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Hajibandeh S, Hajibandeh S, Hablus MA, Bari H, Pathanki AM, Ali M, Ahmad J, Marangoni G, Khan S, Lam FT. Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy. Ann Hepatobiliary Pancreat Surg 2024; 28:302-314. [PMID: 38522846 PMCID: PMC11341886 DOI: 10.14701/ahbps.24-015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
This study aimed to compare outcomes of hand-sewn and stapler closure techniques of pancreatic stump in patients undergoing distal pancreatectomy (DP). Impact of stapler closure reinforcement using mesh on outcomes was also evaluated. Literature search was carried out using multiple data sources to identify studies that compared hand-sewn and stapler closure techniques in management of pancreatic stump following DP. Odds ratio (OR) was determined for clinically relevant postoperative pancreatic fistula (POPF) via random-effects modelling. Subsequently, trial sequential analysis was performed. Thirty-two studies with a total of 4,022 patients undergoing DP with hand-sewn (n = 1,184) or stapler (n = 2,838) closure technique of pancreatic stump were analyzed. Hand-sewn closure significantly increased the risk of clinically relevant POPF compared to stapler closure (OR: 1.56, p = 0.02). When stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.54, p = 0.002). When only randomized controlled trials were considered, there was no significant difference in clinically relevant POPF between hand-sewn and stapler closure techniques (OR: 1.20, p = 0.64) or between reinforced and standard stapler closure techniques (OR: 0.50, p = 0.08). When observational studies were considered, hand-sewn closure was associated with a significantly higher rate of clinically relevant POPF compared to stapler closure (OR: 1.59, p = 0.03). Moreover, when stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.55, p = 0.02). Trial sequential analysis detected risk of type 2 error. In conclusion, reinforced stapler closure in DP may reduce risk of clinically relevant POPF compared to hand-sewn closure or stapler closure without reinforcement. Future randomized research is needed to provide stronger evidence.
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Affiliation(s)
- Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohammed Abdallah Hablus
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
- Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hassaan Bari
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Adithya Malolan Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Majid Ali
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Jawad Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Gabriele Marangoni
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Saboor Khan
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - For Tai Lam
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
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Yin T, Yuan J, Wu Y, Li S, Wang M, He R, Qin R. Retroperitonealization of the pancreatic stump in distal pancreatectomy: a novel technique to reduce postoperative pancreatic fistula. Langenbecks Arch Surg 2023; 408:425. [PMID: 37914974 DOI: 10.1007/s00423-023-03138-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of retroperitonealization of the pancreatic stump in distal pancreatectomy. METHODS Clinical data from the Tongji Hospital pancreatic database were retrospectively reviewed in this study. The data of 68 patients who underwent retroperitonealized distal pancreatectomy from January, 2019, to April, 2021, were collected and analyzed. Sixty-four patients who underwent conventional distal pancreatectomy during the same period were matched. We compared and analyzed the operative outcomes and postoperative complications between the patients in the two groups before and after propensity score matching (PSM). RESULTS Before PSM, the operative outcomes and postoperative complications were comparable between the two groups. After PSM, the retroperitonealized group had a lower incidence of postoperative pancreatic fistula (POPF) (10.53% vs 31.58%, P = 0.047) and shorter time until drainage removal (10.00, 8.00-13.00 days vs 13.00, 10.00-18.00 days, P = 0.005). In the univariate and multivariate regression analyses, non-retroperitonealization and intra-abdominal infection were found to be independent risk factors for postoperative pancreatic fistula (POPF). CONCLUSION Retroperitonealization of the pancreatic stump can reduce the incidence of POPF after distal pancreatectomy.
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Affiliation(s)
- Taoyuan Yin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Jingxiong Yuan
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Yi Wu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Shizhen Li
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Ruizhi He
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China.
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China.
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Kaneda Y, Kimura Y, Saito A, Ae R, Kawahira H, Sata N. Pancreas Ligation Device for Distal Pancreatectomy: An Ex Vivo Follow-Up Porcine Study. Cureus 2023; 15:e44771. [PMID: 37692176 PMCID: PMC10484152 DOI: 10.7759/cureus.44771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction Postoperative pancreatic fistula (POPF) is a critical complication occurring with a high incidence after distal pancreatectomy. To minimize the risk of POPF, we developed an innovative pancreas ligation device capable of closing the pancreatic stump without causing traumatic injury to the pancreatic duct and artery. We conducted an ex vivo follow-up study to compare the pressure resistance of the pancreas ligation device with that of a regular linear stapler. Materials and methods The pancreases were excised from 20 pigs and divided into two groups: ligation group (n = 10) and stapler group (n = 10). Distal pancreatectomy was performed, and the pancreatic stump was closed using either a pancreas ligation device or a regular linear stapler. The main pancreatic duct was cannulated with a 4-French catheter connected to a cannula and syringe filled with contrast medium. Using fluoroscopy detection, pressure resistance was defined as the maximum pressure without leakage from the pancreatic stump. Results No significant differences were found between the two groups regarding sex, age, body weight, or pancreatic thickness. In the ligation group, no leakage was observed at the stump in any pancreas. However, in the stapler group, six of 10 pancreases showed leakage at the staple line or into the parenchyma. Pressure resistance was significantly higher in the ligation group than in the stapler group (median: 42.8 vs. 34.3 mmHg, P = 0.023). Conclusions These findings suggest the effectiveness of a pancreas ligation device in reducing the incidence of POPF after distal pancreatectomy. Our ligation device is expected to be a useful alternative to a linear stapler for pancreatic stump closure.
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Affiliation(s)
- Yuji Kaneda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
- Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Yuki Kimura
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Akira Saito
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, JPN
| | - Hiroshi Kawahira
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
- Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
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Jia B, Chen Q, Jiang P, Liu Y. An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. Surg Today 2022; 52:1430-1437. [PMID: 35138460 DOI: 10.1007/s00595-022-02470-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
PURPOSES Postoperative pancreatic fistula is the most common and severe postoperative complication of distal pancreatectomy. Treatment of pancreatic stump to reduce the incidence of postoperative pancreatic fistula is crucial. This study evaluated the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. METHODS Prospectively collected data of consecutive patients who underwent distal pancreatectomy from April 2013 to May 2020 with pancreatic transection performed by the bare stapler method (131 patients), stapler + hand-sewn closure method (199 patients), and stapler + titanium clip method (209 patients) were reviewed retrospectively and compared between groups. RESULTS No statistically significant differences were observed in basic data among the three groups. There were also no significant differences among the three groups in terms of the intraoperative data or tumor pathological types, except for the number of laparoscopic treatment cases (23, 53, and 80 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and pancreatic neuroendocrine tumor cases (15, 29, and 12, respectively; P < 0.05). There were no significant differences in postoperative complications or parameters, except for the number of clinical pancreatic fistula cases (31, 27, and 13 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and postoperative length of hospital stay (11.6 ± 8.3, 10.6 ± 9.7, and 9.3 ± 6.9 days, respectively; P < 0.05). The stapler + titanium clip group had a significantly lower number of clinical pancreatic fistula cases and shorter postoperative length of hospital stay than the other groups. The univariate analysis showed that pancreatic resection line thickness was an independent risk factor for clinical pancreatic fistula after operation. CONCLUSION Stapler closure combined with titanium clips to reinforce the pancreatic stump is simple and easy to implement, effectively reduces the incidence of clinical pancreatic fistula, and shortens the postoperative length of hospital stay.
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Affiliation(s)
- Baoxing Jia
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Qingmin Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Peiqiang Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China.
