Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial

New technique of end to side two layered and stented duct to mucosa pancreaticojejunostomy with omental wrapping during Whipple operation

BACKGROUND

A leaking pancreaticojejunal anastomosis is typically the cause of major problems following pancreaticoduodenectomy. To stop fistula formation, omental flaps were positioned around the pancreaticojejunal anastomosis.

METHODS

Forty-eight individuals who had pancreaticoduodenectomy procedures performed between March 2022 and March 2024 were examined. Based on the placement of a stent and omental flaps around the pancreaticojejunal anastomosis, the patients were split into two groups: group A, consisting of twenty-four patients, did not get omental wrapping and stenting, and group B, consisting of twenty-four patients, received omental wrapping with stent inside the pancreaticojejunal anastomosis. To evaluate the efficacy of the omental flap operation in preventing postoperative pancreatic fistula and other complications, perioperative data from both groups was examined.

RESULTS

There were no discernible variations in the clinical traits of the two groups. Group B experienced considerably lower occurrences of postoperative pancreatic fistula (20.8% vs. 4.2%), post-pancreatectomy hemorrhage (4.2% vs. 0%), biliary fistula (4.2% vs. 0%), and delayed gastric emptying (12.5% vs. 4.2%). Group B had a considerably lower overall morbidity rate (41.7% vs. 8.3%) and shorter hospital stay (15.3 vs. 10.9 days) than to group A.

CONCLUSION

Following pancreaticoduodenectomy, pancreatic stent and omental flaps around the pancreatic anastomosis can lower the risk of postoperative pancreatic fistula, post-pancrectomy bleeding, and delayed gastric emptying. This straightforward and efficient treatment can decrease the overall morbidity following pancreaticoduodenectomy.

TRIAL REGISTRATION

The trial registration was recorded as ClinicalTrial.gov Identifier No.: NCT06630910 on 10/05/2024. Our study also adheres to the Declaration of Helsinki.

Obsidian ASG autologous platelet-rich fibrin matrix for the prevention of postoperative pancreatic fistula following pancreatic resection: study protocol for a feasibility trial at the Medical University of Vienna

INTRODUCTION

Postoperative pancreatic fistula (POPF) is the most frequent complication after partial pancreatectomy, which is by definition associated with clinical consequences requiring changes in postoperative management. Despite numerous scientific efforts, effective procedures to prevent POPF are lacking. Obsidian ASG autologous platelet-rich fibrin matrix has been effectively applied to prevent anastomotic leakage following colorectal surgery. This study is the first to investigate the feasibility of using the sealant in pancreatic surgery.

METHODS AND ANALYSIS

25 consecutive patients scheduled for elective formal partial pancreatectomy due to any underlying disease fulfilling the eligibility criteria will be included. Obsidian ASG sealant prepared out of 120 mL of each patient's whole blood will be applied to the pancreatic stump or the pancreatic anastomosis, respectively. The primary endpoint is the feasibility of the procedure, for example, the proportion of patients undergoing successful trial intervention. Secondary endpoints comprise safety and surgical outcome parameters including rate and severity of POPF as well as further pancreas-specific complications as defined by the International Study Group of Pancreatic Surgery during 90 days after surgery. Patients will be matched with a historic collective in a 1:2 ratio to gain first data on efficacy.

ETHICS AND DISSEMINATION

This trial and the associated study protocol (V.1.1.1, date 26 March 2024) were approved by the institution's ethics committee (reference number 2191/2023). All trial procedures are performed in accordance with the International Council for Harmonisation harmonised tripartite guideline on Good Clinical Practice and the ethical principles of the Declaration of Helsinki. After completion of the study, results will be published in due course.

TRIAL REGISTRATION NUMBER

The trial was registered in the German Clinical Trials Register on 6 May 2024 (DRKS-ID: DRKS00034052).

Visualization of Intraoperative Pancreatic Leakage (ViP): The IDEAL Stage I First-in-human, Single-arm Clinical Pilot Trial of SmartPAN

Background

The invisible fluid leaking from a partially resected pancreas is associated with complications including postoperative pancreatic fistula (POPF), calling for strategies to visualize intraoperative leakage. This single-arm, monocentric trial aims to evaluate the usefulness and safety of SmartPAN, a hydrogel that reacts to alkali pancreatic fluids by changing color and thus enables the surgeon to take immediate action to close leakage.

Methods

Patients awaiting partial pancreatic resection for any indication were recruited to receive intraoperative SmartPAN application. Trial endpoints covered SmartPAN usability and safety according to reports completed by surgeons after each operation, laboratory measurements of nonbiodegradable compounds in body fluids, and clinical evaluations over 30 days of follow-up.

Results

In total 42 patients were recruited to the trial and 29 received partial pancreatic resection with SmartPAN application according to protocol. All 16 attending surgeons rated SmartPAN as easy to learn and use, mostly agreeing that it was useful and that they intended to use it frequently. No adverse effects or complications were associated with SmartPAN, nor were its compounds detected in blood or abdominal fluids. Positive leakage response was detected in 10/29 surgeries. POPF developed in 7 patients, including 2 intraoperatively detected leakages, thereof 1 with targeted closure as well as 5 with no leakage detected.

Conclusion

This study represents the first-in-human clinical trial of SmartPAN and the precursor to randomized controlled trials. The outcomes support SmartPAN's clinical usability and safety and showcase the device's potential to intraoperatively visualize precursors of POPF.

Suture versus stapler in distal pancreatectomy and its impact on postoperative pancreatic fistula

Postoperative pancreatic fistula is a critical complication after distal pancreatectomy. The aim of this systematic review is to assess new reports on the main pancreatic stump closure techniques (stapler and hand-sewn suture) in distal pancreatectomy, to define their influence on postoperative pancreatic fistula rates. A literature review was performed following PRISMA guidelines (PROSPERO: CRD42023408181). The survey was conducted in Medline (via PubMed) and EMBASE. Clinical trials and cohorts were included if they assessed pancreatic fistula rates after distal pancreatectomy, and excluded if they used a fistula rating system other than the ISGPF one. The risk of bias was assessed using the Study Quality Assessment Tools | NHLBI, NIH. A meta-analysis was presented as forest-plots. Eleven articles were included, representing 1498 patients. No significant difference was found between Suture and Bare stapler (95% CI 0.91-1.68) or Bare stapler and Reinforced stapler for A-graded fistula rates (95% CI 0.78-1.28) and B-graded fistula rates (I-squared = 0.0%, p = 0.784). Most articles showed unclear risk of detection bias. This meta-analysis found no difference in fistula rates between stump closure techniques. This choice should be made by surgeons' and hospital administration's preferences.

Combined division of the splenic vessels and pancreatic parenchyma during laparoscopic distal pancreatectomy is a safe alternative to separate division: a single-institution retrospective study

BACKGROUND

Limited data exists regarding the safety and outcomes of combined division of the splenic vessels with the pancreatic parenchyma during laparoscopic distal pancreatectomy (LDP). This study aims to evaluate the combined division technique.

METHODS

Patients who underwent LDP for pancreatic cancer from April 2011 to December 2022 were retrospectively reviewed and categorized into the following groups: combined (CV) versus separate (SV) division of the splenic vein; combined (CA) versus separate (SA) division of the splenic artery; and combined (CAV) versus separate (SAV) division of the splenic artery and vein, with or without the pancreatic parenchyma.

RESULTS

Among the 80 patients included, 44 underwent CV and 36 underwent SV. Operative time and major morbidity were significantly lower in CV compared with SV. Similar findings were observed in CAV versus SAV, as well as lower blood loss in CAV. Operative time was significantly lower in CA versus SA. Pancreatic fistula and postpancreatectomy hemorrhage rates showed no significant differences between groups. No patient developed splenic arteriovenous fistula in follow-up.

CONCLUSION

Combined division of the splenic vessels with the pancreatic parenchyma during LDP is safe and associated with improved outcomes compared with separate division.

