Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatico-duodenectomy (PD) has been associated with soft gland texture and/or small pancreatic duct. We hy-pothesized that selective use of pancreaticogastrostomy (PG) over pancreaticojejunostomy (PJ) in those scenarios would decrease the rate of CR-POPF.Methods: Review of prospective database of all PD's performed at a single institution between 2009 and 2019 was performed. The pancreatic remnant was deemed "high risk " if soft gland and/or small duct were present.Results: PJ was performed in 199 (147 "low-risk " and 52 "high-risk ") cases, and 110 patients (all "high -risk ") had a PG. Overall CR-POPF rate was 11.9% with no difference between the groups. Risk-stratified analysis within PJ group showed CR-POPF rate of 5.4% versus 36% in "low-risk " versus "high risk " scenarios, respectively; the use of PG significantly decreased CR-POPF rate (9.1%, p < 0.0001). Gastrointestinal bleeding was more likely to occur following PG than PJ. Soft gland texture and gastrointestinal bleeding were the strongest predictors of CR-POPF in PJ and PG groups, respectively.Conclusion: Selective use of PG after PD in "high-risk " scenarios mitigates the risk of CR-POPF. Increased rate of gastrointestinal bleeding calls for further refinement of the technique and heightened postoperative vigilance.