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Hajibandeh S, Hajibandeh S, Hablus MA, Bari H, Pathanki AM, Ali M, Ahmad J, Marangoni G, Khan S, Lam FT. Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy. Ann Hepatobiliary Pancreat Surg 2024; 28:302-314. [PMID: 38522846 PMCID: PMC11341886 DOI: 10.14701/ahbps.24-015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
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.
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Affiliation(s)
- Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohammed Abdallah Hablus
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
- Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hassaan Bari
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Adithya Malolan Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Majid Ali
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Jawad Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Gabriele Marangoni
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Saboor Khan
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - For Tai Lam
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
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van Bodegraven EA, Balduzzi A, van Ramshorst TME, Malleo G, Vissers FL, van Hilst J, Festen S, Abu Hilal M, Asbun HJ, Michiels N, Koerkamp BG, Busch ORC, Daams F, Luyer MDP, Ramera M, Marchegiani G, Klaase JM, Molenaar IQ, de Pastena M, Lionetto G, Vacca PG, van Santvoort HC, Stommel MWJ, Lips DJ, Coolsen MME, Mieog JSD, Salvia R, van Eijck CHJ, Besselink MG. Prophylactic abdominal drainage after distal pancreatectomy (PANDORINA): an international, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet Gastroenterol Hepatol 2024; 9:438-447. [PMID: 38499019 DOI: 10.1016/s2468-1253(24)00037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024]
Abstract
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).
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Affiliation(s)
- Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Alberto Balduzzi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Tess M E van Ramshorst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, OLVG, Amsterdam, Netherlands
| | | | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery and Pulmonology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Olivier R C Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Marco Ramera
- Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giovanni Marchegiani
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy; Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Joost M Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, Netherlands
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Gabriella Lionetto
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Casper H J van Eijck
- Department of Surgery and Pulmonology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands.
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Yoshii H, Izumi H, Fujino R, Nomuraa E, Mukai M. Intraoperative Video Analysis of Pancreatic Stump and Stapler Closure-Induced Pancreatic Fistula in Laparoscopic Distal Pancreatectomy: A Retrospective Study. Cureus 2024; 16:e58959. [PMID: 38800290 PMCID: PMC11128150 DOI: 10.7759/cureus.58959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Objectives Pancreatic stump closure in laparoscopic distal pancreatectomy (Lap-DP) is commonly performed using an automatic stapler. Herein, the magnification effect of laparoscopy was used to observe the pancreatic stump and retrospectively investigate factors that may cause postoperative pancreatic fistula. Methods This is a single-center retrospective study. We selected 62 cases of Lap-DP performed between March 2016 and May 2022. We retrospectively analyzed 54 cases where pancreatic transection sites could be observed using an intraoperative video. Pancreatic transection was performed using the Powered ECHELON FLEX®+ GST® System (Ethicon, Somerville, USA). For quantitative studies, we investigated the factors that cause pancreatic fistula and other factors causing pancreatic fistula. Results Pancreatic parenchymal hemorrhage and injury occurred in 22.2% and 29.6% of cases, respectively. International Study Group of Pancreatic Surgery grade B/C pancreatic fistula was observed in 12 cases (22.2%). Univariate analysis of pancreatic (n = 12) and nonpancreatic (n = 42) fistula groups showed no significant differences in pancreatic thickness. The pancreatic fistula group had a significantly high incidence of the hard pancreas (p = .009), pancreatic parenchymal bleeding (p = .002), and pancreatic parenchymal damage (p < .001). Multivariate analysis revealed that pancreatic parenchymal damage was an independent cause of pancreatic fistula (hazard ratio, 81.4 (8.5-772.3), p < .001). Conclusion Pancreatic parenchymal damage due to compression during pancreatic stump closure using an automatic stapler in Lap-DP may cause pancreatic fistula.
