Drainage and irrigation on demand decreases severe septic complications and mortality in pancreatic resections

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Some randomized controlled trials have shown that the omission of drainage is safe for some patients, whereas reintervention rates and mortality rates are substantial for others. The present study aimed to assess fistula-associated outcomes in the setting of routine drain placement and drain irrigation on demand. Methods Between 01/2017 and 12/2022, perioperative and outcome data from patients who underwent consecutive pancreatoduodenectomies (PD, n = 253) or distal pancreatectomies (DP, n = 72) were prospectively collected in the electronic StuDoQ database and analyzed. All patients underwent intraoperative drain placement. Drains were removed starting at postoperative day 2 in PD or at day 5 in DP after testing for amylase concentration. In case of high amylase levels or macroscopically evident fistulas, drain irrigation was started. Nondrained fluid collections underwent percutaneous radiologic or transluminal endoscopic evacuation. Results Clinically relevant fistulas were detected in 53 of 325 patients (POPF grade B 16.3%, grade C 1.2%), and interventional or endoscopic drainage was necessary in 14 and 5 patients, respectively (overall 5.8%). Fistulas that required drainage were observed in 4.0% of patients with PD and in 12.5% with DP (p = 0.009). Delayed fistula-associated postpancreatectomy hemorrhage (PPH) was present in 1.2% (4/325) of patients. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). The 30-day and in-hospital mortality rates were both 1.5% (5/325), and the rate of fistula-associated mortality was 0.6% (2/325). Conclusion In pancreatectomies, a standardized drainage protocol including on-demand drain irrigation results in very low fistula-associated morbidity and mortality and an infrequent need for interventional or surgical reintervention. pancreatoduodenectomy distal pancreatectomy surgery drainage fistula INTRODUCTION Pancreatic surgery is still associated with relevant perioperative morbidity and mortality, and pancreatic fistulas are the predominant cause of septic complications. The intraoperative placement of drains adjacent to the pancreaticojejunostomy in pancreatic head resections or to the pancreatic stump in distal pancreatectomy, with the intention to evacuate leaking pancreatic fluid and thereby prevent potential further complications, continues to be controversial 1 . For pancreatoduodenectomies (PDs), data from some randomized controlled trials have demonstrated that prophylactic drainage of the pancreaticojejunostomy can be omitted without increasing fistula-associated complications or mortality 2,3 . However, the reintervention rate of 19% and the relaparotomy rate of 13.4% in the German PANDRA trial were relatively high, with no differences between the drain and the no drain groups 3 . In contrast, a Dutch randomized controlled trial (RCT) demonstrated that the elimination of prophylactic routine drainage in pancreatoduodenectomies increases the frequency and severity of complications and is associated with a substantial increase in mortality 4 . In distal pancreatectomy (DP), clinical outcomes and the need for reinterventions were comparable between the drain group and the no-drain group 5,6 . More recent data have suggested that drains can be selectively omitted in PDs according to risk-stratification 7 . When the pancreatic texture is hard and the main pancreatic duct diameter is large, the risk of postoperative pancreatic fistula (POPF) is generally low, and intraoperative drain placement may not be necessary. However, in high-risk anastomoses with soft pancreatic parenchyma and a small main pancreatic duct diameter, routine drain placement may be beneficial for preventing septic complications that are triggered by POPF 7 . Similar to a Swiss group, which recently published their strategy of early perianastomotic irrigation with passive drainage 8 , the present analysis describes a drain management concept that includes routine drainage and drain irrigation on demand in selected cases. In a consecutive series of 325 patients who underwent pancreatic resection, Robinson drainages, a closed passive drainage system, were placed in all patients intraoperatively to the pancreatic anastomosis in PD or to the pancreatic stump in DP. In the case of highly increased amylase levels in drains or in patients with suspected superinfected POPF, continuous drain irrigation was performed via an indwelling single-lumen central line catheter that was inserted into the drains, with the aim of diluting the leaking pancreatic fluid and improving evacuation via the drains. We demonstrate that a strict adherence to this drainage protocol results in a very low need for reinterventions, including radiologically or endoscopically placed drainages, and a low reoperation and mortality rate in PDs as well as in DPs. METHODS PATIENT SELECTION From a total of 367 consecutive pancreatic resections that were performed between January 2017 and December 2022 at the Department of General Surgery, Evangelisches Krankenhaus Düsseldorf, a high-volume pancreatic center in Germany, 253 pancreatoduodenectomies and 72 distal pancreatectomies were identified from the review board-approved prospectively maintained pancreatic StuDoQ database. Duodenum-preserving pancreatic head resections (n = 17), total pancreatectomies (n = 13), planned completion pancreatectomies (n = 4), pancreatic segmental resections (n = 3), enucleations (n = 4), and pancreatic resections combined with gastrectomy for gastric malignancy (n = 1) were excluded from the present analysis. Patients who underwent extended pancreatectomies, as defined by the ISGPS 9 , were not excluded. SURGICAL ELIGIBILITY Standard preoperative evaluation included physical examination, routine laboratory testing including serum levels of carbohydrate antigen 19 − 9 (CA 19 − 9), contrast-enhanced multidetector computed tomography of the abdomen and thorax, and/or state-of-the-art magnetic resonance imaging. Endoscopic ultrasound with/without fine needle aspiration or bile duct brushing were optional diagnostic procedures but were regularly performed for cystic tumors or distal bile duct tumors. Tumors were excluded from primary exploration if the presence of metastatic disease was identified by presurgical imaging studies. Neoadjuvant therapy was performed for histology- or cytology-proofed locally advanced pancreatic disease and was considered, but not mandatorily performed, for borderline resectable tumors, as defined by the International Study Group of Pancreatic Surgery (ISGPS) 10 . Patients with oligo-metastasized pancreatic cancer who responded well to combination chemotherapy according to imaging studies CA19-9 levels qualified for resection. Surgery for cystic tumors was indicated according to the Fukuoka guidelines 11 . Patients with duodenal or distal bile duct cancer generally qualified for resection when concomitant liver resection was not mandatory for complete tumor resection. Surgery for neuroendocrine tumors or chronic pancreatitis was indicated according to the ENETS Consensus Guidelines 12 or the German S3 Consensus Guidelines 13 , respectively. All pancreatic resections were agreed upon preoperatively in the institutional interdisciplinary tumor board evaluation of patients. SURGICAL INTERVENTION All pancreatic resections were performed by three experienced senior surgeons (H.P.-H., T.H., and W.H.) or under their supervision. According to the tumor location within the pancreas, PD or DP was performed. Extended pancreatectomies with resection of adjacent organs and/or vessels were performed when necessary to achieve complete tumor resection in borderline or locally advanced tumors 9 . “En bloc” tumor resection was always anticipated to avoid intraoperative spillage of tumor cells. Intraoperative frozen sections of the pancreatic and/or bile duct transection margin were always taken for the decision to potentially extend the resection. Pylorus preservation in PDs was performed whenever feasible when no tumor infiltration or severe inflammatory changes were present. None of the PDs were performed laparoscopically or robot-assisted, whereas distal pancreatectomy was performed laparoscopically whenever patients and tumor extension were deemed suitable. In DP, spleen preservation according to the Warshaw operation 14 was performed in patients with non-malignant disease whenever feasible. End-to-side pancreaticojejunostomy was performed via the double-layer technique with interrupted sutures PDS 5 − 0, with the inner row in the duct-to-mucosa technique. In the entire series, no total pancreatectomy was performed in high-risk situations with a small pancreatic duct or a very soft pancreatic texture, with the intention of preventing pancreatic fistula-associated complications. Closure of the pancreatic stump in distal pancreatectomy was dependent on the pancreatic texture, irrespective of whether the surgery was open or laparoscopic. A soft and relatively thin pancreas was closed and transected via Endo-GIA™ 60 mm medium/thick with Tri-Staple™ Technology, whereas a thick or hard pancreas was dissected by a scalpel via the fish-mouth technique, and closure was performed with interrupted sutures PDS 5 − 0 (Ethicon), with primary closure of the pancreatic duct by selective suture when feasible. Additional coverage of the pancreatic stump by a teres ligament patch was performed at the discretion of the surgeon, with the intention of reducing the severity of potential pancreatic fistula 15 . In all pancreatoduodenectomies, a prophylactic falciform ligamentum wrap around the hepatic artery was placed to prevent postpancreatic hemorrhage from the stump of the gastroduodenal artery 16 . Prophylactic drains CH 20 (Drainsid® Silicone, Asid Bonz GmbH, Germany) were placed routinely in all patients. The drains were located to the anterior and posterior aspect of the pancreaticojejunostomy in PDs, and in DPs they were placed right next to the pancreatic stump. DRAIN MANAGEMENT Postoperatively, the drainage fluid was inspected at least once daily. Starting on postoperative day 2, amylase levels in the drainage fluid were measured every other day. When the amylase level in the drain fluid was less than three times the serum level and drain fluid was macroscopically inconspicuous, the drain was removed on postoperative day ≥ 2 in PD patients and on postoperative day ≥ 5 in DP patients. In cases where amylase levels in drains were