Appropriate scenarios for the prevention of postoperative pancreatic fistula
============================================================================

* Bao Jin
* Huayu Yang

We read with great interest the article, “Prevention of postoperative pancreatic fistula after pancreatectomy: results of a Canadian RAND/UCLA appropriateness expert panel” by Hallet and colleagues.1 The panel identified appropriate and inappropriate scenarios for prevention of postoperative pancreatic fistula (POPF). The authors scored the appropriateness of perioperative care and surgical techniques for pancreaticoduodenectomy and distal pancreatectomy, and identified 26 appropriate scenarios and 5 inappropriate scenarios.1

Postoperative pancreatic fistula is a common complication of pancreatic surgery, with an incidence of 5%–30%, and may lead to serious complications, such as postoperative bleeding, organ failure and death.2 The most widely used diagnostic criteria and grading system for POPF comes from the International Study Group on Pancreatic Fistula; it was created in 2005 and updated in 2016 to define grade A pancreatic fistula as biochemical leak, and grade B and C pancreatic fistula as clinically relevant pancreatic fistula.2 Currently, a number of risk score models have been developed for predicting pancreatic fistula, including the Callery model (also known as the Fistula Risk Score), the Roberts model, and the Mungroop model (also known as the alternative Fistula Risk Score).3–5 However, few studies have focused on appropriate interventions to prevent POPF. We applaud Hallet and colleagues for providing guidance to clinicians for the prevention of POPF.

Adequate preoperative evaluation, meticulous operation and postoperative management are important measures to prevent postoperative complications such as pancreatic fistula, and anastomotic technique and surgical drainage are the keys.6,7 Although Hallet and colleagues gave specific guidelines based on the opinions of the expert group, large-scale international multicentre studies are still needed for further confirmation.

## Footnotes

*   **Competing interests:** None declared.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

## References

1.  Hallet J, Theodosopoulos E, Abou-Khalil J, et al. Prevention of postoperative pancreatic fistula after pancreatectomy: results of a Canadian RAND/UCLA appropriateness expert panel. Can J Surg 2022;65:E135–42.
    
    

2.  Eskander MF, Cloyd JM. Predicting postoperative pancreatic fistula: one size may not fit all. Hepatobiliary Surg Nutr 2021;10:113–5.
    
    

3.  Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013;216:1–14.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1016/j.jamcollsurg.2012.09.002&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=23122535&link_type=MED&atom=%2Fcjs%2F65%2F6%2FE734.atom) 

4.  Roberts KJ, Hodson J, Mehrzad H, et al. A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB (Oxford) 2014;16:620–8.
    
    

5.  Mungroop TH, van Rijssen LB, van Klaveren D, et al. Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation. Ann Surg 2019;269:937–43.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fcjs%2F65%2F6%2FE734.atom) 

6.  Kaido T, Hirose S, Miyachi Y. Short postoperative hospital stay after pancreaticoduodenectomy: what is real minimally invasive surgery? Hepatobiliary Surg Nutr 2021;10:853–6.
    
    

7.  Jin J, Wang H, Peng F, et al. Prognostic significance of preoperative Naples prognostic score on short- and long-term outcomes after pancreatoduodenectomy for ampullary carcinoma. Hepatobiliary Surg Nutr 2021;10:825–38.