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5
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Kaneda Y, Kimura Y, Saito A, Ohzawa H, Ae R, Kawahira H, Lefor AK, Sata N. Innovative Pancreas Ligation Band for Distal Pancreatectomy: A Pilot In Vivo Porcine Study. Cureus 2021; 13:e18238. [PMID: 34589376 PMCID: PMC8461750 DOI: 10.7759/cureus.18238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Although new techniques and devices have been introduced, the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy remains high. To reduce the risk of POPF, we developed an innovative ligation band and conducted this pilot study to assess the possibility of reducing the incidence of POPF and pancreatic necrosis after distal pancreatectomy. Methods Distal pancreatectomy was performed in three pigs. In two animals, ligation of the pancreas was performed while maintaining arterial blood flow to the stump, and in one animal, the arterial blood flow was occluded. After ligation, the pancreas was sharply divided. Animals were sacrificed seven days later, and the remnant pancreas was assessed histologically. POPF was defined as amylase in ascites > 3x the preoperative serum amylase level. The following equation was used to quantify the extent of necrotic tissue: necrotic tissue residual rate = necrotic tissue area/ cross-sectional area. Results All animals survived, and no POPF developed. For two animals in which arterial blood flow to the stump was maintained, necrotic tissue residual rates at the ligation line were 24% and 31%. At the pancreatic stump, necrotic tissue residual rates were 37% and 50%. In the animal in which arterial blood flow to the stump was occluded, the necrotic tissue residual rate at the ligation line was 83% and that at the pancreatic stump was 78%, both higher than that in animals in which arterial blood flow was maintained. In all animals, there was no injury to pancreatic tissue at the ligation line. Conclusion The pancreas ligation band can potentially prevent POPF after distal pancreatectomy by atraumatic ligation, and the band ligates the pancreatic stump while maintaining arterial blood flow and limiting pancreatic necrosis.
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Affiliation(s)
- Yuji Kaneda
- Department of Surgery, Jichi Medical University, Shimotsuke, JPN.,Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Yuki Kimura
- Department of Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Akira Saito
- Department of Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Hideyuki Ohzawa
- Department of Clinical Oncology, Jichi Medical University, Shimotsuke, JPN
| | - Ryusuke Ae
- Division of Public Health, Jichi Medical University, Shimotsuke, JPN
| | - Hiroshi Kawahira
- Department of Surgery, Jichi Medical University, Shimotsuke, JPN.,Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Alan K Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, JPN
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Kobayashi E, Tsuchiya S, Akagi Y, Tomii N, Nakagawa K, Inai K, Muragaki Y, Asano T, Kim D. A novel reaction force-fluorescence measurement system for evaluating pancreatic juice leakage from an excised swine pancreas during distal pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:877-886. [PMID: 32510850 DOI: 10.1002/jhbp.775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Resection using a stapler is a popular approach to distal pancreatectomy. However, the resulting leakage of pancreatic juice represents a serious problem. We have developed a force-fluorescence measurement as a first step towards the quantitative evaluation of pancreatic leakage due to tissue tearing under compression. METHODS The system comprises a testing machine with an indenter, similar in size to a stapler, which controls compression speed and measures reaction force, and a fluorescence measurement system to measure pancreatic juice leakage. Pancreatic juice leakage is measured as the maximum value of the increasing rate of fluorescence intensity (max value). Ten excised swine pancreases were compressed at a speed of 500, 100, and 10 mm/min until their thicknesses became 2 mm. RESULTS A strong positive correlation (0.804) was observed between the increase in max value before and after compression and the amount of reaction force drop due to tissue destruction. No pancreatic juice leakage was observed when compressed slowly (10 mm/min). CONCLUSIONS We have successfully developed a novel force-fluorescence measurement system that can detect and quantify pancreatic juice leakage caused by tissue tearing. This system can determine the optimal compression conditions for preventing pancreatic juice leakage.
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Affiliation(s)
- Etsuko Kobayashi
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Shinjuku-ku, Japan
| | - Shuto Tsuchiya
- School of Engineering, the University of Tokyo, Bunkyo-ku, Japan
| | - Yuki Akagi
- School of Engineering, the University of Tokyo, Bunkyo-ku, Japan
| | - Naoki Tomii
- School of Medicine, the University of Tokyo, Bunkyo-ku, Japan
| | - Keiichi Nakagawa
- School of Engineering, the University of Tokyo, Bunkyo-ku, Japan
| | - Kunihiro Inai
- School of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yoshihiro Muragaki
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Shinjuku-ku, Japan
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Miao Y, Lu Z, Yeo CJ, Vollmer CM, Fernandez-Del Castillo C, Ghaneh P, Halloran CM, Kleeff J, de Rooij T, Werner J, Falconi M, Friess H, Zeh HJ, Izbicki JR, He J, Laukkarinen J, Dejong CH, Lillemoe KD, Conlon K, Takaori K, Gianotti L, Besselink MG, Del Chiaro M, Montorsi M, Tanaka M, Bockhorn M, Adham M, Oláh A, Salvia R, Shrikhande SV, Hackert T, Shimosegawa T, Zureikat AH, Ceyhan GO, Peng Y, Wang G, Huang X, Dervenis C, Bassi C, Neoptolemos JP, Büchler MW. Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2020; 168:72-84. [PMID: 32249092 DOI: 10.1016/j.surg.2020.02.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.
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Affiliation(s)
- Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China.
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jörg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jin He
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Keith D Lillemoe
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marco Montorsi
- Humanitas University and Research Hospital IRCCS, Milan, Italy
| | - Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, HCL, UCBL1, Lyon, France
| | | | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Güralp O Ceyhan
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Yunpeng Peng
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Guangfu Wang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Xumin Huang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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8
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An outcome analysis of predictive factors for portal or splenic vein thrombosis after distal pancreatectomy. Surg Today 2020; 50:1282-1289. [PMID: 32346760 DOI: 10.1007/s00595-020-02004-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/05/2020] [Indexed: 02/07/2023]
Abstract
PURPOSES The aim of this study was to explore predictive factors for portal or splenic vein thrombosis (VT) that might cause serious problems after distal pancreatectomy (DP). METHODS A total of 230 patients who underwent DP between 2008 and 2017 were retrospectively reviewed to identify predictive factors for portal or splenic VT. RESULTS Ultimately, 164 patients were analyzed. Portal or splenic VT was significantly correlated with age < 65 years old, benign tumor, laparoscopic surgery, preservation of the inferior mesenteric vein (IMV) and left gastric vein (LGV), preservation of the IMV only, no drainage vein, length of the residual splenic vein (RSV) ≥ 26 mm, vessel dissection with a linear stapler, and intra-abdominal abscess (all P < 0.05). Furthermore, a multivariate analysis indicated that the length of the RSV (odds ratio [OR]: 9.15, P = 0.03) was an independent predictive factor for portal VT and that the length of the RSV (OR: 37.9, P < 0.01), vessel dissection with a linear stapler (OR: 6.49, P = 0.03), and intra-abdominal abscess (OR: 23.0, P = 0.02) were independent predictive factors for splenic VT. CONCLUSION As the length of the RSV was significantly associated with portal or splenic VT, a follow-up imaging diagnosis might be recommended for such cases.
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9
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Jiang L, Ning D, Chen X. Prevention and treatment of pancreatic fistula after pancreatic body and tail resection: current status and future directions. Front Med 2019; 14:251-261. [PMID: 31840199 DOI: 10.1007/s11684-019-0727-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/12/2019] [Indexed: 02/08/2023]
Abstract
Postoperative pancreatic fistula (POPF) is the most common and critical complication after pancreatic body and tail resection. How to effectively reduce the occurrence of pancreatic fistula and conduct timely treatment thereafter is an urgent clinical issue to be solved. Recent research standardized the definition of pancreatic fistula and stressed the correlation between POPF classification and patient prognosis. According to the literature, identification of the risk factors for pancreatic fistula contributed to lowering the rate of the complication. Appropriate management of the pancreatic stump and perioperative treatment are of great significance to reduce the rate of POPF in clinical practice. After the occurrence of POPF, the treatment of choice should be determined according to the classification of the pancreatic fistula. However, despite the progress and promising treatment approaches, POPF remains to be a clinical issue that warrants further studies in the future.
