Does Stent Externalization Matter in Robotic Pancreaticoduodenectomy? A Risk‐Stratified Comparison of Internal and External Pancreatic Stenting

BACKGROUND: Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following pancreaticoduodenectomy (PD), and whether internal or external stenting better mitigates POPF after robotic PD (RPD) remains unclear. METHODS: A retrospective review was conducted of patients who underwent RPD with internalized or externalized pancreatic duct stents at a single academic institution (2020-2026). POPF was graded by ISGPS criteria, with risk stratified by Fistula Risk Score (FRS) and Alternative FRS (A-FRS). Ninety-day outcomes were recorded. RESULTS: Of 182 patients, 83 (45.6%) received an externalized stent. Age, sex, BMI, and PDAC proportion were similar between internal and external stent groups, as was fistula risk (74.7% vs. 71.1% intermediate/high risk) (all p > 0.05). Overall POPF rate was nearly identical (18.2% vs. 18.1%; p = 0.985), with most fistulas (73.5%) being biochemical leaks and no Grade C fistulas. Among low/intermediate A-FRS patients, clinically-relevant POPF rates were comparable (2.6% vs. 2.9%; p = 0.994). In high A-FRS patients, external stenting was associated with significantly fewer clinically-relevant POPFs (0.0% vs. 21.7%) and more biochemical leaks (35.7% vs. 8.7%, p = 0.04). External stenting did not increase length of stay or readmission. CONCLUSIONS: In high fistula-risk RPD patients, external stenting was associated with fewer clinically-relevant POPFs, suggesting externalization may prevent progression to clinically-relevant POPF.