LAUSR

We thank the authors for their corrections to the reference errors in Table 1. We appreciate the comments on our preliminary data and the literature selection; however, these are beyond the scope of a technical paper. We look forward to presenting an adequately powered analysis as we accrue data. For interest, we performed a pooled analysis of individual studies used in the three meta‐analyses of contention, with the addition of Kawaii et al.'s findings. This did not overturn the overall conclusion as anticipated by the authors (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.56–1.53, p = 0.75) (Figure 1). Importantly, it was not possible to differentiate between Grade B and Grade C postoperative pancreatic fistula (POPF), which was the insight offered by Jiang et al. Their meta‐analysis reported a significantly lower rate of Grade C POPF with the use of an external versus internal stent (OR 0.58, 95% CI 0.35–0.96). Further, Kawaii et al.'s findings that external pancreatic stenting was significantly associated with an increased risk of clinically relevant POPF appears to be an outlier in its effect size. The Witzel tunnel is a well‐described technique to address the risk of leak when removing feeding jejunostomy tubes. Its use in the context of an external pancreatic stent adopts the same principle. In our unit, peripancreatic collections post stent removal has not been an issue. Importantly, no single technique has been unequivocally shown to reduce the risk of CR‐POPF post pancreatoduodenectomy (PD). Current evidence supports the use of the Fistula Risk Score (FRS) to identify patients at higher risk of CR‐POPF and the application of risk‐mitigating strategies accordingly. The Pancreatic Anastomosis Audit Study Group published a recent meta‐ analysis on perioperative interventions to reduce CR‐POPF following PD and found that external pancreatic stenting was the only intervention to reduce both CR‐POPF and all POPF. The exact mechanism is unclear; hypotheses are that it (i) decompresses the system, and/or (ii) provides a track for controlled leaks. Clearly evidence is still evolving, and further research is needed. We nevertheless maintain that external pancreatic is a valuable tool to have in a surgeon's armamentarium.