Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial?

Abstract

AIM:To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP) and to determine the effectiveness of using a stapled and a sutured closed of pancreatic stump. METHODS:Sixty-four patients underwent DP during a 10-year period. Information regarding diagnosis, operative details, and perioperative morbidity or mortality was collected. Eight risk factors were examined. RESULTS:Indications for DP included primary pancreatic disease (n = 38, 59%) and non-pancreatic malignancy (n = 26, 41%). Postoperative mortality and morbidity rates were 1.5% and 37% respectively; one patient died due to sepsis and two patients required a reoperation due to postoperative bleeding. Pancreatic fistula was developed in 14 patients (22%); 4 of fistulas were classified as Grade A, 9 as Grade B and only 1 as Grade C. Incidence of pancreatic fistula rate was significantly associated with four risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, and texture of pancreatic parenchyma. The role that technique (either stapler or suture) of pancreatic stump closure plays in the development of pancreatic leak remains unclear. CONCLUSION:The pancreatic fistula rate after DP is 22%. This is reduced for patients with non-pancreatic malignancy, fibrotic pancreatic tissue, postoperative prophylactic octreotide therapy and concomitant splenectomy.

Optimal Technical Management of Stump Closure Following Distal Pancreatectomy: A Retrospective Review of 215 Cases

“…Another fact that we found to be significant Several authors state that the texture of the pancreatic parenchyma is an important risk factor associated with the development of post-operative pancreatic fistula. 3,12,13 Fibrotic pancreatic tissue is believed to be less likely to leak as compared to soft pancreatic parenchymal tissue, as long as the continuity of the main pancreatic duct is not compromised. Due to the retrospective nature of our study, we were unable to include pancreatic texture as a variable in our analysis as we found that it was not consistently reported in the operative reports and medical records that were reviewed.…”

“…Obesity, patient age, trauma, malignancy, duct obstruction and texture of the pancreatic parenchyma have all been implicated as potential risk factors 9,12 . However, surgical technique is also considered an important risk factor for the development of pancreatic fistula 9 .…”

“…A wide variety of surgical techniques for parenchymal transection and closure of the pancreatic remnant have been described in an effort to reduce the occurrence of fistula. These techniques include stapled closures, sutured closures, combined stapled and sutured closures, ultrasonic dissection, sealing with fibrin glue, application of mesh, seromuscular flaps, pancreaticoenteric anastomosis and ligation of the main pancreatic duct at the transection line 3,[6][7][8][9][11][12][13][14][15][16][17][18][19][20][21] . Currently, there is no consensus as to the optimal surgical technique 5 for pancreatic transection and stump closure during distal pancreatectomy.…”

Laparoscopic distal pancreatectomy in children with solid pseudopapillary tumour (Frantz tumour) – a report of two cases and review of the literature

“…The main problems after surgery of the pancreas are pancreatic fistula, sterile collection, abscess and wound disruption, all of them believed to be due to pancreatic leakage from the stump and reaching an incidence rate of 11-27% [4,7,8,13,15,20,23]. Stapler transection of the pancreas body is the most preferred in laparoscopic pancreatic surgery [5,6,9,13,24,25].…”

Laparoscopic Distal Pancreatectomy: Feasibility Study of Radiofrequency-Assisted Transection in a Porcine Model

“…1,10,20 We can speculate that this risk is in part increased by the crushing of the pancreatic tissue and the consequent destruction of small pancreatic ducts due to the pressure applied by a mechanical stapler before cutting and staple application. 11 In our model no pressure is applied to the pancreatic tissue, and only the previously sealed parenchyma are then cut by the device, thus avoiding the rupture of small pancreatic ducts before sealing.…”