Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels

Pedicled ligament flaps during pancreatoduodenectomy are associated with reduced hemorrhage from hepatic artery and gastroduodenal artery stump during pancreatoduodenectomy: a systematic review, meta-analysis and trial sequential analysis

BACKGROUND

The aim of this study was to investigate whether pedicled ligament flaps (PLF) covering around the hepatic and gastroduodenal artery stump can provide better clinical outcomes in pancreatoduodenectomy (PD).

METHODS

We conducted a comprehensive search of databases (inception to January 2023) to identify studies comparing PD with or without PLF covering the skeletonized arteries. The perioperative and postoperative outcomes were compared. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated using fixed-effects models.

RESULTS

Ten studies were included in the qualitative synthesis. Six studies with 3538 patients met the inclusion criteria for the meta-analysis. Patients in the PLF group had a significantly lower rate of PPH from the hepatic artery or gastroduodenal artery stump (H/G PPH) (OR: 0.41; 95 % CI, 0.22-0.75; P < 0.01) and overall PPH (OR: 0.65; 95 % CI, 0.46-0.93; P = 0.02). There were no significant differences between the two groups in terms of morbidity, grade B/C postoperative pancreatic fistula (B/C POPF), delayed gastric emptying (DGE), reoperation, or mortality.

CONCLUSION

Prophylactic pedicled ligament flaps covering around the skeletonized arteries significantly reduced overall PPH and H/G PPH, and it seemed to have no obvious influence on other complications.

Wrapping gastroduodenal artery stump with the teres hepatis ligament to prevent postpancreatectomy hemorrhage after pancreaticoduodenectomy

BACKGROUND

Gastroduodenal artery (GDA) stump erosion hemorrhage is a fatal complication after pancreaticoduodenectomy. This study aimed to determine whether GDA stump wrapping with the teres hepatis ligament during pancreaticoduodenectomy decreased the incidence of postpancreatectomy hemorrhage (PPH).

METHODS

We reviewed 307 patients who had undergone pancreaticoduodenectomy between March 2019 and June 2022. The patients were divided into two groups according to application of GDA stump wrapping with the teres hepatis ligament: GDA wrapping group (165 patients) and no-wrapping group (142 patients). The perioperative data were compared between the groups.

RESULTS

The clinical characteristics were balanced between the two groups. Grades B and C PPH and GDA-stump-related hemorrhage were significantly reduced in the GDA wrapping group compared with the no-wrapping group (PPH B/C, 13.4% vs 6.1%, P = 0.029; GDA hemorrhage, 5.6% vs 0.6%, P = 0.014). No difference was observed in the incidence of clinically relevant postoperative pancreatic fistula, biliary leak, intra-abdominal abscess, delayed gastric emptying, 90-day mortality, and postoperative hospital stay between the two groups.

CONCLUSION

Wrapping GDA stump with the teres hepatis ligament reduced the incidence of GDA-stump-related PPH. Therefore, the wrapping technique is a simple and effective strategy to prevent PPH. Prospective studies are needed to confirm the benefit of this procedure.

Utility of Falciform Ligament in Abdominal Surgery: A Systematic Review

OBJECTIVE

The aim of the present systematic review was to assess current trends in use of falciform ligament in abdominal surgery.

BACKGROUND

The falciform ligament has been proposed in surgical literature as a suitable pedicle or flap with acceptable surgical outcomes; however, it is underutilized in abdominal surgery.

METHODS

We performed a literature search and meta-analysis. All English studies describing use of a falciform ligament were eligible for inclusion.

RESULTS

Of the 547 articles mentioning use of falciform ligament, 32 full text articles were included in this review. The majority were case reports (n = 14). The mremaining papers included retrospective analysis (n = 10), randomized control trials (n = 2), reviews (n = 3), and technique descriptions (n = 6).

CONCLUSION

The falciform ligament appears to be a safe and easily accessible natural tissue with a variety of surgical applications. It is most useful as a pedicle flap and could have benefit in foregut surgery including hepatic, pancreatic, biliary, gastric, and esophageal operations.

The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence

PURPOSE

Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).

METHODS

All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups.

RESULTS

Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013).

