Available online 13 December 2022, 101897

Many intraoperative factors are potentially modifiable during pancreatoduodenectomy.

A relatively high number of suboptimal intraoperative parameters was observed.

An intraoperative checklist could function as a useful warning tool.

Suboptimal intraoperative conditions might contribute to POPF development.

This relation should be further determined by future, large, prospective studies.

Postoperative pancreatic fistula (POPF) is a severe complication following pancreatoduodenectomy (PD). Previous research in colorectal surgery demonstrated suboptimal intraoperative conditions to be related with an increased risk of anastomotic leakage. Aim of this study was to evaluate the intraoperative condition of patients undergoing PD by both assessing whether these known intraoperative modifiable risk factors in colorectal surgery are also present during PD and by measuring compliance to intraoperative ERAS guidelines. Secondly, to determine the relation of these factors with POPF.

This prospective single center study included patients undergoing PD from 2016 - 2020. Parameters regarding the patient's general condition, local perfusion, oxygenation, surgical factors and ERAS elements were measured with a checklist intraoperatively, before the creation of the pancreatojejunal anastomosis. Uni- and multivariable logistic regression analyses were performed.

83 patients were included. POPF occurred in 27.7% (9.0% grade B, 10.0% grade C). Patients with POPF significantly had more other postoperative complications compared to patients without POPF (100% vs. 76.2%, p = 0.017). A suboptimal intraoperative condition was observed in 89.2%. Overall compliance to the intraoperative ERAS guideline was 0%. In univariable analysis, soft pancreatic tissue, pancreatic duct <3mm, tumor location and intraoperative vasopressor administration were significantly associated with POPF. In multivariable analysis, only soft pancreatic tissue was independently associated with POPF (OR 13.627; 95% CI 1.656–112.157, p = 0.015).

Awareness amongst surgeons and anesthesiologists should be created. The influence of these intraoperative factors on POPF should be further evaluated in future, larger studies.

Postoperative pancreatic fistula

Modifiable perioperative risk factors

Pancreatoduodenectomy

Pancreatojejunostomy

Pancreato-enteric anastomosis

The intraoperative condition

© 2022 The Authors. Published by Elsevier Ltd.