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Affiliation(s)
- Hisamichi Yoshii
- Department of Gastroenterology, Tokai University Hachioji Hospital, Hachioji, JPN
| | - Hideki Izumi
- Department of Gastroenterology, Tokai University Hachioji Hospital, Hachioji, JPN
| | - Rika Fujino
- Department of Gastroenterology, Tokai University Hachioji Hospital, Hachioji, JPN
| | - Eiji Nomuraa
- Department of Gastroenterology, Tokai University Hachioji Hospital, Hachioji, JPN
| | - Masaya Mukai
- Department of Gastroenterology, Tokai University Hachioji Hospital, Hachioji, JPN
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Harimoto N, Igarashi T, Okuyama T, Hoshino K, Hagiwara K, Kawai S, Ishii N, Tsukagoshi M, Araki K, Shirabe K. Preoperative zinc status predicts the occurrence and healing time of pancreatic fistula after distal pancreatectomy. World J Surg 2024; 48:186-192. [PMID: 38686792 DOI: 10.1002/wjs.12011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/21/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND There are few studies that examined the relationship between preoperative zinc (Zn) concentrations and postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP). METHODS Data from 98 patients who underwent DP between January 2016 and April 2022 were retrospectively reviewed. Patients' clinicopathological and surgical outcomes were analyzed, and we examined the relationship between Zn and clinically relevant POPF (CR-POPF) after DP. RESULTS In this series, 41 (41.8%) patients had POPF and 31 (31.8%) patients had CR-POPF. The cut-off value for the preoperative Zn concentration was 74 μg/dL for POPF and CR-POPF. Patients with low Zn concentrations were significantly related with high age, low albumin concentrations, higher CRP concentrations, higher NLR, lower PNI, higher rates of POPF and CR-POPF, longer POPF healing time, longer hospital stay, and postoperative complications than patients with high Zn concentrations. The healing time of POPF after DP was significantly negatively correlated with serum Zn concentrations. A multivariate logistic regression analysis showed that preoperative lower Zn concentrations and a prolonged operation time were independent predictors of CR-POPF and the healing time of POPF after DP. The POPF healing time in patients with high Zn was significantly shorter than that in patients with low Zn concentrations. CONCLUSIONS This retrospective study showed the association between the preoperative Zn concentrations and the occurrence of POPF and the healing time after DP. Zn is a simple biomarker for malnutrition, which may lead to POPF after DP.
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Affiliation(s)
- Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Takamichi Igarashi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Takayuki Okuyama
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Kouki Hoshino
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Shunsuke Kawai
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Mariko Tsukagoshi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
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Xia N, Li J, Huang X, Tian B, Xiong J. Reinforced stapling does not reduce postoperative pancreatic fistula in distal pancreatectomy: a systematic review and meta-analysis. Updates Surg 2023; 75:2063-2074. [PMID: 37950142 DOI: 10.1007/s13304-023-01691-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
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.
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Affiliation(s)
- Ning Xia
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Jiao Li
- Department of Emergency Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
- Disaster Medical Center, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Xing Huang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Bole Tian
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Junjie Xiong
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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Kaneda Y, Kimura Y, Saito A, Ae R, Kawahira H, Sata N. Pancreas Ligation Device for Distal Pancreatectomy: An Ex Vivo Follow-Up Porcine Study. Cureus 2023; 15:e44771. [PMID: 37692176 PMCID: PMC10484152 DOI: 10.7759/cureus.44771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/12/2023] Open
Abstract
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.
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Affiliation(s)
- Yuji Kaneda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
- Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Yuki Kimura
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Akira Saito
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, JPN
| | - Hiroshi Kawahira
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
- Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
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Jing W, Huang Y, Feng J, Li H, Yu X, Zhao B, Wei P. The clinical effectiveness of staple line reinforcement with different matrix used in surgery. Front Bioeng Biotechnol 2023; 11:1178619. [PMID: 37351469 PMCID: PMC10282759 DOI: 10.3389/fbioe.2023.1178619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
Staplers are widely used in clinics; however, complications such as bleeding and leakage remain a challenge for surgeons. To tackle this issue, buttress materials are recommended to reinforce the staple line. This Review provides a systematic summary of the characteristics and applications of the buttress materials. First, the physical and chemical properties of synthetic polymer materials and extracellular matrix used for the buttress materials are introduced, as well as their pros and cons in clinical applications. Second, we review the clinical effects of reinforcement mesh in pneumonectomy, sleeve gastrectomy, pancreatectomy, and colorectal resection. Based on the analysis of numerous research data, we believe that buttress materials play a crucial role in increasing staple line strength and reducing the probability of complications, such as bleeding and leakage. However, considering the requirements of bioactivity, degradability, and biosafety, non-crosslinked small intestinal submucosa (SIS) matrix material is the preferred candidate. It has high research and application value, but further studies are required to confirm this. The aim of this Review is to provide comprehensive guidance on the selection of materials for staple line reinforcement.
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Affiliation(s)
| | | | | | | | | | - Bo Zhao
- *Correspondence: Bo Zhao, ; Pengfei Wei,
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8
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Kelemen D, Kerbeche A, Farkas N, Vereczkei A. New method of remnant closure during distal pancreatectomy. Langenbecks Arch Surg 2023; 408:176. [PMID: 37140674 PMCID: PMC10160139 DOI: 10.1007/s00423-023-02916-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/28/2023] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- D Kelemen
- Department of Surgery, Medical Faculty, Clinical Center, University of Pécs, Ifjúság u. 13., 7624, Pécs, Hungary.