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Affiliation(s)
- Li Jiang
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Deng Ning
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaoping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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10
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Machado MC, Machado MAC. Drainage after distal pancreatectomy: Still an unsolved problem. Surg Oncol 2019; 30:76-80. [DOI: 10.1016/j.suronc.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/10/2019] [Accepted: 06/04/2019] [Indexed: 02/07/2023]
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11
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Kondo N, Uemura K, Nakagawa N, Okada K, Kuroda S, Sudo T, Hadano N, Matstukawa H, Satoh D, Sasaki M, Abe T, Fukuda S, Oshita A, Nakashima A, Hashimoto Y, Ohdan H, Murakami Y. A Multicenter, Randomized, Controlled Trial Comparing Reinforced Staplers with Bare Staplers During Distal Pancreatectomy (HiSCO-07 Trial). Ann Surg Oncol 2019; 26:1519-1527. [PMID: 30783854 DOI: 10.1245/s10434-019-07222-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although distal pancreatectomy (DP) using a reinforced stapler is expected to reduce PF, no multicenter RCT has been performed. To investigate whether reinforced staplers reduce the incidence of clinically relevant pancreatic fistula (PF) after DP compared with staplers without reinforcement. METHODS Between July 2016 and December 2017, patients scheduled for DP were enrolled in a multicenter, randomized, controlled trial (RCT) at nine hospitals in Hiroshima Japan. Patients were randomized either to reinforced stapler or bare stapler. The primary endpoint was incidence of clinically relevant PF. This RCT was registered with UMIN Clinical Trial Registry (UMIN000022341). RESULTS A total of 122 patients were assigned to reinforced stapler (n = 61) or bare stapler (n = 61), and 119 patients (61 reinforced stapler and 59 bare stapler) were analyzed. There was no significant difference in the incidence of clinically relevant PF between the reinforced stapler and bare stapler groups (16.3% vs. 27.1%, p = 0.15). Furthermore, the rates of major complication (16.3% vs. 18.6%, p = 0.74), postpancreatectomy hemorrhage (0% vs. 3.4%, p = 0.08), and median postoperative in-hospital days (19 days vs. 20 days, p = 0.78) did not differ between the two groups. Within a subset of 82 patients in whom the thickness of pancreatic transection line was less than 14 mm, a significant difference was found in the incidence of clinically relevant PF (4.5% vs. 21.0% in the reinforced stapler vs. bare stapler groups, respectively, p = 0.01). CONCLUSIONS Reinforced stapler for pancreatic transection during DP does not reduce the incidence of clinically relevant PF compared to stapler without reinforcement.
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Affiliation(s)
- Naru Kondo
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Kenichiro Uemura
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Naoya Nakagawa
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Kenjiro Okada
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Takeshi Sudo
- Department of Surgery, Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Naoto Hadano
- Department of Surgery, Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Hiroyoshi Matstukawa
- Department of Gastroenterological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Daisuke Satoh
- Department of Gastroenterological Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Masaru Sasaki
- Department of Surgery, Hiroshima General Hospital, Hatsukaichi, Japan
| | - Tomoyuki Abe
- Department of Surgery, Onomichi General Hospital, Onomichi, Japan
| | - Saburo Fukuda
- Department of Surgery, Chugoku Rosai Hospital, Kure, Japan
| | - Akihiko Oshita
- Department of Gastroenterological Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Akira Nakashima
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Yasushi Hashimoto
- Department of Surgery, Hiroshima Memorial Hospital, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yoshiaki Murakami
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.
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12
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Dokmak S, Ftériche FS, Meniconi RL, Aussilhou B, Duquesne I, Perrone G, Romdhani C, Belghiti J, Lévy P, Soubrane O, Sauvanet A. Pancreatic fistula following laparoscopic distal pancreatectomy is probably unrelated to the stapler size but to the drainage modality and significantly decreased with a small suction drain. Langenbecks Arch Surg 2019; 404:203-212. [DOI: 10.1007/s00423-019-01756-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 01/21/2019] [Indexed: 01/02/2023]
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13
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Dumitrascu T, Eftimie M, Aiordachioae A, Stroescu C, Dima S, Ionescu M, Popescu I. Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy. World J Gastrointest Surg 2018; 10:84-89. [PMID: 30510633 PMCID: PMC6259023 DOI: 10.4240/wjgs.v10.i8.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/24/2018] [Accepted: 11/04/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy (SPDP). No previous studies explored potential predictors of morbidity after SPDP. METHODS The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni- and multivariate analyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo. RESULTS Overall morbidity rate was 34.1% (14 patients): grade I (6 patients, 14.6%), grade II (2 patients, 4.8%), grade IIIa (1 patient, 2.4%), and grade IIIb (5 patients, 12.2%). A number of 5 patients (12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients (19.5%). Univariate analysis identified male gender (P = 0.034), increased body mass index (P = 0.002) and neuroendocrine pathology (P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio (OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index (OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP. CONCLUSION Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.
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Affiliation(s)
- Traian Dumitrascu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihai Eftimie
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Andra Aiordachioae
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Cezar Stroescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Simona Dima
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihnea Ionescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Irinel Popescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
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14
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Vass DG, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts K, Sutcliffe RP. Utility of drain fluid amylase measurement on the first postoperative day after distal pancreatectomy. HPB (Oxford) 2018; 20:803-808. [PMID: 29802050 DOI: 10.1016/j.hpb.2017.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 06/29/2017] [Accepted: 08/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early exclusion of a postoperative pancreatic fistula (POPF) may facilitate earlier drain removal in selected patients after distal pancreatectomy. The purpose of this study was to evaluate the role of first postoperative day drain fluid amylase (DFA1) measurement to predict POPF. METHODS Patients in whom DFA1 was measured after distal pancreatectomy were identified from a prospectively maintained database over a five-year period. A cut-off value of DFA1 was derived using ROC analysis, which yielded sensitivity and negative predictive value of 100% for excluding POPF. RESULTS DFA1 was available in 53 of 138 (38%) patients who underwent distal pancreatectomy. 19 of 53 patients (36%) developed a pancreatic fistula (Grade A - 15, Grade B - 3, Grade C - 1). Median DFA1 was significantly higher in those who developed a pancreatic fistula (5473; range 613-28,450) compared those without (802; range 57-2350). p < 0.0001. Using ROC analysis, a DFA1 less than 600 excluded pancreatic fistula with a sensitivity of 100% (AUROC of 0.91; SE = 0.04, p < 0.001). CONCLUSION First postoperative day drain fluid amylase measurement may have a role in excluding pancreatic fistula after distal pancreatectomy. Such patients may be suitable for earlier drain removal.
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Affiliation(s)
- David G Vass
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK.
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, UK
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
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Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience. PLoS One 2018; 13:e0197553. [PMID: 29897920 PMCID: PMC5999073 DOI: 10.1371/journal.pone.0197553] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 05/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP. Methods We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques. Results 8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02). Conclusion After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.
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16
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Randomized Controlled Trial of Pancreaticojejunostomy versus Stapler Closure of the Pancreatic Stump During Distal Pancreatectomy to Reduce Pancreatic Fistula. Ann Surg 2017; 264:180-7. [PMID: 26473652 PMCID: PMC4902322 DOI: 10.1097/sla.0000000000001395] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives: The aim of this study was to evaluate in a multicenter randomized controlled trial (RCT) whether pancreaticojejunostomy (PJ) of pancreatic stump decreases the incidence of pancreatic fistula after distal pancreatectomy (DP) compared with stapler closure. Background: Several studies reported that PJ of pancreatic stump reduces the incidence of pancreatic fistula after DP. However, no RCT has confirmed the efficacy of PJ of pancreatic stump. Methods: One hundred thirty-six patients scheduled for DP were enrolled in this study between June 2011 and March 2014 at 6 high-volume surgical centers in Japan. Enrolled patients were randomized to either stapler closure or PJ. The primary endpoint was the incidence of pancreatic fistula based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01384617). Results: Sixty-one patients randomized to stapler and 62 patients randomized to PJ were analyzed by intention-to-treat. Pancreatic fistula occurred in 23 patients (37.7%) in the stapler closure group and 24 (38.7%) in the PJ group (P = 0.332) in intention-to-treat analysis. The incidence of clinically relevant pancreatic fistula (grade B or C) was 16.4% for stapler closure and 9.7% for PJ (P = 0.201). Mortality was zero in both groups. In a subgroup analysis for thickness of pancreas greater than 12 mm, the incidence of clinically relevant pancreatic fistula occurred in 22.2% of the patients in the stapler closure group and in 6.2% of the PJ group (P = 0.080). Conclusions: PJ of the pancreatic stump during DP does not reduce pancreatic fistula compared with stapler closure.