Laparoscopic distal pancreatectomy with pancreatic remnant-gastric coverage: a modified technique to reduce postoperative pancreatic fistula

BACKGROUND

To evaluate the efficacy and safety of a modified pancreatic remnant-gastric coverage technique in laparoscopic distal pancreatectomy (LDP).

METHODS

This retrospective study analyzed clinical data from 63 patients who underwent LDP between March 2017 and April 2024 at the Hepatobiliary and Pancreatic Surgery Department, The Affiliated LiHuiLi Hospital of Ningbo University. Patients were divided into two groups based on the pancreatic remnant management method: the experimental group (n = 28) underwent pancreatic remnant-gastric coverage, while the control group (n = 35) had the pancreatic remnant closed using a stapler followed by hand-sewn reinforcement. The parameters observed included general patient characteristics, intraoperative data, and postoperative data. We compared and analyzed all the above data between the two groups of patients both before and after propensity score matching (PSM).

RESULTS

All 63 patients were successfully operated. Before PSM, the incidence of POPF (Grade B/C) in the experimental group was significantly lower than in the control group (14.3% vs 34.3%, P < 0.05). And the incidence of POPF (BL) in the experimental group was lower than in the control group (39.3% vs 51.4%). After PSM, the difference in the incidence of POPF (Grade B/C) between the two groups remained statistically significant (16.0% vs 32.0%, P < 0.05). The incidence of POPF (BL) in the experimental group was also lower than in the control group (36.0% vs 56.0%). There were no statistically significant differences between the two groups in terms of operation time, pancreatic texture, thickness of pancreatic stump, intraoperative bleeding, intraoperative transfusion, post-pancreatectomy hemorrhage, abdominal infection, encapsulated effusion, or delayed gastric emptying both before and after PSM (P > 0.05).

CONCLUSION

The use of the modified pancreatic remnant-gastric coverage in LDP effectively reduces the incidence of POPF and is both safe and feasible, making it a technique worth promoting.

An improved invagination pancreaticojejunostomy technique associated with a lower incidence of pancreatic fistula: A single-center study

PURPOSE

This study compared the incidence of postoperative pancreatic fistula (POPF) between standard invagination pancreaticojejunostomy (PJ) and an improved PJ technique after pancreaticoduodenectomy and evaluated the clinical utility of the improved PJ procedure.

METHODS

Clinical and postoperative data of 363 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Soochow University from February 2018 to October 2021 were analyzed retrospectively. In our cohort, 155 patients underwent the improved PJ technique (group A), and 208 underwent standard invagination PJ (group B). Data on demographic characteristics, pathological nature, intraoperative factors, and postoperative complications, including POPF, were collected and analyzed.

RESULTS

There were no significant between-group differences in demographic characteristics (p > 0.05). The improved PJ technique was associated with a significantly lower incidence of clinically relevant POPF (CR-POPF) in the total cohort (11.6 % vs. 26.4 %, p < 0.001) and in the subgroup with high fistula risk scores (16.0 % vs. 38.6 %, p < 0.001).

CONCLUSION

The improved invagination PJ technique reduces the incidence of CR-POPF and improves prognosis.

Powered stapler and polyglycolic acid sheet for pancreatic fistula after distal pancreatectomy

BACKGROUND

Although distal pancreatectomy (DP) is crucial for the treatment of pancreatic diseases, it often leads to postoperative pancreatic fistula (POPF), a complication with significant management challenges and health effects. Despite the use of various techniques, including suturing methods, staplers, and biodegradable materials, the optimal strategy to reduce POPF remains unclear. This study investigated the combined use of powered staplers and polyglycolic acid (PGA) sheets to mitigate POPF.

METHODS

This study retrospectively analyzed the data of 165 patients who underwent DP at Sapporo Medical University Hospital between January 2013 and August 2023. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients treated without (group O, n = 50) and with powered staplers and PGA sheets (group P, n = 115). In addition, the surgical techniques, patient demographics, and postoperative outcomes were examined.

RESULTS

This study found no significant difference in the overall incidence of POPF between the groups. However, group P had a significantly lower incidence of CR-POPF than group O (20.9% vs 40.0%, respectively; P = .011). Multivariate analysis demonstrated that male sex (odds ratio [OR], 2.81; 95% CI, 1.26-6.26; P = .012) and pancreatic thickness of more than 14 mm (OR, 2.85; 95% CI, 1.17-6.95; P = .021) were independent risk factors for CR-POPF. The use of powered staplers and PGA sheets (OR, 0.38; 95% CI, 0.17-0.85; P = .017) was associated with reduced CR-POPF risk.

CONCLUSION

The combined use of powered staplers and PGA sheets can significantly decrease the incidence of CR-POPF in patients with DP.

Abdominal drainage after minimally invasive distal pancreatectomy: out of sight, out of mind?

BACKGROUNDS

The use of drains in pancreatic surgery remains controversial. The present study investigated postoperative outcomes in patients undergoing minimally invasive distal pancreatectomy (MIDP) without intraperitoneal drain placement.

METHODS

Data of consecutive patients undergoing MIDP between 2013 and 2023 were prospectively collected. Patients were divided in drain group (DG), including patients with prophylactic abdominal drain placed, and no-drain group (NDG) including those without drain. The groups were compared in terms of postoperative outcomes, using a propensity score-matched analysis.

RESULTS

116 patients were selected. After matching, DG and NDG consisted of 29 patients each. The rates of POPF and abdominal collection were lower in NDG in comparison to DG (3.4% vs. 27.6%, p 0.025 and 3.4% vs. 31.0%, p 0.011, respectively). The length of stay was significantly shorter in the NDG (5 vs. 9 days, p < 0.001). No difference between the groups was found for other outcomes.

CONCLUSION

Drain omission was associated with lower rates of POPF and abdominal collections, as well as shorter hospital stays, not affecting the rate of severe complication, reoperation and readmission.

Advantage of Postoperative Inflammatory Status after Laparoscopic Distal Pancreatectomy

INTRODUCTION

Laparoscopic distal pancreatectomy (LDP) is a safe and effective procedure; however, its impact on perioperative inflammatory reactions compared with open distal pancreatectomy (ODP) remains unclear. This study aimed to assess short-term outcomes following LDP and ODP regarding inflammatory reactions.

METHODS

This retrospective study of 77 consecutive patients who underwent distal pancreatectomy for low-grade malignancies between 2005 and 2022 compared white blood cell (WBC) count, C-reactive protein (CRP) level, serum albumin level, and CRP/albumin ratio (CAR) between LDP and ODP. Complications, especially postoperative pancreatic fistula (POPF), recovery program, and hospital stay period, were also compared.

RESULTS

POPF (17.1% vs. 38.7%, p = 0.039) and surgical morbidity (≥Clavien-Dindo grade III, 12.2% vs. 32.3%, p = 0.038) were significantly lower in LDP than in ODP, as for the difference in postoperative inflammatory response, including CRP and CAR, was just temporary. By multivariate analysis, CAR ≥6.94 on POD 3 was significant predictor of POPF (42.1% vs. 13.2%, odds ratio 4.828, p = 0.030).

CONCLUSION

LDP has lower POPF and earlier postoperative recovery. CAR could be a predictor of POPF.

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.

Pancreatic Surgery in Children: Complex, Safe, and Effective

OBJECTIVE

The aim of this study was to assess indications for and report outcomes of pancreatic surgery in pediatric patients.

BACKGROUND

Indications for pancreatic surgery in children are rare and data on surgical outcomes after pediatric pancreatic surgery are scarce.

METHODS

All children who underwent pancreatic surgery at a tertiary hospital specializing in pancreatic surgery between 2003 and 2022 were identified from a prospectively maintained database. Indications, surgical procedures, and perioperative as well as long-term outcomes were analyzed.

