Pancreatic Duct Stenting during Pancreaticoduodenectomy: Outcomes from a Standardized Duct-to-Mucosa Cohort with Propensity Score Weighting

Abstract

Background Postoperative pancreatic fistula (POPF) remains one of the most important complications after pancreaticoduodenectomy (PD), and the optimal transanastomotic pancreatic duct drainage strategy remains debated.Aims To evaluate the association between pancreatic duct stenting strategy and clinically relevant POPF (CR-POPF) after PD.Methods We retrospectively analyzed consecutive open PDs (2010-2020). Only patients undergoing standardized duct-to-mucosa pancreaticojejunostomy with a transanastomotic stent (external or internal) were included. The cohort comprised 302 patients (external n = 238; internal n = 64). The primary outcome was CR-POPF (ISGPS grade B-C). Propensity score-based inverse probability of treatment weighting (IPTW) was applied.Results CR-POPF occurred in 9.9% of patients and was lower with external versus internal stenting (8.0% vs. 17.2%, p = 0.029). Biliary leak was also less frequent with external stenting (4.6% vs. 14.1%, p = 0.019). In IPTW-weighted analysis, external stenting was independently associated with lower odds of CR-POPF (OR 0.31, 95% CI 0.14-0.70; p = 0.005). E-value analysis suggested moderate robustness to unmeasured confounding (E-value 5.9). Thirty-day mortality was numerically lower with external stenting (2.5% vs. 7.8%, p = 0.059).Conclusions External pancreatic duct stenting was associated with lower CR-POPF rates after standardized PD. Prospective randomized studies are needed to confirm these findings and guide stenting strategy selection.