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17
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Bovine Serum Albumin-Glutaraldehyde Sealed Fish-Mouth Closure of the Pancreatic Remnant during Distal Pancreatectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2017; 2017:9747421. [PMID: 28194043 PMCID: PMC5282416 DOI: 10.1155/2017/9747421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/28/2016] [Indexed: 12/11/2022]
Abstract
Introduction. Postoperative pancreatic fistula formation remains the major complication after distal pancreatectomy. At our institution, we have recently developed a novel bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure technique of the pancreatic remnant during distal pancreatectomy. The aim of this study was to analyze the impact of this approach with regard to technical feasibility and overall postoperative outcome. Patients and Methods. 32 patients who underwent a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant during distal pancreatectomy between 2012 and 2014 at our institution were analyzed for clinically relevant postoperative pancreatic fistula formation (Grades B and C according to ISGPF definition) and overall postoperative morbidity. Results. Three out of 32 patients (9.4%) developed Grade B pancreatic fistula, which could be treated conservatively. No Grade C pancreatic fistulas were observed. Postpancreatectomy hemorrhage occurred in 1 patient (3.1%). Overall postoperative complications > Clavien II were observed in 5 patients (15.6%). There was no postoperative mortality. Conclusion. The performance of a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant was shown to be technically feasible and may lead to a significant decrease of postoperative pancreatic fistula formation after distal pancreatectomy.
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18
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Peck GL, Blitzer DN, Bulauitan CS, Huntress LA, Truche P, Feliciano DV, Dente CJ. Outcomes after Distal Pancreatectomy for Trauma in the Modern Era. Am Surg 2016. [DOI: 10.1177/000313481608200614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple stump closure techniques after distal pancreatectomy (DP) for trauma have been described, and all are associated with a significant fistula rate. With increasing emphasis on abbreviated laparotomy, stapled pancreatectomy has become more common. This study describes the outcomes of patients with different closure techniques of the pancreatic stump after resection following pancreatic trauma. Retrospective analysis of 50 trauma patients, who sustained grade III pancreatic injuries with subsequent DP and stapled stump closure, were conducted from 1995 to 2011. Demographic, operative, and outcome data were analyzed to characterize patients, and to directly compare closure techniques. After 12 patients were excluded because of early death (<72 hours), final analyses included 38 patients: 19 (50%) had stapled closure alone and 19 (50%) had stapling with adjunct, including additional closure with sutures, fibrin sealants, or a combination of sutures with fibrin sealants/omental coverage. Twenty-four patients (63%) had postoperative complications, most commonly pancreatic fistula (n = 11, 29%). There were no significant differences with regard to pancreatic fistula or other abdominal complications between closure groups, or were any factors associated with increased likelihood of complications. DP remains a morbid operation after trauma regardless of closure technique. Stapled closure alone is perhaps the method of choice in this setting due to the time constraints directly related to outcomes.
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Affiliation(s)
- Gregory L. Peck
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | | | | | - Paul Truche
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey
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Kollár D, Huszár T, Pohárnok Z, Cselovszky É, Oláh A. A Review of Techniques for Closure of the Pancreatic Remnant following Distal Pancreatectomy. Dig Surg 2016; 33:320-8. [PMID: 27215609 DOI: 10.1159/000445017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The prevalence of pancreatic diseases needing surgical intervention is continuously rising. Distal pancreatectomy is performed in the case of pathologies affecting the left side of the pancreas. More and more sophisticated surgical techniques have appeared and an increasing number of published articles discuss the possibilities for closure of the pancreatic remnant. However, the optimum solution is still under debate, as none of the examined techniques have been proven superior in reducing the incidence of the most common surgical complication, the formation of a postoperative pancreatic fistula (PF). Fistula rates have been stationary at 20-30% in the past decades despite the apparent advancement of medicine. This review presents a survey of the relevant articles examining different closure strategies and risk factors to reduce fistula formation rate. International medical publication database search and assessment was carried out to include the findings of studies investigating the efficacy of pancreatic remnant closure techniques to gain a clearer view on the complexity of pancreas fistulas. Emphasis is on indications for surgery, risk factors for postoperative fistula formation and strategies to seal the pancreatic remnant to avoid leakage. Findings suggest that careful patient selection, meticulous surgical techniques are equally important to reduce fistula rates. Ideal closure of the pancreatic remnant is still to be developed, as none of the widespread techniques (hand-sewn suture or staple closure) proved to be statistically significantly superior. Additional closure and covering methods (seromuscular patch, falciform ligament patch, pancreatico-enteric anastomosis, reinforced staplers, fibrin glue etc.) can have profitable effect but strong evidences are yet to come due to small case numbers. The recent introduction of standardized classification of PFs and future prospective randomized trials are more likely to be susceptible to determine if any of the standard or experimental closure techniques is more beneficial than the others.
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Affiliation(s)
- Dániel Kollár
- Department of Surgery, Petz Aladx00E1;r Teaching Hospital, Gyx0151;r, Hungary
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20
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Preoperative computed tomography scan to predict pancreatic fistula after distal pancreatectomy using gland and tumor characteristics. Am J Surg 2016; 211:871-6. [DOI: 10.1016/j.amjsurg.2016.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 01/15/2023]
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21
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Fujii T, Yamada S, Murotani K, Sugimoto H, Hattori M, Kanda M, Takami H, Nakayama G, Nomoto S, Fujiwara M, Nakao A, Kodera Y. Modified Blumgart Suturing Technique for Remnant Closure After Distal Pancreatectomy: a Propensity Score-Matched Analysis. J Gastrointest Surg 2016; 20:374-84. [PMID: 26497190 DOI: 10.1007/s11605-015-2980-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 10/07/2015] [Indexed: 01/31/2023]
Abstract
Despite recent advances in surgical techniques including staple closure and ultrasonic devices, the reported incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Therefore, we devised a new strategy in which the pancreatic stump is enveloped with the elevated jejunum (EJ) by a modified Blumgart anastomotic technique. Eighty-one patients who underwent open DP with splenectomy from January 2008 to December 2014 were enrolled. Comparisons were made between 42 patients who underwent placement of an EJ patch using the modified Blumgart method after scalpel transection and 39 patients who underwent scalpel transection alone, using unmatched and propensity score-matched analysis. After 25 patients from each group were selected by propensity score matching, the EJ patch technique was significantly associated with a lower incidence of clinically relevant POPF (P = 0.036). Multivariate analysis showed that the EJ patch was an independent predictor of a lower incidence of POPF (odds ratio, 0.16; 95 % confidence interval, 0.01–0.48; P = 0.017) as was the estimated remnant pancreatic volume. Addition of the EJ patch improves postoperative outcomes in patients who undergo open DP with splenectomy by scalpel transection and hand-sewn closure of the pancreatic remnant.
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22
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Fujii T, Yamada S, Murotani K, Okamura Y, Ishigure K, Kanda M, Takeda S, Morita S, Nakao A, Kodera Y. Oral Food Intake Versus Fasting on Postoperative Pancreatic Fistula After Distal Pancreatectomy: A Multi-Institutional Randomized Controlled Trial. Medicine (Baltimore) 2015; 94:e2398. [PMID: 26717392 PMCID: PMC5291633 DOI: 10.1097/md.0000000000002398] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The usefulness of enteral nutrition via a nasointestinal tube for patients who develop postoperative pancreatic fistula (POPF) after miscellaneous pancreatectomy procedures has been reported. However, no clear evidence regarding whether oral intake is beneficial or harmful during management of POPF after distal pancreatectomy (DP) is currently available.To investigate the effects of oral food intake on the healing process of POPF after DP.Multi-institutional randomized controlled trial in Nagoya University Hospital and 4 affiliated hospitals.Patients who developed POPF were randomly assigned to the dietary intake (DI) group (n = 15) or the fasted group (no dietary intake [NDI] group) (n = 15). The primary endpoint was the length of drain placement.No significant differences were found in the length of drain placement between the DI and NDI groups (12 [6-58] and 12 [7-112] days, respectively; P = 0.786). POPF progressed to a clinically relevant status (grade B/C) in 5 patients in the DI group and 4 patients in the NDI group (P = 0.690). POPF-related intra-abdominal hemorrhage was found in 1 patient in the NDI group but in no patients in the DI group (P = 0.309). There were no significant differences in POPF-related intra-abdominal hemorrhage, the incidence of other complications, or the length of the postoperative hospital stay between the 2 groups.Food intake did not aggravate POPF and did not prolong drain placement or hospital stay after DP. There may be no need to avoid oral DI in patients with POPF.
