Application of polyethylene glycolic acid felt with fibrin sealant to prevent postoperative pancreatic fistula in pancreatic surgery

The efficacy of wrapping with polyglycolic acid mesh and fibrin glue in preventing clinically relevant pancreatic fistula after minimally invasive distal pancreatectomy (WRAP Study): study protocol for a multicenter randomized controlled trial in Japan

BACKGROUND

Postoperative pancreatic fistula (POPF) continues to be the most common complication after distal pancreatectomy (DP). Recent advancements in surgical techniques have established minimally invasive distal pancreatectomy (MIDP) as the standard treatment for various conditions, including pancreatic cancer. However, MIDP has not demonstrated a clear advantage over open DP in terms of POPF rates, indicating the need for additional strategies to prevent POPF in MIDP. This trial (WRAP study) aims to evaluate the efficacy of wrapping the pancreatic stump with polyglycolic acid (PGA) mesh and fibrin glue in preventing clinically relevant (CR-) POPF following MIDP.

METHODS

This multicenter, randomized controlled trial will include patients scheduled for laparoscopic or robotic DP for tumors in the pancreatic body and/or tail. Eligible participants will be centrally randomized into either the control group (Group A) or the intervention group (Group B), where the pancreatic stump will be reinforced by PGA mesh and fibrin glue. In both groups, pancreatic transection will be performed using a bioabsorbable reinforcement-attached stapler. A total of 172 patients will be enrolled across 14 high-volume centers in Japan. The primary endpoint is the incidence of CR-POPF (International Study Group of Pancreatic Surgery grade B/C).

DISCUSSION

The WRAP study will determine whether the reinforcement of the pancreatic stump with PGA mesh and fibrin glue, a technique whose utility has been previously debated, could become the best practice in the era of MIDP, thereby enhancing its safety.

TRIAL REGISTRATION

This trial was registered with the Japan Registry of Clinical Trials on June 15, 2024 (jRCTs032240120).

Appropriate linear stapler selection for avoiding postoperative pancreatic fistula after distal pancreatectomy: A retrospective cohort study

BACKGROUND

Despite the progress in surgical techniques and perioperative managements, the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Recently, pancreatic dissection using a linear stapler has been widely performed; however, risk factors influencing the occurrence of POPF after DP using a liner stapler is not fully understood. The purpose of this paper was to evaluate whether the relations between staple height and pancreatic thickness or main pancreatic duct (MPD) diameter influenced the incidence of POPF.

METHODS

Patients who underwent DP without other organ resections between 2015 and 2022 were retrospectively reviewed. Compression Index (CI) was defined as staple height/pancreatic thickness, and Suturing Index (SI) was defined as staple height/ MPD diameter.

RESULTS

In 51 patients undergoing DP, 16 patients (31.4%) developed POPF. ROC analyses revealed that lower CI and higher SI significantly increased the incidence of POPF, and the cutoff values were 0.186 and 0.821, respectively. Univariate and multivariate analyses revealed that CI ≤ 0.186 and SI ≥ 0.821 were independent risk factors for POPF after DP. Moreover, the incidence of POPF in patients fulfilling both CI > 0.186 and SI < 0.821 was 5.9%, which was extremely lower than in those without fulfilling the criteria (44.1%), suggesting that this new criteria in combination with CI and SI was an excellent predictor of POPF.

CONCLUSIONS

It is possible that stapler cartridge selection using our new criteria in combination with CI and SI may reduce the incidence of POPF.

Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy

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.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most frequent and potentially life-threatening complications following pancreatic surgery. Fibrin sealants have been used in some centres to reduce POPF rate. However, the use of fibrin sealant during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2020.

OBJECTIVES

To evaluate the benefits and harms of fibrin sealant use for the prevention of POPF (grade B or C) in people undergoing pancreatic surgery compared to no fibrin sealant use.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 09 March 2023, together with reference checking, citation searching, and contacting study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 RCTs, randomising 1989 participants, comparing fibrin sealant use versus no fibrin sealant use for different locations: stump closure reinforcement (eight trials), pancreatic anastomosis reinforcement (five trials), or main pancreatic duct occlusion (two trials). Six RCTs were carried out in single centres; two in dual centres; and six in multiple centres. One RCT was conducted in Australia; one in Austria; two in France; three in Italy; one in Japan; two in the Netherlands; two in South Korea; and two in the USA. The mean age of the participants ranged from 50.0 years to 66.5 years. All RCTs were at high risk of bias. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included eight RCTs involving 1119 participants: 559 were randomised to the fibrin sealant group and 560 to the control group after distal pancreatectomy. Fibrin sealant use may result in little to no difference in the rate of POPF (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.73 to 1.21; 5 studies, 1002 participants; low-certainty evidence) and overall postoperative morbidity (RR 1.20, 95% CI 0.98 to 1.48; 4 studies, 893 participants; low-certainty evidence). After fibrin sealant use, approximately 199 people (155 to 256 people) out of 1000 developed POPF compared with 212 people out of 1000 when no fibrin sealant was used. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto odds ratio (OR) 0.39, 95% CI 0.12 to 1.29; 7 studies, 1051 participants; very low-certainty evidence) and total length of hospital stay (mean difference (MD) 0.99 days, 95% CI -1.83 to 3.82; 2 studies, 371 participants; very low-certainty evidence). Fibrin sealant use may reduce the reoperation rate slightly (RR 0.40, 95% CI 0.18 to 0.90; 3 studies, 623 participants; low-certainty evidence). Serious adverse events were reported in five studies (732 participants), and there were no serious adverse events related to fibrin sealant use (low-certainty evidence). The studies did not report quality of life or cost-effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included five RCTs involving 519 participants: 248 were randomised to the fibrin sealant group and 271 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF (RR 1.34, 95% CI 0.72 to 2.48; 3 studies, 323 participants; very low-certainty evidence), postoperative mortality (Peto OR 0.24, 95% CI 0.05 to 1.06; 5 studies, 517 participants; very low-certainty evidence), reoperation rate (RR 0.74, 95% CI 0.33 to 1.66; 3 studies, 323 participants; very low-certainty evidence), and total hospital cost (MD -1489.00 US dollars, 95% CI -3256.08 to 278.08; 1 study, 124 participants; very low-certainty evidence). After fibrin sealant use, approximately 130 people (70 to 240 people) out of 1000 developed POPF compared with 97 people out of 1000 when no fibrin sealant was used. Fibrin sealant use may result in little to no difference both in overall postoperative morbidity (RR 1.02, 95% CI 0.87 to 1.19; 4 studies, 447 participants; low-certainty evidence) and in total length of hospital stay (MD -0.33 days, 95% CI -2.30 to 1.63; 4 studies, 447 participants; low-certainty evidence). Serious adverse events were reported in two studies (194 participants), and there were no serious adverse events related to fibrin sealant use (very low-certainty evidence). The studies did not report quality of life. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two RCTs involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto OR 1.41, 95% CI 0.63 to 3.13; 2 studies, 351 participants; very low-certainty evidence), overall postoperative morbidity (RR 1.16, 95% CI 0.67 to 2.02; 2 studies, 351 participants; very low-certainty evidence), and reoperation rate (RR 0.85, 95% CI 0.52 to 1.41; 2 studies, 351 participants; very low-certainty evidence). Fibrin sealant use may result in little to no difference in the total length of hospital stay (median 16 to 17 days versus 17 days; 2 studies, 351 participants; low-certainty evidence). Serious adverse events were reported in one study (169 participants; low-certainty evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report POPF, quality of life, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealant use may result in little to no difference in the rate of POPF in people undergoing distal pancreatectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF in people undergoing pancreaticoduodenectomy. The effect of fibrin sealant use on postoperative mortality is uncertain in people undergoing either distal pancreatectomy or pancreaticoduodenectomy.