CONCLUSION

The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

Application of the Falciform Ligament Patch for the Prevention of Duodenal Stump Leakage After Gastrectomy: Technical Report on a Case Series

Background: Duodenal stump leakage (DSL) is a serious complication after gastrectomy. In this study, we developed a novel prevention technique using a falciform ligament patch (FLP) to prevent DSL among high-risk patients after gastrectomy. Materials and Methods: From January 2019 to July 2021, 14 patients who were judged to be at high risk for DSL during preoperative examinations or surgery were included in this retrospective study, and the FLP was applied to the duodenal stump. The falciform ligament was separated from the liver after duodenal transection during gastrectomy; the end part was used to cover the duodenal stump and was fixed using nonabsorbable polypropylene sutures. Results: In total, 14 patients who underwent FLP had one or two risk factors that were identified: 5 patients, gastric cancer duodenal invasion; 4 patients, gastric outlet obstruction (GOO); 1 patient, cancer involving the distal resection margin; 1 patient, duodenal gastrointestinal stromal tumor involving the distal resection margin; 1 patient, gastric cancer duodenal invasion and GOO; and 2 patients, cancer involving the distal resection margin and GOO. FLP construction was successful, and no patient developed complications of DSL. The average hospital stay was 11.9 days, and the patients were discharged without any morbidities after surgery. Conclusions: Therefore, the FLP can be used to prevent DSL among high-risk patients after gastrectomy.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy

BACKGROUND AND PURPOSE

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy.

METHODS

Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed.

RESULTS

The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy.

CONCLUSIONS

Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BACKGROUND

The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery.

METHODS

The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used.

RESULTS

Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality.

CONCLUSIONS

A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy

BACKGROUND

The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD.

METHODS

Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals.

RESULTS

Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620).

DISCUSSION

Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.

Flooring the Major Vessels with Falciform Ligament to Prevent Post-Pancreatectomy Hemorrhage

BACKGROUND

One of the most severe pancreatic surgery complications is post-pancreatectomy hemorrhage (PPH). This study's aim was to evaluate the efficacy of flooring the major vessels with falciform ligament in preventing PPH after pancreatoduodenectomy (PD).

METHODS

This study was a retrospective review of 500 consecutive patients who underwent PD between Jan 2010 and Dec 2019 at Hiroshima University. Morbidities, including postoperative pancreatic fistula (POPF) or PPH and 90-day mortality, were analyzed. The study cohort was divided into two groups based on the time of surgery (2010-2016 and 2017-2019), i.e., before and after implementation of falciform ligament flooring method. The patient characteristics, operative parameters, clinicopathological factors, morbidity, and mortality were compared between the two periods.

RESULTS

Morbidity and mortality rates in the entire cohort were 21% and 1.4%, respectively. The incidence of Grade B/C POPF and PPH was 9.0% and 3.8%, respectively. There was no significant difference between the two periods with respect to Grade B/C POPF, morbidity rate, and mortality rate; however, the rate of Grade B/C PPH significantly decreased from 5.2 to 1.6% p = .027. On multivariate analysis, the absence of the falciform ligament flooring method was an independent PPH risk factor p = .003.

CONCLUSIONS

Falciform ligament flooring method may help decrease the incidence of PPH after PD.

Postoperative hemorrhage complications following the Whipple procedure

Objectives

Although the Whipple operation is an essential surgical technique, its high morbidity (30% to 60%) and mortality (5%) are problems to be addressed. The incidence of postoperative hemorrhage has been reported between 5% and 16% in the literature. In this study, the data and results regarding postoperative hemorrhage complications from our clinic were evaluated.

Material and Methods

The files of 185 patients who had undergone Whipple operation in our hospital in the last five years were evaluated retrospectively, and the causes of hemorrhage were attempted to be determined.

Results

It was found that 6 out of the 13 (7%) patients who had hemorrhage died. In six of there 13 cases, hemorrhage occurred due to fistulas from the portal vein, gastroduodenal artery, and pancreatic arteries at variable periods. Two cases were found to have developed disseminated intravascular coagulation as a result of sepsis. Early intervention was performed in two cases who bled from the meso veins and in one case who bled from the portal vein. Laparotomy and hemostasis were performed in a patient who bled from the gastric anastomosis line. In a patient who had been taking low molecular weight heparin, bleeding from the drains and nasogastric tube stopped following the cessation of the drug.

