Procedure-specific morbidity of pancreatoduodenectomy: a systematic review of incidence and risk factors

Background Pancreatoduodenectomy (PD) remains the only curative-intent treatment option for patients with cancer affecting the head of the pancreas. It is high-risk and overall morbidity is around 40%. Due to the necessary resection and subsequent anastomoses required, multiple procedure-specific complications are possible. An in-depth understanding of the recent evidence on these will guide the consenting process and allow surgeons to evaluate their own performance. We aimed to consolidate the recent literature on preselected PD complications (postoperative pancreatic fistula (POPF), bile leak (BL), gastrojejunal leak, postpancreatectomy haemorrhage (PPH), cholangitis, and chyle leak (CL)). Methods A search of the PubMed database was carried out on 1st July 2021. Articles from July 2011 through to July 2021 were included. The initial search returned 297 results. After screening, 226 articles were excluded. The remaining 71 were assessed for eligibility and a further 34 were excluded. 37 were included in the final synthesis (two meta-analyses and 35 single/multicentre studies). Results Due to recently updated diagnostic criteria, differing definitions among authors and subclinical cases, true incidence rates are difficult to appreciate. The following were obtained: POPF (excluding biochemical leak): 10.0-25.9%, BL: 3.0-7.9%, gastrojejunal anastomotic leak: 0.4-1.2%, PPH: 7.3-13.6%, cholangitis: 0.05-21.1% and CL: 2.6-19.0%. Numerous risk factors, both modifiable and non-modifiable, were identified for each. Conclusion Most of the recent evidence on the studied complications comes from single institution studies of retrospective design. Robust case-control studies are required so predictive models can estimate the likelihood of specific complications in individual patients.