Blumgart anastomosis with polyglycolic acid felt reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: A propensity score analysis

Polyglycolic acid (PGA) felt has been used to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). However, there has been no related research on Blumgart anastomosis. Therefore, this study aimed to investigate the practical significance of Blumgart anastomosis with our new method involving PGA felt to prevent CR-POPF following PD. Data from 133 consecutive patients who underwent Blumgart anastomosis during PD between June 2015 and November 2021 were reviewed. We applied PGA felt to 35 of these patients starting from July 2020. Surgical outcomes were analyzed by propensity score matching. Thirty-five (35.7%) of the 98 patients in the without-PGA group were matched with an equal number from the with-PGA group after adjusting for covariates. CR-POPF was found in 17 patients (49%) in the without-PGA group and two patients (6%) in the with-PGA group (P < .001). The multivariate analysis results indicated that male sex, pancreatic duct size <3 mm, soft pancreatic texture, and nonuse of PGA were independently associated with CR-POPF after PD. In conclusion, Blumgart anastomosis with our new penetrating method for PGA felt reduces the incidence of CR-POPF after PD.

Covering reinforced staples with polyethylene glycolic acid felt-covered fibrin sealant to prevent pancreatic fistula after distal pancreatomy: a retrospective comparative study

BACKGROUND

In accordance with previous reports on the utility of polyethylene glycolic acid (PGA) felt and fibrin glue for postoperative pancreatic fistula (POPF), we usually perform distal pancreatectomy (DP) with a PGA felt reinforcement stapler when dissecting the pancreas and cover the stump with PGA felt and fibrin glue (the PPF method). In this study, we retrospectively analyzed our DP cases to compare the risk factors for POPF and the postoperative course of patients receiving the PPF method of treatment versus that of those receiving conventional treatment.

METHODS

A total of 127 DP procedures performed in our department between January 2008 and June 2021 were retrospectively analysed.

RESULTS

In the PPF method, grade B/C POPF rate tended to decrease, and POPF rate showed a significant decrease. The duration of drainage and the length of postoperative hospitalisation were also significantly shorter with the PPF method. The risk of grade B/C POPF significantly decreased with the PPF method if the pancreas was thick (> 13.5 mm) or the patients were obese.

CONCLUSIONS

The PPF method is useful for POPF in DP and is particularly effective when a thick pancreas or obese patient is involved. Removing the drainage tube early in the PPF method may lead to early discharge.

The outcome of bioabsorbable staple line reinforcement versus standard stapler for distal pancreatectomy: A systematic review and meta-analysis

Background and Aim

In the era of minimally invasive procedures and as a way to decrease the incidence of post-operative pancreatic fistula (POPF), the use of staplers for distal pancreatectomy (DP) has increased dramatically. Our aim was to investigate whether reinforced staplers decrease the incidence of clinically relevant PF after DP compared with staplers without reinforcement.

Methods

PubMed, Scopus, Web of Science and Cochrane Library were searched for eligible studies from inception to 1 November 2021, and a systematic review and a meta-analysis were done to detect the outcomes after using reinforced staplers versus standard stapler for DP.

Results

Seven studies with a total of 681 patients were included. The overall incidence of POPF and the incidence of Grade A POPF after DP are similar for the two groups (overall POPF, risk ratio [RR] = 0.85, 95% confidence interval [CI] = 0.71-1.01, P = 0.06; I2 = 38% and Grade A POPF, RR = 1.15, 95% CI = 0.78-1.69, P = 0.47; I2 = 49%). However, the incidence of clinically significant POPF (Grades B and C) is significantly lower in DP with reinforced staplers than DP with bare staplers (Grades B and C, RR = 0.45, 95% CI = 0.29-0.71, P = 0.0005; I2 = 17%). Nevertheless, the time of the operation, the blood loss during surgical procedure, the hospital stay after the surgery and the thickness of the pancreas are similar for both techniques.

Conclusion

Although staple line reinforcement after DP failed to prevent biochemical PF, it significantly reduced the rate of clinically relevant POPF in comparison to standard stapling.

The clinical impact of modified transpancreatic mattress sutures with polyglactin 910 woven mesh on postoperative pancreatic fistula in distal pancreatectomy

BACKGROUND

We previously reported the stump closure method for the remnant pancreas in distal pancreatectomy, in which soft coagulation and polyglycolic acid felt attached with fibrin glue were utilized. Transpancreatic mattress suture with polyglactin 910 woven mesh was recently reported as a novel stump closure technique. We developed the modified transpancreatic mattress suture with polyglactin 910 woven mesh method, which combined our polyglycolic acid felt method with the transpancreatic mattress suture with polyglactin 910 woven mesh method.

METHODS

The polyglycolic acid felt group included patients undergoing distal pancreatectomy in whom the pancreatic stump was closed with the polyglycolic acid felt method from 2017 to 2018 (n = 54); whereas the modified transpancreatic mattress suture with polyglactin 910 woven mesh group included those whose stump was closed with the modified transpancreatic mattress suture with polyglactin 910 woven mesh method from 2019 to 2020 (n = 51). Perioperative parameters, including grade B/C postoperative pancreatic fistula (clinically relevant postoperative pancreatic fistula), were assessed according to the stump closure method.