greater than 5000 U/ml or when macroscopic changes in drain fluid regarding consistency and color (toward grayish), were present, indicating suspected superinfected pancreatic fistula, a single lumen central line catheter (One-Lumen CVC, Ga. 14, Teleflex Medical, Ireland) was inserted into the drains, and continuous irrigation with ≥ 1000 ml of saline per day was started. Concomitantly, blood measurements, including white blood cell count, C-reactive protein (CRP), and amylase levels, were performed regularly. In patients with continuously increasing or persistently high systemic infection parameters (white blood cell count or CRP) and/or fever, contrast-enhanced computed tomography of the abdomen with/without the thorax was performed. In cases where a fluid collection was suspicious for being infected, a percutaneous radiologically guided interventional irrigation drainage tube (Peter Pflugbeil GmbH, Zorneding, Germany) was inserted whenever feasible, and antibiotic therapy was implemented. The drainage size ranged between 10F and 16F depending on the size and location of the fluid collection. In the case of fluid collections that were better accessible via transluminal drainage, one or two transgastric or transduodenal pigtail catheters (EndoStay®, 10F, Peter Pflugbeil GmbH, Germany) were placed endoscopically, guided by endoscopic ultrasound (EUS). PARAMETER ANALYSIS All parameters were prospectively collected in the electronic StuDoq database, maintained by the Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). The following parameters were analyzed: age and sex of the patients, American Society of Anesthesiologists (ASA) score, body mass index, diabetes mellitus status, type of histology, pancreatic Fistula Risk Score (FRS, includes pancreatic texture and main pancreatic duct diameter) for PDs 17 , neoadjuvant therapy, preoperative bile duct stenting, type of surgery (laparoscopic vs. open), intraoperative blood loss, and operative time. Surgical and nonsurgical morbidities were categorized according to the Clavien-Dindo classification 18 and were analyzed for categories 3B and more. The parameters of surgical morbidity included anastomotic leakage, postoperative pancreatic fistula (POPF) according to the updated ISGPS definition 19 , postpancreatectomy hemorrhage (PPH) 20 , the need for relaparotomy, intraabdominal abscess or fluid collection with the need for interventional or endoscopic intervention, and wound infections that require operative reintervention. Importantly, there was strict adherence to the updated ISGPS POPF definition 19 within the entire study period. An increase in amylase concentration in the drains within the first 3 weeks was considered a biochemical leak, as long as there was no deviation from the normal postoperative pathway related to the leak. As soon as a central line catheter was inserted into the drains and irrigation was started, the patient was defined a having POPF grade B. Similarly, patients with amylase-rich drainage fluid or contrast-enhanced peripancreatic fluid collections who received antibiotic therapy were grouped into POPF grade B, as were patients who received interventional or endoscopic drainage or an angiographic procedure for POPF-related bleeding. Patients who experienced POPF-related reoperation, organ failure, or death were defined as having POPF grade C 19 . The duration of hospital stay was recorded, as well as in-hospital, 30-day, and 90-day mortality. After the data were extracted from the StuDoQ database, specific data on PPH, reoperation, and POPF grades B and C were checked and refined by reevaluating the original patient data. FOLLOW-UP The patients were followed up for at least 90 days after surgery. For those patients who were not included in our follow-up program, patients, general practitioners, relatives, and insurance companies were contacted by telephone and asked about eventual complications and patient survival or the documented day of death. The 90-day follow-up data were incomplete for 39 patients (12% of all patients). STATISTICAL ANALYSIS SAS software (Release 9.4, SAS Institute, Inc, Cary, NC, USA) was used for statistical analysis. The quantitative variables age, serum CA 19 − 9 concentration, length of hospital stay, operative time, and blood loss are expressed as medians with interquartile ranges. Variables with categorical scores are presented with absolute and relative frequencies. Subgroups of patients were analyzed by using the Fisher exact test and the χ2 test, when appropriate. Two-sided P values < 0.05 were considered to indicated statistical significance. RESULTS From 367 consecutive pancreatic resections that were performed at the Evangelisches Krankenhaus Düsseldorf between 01/2017 and 12/2022, 253 patients who underwent PD and 72 patients with DP were evaluated. Sixty-four percent of DPs were performed laparoscopically. The median age of the patients was 70 years, and the male-to-female was 51–49%. Most patients had pancreatic ductal adenocarcinoma (47%), followed by adenoma or carcinoma of the papilla vateri (10.5%), intraductal papillary mucinous neoplasms including carcinoma (IPMN or IPMC, 10.2%), distal bile duct cancer (9.2%), and others (Table 1 ). Patient characteristics, including the ASA score, BMI, presence of diabetes mellitus, neoadjuvant therapy, preoperative biliary drainage, pancreatic texture and main pancreatic duct diameter, are presented in Table 1 . A soft pancreatic texture was present in 47.8% of patients, with a median pancreatic duct diameter of 3 mm. Table 1 Patient and tumor characteristics Parameter Sex ratio, male : female 51% : 49% Age [years], mean ± SD 70 ± 11.8 Histology, n (%) Pancreatic ductal adenocarcinoma 154 (47.4%) Adenoma / carcinoma of papilla vateri 34 (10.5%) IPMN/IPMC 33 (10.2%) Distal bile duct cancer 30 (9.2%) Chronic pancreatitis / AIP 19 (5.8%) Duodenal adenoma / carcinoma 13 (4%) Neuroendocrine tumor 13 (4%) Other 29 (8.9%) ASA-Score, n (%) I 7 (2.2%) II 131 (40.3%) III 185 (56.9%) IV 2 (0.6%) Body mass index, mean ± SD 25.5 ± 4.4 Diabetes mellitus, n (%) 70 (21.5%) Neoadjuvant therapy, n (%) Yes 14 (4.3%) No 311 (95.7%) Preoperative biliary drainage, n (%) Yes 144 (44.3%) No 181 (55.7%) Pancreatic texture, n (%) * Hard 132(52.2%) Soft 121 (47.8%) Main pancreatic duct diameter [mm], median (IQR) * 3 ( 2 – 5 ) American Society of Anesthesiologists physical status classification (ASA), Standard deviation (SD), interquartile range (IQR) * Only pancreatoduodenectomies were evaluated The perioperative and postoperative outcomes for PD and DP patients are presented in Table 2 . As expected, the duration of surgery was longer in the PD groups than in the DP group. Similarly, blood loss was greater in PD patients. Overall, Clavien-Dindo complications ≥ 3B occurred in 9.8% of patients. Clinically relevant fistulas (POPF grades B and C) were detected in 53 of 325 patients (16.3%), with a low percentage of type C fistulas (1.2%). Most fistulas were treated with antibiotics, prolonged drainage, and/or irrigation of intraoperatively placed drains. There was a need for interventional external or endoscopic internal drainage in 14 and 5 patients, respectively (overall 5.8%). Interventional or endoscopic drainage was performed more frequently in DP patients (12.5%) than in PD patients (4.0%, p = 0.009). Table 2 Perioperative and postoperative outcome Parameter PD DP overall Number of patients 253 72 325 Duration of surgery [min], median (IQR) 295 (258–344) 199 (165–229) 281 (235–331) Blood loss [ml], median (IQR) 500 (350–800) 250 (100–600) 450 (250–750) Morbidity Clavien Dindo complication ≥ 3B 24 (9.5%) 8 (11.1%) 32 (9.8%) Clinically relevant POPF 36 (14.2%) 17 (23.6%) 53 (16.3%) Grade B 33 (13%) 16 (22.2%) 49 (15.1%) Grade C 3 (1.2%) 1 (1.4%) 4 (1.2%) Interventional external drainage 9 (3.6%) 1 5 (6.9%) 2 14 (4.3%) Transluminal endoscopic drainage 1 (0.4%) 1 4 (5.6%) 2 5 (1.5%) Bleeding 6 (2.4%) 2 (2.8%) 8 (2.5%) Early PPH 1 (0,4%) 1 (1.4%) 2 (0.6%) Delayed PPH 5 (2.0%) 1 (1.4%) 6 (1.4%) Angiographic intervention 1 (0.4%) 1 (0.4%) 2 (0.6%) Relaparotomy 16 (6.3%) 4 (5.5%) 20 (6.2%) Mortality, n (%) In-hospital 4 (1.6%) 1 (1.4%) 5 (1.5%) 30-day 4 (1.6%) 1 (1.4%) 5 (1.5%) 90-day 12 (5.3%) 1 (1.7%) 13 (4.5%) Hospital stay [days], median (IQR) 17 ( 13 – 23 ) 13.5 ( 10 – 17 ) 16 ( 12 – 22 ) Postoperative Pancreatic Fistula (POPF) according to the ISGFS definition 19 . Postoperative pancreatic hemorrhage (PPH) according to the ISGFS definition 20 . Interquartile range (IQR). 1,2 When interventional and endoscopic drainage were combined, drainage was needed more frequently in DP as compared to PD (p = 0.009) Follow-up was completed in 226 patients with PD and 60 patients with DP. 39 patients were lost to follow-up. Postpancreatectomy hemorrhage (PPH) was detected in 8 patients (2.5%), of whom two patients had early PPH (within 24 hrs.). Six patients had delayed PPH (later than 24 hrs). Bleeding was defined as grade B in five patients and grade C in three patients. Delayed PPH resulted in surgical evacuation of intraabdominal hematoma in two patients, endoscopic intervention for a bleeding ulcera at the gastojejunostomy in one patient, a combination of radiological endovascular and surgical interventions in two patients, and combined surgical/endoscopic intervention in one patient. PPH was associated with POPF in only three patients. The overall reoperation rate was 6.2% (20 of 325 patients). Of these, five were POPF-associated (1.5%), with only one completion pancreatectomy because of a major leakage of the pancreaticojejunostomy and severe septic complications. Six reoperations were related to an insufficiency or leakage of the hepaticojejunostomy or an aberrant Luschka duct, and two were due to early bleeding without signs of POPF. