High-Risk Pancreatic Anastomosis: Prediction, Mitigation, and Management of Postoperative Pancreatic Fistula

The implementation of composite scores for risk stratification in routine daily practice has opened a new era of pancreatic surgery. Personalized risk assessment methods pave the way to a tailored approach during each stage of the surgical itinerary. Simple and easily detectable preoperative parameters allow engaging different risk-stratified clinical pathways to optimize postoperative outcomes. Intraoperative assessment of individual risk allows the adoption of different operative techniques, as many efforts have been made to reduce the incidence of severe morbidity and pancreatic fistula burden in the high-risk scenario through the systematic adoption of mitigation strategies (e.g., abdominal drains and trans-anastomotic stents). Finally, accurate and objective postoperative management can either lead to fast recovery in low-risk patients or allow mitigation of severe complications in high-risk settings. Different clinical pathways are not rigid or unique, but an ongoing assessment of individual risk can lead to interchangeable ways in the surgical path, optimizing results in each scenario.