RESULTS

The incidence of clinically relevant postoperative pancreatic fistula was significantly lower in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group than in the polyglycolic acid felt group (7.8% vs 22.2%, P = .036). In multivariate analysis, the use of neoadjuvant chemoradiotherapy and the transpancreatic mattress suture with polyglactin 910 woven mesh method were independent factors for preventing clinically relevant postoperative pancreatic fistula (P = .011 and 0.0038, respectively). Moreover, in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group, the incidence of clinically relevant postoperative pancreatic fistula in patients with a thick pancreas (≥13 mm, 6.7%) was comparably as low as that in patients with a thin pancreas (<13 mm, 9.5%).

CONCLUSION

The modified transpancreatic mattress suture with polyglactin 910 woven mesh method is an effective stump closure technique to prevent clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Our results warrant further prospective investigation to evaluate the efficacy of the modified transpancreatic mattress suture with polyglactin 910 woven mesh method compared with other standard closure methods (eg, stapler closure or hand-sewn closure).

Reduction in post-operative pancreatic fistula with polyethylene glycol and recombinant human albumin sealant following stapled distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a significant cause of morbidity in patients undergoing distal pancreatectomy (DP). The use of polyethylene glycol (PEG) and recombinant human albumin sealant gel applied to the transected pancreatic margin in DP may reduce POPF rates and was assessed.

METHODS

A retrospective single centre cohort study of patient undergoing DP at an Australian high volume tertiary institution between January 2015 and January 2021. Rates of POPF in patients undergoing stapled pancreatic transection with PEG sealant were compared to other methods.

RESULTS

A total of 54 cases were identified for analysis, with 16 undergoing stapled DP combined with staple line application of PEG (PEG group). Most patients in the control group had stapled DP 92% (35 of 38), with 47% (18 of 38) combined with a reinforcing buttress, with or without the use other glue types. Overall, 28 of 54 (52%) developed a POPF, with a significantly lower rate in the PEG group (3 of 16 vs. 25 of 38 in the Control group; p = 0.003). Clinically significant Grade B/C POPF was lower in the PEG group (0 of 16 vs. 9 of 28 in the Control group; p = 0.045), and patients in the PEG group had a shorter median (range) length of hospital stay (6 [4-14] days vs. 10 [6-41] days p = 0.04).

CONCLUSION

Stapled DP with the application of PEG and recombinant human albumin sealant to the transection line appears to be associated with a lower rate of clinically significant POPF.

Predicting postoperative pancreatic fistula in pancreatic head resections: which score fits all?

Purpose

Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to select those who might benefit from strategies to prevent complications. The aim of this study was to validate ten prognostic scores in patients who underwent pancreatic head surgery.

Methods

A total of 364 patients were included in this study between September 2012 and August 2017. Ten risk scores were applied to this cohort. Univariate and multivariate analyses were performed considering all risk factors in the scores. Furthermore, the stratification of patients into risk categories was statistically tested.

Results

Nine of the scores (Ansorge et al., Braga et al., Callery et al., Graham et al., Kantor et al., Mungroop et al., Roberts et al., Yamamoto et al. and Wellner et al.) showed strong prognostic stratification for developing POPF (p < 0.001). There was no significant prognostic value for the Fujiwara et al. risk score. Histology, pancreatic duct diameter, intraabdominal fat thickness in computed tomography findings, body mass index, and C-reactive protein were independent prognostic factors on multivariate analysis.

Conclusion

Most risk scores tend to stratify patients correctly according to risk for POPF. Nevertheless, except for the fistula risk score (Callery et al.) and its alternative version (Mungroop et al.), many of the published risk scores are obscure even for the dedicated pancreatic surgeon in terms of their clinical practicability. There is a need for future studies to provide strategies for preventing POPF and managing patients with high-risk stigmata.

Pancreaticoduodenectomy and external Wirsung stenting: Our outcomes in 80 cases

INTRODUCTION

There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique.

PATIENTS AND METHODS

A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting.

RESULTS

Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2%, 53.6% and 19.2%, respectively.

CONCLUSIONS

Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.

Wrapping the pancreas with a polyglycolic acid sheet before stapling reduces the risk of fluid collection on the pancreatic stump after distal pancreatectomy

Background

Postoperative pancreatic fistula (POPF) and postoperative fluid collection (POFC) are common complications after distal pancreatectomy (DP). The previous method of reducing the risk of POPF was the application of a polyglycolic acid (PGA) sheet to the pancreatic stump after cutting the pancreas with a stapler (After-stapling); the new method involves wrapping the pancreatic resection line with a PGA sheet before stapling (Before-stapling). The study aimed to compare the incidence of POPF and POFC between two methods.

Methods

Data of patients who underwent open or laparoscopic DPs by a single surgeon from October 2010 to February 2020 in a tertiary referral hospital were retrospectively analyzed. POPF was defined according to the updated International Study Group of Pancreatic Fistula criteria. POFC was measured by postoperative computed tomography (CT).

Results

Altogether, 182 patients were enrolled (After-stapling group, n = 138; Before-stapling group, n = 44). Clinicopathologic and intraoperative findings between the two groups were similar. Clinically relevant POPF rates were similar between both groups (4.3% vs. 4.5%, p = 0.989). POFC was significantly lesser in the Before-stapling group on postoperative day 7 (p < 0.001).

Conclusions

Wrapping the pancreas with PGA sheet before stapling was a simple and effective way to reduce POFC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08387-0.

Results of Standard Stapler Closure of Pancreatic Remnant After Distal Spleno-Pancreatectomy for Adenocarcinoma

Background/Aim: The purpose of this study was to evaluate the results of stapled closure of the pancreatic remnant after cold-knife section of the pancreatic isthmus and distal pancreatectomy for adenocarcinoma. Methods: A retrospective evaluation of 57 consecutive patients undergoing distal spleno-pancreatectomy for adenocarcinoma was performed. The pancreatic isthmus was systematically straight-sectioned with a cold knife, and the remnant was stapled close without additional stitches or adjuncts. The study's main endpoints were postoperative mortality, the occurrence of a pancreatic fistula, the need for a re-operation, the postoperative length of stay in the hospital, the rate of re-admission, and late survival. Results: Postoperative mortality was absent. Seventeen patients (29.8%) presented a pancreatic fistula of grade A in seven cases (41.2%), grade B in eight cases (47.1%), and grade C in two cases (11.8%). Re-operation was required in the two patients (3.5%) with grade C fistula in order to drain an intra-abdominal abscess. The mean postoperative length of stay in the hospital was 15 days (range, 6-62 days). No patient required re-admission. Twenty-nine patients (50.8%) were alive and free from disease, respectively, 12 patients (21.1%) at 12 months, 13 patients (22.8%) at 60 months, and four patients (7.0%) at 120 months from the operation. The remaining patients died of metastatic disease 9-37 months from the operation. Lastly, disease-related mortality was 49.1%. Conclusion: Stapler closure of the pancreatic remnant allows good postoperative results, limiting the formation of pancreatic fistula to the lower limit of its overall reported incidence.