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). Both, the 30-day and in-hospital mortality rates were 1.5%, with no differences between PD patients and DP patients. The 90-day mortality rate was 5.3% for PD patients and 1.7% for DP patients (p = 0.31), and 4.5% for all patients. The 30-day and in-hospital mortality attributed to POPF was 0.6% (2 of 325 patients). Higher score points in the pancreatic Fistula Risk Score (FRS) correlated with increasing rates of clinically relevant pancreatic fistulas (Table 3 ). The POPF grade B increased from 0–3.2%, 17.0% and 22.6% for FRSs of 0, 1–2, 3–6, and 7–10, respectively. Similarly, POPF grade C increased from 0–3.8%. The rate of interventional external or endoscopic internal drainage increased from 0–5.7%. The rates of delayed PPH and mortality were 0% for patients with pancreatic FRS of 0, and there were no significant differences among patients with FRSs of 1–2, 3–6, and 7–10 (Table 3 ). Table 3 Fistula risk score (FRS) and complications in pancreatoduodenectomy FRS n POPF B POPF C Interv./endos. drainage Delayed PPH In-hospital mortality 0 25 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1–2 63 2 (3.2%) 0 (0%) 1 (1.6%) 2 (3.2%) 1 (1.6%) 3–6 112 19 (17.0%) 1 (0.9%) 6 (5.4%) 3 (2.7%) 2 (1.8%) 7–10 53 12 (22.6%) 2 (3.8%) 3 (5.7%) 1 (1.9%) 1 (1.9%) Fistula Risk Score (FRS) according to the definition by Callery et al. 17 , Postoperative Pancreatic Fistula (POPF) according to the ISGPS definition 19 , Postoperative Pancreatic Hemorrhage (PPH) according to the ISGPS definition 20 . DISCUSSION The present study describes a strategy of routine drain placement and drain irrigation on demand in patients with PD and DP, which results in superior patient outcomes when focusing on reinterventions, septic complications and mortality as compared to earlier studies. The necessity of routine drainage in pancreatectomy is controversial. There have been several randomized controlled trials, with some conflicting results. The Dutch RCT with 137 randomized patients undergoing PD had to be stopped early because of an increase in mortality from 3–12% in patients without intraperitoneal drainage 4 . The German PANDRA trial, that included 438 randomized patients who underwent pancreatic head resections, demonstrated that the omission of drains was not inferior to routine drainage in terms of postoperative reintervention and was superior in terms of clinically relevant pancreatic fistula rate and fistula-associated complications 3 . However, there was a relatively high overall reintervention rate of 19.0%. Interestingly, 40 of the 193 randomized patients (20.7%) who were allocated to the no-drain group received drains and had worse results with regard to the reintervention rate, morbidity, and mortality. As expected, there was a correlation between reintervention and the soft texture of the pancreas. In a US multi-institutional series, the omission of drains in patients with a low FRS and selective drain management of high-risk pancreatic anastomoses, including externalized stents and intraperitoneal drainage, was supposed to provide optimal outcomes 7 . Recently, a prospective Swiss series with 73 high-risk patients (main pancreatic duct ≤ 3 mm and soft parenchyma) compared prophylactic perianastomotic irrigation via Salem Sump drains with passive drainage via Easy Flow drains 8 . The irrigation group showed lower POPF rates (12.7% vs. 69.2%) and a tendency toward lower mortality (4.2% vs. 13.0%). However, the high POPF and mortality rates in the Easy Flow group and the standard insertion of 5 drains in the prophylactic irrigation group limit the generalization of this drainage concept. In DP, the omission of routine intraperitoneal drainage had no effects on clinical outcomes, including clinically relevant POPF, frequency of postoperative imaging, percutaneous drain placement, reoperation, or mortality in a RCT with 344 patients 5 . Simultaneously, to the Swiss group, we established our concept of routine intraperitoneal drain placement and irrigation on demand in patients undergoing PD as well as DP. In the case of highly increased amylase levels in drains or in patients with suspected superinfected POPF, continuous drain irrigation was started via an indwelled single-lumen central line that was inserted into the Robinson drains, with the aim of diluting the leaking pancreatic fluid and improving evacuation via the drains. When compared to the original Fistula Risk Score (FRS) publication 17 and its multi-institutional validation 21 , the sum of clinically relevant POPF grade B and C rates was similar when the four FRS groups were evaluated. However, one must be aware of differences in the underlying POPF definitions, which changed in 2016 with the publication of the updated POPF definition 19 . In the present series, there was strict adherence to the updated fistula definition. As soon as irrigation of the drains was started or there were signs of infection related to POPF and antibiotic therapy was needed, the fistula was defined as POPF grade B. This included patients who had already undergone removal the peritoneal drains and had developed peripancreatic fluid collections that were not accessible for interventional or endoscopic drainage, but antibiotic therapy was indicated. This explains the relatively high rate of grade B fistulas, whereas grade C fistulas (defined as patients who required reoperation for POPF or who had POPF-related organ failure or mortality) were uncommon, with only 1.2% of patients who had PD and 1.4% who had DP. POPF grade B includes a wide variety of patients: patients who require prolonged drainage for > 3 weeks, those who need POPF-related antibiotic therapy, and patients who require an interventional or endoscopic intervention for peripancreatic fluid collection or a radiologic endovascular procedure for POPF-related bleeding. Therefore, in the present study we present specific data on interventional or endoscopic drainage procedures as well as on angiographic bleeding therapy. In the present series, only 5.8% of patients required interventional or endoscopic drainage. Postoperative drain insertion was necessary significantly more often in DP patients than in PD patients. Radiologic endovascular procedures for PPH were performed in a low percentage of patients (0.6%), with no differences between PD and DP patients, and the rate of fistula- and delayed PPH-associated reoperation was 1.5%. The described drain management approach may contribute to very low 30-day and in-hospital mortality rates of 1.5%, with no differences between PD and DP patients. The 30-day and in-hospital mortality rated attributed to POPF were only 0.6%. The present study cohort was characterized by a relatively high percentage of patients with high-risk anastomosis (FRS ≥ 7 in 21% of patients), as defined by a soft pancreatic texture, a small pancreatic duct diameter, and a high-risk pathology. Some authors recommend total pancreatectomy for selected patients at high risk for postoperative pancreatic fistula to reduce septic complications and mortality, but this is unavoidably associated with endocrine and exocrine insufficiency and a worse diabetes-specific quality of life 22,23 as long as it is not combined with islet autotransplantation 24 . During the 6-year period of the present series, no total pancreatectomy was performed to avoid a high-risk anastomosis at the authors’ center. All reconstructions after PD were performed by a double layer end-to-side pancreaticoduodenectomy. Only one completion pancreatectomy was necessary in a patient with a major leakage of the pancreaticojejunostomy and consequential septic multiorgan failure. Completion pancreatectomy for the management of PD complications is regarded as a salvage procedure in patients with uncontrollable pancreatic fistulas and is associated with a high mortality rate of up to 37% 25 . The reported advantageous results in the present study on a patient cohort that includes a high percentage of high-risk anastomosis may provide some evidence of the feasibility and value of the proposed drainage concept including irrigation via drains on demand. One may argue that in low-risk patients, intraperitoneal drainage may always be omitted. However, as a side effect in the present series, a leak of the hepaticojejunostomy or from a Luschka duct was detected early in six patients, with subsequent successful revision of the anastomosis on postoperative day one because of the early detection of the leak. In all those patients, the drain that was located to the dorsal aspect of the pancreaticojejunostomy and that was externalized at the right upper flank also drained the bile. No interventional procedure, such as PTCD, was required for delayed insufficiency of the hepaticojejunostomy. In DP, which was associated with a significantly greater need for postoperative interventional or endoscopic drainage than in PD, one may argue that our drainage concept with irrigation on demand is redundant. We agree that not all fluid collections, which were typically located adjacent to the pancreatic stump, were drained sufficiently, and that drain irrigation did not prevented septic complications or the need for additional drainage in all patients. Some fistulas may have even become superinfected by prolonged drainage. However, the postoperative need for percutaneous or endoscopic drains was comparable to that of the no-drain group in the Dutch RCT 5 . Our study has several limitations and strengths. First, and most importantly, there was no control group available to provide robust evidence for the benefits of the proposed fistula management technique. Second, the study is a prospective single-institution series with the restriction that all pancreatectomies were performed or supervised by only three experienced pancreatic surgeons. However, a uniform pancreatic perioperative protocol was applied for the entire study period, which included the drainage management concept as described, and no major treatment variances were inherent. A strength of the study is that prospective data reporting to the StuDoQ database was performed by two experienced surgeons (A.G., H.P.