"Does perioperative hydrocortisone reduce morbidity after pancreatoduodenectomy? A propensity score matched analysis"

Does perioperative hydrocortisone reduce morbidity after pancreatoduodenectomy A propensity score matched analysis

Reviewed by

Reza Lankarani

M.D

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Published: 20 July 2025

https://doi.org/10.1007/s13304-025-02280-4

Updates in Surgery, Springer

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This propensity score-matched analysis by Radulova-Mauersberger et al. inv

estigates whether perioperative hydrocortisone (HC) reduces morbidity after pancreatoduodenectomy (PD). The study leverages a decade-long database (2012–2022), matching 110 HC-treated patients (100 mg IV for 48h) with 110 non-HC controls. The primary finding—no significant reduction in overall morbidity, POPF, PPAP, or major complications (CDC ≥3) with HC—challenges prior hypotheses about HC’s anti-inflammatory benefits in pancreatic surgery. Notably, HC did not mitigate postoperative hyperamylasemia (POH) or PPAP incidence, even after stratifying by F

RS risk. However, HC was associated with significantly reduced in-hospital mortality (1.8% vs. 9.1%, p=0.03) and shorter ICU stays (p=0.05), suggesting potential systemic protective effects unrelated to fistula or pancreatitis.

Strengths Assessment :

The study’s princ

ipal strength lies in its robust methodology. The 1:1 propensity score matching effectively balanced critical confounders (e.g., FRS, pancreatic texture, duct diameter, ISGPS-POPF risk), minimizing selection bias inherent to retrospective designs. The authors furt

her enhanced rigor through comprehensive subgroup

analyses (e.g., FRS stratification) and adherence

to standardized outcome definitions (ISGPS, CDC), ensu

ring clinical relevance. Additionally, the large matched cohort (n=220) derived from a high-volume center provides substantial statistical powel inference, and unmeasured confounders (e.g., surgeon experience, evolving perioperative protocols) may persist. The omission of acinar cell quantification (a biomarker in prior RCTs) precludes direct mechanistic comparisons. Nevertheless, this study offers pivotal real-world evidence that HC’s purported anti-inflammatory benefits may not translate to reduced pancreatic-specific complications, urging caution in clinical adoption and underscoring the need for biomarker-driven RCTs.

Final Comment:

This analysis excels in methodological rigor and clinical nuance, contributing critical equipoise to the steroid-prophylaxis debate in pancreatic surgery. While HC failed its primary endpoint, its mortality benefit warrants deeper mechanistic exploration.

Conclusion:

This study provides valuable real-world evidence but underscores the complexity of inflammation modulation in PD. While HC does not reduce POPF/PPAP, its association with lower mortality merits validation in prospective trials. Future research should prioritize:

Multicenter RCTs with biomarker stratification.

Integration with minimally invasive techniques .

Comparative efficacy studies of HC vs. dexamethasone.

The findings align with the broader trend of refining perioperative care through precision medicine and technological advancements in surgery.

Dr.

Reza Lankarani

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