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Affiliation(s)
- Tsutomu Fujii
- From the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan (TF, SY, YO, MK, AN, YK); Center for Clinical Research, Aichi Medical University, Nagakute, Japan (KM); Department of Surgery, Konan Kosei Hospital, Konan, Japan (KI); Department of Surgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (ST); Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan (SM); and Department of Surgery, Nagoya Central Hospital, Nagoya, Japan (AN)
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Probst P, Hüttner FJ, Klaiber U, Knebel P, Ulrich A, Büchler MW, Diener MK, Cochrane Upper GI and Pancreatic Diseases Group. Stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy. Cochrane Database Syst Rev 2015; 2015:CD008688. [PMID: 26544925 PMCID: PMC11131144 DOI: 10.1002/14651858.cd008688.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Resections of the pancreatic body and tail reaching to the left of the superior mesenteric vein are defined as distal pancreatectomy. Most distal pancreatectomies are elective treatments for chronic pancreatitis, benign or malignant diseases, and they have high morbidity rates of up to 40%. Pancreatic fistula formation is the main source of postoperative morbidity, associated with numerous further complications. Researchers have proposed several surgical resection and closure techniques of the pancreatic remnant in an attempt to reduce these complications. The two most common techniques are scalpel resection followed by hand-sewn closure of the pancreatic remnant and stapler resection and closure. OBJECTIVES To compare the rates of pancreatic fistula in people undergoing distal pancreatectomy using scalpel resection followed by hand-sewn closure of the pancreatic remnant versus stapler resection and closure. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Biosis and Science Citation Index from database inception to October 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for inclusion and extracted the data. Taking into consideration the clinical heterogeneity between the trials (e.g. different endpoint definitions), we analysed data using a random-effects model with Review Manager (RevMan), calculating risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS In two eligible trials, a total of 381 participants underwent distal pancreatic resection and were randomised to closure of the pancreatic remnant either with stapler (n = 191) or scalpel resection followed by hand-sewn closure (n = 190). One was a single centre pilot RCT and the other was a multicentre blinded RCT. The single centre pilot RCT evaluated 69 participants in five intervention arms (stapler, hand-sewn, fibrin glue, mesh and pancreaticojejunostomy), although we only assessed the stapler and hand-sewn closure groups (14 and 15 participants, respectively). The multicentre RCT had two interventional arms: stapler (n = 177) and hand-sewn closure (n = 175). The rate of postoperative pancreatic fistula was the main outcome, and it occurred in 79 of 190 participants in the hand-sewn group compared to 65 of 191 participants in the stapler group. Neither the individual trials nor the meta-analysis showed a significant difference between resection techniques (RR 0.90; 95% CI 0.55 to 1.45; P = 0.66). In the same way, postoperative mortality and operation time did not differ significantly. The single centre RCT had an unclear risk of bias in the randomisation, allocation and both blinding domains. However, the much larger multicentre RCT had a low risk of bias in all domains. Due to the small number of events and the wide confidence intervals that cannot exclude clinically important benefit or harm with stapler versus hand-sewn closure, there is a serious possibility of imprecision, making the overall quality of evidence moderate. AUTHORS' CONCLUSIONS The quality of evidence is moderate and mainly based on the high weight of the results of one multicentre RCT. Unfortunately, there are no other completed RCTs on this topic except for one relevant ongoing trial. Neither stapler nor scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy showed any benefit compared to the other method in terms of postoperative pancreatic fistula, overall postoperative mortality or operation time. Currently, the choice of closure is left up to the preference of the individual surgeon and the anatomical characteristics of the patient. Another (non-European) multicentre trial (e.g. with an equality or non-inferiority design) would help to corroborate the findings of this meta-analysis. Future trials assessing novel methods of stump closure should compare them either with stapler or hand-sewn closure as a control group to ensure comparability of results.
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Affiliation(s)
- Pascal Probst
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Felix J Hüttner
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Ulla Klaiber
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Phillip Knebel
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Alexis Ulrich
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Markus W Büchler
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Markus K Diener
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
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Ariyarathenam AV, Bunting D, Aroori S. Laparoscopic Distal Pancreatectomy Using the Modified Prolonged Prefiring Compression Technique Reduces Pancreatic Fistula. J Laparoendosc Adv Surg Tech A 2015; 25:821-5. [DOI: 10.1089/lap.2015.0200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Arun V. Ariyarathenam
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
| | - David Bunting
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
| | - Somaiah Aroori
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
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25
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Mita K, Ito H, Murabayashi R, Asakawa H, Nabetani M, Kamasako A, Koizumi K, Hayashi T. Use of a Fibrinogen/Thrombin-Based Collagen Fleece (TachoComb, TachoSil) With a Stapled Closure to Prevent Pancreatic Fistula Formation Following Distal Pancreatectomy. Surg Innov 2015; 22:601-5. [DOI: 10.1177/1553350615580649] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background/Purpose. Postoperative pancreatic fistula formation remains a source of significant morbidity following distal pancreatectomy. The aim of this study was to evaluate the rate of clinically significant fistulas (International Study Group on Pancreatic Fistula grade B and grade C) after distal pancreatectomy using a fibrinogen/thrombin-based collagen fleece (TachoComb, TachoSil) with a stapled closure. Methods. Seventy-five patients underwent distal pancreatectomy at our institution between January 2005 and March 2014. A fibrinogen/thrombin-based collagen fleece was applied to the staple line of the pancreas before stapling. Results. Twenty-six patients (34.7%) developed a pancreatic fistula, 8 patients (10.7%) developed a grade B fistula, and no patients developed a grade C fistula. The duration of the drain was significantly different in patients with or without a pancreatic fistula (8.0 ± 4.5 vs 5.4 ± 1.3 days, P = .0003). Histological analysis showed that there was a tight covering with the fibrinogen/thrombin-based collagen fleece. Conclusion. The fibrinogen/thrombin-based collagen fleece (TachoComb, TachoSil) with a stapled closure has low rates of fistula formation and provides a safe alternative to the conventional stapled technique in distal pancreatectomy.
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26
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Hand-assisted laparoscopic total gastrectomy with regional lymph node dissection for advanced gastric cancer. Surg Laparosc Endosc Percutan Tech 2015; 24:e78-84. [PMID: 24710226 DOI: 10.1097/sle.0b013e31828fa6fd] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Laparoscopic-assisted distal gastrectomy has been applied to the treatment of gastric cancer. However, there have been few reports on the laparoscopic-assisted total gastrectomy for advanced gastric cancer, mainly because of the difficulty of the procedure. METHODS Here, we report a series of cases where the hand-assisted laparoscopic total gastrectomies with regional lymph node dissection were performed successfully. RESULTS The average operative time was 245 minutes. The mean blood loss was 110 mL. The number of dissected lymph nodes per patient was beyond 15 nodes satisfying a reliable evaluation of nodal status. All resection specimens had no residual tumor at the proximal or distal resection margins. The mean oral feeding was 3.6 days. The mean postoperative length of stay was 8.7 days. CONCLUSIONS The hand-assisted laparoscopic D2 total gastrectomy for advanced gastric cancer is both technically feasible and safe.
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27
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Doud AN, Randle RW, Clark CJ, Levine EA, Swett KR, Shen P, Stewart JH, Votanopoulos KI. Impact of distal pancreatectomy on outcomes of peritoneal surface disease treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 2014; 22:1645-50. [PMID: 25120249 DOI: 10.1245/s10434-014-3976-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Left upper quadrant involvement by peritoneal surface disease (PSD) may require distal pancreatectomy (DP) to obtain complete cytoreduction. Herein, we study the impact of DP on outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). METHODS Analysis of a prospective database of 1,019 procedures was performed. Malignancy type, performance status, resection status, comorbidities, Clavien-graded morbidity, mortality, and overall survival were reviewed. RESULTS DP was a component of 63 CRS/HIPEC procedures, of which 63.3 % had an appendiceal primary. While 30-day mortality between patients with and without DP was no different (2.6 vs. 3.2 %; p = 0.790), 30-day major morbidity was worse in patients receiving a DP (30.2 vs. 18.8 %; p = 0.031). Pancreatic leak rate was 20.6 %. Intensive care unit days and length of stay were longer in DP versus non-DP patients (4.6 vs. 3.5 days, p = 0.007; and 22 vs. 14 days, p < 0.001, respectively). Thirty-day readmission was similar for patients with and without DP (29.2 vs. 21.1 %; p = 0.205). Median survival for low-grade appendiceal cancer (LGA) patients requiring DP was 106.9 months versus 84.3 months when DP was not required (p = 0.864). All seven LGA patients undergoing complete cytoreduction inclusive of DP were alive at the conclusion of the study (median follow-up 11.8 years). CONCLUSIONS CRS/HIPEC including DP is associated with a significant increase in postoperative morbidity but not mortality. Survival was similar for patients with LGA whether or not DP was performed. Thus, the need for a DP should not be considered a contraindication for CRS/HIPEC procedures in LGA patients when complete cytoreduction can be achieved.
