Prevention of postoperative pancreatic fistula after pancreatectomy: results of a Canadian RAND/UCLA appropriateness expert panel

Abstract

Background:We aimed to define the appropriateness of interventions for the prevention of postoperative pancreatic fistulas (POPF) after pancreatectomy, given the lack of consistent data on this topic.Methods: Using the RAND/UCLA appropriateness method, we assembled an expert panel to rate clinical scenarios for interventions to prevent POPF after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). Results:The following interventions were rated appropriate: individualized risk prediction for all patients; perioperative pasireotide administration for patients undergoing PD who have a soft pancreatic gland and a pancreatic duct size of less 3 mm and for patients undergoing DP; pancreaticogastrostomy for patients undergoing PD who have a soft pancreatic gland and pancreaticojejunostomy for PD for patients with a pancreatic duct size of 6 mm or greater regardless of pancreatic gland texture; duct-to-mucosa anastomosis for all patients undergoing PD and dunking anastomosis for patients undergoing PD who have a pancreatic duct size of less than 3 mm with a firm pancreatic gland; simple stapled and reinforced stapled transection for all DP; surgical drains for PD and DP in patients with a soft pancreatic gland; and open and minimally invasive surgery for DP and open surgery for PD. The following were rated inappropriate: gastrointestinal anastomosis for stump closure in all DP and omission of surgical drain in PD for patients with a pancreatic duct diameter less than 3 mm and a soft pancreatic gland. Conclusion:The expert panel identified appropriate and inappropriate scenarios for POPF prevention following pancreatectomy, to provide guidance to clinicians. However, the appropriateness of the interventions in the majority of the clinical scenarios was rated as uncertain, demonstrating equipoise. Contexte :Nous avons voulu clarifier le bien-fondé des interventions de prévention des fistules pancréatiques postopératoires (FPPO) après la pancréatectomie, car on déplore un manque de données cohérentes à ce sujet.Méthodes : Nous avons formé un comité d'experts qui a appliqué la méthode de consensus RAND/UCLA pour évaluer les scénarios cliniques d'interventions de prévention des FPPO après la pancréatoduodénectomie (PD) et la pancréatectomie distale, ou gauche (PG).Résultats : Les interventions suivantes ont été jugées appropriées : évaluation systématique du risque chez tous les patients; administration périopératoire de pasiréotide chez les patients soumis à une PD qui ont un pancréas mou et un canal pancréatique de moins de 3 mm de diamètre et chez les patients soumis à une PG; pancréatogastrostomie chez les patients soumis à une PD qui ont un pancréas mou et pancréatojéjunostomie chez les patients soumis à une PD dont le canal pancréatique mesure 6 mm ou plus de diamètre, indépendamment de la texture du pancréas; anastomose canal-muqueuse chez tous les patients soumis à une PD et anastomose en « dunking » chez les patients soumis à une PD qui ont un canal pancréatique de moins de 3 mm de diamètre et un pancréas fe...

Appropriate scenarios for the prevention of postoperative pancreatic fistula

“…We read with great interest the arti cle, "Prevention of postoperative pancreatic fistula after pancreatec tomy: results of a Canadian RAND/ UCLA appropriateness expert panel" by Hallet and colleagues. 1 The panel identified appropriate and inappropriate scenarios for pre vention of postoperative pancreatic fistula (POPF). The authors scored the appropriateness of perioperative care and surgical techniques for pancreaticoduodenectomy and distal pancreatectomy, and identified 26 appropriate scenarios and 5 inap propriate scenarios.…”

“…The authors scored the appropriateness of perioperative care and surgical techniques for pancreaticoduodenectomy and distal pancreatectomy, and identified 26 appropriate scenarios and 5 inap propriate scenarios. 1 Postoperative pancreatic fistula is a common complication of pan creatic surgery, with an incidence of 5%-30%, and may lead to serious complications, such as postoperative bleeding, organ failure and death. 2 The most widely used diagnostic criteria and grading system for POPF comes from the International Study Group on Pancreatic Fistula; it was created in 2005 and updated in 2016 to define grade A pancreatic fistula as biochemical leak, and grade B and C pancreatic fistula as clinically relevant pancreatic fistula.…”