A Thick Pancreas Is a Risk Factor for Pancreatic Fistula after a Distal Pancreatectomy: Selection of the Closure Technique according to the Thickness

Abstract

Background/Aims: Hand-sewn closures or stapler closures of the pancreatic remnant after a distal pancreatectomy have commonly been employed; however, the choice of technique in each patient depending on their clinical characteristics has not been discussed. Methods: Forty-eight patients who underwent a distal pancreatectomy at Osaka University Hospital between January 2007 and October 2009 were enrolled. A hand-sewn closure was planned during the 1st period (before June 2008, 26 consecutive patients), whereas a stapler closure was planned for the 2nd period (after June 2008, 22 consecutive patients). The incidence of pancreatic fistula and the patients’ characteristics were retrospectively investigated. Results: Seven patients (27%) developed a fistula in the hand-sewn group, while 5 (23%) developed a fistula in the stapler group (p = n.s.). Using logistic regression analysis for all patients, younger age and the thickness of the pancreatic remnant were identified as independent risk factors for pancreatic fistula. In the stapler group, 50% of patients with a thick pancreas developed a pancreatic fistula, while no patients with a thin pancreas developed one. Conclusion: Thick pancreas is one of the risk factors for pancreatic fistula after a distal pancreatectomy; however, a stapler closure seems to be suitable at least for thin pancreas.

Distal Pancreatectomy Utilizing a Flexible Stapler Closure Eliminates the Risk of Pancreas-Related Factors for Postoperative Pancreatic Fistula

“…The well-known risk factors associated with PF after DP, including stapler DP, are as follows: patient age [19], body mass index [21,25], previous laparotomy [20], pancreatic pathology [26], no duct ligation [3,11,19,27], additional resection [21], radical lymphadenectomy [19], prolonged operative time [16,20,27], and factors related to the pancreas, such as diabetes mellitus [20,26], pancreas transection parts [3], soft pancreas texture [28], and thick pancreas [17]. In this study, operative time (≥300 min) was the only independent risk factor of clinically relevant PF, and the factors noted above showed no impact on PF.…”

“…The thickness of the pancreas at the proposed transection line for the pancreas was measured using preoperative computed tomography images [17]. Intraoperative data obtained included texture of the pancreas at the site of transection (graded as soft or hard by the surgeon), transection line for the pancreas (head, body), ligation of the main pancreatic duct stump on the cutting surface of the pancreas (yes or no), concomitant resection of other organs (yes or no), radical lymphadenectomy (yes or no), operative time, intraoperative blood loss, and blood transfusion (table 2).…”

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

“…Down-sides are the higher costs and the lack of individual ligation of the MPD. Furthermore, it seems unsafe to use staplers in a pancreas with thick parenchyma [18,28]. …”

Closure method for thick pancreas stump after distal pancreatectomy: soft coagulation and polyglycolic acid felt with fibrin glue

“…However, compressing the pancreas itself could cause injury to the pancreatic parenchyma during both techniques, potentially leading to clinically relevant PF, especially in cases with a thick pancreatic parenchyma. Indeed, a thick pancreatic parenchyma is reported to be a risk factor for increased incidence of POPF [11,[22][23][24]. In this context, closure of the pancreatic stump, with minimization of injury to the pancreatic parenchyma, is critical to decreasing the risk of PF after DP.…”