399 Fail to Prepare, Prepare to Fail: Preoperative Practice Variability in Open Pancreatoduodenectomy Among UK HPB Surgeons

Abstract Aim To evaluate variability in preoperative assessment and pathways for patients undergoing open pancreatoduodenectomy (Whipple/PPPD) among hepatobiliary and pancreatic (HPB) surgeons in the United Kingdom (UK) and Ireland. Method A national cross-sectional survey was distributed to consultant HPB surgeons across the UK and Ireland via google forms. Questions ranged across the entirety of the patients’ journey, though the present addresses their pre-operative course including operability-criteria, prehabilitation, biliary drainage, histology and imaging. Responses were analyzed descriptively. Results 38 responses were received from consultants across 30 different hospitals. 19/38 (50%) surgeons reported access to a formal prehabilitation program, with variation in content. Criteria for operability varied with the most common as radiologic (NCCN; 97.4%), followed by performance status (WHO;73.7%). Selective preoperative biliary drainage was used by most (30/38,78.9%), but criteria varied, including NAT use, high bilirubin and diagnostic uncertainty. ERCP was the most common drainage technique (35/38,92.1%). A histological diagnosis was required for 6/38 (15.8%) responders. The PACT-UK imaging tool was used by 21/38 (55.3%) and time from latest imaging required before surgery varied; ≤4 weeks in 21/38 (55.3%), 4–6 weeks in 15/38 (39.5%), and >6 weeks in 2/38 (5.3%). CT-pancreas protocol was standard (38/38, 100%), with 25/38 (66%) and 9/38 (24%) completing a CT-PET and MRI also, as routine, respectively. Conclusions This survey demonstrates substantial variability in preoperative optimisation in PD. Differences in prehabilitation access, drainage thresholds, and imaging intervals could contribute to variability in outcomes. The impact of such variability is unknown, and the optimal pre-operative pathway remains to be defined.