Postoperative narcotic use is associated with development of clinically relevant pancreatic fistulas after distal pancreatectomy Stacy J. Kowalsky, MD a , Mazen S. Zenati, PhD b , Mashaal Dhir, MD a , Eric G. Schaefer, PharmD c , Andrew Dopsovic, PharmD c , Kenneth K. Lee, MD a , Melissa E. Hogg, MD a , Herbert J. Zeh, MD a , Charles M. Vollmer, MD d , and Amer H. Zureikat, MD a, * a Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA b Division of Biostatistics, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA c Pharmacy Department, University of Pittsburgh Medical Center, Pittsburgh, PA d University of Pennsylvania Perelman School of Medicine, Philadelphia, PA ARTICLE INFO Article history: Accepted 24 October 2017 A B ST R AC T Background. Various strategies to decrease postoperative pancreatic fistula after a distal pancreatec- tomy have proved unsuccessful. Because narcotics can cause spasm of the sphincter of Oddi and thereby increase pressure within the pancreatic duct stump, we hypothesized that increased narcotic use would be associated with increased occurrence of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Methods. Retrospective analysis of consecutive distal pancreatectomies (2011–2016) was performed. Postoperative narcotic use was calculated in morphine equivalents. Postoperative pancreatic fistula was graded according to the International Study Group on Pancreatic Surgery. Perioperative variables were evaluated using multivariate logistic regression with clinically relevant postoperative pancreatic fistula as the dependent outcome. Results. In the study, 310 distal pancreatectomies were analyzed (61% robotic, 20% open, 19% laparo- scopic). Average age was 62 (53% female), and median total dose of morphine equivalents was 424mg (interquartile range 242–768). Clinically relevant postoperative pancreatic fistula occurred in 21.6%. Clin- ically relevant postoperative pancreatic fistula and not clinically relevant postoperative pancreatic fistula cohorts were similar in most demographics and operative variables, but clinically relevant postopera- tive pancreatic fistula patients had fewer stapled transections (80 vs 90%, P = .025), less pancreatic cancers (11 vs 35%, P < .001), and greater median total morphine equivalents (577 vs 403 mg, P < .009). On uni- variate analysis, clinically relevant postoperative pancreatic fistula was associated with body mass index, nonstapled transection, suture ligation of the PD, a nonpancreatic cancer pathology, prophylactic octreotide, and total morphine equivalents >424 (cohort median). On multivariate analysis, only pancreatic cancer pathology was protective against a clinically relevant postoperative pancreatic fistula (odds ratio 0.24, confidence interval, 0.10–0.50, P = .001), while increasing total morphine equivalents were predictive of a clinically relevant postoperative pancreatic fistula (odds ratio 1.13, confidence interval, 1.01–1.27, P = .035) with a 13% increased risk for every approximate ≈100 mg increase in total morphine equivalents. Conclusion. In this retrospective analysis, postoperative narcotic use was associated with the develop- ment of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Limiting narcotic use may be one of the few available mitigating strategies against the development of a clinically rele- vant postoperative pancreatic fistula after distal pancreatectomy. © 2017 Elsevier Inc. All rights reserved. Postoperative pancreatic fistula (POPF), or drainage of pancre- atic secretions from the transected edge of the pancreas after distal pancreatectomy (DP), can occur in up to 60% to 70% of cases. 1 Clin- ically relevant POPF (CR-POPF), i.e. POPFs that require alterations in clinical management, comprise up to 20% to 30% of fistulae after DP. 2-8 These complications are a substantial source of prolonged hos- pital stays (both index hospitalization and readmissions) and are associated with a doubling of hospital costs according to one Presented at an oral presentation at the 51st Annual Pancreas Club Meeting, Chicago, IL, May 5, 2017. * Corresponding author. Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, 5150 Centre Avenue Suite 421, Pittsburgh, PA 15232. E-mail address: zureikatah@upmc.edu (A.H. Zureikat). https://doi.org/10.1016/j.surg.2017.10.042 0039-6060/© 2017 Elsevier Inc. All rights reserved. Surgery ■■ (2017) ■■–■■ ARTICLE IN PRESS Please cite this article in press as: Stacy J. Kowalsky, et al., Postoperative narcotic use is associated with development of clinically relevant pancreatic fistulas after distal pancreatec- tomy, Surgery (2017), doi: 10.1016/j.surg.2017.10.042 Contents lists available at ScienceDirect Surgery journal homepage: www.elsevier.com/locate/ymsy