Role of Octreotide in Pancreatic Surgeries

Octreotide has no beneficial effects on outcomes after pancreaticoduodenectomy and its routine use is not warranted in pancreatic surgeries. 1

Mechanism of Action and Rationale

Octreotide is a synthetic somatostatin analogue that reduces splanchnic blood flow and inhibits pancreatic exocrine secretion 1
The theoretical rationale for its use is to reduce the risk of pancreatic anastomotic fistulas by decreasing the volume of pancreatic exocrine secretions 1
Continuous pancreatic juice secretion and soft pancreatic parenchyma are considered major risk factors for postoperative complications 2

According to the Enhanced Recovery After Surgery (ERAS) Society guidelines (2012), somatostatin and its analogues have no beneficial effects on outcome after pancreaticoduodenectomy (PD) 1
The guidelines specifically state that "in general, their use is not warranted" 1
The most recent meta-analysis reviewed by the guidelines involved 17 trials with 1457 patients undergoing PD and 686 undergoing distal or other resections 1

While the use of somatostatin analogues reduced the crude rate of pancreatic fistulas, the rate of clinically significant fistulas as well as overall major morbidity and mortality remained unchanged 1
Subgroup analyses of pancreaticoduodenectomy patients showed no significant effect of somatostatin/octreotide on any of the reported outcomes 1
The commonly believed beneficial effect of somatostatin in cases with acknowledged risk factors (soft pancreas, small pancreatic duct) is not substantiated by the available evidence 1

Some older studies from the 1990s suggested that perioperative octreotide administration reduced postoperative complications 2, 3, 4
A 1999 review of six placebo-controlled trials reported significantly fewer postoperative complications in octreotide groups compared to placebo groups 2
However, these studies used different definitions of complications and included varied pancreatic pathologies and surgical techniques 5

A 2023 narrative review indicates that there is considerable heterogeneity among studies assessing octreotide's role in preventing postoperative pancreatic fistula (POPF), making data comparison difficult and results inconclusive 5
The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate 5
The ERAS Society guidelines, which represent the most authoritative consensus, do not recommend routine use 1

In contrast to its role in preventing surgical complications, octreotide has specific therapeutic uses in managing symptoms of functional neuroendocrine tumors of the pancreas 1
For preoperative management of neuroendocrine tumors, octreotide can be considered for symptom control in most pancreatic NET subtypes 1
However, octreotide should be used with caution in patients with insulinoma as it can suppress counterregulatory hormones and potentially worsen hypoglycemia 1

Despite theoretical benefits, the highest quality evidence does not support routine use of octreotide in pancreatic surgeries 1
Surgeons should focus on other aspects of perioperative care that have demonstrated benefits, such as maintaining near-zero fluid balance and avoiding fluid overload 1
The decision to use octreotide should be based on specific patient factors rather than routine prophylaxis 1

Relying on older studies that showed benefits without considering their methodological limitations and heterogeneity 5
Using octreotide in patients with insulinoma without confirming somatostatin receptor positivity, which can precipitously worsen hypoglycemia 1
Assuming that octreotide will prevent clinically significant pancreatic fistulas when evidence suggests it only reduces crude rates of fistulas 1