RESULTS

In total, 73 children with a mean age of 12.8 years (range: 4 mo to 18 y) underwent pancreatic surgery during the observation period. Indications included chronic pancreatitis (n=35), pancreatic tumors (n=27), and pancreatic trauma (n=11). Distal pancreatectomy was the most frequently performed procedure (n=23), followed by pancreatoduodenectomy (n=19), duodenum-preserving pancreatic head resection (n=10), segmental pancreatic resection (n=7), total pancreatectomy (n=3), and others (n=11). Postoperative morbidity occurred in 25 patients (34.2%), including 7 cases (9.6%) with major complications (Clavien-Dindo≥III). There was no postoperative (90-d) mortality. The 5-year overall survival was 90.5%. The 5-year event-free survival of patients with chronic pancreatitis was 85.7%, and 69.0% for patients with pancreatic tumors.

CONCLUSION

This is the largest single-center study on pediatric pancreatic surgery in a Western population. Pediatric pancreatic surgery can be performed safely. Centralization in pancreatic centers with high expertise in surgery of adult and pediatric patients is important as it both affords the benefits of pancreatic surgery experience and ensures that surgical management is adapted to the specific needs of children.

Minimally invasive versus open distal pancreatectomy for resectable pancreatic neuroendocrine tumors: A propensity score matched multicentric comparative French study

BACKGROUND

Minimally invasive surgery has gained momentum for left pancreatic resections. However, debate remains about whether it has any advantage over open surgery for distal pancreatectomy for pancreatic neuroendocrine tumors.

METHODS

This retrospective review examined pancreatectomies performed for resectable pancreatic neuroendocrine tumors at 21 centers in France between January 2014 and December 2018. Short and long-term outcomes were compared before and after propensity score matching based on tumor size, sex, age, body mass index, center, and method of pancreatic transection.

RESULTS

During the period study, 274 patients underwent left pancreatic resection for pancreatic neuroendocrine tumors [109 underwent distal splenopancreatectomy, and 165 underwent spleen-preserving distal pancreatectomy [(splenic vessel preservation (n = 97; 58.7%)/splenic vessel resection (n = 68; 41.3%)]. Before propensity score matching, minimally invasive surgery was associated with a lower rate of major morbidity (P = .004), lower rate of postoperative delayed gastric emptying (P = .04), and higher rate of "textbook" outcomes (P = .04). After propensity score matching, there were 2 groups of 54 patients (n = 30 distal splenopancreatectomy; n = 78 spleen-preserving distal pancreatectomy). Minimally invasive surgery was associated with less blood loss (P = .05), decreased rate of major morbidity (6% vs. 24%; P = .02), less delayed gastric emptying (P = .05) despite similar rates of postoperative fistula, hemorrhage, and reoperation (P > .05). The 5-year overall survival (79% vs. 75%; P = .74) and recurrence-free survival (10% vs 17%; P = .39) were similar.

CONCLUSION

Minimally invasive surgery for left pancreatic resection can be safely proposed for patients with resectable left pancreatic neuroendocrine tumors. Minimally invasive surgery decreases the rate of major complications while providing comparable long-term oncologic outcomes.

Postoperative Complications and Mobilization Following Major Abdominal Surgery With Versus Without Fitness Tracker-based Feedback (EXPELLIARMUS): A Student-led Multicenter Randomized Controlled Clinical Trial of the CHIR-Net SIGMA Study Group

OBJECTIVE

To determine whether daily postoperative step goals and feedback through a fitness tracker (FT) reduce the rate of postoperative complications after surgery.

BACKGROUND

Early and enhanced postoperative mobilization has been advocated to reduce postoperative complications, but it is unknown whether FT alone can reduce morbidity.

METHODS

EXPELLIARMUS was performed at 11 University Hospitals across Germany by the student-led clinical trial network SIGMA. Patients undergoing major abdominal surgery were enrolled, equipped with an FT, and randomly assigned to the experimental (visible screen) or control intervention (blackened screen). The experimental group received daily step goals and feedback through the FT. The primary end point was postoperative morbidity within 30 days using the Comprehensive Complication Index (CCI). All trial visits were performed by medical students in the hospital with the opportunity to consult a surgeon-facilitator who also obtained informed consent. After discharge, medical students performed the 30-day postoperative visit through telephone and electronic questionnaires.

RESULTS

A total of 347 patients were enrolled. Baseline characteristics were comparable between the 2 groups. The mean age of patients was 58 years, and 71% underwent surgery for malignant disease, with the most frequent indications being pancreatic, colorectal, and hepatobiliary malignancies. Roughly one-third of patients underwent laparoscopic surgery. No imputation for the primary end point was necessary as data completeness was 100%. There was no significant difference in the CCI between the 2 groups in the intention-to-treat analysis (mean±SD CCI experimental group: 23±24 vs. control: 22±22; 95% CI: -6.1, 3.7; P=0.628). All secondary outcomes, including quality of recovery, 6-minute walking test, length of hospital stay, and step count until postoperative day 7 were comparable between the 2 groups.

CONCLUSIONS

Daily step goals combined with FT-based feedback had no effect on postoperative morbidity. The EXPELLIARMUS shows that medical students can successfully conduct randomized controlled trials in surgery.

Prolonged pre-firing pancreatic compression with linear staplers in distal pancreatectomy: a valuable technique for post-operative pancreatic fistula prevention

PURPOSE

Post-operative pancreatic fistula (POPF) remains the main complication after distal pancreatectomy (DP). The aim of this study is to evaluate the potential benefit of different durations of progressive stapler closure on POPF rate and severity after DP.

METHODS

Patients who underwent DP between 2016 and 2023 were retrospectively enrolled and divided into two groups according to the duration of the stapler closure: those who underwent a progressive compression for < 10 min and those for ≥ 10 min.

RESULTS

Among 155 DPs, 83 (53.5%) patients underwent pre-firing compression for < 10 min and 72 (46.5%) for ≥ 10 min. As a whole, 101 (65.1%) developed POPF. A lower incidence rate was found in case of ≥ 10 min compression (34-47.2%) compared to < 10 min compression (67- 80.7%) (p = 0.001). When only clinically relevant (CR) POPFs were considered, a prolonged pre-firing compression led to a lower rate (15-20.8%) than the < 10 min cohort (32-38.6%; p = 0.02). At the multivariate analysis, a compression time of at least 10 min was confirmed as a protective factor for both POPF (OR: 5.47, 95% CI: 2.16-13.87; p = 0.04) and CR-POPF (OR: 2.5, 95% CI: 1.19-5.45; p = 0.04) development. In case of a thick pancreatic gland, a prolonged pancreatic compression for at least 10 min was significantly associated to a lower rate of CR-POPF compared to < 10 min (p = 0.04).

CONCLUSION

A prolonged pre-firing pancreatic compression for at least 10 min seems to significantly reduce the risk of CR-POPF development. Moreover, significant advantages are documented in case of a thick pancreatic gland.

Comparison of outcomes with stapler versus hand-sewn closure of the pancreatic stump following minimally invasive distal pancreatectomy: a retrospective cohort study

Background:

Pancreatic fistula after distal pancreatectomy is a common and potentially lethal complication. The optimal closure method for the pancreatic remnant during minimally invasive distal pancreatectomy (MDP) remains unclear.

Methods:

Data of consecutive patients who underwent MDP in our institution between July 2018 and June 2021 were collected. The outcomes of MDP with stapler and hand-sewn closure were compared. The primary outcome was clinically relevant postoperative pancreatic fistula (CR-POPF) per the International Study Group of Pancreatic Surgery definition.

Results:

Of the 384 patients (stapler closure, 339; hand-sewn closure, 45) enrolled, 249 developed CR-POPF (grades B and C: 242 and 7 patients, respectively). The rates of grade B and grade C POPF in the stapler group were similar to the corresponding rates in the hand-sewn group (64.6% and 1.5% vs 51.1% and 4.4%, P = .078 and P = .223, respectively). No differences between the stapler and hand-sewn groups were observed regarding the median operation time (207 vs 222 minutes, P = .139), incidence of major complications (16.5% vs 20.0%, P = .559), and mortality (0.2% vs 0%, P = 1.000). The independent risk factors of CR-POPF were abdominal abscess, prolonged operation time, and transection site (P = .004, .006, and .001, respectively).