Pancreaticoduodenectomy and external Wirsung stenting: our outcomes in 80 cases

INTRODUCTION

There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique.

PATIENTS AND METHODS

A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting.

RESULTS

Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2, 53.6 and 19.2%, respectively.

CONCLUSIONS

Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.

Effect of polyglycolic acid mesh for prevention of pancreatic fistula after pancreatectomy: A systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is the most common and intractable complication after partial pancreatectomy, with an incidence of 13% to 64%. Polyglycolic acid (PGA) mesh is a new technique that is designed to prevent POPF, and its effect has been evaluated in several randomized controlled trials and some retrospective cohort studies. In this study, we systematically and comprehensively analyzed the efficacy of PGA mesh based on reported studies.We searched Medline, Embase, and Cochrane Library databases in English between January 2010 and October 2019. Analysis was performed by using Review Manger 5.3 software.Three RCTs and 8 nonrandomized studies were eligible with a total of 1598 patients including 884 PGA group patients and 714 control group patients. For pancreatoduodenectomy (PD), distal pancreatectomy (DP), and the 2 partial pancreatectomy (PD or DP), we found significant statistical differences in overall POPF (relative risk [RR] = 0.75, 95% confidence interval [CI] = 0.61-0.91, P = .004; RR = 0.74, 95% CI = 0.57-0.96, P = .02; RR = 0.76, 95% CI = 0.64-0.89, P = .0009, respectively) and clinical pancreatic fistula (PF) (RR = 0.5, 95% CI = 0.37-0.68, P < .00001; RR = 0.31, 95% CI = 0.21-0.46, P < .00001; RR = 0.41, 95% CI = 0.32-0.52, P < .00001, respectively) in favor of PGA. For partial pancreatectomy, significant statistical differences were found in overall complications (RR = 0.77, 95% CI: 0.67-0.88, P = .0002) and estimated blood loss (weighted mean difference [WMD] = -53.58; 95% CI: -101.20 to -5.97, P = .03) in favor of PGA. We did not find significant differences regarding operative time (WMD = -8.86; 95% CI: -27.59 to 9.87, P = .35) and hospital stay (WMD = -2.73; 95% CI: -7.53 to 2.06, P = .26).This meta-analysis shows the benefits of the PGA mesh technique regarding POPF, clinical PF, and postoperative complications. This still needs to be verified by more randomized control trials.

Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS)

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.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants have been used in some centers to reduce postoperative pancreatic fistula. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2018.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2019, Issue 2), MEDLINE (1946 to 13 March2019), Embase (1980 to 11 March 2019), Science Citation Index Expanded (1900 to 13 March 2019), and Chinese Biomedical Literature Database (CBM) (1978 to 13 March 2019).

SELECTION CRITERIA

We included all randomised controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 12 studies involving 1604 participants in the review. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included seven studies involving 860 participants: 428 were randomised to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence) or length of hospital stay (MD 0.99 days, 95% CI -1.83 to 3.82; 371 participants; two studies; very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included four studies involving 393 participants: 186 were randomised to the fibrin sealant group and 207 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (16.7% versus 11.7%; RR 1.14, 95% CI 0.28 to 4.69; 199 participants; two studies; very low-quality evidence). We are uncertain whether fibrin sealants reduce postoperative mortality (0.5% versus 2.4%; Peto OR 0.26, 95% CI 0.05 to 1.32; 393 participants; four studies; low-quality evidence) or length of hospital stay (MD 0.01 days, 95% CI -3.91 to 3.94; 323 participants; three studies; very low-quality evidence). There is probably little or no difference in overall postoperative morbidity (52.6% versus 50.3%; RR 1.04, 95% CI 0.87 to 1.24; 323 participants; three studies; moderate-quality evidence) between the groups. We are uncertain whether fibrin sealants reduce reoperation rate (5.2% versus 7.7%; RR 0.74, 95% CI 0.33 to 1.66; 323 participants; three studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two studies involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (median 16 to 17 days versus 17 days; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study (169 participants; low-quality evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3 mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea

BACKGROUND

Partial pancreatoduodenectomy is performed for malignant and benign diseases of the pancreatic head region. The procedure is considered highly difficult and highly invasive. Postoperative pancreatic fistula (POPF) is an important complication because of several consequent complications, including intraabdominal haemorrhage, often increasing hospital stays and surgical mortality. Although many kinds of pancreaticojejunostomy aimed at reducing POPF have been examined to date, the technique has not yet been standardized. We devised a new method using double-coated polyglycolic acid felt after pancreaticojejunostomy. The aim of the PLANET-PJ trial is to evaluate the superiority of polyglycolic acid felt reinforcement in preventing POPF after pancreaticojejunostomy in patients undergoing partial pancreatoduodenectomy to previous anastomosis methods.

METHODS

Patients diagnosed with pancreatic or periampullary lesions in whom it is judged that the main pancreatic duct diameter was 3 mm or less on the left side of the portal vein without pancreatic parenchymal atrophy due to obstructive pancreatitis are considered eligible for inclusion. This study is designed as a multicentre randomized phase III trial in Japan and the Republic of Korea. Eligible patients will be centrally randomized to either group A (polyglycolic acid felt reinforcement) or group B (control). In total, 514 patients will be randomized in 31 high-volume centres in Japan and Republic of Korea. The primary endpoint is the incidence of POPF (International Study Group of Pancreatic Surgery grade B/C).

DISCUSSION

The PLANET-PJ trial evaluates the efficacy of a new method using double-coated polyglycolic acid felt reinforcement for preventing POPF after pancreaticojejunostomy. This new method may reduce POPF.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03331718 . University Hospital Medical Information Network Clinical Trials Registry, UMIN000029647. Registered on 30 November 2017. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000033874.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

How to close the pancreatic stump and the role of sealants

Postoperative pancreatic fistula (POPF) is the most common and also the most threatening complication following distal pancreatectomy. For this reason, morbidity and mortality of this operation remain still high. Over the last two decades, many different studies have been performed aiming to reduce the rate and the severity of POPF. However, effective treatments to prevent or avoid clinically relevant pancreatic fistula are still unclear. In this review, we discuss the current evidence on such a relevant topic.

The rate of postoperative pancreatic fistula after distal pancreatectomy is independent of the pancreatic stump closure technique - A retrospective analysis of 284 cases

BACKGROUND

Many techniques have been developed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy, but POPF rates remain high. The aim of our study was to analyze POPF occurrence after closure of the pancreatic remnant by different operative techniques.

