title: Externalized Stents for Pancreatoduodenectomy Provide Value Only in High-Risk Scenarios.
abstract: Evidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted.
  
  
  
  From 2001 to 2015, PDs were performed at three institutions, with externalized stents placed at the surgeon's discretion. The Fistula Risk Score (FRS) and the Modified Accordion Severity Grading System were used to analyze occurrence and severity of clinically relevant postoperative pancreatic fistula (CR-POPF) across various risk scenarios.
  
  
  
  Of 729 PDs, externalized stents were placed during 129 (17.7 %). Overall, CR-POPFs occurred in 77 (10.6 %) patients. The median FRS of patients who received externalized stents was significantly higher compared with patients who did not (6 vs. 3, p < 0.0001). Patients with negligible, low, or moderate CR-POPF risk (FRS 0-6) did not demonstrate improved outcomes with externalized stents; however, among high-risk patients (FRS 7-10), stents were associated with significantly reduced rates of CR-POPF (14.0 vs. 36.4 %, p = 0.031), severe complications (p = 0.039), and hospital stay (p = 0.014) compared with no stents. The average complication burden of CR-POPF was significantly lower for patients with externalized stents (p = 0.035).
  
  
  
  This multicenter study, the largest comparative analysis of externalized trans-anastomotic stents versus no stent for PD, demonstrates a risk-stratified benefit to externalized stents.
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: McMillan
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
authors.forename: Brett L
authors.initials: BL
authors.lastname: Ecker
authors.affiliation: Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Behrman
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
authors.forename: Mark P
authors.initials: MP
authors.lastname: Callery
authors.affiliation: Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA.
authors.forename: John D
authors.initials: JD
authors.lastname: Christein
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Drebin
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.affiliation: Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
authors.forename: Tara S
authors.initials: TS
authors.lastname: Kent
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
authors.forename: Major K
authors.initials: MK
authors.lastname: Lee
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Roses
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Sprys
authors.affiliation: Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA. Charles.Vollmer@uphs.upenn.edu.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Vollmer
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000009:adverse effects; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000209:etiology / Q000517:prevention & control*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D020379:Risk Adjustment; D012720:Severity of Illness Index; D015607:Stents / Q000009:adverse effects
keywords: Pancreatectomy; Pancreatic fistula; Pancreatoduodenectomy; Stent