Pancreaticojejunostomy Versus Neoprene-based Pancreatic Duct Occlusion in Pancreaticoduodenectomy for Patients at Intermediate-high Risk of Post-operative Pancreatic Fistula

Objective: To compare the short-term outcomes of pancreaticojejunostomy (PJ) and pancreatic duct occlusion (PDO) in patients at intermediate-high risk of postoperative pancreatic fistula (POPF). Summary background data: Postoperative pancreatic fistula (POPF) is the most fearsome complication of pancreaticoduodenectomy (PD). Methods: Patients undergoing PD with intermediate-high fistula risk scores (FRS) at two tertiary centers between 2012 and 2022 were included. To reduce biases between the groups, entropy balance and inverse probability of treatment weighting (EB-IPTW) were used. Results: A total of 302 patients were included (224, 74.2% PJs and 78, 25.8% PDOs). After EB-IPTW, two weighted pseudo-populations of 224 patients were obtained. Major complications, POPF, reoperations and post-operative mortality were similar. Patients undergoing PDO had lower rates of grade C POPF (3.3% vs 6.7%), delayed gastric emptying (15.7% vs 24.6%, p=0.02), intraabdominal collections (7.3% vs 20.5%, p<0.001) and 90-day readmissions (2.7% vs 9.4%, p=0.005). In subgroup analysis, PDO reduced POPF in patients with high FRS and blood loss > 400 mL, while PJ was more effective in intermediate FRS class, duct diameter ≥ 2 mm, blood loss < 400 mL, ASA class > II, younger patients and BMI < 25 kg/m2. In the unbalanced cohorts, completion pancreatectomy was required in 10 (4.5%) patients after PJ and in 1 (1.2%) after PDO. Conclusion: The main perioperative outcomes of PJ and PDO after PD in intermediate-high risk FRS patients are similar. PDO decreases the rate of POPF in patients with high-risk FRS, and reduces the need of completion pancreatectomy in case of reoperation.