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Affiliation(s)
- Andrea N Doud
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, USA
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Čečka F, Jon B, Šubrt Z, Ferko A. Surgical technique in distal pancreatectomy: a systematic review of randomized trials. BIOMED RESEARCH INTERNATIONAL 2014; 2014:482906. [PMID: 24971333 PMCID: PMC4058114 DOI: 10.1155/2014/482906] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/07/2014] [Accepted: 05/11/2014] [Indexed: 12/13/2022]
Abstract
Despite recent improvements in surgical technique, the morbidity of distal pancreatectomy remains high, with pancreatic fistula being the most significant postoperative complication. A systematic review of randomized controlled trials (RCTs) dealing with surgical techniques in distal pancreatectomy was carried out to summarize up-to-date knowledge on this topic. The Cochrane Central Registry of Controlled Trials, Embase, Web of Science, and Pubmed were searched for relevant articles published from 1990 to December 2013. Ten RCTs were identified and included in the systematic review, with a total of 1286 patients being randomized (samples ranging from 41 to 450). The reviewers were in agreement for application of the eligibility criteria for study selection. It was not possible to carry out meta-analysis of these studies because of the heterogeneity of surgical techniques and approaches, such as varying methods of pancreas transection, reinforcement of the stump with seromuscular patch or pancreaticoenteric anastomosis, sealing with fibrin sealants and pancreatic stent placement. Management of the pancreatic remnant after distal pancreatectomy is still a matter of debate. The results of this systematic review are possibly biased by methodological problems in some of the included studies. New well designed and carefully conducted RCTs must be performed to establish the optimal strategy for pancreatic remnant management after distal pancreatectomy.
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Affiliation(s)
- Filip Čečka
- Department of Surgery, Faculty of Medicine and University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic
| | - Bohumil Jon
- Department of Surgery, Faculty of Medicine and University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic
| | - Zdeněk Šubrt
- Department of Surgery, Faculty of Medicine and University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic
- Department of Field Surgery, Military Health Science Faculty Hradec Králové, Defence University Brno, Třebešská 1575, 500 01 Hradec Králové, Czech Republic
| | - Alexander Ferko
- Department of Surgery, Faculty of Medicine and University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic
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Sato N, Mori Y, Minagawa N, Tamura T, Shibao K, Higure A, Yamaguchi K. Rapid postoperative reduction in prognostic nutrition index is associated with the development of pancreatic fistula following distal pancreatectomy. Pancreatology 2014; 14:216-20. [PMID: 24854618 DOI: 10.1016/j.pan.2014.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 02/17/2014] [Accepted: 02/19/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUNDS Despite recent advances in surgical techniques and devices for pancreatic remnant closure, postoperative pancreatic fistula (POPF) still remains one of the common complications after distal pancreatectomy (DP). Identification of risk factors for POPF may lead to the development of new strategies to prevent this ominous complication. METHODS We retrospectively reviewed data on 44 patients undergoing DP with the use of a stapler to identify risk factors for POPF. Study variables included preoperative prognostic nutritional index (PNI) and reduction rate of PNI on postoperative day (POD) 7. RESULTS POPF occurred in 23 patients (52%), of which 13 (56%) were grade B or C. Univariate analyses comparing patients with POPF and those without POPF showed significant differences in body mass index (P = 0.0102), pancreatic thickness (P = 0.0134), white blood cell count on POD7 (P = 0.0432), C-reactive protein level on POD7 (P = 0.0123), and PNI reduction rate (P = 0.0471). A multivariate analysis revealed pancreatic thickness (P = 0.0121) and PNI reduction rate (P = 0.0165) to be significant factors for POPF. Furthermore, the PNI reduction rate was significantly higher in patients with clinically relevant (grade B/C) POPF than in those with no or grade A POPF (P = 0.0257). In most patients, the massive postoperative PNI reduction preceded the diagnosis of clinically relevant POPF. CONCLUSIONS These findings suggest that rapid postoperative reduction in PNI is associated with the development of POPF.
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Affiliation(s)
- Norihiro Sato
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Yasuhisa Mori
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Noritaka Minagawa
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshihisa Tamura
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazunori Shibao
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Aiichiro Higure
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Koji Yamaguchi
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
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Yui R, Satoi S, Toyokawa H, Yanagimoto H, Yamamoto T, Hirooka S, Yamaki S, Ryota H, Michiura T, Inoue K, Matsui Y, Kwon AH. Less morbidity after introduction of a new departmental policy for patients who undergo open distal pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:72-7. [PMID: 23804436 DOI: 10.1002/jhbp.4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this study was to retrospectively compare morbidity and mortality before and after introduction of a new departmental policy for patients who undergo distal pancreatectomy. METHODS We have introduced the use of an ultrasonically-activated device in distal pancreatectomy, an "early removal of drains" policy and perioperative management using a clinical pathway since May 2006. Group A consisted of 52 consecutive patients from 2000 to February 2006. Group B consisted of 57 consecutive patients from May 2006 to 2010. RESULTS Although there was no difference in the fluid collection rate within 30 postoperative days (Group A, 44% vs. Group B, 35%), the rates of intra-abdominal abscess (A, 19% vs. B, 4%) and grade 3/4 of the Clavien classification (A, 23% vs. B, 9%) in Group B were significantly lower than in Group A (P < 0.05). Time of drain removal (median 3 days vs. 8 days) and length of in-hospital stay (median 8 days vs. 17 days) in Group B were significantly shorter than in Group A (P < 0.001). CONCLUSION The implementation of new departmental guidelines for distal pancreatectomy was closely associated with a low frequency of intra-abdominal abscess and grade 3/4 Clavien score, resulting in a shorter in-hospital stay.
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Affiliation(s)
- Rintaro Yui
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
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Ceylan C, Odabaş Ö, Doğan S, Yığman M. Recurrent pancreatic fistula occurring after nephrectomy in patients with a renal hydatid cyst: a case report. Turk J Urol 2013; 39:64-7. [PMID: 26328082 DOI: 10.5152/tud.2013.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Accepted: 01/19/2012] [Indexed: 11/22/2022]
Abstract
Pancreatic fistula (PF) is an important complication that may develop during intra-abdominal surgeries and following distal pancreas trauma. In the early period, drainage from the surgical site and increased amylase production based on the biochemical examination of the drainage fluid are the factors for diagnosis. In contrast, in association with fluid collected from the surgical site, intra-abdominal abscess and high fever may lead to the diagnosis in the late period. Endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of intra-abdominal fluid collection after PF and intra-abdominal percutaneous stent placement as well as the placement of a pancreatic stent in the pancreatic channel may be alternative methods to stop drainage. However, the complete resolution of fluid drainage may take months. In our case, drainage from the pancreatic fistula area took longer to resolve than the periods previously reported in the English literature. The tail of the pancreas can be injured during the extraction of especially aggressive and metastatic masses from organs near to the distal pancreas. Injury to the tail of the pancreas can also occur during the extraction of benign-like renal hydatid cysts and/or malignant left kidney masses. However, PF can be treated with noninvasive methods, such as percutaneous treatment and ERCP.