Conclusion

Preventive procedures such as connection of the vascular structures, use of vascular sealants, omental patching during surgery, and reducing the risk of complications by using somatostatin analogs were performed to prevent hemorrhages after Whipple operations. In addition to standard methods, angiography and embolization have emerged as effective methods in the diagnosis and treatment of hemorrhages. Furthermore, determination and elimination of independent risk factors, such as jaundice, affecting fistula formation and bleeding in the perioperative period, is important for prevention.

Falciform ligament wrap for prevention of gastroduodenal artery bleed after pancreatoduodenectomy

BACKGROUND

The present study aims to assess the effectiveness and current evidence of a pedicled falciform ligament wrap around the gastroduodenal artery stump for prevention of erosion hemorrhage after pancreatoduodenectomy (PD).

METHODS

Retrospective data were pooled for meta-analysis. At the own center, patients who underwent PD between 2012 and 2015 were retrospectively analyzed based on the intraoperative performance of the wrap. A systematic literature review and meta-analysis was performed that combined the published and the obtained original data. The following databases were searched: Medline, Embase, Web of Science, and the Cochrane Library.

RESULTS

At the own center, a falciform ligament wrap was performed in 39 of 196 PDs (20%). The wrap group contained more ampullary neoplasms, but the pancreatic fistula rate was not significantly different from the nonwrap group (28% versus 32%). In median, erosion hemorrhage occurred after 21.5 d, and it was lethal in 39% of the patients. Its incidence was not significantly lower in the wrap group (incidence: 7.7% versus 9.6% in the nonwrap group). The systematic literature search yielded four retrospective studies with a high risk of bias; only one study was controlled. When the five data sets of published and own cases with a falciform ligament wrap were pooled, the incidence of erosion hemorrhage was 5 of 533 cases (0.9%) compared with 24 of 297 cases (8.1%) without the wrap.

CONCLUSIONS

The reported incidence of erosion hemorrhage after the falciform ligament wrap is low, but there are still insufficient controlled data to support its general use.

Wrapping in pancreatic surgery: a systematic review

BACKGROUND

Wrapping in pancreatic surgery involves the use of the omentum or falciform ligament (FL) to wrap the local retroperitoneal vessels, the pancreatojejunal anastomosis or the pancreatic section of distal pancreatectomy. However, there is no clear evidence that wrapping in fact provides benefits. We have performed a systematic review of the literature about this topic.

METHODS

We conducted a literature search in the PubMed/MEDLINE database (1966-2012) for any language using various combinations of the following terms: wrapping, omental, omentum, pancreas, pancreatoduodenectomy and falciform ligament.

RESULTS

We selected 12 articles. Among five series that included a control group, only one obtained a statistically significant reduction in pancreatic fistula (PF) in the wrapping group and other series showed a lower percentage of post-operative haemorrhage in the wrapping group. In the seven series without control groups, a slight decrease in the rate of post-operative bleeding and PF was observed.

CONCLUSIONS

On the basis of the literature available at present, we cannot recommend the use of wrapping with omentum and/or FL in pancreatic surgery. Prospective randomized studies applying a systematic wrapping technique are needed in order to establish whether its use should be generalized.

"Wrapping the gastroduodenal artery stump" during pancreatoduodenectomy reduced the stump hemorrhage incidence after operation

OBJECTIVE

After pancreaticoduodenectomy (PD), the postoperative gastroduodenal artery stump (GDAS) hemorrhage is one of the most serious complications. The purpose of this study is to determine whether wrapping the GDAS during PD could decrease the postoperative GDAS hemorrhage incidence.

METHODS

A retrospective review involving 280 patients who underwent PD from 2005 to 2012 was performed. Wrapping the GDAS during PD was defined as "Wrapping the GDAS using the teres hepatis ligamentum during PD". A total of 140 patients accepted the "wrapping" procedure (wrapping group). The other 140 patients didn't apply the procedure (non-wrapping group). Age, sex, preoperative data, estimated intraoperative blood loss, postoperative complications, pathologic parameters and hospitalization time were compared between two groups.

RESULTS

There were no significant differences in patient characteristics between two groups. After wrapping, the incidence of postoperative GDAS bleeding decreased significantly (1/140 vs. 9/140, P=0.01). The rates of the other complications (such as intra-abdominal infection pancreatic fistula, billiary fistula, gastrointestinal bleeding, et al.) showed no significant differences.