-H.), which guarantees high data quality. Furthermore, data on specific issues of the manuscript, e.g. PPH and reoperations, were checked and refined by reevaluating the original patient data. Guaranteeing uniform and correct fistula reporting, the fistula data of all included patients were classified according to the newest POPF definition 19 , which was upgraded in 2016 just prior to the study period. Second, all of our PDs and DPs were included in the study, with no exclusion criteria, unlike well-designed RCTs. This may well reflect “real life” in a pancreatic cancer center. Because of its clinical relevance in the management of patients, the detailed presentation on distinct information of POPF grade B, with differentiation between drain irrigation and antibiotic therapy versus the need for additional radiological or endoscopic interventions, seems advantageous as compared to the sole reporting on the incidence of grade B fistulas. CONCLUSION The present single-center analysis provides some evidence that the concept of routine drainage and irrigation on demand in PDs and DPs may benefit patient outcomes when focusing on reinterventions, septic complications, and early mortality. Abbreviations AIP autoimmune pancreatitis ASA American Society of Anesthesiologists CA 19 − 9 Carbohydrate antigen 19 − 9 CRP C-reactive protein DP Distal pancreatectomy FRS Fistula Risk Score IPMC Intraductal papillary mucinous carcinoma IPMN Intraductal papillary mucinous neoplasm ISGPS International Study Group of Pancreatic Surgery PD Pancreatoduodenectomy PPH Postpancreatectomy hemorrhage POPF Postoperative Pancreatic Fistula RCT Randomized controlled trial QOL Quality of life Declarations Authors’ contributions: Alexander Gluth: Study concept and design, acquisition of data, analysis and interpretation of data, and drafting of the manuscript Hubert Preissinger-Heinzel: Acquisition of data, analysis and interpretation of data, critical revision of manuscript Katharina Schmitz: Acquisition of data, critical revision of manuscript Thomas Hallenscheidt: analysis and interpretation of the data and critical revision of the manuscript Torsten Beyna: analysis and interpretation of data and critical revision of the manuscript Thomas Lauenstein: analysis and interpretation of data, critical revision of the manuscript Werner Hartwig: Study concept and design, analysis and interpretation of data, and drafting of the manuscript. 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Van Buren G, 2nd, Bloomston M, Schmidt CR, et al. A Prospective Randomized Multicenter Trial of Distal Pancreatectomy With and Without Routine Intraperitoneal Drainage. Annals of surgery 2017;266(3):421–431. (In eng). DOI: 10.1097/sla.0000000000002375 . van Bodegraven EA, van Ramshorst TME, Balduzzi A, et al. Routine abdominal drainage after distal pancreatectomy: meta-analysis. The British journal of surgery 2022;109(6):486–488. (In eng). DOI: 10.1093/bjs/znac042 . McMillan MT, Malleo G, Bassi C, et al. Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification. Annals of surgery 2017;265(6):1209–1218. (In eng). DOI: 10.1097/sla.0000000000001832 . Adamenko O, Ferrari C, Porreca A, et al. Perianastomotic Irrigation With Passive Drainage Dramatically Decreases POPF Rate After High-risk Pancreaticoduodenectomy. Ann Surg Open 2022;3(2):e154. (In eng). DOI: 10.1097/as9.0000000000000154 . Hartwig W, Vollmer CM, Fingerhut A, et al. Extended pancreatectomy in pancreatic ductal adenocarcinoma: definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS). Surgery 2014;156(1):1–14. (In eng). DOI: 10.1016/j.surg.2014.02.009 . Bockhorn M, Uzunoglu FG, Adham M, et al. Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2014;155(6):977–88. (In eng). DOI: 10.1016/j.surg.2014.02.001 . Tanaka M, Fernández-Del Castillo C, Kamisawa T, et al. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology: official journal of the International Association of Pancreatology 2017;17(5):738–753. (In eng). DOI: 10.1016/j.pan.2017.07.007 . Falconi M, Eriksson B, Kaltsas G, et al. ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic Neuroendocrine Tumors and Non-Functional Pancreatic Neuroendocrine Tumors. Neuroendocrinology 2016;103(2):153–71. (In eng). DOI: 10.1159/000443171 . Hoffmeister A, Mayerle J, Beglinger C, et al. English language version of the S3-consensus guidelines on chronic pancreatitis: Definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis. Zeitschrift fur Gastroenterologie 2015;53(12):1447–95. (In eng). DOI: 10.1055/s-0041-107379 . Warshaw AL. Conservation of the spleen with distal pancreatectomy. Archives of surgery 1988;123(5):550–3. (In eng). DOI: 10.1001/archsurg.1988.01400290032004 . Hassenpflug M, Hinz U, Strobel O, et al. Teres Ligament Patch Reduces Relevant Morbidity After Distal Pancreatectomy (the DISCOVER Randomized Controlled Trial). Annals of surgery 2016;264(5):723–730. (In eng). DOI: 10.1097/sla.0000000000001913 . Welsch T, Müssle B, Korn S, et al. Pancreatoduodenectomy with or without prophylactic falciform ligament wrap around the hepatic artery for prevention of postpancreatectomy haemorrhage: randomized clinical trial (PANDA trial). The British journal of surgery 2021;109(1):37–45. (In eng). DOI: 10.1093/bjs/znab363 . Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM, Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. Journal of the American College of Surgeons 2013;216(1):1–14. (In eng). DOI: 10.1016/j.jamcollsurg.2012.09.002 . Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of surgery 2004;240(2):205–13. (In eng). DOI: 10.1097/01.sla.0000133083.54934.ae . Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;161(3):584–591. (In eng). DOI: 10.1016/j.surg.2016.11.014 . Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142(1):20–5. (In eng). DOI: 10.1016/j.surg.2007.02.001 . Miller BC, Christein JD, Behrman SW, et al. A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2014;18(1):172–79; discussion 179 – 80. (In eng). DOI: 10.1007/s11605-013-2337-8 . Luu AM, Olchanetski B, Herzog T, Tannapfel A, Uhl W, Belyaev O. Is primary total pancreatectomy in patients with high-risk pancreatic remnant justified and preferable to pancreaticoduodenectomy? -a matched-pairs analysis of 200 patients. Gland Surg 2021;10(2):618–628. (In eng). DOI: 10.21037/gs-20-670 . Marchegiani G, Perri G, Burelli A, et al. High-risk Pancreatic Anastomosis Versus Total Pancreatectomy After Pancreatoduodenectomy: Postoperative Outcomes and Quality of Life Analysis. Annals of surgery 2022;276(6):e905-e913. (In eng). DOI: 10.1097/sla.0000000000004840 . Balzano G, Zerbi A, Aleotti F, et al. Total Pancreatectomy With Islet Autotransplantation as an Alternative to High-risk Pancreatojejunostomy After Pancreaticoduodenectomy: A Prospective Randomized Trial. Annals of surgery 2023;277(6):894–903. (In eng). DOI: 10.1097/sla.0000000000005713 . Loos M, König AK, von Winkler N, et al. Completion Pancreatectomy After Pancreatoduodenectomy: Who Needs It? Annals of surgery 2023;278(1):e87-e93. (In eng). DOI: 10.1097/sla.0000000000005494 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Sep, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 08 Jul, 2024 Reviews received at journal 30 Jun, 2024 Reviews received at journal 28 Jun, 2024 Reviewers agreed at journal 26 Jun, 2024 Reviewers agreed at journal 21 Jun, 2024 Reviews received at journal 21 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers invited by journal 09 Apr, 2024 Editor assigned by journal 22 Mar, 2024 Submission checks completed at journal 20 Mar, 2024 First submitted to journal 18 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4122423","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":282602533,"identity":"26375fb3-ab29-4045-af7b-9b5237f7f4f7","order_by":0,"name":"Alexander Gluth","email":"","orcid":"","institution":"Evangelisches Krankenhaus Düsseldorf","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Gluth","suffix":""},{"id":282602534,"identity":"5f0b3148-547f-477f-ac39-d06f925bc8fd","order_by":1,"name":"Hubert Preissinger-Heinzel","email":"","orcid":"","institution":"Evangelisches Krankenhaus Düsseldorf","correspondingAuthor":false,"prefix":"","firstName":"Hubert","middleName":"","lastName":"Preissinger-Heinzel","suffix":""},{"id":282602535,"identity":"a5b7fa99-b2ad-49e4-a43a-9caa144247da","order_by":2,"name":"Katharina Schmitz","email":"","orcid":"","institution":"Evangelisches Krankenhaus Düsseldorf","correspondingAuthor":false,"prefix":"","firstName":"Katharina","middleName":"","lastName":"Schmitz","suffix":""},{"id":282602536,"identity":"852bbdd6-421f-4f22-bcea-a927677b16b8","order_by":3,"name":"Thomas Hallenscheidt","email":"","orcid":"","institution":"Evangelisches Krankenhaus Düsseldorf","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Hallenscheidt","suffix":""},{"id":282602537,"identity":"bcd3dfab-cc34-4900-af61-f5ec5495cdfe","order_by":4,"name":"Torsten Beyna","email":"","orcid":"","institution":"Evangelisches Krankenhaus Düsseldorf","correspondingAuthor":false,"prefix":"","firstName":"Torsten","middleName":"","lastName":"Beyna","suffix":""},{"id":282602538,"identity":"7cd54c15-73b0-47a7-b3f8-5051c924126c","order_by":5,"name":"Thomas Lauenstein","email":"","orcid":"","institution":"Evangelisches Krankenhaus Düsseldorf","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Lauenstein","suffix":""},{"id":282602539,"identity":"4246136f-43d0-40bc-baa5-c1ca66e2f978","order_by":6,"name":"Werner Hartwig","email":"data:image/png;base64,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","orcid":"","institution":"Evangelisches Krankenhaus Düsseldorf","correspondingAuthor":true,"prefix":"","firstName":"Werner","middleName":"","lastName":"Hartwig","suffix":""}],"badges":[],"createdAt":"2024-03-18 10:37:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4122423/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4122423/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-024-03464-z","type":"published","date":"2024-09-11T15:58:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64619929,"identity":"4a6344ec-10a7-4938-9ead-e486dd9b7892","added_by":"auto","created_at":"2024-09-16 16:17:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":570568,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4122423/v1/830d35da-605c-48b4-9d8f-f2afc4775e1a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Drainage and irrigation on demand decreases severe septic complications and mortality in pancreatic resections","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePancreatic surgery is still associated with relevant perioperative morbidity and mortality, and pancreatic fistulas are the predominant cause of septic complications. The intraoperative placement of drains adjacent to the pancreaticojejunostomy in pancreatic head resections or to the pancreatic stump in distal pancreatectomy, with the intention to evacuate leaking pancreatic fluid and thereby prevent potential further complications, continues to be controversial \u003csup\u003e1\u003c/sup\u003e. For pancreatoduodenectomies (PDs), data from some randomized controlled trials have demonstrated that prophylactic drainage of the pancreaticojejunostomy can be omitted without increasing fistula-associated complications or mortality \u003csup\u003e2,3\u003c/sup\u003e. However, the reintervention rate of 19% and the relaparotomy rate of 13.4% in the German PANDRA trial were relatively high, with no differences between the drain and the no drain groups \u003csup\u003e3\u003c/sup\u003e. In contrast, a Dutch randomized controlled trial (RCT) demonstrated that the elimination of prophylactic routine drainage in pancreatoduodenectomies increases the frequency and severity of complications and is associated with a substantial increase in