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Don't Calculate Post-hoc Power Using Observed Estimate of Effect Size.

Second, the particular aim of this research was to identify optimal fistula mitigation strategies for the ‘‘high risk’’ patient, as identified by FRS scores ranging from 7 to 10. We were particularly interested in providing strategic insights to improve outcomes for this most vulnerable patient subset since the clinically-relevant fistula (CR-POPF) rate approaches or exceeds 30% in this scenario. In this context, the exclusion of negligible, low and intermediate risk patients does not represent a bias, but rather is a reflection of this study’s focal aim and design. In previous works utilizing all FRS patients from the Pancreas Fistula Study Group dataset, we have performed risk-stratified analyses of internal stents, external stents, octreotide prophylaxis, intraperitoneal drainage, and pancreatogastrostomy reconstruction. Despite these analyses of individual mitigation strategies, we cannot currently determine how these individual strategies interact, nor define an optimal fistula mitigation bundle for the lower FRS risk zones, particularly due to the low encountered incidence (0–4%) of the outcome of interest—CR-POPF. However, a collective summary, FRS zone-byzone, of the results of these studies has been collated in a tabular form in another publication. A third question regards the CR-POPF associated mortality in this study population. The overall 90-day mortality rate for these high FRS risk patients was 4.6%, of which nearly two-thirds suffered a CR-POPF (see Table 3 in manuscript). The pancreatic fistula, or its immediate complications, was considered the cause of death for 2.3% of the 522 patients, and thus half of all postoperative mortalities. We suspect these higher numbers reflect the greater fistula rate, and inherent glandular risk, encountered in this particular population. Finally, it is possible that this so-called technique of ‘‘external venting stents’’ as described by Oguro et al may be particularly beneficial for this scenario, although—as you recently note in your extensive review of CRPOPF-related mortality after PD—this strategy was rarely used (0.9% of PDs) and without improvement in mortality (P 1⁄4 0.999). We agree with your enthusiasm to improve the delivery of surgical care by targeting a reduction in CR-POPF-related mortality and are intrigued by the data you provide from Oguro et al. However, we would like to clarify for the general readership that this strategy relies on a 2-stage operative approach. In the first stage, the jejunum is apparently approximated to the cut-edge of the pancreas using just a posterior attachment, without formation of an actual enterotomy. The pancreatic duct is then cannulated with an externalized stent, creating, in effect, a controlled pancreatico-atmospheric fistula (thus, all patients actually have a CR-POPF). The patient is then subjected to a second operation, 3 months or later, to ‘‘take down’’ the fistula and convert it to a formal pancreatico-jejunostomy at that point. In our opinion, this approach seems excessive, inefficient, and impractical. It remains to be determined if these results can be confirmed at other institutions or, furthermore, in a randomized controlled trial.