A Review of Techniques for Closure of the Pancreatic Remnant following Distal Pancreatectomy

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.

Network meta-analysis comparing techniques and outcomes of stump closure after distal pancreatectomy

“…The overall incidence of POPF after distal pancreatectomy remains high; approximately 30 per cent of patients develop POPF with significant clinical consequences, including the need for radiological interventions, prolonged hospital stay, readmissions and increased healthcare costs. Several risk factors for POPF after distal pancreatectomy have been identified, including high BMI, absence of pancreatic duct ligation, a soft pancreas and splenic preservation.…”

“…For the purpose of this study, distal pancreatectomy included the terms left pancreatectomy and subtotal pancreatectomy. Methods of anastomotic closure included pancreatojejunostomy and pancreatogastrostomy. Patch closure included seromuscular patch or round ligament patch coverage following stapler or suture closure.…”

“…Many techniques of pancreatic stump closure have been described in the literature, including sutured closure, stapler‐based transection and stapler closure of the stump, combination of stapler‐based resection with manual sutures along the stapler line, pancreaticoenteric or pancreaticogastric anastomosis, ultrasonic or radiofrequency ablation, application of fibrin glue to cover the pancreatic stump, mesh application to the stump or to reinforce staple lines, and use of autologous patches with the round ligament ( Fig . ).…”

Diagnosis and Management of Blunt Pancreatic Trauma

“…In isolated pancreatic injury, laparotomies aim to avoid pancreatic complications. However, the most dreaded risks, such as pancreatic fistulas and pseudocysts, frequently occur post-operatively as well (52). This phenomenon promotes the use of less invasive measures such as observation, supportive symptomatic treatment or percutaneous drainage of fluid collections.…”

Pancreatic Surgery: Past, Present, and Future

“…These surgical techniques were precisely described with intraoperative pictures in this issue. In order to decrease the occurrence of pancreatic leak, Kollár et al [9] extensively analyzed several possible management of the pancreatic stump following a distal pancreatectomy.…”