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Affiliation(s)
- Cavit Ceylan
- 3 Clinic of Urology, Türkiye Yüksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Öner Odabaş
- 3 Clinic of Urology, Türkiye Yüksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Serkan Doğan
- 3 Clinic of Urology, Türkiye Yüksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Metin Yığman
- 3 Clinic of Urology, Türkiye Yüksek Ihtisas Training and Research Hospital, Ankara, Turkey
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Carter TI, Fong ZV, Hyslop T, Lavu H, Tan WP, Hardacre J, Sauter PK, Kennedy EP, Yeo CJ, Rosato EL. A dual-institution randomized controlled trial of remnant closure after distal pancreatectomy: does the addition of a falciform patch and fibrin glue improve outcomes? J Gastrointest Surg 2013; 17:102-9. [PMID: 22798186 DOI: 10.1007/s11605-012-1963-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/01/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of the study was to assess the efficacy of two pancreatic remnant closure techniques following distal pancreatectomy: (1) stapled or sutured closure versus (2) stapled or sutured closure plus falciform patch and fibrin glue reinforcement in the setting of a prospective randomized trial, with the primary endpoint being pancreatic fistula. Pancreatic stump leak following left-sided pancreatic resection (distal pancreatectomy) remains common. Despite multiple and varied techniques for closure, the reported leak rate varies up to 30 %. A retrospective analysis by Iannitti et al. (J Am Coll Surg 203(6):857-864, 2006) detected a decreased leak rate in patients receiving a traditional closure buttressed with an autologous falciform ligament patch and fibrin glue. METHODS Between April 2008 and October 2011, all willing patients scheduled to undergo distal pancreatectomy at the authors' institutions were consented and enrolled at the preoperative office visit. Patients were intraoperatively stratified as having hard or soft glands and randomized to one of two groups: (1) closure utilizing stapling or suturing (SS) versus (2) stapled or sutured plus falciform ligament patch and fibrin glue (FF). The trial design and power analysis (α = 0.05, β = 0.2, power 80 %, chi-square test) hypothesized that the FF intervention would reduce the primary endpoint (pancreatic fistula) from 30 % to 15 % and targeted an accrual goal of 190 patients. Secondary endpoints included length of postoperative hospital stay, 30-day mortality, hospital readmission, and ISGPF fistula grade (A, B, and C). RESULTS The trial accrued 109 patients, 55 in the SS group and 54 in the FF group. Enrollment was closed prior to the target accrual, following an interim analysis and futility calculation. Due to insufficient enrollment, patients stratified as having a hard gland were excluded (n = 8) from analysis, leaving 101 patients in the soft stratum. The overall pancreatic leak rate was 19.8 % (20 patients) for patients with soft glands. Patients randomized to the FF group had a leak rate of 20 %, as compared with 19.6 % in the SS group (p = 1.000). Fistula grades in both groups were identical: 1A, 8B, and 1C in the FF group as compared to 1A, 8B, and 1C in the SS group. Complication rates were comparable between the two groups. The median length of postoperative hospital stay was 5 days in both groups. There was a trend towards a higher 30-day readmission rate in the FF group (28 % vs. 17.6 %, p = 0.243). CONCLUSION The addition of a falciform ligament patch and fibrin glue to standard stapled or sutured remnant closure did not reduce the rate or severity of pancreatic fistula in patients undergoing distal pancreatectomy (ClinicalTrials.gov NCT00889213).
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Affiliation(s)
- Timothy I Carter
- Department of Surgery and the Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
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Management of remnant pancreatic stump fto prevent the development of postoperative pancreatic fistulas after distal pancreatectomy: current evidence and our strategy. Surg Today 2012; 43:595-602. [PMID: 23093346 DOI: 10.1007/s00595-012-0370-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 07/02/2012] [Indexed: 12/19/2022]
Abstract
Distal pancreatectomy (DP) is the most common surgical procedure for treating benign and malignant lesions in the body or tail of the pancreas. Although the mortality rate related to DP has recently been reduced, the postoperative morbidity remains high. The most frequent and dismal complication occurring after DP is the development of postoperative pancreatic fistulas (POPF). Several resection methods and closure techniques for treating remnant pancreas have been developed in an effort to reduce the incidence of complications, especially POPF. However, the optimal procedure has not yet been established. In this review, we summarize the current clinical data and evidence for surgical techniques and perioperative management strategies for preventing POPF after DP. Finally, we introduce our non-closure technique for managing remnant pancreatic stumps.
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Iacobone M, Citton M, Nitti D. Laparoscopic distal pancreatectomy: Up-to-date and literature review. World J Gastroenterol 2012; 18:5329-37. [PMID: 23082049 PMCID: PMC3471101 DOI: 10.3748/wjg.v18.i38.5329] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/19/2012] [Accepted: 05/13/2012] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.
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Rostas JW, Richards WO, Thompson LW. Improved rate of pancreatic fistula after distal pancreatectomy: parenchymal division with the use of saline-coupled radiofrequency ablation. HPB (Oxford) 2012; 14:560-4. [PMID: 22762405 PMCID: PMC3406354 DOI: 10.1111/j.1477-2574.2012.00499.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most common significant complication after distal pancreatectomy (DP) and results in substantial morbidity. Many different methods are available to divide the pancreatic parenchyma and achieve stump closure, but demonstrating an improvement in the incidence of POPF has been difficult. METHODS A single-institution, retrospective review was conducted to evaluate all hand-assisted laparoscopic DP performed from October 2008 to July 2011 utilizing saline-coupled radiofrequency ablation (RFA) as the exclusive method of achieving division of the pancreatic parenchyma and closure of the proximal pancreatic remnant. All significant complications within the perioperative period were noted. RESULTS Thirty-four patients met the criteria for inclusion in the study. One patient was lost to follow-up and thus excluded. Three patients (9.1%) demonstrated a POPF; two were treated with prolonged placement of the intraoperative drain (grade A: 6.1%) and the third was treated with endoscopic cystogastrostomy (grade C: 3.0%). One other significant complication (3.0%) of a perforated gastric ulcer that required partial gastrectomy occurred. CONCLUSIONS The use of saline-coupled RFA alone for pancreatic parenchymal division and closure after DP is safe and effective. This study found an overall significant complication rate of 6.1%, and a rate of clinically significant POPF of 3.0%.
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Affiliation(s)
- Jack W Rostas
- Department of Surgery, University of South AlabamaPC, Mobile, AL, USA
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Wellner UF, Makowiec F, Sick O, Hopt UT, Keck T. Arguments for an individualized closure of the pancreatic remnant after distal pancreatic resection. World J Gastrointest Surg 2012; 4:114-20. [PMID: 22655125 PMCID: PMC3364336 DOI: 10.4240/wjgs.v4.i5.114] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 03/26/2012] [Accepted: 04/10/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze risk factors for postoperative pancreatic fistula (POPF) rate after distal pancreatic resection (DPR).
METHODS: We performed a retrospective analysis of 126 DPRs during 16 years. The primary endpoint was clinically relevant pancreatic fistula.
RESULTS: Over the years, there was an increasing rate of operations in patients with a high-risk pancreas and a significant change in operative techniques. POPF was the most prominent factor for perioperative morbidity. Significant risk factors for pancreatic fistula were high body mass index (BMI) [odds ratio (OR) = 1.2 (CI: 1.1-1.3), P = 0.001], high-risk pancreatic pathology [OR = 3.0 (CI: 1.3-7.0), P = 0.011] and direct closure of the pancreas by hand suture [OR = 2.9 (CI: 1.2-6.7), P = 0.014]. Of these, BMI and hand suture closure were independent risk factors in multivariate analysis. While hand suture closure was a risk factor in the low-risk pancreas subgroup, high BMI further increased the fistula rate for a high-risk pancreas.
CONCLUSION: We propose a risk-adapted and indication-adapted choice of the closure method for the pancreatic remnant to reduce pancreatic fistula rate.
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Affiliation(s)
- Ulrich Friedrich Wellner
- Ulrich Friedrich Wellner, Frank Makowiec, Olivia Sick, Ulrich Theodor Hopt, Tobias Keck, Department of General and Visceral Surgery, University of Freiburg, 79106 Freiburg, Germany
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After distal pancreatectomy pancreatic leakage from the stump of the pancreas may be due to drain failure or pancreatic ductal back pressure. J Gastrointest Surg 2012; 16:993-1003. [PMID: 22392088 DOI: 10.1007/s11605-012-1849-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 02/15/2012] [Indexed: 01/31/2023]
Abstract
HYPOTHESIS The method to lower postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) involves controlling risk factors for leakage from the pancreatic stump. GOAL The aim of this study was to identify controllable risk factors for POPF. METHODS In order to promote homogeneity, we used a single surgeon case series and then calculated POPF with a public web-based tool based on the severity classification system of the International Study Group of Pancreatic Surgery (ISGPS). A total of 223 consecutive cases of DPs were reviewed. DP involved the same hand-sewn fish-mouth closure of the pancreatic stump. All received postoperative epidural anesthesia. Logistic regression analysis identified risk factors for clinically relevant POPF (grade B/C). RESULTS Mortality was zero. ISGPS gradings were: no POPF 53%, grade A = 32%, B = 13.9%, and C = 0.9%. The clinical-relevant POPF (B/C) rate was 14.8% of which 24% represented surgical drain failure due to lack of patency and/or misplaced from their original location. Preoperative endoscopic ablation and/or stenting of Wirsung's duct was a significant risk factor to lower grade B/C leak (3%). Multivariate analysis identified two controllable risk factors-intraoperative blood loss >1,000 ml and those who did not undergo preoperative endoscopic interventions of Wirsung's duct. In the group with presumed intact pancreatic sphincters (no endoscopic intervention, n = 177), the use of postoperative intravenous opioids (with epidural failure) was a risk factor for B/C leak (34%). These findings suggest that increased back pressure in the pancreatic duct has a role in promoting pancreatic stump leakage. CONCLUSIONS Using the ISGPS definition and its web-based tool, the incidence of clinically relevant leakage was 14.8% in 223 cases of DP. Opportunities to lower this rate are improving our surgical drain technology, limiting intraoperative blood loss, and avoiding postoperative intravenous narcotics with epidural analgesia.