mortality \u003csup\u003e4\u003c/sup\u003e. In distal pancreatectomy (DP), clinical outcomes and the need for reinterventions were comparable between the drain group and the no-drain group \u003csup\u003e5,6\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMore recent data have suggested that drains can be selectively omitted in PDs according to risk-stratification \u003csup\u003e7\u003c/sup\u003e. When the pancreatic texture is hard and the main pancreatic duct diameter is large, the risk of postoperative pancreatic fistula (POPF) is generally low, and intraoperative drain placement may not be necessary. However, in high-risk anastomoses with soft pancreatic parenchyma and a small main pancreatic duct diameter, routine drain placement may be beneficial for preventing septic complications that are triggered by POPF \u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSimilar to a Swiss group, which recently published their strategy of early perianastomotic irrigation with passive drainage \u003csup\u003e8\u003c/sup\u003e, the present analysis describes a drain management concept that includes routine drainage and drain irrigation on demand in selected cases. In a consecutive series of 325 patients who underwent pancreatic resection, Robinson drainages, a closed passive drainage system, were placed in all patients intraoperatively to the pancreatic anastomosis in PD or to the pancreatic stump in DP. In the case of highly increased amylase levels in drains or in patients with suspected superinfected POPF, continuous drain irrigation was performed via an indwelling single-lumen central line catheter that was inserted into the drains, with the aim of diluting the leaking pancreatic fluid and improving evacuation via the drains. We demonstrate that a strict adherence to this drainage protocol results in a very low need for reinterventions, including radiologically or endoscopically placed drainages, and a low reoperation and mortality rate in PDs as well as in DPs.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePATIENT SELECTION\u003c/h2\u003e \u003cp\u003e From a total of 367 consecutive pancreatic resections that were performed between January 2017 and December 2022 at the Department of General Surgery, Evangelisches Krankenhaus D\u0026uuml;sseldorf, a high-volume pancreatic center in Germany, 253 pancreatoduodenectomies and 72 distal pancreatectomies were identified from the review board-approved prospectively maintained pancreatic StuDoQ database. Duodenum-preserving pancreatic head resections (n\u0026thinsp;=\u0026thinsp;17), total pancreatectomies (n\u0026thinsp;=\u0026thinsp;13), planned completion pancreatectomies (n\u0026thinsp;=\u0026thinsp;4), pancreatic segmental resections (n\u0026thinsp;=\u0026thinsp;3), enucleations (n\u0026thinsp;=\u0026thinsp;4), and pancreatic resections combined with gastrectomy for gastric malignancy (n\u0026thinsp;=\u0026thinsp;1) were excluded from the present analysis. Patients who underwent extended pancreatectomies, as defined by the ISGPS \u003csup\u003e9\u003c/sup\u003e, were not excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSURGICAL ELIGIBILITY\u003c/h2\u003e \u003cp\u003eStandard preoperative evaluation included physical examination, routine laboratory testing including serum levels of carbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9 (CA 19\u0026thinsp;\u0026minus;\u0026thinsp;9), contrast-enhanced multidetector computed tomography of the abdomen and thorax, and/or state-of-the-art magnetic resonance imaging. Endoscopic ultrasound with/without fine needle aspiration or bile duct brushing were optional diagnostic procedures but were regularly performed for cystic tumors or distal bile duct tumors. Tumors were excluded from primary exploration if the presence of metastatic disease was identified by presurgical imaging studies. Neoadjuvant therapy was performed for histology- or cytology-proofed locally advanced pancreatic disease and was considered, but not mandatorily performed, for borderline resectable tumors, as defined by the International Study Group of Pancreatic Surgery (ISGPS) \u003csup\u003e10\u003c/sup\u003e. Patients with oligo-metastasized pancreatic cancer who responded well to combination chemotherapy according to imaging studies CA19-9 levels qualified for resection. Surgery for cystic tumors was indicated according to the Fukuoka guidelines \u003csup\u003e11\u003c/sup\u003e. Patients with duodenal or distal bile duct cancer generally qualified for resection when concomitant liver resection was not mandatory for complete tumor resection. Surgery for neuroendocrine tumors or chronic pancreatitis was indicated according to the ENETS Consensus Guidelines \u003csup\u003e12\u003c/sup\u003e or the German S3 Consensus Guidelines \u003csup\u003e13\u003c/sup\u003e, respectively. All pancreatic resections were agreed upon preoperatively in the institutional interdisciplinary tumor board evaluation of patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSURGICAL INTERVENTION\u003c/h2\u003e \u003cp\u003eAll pancreatic resections were performed by three experienced senior surgeons (H.P.-H., T.H., and W.H.) or under their supervision. According to the tumor location within the pancreas, PD or DP was performed. Extended pancreatectomies with resection of adjacent organs and/or vessels were performed when necessary to achieve complete tumor resection in borderline or locally advanced tumors \u003csup\u003e9\u003c/sup\u003e. \u0026ldquo;En bloc\u0026rdquo; tumor resection was always anticipated to avoid intraoperative spillage of tumor cells. Intraoperative frozen sections of the pancreatic and/or bile duct transection margin were always taken for the decision to potentially extend the resection. Pylorus preservation in PDs was performed whenever feasible when no tumor infiltration or severe inflammatory changes were present. None of the PDs were performed laparoscopically or robot-assisted, whereas distal pancreatectomy was performed laparoscopically whenever patients and tumor extension were deemed suitable. In DP, spleen preservation according to the Warshaw operation \u003csup\u003e14\u003c/sup\u003e was performed in patients with non-malignant disease whenever feasible.\u003c/p\u003e \u003cp\u003eEnd-to-side pancreaticojejunostomy was performed via the double-layer technique with interrupted sutures PDS 5\u0026thinsp;\u0026minus;\u0026thinsp;0, with the inner row in the duct-to-mucosa technique. In the entire series, no total pancreatectomy was performed in high-risk situations with a small pancreatic duct or a very soft pancreatic texture, with the intention of preventing pancreatic fistula-associated complications.\u003c/p\u003e \u003cp\u003eClosure of the pancreatic stump in distal pancreatectomy was dependent on the pancreatic texture, irrespective of whether the surgery was open or laparoscopic. A soft and relatively thin pancreas was closed and transected via Endo-GIA\u0026trade; 60 mm medium/thick with Tri-Staple\u0026trade; Technology, whereas a thick or hard pancreas was dissected by a scalpel via the fish-mouth technique, and closure was performed with interrupted sutures PDS 5\u0026thinsp;\u0026minus;\u0026thinsp;0 (Ethicon), with primary closure of the pancreatic duct by selective suture when feasible. Additional coverage of the pancreatic stump by a teres ligament patch was performed at the discretion of the surgeon, with the intention of reducing the severity of potential pancreatic fistula \u003csup\u003e15\u003c/sup\u003e. In all pancreatoduodenectomies, a prophylactic falciform ligamentum wrap around the hepatic artery was placed to prevent postpancreatic hemorrhage from the stump of the gastroduodenal artery \u003csup\u003e16\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eProphylactic drains CH 20 (Drainsid\u0026reg; Silicone, Asid Bonz GmbH, Germany) were placed routinely in all patients. The drains were located to the anterior and posterior aspect of the pancreaticojejunostomy in PDs, and in DPs they were placed right next to the pancreatic stump.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDRAIN MANAGEMENT\u003c/h2\u003e \u003cp\u003ePostoperatively, the drainage fluid was inspected at least once daily. Starting on postoperative day 2, amylase levels in the drainage fluid were measured every other day. When the amylase level in the drain fluid was less than three times the serum level and drain fluid was macroscopically inconspicuous, the drain was removed on postoperative day\u0026thinsp;\u0026ge;\u0026thinsp;2 in PD patients and on postoperative day\u0026thinsp;\u0026ge;\u0026thinsp;5 in DP patients. In cases where amylase levels in drains were greater than 5000 U/ml or when macroscopic changes in drain fluid regarding consistency and color (toward grayish), were present, indicating suspected superinfected pancreatic fistula, a single lumen central line catheter (One-Lumen CVC, Ga. 14, Teleflex Medical, Ireland) was inserted into the drains, and continuous irrigation with \u0026ge;\u0026thinsp;1000 ml of saline per day was started. Concomitantly, blood measurements, including white blood cell count, C-reactive protein (CRP), and amylase levels, were performed regularly.\u003c/p\u003e \u003cp\u003eIn patients with continuously increasing or persistently high systemic infection parameters (white blood cell count or CRP) and/or fever, contrast-enhanced computed tomography of the abdomen with/without the thorax was performed. In cases where a fluid collection was suspicious for being infected, a percutaneous radiologically guided interventional irrigation drainage tube (Peter Pflugbeil GmbH, Zorneding, Germany) was inserted whenever feasible, and antibiotic therapy was implemented. The drainage size ranged between 10F and 16F depending on the size and location of the fluid collection. In the case of fluid collections that were better accessible via transluminal drainage, one or two transgastric or transduodenal pigtail catheters (EndoStay\u0026reg;, 10F, Peter Pflugbeil GmbH, Germany) were placed endoscopically, guided by endoscopic ultrasound (EUS).