Intraoperative Mitigation Strategies Aimed at Reducing Clinically Relevant Postoperative Pancreatic Fistula After Pancreaticoduodenectomy: A Single-Center Retrospective Cohort Study.

Background Clinically relevant postoperative pancreatic fistula (CR-POPF) remains one of the most important drivers of morbidity after pancreaticoduodenectomy (PD). Several intraoperative adjuncts have been proposed to protect the pancreatic anastomosis or reduce ductal and biliopancreatic pressure, but their comparative real-world impact remains uncertain. Methods We conducted a retrospective single-center cohort study of consecutive adult patients who underwent PD at ASST Cremona between December 2021 and January 2026. Patients were stratified according to the 2016 International Study Group of Pancreatic Surgery classification into no POPF, Grade B POPF, and Grade C POPF. The primary endpoint was CR-POPF, defined as Grade B or C POPF. Intraoperative adjuncts of interest included intraoperative percutaneous transhepatic biliary drainage (PTBD), sponge-assisted negative-pressure drainage, coronary stent support of the pancreatic anastomosis, and externalized Wirsung duct stenting. Secondary outcomes included major morbidity (Clavien-Dindo ≥3a), postoperative interventions, reoperation, unplanned ICU admission, length of stay, readmission, and 30-day mortality. Results Seventy-six patients were included. Overall, 52 patients (68.4%) did not develop POPF, while 24 (31.6%) developed CR-POPF, including 18 Grade B fistulas (23.7%) and six Grade C fistulas (7.9%). A soft pancreatic remnant, a smaller main pancreatic duct diameter, and a higher Fistula Risk Score (FRS) were significantly associated with POPF. Intraoperative PTBD was used in 56 patients (73.7%), externalized Wirsung duct stenting in 40 (52.6%), coronary stenting in 35 (46.1%), and sponge-assisted drainage in five (6.6%). In exploratory parsimonious logistic regression models, none of the adjunctive strategies was significantly associated with reduced CR-POPF. Low FRS (1-2) was protective against CR-POPF (OR: 0.19; 95% CI: 0.05-0.66; p = 0.009). CR-POPF was associated with longer postoperative stay, higher major morbidity, more abdominal collections, greater need for interventional radiology or endoscopic treatment, reoperation, unplanned ICU admission, and higher 30-day mortality in Grade C cases. Conclusions In this single-center cohort, CR-POPF after PD was mainly associated with pancreatic texture, duct size, and FRS rather than with any single intraoperative adjunct. These findings support individualized, risk-stratified anastomotic protection and highlight the need for larger prospective studies to clarify which patients may benefit from specific technical adjuncts.