Practice variation and limited adoption of evidence in POPF prevention after pancreatoduodenectomy: an international E-AHPBA-endorsed survey

BACKGROUND: Postoperative pancreatic fistula (POPF) remains a major source of morbidity after pancreatoduodenectomy. This international survey assessed contemporary preventive strategies and practice variation. METHODS: An online survey was distributed to HPB surgeons worldwide. The questionnaire addressed risk assessment, anastomotic technique, pancreatic duct stenting, drain management, antibiotic prophylaxis and somatostatin analogue use. Responses were analysed descriptively. RESULTS: 283 surgeons from 48 countries completed the survey. Intraoperative POPF risk assessment was routinely performed by 228/283 respondents (80.6%), yet formal risk tools were used inconsistently. Pancreatic reconstruction was largely uniform, with pancreatojejunostomy performed by 252/283 surgeons (89.0%). Pancreatic duct stenting showed marked variation, with 160/283 respondents (56.5%) reporting routine or frequent use and internal stents preferred by 179/227 surgeons (78.9%). Almost all respondents used intra-abdominal drains (279/283, 98.6%), but the timing of drain removal varied substantially. Ureidopenicillins were used as antibiotic prophylaxis by 120/268 respondents (44.8%), whereas 95/268 (35.4%) used second-generation cephalosporins. Somatostatin analogue use was highly heterogeneous. DISCUSSION: Preventive strategies against POPF vary widely across institutions. Heterogeneity persists even in areas supported by randomized evidence, highlighting important gaps between available data and routine clinical practice and identifying priorities for future interventional studies.