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Sepesi B, Moalem J, Galka E, Salzman P, Schoeniger LO. The influence of staple size on fistula formation following distal pancreatectomy. J Gastrointest Surg 2012; 16:267-74. [PMID: 22015618 DOI: 10.1007/s11605-011-1715-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 09/21/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic fistula continues to be a source of significant morbidity following distal pancreatic resections. The technique of pancreatic division varies widely among surgeons, and there is no evidence that identifies a single method as superior. In our practice, the technique of distal pancreatic resection has evolved from cut-and-sew to stapled technique with green and recently white cartridge. The aim of our study was to evaluate the rate of clinically significant fistulas [International Study Group on Pancreatic Fistula (ISGPF) grade B or C] following distal pancreatectomy and to identify variables associated with a low rate of fistula development. METHODS Clinical records of all patients who underwent distal pancreatic resections between February 1999 and July 2010 by a single surgeon were retrospectively reviewed focusing on the incidence and type of pancreatic fistula as defined by ISGPF. Study variables included age, gender, surgical approach, extent of resection, ASA classification, type of stapler cartridge, use of Seamguard™, and ISGPF classification. Statistical analysis was performed using Fisher's exact test, and univariate and multivariate logistic regression. RESULTS Sixty-four patients (median age 60, range 21-85; 54% male) underwent distal pancreatic resection (laparoscopy 50% vs. open 50%). The most common indications were pancreatic adenocarcinoma (N = 15; 23%) and neuroendocrine neoplasms (N = 14; 22%). Clinically significant pancreatic fistula developed in 24% (N = 15). The rate of fistula with cut-and-sew technique was 36% (4/11), with stapled green cartridge 31% (9/29) and only 5% (1/21) with stapled vascular cartridge. Univariate logistic regression identified vascular cartridge size (p = 0.04, OR 0.11) and open stapled technique (p = 0.05, OR 0.12) as variables significantly associated with a low fistula rate. Both vascular cartridge size (p = 0.05, OR 0.10) and open stapled technique (p = 0.04, OR 0.08) remained significant when analyzed by multivariate logistic regression. Division of pancreatic parenchyma with vascular cartridges resulted in significantly (p = 0.03, OR 9.0) lower fistula rate compared to green cartridges. The use of Seamguard™ did not affect fistula rate (16% vs. 27%; p = 0.34) nor did the performance of multivisceral resection vs. distal pancreatectomy/splenectomy alone (21% vs. 23%, p = 1.0). CONCLUSION The optimal technique of pancreatic division has not been conclusively established. Dividing the pancreas utilizing vascular (2.5 mm) staple cartridges significantly decreased the rate of clinically significant pancreatic fistula and we have changed our practice accordingly. A prospective randomized trial is necessary to validate these results.
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Affiliation(s)
- Boris Sepesi
- Department of Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA
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The use of bovine pericardial buttress on linear stapler fails to reduce pancreatic fistula incidence in a porcine pancreatic transection model. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2011; 2011:624060. [PMID: 22114365 PMCID: PMC3202096 DOI: 10.1155/2011/624060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 08/22/2011] [Indexed: 01/29/2023]
Abstract
We investigate the effectiveness of buttressing the surgical stapler to reduce postoperative pancreatic fistulae in a porcine model. As a pilot study, pigs (n = 6) underwent laparoscopic distal pancreatectomy using a standard stapler. Daily drain output and lipase were measured postoperative day 5 and 14. In a second study, pancreatic transection was performed to occlude the proximal and distal duct at the pancreatic neck using a standard stapler (n = 6), or stapler with bovine pericardial strip buttress (n = 6). Results. In pilot study, 3/6 animals had drain lipase greater than 3x serum on day 14. In the second series, drain volumes were not significantly different between buttressed and control groups on day 5 (55.3 ± 31.6 and 29.3 ± 14.2 cc, resp.), nor on day 14 (9.5 ± 4.2 cc and 2.5 ± 0.8 cc, resp., P = 0.13). Drain lipase was not statistically significant on day 5 (3,166 ± 1,433 and 6,063 ± 1,872 U/L, resp., P = 0.25) or day 14 (924 ± 541 and 360 ± 250 U/L). By definition, 3/6 developed pancreatic fistula; only one (control) demonstrating a contained collection arising from the staple line. Conclusion. Buttressed stapler failed to protect against pancreatic fistula in this rigorous surgical model.
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Park SJ, Seo HI, Go SH, Yun SP, Lee JY. Complication analysis of distal pancreatectomy based on early personal experience. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2011; 15:243-7. [PMID: 26421046 PMCID: PMC4582465 DOI: 10.14701/kjhbps.2011.15.4.243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 07/29/2011] [Accepted: 10/03/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUNDS/AIMS The objective of this study was to evaluate the relationship between initial personal experiences with distal pancreatectomy and perioperative risk factors, outcomes, and management of pancreatic fistulas. METHODS Between May, 2007 and May, 2010, a total of 28 patients who had undergone elective distal pancreatectomy were evaluated for this study. Perioperative factors and the occurrence of pancreatic fistula were analyzed on the basis of International Study Group of Pancreatic Fistula (ISGPF) criteria. RESULTS There were sixteen cases of benign neoplasms and twelve cases of malignant tumors. The remnant pancreas was manually sutured with ligation of the pancreatic duct (n=14), auto-suture stapling along with manual sutures (n=12), or stapling alone (n=2). According to the ISGPF classification, morbidity and mortality associated with pancreatic fistulas was 42.9% (n=12) and 0%, respectively. These pancreatic fistulae were classified as grade A in 8 cases (28.6%), grade B in 3 cases (10.7%), and grade C in one case (3.6%). All patients with pancreatic fistula were treated conservatively. CONCLUSIONS Perioperative factors do not affect the risk of pancreatic fistula. Adequate drainage is the most effective method for management of a pancreatic fistula after distal pancreatectomy.
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Affiliation(s)
- Sung-Jin Park
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Hyung-Il Seo
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Soo-Hee Go
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Sung-Pil Yun
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Ji-Yeon Lee
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
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Laparoscopic distal pancreatectomy with or without splenectomy: how I do it. J Gastrointest Surg 2011; 15:215-8. [PMID: 20824382 DOI: 10.1007/s11605-010-1313-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 08/09/2010] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Although the technique of distal pancreatectomy with or without en bloc splenectomy has been well described, the execution of this procedure may be technically challenging when performed laparoscopically. In this technical report, we aimed to describe the technique of laparoscopic distal pancreatectomy with or without splenic preservation. DISCUSSION Laparoscopic distal pancreatectomy with or without splenectomy is a safe and effective surgical approach for the correction of various conditions. It has been proven to be a feasible solution for the treatment of benign inflammatory conditions as well as neoplasms. Splenic preservation requires careful and meticulous dissection, but may be done safely.
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Hackert T, Werner J, Büchler MW. Postoperative pancreatic fistula. Surgeon 2010; 9:211-7. [PMID: 21672661 DOI: 10.1016/j.surge.2010.10.011] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Revised: 10/10/2010] [Accepted: 10/14/2010] [Indexed: 12/16/2022]
Abstract
Postoperative pancreatic fistula is an important complication after pancreatic resection. The frequency of its incidence varies between 3% after pancreatic head resections and up to 30% following distal pancreatectomy. In recent years, the international definition of pancreatic fistula has been standardised according to the approach of the International Study Group on Pancreatic Fistula (ISGPF). Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically. The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula.
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Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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