Conclusion:

The incidence and severity of CR-POPF by stapler closure of the pancreatic stump were comparable to those associated with hand-sewn closure in MDP in this retrospective cohort. Randomized controlled trials are needed to verify this finding.

Prophylactic abdominal drainage after distal pancreatectomy (PANDORINA): an international, multicentre, open-label, randomised controlled, non-inferiority trial

BACKGROUND

Prophylactic passive abdominal drainage is standard practice after distal pancreatectomy. This approach aims to mitigate the consequences of postoperative pancreatic fistula (POPF) but its added value, especially in patients at low risk of POPF, is currently being debated. We aimed to assess the non-inferiority of a no-drain policy in patients after distal pancreatectomy.

METHODS

In this international, multicentre, open-label, randomised controlled, non-inferiority trial, we recruited patients aged 18 years or older undergoing open or minimally invasive elective distal pancreatectomy for all indications in 12 centres in the Netherlands and Italy. We excluded patients with an American Society of Anesthesiology (ASA) physical status of 4-5 or WHO performance status of 3-4, added by amendment following the death of a patient with ASA 4 due to a pre-existing cardiac condition. Patients were randomly assigned (1:1) intraoperatively by permuted blocks (size four to eight) to either no drain or prophylactic passive drain placement, stratified by annual centre volume (<40 or ≥40 distal pancreatectomies) and low risk or high risk of grade B or C POPF. High-risk was defined as a pancreatic duct of more than 3 mm in diameter, a pancreatic thickness at the neck of more than 19 mm, or both, based on the Distal Pancreatectomy Fistula Risk Score. Other patients were considered low-risk. The primary outcome was the rate of major morbidity (Clavien-Dindo score ≥III), and the most relevant secondary outcome was grade B or C POPF, grading per the International Study Group for Pancreatic Surgery. Outcomes were assessed up to 90 days postoperatively and analysed in the intention-to-treat population and per-protocol population, which only included patients who received the allocated treatment. A prespecified non-inferiority margin of 8% was compared with the upper limit of the two-sided 95% CI (Wald) of unadjusted risk difference to assess non-inferiority. This trial is closed and registered in the Netherlands Trial Registry, NL9116.

FINDINGS

Between Oct 3, 2020, and April 28, 2023, 376 patients were screened for eligibility and 282 patients were randomly assigned to the no-drain group (n=138; 75 [54%] women and 63 [46%] men) or the drain group (n=144; 73 [51%] women and 71 [49%] men). Seven patients in the no-drain group received a drain intraoperatively; consequently, the per-protocol population included 131 patients in the no-drain group and 144 patients in the drain group. The rate of major morbidity was non-inferior in the no-drain group compared with the drain group in the intention-to-treat analysis (21 [15%] vs 29 [20%]; risk difference -4·9 percentage points [95% CI -13·8 to 4·0]; pnon-inferiority=0·0022) and the per-protocol analysis (21 [16%] vs 29 [20%]; risk difference -4·1 percentage points [-13·2 to 5·0]; pnon-inferiority=0·0045). Grade B or C POPF was observed in 16 (12%) patients in the no-drain group and in 39 (27%) patients in the drain group (risk difference -15·5 percentage points [95% CI -24·5 to -6·5]; pnon-inferiority<0·0001) in the intention-to-treat analysis. Three patients in the no-drain group died within 90 days; the cause of death in two was not considered related to the trial. The third death was a patient with an ASA score of 4 who died after sepsis and a watershed cerebral infarction at second admission, leading to multiple organ failure. No patients in the drain group died within 90 days.

INTERPRETATION

A no-drain policy is safe in terms of major morbidity and reduced the detection of grade B or C POPF, and should be the new standard approach in eligible patients undergoing distal pancreatectomy.

FUNDING

Ethicon UK (Johnson & Johnson Medical, Edinburgh, UK).

Efficacy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy

BACKGROUND

A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult.

METHODS

Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated.

RESULTS

In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay was longer in the UCS group than in the stapler group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure.

CONCLUSIONS

PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.

Cavitron ultrasonic surgical aspirator (CUSA) compared with conventional pancreatic transection in distal pancreatectomy: study protocol for the randomised controlled CUSA-1 pilot trial

BACKGROUND

Postoperative pancreatic fistula (POPF) remains the most common and serious complication after distal pancreatectomy. Many attempts at lowering fistula rates have led to unrewarding insignificant results as still up to 30% of the patients suffer from clinically relevant POPF. Therefore, the development of new innovative methods and procedures is still a cornerstone of current surgical research.The cavitron ultrasonic surgical aspirator (CUSA) device is a well-known ultrasound-based parenchyma transection method, often used in liver and neurosurgery which has not yet been thoroughly investigated in pancreatic surgery, but the first results seem very promising.

METHODS

The CUSA-1 trial is a randomised controlled pilot trial with two parallel study groups. This single-centre trial is assessor and patient blinded. A total of 60 patients with an indication for open distal pancreatectomy will be intraoperatively randomised after informed consent. The patients will be randomly assigned to either the control group with conventional pancreas transection (scalpel or stapler) or the experimental group, with transection using the CUSA device. The primary safety endpoint of this trial will be postoperative complications ≥grade 3 according to the Clavien-Dindo classification. The primary endpoint to investigate the effect will be the rate of POPF within 30 days postoperatively according to the ISGPS definition. Further perioperative outcomes, including postpancreatectomy haemorrhage, length of hospital stay and mortality will be analysed as secondary endpoints.

DISCUSSION

Based on the available literature, CUSA may have a beneficial effect on POPF occurrence after distal pancreatectomy. The rationale of the CUSA-1 pilot trial is to investigate the safety and feasibility of the CUSA device in elective open distal pancreatectomy compared with conventional dissection methods and gather the first data on the effect on POPF occurrence. This data will lay the groundwork for a future confirmatory multicentre randomised controlled trial.

ETHICS AND DISSEMINATION

The CUSA-1 trial protocol was approved by the ethics committee of the University of Heidelberg (No. S-098/2022). Results will be published in an international peer-reviewed journal and summaries will be provided in lay language to study participants and their relatives.

TRIAL REGISTRATION NUMBER

DRKS00027474.

Comparing the distal pancreatectomy fistula risk score (D-FRS) and DISPAIR-FRS for predicting pancreatic fistula after distal pancreatectomy

BACKGROUNDS

Distal pancreatectomy fistula risk score (D-FRS) and DISPAIR-FRS has not been widely validated for predicting postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP).

METHODS

We retrospectively analysed 104 patients undergoing DP. The predictive value of the D-FRS and DISPAIR-FRS were compared. Risk factors associated with POPF were investigated by multivariate analysis.

RESULTS

Of the 104 patients, 23 (22.1%) were categorized into the POPF group (all grade B). The areas under the ROC (AUCs) of the D-FRS (preoperative), D-FRS (intraoperative), and DISPAIR-FRS were 0.737, 0.809, and 0.688, respectively. Stratified by the D-FRS (preoperative), the POPF rates in low-risk, intermediate-risk, and high-risk groups were 5%, 22.6%, and 36.4%, respectively. By the D-FRS (intraoperative), the POPF rates in low-risk, intermediate-risk, and high-risk groups were 8.8%, 47.1%, and 47.4%, respectively. By the DISPAIR-FRS, the POPF rates in low-risk, intermediate-risk, and extreme-high-risk groups were 14.8%, 23.8% and 62.5%, respectively. Body mass index and main pancreatic duct diameter were independent risk factors of POPF both in preoperative (P = 0.014 and P = 0.033, respectively) and intraoperative (P = 0.015 and P = 0.039) multivariate analyses.

CONCLUSION

Both the D-FRS (preoperative), D-FRS (intraoperative), and DISPAIR-FRS has good performance in POPF prediction after DP. The risk stratification was not satisfactory in current Asian cohort.

A novel electrode for reducing tissue thermal damage in radiofrequency-induced intestinal anastomosis

PURPOSE

This study aimed to design a novel electrode for reducing tissue thermal damage in radiofrequency-induced intestinal anastomosis.