METHODS

Between 2006 and 2017, 284 patients underwent distal pancreatectomy in our institution. For subgroup analysis the patients were divided into hand-sewn (n = 201) and stapler closure (n = 52) groups. The hand-sewn closure was performed in three different ways (fishmouth-technique, n = 27; interrupted transpancreatic U-suture technique, n = 77; common interrupted suture, n = 97). All other techniques were summarized in a separate group (n = 31). Results were gained by analysis of our prospective pancreatic database.

RESULTS

The median age was 63 (range 23-88) years. 74 of 284 patients (26%) were operated with spleen preservation (similar rates in subgroups). ASA-classes, median BMI as well as frequencies of malignant diseases, chronic pancreatitis, alcohol and nicotine abuse were also comparable in the subgroups. Neither the rates of overall POPF (fishmouth-technique 30%, common interrupted suture 40%, stapler closure 33% and interrupted U-suture 38%) nor the rates of POPF grades B and C showed significant differences in the subgroups. However is shown to be associated with pancreatic function and parenchymal texture.

CONCLUSION

In our experience the technique of pancreatic stump closure after distal resection did not influence postoperative pancreatic fistula rate. As a consequence patient specific reasons rather than surgical techniques may be responsible for POPF formation after distal pancreatectomy.

A Novel Non-Gas Endospray for Applying Fibrin Glue in Laparoscopic Surgery

Purpose: Fibrin glue and polyglycolic acid felt are used for tissue repair in various surgical procedures. However, using a spray device to apply fibrin sealant during laparoscopic surgery can increase the intraperitoneal pressure, which can cause complications such as air embolism. We developed a novel non-gas endospray for use in laparoscopic surgery. This study aimed to evaluate the sealing effect of this non-gas endospray in comparison with a conventional gas-spray device and to evaluate the safety of its application in the clinical setting. Materials and Methods: An ex vivo pressure test model was used to assess the sealing effect of the non-gas endospray (method 1) versus conventional gas-spray (method 2). A bottle was sealed with a rabbit skin sample that had been pierced nine times by a 19G needle. Each skin sample was sealed using either method 1 or method 2 (n = 10 for each method). The non-gas endospray was then used in two patients undergoing laparoscopic splenectomy with CO₂ pneumoperitoneum. Intra-abdominal pressure was measured throughout the surgery. Results: Bursting pressures were similar in method 1 (246.9 ± 123.2 mmHg) and method 2 (265.5 ± 93.6 mmHg; P = 0.7082). During laparoscopic splenectomy, the non-gas endospray was successfully used to apply fibrin glue without any increase in intra-abdominal pressure. Conclusions: The novel non-gas endospray produced a strong sealing effect similar to that of a conventional gas-spray device and has thus far proved feasible in the clinical setting.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018).

SELECTION CRITERIA

We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience

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.

Clinical complications in the application of polyglycolic acid sheets with fibrin glue after resection of mucosal lesions in oral cavity

OBJECTIVES

Covering open wounds with a polyglycolic acid (PGA) sheet using fibrin glue after resection of oral mucosal lesions is reportedly useful. We focused on clinical complications of this procedure: development of marked granuloma-like neoplasm (GLN) and abnormal postoperative bleeding (APB) on the resected region.

STUDY DESIGN

The characteristics of 100 cases with PGA sheet application after the resection of oral mucosal lesion were examined retrospectively by the medical records and/or oral photographs at our department between 2010 and 2016.

RESULTS

Our retrospective analysis identified included 8 cases of GLN development and 7 cases of APB. There was a significantly higher risk of GLN development when the PGA sheet was applied to the raw surface of the tongue. There were no immediate APBs, but 4 APBs occurred several hours after surgery. All APB cases involved the tongue.

CONCLUSIONS

Both GLNs and APBs are minor complications. Although all cases of GLNs did not involve the recurrence of a tumor, follow-up with incisional or excisional biopsy should be performed. APB in the oral cavity induced by the PGA sheet peeling due to fluctuating adhesive force of the PGA sheets and fibrin glue can sometimes induce life-threatening events.

Prevention of pancreatic fistula using polyethylene glycolic acid mesh reinforcement around pancreatojejunostomy: the propensity score-matched analysis

BACKGROUND

Several small-scale studies have shown that wrapping polyethylene glycolic acid (PGA) mesh around the anastomotic site reinforced pancreaticojejunostomy following pancreatoduodenectomy (PD) with favorable outcomes. This study investigated the efficacy of PGA mesh for reducing postoperative pancreatic fistula (POPF) and evaluated other risk factors for POPF.

METHODS

This study enrolled 464 consecutive patients who underwent PD performed by one surgeon between 2006 and 2015, including a PGA group of 281 patients (60.6%) and a control group of 183 patients (39.4%). All pancreatico-enteric anastomoses were performed using double-layered, duct-to-mucosa, end-to-side pancreaticojejunostomy.

RESULTS

Mean patient age was 63.1 years. The rates of overall (27.0% vs. 37.2%, P = 0.024) and clinically relevant (Grades B, C; 13.9% vs. 24.0%, P = 0.006) POPF were significantly lower in the PGA than in the control group. Following propensity score matching, the rates of clinically relevant POPF (12.6% vs. 22.4%, P = 0.024) and complications (40.2% vs. 63.8%, P < 0.001) remained significantly lower in the PGA group. Multivariate analysis showed that non-pancreatic disease, greater blood loss, higher body mass index, and non-application of PGA mesh were significantly associated with the development of clinically relevant POPF.

CONCLUSIONS

PGA mesh reinforcement of pancreaticojejunostomy may prevent POPF as well as reducing overall abdominal complications after PD.

Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation

OBJECTIVE

To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.

BACKGROUND

Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk.

METHODS

This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance.

RESULTS

There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment.

CONCLUSIONS

This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.

Risk factors of postoperative pancreatic fistula in patients after distal pancreatectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is a common complication following distal pancreatectomy (DP). However, the risk factors of this complication in patients after DP still remain controversial. The aim of our study is to estimate the association between potential risk factors and POPF. Relevant articles published up to June 21, 2016 were identified via PubMed, EMBASE, Web of Science, and The Cochrane Library. Studies that examined the risk factors of POPF following DP were enrolled. 20 articles (2070 patients) were finally included in this study. The pooled data suggested that patients with soft pancreas, higher Body Mass Index (BMI), blood transfusion, elevated intraoperative blood loss, and longer operative time had a decreased risk for POPF. However, age, gender, malignant pathology, types of stump closure, octreotide therapy, history of diabetes and chronic pancreatitis, splenectomy, multiorgan resection, main duct ligation, preoperative serum albumin levels, PGA felt wrapping, and extended lymphadenectomy could not be regarded as risk factors for POPF. Our analytic data demonstrated that pancreas texture, BMI, blood transfusion, intraoperative blood loss, and operative time were clinical predictor for POPF. This study may assist surgeons to screen patients with high risk of POPF and select appropriate treatment measures.