CONCLUSIONS

Wrapping the GDAS during PD significantly reduced the postoperative GDAS hemorrhage incidence. And the "wrapping" had no obvious influence on other complications.

Relative displacement of anastomotic site of pancreato-jejunostomy in pancreatico-duodenectomy: a novel surgical reconstructive technique

INTRODUCTION

Intra-abdominal hemorrhage following pancreatic fistula is a fatal complication after pancreatico-duodenectomy. Intra-abdominal hemorrhage has reportedly decreased with the use of fibrin glue or polyglycolic acid felt and wrapping of the skeletonized vessels by omentum or falciform ligament. However, there are no extremely effective methods for the prevention of hemorrhage. Here, we report our novel and simple method for the prevention of intra-abdominal hemorrhage due to pancreatic fistula.

METHODS

The anastomotic site of the pancreato-jejunostomy in pancreatico-duodenectomy is displaced from the superior to inferior side of the transverse mesocolon through a small window created on the left side of the middle colic artery of the transverse mesocolon. This procedure is expected to prevent exposure of the skeletonized vessels to activated pancreatic juice from a pancreatic fistula after lymph node dissection, decreasing the incidence of hemorrhage. Two drains are placed on the superior and inferior sides of the transverse mesocolon. We performed this procedure in seven patients and compared the amylase level in the drainage fluid from the superior and inferior sides.

RESULTS

There was no difference in the fluid amylase level from the drains between the superior and inferior sides, because a pancreatic fistula was not present in all our patients. Therefore, we could not evaluate the efficacy of this method in the current study.

CONCLUSIONS

Our procedure is theoretically expected to prevent intra-abdominal hemorrhage and will be an option in pancreatico-duodenectomy, especially for patients with a soft pancreas. However, it is necessary to evaluate the performance and results of this procedure in many more patients.

Pancreaticodigestive anastomosis and the postoperative management strategies to prevent postoperative pancreatic fistula formation after pancreaticoduodenectomy

Over the past 100 years, advances in surgical techniques and perioperative management have reduced the morbidity and mortality after pancreaticoduodenectomy (PD). Many techniques have been proposed for the reconstruction of the pancreaticodigestive anastomosis to prevent the development of a postoperative pancreatic fistula (POPF), but which is the best approach is still highly debated. We carried out a systematic review to determine and compare the effectiveness of various methods of anastomosis after PD. A meta-analysis and most randomized controlled trials (RCTs) showed that the mortality, POPF rate and incidence of other postoperative complications were not statistically different between the pancreaticogastrostomy and pancreaticojejunostomy (PJ) groups. One RCT showed that a binding PJ significantly decreased the risk of POPF and other postoperative complications compared with conventional PJ. External duct stenting reduced the risk of clinically relevant POPF in a meta-analysis and RCTs. The prophylactic use of octreotide after PD does not result in a reduced incidence of POPF. In conclusion, our findings suggest that the successful management of pancreatic anastomoses may depend more on the meticulous surgical technique, surgical volume, and other management parameters than on the type of technique used. However, some new approaches, such as binding PJ, and the use of external stents should be considered in further RCTs.

Jejunal scarf-covering method in pancreaticojejunostomy after total gastrectomy

Pancreatic fistula is the most serious postoperative complication after pancreaticoduodenectomy, and it leads to intra-abdominal abscess, sepsis, hemorrhage and high mortality. To prevent pancreatic fistula, wrapping of skeletonized vessels and the anastomotic site of the pancreaticoenterostomy using the round ligament, greater omentum, or both has been evaluated. However, the round ligament and greater omentum have already been resected in patients who have previously undergone total gastrectomy, making them unavailable in pancreaticoduodenectomy. Therefore, we developed a procedure for wrapping the anastomotic site of the pancreaticojejunostomy using the jejunum, namely the 'jejunal scarf-covering method' as a novel technique to prevent pancreatic fistula following pancreaticoduodenectomy in patients who have previously undergone total gastrectomy.