MATERIAL AND METHODS

We developed and compared two electrodes (Ring electrode, and Plum electrode with reduced section of the middle fusion area by nearly 80% arising from novel structural design) by performing ex-vivo experiments and finite element analysis.

RESULTS

In contrast to the Ring electrode group, slightly higher mean strength is acquired with the tensile force and burst pressure results increasing from 9.7 ± 1.47 N, 84.0 ± 5.99 mmHg to 11.1 ± 1.71 N, 89.4 ± 6.60 mmHg, respectively, as well as a significant reduction in tissue thermal damage for the Plum electrode group, with compression pressure of 20 kPa, RF energy of 120 W and welding duration of 8 s applied to the target regions to achieve anastomosis. Besides, the novel structural design of the Plum electrode can counteract the tension generated by intestinal peristalsis and enhance the biomechanical strength of the anastomotic area. The histological observation showed that the fusion area of the two-layer intestinal tissue is tightly connected with decreased thickness.

CONCLUSION

The novel electrode (Plum electrode) could reduce tissue thermal damage in radiofrequency-induced intestinal anastomosis.

Comparison of manual sutures and laparoscopic stapler for pancreatic stump closure techniques in robotic distal pancreatectomy: a single-center experience

BACKGROUND

Postoperative pancreatic fistulas (POPFs) are prevalent and major postoperative complications of distal pancreatectomy (DP). There are numerous ways to manage the pancreatic stump. However, no single approach has been shown to be consistently superior. Moreover, the potential role of robotic systems in reducing POPFs has received little attention.

METHODS

The clinical data of 119 patients who had consecutively received robotic distal pancreatectomy between January 2019 and December 2022 were retrospectively analyzed. Patients were divided into two groups according to the method of handling the pancreatic stump. The attributes of the patients and the variables during the perioperative period were compared.

RESULTS

The analysis included 72 manual sutures and 47 stapler procedures. The manual suture group had a shorter operative time (removing installation time) than the stapler group (125.25 ± 63.04 min vs 153.30 ± 62.03 min, p = 0.019). Additionally, the manual suture group had lower estimated blood loss (50 mL vs 100 mL, p = 0.009) and a shorter postoperative hospital stay. There were no significant differences in the incidence of clinically relevant POPFs between the two groups (18.1% vs 23.4%, P > 0.05). No perioperative death occurred in either group.

CONCLUSION

The manual suturing technique was shown to have an incidence of POPFs similar to the stapler technique in robotic distal pancreatectomy and to be safe and feasible.

Endoscopic main duct stenting in refractory postoperative pancreatic fistula after distal pancreatectomy - a friend or a foe?

BACKGROUND

Clinically relevant (CR) postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) are common. Endoscopic treatment (ET) has only scarcely been explored. The aim of this study was to evaluate risk factors for CR POPF after DP and the efficacy of ET in adjunct to standard therapy.

METHODS

Consecutive patients without previous pancreatic surgery who underwent DP between 2011 and 2020 were evaluated, analyzing risk factors for CR POPF. The choice and performance of ET, main pancreatic duct (MPD) stenting, was not standardized. Healing time and complications after ET were registered.

RESULTS

406 patients underwent DP, CR POPF occurred in 29.6%. ET was performed in 17 patients 27 days (median) after index surgery. Risk for CR POPF was increased in ASA-PS 1-2 patients, MPD ≤ 3 mm, procedure time ≥ 3 h, and CRP ≥ 180 on postoperative day 3. POPF resolved with standard treatment after 32 days and 59 days in the ET group (p < 0.001). There was one mortality in the ET-group (not procedure related). Mild post-ERCP pancreatitis occurred in three patients.

CONCLUSIONS

CR POPF is common after DP. Long operating time, a narrow MPD, low ASA score, and high postoperative CRP were risk factors for CR POPF. ET was not beneficial but proper evaluation was not possible due to few patients and non-standardized treatment. Complications after ET appeared mild.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio on postoperative day three as a biochemical predictor of clinically significant pancreatic fistula in patients undergoing distal pancreatectomy

INTRODUCTION AND AIMS

Distal pancreatectomy is a frequent procedure and postoperative fistula, its most common complication, has an incidence of 30 to 60%. The aim of the present work was to study the role of the neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio, as indicators of inflammatory response in the setting of pancreatic fistula.

METHODS

A retrospective observational study was conducted on patients that underwent distal pancreatectomy. The diagnosis of postoperative pancreatic fistula was made according to the definition proposed by the International Study Group on Pancreatic Fistula. The relation of postoperative pancreatic fistula to the neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio was determined in the postoperative evaluation. SPSS v.21 software was utilized for the statistical analysis and a P<.05 was considered statistically significant.

RESULTS

A total of 12 patients (27.2%) developed grade B or grade C postoperative pancreatic fistula. ROC curves were constructed and a threshold of 8.3 (PPV 0.40, NPV 0.86) was established for the neutrophil-to-lymphocyte ratio, with an area under the curve of 0.71, sensitivity of 0.81, and specificity of 0.62, whereas a threshold of 33.2 (PPV 0.50, NPV 0.84) was established for the platelet-to-lymphocyte ratio, with an area under the curve of 0.72, sensitivity of 0.72, and specificity of 0.71.

CONCLUSION

The neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio are serologic markers that can aid in identifying patients that will present with grade B or grade C postoperative pancreatic fistula, thus helping to provide an opportune focus on care and resources.

Nationwide validation of the distal fistula risk score (D-FRS)

PURPOSE

Distal pancreatectomy (DP) is associated with a high complication rate of 30-50% with postoperative pancreatic fistula (POPF) as a dominant contributor. Adequate risk estimation for POPF enables surgeons to use a tailor-made approach. Assessment of the risk of POPF prior to DP can lead to the application of preventive strategies. The current study aims to validate the recently published preoperative and intraoperative distal fistula risk score (D-FRS) in a nationwide cohort.

METHODS

This nationwide retrospective Dutch cohort study included all patients after DP for any indication, all of whom were registered in the Dutch Pancreatic Cancer Audit (DPCA) database between 2013 and 2021. The D-FRS was validated by filling in the probability equations with data from this cohort. The predictive capacity of the models was represented by an area under the receiver operating characteristic (AUROC) curve.

RESULTS

A total of 896 patients underwent DP of which 152 (17%) developed POPF of whom 144 grade B (95%) and 8 grade C (5%). The preoperative D-FRS, consisting of the variables pancreatic neck thickness and pancreatic duct diameter, showed an AUROC of 0.73 (95%CI 0.68-0.78). The intraoperative D-FRS, comprising pancreatic neck, duct diameter, BMI, operating time, and soft pancreatic aspect, showed an AUROC of 0.69 (95%CI 0.64-0.74).

CONCLUSION

The current study is the first nationwide validation of the preoperative and intraoperative D-FRS showing acceptable distinguishing capacity for only the preoperative D-FRS for POPF. Therefore, the preoperative score could improve prevention and mitigation strategies such as drain management, which is currently investigated in the multicenter PANDORINA trial.

ROBOTIC ASSISTED VERSUS LAPAROSCOPIC DISTAL PANCREATECTOMY: A RETROSPECTIVE STUDY

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is associated with less blood loss and faster functional recovery. However, the benefits of robotic assisted distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) are unknown.

AIMS

To compare RDP versus LDP for surgical treatment of benign lesions, pre-malignant and borderline malignant pancreatic neoplasias.

METHODS

This is a retrospective study comparing LDP with RDP. Main outcomes were overall morbidity and overall costs. Secondary outcomes were pancreatic fistula (PF), infectious complications, readmission, operative time (OT) and length of hospital stay (LOS).