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePARAMETER ANALYSIS\u003c/h2\u003e \u003cp\u003eAll parameters were prospectively collected in the electronic StuDoq database, maintained by the Deutsche Gesellschaft f\u0026uuml;r Allgemein- und Viszeralchirurgie (DGAV). The following parameters were analyzed: age and sex of the patients, American Society of Anesthesiologists (ASA) score, body mass index, diabetes mellitus status, type of histology, pancreatic Fistula Risk Score (FRS, includes pancreatic texture and main pancreatic duct diameter) for PDs \u003csup\u003e17\u003c/sup\u003e, neoadjuvant therapy, preoperative bile duct stenting, type of surgery (laparoscopic vs. open), intraoperative blood loss, and operative time. Surgical and nonsurgical morbidities were categorized according to the Clavien-Dindo classification \u003csup\u003e18\u003c/sup\u003e and were analyzed for categories 3B and more. The parameters of surgical morbidity included anastomotic leakage, postoperative pancreatic fistula (POPF) according to the updated ISGPS definition \u003csup\u003e19\u003c/sup\u003e, postpancreatectomy hemorrhage (PPH) \u003csup\u003e20\u003c/sup\u003e, the need for relaparotomy, intraabdominal abscess or fluid collection with the need for interventional or endoscopic intervention, and wound infections that require operative reintervention. Importantly, there was strict adherence to the updated ISGPS POPF definition \u003csup\u003e19\u003c/sup\u003e within the entire study period. An increase in amylase concentration in the drains within the first 3 weeks was considered a biochemical leak, as long as there was no deviation from the normal postoperative pathway related to the leak. As soon as a central line catheter was inserted into the drains and irrigation was started, the patient was defined a having POPF grade B. Similarly, patients with amylase-rich drainage fluid or contrast-enhanced peripancreatic fluid collections who received antibiotic therapy were grouped into POPF grade B, as were patients who received interventional or endoscopic drainage or an angiographic procedure for POPF-related bleeding. Patients who experienced POPF-related reoperation, organ failure, or death were defined as having POPF grade C \u003csup\u003e19\u003c/sup\u003e. The duration of hospital stay was recorded, as well as in-hospital, 30-day, and 90-day mortality. After the data were extracted from the StuDoQ database, specific data on PPH, reoperation, and POPF grades B and C were checked and refined by reevaluating the original patient data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFOLLOW-UP\u003c/h2\u003e \u003cp\u003eThe patients were followed up for at least 90 days after surgery. For those patients who were not included in our follow-up program, patients, general practitioners, relatives, and insurance companies were contacted by telephone and asked about eventual complications and patient survival or the documented day of death. The 90-day follow-up data were incomplete for 39 patients (12% of all patients).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSTATISTICAL ANALYSIS\u003c/h2\u003e \u003cp\u003eSAS software (Release 9.4, SAS Institute, Inc, Cary, NC, USA) was used for statistical analysis. The quantitative variables age, serum CA 19\u0026thinsp;\u0026minus;\u0026thinsp;9 concentration, length of hospital stay, operative time, and blood loss are expressed as medians with interquartile ranges. Variables with categorical scores are presented with absolute and relative frequencies. Subgroups of patients were analyzed by using the Fisher exact test and the χ2 test, when appropriate. Two-sided P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered to indicated statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFrom 367 consecutive pancreatic resections that were performed at the Evangelisches Krankenhaus D\u0026uuml;sseldorf between 01/2017 and 12/2022, 253 patients who underwent PD and 72 patients with DP were evaluated. Sixty-four percent of DPs were performed laparoscopically. The median age of the patients was 70 years, and the male-to-female was 51\u0026ndash;49%. Most patients had pancreatic ductal adenocarcinoma (47%), followed by adenoma or carcinoma of the papilla vateri (10.5%), intraductal papillary mucinous neoplasms including carcinoma (IPMN or IPMC, 10.2%), distal bile duct cancer (9.2%), and others (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patient characteristics, including the ASA score, BMI, presence of diabetes mellitus, neoadjuvant therapy, preoperative biliary drainage, pancreatic texture and main pancreatic duct diameter, are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A soft pancreatic texture was present in 47.8% of patients, with a median pancreatic duct diameter of 3 mm.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient and tumor characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex ratio, male : female\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e51% : 49%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge [years], mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e70\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreatic ductal adenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e154 (47.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenoma / carcinoma of papilla vateri\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e34 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPMN/IPMC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e33 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal bile duct cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e30 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic pancreatitis / AIP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e19 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuodenal adenoma / carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e13 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuroendocrine tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e13 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e29 (8.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA-Score, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e131 (40.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e185 (56.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes mellitus, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e70 (21.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeoadjuvant therapy, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e311 (95.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative biliary drainage, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e144 (44.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e181 (55.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePancreatic texture, n (%)\u003c/b\u003e \u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e132(52.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e121 (47.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain pancreatic duct diameter [mm], median (IQR)\u003c/b\u003e \u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3 (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAmerican Society of Anesthesiologists physical status classification (ASA), Standard deviation (SD), interquartile range (IQR)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e Only pancreatoduodenectomies were evaluated\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe perioperative and postoperative outcomes for PD and DP patients are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. As expected, the duration of surgery was longer in the PD groups than in the DP group. Similarly, blood loss was greater in PD patients. Overall, Clavien-Dindo complications\u0026thinsp;\u0026ge;\u0026thinsp;3B occurred in 9.8% of patients. Clinically relevant fistulas (POPF grades B and C) were detected in 53 of 325 patients (16.3%), with a low percentage of type C fistulas (1.2%). Most fistulas were treated with antibiotics, prolonged drainage, and/or irrigation of intraoperatively placed drains. There was a need for interventional external or endoscopic internal drainage in 14 and 5 patients, respectively (overall 5.8%). Interventional or endoscopic drainage was performed more frequently in DP patients (12.5%) than in PD patients (4.0%, p\u0026thinsp;=\u0026thinsp;0.009).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative and postoperative outcome\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eoverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e325\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of surgery [min], median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e295 (258\u0026ndash;344)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e199 (165\u0026ndash;229)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e281 (235\u0026ndash;331)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss [ml], median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e500 (350\u0026ndash;800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e250 (100\u0026ndash;600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e450 (250\u0026ndash;750)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien Dindo complication\u0026thinsp;\u0026ge;\u0026thinsp;3B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (9.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinically relevant POPF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (23.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (16.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (15.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventional external drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3.6%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.9%)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransluminal endoscopic drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.6%)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly PPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0,4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed PPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngiographic intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelaparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90-day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital stay [days], median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5 (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePostoperative Pancreatic Fistula (POPF) according to the ISGFS definition \u003csup\u003e19\u003c/sup\u003e.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePostoperative pancreatic hemorrhage (PPH) according to the ISGFS definition \u003csup\u003e20\u003c/sup\u003e.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eInterquartile range (IQR).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e1,2\u003c/sup\u003eWhen interventional and endoscopic drainage were combined, drainage was needed more frequently in DP as compared to PD (p\u0026thinsp;=\u0026thinsp;0.009)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eFollow-up was completed in 226 patients with PD and 60 patients with DP. 39 patients were lost to follow-up.