Efficacy of Reinforced Stapler Versus Hand-sewn Closure of the Pancreatic Stump During Pure Laparoscopic Distal Pancreatectomy to Reduce Pancreatic Fistula

Abstract

Background: Laparoscopic distal pancreatectomy (L-DP) is the standard procedure for treating left-sided pancreatic tumors. Stapler closure of the pancreas is the preferred method for L-DP; however, postoperative pancreatic fistula (POPF) remains a challenging problem. The present study aimed to compare the surgical outcomes of staple closure using a reinforcing stapler (RS) and transection using an ultrasonic dissector followed by hand-sewn (HS) closure in a fish-mouth manner in pure L-DP and to determine independent perioperative risk factors for clinically relevant postoperative pancreatic fistula (CR-POPF).Patients and Methods: Among the 85 patients who underwent pure L-DP between February 2011 and August 2021, 80 of whom the pancreatic stump was closed with RS (n = 59) or HS (n = 21) were retrospectively investigated. Associations between potential risk factors and POPF were assessed using univariate analysis. The factors, of which the P value was determined to be <0.1 by univariate analysis, were entered into a multivariate regression analysis to ascertain independent predictive factors. Results:The surgery time and estimated blood loss were not significantly different between the two groups. Overall, 13 patients (16.3%) developed CR-POPF (B = 12 and C = 1). The rate of CR-POPF was lower in RS than in HS; however, the difference was not statistically significant (RS vs HS: 11.9% vs 28.9%, P = 0.092). Consistent with the results for CR-POPF, the rate of Clavien-Dindo IIIa or more postoperative complications and the length of hospital stay were also not significantly different between the two groups (RS vs HS: 10.2, 12% vs 14.3%, 14 d). In the univariate analysis of risk factors for CR-POPF, the pancreatic thickness at the transection site, procedure for stump closure, and estimated blood loss were associated with a significantly higher rate of CR-POPF. The multivariate analysis revealed that the pancreatic thickness at the transection site (cutoff: 12 mm) was the only independent risk factor for CR-POPF (odds ratio: 6.5l, 95% CI: 1.4-30.4, P = 0.018). The rate of CR-POPF was much lower in RS than in HS for pancreatic thickness <12 mm (RS vs HS: 4.1% vs 28.6%), whereas that was rather higher in RS than in HS for pancreatic thickness ≥ 12 mm (RS vs HS: 50% vs 28.6%).Conclusions: RS closure was superior to HS closure for pancreatic thickness <12 mm and for prevention of CR-POPF after pure L-DP. It is necessary to seek more reliable procedures for pancreatic stump closure in patients with a pancreatic thickness of ≥ 12 mm.

Clamp-crushing Pancreatic Transection in Minimally Invasive Distal Pancreatectomy

“…The method used for transection of the pancreas during DP requires attention to 2 important points: securing a sufficient surgical margin [10][11][12] and preventing POPF. [4][5][6][7] Regarding the surgical margin, it can be sometimes difficult to achieve an adequate pancreatic transection margin for tumors located in the pancreatic body. In such tumors, transecting the pancreas with the stapler can reduce the surgical margin because a cutting allowance is required to enable the insertion of the thick stapling device.…”

“…[1][2][3] Linear staplers are generally used for pancreatic transection in MIDP because of their ease of use. [4][5][6][7] Reinforced linear staplers have also had a positive impact and have recently become widely used for pancreatic transection as they can prevent postoperative pancreatic fistula (POPF). [4][5][6] However, pancreatic transection by linear stapler is less suitable for tumors in the pancreatic body and above the portal vein, as this method reduces the width of the surgical margin.…”

“…[4][5][6][7] Reinforced linear staplers have also had a positive impact and have recently become widely used for pancreatic transection as they can prevent postoperative pancreatic fistula (POPF). [4][5][6] However, pancreatic transection by linear stapler is less suitable for tumors in the pancreatic body and above the portal vein, as this method reduces the width of the surgical margin. 8 Therefore, in a limited number of cases, a method of pancreatic transection that can achieve a wider surgical margin than that of stapler transection is sometimes required.…”

“…However, the treatment of the pancreatic stump and pancreatic duct is a major issue in pancreatic transection methods that do not use a stapler because improper treatment can cause severe POPF. 5 Conventionally, ligation of the main pancreatic duct (MPD) and fishmouth suturing is performed as basic treatment of the pancreatic stump if a stapler is not used. However, this method is difficult to perform in laparoscopic distal pancreatectomy (DP), and POPF remains a serious concern even in the open approach.…”

“…However, this method is difficult to perform in laparoscopic distal pancreatectomy (DP), and POPF remains a serious concern even in the open approach. 5,9 To the best of our knowledge, no report has described in detail a method for pancreatic transection that does not use a stapling device for ductal treatment during MIDP, by video. Herein, we report a pancreatic transection method that employs the parenchymal clamp-crushing procedure to achieve sufficient surgical margin and provide a video of the procedure (Supplemental Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A413).…”