RESULTS

Thirty patients submitted to LDP and 29 submitted to RDP were included in the study. There was no difference regarding preoperative characteristics. There was no difference regarding overall complications (RDP - 72,4% versus LDP - 80%, p=0,49). Costs were superior for patients submitted to RDP (RDP=US$ 6,688 versus LDP=US$ 6,149, p=0,02), mostly due to higher costs of surgical materials (RDP=US$ 2,364 versus LDP=1,421, p=0,00005). Twenty-one patients submitted to RDP and 24 to LDP developed pancreatic fistula (PF), but only 4 RDP and 7 LDP experienced infectious complications associated with PF. OT (RDP=224 min. versus LDP=213 min., p=0.36) was similar, as well as conversion to open procedure (1 RDP and 2 LDP).

CONCLUSIONS

The postoperative morbidity of robotic distal pancreatectomy is comparable to laparoscopic distal pancreatectomy. However, the costs of robotic distal pancreatectomy are slightly higher.

Reinforced stapling does not reduce postoperative pancreatic fistula in distal pancreatectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is a severe complication after distal pancreatectomy (DP); however, it is unclear how to effectively reduce the incidence. The purpose of this meta-analysis is to determine whether reinforced stapling reduces POPF after DP. From February 2007 to April 2023, a comprehensive search of electronic data and references was conducted in PubMed/Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. In this study, the perioperative outcomes were evaluated for the reinforced stapler (RS) group and the standard stapler (SS) group in DP using Review Manager Software. Using fixed- or random-effects models, pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. In total, three randomized clinical trials (RCTs) with 425 patients and five observational clinical studies (OCS) with 318 patients were included. In pooled meta-analyses from RCTs, there was no difference between the two groups in the incidence of POPF (OR = 0.79; 95% CI [0.47,1.35]; P = 0.39), intraoperative blood loss (MD = 10.66; 95% CI [- 28.83,50.16]; P = 0.6), operative time (MD = 9.88; 95% CI [- 8.92,28.67]; P = 0.3), major morbidity (OR = 1.12; 95% CI [0.67,1.90]; P = 0.66), reoperation (OR = 0.97; 95% CI [0.41,2.32]; P = 0.95), readmission (OR = 0.99; 95% CI [0.57,1.72]; P = 0.97) or hospital stay (MD = - 0.95; 95% CI [- 5.22,3.31]; P = 0.66). However, the results of POPF and readmission were favorable for RS in the OCS group.

Chronic Glucocorticoid Use is a Potential Risk Factor for Delayed Pancreatic Fistula after Laparoscopic Distal Pancreatectomy: A Retrospective Analysis

Pancreatic fistula is a potentially morbid complication after distal pancreatectomy. Chronic glucocorticoid use is one of the risk factors for pancreatic fistula in pancreaticoduodenectomy, though it has not been reported in distal pancreatectomy. We explored whether chronic glucocorticoid use can be a risk factor for pancreatic fistula in distal pancreatectomy. We reviewed 408 consecutive patients who underwent elective distal pancreatectomy from 2011 to 2021. We evaluated two kinds of pancreatic fistula (postoperative pancreatic fistula and delayed pancreatic fistula). We defined delayed pancreatic fistula as a patient who was re-admitted for pancreatic fistula after the first discharge from the hospital. Preoperative characteristics and postoperative outcomes were analyzed. Two hundred sixty-seven patients underwent open distal pancreatectomy, while 141 patients had laparoscopic distal pancreatectomy. A comparison of patient with and without chronic glucocorticoid use showed that only patients with chronic glucocorticoid use developed delayed pancreatic fistula (0% vs. 16.7%; p < 0.001). In addition, delayed pancreatic fistula occurred in only laparoscopic distal pancreatectomy patients with chronic glucocorticoid use (0% vs. 25.0%; p < 0.001). Although sample size is small, it is reasonable to presume that chronic glucocorticoid use is a potential risk factor for delayed pancreatic fistula in laparoscopic distal pancreatectomy.

Retroperitonealization of the pancreatic stump in distal pancreatectomy: a novel technique to reduce postoperative pancreatic fistula

PURPOSE

To evaluate the efficacy and safety of retroperitonealization of the pancreatic stump in distal pancreatectomy.

METHODS

Clinical data from the Tongji Hospital pancreatic database were retrospectively reviewed in this study. The data of 68 patients who underwent retroperitonealized distal pancreatectomy from January, 2019, to April, 2021, were collected and analyzed. Sixty-four patients who underwent conventional distal pancreatectomy during the same period were matched. We compared and analyzed the operative outcomes and postoperative complications between the patients in the two groups before and after propensity score matching (PSM).

RESULTS

Before PSM, the operative outcomes and postoperative complications were comparable between the two groups. After PSM, the retroperitonealized group had a lower incidence of postoperative pancreatic fistula (POPF) (10.53% vs 31.58%, P = 0.047) and shorter time until drainage removal (10.00, 8.00-13.00 days vs 13.00, 10.00-18.00 days, P = 0.005). In the univariate and multivariate regression analyses, non-retroperitonealization and intra-abdominal infection were found to be independent risk factors for postoperative pancreatic fistula (POPF).

CONCLUSION

Retroperitonealization of the pancreatic stump can reduce the incidence of POPF after distal pancreatectomy.

Comparative outcomes of extended distal pancreatectomy and distal pancreatectomy

PURPOSE

Patients with locally advanced pancreatic body/tail tumors, gastric cancer, or colon cancer often have contiguous organ involvement requiring extensive pancreatic resection. This study was performed to compare surgical complications and the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between distal pancreatectomy (DP) with extended organ resection and standard DP.

METHODS

In total, 128 patients who underwent DP from January 2012 to January 2021 were retrospectively reviewed. Extended DP was defined according to the International Study Group of Pancreatic Surgery definition.

RESULTS

Of the 128 patients, 62 (48.4%) underwent extended DP and 66 (51.6%) underwent DP. Blood loss was greater (p < 0.001), the incidence of major complications was higher (p = 0.032), and the hospital stay was longer (p = 0.002) in the extended DP group than in the DP group. There were no differences in the incidence of CR-POPF, the readmission rate, or the need for postoperative intervention drainage. Univariate and multivariate analyses showed that extended DP was not a risk factor for CR-POPF or major complications.

CONCLUSION

Extended DP can be performed with comparable CR-POPF occurrence and mortality but increased morbidity when compared with standard DP.

Metal-free laparoscopic distal pancreatectomy using transpancreatic mattress suture with polyglycolic acid sheet and fibrin glue: A case report

Laparoscopic distal pancreatectomy (LDP) is the standard surgery for malignant and premalignant tumors of the pancreatic body and tail. A stapler is commonly used to close the pancreatic stump due to its simplicity; however, the use of a stapler is associated with the risk of metal allergy and postoperative pancreatic fistula, especially in thick pancreases. Here, we present a case of LDP without metal instruments, including staplers and clips, in a 54-year-old woman with a metal allergy and a thick pancreas. The pancreatic stump was closed using the transpancreatic mattress suture method with a polyglycolic acid sheet (PGA) and fibrin glue. The postoperative course was uneventful. Metal-free LDP is useful and can be adopted regardless of the patient's background, such as a metal allergy or pancreatic thickness.

Pancreas Ligation Device for Distal Pancreatectomy: An Ex Vivo Follow-Up Porcine Study

Introduction Postoperative pancreatic fistula (POPF) is a critical complication occurring with a high incidence after distal pancreatectomy. To minimize the risk of POPF, we developed an innovative pancreas ligation device capable of closing the pancreatic stump without causing traumatic injury to the pancreatic duct and artery. We conducted an ex vivo follow-up study to compare the pressure resistance of the pancreas ligation device with that of a regular linear stapler. Materials and methods The pancreases were excised from 20 pigs and divided into two groups: ligation group (n = 10) and stapler group (n = 10). Distal pancreatectomy was performed, and the pancreatic stump was closed using either a pancreas ligation device or a regular linear stapler. The main pancreatic duct was cannulated with a 4-French catheter connected to a cannula and syringe filled with contrast medium. Using fluoroscopy detection, pressure resistance was defined as the maximum pressure without leakage from the pancreatic stump. Results No significant differences were found between the two groups regarding sex, age, body weight, or pancreatic thickness. In the ligation group, no leakage was observed at the stump in any pancreas. However, in the stapler group, six of 10 pancreases showed leakage at the staple line or into the parenchyma. Pressure resistance was significantly higher in the ligation group than in the stapler group (median: 42.8 vs. 34.3 mmHg, P = 0.023). Conclusions These findings suggest the effectiveness of a pancreas ligation device in reducing the incidence of POPF after distal pancreatectomy. Our ligation device is expected to be a useful alternative to a linear stapler for pancreatic stump closure.