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostpancreatectomy hemorrhage (PPH) was detected in 8 patients (2.5%), of whom two patients had early PPH (within 24 hrs.). Six patients had delayed PPH (later than 24 hrs). Bleeding was defined as grade B in five patients and grade C in three patients. Delayed PPH resulted in surgical evacuation of intraabdominal hematoma in two patients, endoscopic intervention for a bleeding ulcera at the gastojejunostomy in one patient, a combination of radiological endovascular and surgical interventions in two patients, and combined surgical/endoscopic intervention in one patient. PPH was associated with POPF in only three patients. The overall reoperation rate was 6.2% (20 of 325 patients). Of these, five were POPF-associated (1.5%), with only one completion pancreatectomy because of a major leakage of the pancreaticojejunostomy and severe septic complications. Six reoperations were related to an insufficiency or leakage of the hepaticojejunostomy or an aberrant Luschka duct, and two were due to early bleeding without signs of POPF. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). Both, the 30-day and in-hospital mortality rates were 1.5%, with no differences between PD patients and DP patients. The 90-day mortality rate was 5.3% for PD patients and 1.7% for DP patients (p\u0026thinsp;=\u0026thinsp;0.31), and 4.5% for all patients. The 30-day and in-hospital mortality attributed to POPF was 0.6% (2 of 325 patients).\u003c/p\u003e \u003cp\u003eHigher score points in the pancreatic Fistula Risk Score (FRS) correlated with increasing rates of clinically relevant pancreatic fistulas (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The POPF grade B increased from 0\u0026ndash;3.2%, 17.0% and 22.6% for FRSs of 0, 1\u0026ndash;2, 3\u0026ndash;6, and 7\u0026ndash;10, respectively. Similarly, POPF grade C increased from 0\u0026ndash;3.8%. The rate of interventional external or endoscopic internal drainage increased from 0\u0026ndash;5.7%. The rates of delayed PPH and mortality were 0% for patients with pancreatic FRS of 0, and there were no significant differences among patients with FRSs of 1\u0026ndash;2, 3\u0026ndash;6, and 7\u0026ndash;10 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFistula risk score (FRS) and complications in pancreatoduodenectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFRS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePOPF B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePOPF C\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterv./endos. drainage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDelayed PPH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u0026ndash;2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u0026ndash;6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u0026ndash;10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (22.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (5.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eFistula Risk Score (FRS) according to the definition by Callery et al. \u003csup\u003e17\u003c/sup\u003e, Postoperative Pancreatic Fistula (POPF) according to the ISGPS definition \u003csup\u003e19\u003c/sup\u003e, Postoperative Pancreatic Hemorrhage (PPH) according to the ISGPS definition \u003csup\u003e20\u003c/sup\u003e.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study describes a strategy of routine drain placement and drain irrigation on demand in patients with PD and DP, which results in superior patient outcomes when focusing on reinterventions, septic complications and mortality as compared to earlier studies.\u003c/p\u003e \u003cp\u003eThe necessity of routine drainage in pancreatectomy is controversial. There have been several randomized controlled trials, with some conflicting results. The Dutch RCT with 137 randomized patients undergoing PD had to be stopped early because of an increase in mortality from 3\u0026ndash;12% in patients without intraperitoneal drainage \u003csup\u003e4\u003c/sup\u003e. The German PANDRA trial, that included 438 randomized patients who underwent pancreatic head resections, demonstrated that the omission of drains was not inferior to routine drainage in terms of postoperative reintervention and was superior in terms of clinically relevant pancreatic fistula rate and fistula-associated complications \u003csup\u003e3\u003c/sup\u003e. However, there was a relatively high overall reintervention rate of 19.0%. Interestingly, 40 of the 193 randomized patients (20.7%) who were allocated to the no-drain group received drains and had worse results with regard to the reintervention rate, morbidity, and mortality. As expected, there was a correlation between reintervention and the soft texture of the pancreas. In a US multi-institutional series, the omission of drains in patients with a low FRS and selective drain management of high-risk pancreatic anastomoses, including externalized stents and intraperitoneal drainage, was supposed to provide optimal outcomes \u003csup\u003e7\u003c/sup\u003e. Recently, a prospective Swiss series with 73 high-risk patients (main pancreatic duct\u0026thinsp;\u0026le;\u0026thinsp;3 mm and soft parenchyma) compared prophylactic perianastomotic irrigation via Salem Sump drains with passive drainage via Easy Flow drains \u003csup\u003e8\u003c/sup\u003e. The irrigation group showed lower POPF rates (12.7% vs. 69.2%) and a tendency toward lower mortality (4.2% vs. 13.0%). However, the high POPF and mortality rates in the Easy Flow group and the standard insertion of 5 drains in the prophylactic irrigation group limit the generalization of this drainage concept. In DP, the omission of routine intraperitoneal drainage had no effects on clinical outcomes, including clinically relevant POPF, frequency of postoperative imaging, percutaneous drain placement, reoperation, or mortality in a RCT with 344 patients \u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSimultaneously, to the Swiss group, we established our concept of routine intraperitoneal drain placement and irrigation on demand in patients undergoing PD as well as DP. In the case of highly increased amylase levels in drains or in patients with suspected superinfected POPF, continuous drain irrigation was started via an indwelled single-lumen central line that was inserted into the Robinson drains, with the aim of diluting the leaking pancreatic fluid and improving evacuation via the drains. When compared to the original Fistula Risk Score (FRS) publication \u003csup\u003e17\u003c/sup\u003e and its multi-institutional validation \u003csup\u003e21\u003c/sup\u003e, the sum of clinically relevant POPF grade B and C rates was similar when the four FRS groups were evaluated. However, one must be aware of differences in the underlying POPF definitions, which changed in 2016 with the publication of the updated POPF definition \u003csup\u003e19\u003c/sup\u003e. In the present series, there was strict adherence to the updated fistula definition. As soon as irrigation of the drains was started or there were signs of infection related to POPF and antibiotic therapy was needed, the fistula was defined as POPF grade B. This included patients who had already undergone removal the peritoneal drains and had developed peripancreatic fluid collections that were not accessible for interventional or endoscopic drainage, but antibiotic therapy was indicated. This explains the relatively high rate of grade B fistulas, whereas grade C fistulas (defined as patients who required reoperation for POPF or who had POPF-related organ failure or mortality) were uncommon, with only 1.2% of patients who had PD and 1.4% who had DP.\u003c/p\u003e \u003cp\u003ePOPF grade B includes a wide variety of patients: patients who require prolonged drainage for \u0026gt;\u0026thinsp;3 weeks, those who need POPF-related antibiotic therapy, and patients who require an interventional or endoscopic intervention for peripancreatic fluid collection or a radiologic endovascular procedure for POPF-related bleeding. Therefore, in the present study we present specific data on interventional or endoscopic drainage procedures as well as on angiographic bleeding therapy. In the present series, only 5.8% of patients required interventional or endoscopic drainage. Postoperative drain insertion was necessary significantly more often in DP patients than in PD patients. Radiologic endovascular procedures for PPH were performed in a low percentage of patients (0.6%), with no differences between PD and DP patients, and the rate of fistula- and delayed PPH-associated reoperation was 1.5%. The described drain management approach may contribute to very low 30-day and in-hospital mortality rates of 1.5%, with no differences between PD and DP patients. The 30-day and in-hospital mortality rated attributed to POPF were only 0.6%.\u003c/p\u003e \u003cp\u003eThe present study cohort was characterized by a relatively high percentage of patients with high-risk anastomosis (FRS\u0026thinsp;\u0026ge;\u0026thinsp;7 in 21% of patients), as defined by a soft pancreatic texture, a small pancreatic duct diameter, and a high-risk pathology. Some authors recommend total pancreatectomy for selected patients at high risk for postoperative pancreatic fistula to reduce septic complications and mortality, but this is unavoidably associated with endocrine and exocrine insufficiency and a worse diabetes-specific quality of life \u003csup\u003e22,23\u003c/sup\u003e as long as it is not combined with islet autotransplantation \u003csup\u003e24\u003c/sup\u003e. During the 6-year period of the present series, no total pancreatectomy was performed to avoid a high-risk anastomosis at the authors\u0026rsquo; center. All reconstructions after PD were performed by a double layer end-to-side pancreaticoduodenectomy. Only one completion pancreatectomy was necessary in a patient with a major leakage of the pancreaticojejunostomy and consequential septic multiorgan failure. Completion pancreatectomy for the management of PD complications is regarded as a salvage procedure in patients with uncontrollable pancreatic fistulas and is associated with a high mortality rate of up to 37% \u003csup\u003e25\u003c/sup\u003e. The reported advantageous results in the present study on a patient cohort that includes a high percentage of high-risk anastomosis may provide some evidence of the feasibility and value of the proposed drainage concept including irrigation via drains on demand.