New polyglycolic acid fabric for the prevention of postoperative pancreatic fistulas

BACKGROUND

The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy is approximately 30%. The most serious complications of pancreatic resection, such as mortality and prolonged hospitalization, are unresolved despite the proposal of various surgical procedures. We developed a new polyglycolic acid (PGA) fabric composed of fine diameter fibers to prevent POPF, and macroscopically and microscopically evaluated the effects of applying it to the pancreatic remnant.

METHODS

The ventral pancreatic surface was cauterized to create the experimental model of POPF in 33 female Wistar/ST rats. The injured sites were wrapped with nonwoven PGA fabrics of different fiber diameters and porosities in the treated rats; one group of rats remained untreated. Survival, incidence of generalized peritonitis, and microscopic findings around the pancreas were investigated.

RESULTS

The PGA fabrics acted as a scaffold for tissue repair and resulted in superior survival. Generalized peritonitis was milder in the PGA treated groups. With the new PGA fabric, abundant fibroblast infiltration and a uniformly-developed, self-organized barrier wall prevented both pancreatic leak and spread of inflammation.

CONCLUSION

Application of the newly developed PGA fabric to the pancreatic remnant prevented POPF, and the essential factor for preventing pancreatic leak was the early formation of a self-organized barrier.

Optimal stapler cartridge selection according to the thickness of the pancreas in distal pancreatectomy

Stapling is a popular method for stump closure in distal pancreatectomy (DP). However, research on which cartridges are suitable for different pancreatic thickness is lacking. To identify the optimal stapler cartridge choice in DP according to pancreatic thickness.From November 2011 to April 2015, data were prospectively collected from 217 consecutive patients who underwent DP with 3-layer endoscopic staple closure in Seoul National University Hospital, Korea. Postoperative pancreatic fistula (POPF) was graded according to International Study Group on Pancreatic Fistula definitions. Staplers were grouped based on closed length (CL) (Group I: CL ≤ 1.5 mm, II: 1.5 mm < CL < 2 mm, III: CL ≥ 2 mm). Compression ratio (CR) was defined as pancreas thickness/CL. Distribution of pancreatic thickness was used to find the cut-off point of thickness which predicts POPF according to stapler groups.POPF developed in 130 (59.9%) patients (Grade A; n = 86 [66.1%], B; n = 44 [33.8%]). The numbers in each stapler group were 46, 101, and 70, respectively. Mean thickness was higher in POPF cases (15.2 mm vs 13.5 mm, P = 0.002). High body mass index (P = 0.003), thick pancreas (P = 0.011), and high CR (P = 0.024) were independent risk factors for POPF in multivariate analysis. Pancreatic thickness was grouped into <12 mm, 12 to 17 mm, and >17 mm. With pancreatic thickness <12 mm, the POPF rate was lowest with Group II (I: 50%, II: 27.6%, III: 69.2%, P = 0.035).The optimal stapler cartridges with pancreatic thickness <12 mm were those in Group II (Gold, CL: 1.8 mm). There was no suitable cartridge for thicker pancreases. Further studies are necessary to reduce POPF in thick pancreases.

Effect of Octreotide Injection on Postoperative Drainage After Neck Dissection: A Preliminary Report of a Prospective, Matched Case-Control Study

Objectives

Somatostatin inhibits lymph production and reduces lymph flow into the lymphatic duct. We hypothesized that octreotide, a long-acting somatostatin analog, would reduce drainage after neck dissection (ND) by reducing the overall lymphatic flow in the neck as well as thoracic duct flow.

Methods

From 2012 to 2014, total 123 patients who had undergone left-sided comprehensive ND, were divided into an octreotide group (49 patients) and a control group (74 patients). Seventeen patients from the octreotide group and 17 from the control group were individually matched by age (±10 years), sex, body mass index (±1 kg/m²), type of cancer, surgeon, and the extent of surgery. These 34 patients were finally included in the study.

Results

The total fluid drainage volume (540.9 mL vs. 707.9 mL) and drainage volume during the period of octreotide use (the first 5 postoperative days) (461.1 mL vs. 676.4 mL) were significantly lower in the octreotide group. The duration of drain placement (6.3 days vs. 9.4 days) was also shorter in the octreotide group. In the octreotide group, the mean triglyceride concentration in the drainage fluid was significantly lower than that in the control group (43.1 mg/dL vs. 88.8 mg/dL). There was no complication associated with the use of octreotide.

Conclusion

Our study has shown that postoperative octreotide injections reduce postoperative drainage and the duration of drain placement. Further studies with larger patient populations are warranted to confirm these results and to evaluate the clinical benefits for patients.

Pancreatic fistula after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis: effect of fibrin glue and polyglycolic acid felt on prophylaxis of postoperative complications

BACKGROUND

This study aimed to determine the effect of fibrin glue and polyglycolic acid (PGA) felt on prevention of pancreatic fistula (PF) after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis.

METHODS

Fifty consecutive patients were enrolled in this prospective study. Twenty-three patients underwent laparoscopic splenectomy with a fibrin sheet (fibrin sheet group). The sealing ability of each treatment was evaluated by an ex vivo pressure test model. Based on the results from ex vivo experiments, 27 patients received prophylaxis using fibrin glue and PGA felt (PGA with fibrin group). The primary endpoint was the incidence of PF.

RESULTS

Significantly more (5, 22%) patients developed PF in the fibrin sheet group than in the PGA with fibrin group (0%, P = .037).

CONCLUSIONS

Our new application of fibrin glue and PGA felt is an effective prophylactic procedure for preventing development of PF after laparoscopic splenectomy.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched The Cochrane Library (2015, Issue 7), MEDLINE (1946 to 26 August 2015), EMBASE (1980 to 26 August 2015), Science Citation Index Expanded (1900 to 26 August 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 26 August 2015).

