Prophylactic octreotide for pancreatoduodenectomy: more harm than good?

Abstract

This multi-institutional study, using ISGPF criteria, evaluates POPF development across the entire risk spectrum. Octreotide appears to confer no benefit in preventing a CR-POPF, and may even potentiate CR-POPF development in the presence of risk factors. This analysis suggests octreotide should not be utilized as a POPF mitigation strategy.

Prophylactic octreotide in pancreatoduodenectomy: response to Yang et al.

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We appreciate the comments of Yang and colleagues on our recent work entitled 'Prophylactic octreotide for pancreatoduodenectomy: more harm than good?' 1 We agree with several of their points, particularly that the current evidence in the translational literature directly linking octreotide to the formation of fistulas is far from definitive; however, defining the mechanism of fistula development in the setting of prophylactic octreotide was beyond the scope of our paper. Despite this, we cited over 15 studies that may explain our clinical findings.Secondly, although our findings contrast with those of several randomized controlled trials (RCTs), each of those studies predated the advent of the International Study Group on Pancreatic Fistula, 2 which established definitions for clinically relevant postoperative pancreatic fistula (CR-POPF) through international consensus.

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“…We appreciate the comments of Yang and colleagues on our recent work entitled 'Prophylactic octreotide for pancreatoduodenectomy: more harm than good?' 1 We agree with several of their points, particularly that the current evidence in the translational literature directly linking octreotide to the formation of fistulas is far from definitive; however, defining the mechanism of fistula development in the setting of prophylactic octreotide was beyond the scope of our paper. Despite this, we cited over 15 studies that may explain our clinical findings.…”

Defining the practice of pancreatoduodenectomy around the world

“…One of the more contentious management issues upon which pancreatic surgeons must make decisions regards the administration of prophylactic somatostatin analogues, such as octreotide. At least eight high‐volume (>100 patients) RCTs have investigated the use of octreotide with inconclusive findings . However, much of this incongruence can be attributed to the evolution of nomenclature for postoperative complications.…”

“…For example, before the advent of the ISGPF nomenclature for fistulae, studies did not differentiate between the incidence of innocuous biochemical (Grade A) and clinically relevant (Grades B and C) fistulae. Since the emergence of the ISGPF, no high‐volume, randomized trials have found octreotide to be associated with lower rates of clinically relevant fistula; however, the largest retrospective study to evaluate octreotide showed it to be associated with a reduced incidence of biochemical fistula and, in fact, higher rates of clinically relevant fistula …”

Pancreatoduodenectomy: Brazilian practice patterns

“…In a brilliant study performed by McMillan et al 26 , prophylactic octreotide was associated with a greater incidence of clinically relevant pancreatic fistula, re-operation, and increased length of hospital stay. The explanations by the authors are that octreotide can decrease pancreatic perfusion and gastroduodenal blood flow, impair wound healing at the site of the anastomosis, and suppress the secretion of anabolic and tropic hormones that improve the wound-healing process 26 . However, in a prospective randomized, double-blind trial, Allen et al 1 found that perioperative treatment with pasireotide decreased the rate of clinically significant postoperative pancreatic fistula…”