# Current German practices in the prevention and management of postoperative pancreatic fistula following pancreatoduodenectomy: a nationwide survey

## TL;DR

A survey of German hospitals shows varied practices in preventing and managing a dangerous complication after a common pancreatic surgery.

## Contribution

The study provides a detailed nationwide assessment of current practices in Germany for managing postoperative pancreatic fistula after pancreatoduodenectomy.

## Key findings

- Most hospitals use duct-to-mucosa pancreatojejunostomy and abdominal drainage for POPF prevention.
- Prophylactic use of somatostatin analogs and pancreatic duct stenting is common, but prophylactic pancreatectomy is rare.
- Therapeutic strategies include antibiotics and CT-guided drainage, with limited variation by hospital type or volume.

## Abstract

Postoperative pancreatic fistula (POPF) is the most frequent and clinically significant complication following pancreatoduodenectomy (PD) and represents the leading cause of postoperative mortality. Prevention, early recognition and adequate treatment are crucial for improving outcomes.

A nationwide survey was conducted in October and November 2024, targeting 112 German hospitals routinely performing pancreatoduodenectomies. The questionnaire assessed surgical volumes, preferred anastomotic techniques, prophylactic and therapeutic strategies for POPF and postoperative monitoring practices. Data were collected via paper-based forms and QR code-assisted online formats.

A total of 77 hospitals, with an average annual volume of 45 PDs, participated in the survey (69% response rate). The pancreas was most commonly anastomosed with the jejunum (88%), with duct-to-mucosa pancreatojejunostomy (PJ) being the most frequently employed technique (39%). Abdominal drainage was routinely used in 91% of centers, with significantly higher rates observed in non-university and low-volume hospitals. Most participants estimated that 20–30% of cases involved high-risk anastomoses, primarily based on pancreatic texture and duct diameter. Only 18% of hospitals reported modifying their anastomotic technique in high-risk situations. As prophylactic measures, the use of somatostatin analogs (65%) and pancreatic duct stenting (36%) were the most common strategies, while prophylactic pancreatectomy was rarely performed (≤ 5% in 83% of centers). Therapeutic management of POPF primarily involved antibiotics (57%) and somatostatin analogs (54%), with interventional drainage – preferably CT-guided (82%) – required in 0–20% of cases, according to 96% of responses. Therapeutic pancreatectomy was reported to be mainly needed in 1–5% of cases. Neither prophylactic nor therapeutic management of POPF differed significantly by hospital type or volume.

The survey reveals substantial variability in anastomotic techniques and in prophylactic and therapeutic strategies for POPF among German surgical centers, reflecting the current lack of high-level evidence in many areas. While minimally invasive management is widely adopted, the findings underscore the need for standardized protocols, improved risk stratification and further clinical trials to strengthen evidence-based practice in pancreatic surgery.