SELECTION CRITERIA

We included all randomized controlled trials that compared fibrin sealant group (fibrin glue or fibrin sealant patch) versus control group (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We included nine trials involving 1095 participants who were randomized to the fibrin sealant group (N = 550) and the control group (N = 545) after pancreatic surgery. All of the trials were at high risk of bias. There was no evidence of differences in overall postoperative pancreatic fistula (fibrin sealant 29.6%; control 31.0%; RR 0.93, 95% CI 0.71 to 1.21; P = 0.58; nine studies; low-quality evidence), postoperative mortality (3.1% versus 2.1%; Peto OR 1.29, 95% CI 0.59 to 2.82; P = 0.53; eight studies; very low-quality evidence), overall postoperative morbidity (29.6% versus 28.9%; RR 1.04, 95% CI 0.82 to 1.32; P = 0.77; five studies), reoperation rate (8.7% versus 10.7%; RR 0.80, 95% CI 0.53 to 1.21; P = 0.29; five studies), or length of hospital stay (12.9 days versus 13.1 days; MD -0.73 days, 95% CI -2.20 to 0.74; P = 0.331; six studies) between the groups. The proportion of postoperative pancreatic fistula that was clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was inadequate evidence to establish the effect of fibrin sealants on clinically significant postoperative pancreatic fistula (9.4% versus 13.4%; RR 0.72, 95% CI 0.42 to 1.21; P = 0.21; three studies). Quality of life and cost effectiveness were not reported in any of the trials.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants do not seem to prevent postoperative pancreatic fistula in people undergoing pancreatic surgery.

Application of polyglycolic acid sheets and fibrin glue spray to bone surfaces during oral surgery: a case series

PURPOSE

Previous studies have described the use of a combination of polyglycolic acid (PGA) sheets (a resorbable biomaterial) and fibrin glue spray to treat open soft tissue wounds during oral surgery, which have produced good results. However, there have not been any detailed investigations of the use of these materials to treat exposed hard tissue wounds. This study investigated the combination of PGA sheets and fibrin glue spray to treat exposed bone surfaces during oral surgery.

MATERIALS AND METHODS

PGA sheets and fibrin glue spray were applied to exposed bone surfaces after lesion resection in 8 patients (10 sites) who had been diagnosed with malignant tumors. The sheets were cut into pieces (width, 5 to 10 mm) and applied to the exposed bone surface.

RESULTS

PGA adhesion was confirmed for the final time on postoperative days 28 to 56 (mean, 35.8 days), and there were no cases in which the PGA sheets fell off the wound prematurely. Epithelialization of the wound surface occurred gradually and was complete by postoperative weeks 4 to 5, regardless of the size of the wound.

CONCLUSION

This method was considered very effective at preventing postoperative bleeding, alleviating postoperative pain, and promoting epithelialization during the reconstruction of bone surfaces after tumor resection in the oral cavity.

The value of drains as a fistula mitigation strategy for pancreatoduodenectomy: something for everyone? Results of a randomized prospective multi-institutional study

BACKGROUND

A recent randomized, controlled trial investigating intraperitoneal drain use during pancreatoduodenectomy (PD) had a primary goal of assessing overall morbidity. It was terminated early with findings that routine elimination of drains in PD increases mortality and the severity and frequency of overall complications. Here, we provide a follow-up analysis of drain value in reference to clinically relevant postoperative pancreatic fistula (CR-POPF).

METHODS

Nine institutions performed 137 PDs, with patients randomized to intraperitoneal drainage (N = 68) or no drainage (N = 69). The Fistula Risk Score (FRS), a 10-point scale derived from four validated risk factors for CR-POPF, facilitated risk adjustment between treatment groups.

RESULTS

There was no difference in fistula risk between the two cohorts. Overall, CR-POPF rates were higher in the no drain group compared to the drain group (20.3 vs. 13.2%; p = 0.269). Patients with negligible/low FRS risk had higher rates of CR-POPF when drains were used (14.8 vs. 4.0%; p = 0.352). Conversely, there were significantly fewer CR-POPFs (12.2 vs. 29.5%; p = 0.050) when drains were used with moderate/high risk patients. Lastly, moderate/high risk patients who suffered a CR-POPF had reduced 90-day mortality (22.2 vs. 42.9%) when a drain was used.

CONCLUSION

The results of this analysis suggest that drains diminish the rate and severity of CR-POPF in patients with moderate/high risk, but they could possibly be avoided in the roughly one third of patients with negligible/low risk.

Surgical management of pancreatic cancer--distal pancreatectomy

Distal pancreatectomy is the standard procedure for tumors located in the body and tail of the pancreas. In the last three decades, significant progress has been made with regard to technical aspects as well as perioperative care so that excellent mortality and morbidity rates can be achieved. Recently, there is growing evidence that distal pancreatectomy may be performed laparoscopically in selected patients, offering the advantages of minimally invasive surgery. Unfortunately, the oncologic outcomes for pancreatic adenocarcinoma remain poor, in part due to the late stage of presentation in most patients. We review the history of distal pancreatectomy, discuss current indications for performing this procedure, compare operative techniques in performing distal pancreatectomy, and review both the early complications seen in patients who have undergone a distal pancreatectomy and the long-term metabolic and oncologic outcomes of these patients.

Systematic review and meta-analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy

BACKGROUND

Established closure techniques for the pancreatic remnant after distal pancreatectomy include stapler, suture and anastomotic closure. However, controversy remains regarding the ideal technique; therefore, the aim of this study was to compare closure techniques and risk of postoperative pancreatic fistula (POPF).

METHODS

A systematic review was carried out according to PRISMA guidelines for studies published before January 2014 that compared at least two closure techniques for the pancreatic remnant in distal pancreatectomy. A random-effects model was constructed using weighted odds ratios (ORs).

RESULTS

Thirty-seven eligible studies matched the inclusion criteria and 5252 patients who underwent distal pancreatectomy were included. The primary outcome measure, the POPF rate, ranged 0 from to 70 per cent. Meta-analysis of the 31 studies comparing stapler versus suture closure showed that the stapler technique had a significantly lower rate of POPF, with a combined OR of 0.77 (95 per cent c.i. 0.61 to 0.98; P = 0.031). Anastomotic closure was associated with a significantly lower POPF rate than suture closure (OR 0.55, 0.31 to 0.98; P = 0.042). Combined stapler and suture closure had significantly lower POPF rates than suture closure alone, but no significant difference compared with stapler closure alone.

CONCLUSION

The use of stapler closure or anastomotic closure for the pancreatic remnant after distal pancreatectomy significantly reduces POPF rates compared with suture closure. The combination of stapler and suture closure shows superiority over suture closure alone.

Fibrin sealants and topical agents in hepatobiliary and pancreatic surgery: a critical appraisal

INTRODUCTION

Fibrin sealants and topical hemostatic agents have been used extensively in hepatobiliary and pancreatic (HPB) surgery to promote coagulation and clot formation decreasing the need for allogeneic blood transfusion and to act as tissue sealants, ideally preventing biliary, enteric, and pancreatic leaks.

