Stereotactic body radiotherapy as a rescue modality for definitive treatment of therapy-refractory fistulas after pancreatic surgery

Postoperative pancreatic fistula (POPF) Grade B/C, according to ISGPS 2016 criteria, poses a significant challenge due to severe complications such as sepsis, hemorrhage, and organ failure. When standard treatments are unsuccessful, treatment options become limited. This series investigates the use of MR-guided stereotactic body radiotherapy (SBRT) as a potential rescue therapy for refractory POPF. Between 2020 and 2025, five patients with refractory Grade B/C POPF and severe complications—including sepsis, abscesses, superinfection, or high-output fistulas—received MR-guided SBRT after failing conventional approaches. The treatment comprised 5 fractions of 4–8 Gy each. Success was defined as the permanent removal of drainage without any subsequent deterioration. All five patients were male, with surgical procedures including proximal (n = 1), distal pancreatic resection (n = 3), or necrosectomy (n = 1). The median drain output significantly decreased from 47.5 ml/day to 2 ml/day. Drains were removed after a median of 44 days. No gastrointestinal toxicity was observed; only one patient reported mild fatigue. The interval until rehospitalization markedly decreased from a median of 14 days pre-treatment to zero days post-treatment. Rehospitalizations before SBRT were caused by abscesses or drain malfunctions, but none occurred afterward. This is the first series to evaluate MR-guided SBRT as a treatment for refractory POPF. The findings suggest that this non-invasive approach could reduce morbidity and offers a promising alternative when traditional methods fail. Further research with larger cohorts is necessary to confirm these outcomes. Key findings: What is known and what is new? What is the implication, and what should change now?