Comparison of endoscopic and radiologic drainage for symptomatic postoperative pancreatic fistula-associated collections after distal pancreatectomy.

Abstract

Background: After distal pancreatectomy (DP), symptomatic postoperative pancreatic fistula (POPF)-associated collections are common and lead to readmissions. The choice of drainage modality remains debated. This study compared endoscopic and radiologic drainage as first-line treatment.

Methods: This retrospective, single-center study included patients undergoing DP with or without splenectomy from 2012 to 2024. Patients who underwent DP with a concomitant digestive or vascular procedure or pancreatic anastomosis were excluded. The primary outcome was total hospital stay, defined as the sum of the index hospitalization and readmissions.

Results: Among 607 patients, 124 (20.4%) had POPF, including 94 (15.5%) with a symptomatic collection. Of these, 25 underwent endoscopic drainage (lumen-apposing metal stent, n = 19; double-pigtail stent, n = 6), 12 underwent radiologic drainage, and 57 received another treatment (medical treatment alone, n = 35; drain tract recanalization, n = 15; surgical reoperation, n = 4; endoscopic sphincterotomy, n = 3). The endoscopic and radiologic drainage groups were comparable, except for collection location adjacent to the pancreatic transection margin (endoscopic: 92% vs radiologic: 50%; p = 0.008). Total hospital stay within 90 days was shorter after endoscopic drainage (19 vs 31 days; p = 0.023), with no deaths within 90 days. The clinical success rate was higher after endoscopic drainage (76% vs 50%; p = 0.15), whereas drainage dysfunction was more frequent after radiologic drainage (17% vs 4%; p = 0.2). Four severe complications occurred: three after endoscopic drainage using a LAMS, including two hemorrhagic complications, and one after radiologic drainage. In univariable analysis, collection location adjacent to the pancreatic transection margin and endoscopic drainage were associated with shorter total hospital stay within 90 days (β = - 17 days; 95% CI - 29 to - 4.2; p = 0.010 and β = - 13 days; 95% CI - 24 to - 1.6; p = 0.026, respectively).

Conclusions: After DP, first-line endoscopic drainage of symptomatic POPF-associated collections was associated with a shorter total hospital stay and a trend toward a higher clinical success rate but may carry a risk of bleeding.