RESULTS

Current literature has demonstrated some favorable outcomes using many different products for application in the field of HPB surgery. However, critical findings exist demonstrating lack of reproducible efficacy or benefit. In all, many clinical trials have demonstrated effectiveness of fibrin sealants and other agents at reducing the need for intraoperative and postoperative blood transfusion. Ability to effectively seal tissues providing biliostatic effect or preventing postoperative fistula formation remains debated as definitive evidence is lacking.

CONCLUSIONS

In the following invited review, we discuss current literature describing the use of topical agents and fibrin sealants in liver and pancreas surgery. We summarize major contemporary clinical trials and their findings regarding the use of these agents in HPB surgery and provide evidence from the preclinical literature as to the translation of these products into the clinical arena.

Fibrin sealants and topical agents in hepatobiliary and pancreatic surgery: a critical appraisal

INTRODUCTION

Fibrin sealants and topical hemostatic agents have been used extensively in hepatobiliary and pancreatic (HPB) surgery to promote coagulation and clot formation decreasing the need for allogeneic blood transfusion and to act as tissue sealants, ideally preventing biliary, enteric, and pancreatic leaks.

RESULTS

Current literature has demonstrated some favorable outcomes using many different products for application in the field of HPB surgery. However, critical findings exist demonstrating lack of reproducible efficacy or benefit. In all, many clinical trials have demonstrated effectiveness of fibrin sealants and other agents at reducing the need for intraoperative and postoperative blood transfusion. Ability to effectively seal tissues providing biliostatic effect or preventing postoperative fistula formation remains debated as definitive evidence is lacking.

CONCLUSIONS

In the following invited review, we discuss current literature describing the use of topical agents and fibrin sealants in liver and pancreas surgery. We summarize major contemporary clinical trials and their findings regarding the use of these agents in HPB surgery and provide evidence from the preclinical literature as to the translation of these products into the clinical arena.

Use and results of consensus definitions in pancreatic surgery: a systematic review

BACKGROUND

Because of the lack of standardized definitions of complications in gastrointestinal operations, consensus definitions have been developed in recent years. The aim of the current study was to systematically review the available consensus definitions and to report their use, acceptance, and results.

METHODS

A systematic search of the literature was conducted of the Medline, Cochrane, and ISI Web of Science databases. All articles published until August 2011 and that applied the identified consensus definitions were considered. Inclusion criteria for quantitative analysis were studies with correct usage of the definition and 100 or more patients who were treated after the year 2000.

RESULTS

Seven consensus definitions were identified: postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, posthepatectomy liver failure, bile leakage after hepatobiliary and pancreatic surgery, posthepatectomy hemorrhage, and anastomotic leakage after anterior resection of the rectum. Of 1,637 articles retrieved from the literature search, 59 articles that correctly applied the definitions met the inclusion criteria. Subanalyses were feasible for definitions after pancreatic surgery. According to the consensus definitions, the median complication rates of retrospective studies were 21.9% (postoperative pancreatic fistula, n = 11,244 patients), 5.9% (postpancreatectomy hemorrhage, n = 3,311 patients), and 22.8% (delayed gastric emptying, n = 4,553 patients) after pancreatic resections. The incidences were not substantially different in prospective trials. Validation was performed for all three definitions, demonstrating that the severity grades significantly correlated with the clinical course of the patients.

CONCLUSION

The available consensus definitions were increasingly cited and facilitate scientific comparability and transparency if appropriately applied. The present data update the incidences of major pancreatic complications.

Does fibrin glue sealant decrease the rate of anastomotic leak after a pancreaticoduodenectomy? Results of a prospective randomized trial

BACKGROUND

The aim of this study was to evaluate the effect of topical fibrin glue applied externally to all anastomoses after a pancreaticoduodenectomy (PD) on drain lipase levels, anastomotic leaks, complication rates and length of hospital stay.

METHODS

A standardized non-pylorus preserving PD was performed with or without fibrin glue applied to each anastomosis.

RESULTS

Fifty-seven patients were randomized: 32 with and 25 without TISSEEL. There were no statistical differences in each group with respect to drain lipase levels (high 40% versus 43%, P = 0.794), complications including gastric or biliary leaks (24% versus 28%, P = 1.00), wound infection (16% versus 9%, P = 0.28) and a Clavien score of 3 or more (16% versus 25%, P = 0.757) or hospital stay (12 versus 17 days, P = 0.777). Most patients with elevated drain lipase levels had an unaltered clinical course not predictive of adverse outcomes. However, the operative finding of a soft pancreas (27 out of 57 patients) was associated with post-operative complications (P = 0.002). There were no peri-operative deaths.

CONCLUSIONS

Fibrin glue application to all anastomoses does not alter drain lipase levels. Drain lipase levels are not a significant surrogate marker for clinically significant anastomotic leaks or complications. Fibrin glue application did not reduce the incidence of an anastomotic leak or complications.

Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis

BACKGROUND

Different methods of pancreatic stump closure after distal pancreatectomy (DP) have been described to decrease the incidence of pancreatic fistula (PF) which still represents one of the most common complications in pancreatic surgery. We retrospectively compared the pancreato-jejunostomy technique with the hand-sewn closure of the pancreatic stump after DP, and analyzed clinical outcomes between the two groups, focusing on PF rate.

METHODS

Thirty-six patients undergoing open DP at our institution between May 2005 and December 2011 were included. They were divided in two groups depending on pancreatic remnant management: in 24 cases the stump was closed by hand-sewn suture (Group A), while in 12 earlier cases a pancreato-jejunostomy was performed (Group B). We analyzed postoperative data in terms of mortality, morbidity and length of hospital stay between the two groups.

RESULTS

PF occurred in 7 of 24 (29.1%) cases of group A (control group) compared to zero fistula rate in group B (anastomosis group) (p=0.005). Operative time was significantly higher in the anastomosis group (p=0.024). Mortality rate was 0% in both groups. Other postoperative outcomes such as hemorrhages, infections, medical complications and length of hospital stay were not significant between the two groups.

CONCLUSION

Despite a higher operative time, the pancreato-jejunostomy after DP seems to be related to a lower incidence of PF compared to the hand-sewn closure of the pancreatic remnant.

Management of pancreatic fistulas

The management of pancreatic fistulas can be complex and mandates a multidisciplinary approach. Basic principles of fistula control/patient stabilization, delineation of ductal anatomy, and definitive therapy remain of paramount importance.

Management of remnant pancreatic stump fto prevent the development of postoperative pancreatic fistulas after distal pancreatectomy: current evidence and our strategy

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.