Failure of a Multi-Centric Clinical Trial Investigating Neoadjuvant Radio-Chemotherapy in Resectable Pancreatic Carcinoma (NEOPA-NCT01900327)-Which Lessons Are Learnt?

BACKGROUND

A significant number of clinical trials must be prematurely discontinued due to recruitment failure, and only a small fraction publish results and a failure analysis. Based on our experience on conducting the NEOPA trial on neoadjuvant radiochemotherapy for resectable and borderline resectable pancreatic carcinoma (NCT01900327-funded by the German Federal Ministry of Education and Research-BMBF), we performed an analysis of potential reasons for recruitment failure and general problems in conducting clinical trials in Germany.

METHODS

Systematic analysis of environmental factors, trial history, conducting and funding in the background of the published literature.

RESULTS

The recruitment failure was based on various study-specific conceptional and local environmental aspects and in peculiarities of the German surgical study culture. General reservations against a neo-adjuvant study concept combined with game changing scientific progresses during the long-lasting planning and funding phase have led to a reduced interest in the trial design and recruitment.

CONCLUSIONS

Trial planning and conducting should be focused, professionalized and financed on a national basis. Individual interests must be subordinated to reach the goal to perform more relevant and successful clinical trials in Germany. Bureaucratic processes must be further fastened between a trial idea and the start of a study.

Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial

BACKGROUND

The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking.

METHODS

In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of -7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265).

FINDINGS

Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI -6.2 to 13.6%; pnon-inferiority = 0.039). Median lymph node yield was comparable (22.0 [16.0-30.0] vs 23.0 [14.0-32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0-30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5-5.5] vs 5 [95% CI 4.7-5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67-1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group.

INTERPRETATION

This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer.

FUNDING

Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy

Because distal pancreatectomy (DP) has no reconstructive steps and less frequent vascular involvement, it is thought to be the easier counterpart of pancreaticoduodenectomy. This procedure has a high surgical risk and the overall incidences of perioperative morbidity (mainly pancreatic fistula), and mortality are still high, in addition to the challenges that accompany delayed access to adjuvant therapies (if any) and prolonged impairment of daily activities. Moreover, surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes. From this perspective, new surgical approaches, and aggressive techniques, such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection, could lead to improved survival in those affected by more locally advanced tumors. Conversely, minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress. The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications, length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy. Because a dedicated multidisciplinary team is crucial to pancreatic surgery, hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign, borderline, and malignant diseases of the pancreas. The purpose of this review is to examine the state of the art in distal pancreatectomies, with a special focus on minimally invasive approaches and oncological-directed techniques. The widespread reproducibility, cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

New method of remnant closure during distal pancreatectomy

PURPOSE

Pancreatic fistula following distal pancreatectomies still remains a relevant problem. The present study describes our first series with a new method of pancreatic remnant closure.

METHODS

A free fascia-peritoneum graft - harvested from the internal rectus sheet - was fixed onto the pancreatic stump by one circular stitch. The method was applied in 18 cases.

RESULTS

The postoperative hospital stay was 8 days in average. No clinically relevant postoperative pancreatic fistula (CR-POPF) developed. The morbidity rate was 39%, mostly Clavien-Dindo Grade II types. There was no reoperation or mortality.

CONCLUSION

The first series showed advantageous results with our method. Certainly, further studies are needed for the evaluation of this new and promising technique.

Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation

OBJECTIVE

To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively.

BACKGROUND

POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet.

METHODS

Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014-2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007-2016) to assess discrimination and calibration in an internal-external validation procedure.

RESULTS

Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11-1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32-1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78-0.88) and 0.73 (95% CI: 0.70-0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%-25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74-0.85).

CONCLUSIONS

The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com . The 3 distinct risk groups allow for personalized treatment and benchmarking.

Prediction of postoperative pancreatic fistula and pancreatitis after pancreatoduodenectomy or distal pancreatectomy: A review

BACKGROUND AND OBJECTIVE

Postoperative pancreatic fistula (POPF) is the leading cause of morbidity and early mortality in patients undergoing pancreatic resection. In addition, recent studies have identified postoperative acute pancreatitis (POAP) as an independent contributor to morbidity. Most perioperative mitigation strategies experimented for POPF have been shown to be in vain with no consensus on the best perioperative management. Clinical prediction models have been developed with the hope of identifying high POPF risk patients with the leading idea of finding subpopulations possibly benefiting from pre-existing or novel mitigation strategies. The aim of this review was to map out the existing prediction modeling studies to better understand the current stage of POPF prediction modeling, and the methodology behind them.

METHODS

A narrative review of the existing POPF prediction model studies was performed. Studies published before September 2022 were included.

RESULTS

While the number of POPF prediction models for pancreatoduodenectomy has increased, none of the currently existing models stand out from the crowd. For distal pancreatectomy, two unique POPF prediction models exist, but due to their freshness, no further external validation or adoption in clinics or research has been reported. There seems to be a lack of adherence to correct methodology or reporting guidelines in most of the studies, which has rendered external validity-if assessed-low. Few of the most recent studies have demonstrated preoperative assessment of pancreatic aspects from computed tomography (CT) scans to provide relatively strong predictors of POPF.

CONCLUSIONS

Main goal for the future would be to reach a consensus on the most important POPF predictors and prediction model. At their current state, few models have demonstrated adequate transportability and generalizability to be up to the task. Better understanding of POPF pathophysiology and the possible driving force of acute inflammation and POAP might be required before such a prediction model can be accessed.

Celiac Axis Stenosis is an Underestimated Risk Factor for Increased Morbidity After Pancreatoduodenectomy

OBJECTIVE

To assesses the prevalence and severity of CAS in patients undergoing PD/total pancreatectomy and its association with major postoperative complications after PD.

SUMMARY OF BACKGROUND DATA

CAS may increase the risk of ischemic complications after PD. However, the prevalence of CAS and its relevance to major morbidity remain unknown.

METHODS

All patients with a preoperative computed tomography with arterial phase undergoing partial PD or TP between 2014 and 2017 were identified from a prospective database. CAS was assessed based on computed tomography and graded according to its severity: no stenosis (<30%), grade A (30%-<50%), grade B (50%-≤80%), and grade C (>80%). Postoperative complications were assessed and uni- and multivariable risk analyses were performed.

RESULTS

Of 989 patients, 273 (27.5%) had CAS: 177 (17.9%) with grade A, 83 (8.4%) with grade B, and 13 (1.3%) with grade C. Postoperative morbidity and 90-day mortality occurred in 278 (28.1%) patients and 41 (4.1%) patients, respectively. CAS was associated with clinically relevant pancreatic fistula ( P =0.019), liver perfusion failure ( P =0.003), gastric ischemia ( P =0.001), clinically relevant biliary leakage ( P =0.006), and intensive care unit ( P =0.016) and hospital stay ( P =0.001). Multivariable analyses confirmed grade B and C CAS as independent risk factors for liver perfusion failure; in addition, grade C CAS was an independent risk factor for clinically relevant pancreatic fistula and gastric complications.

CONCLUSIONS

CAS is common in patients undergoing PD. Higher grade of CAS is associated with an increased risk for clinically relevant complications, including liver perfusion failure and postoperative pancreatic fistula. Precise radiological assessment may help to identify CAS. Future studies should investigate measures to mitigate CAS-associated risks.

Advantages of laparoscopic distal pancreatectomy: Systematic review and meta-analysis of randomized and matched studies

BACKGROUND

We sought to provide a meta-analysis and credibility assessment of available randomized controlled trials and propensity score matched studies when assessing early and oncologic outcomes of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.