\u003c/p\u003e \u003cp\u003eOne may argue that in low-risk patients, intraperitoneal drainage may always be omitted. However, as a side effect in the present series, a leak of the hepaticojejunostomy or from a Luschka duct was detected early in six patients, with subsequent successful revision of the anastomosis on postoperative day one because of the early detection of the leak. In all those patients, the drain that was located to the dorsal aspect of the pancreaticojejunostomy and that was externalized at the right upper flank also drained the bile. No interventional procedure, such as PTCD, was required for delayed insufficiency of the hepaticojejunostomy. In DP, which was associated with a significantly greater need for postoperative interventional or endoscopic drainage than in PD, one may argue that our drainage concept with irrigation on demand is redundant. We agree that not all fluid collections, which were typically located adjacent to the pancreatic stump, were drained sufficiently, and that drain irrigation did not prevented septic complications or the need for additional drainage in all patients. Some fistulas may have even become superinfected by prolonged drainage. However, the postoperative need for percutaneous or endoscopic drains was comparable to that of the no-drain group in the Dutch RCT \u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur study has several limitations and strengths. First, and most importantly, there was no control group available to provide robust evidence for the benefits of the proposed fistula management technique. Second, the study is a prospective single-institution series with the restriction that all pancreatectomies were performed or supervised by only three experienced pancreatic surgeons. However, a uniform pancreatic perioperative protocol was applied for the entire study period, which included the drainage management concept as described, and no major treatment variances were inherent. A strength of the study is that prospective data reporting to the StuDoQ database was performed by two experienced surgeons (A.G., H.P.-H.), which guarantees high data quality. Furthermore, data on specific issues of the manuscript, e.g. PPH and reoperations, were checked and refined by reevaluating the original patient data. Guaranteeing uniform and correct fistula reporting, the fistula data of all included patients were classified according to the newest POPF definition \u003csup\u003e19\u003c/sup\u003e, which was upgraded in 2016 just prior to the study period. Second, all of our PDs and DPs were included in the study, with no exclusion criteria, unlike well-designed RCTs. This may well reflect \u0026ldquo;real life\u0026rdquo; in a pancreatic cancer center. Because of its clinical relevance in the management of patients, the detailed presentation on distinct information of POPF grade B, with differentiation between drain irrigation and antibiotic therapy versus the need for additional radiological or endoscopic interventions, seems advantageous as compared to the sole reporting on the incidence of grade B fistulas.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe present single-center analysis provides some evidence that the concept of routine drainage and irrigation on demand in PDs and DPs may benefit patient outcomes when focusing on reinterventions, septic complications, and early mortality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAIP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eautoimmune pancreatitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCA 19\u0026thinsp;\u0026minus;\u0026thinsp;9\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDistal pancreatectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFistula Risk Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraductal papillary mucinous carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPMN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraductal papillary mucinous neoplasm\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISGPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Study Group of Pancreatic Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePancreatoduodenectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostpancreatectomy hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOPF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative Pancreatic Fistula\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlexander Gluth: Study concept and design, acquisition of data, analysis and interpretation of data, and drafting of the manuscript\u003c/p\u003e\n\u003cp\u003eHubert Preissinger-Heinzel: Acquisition of data, analysis and interpretation of data, critical revision of manuscript\u003c/p\u003e\n\u003cp\u003eKatharina Schmitz: Acquisition of data, critical revision of manuscript\u003c/p\u003e\n\u003cp\u003eThomas Hallenscheidt: analysis and interpretation of the data and critical revision of the manuscript\u003c/p\u003e\n\u003cp\u003eTorsten Beyna: analysis and interpretation of data and critical revision of the manuscript\u003c/p\u003e\n\u003cp\u003eThomas Lauenstein: analysis and interpretation of data, critical revision of the manuscript\u003c/p\u003e\n\u003cp\u003eWerner Hartwig: Study concept and design, analysis and interpretation of data, and drafting of the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eH\u0026uuml;ttner FJ, Probst P, Knebel P, et al. 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DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/bjs/znab363\u003c/span\u003e\u003cspan address=\"10.1093/bjs/znab363\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCallery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM, Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. Journal of the American College of Surgeons 2013;216(1):1\u0026ndash;14. (In eng). DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jamcollsurg.2012.09.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jamcollsurg.2012.09.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA. 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DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/sla.0000000000005494\u003c/span\u003e\u003cspan address=\"10.1097/sla.0000000000005494\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"pancreatoduodenectomy, distal pancreatectomy, surgery, drainage, fistula","lastPublishedDoi":"10.21203/rs.3.rs-4122423/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4122423/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe necessity of routine drain placement in pancreatic resections is controversial. Some randomized controlled trials have shown that the omission of drainage is safe for some patients, whereas reintervention rates and mortality rates are substantial for others. The present study aimed to assess fistula-associated outcomes in the setting of routine drain placement and drain irrigation on demand.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween 01/2017 and 12/2022, perioperative and outcome data from patients who underwent consecutive pancreatoduodenectomies (PD, n\u0026thinsp;=\u0026thinsp;253) or distal pancreatectomies (DP, n\u0026thinsp;=\u0026thinsp;72) were prospectively collected in the electronic StuDoQ database and analyzed. All patients underwent intraoperative drain placement. Drains were removed starting at postoperative day 2 in PD or at day 5 in DP after testing for amylase concentration. In case of high amylase levels or macroscopically evident fistulas, drain irrigation was started. Nondrained fluid collections underwent percutaneous radiologic or transluminal endoscopic evacuation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eClinically relevant fistulas were detected in 53 of 325 patients (POPF grade B 16.3%, grade C 1.2%), and interventional or endoscopic drainage was necessary in 14 and 5 patients, respectively (overall 5.8%). Fistulas that required drainage were observed in 4.0% of patients with PD and in 12.5% with DP (p\u0026thinsp;=\u0026thinsp;0.009). Delayed fistula-associated postpancreatectomy hemorrhage (PPH) was present in 1.2% (4/325) of patients. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). The 30-day and in-hospital mortality rates were both 1.5% (5/325), and the rate of fistula-associated mortality was 0.6% (2/325).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn pancreatectomies, a standardized drainage protocol including on-demand drain irrigation results in very low fistula-associated morbidity and mortality and an infrequent need for interventional or surgical reintervention.\u003c/p\u003e","manuscriptTitle":"Drainage and irrigation on demand decreases severe septic complications and mortality in pancreatic resections","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-26 06:46:14","doi":"10.21203/rs.3.rs-4122423/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-08T23:02:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-30T10:47:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-28T10:13:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214019803256363914213174705858943737944","date":"2024-06-27T01:14:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274748694453313550246351700698533504530","date":"2024-06-21T06:44:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-21T07:22:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93c100ef-021c-4944-be4f-3200250fa64d","date":"2024-04-11T16:21:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c1d9d954-4764-4676-b3d7-bf0a638edc7d","date":"2024-04-10T10:15:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-09T21:05:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-22T09:10:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-20T21:29:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-03-18T10:36:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"73a7d597-4359-4c33-b806-33a6b1c2c654","owner":[],"postedDate":"March 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-16T16:12:57+00:00","versionOfRecord":{"articleIdentity":"rs-4122423","link":"https://doi.org/10.1007/s00423-024-03464-z","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2024-09-11 15:58:04","publishedOnDateReadable":"September 11th, 2024"},"versionCreatedAt":"2024-03-26 06:46:14","video":"","vorDoi":"10.1007/s00423-024-03464-z","vorDoiUrl":"https://doi.org/10.1007/s00423-024-03464-z","workflowStages":[]},"version":"v1","identity":"rs-4122423","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4122423","identity":"rs-4122423","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}