Pancreaticoduodenectomy for invasive pancreatic cancer (with video)

Pancreaticoduodenectomy (PD) is the only treatment option that potentially provides a cure for pancreatic head cancer. Various arrangements and modifications have been proposed to achieve pathological margin negative (R0) resection safely. In this article, we introduce a standard procedure for PD, including pancreaticogastrostomy with invagination and mattress sutures (video clip provided), for invasive ductal carcinoma of the pancreatic head, with a description of the need-to-know pitfalls for Board-certified HBP surgeons in Japan. The important points in performing PD for pancreatic cancer are: (1) While dissecting connective tissue and nerve plexus as well as lymph nodes, maintain a dissection plane to expose the surfaces of vessels or other organs to be preserved to achieve R0 resection: i.e., while dissecting the anterior surface of the inferior vena cava and the right side of the superior mesenteric artery, these vessels should be completely exposed with the connective tissue and nerve plexuses being attached to the resection side. (2) There should be early interruption of the afferent blood supply via the inferior pancreaticoduodenal artery to reduce blood loss by avoiding congestion of the pancreatic head and to increase the operative safety (video clip provided). (3) Eligibility for PD should be carefully evaluated because there are many "resectable" but not many "curable" cases. In addition, the clinical significance of various modifications of the surgical techniques used for PD are also discussed.

Use of omentum or falciform ligament does not decrease complications after pancreaticoduodenectomy: nationwide survey of the Japanese Society of Pancreatic Surgery

BACKGROUND

Wrapping is thought to prevent pancreatic fistula and postoperative hemorrhage for pancreaticoduodenectomy (PD), and we analyzed whether omentum/falciform ligament wrapping decreases postoperative complications after PD.

METHODS

This is a retrospective study of wrapping using the omentum/falciform ligament in patients that underwent PD between January 2006 and June 2008 in 139 institutions that were members of the Japanese Society of Pancreatic Surgery.

RESULTS

Ninety-one institutions responded to the questionnaires, and data were accumulated from 3,288 patients. The data from 2,597 patients were acceptable for analysis; 918 (35.3%) patients underwent wrapping and 1,679 patients did not. A pancreatic fistula occurred in 623 patients (37.3%) in the nonwrapping group, in comparison to 393 patients (42.8%) in the wrapping group (P = .006). The incidence of a grade B/C pancreatic fistula was lower in the nonwrapping group than the wrapping group (16.7% vs. 21.5%; P = .002). An intra-abdominal hemorrhage occurred in 54 patients (3.2%) in the nonwrapping group, which was similar to the incidence in the wrapping group (32 patients; 3.5%). The mortality was 1.3% and 1.0% in nonwrapping and wrapping groups, respectively. A multivariate analysis revealed 7 independent risk factors for pancreatic fistula; male, hypoalbuminemia, soft pancreas, long operation time, extended resection, pylorus preservation, and omentum wrapping. There were 4 independent risk factors for early intra-abdominal hemorrhage and 2 independent risk factors for late intra-abdominal hemorrhage.

CONCLUSION

This retrospective study revealed that omentum wrapping did not decrease the incidence of pancreatic fistula. An additional validation study is necessary to evaluate the efficacy of wrapping for PD.

Use of a falciform ligament pedicle flap to decrease pancreatic fistula after distal pancreatectomy

OBJECTIVES

Postoperative pancreatic fistula (POPF) remains a significant source of morbidity after distal pancreatectomy (DP). We describe a technique for coverage of the pancreatic stump after DP using a pedicled falciform ligament flap with a low POPF rate.

METHODS

A retrospective review of clinical, radiographic, and pathologic variables of patients undergoing open DP between November 2005 and August 2009 was performed. After standardized DP, the pancreatic stump was closed using a pedicled falciform ligament flap. Postoperative pancreatic fistula was defined using the International Study Group classification for pancreatic fistula definition.

RESULTS

Twenty-three consecutive patients underwent open DP and splenectomy with closure of the pancreatic stump using a pedicled falciform ligament flap. Pancreatic transection and stump closure was performed in a uniform fashion in all patients. Eight patients (35%) had additional organs resected. Two patients (8.7%) developed grade C POPFs, which were successfully managed with percutaneous drain placement. No additional patients developed a POPF or abdominal abscess. The median length of stay was 5 days. There were no perioperative mortalities.

CONCLUSIONS

We conclude that use of a pedicled falciform ligament flap for coverage of the pancreatic stump is associated with a low incidence of POPF. Continued investigation of this technique is warranted.