines and no accepted consensus on interventions to prevent POPF. We aimed to define the appropriateness of interventions for the prevention of POPF after pancreatectomy. Methods: Using RAND/UCLA appropriateness methods, a national expert panel of 13 hepato-pancreatico-biliary surgeons rated 161 clinical scenarios for interventions to prevent POPF after pancreatectomy. Scenarios were divided into risk prediction, somatostatin analogs, anastomosis for pancreaticoduodenectomy (PD), method of pancreatic transection for distal pancreatectomy (DP), topical surgical adjuncts, and surgical approach (minimally invasive vs. open). Scenarios were created for PD and DP and varied based on known risk factors for POPF, such as pancreatic duct size, gland texture, and intraoperative blood loss. Ratings ranged from 1 (highly inappropriate) to 9 (highly appropriate). An initial round of ratings was followed by an in-person meeting and subsequently a final round of ratings. Median scores from the final rating were used to categorize scenarios as appropriate (rating 1-3), uncertain (rating 4-6), or inappropriate (rating 7-9), and assess agreement among the panel. Results: Unless otherwise specified, there was agreement for all ratings. The following interventions were rated appropriate (26 scenarios): 1) individualized risk prediction for all pancreatectomies, 2) perioperative pasireotide for soft gland in DP and PD with duct 6mm regardless of gland texture, 4) duct-to-mucosa anastomosis for all PD and dunking anastomosis in PD for duct < 3mm with firm gland, 5) stapled transection for all DP and reinforced stapling for DP with soft gland, 6) surgical drains for PD and DP with soft gland, and 7) open and minimally invasive surgery for DP, and open surgery for PD. The following were rated inappropriate (5 scenarios): 1) gastrointestinal anastomosis for stump closure in all DP, 2) omission of surgical drain in PD for duct < 3mm with soft gland (indeterminate agreement). Use of the fistula risk score to direct perioperative management was rated uncertain. Topical agents were rated uncertain for all types of adjuncts and all scenarios for PD and DP. Conclusion: The expert panel has identified 26 appropriate and 5 inappropriate scenarios for the prevention of POPF following pancreatectomy, to provide guidance to clinicians, support standardization of practice and improve care received by patients. There was a high level of agreement