MR-guided SBRT as Salvage Therapy for Persistent Postoperative Pancreatic Fistulas

Overview

This case series reports successful use of MR-guided stereotactic body radiotherapy (SBRT) in five patients with refractory Grade B/C postoperative pancreatic fistulas (POPF) after surgery. SBRT led to significant reduction in drain output, permanent drain removal, and elimination of rehospitalizations without notable toxicity.

Background

Postoperative pancreatic fistula (POPF) Grade B/C is a serious complication following pancreatic surgery, often complicated by sepsis, hemorrhage, and organ failure. Standard treatments sometimes fail to resolve persistent fistulas, leaving limited therapeutic options. MR-guided SBRT is a non-invasive radiotherapy technique that may promote fistula closure by targeted irradiation. This study explores SBRT as a salvage treatment for refractory POPF unresponsive to conventional management.

Data Highlights

Key Findings

• All five patients with refractory Grade B/C POPF achieved permanent drain removal after MR-guided SBRT.
• Median drain output decreased significantly from 47.5 ml/day to 2 ml/day post-treatment.
• Median time to drain removal was 44 days following SBRT.
• Rehospitalizations dropped from a median of 14 days pre-treatment to zero days post-treatment.
• No gastrointestinal toxicity was observed; only one patient experienced mild fatigue.
• SBRT was well tolerated and showed potential as a non-invasive salvage therapy for persistent POPF.

Clinical Implications

MR-guided SBRT may be considered a safe and effective rescue treatment for patients with persistent postoperative pancreatic fistulas unresponsive to standard therapies. Incorporation of SBRT into multidisciplinary management algorithms could reduce morbidity and rehospitalizations. Prospective studies with larger cohorts are needed to validate these promising results.

Conclusion

This first series demonstrates that MR-guided SBRT can successfully close refractory postoperative pancreatic fistulas with minimal toxicity, offering a novel non-invasive salvage option. Further research is warranted to establish its role in clinical practice.

References

1. Bassi et al. 2017 -- The 2016 update of the International study group (ISGPS) definition and grading of postoperative pancreatic fistula
2. Malleo et al. 2014 -- Diagnosis and management of postoperative pancreatic fistula
3. Schrader et al. 2022 -- Stereotactic irradiation of the pancreas: case study of a patient with persistent pancreatic fistula