METHODS

The MEDLINE, Scopus, Web of Science, and Cochrane databases were searched for pertinent literature up to June 2022. Random-effect meta-analyses were applied. Trial sequential analysis was applied to verify whether results were true- or false-positive or -negative findings.

RESULTS

Thirteen studies were identified (2 randomized controlled trials and 11 propensity score matched studies). The early outcomes were assessed on 12 studies, including 4,346 patients. In this population, laparoscopic distal pancreatectomy decreased postoperative stay (mean difference = 1.8 days; P = .001) and estimated blood loss (mean difference = 148 mL; P = .001), and trial sequential analysis confirmed these as true-positive findings. Laparoscopic distal pancreatectomy and open distal pancreatectomy had similar operating times (P = .165), and trial sequential analysis confirmed this as a true-negative finding. Major morbidity, mortality, and readmission were similar, but results were inconclusive by trial sequential analysis. Oncologic outcomes were assessed on 5 studies, including 2,430 patients. In this population, laparoscopic distal pancreatectomy showed higher R0 resection rate (OR = 1.46; P = .001) and shorter time to adjuvant therapy (mean difference 4.0 days P = .003). A survival benefit was observed at 1 year after laparoscopic distal pancreatectomy (OR = 1.45; P = .001), which was not confirmed at 3 years (P = .650).

CONCLUSION

Laparoscopic distal pancreatectomy is superior to open distal pancreatectomy for most of the early outcomes analyzed. The operating time was equalized as a result of the learning curve. Results from patients with pancreatic cancer suggest at least an oncologic noninferiority of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.

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

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.

Overall morbidity after total minimally invasive keyhole oesophagectomy versus hybrid oesophagectomy (the MICkey trial): study protocol for a multicentre randomized controlled trial

BACKGROUND

Oesophageal cancer (EC) is the sixth leading cause of cancer death worldwide. Oesophageal resection is the only curative treatment option for EC which is frequently performed via an abdominal and right thoracic approach (Ivor-Lewis operation). This 2-cavity operation is associated with a high risk of major complications. To reduce postoperative morbidity, several minimally invasive techniques have been developed that can be broadly classified into either hybrid oesophagectomy (HYBRID-E) via laparoscopic/robotic abdominal and open thoracic surgery or total minimally invasive oesophagectomy (MIN-E). Both, HYBIRD-E and MIN-E, compare favourable to open oesophagectomy. However, there is still an evidence gap comparing HYBRID-E with MIN-E with regard to postoperative morbidity.

METHODS

The MICkey trial is a multicentre randomized controlled superiority trial with two parallel study groups. A total of 152 patients with oesophageal cancer scheduled for elective oesophagectomy will be randomly assigned 1:1 to the control group (HYBRID-E) or to the intervention group (MIN-E). The primary endpoint will be overall postoperative morbidity assessed via the comprehensive complication index (CCI) within 30 days after surgery. Specific perioperative parameters, as well as patient-reported and oncological outcomes, will be analysed as secondary outcomes.

DISCUSSION

The MICkey trial will address the yet unanswered question whether the total minimally invasive oesophagectomy (MIN-E) is superior to the HYBRID-E procedure regarding overall postoperative morbidity.

TRIAL REGISTRATION

DRKS00027927 U1111-1277-0214. Registered on 4th July 2022.

Short- and long-term surgical outcomes of pancreatic resection for retroperitoneal sarcoma: A long-term single-center experience of 90 cases

BACKGROUND AND OBJECTIVES

Resection of retroperitoneal sarcoma (RPS) en bloc with pancreas is challenging and controversial. This single-center retrospective study aimed to analyze the impact of pancreatic resection (PR) and its different types on short- and long-term outcomes in patients with RPS.

METHODS

Data from 242 consecutive patients with RPS who underwent surgical treatment at the Peking University Cancer Hospital Sarcoma Center between January 2010 and February 2021 were analyzed. Out of these, 90 patients underwent PR, including pancreaticoduodenectomy (PD) in 31 and distal pancreatectomy (DP) in 59.

RESULTS

Patients in the PR group had a higher major morbidity (37.8% vs. 14.5%) and mortality (8.9% vs. 1.3%) than those in the non-PR group, with a similar 5-year overall survival (OS) rate (46.9% vs. 53.6%). Patients in the PD and DP groups had a slight difference in major morbidity (48.4% vs. 32.2%), mortality (6.4% vs. 10.2%), and 5-year OS rates (43.3% vs. 49.3%). The PR type was not an independent risk factor for major morbidity or OS.

CONCLUSIONS

PR in RPS resection was associated with increased morbidity and mortality with minimal influence on survival. Patients with RPS undergoing PD and DP showed slight differences in terms of safety and OS.

Splenectomy and Distal Pancreaticosplenectomy: Surgical Anatomy and Technique Specific to Advanced Ovarian Cancer

Ovarian cancer is one of the most aggressive malignancies in women and usually presents at an advanced stage. Complete tumor debulking and platinum sensitivity are the two important determinants of survival in ovarian cancer. Upper abdominal surgery with bowel resections and peritonectomy are usually needed to achieve optimal cytoreduction. Splenic disease in the form of diaphragmatic peritoneal disease or omental caking at the splenic hilum is not infrequent. Around 1-2% of these require distal pancreaticosplenectomy (DPS) and the decision to perform DPS versus splenectomy should be made early in the intraoperative period to prevent unnecessary hilar dissection and bleeding. We hereby describe the surgical anatomy of the spleen and pancreas and point of technique of splenectomy and DPS specific to advanced ovarian cancers.

[Familial pancreatic cancer syndrome]

In contrast to many other malignant entities the risk factors for pancreatic cancer are mostly unknown. Hereditary factors are causative in about 3-6% of all pancreatic cancers. In addition to hereditary tumor disposition syndromes and hereditary pancreatitis, the familial pancreatic cancer syndrome accounts for about 75% of all hereditary pancreatic cancers. A familial pancreatic cancer syndrome is present when at least two first-degree relatives in a family have histologically proven pancreatic cancer and there are no criteria for another hereditary syndrome. An underlying uniform monogenetic gene defect in familial pancreatic cancer syndrome is currently unknown and a germline mutation in the BRCA2 gene is so far the most frequently identified genetic alteration. Patients at risk for familial pancreatic cancer should be offered participation in registry studies with associated early detection programs (e.g., the FaPaCa registry). These enable the detection of high-grade neoplasms and pancreatic cancer in the early stages, which appears to reduce mortality; however, the detected pancreatic lesions are often incorrectly diagnostically classified, and patients undergo complex pancreatic resection despite benign findings. Finally, studies have so far not been able to clearly clarify whether patients at risk benefit from an early detection program. According to current data, prophylactic operations are not indicated for familial pancreatic cancer syndrome and should only be performed if there is evidence of a suspicious finding that requires resection.

Surgical outcome and prognosis of pediatric solid-pseudopapillary neoplasm

BACKGROUND

The aim of this study was to clarify the characteristics and outcomes of pediatric patients with solid pseudopapillary neoplasms (SPNs) who underwent pancreatectomy.

METHODS

Pediatric patients with SPNs who underwent pancreatectomy at our institution between 1995 and 2020 were included in the study.

RESULTS

During the period under review, 12 patients underwent pancreatectomy for SPNs (median age: 10 years; range: 6-15 years). The surgical procedures included pancreatoduodenectomy (n = 2; 16.6%), distal pancreatectomy (n = 3; 25%), and enucleation (n = 7; 58.3%). The most common postoperative complication was postoperative pancreatic fistula (n = 6; 50%). Patients who underwent enucleation tended to have higher postoperative complication rates compared with those who underwent other procedures. All patients were alive without recurrence at the end of the study period.

CONCLUSIONS

SPN is associated with a good prognosis, regardless of the surgical procedure. If surgeons select enucleation for pediatric SPNs, they should bear in mind that it is associated with a higher complication rate.