DOI: 10.1177/00031348261501346 ISSN: 0003-1348

Mitigation Strategies: A Standardized Multimodal Pathway to Reduce the Severity of Clinically Relevant Pancreatic Fistula After Pancreaticoduodenectomy

Chiara Casadei, Valentina Zucchini, Tommaso Giuliani, Leonardo Solaini, Carlo Alberto Pacilio, Giuliano La Barba, Paolo Di Gioia, Alessandro Cucchetti, Giorgio Ercolani
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Background

Pancreaticoduodenectomy (PD) carries significant morbidity, primarily due to clinically relevant postoperative pancreatic fistula (CR-POPF). This study investigated the clinical impact of a multimodal mitigation strategy in patients undergoing PD, encompassing prehabilitation, standardized surgical techniques, and optimized postoperative management. The secondary aim was to identify factors associated with grade C POPF.

Methods

A single-center retrospective analysis was conducted using a prospective database of 520 patients who underwent pancreatic surgery at our hospital between January 2016 and December 2025. One hundred eighty-four patients who underwent PD were selected and divided into two cohorts using 2022 as a cutoff, the year in which our multimodal mitigation strategy was introduced.

Results

In the after-2022 cohort, a significant reduction in CR-POPF was observed (39% vs 55%, P = .036), with specific decrease in grade C POPF cases (5% vs 23%, P < .001). A statistically significant reduction in PPH was also observed in the after-2022 cohort (3% vs 17%, P < .001). Furthermore, in after-2022 cohort, there were a reduction of reoperation rate (8% vs 25%, P = .001) and LOS (23.0 days vs 14.5 days, P < .001). For the secondary aim, the multivariate analysis identified the after-2022 period and the occurrence of cardiac and pulmonary complications as factors associated with grade C POPF (respectively P < .001, P = .017 and P < .001).

Conclusions

This study highlights the potential of a structured, multi-level mitigation strategy in improving outcomes after pancreatoduodenectomy, in particular, the severity of pancreatic fistula and its consequences.

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