| | - A Kerbeche
- Department of Surgery, Medical Faculty, Clinical Center, University of Pécs, Ifjúság u. 13., 7624, Pécs, Hungary
| | - N Farkas
- Institute of Bioanalysis, Medical Faculty, University of Pécs, Honvéd u. 1., 7624, Pécs, Hungary
| | - A Vereczkei
- Department of Surgery, Medical Faculty, Clinical Center, University of Pécs, Ifjúság u. 13., 7624, Pécs, Hungary
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9
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De Pastena M, van Bodegraven EA, Mungroop TH, Vissers FL, Jones LR, Marchegiani G, Balduzzi A, Klompmaker S, Paiella S, Tavakoli Rad S, Groot Koerkamp B, van Eijck C, Busch OR, de Hingh I, Luyer M, Barnhill C, Seykora T, Maxwell T T, de Rooij T, Tuveri M, Malleo G, Esposito A, Landoni L, Casetti L, Alseidi A, Salvia R, Steyerberg EW, Abu Hilal M, Vollmer CM, Besselink MG, Bassi C. Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation. Ann Surg 2023; 277:e1099-e1105. [PMID: 35797608 DOI: 10.1097/sla.0000000000005497] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Leia R Jones
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alberto Balduzzi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Shazad Tavakoli Rad
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Caleb Barnhill
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Thomas Seykora
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Massimiliano Tuveri
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Casetti
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
- Department of Surgery, University of California, San Francisco, CA
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
- Department of Surgery, Southampton University, Southampton, UK
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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10
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Management of clinically relevant postoperative pancreatic fistula-related fluid collections after distal pancreatectomy. Surg Endosc 2022:10.1007/s00464-022-09713-w. [DOI: 10.1007/s00464-022-09713-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 10/11/2022] [Indexed: 11/12/2022]
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11
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Tian F, Luo MJ, Sun MQ, Lu J, Huang BW, Guo JC. Staple line lockstitch reinforcement decreases clinically relevant pancreatic fistula following distal pancreatectomy: Results of a propensity score matched retrospective analysis. Front Oncol 2022; 12:999002. [PMID: 36338750 PMCID: PMC9634739 DOI: 10.3389/fonc.2022.999002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background Postoperative pancreatic fistula (POPF) remains the primary complication of distal pancreatectomies. We aimed to review whether staple line reinforcement with continuous lockstitches would lead to decreased grade B and C pancreatic fistula in patients undergoing distal pancreatectomy. Methods This retrospective study enrolled consecutive patients scheduled to undergo distal pancreatectomy at a large tertiary hospital. A comparison was conducted between lockstitch reinforcement and non-reinforcement for remnant closure during distal pancreatectomies from August 2016 to February 2021. Propensity score matching was applied to balance the two groups with covariates including abdominal and back pain, diabetes mellitus, and estimated blood loss. The primary outcome was POPF rate. Results A total of 153 patients were enrolled in the study (89 lockstitch reinforcements, 64 non-reinforcements), of whom 128 patients (64 per group) were analyzed after propensity score matching (1:1). The total POPF rate was 21.9%. POPF was identified in 12.5% (8/64) of the patients who underwent resection with lockstitch reinforcement and 31.2% (20/64) of the patients without reinforcement (odds ratio 0.314, 95% confidence interval 0.130-0.760, P=0.010). No deaths occurred in either group. Neither the major complication rate nor the length of hospital stay after surgery differed between the groups. Conclusions Compared with the use of stapler alone, staple line lockstitch reinforcement for remnant closure during distal pancreatectomy could reduce the POPF rate. Further multicenter randomized clinical trials are required to confirm these results.
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Affiliation(s)
- Feng Tian
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming-jie Luo
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Meng-qing Sun
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Lu
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo-wen Huang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun-chao Guo
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Jun-chao Guo,
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12
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Kawasaki K, Hayashi T, Takahashi M, Morita Y. Covering reinforced staples with polyethylene glycolic acid felt-covered fibrin sealant to prevent pancreatic fistula after distal pancreatomy: a retrospective comparative study. BMC Surg 2022; 22:349. [PMID: 36138405 PMCID: PMC9502575 DOI: 10.1186/s12893-022-01799-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In accordance with previous reports on the utility of polyethylene glycolic acid (PGA) felt and fibrin glue for postoperative pancreatic fistula (POPF), we usually perform distal pancreatectomy (DP) with a PGA felt reinforcement stapler when dissecting the pancreas and cover the stump with PGA felt and fibrin glue (the PPF method). In this study, we retrospectively analyzed our DP cases to compare the risk factors for POPF and the postoperative course of patients receiving the PPF method of treatment versus that of those receiving conventional treatment. METHODS A total of 127 DP procedures performed in our department between January 2008 and June 2021 were retrospectively analysed. RESULTS In the PPF method, grade B/C POPF rate tended to decrease, and POPF rate showed a significant decrease. The duration of drainage and the length of postoperative hospitalisation were also significantly shorter with the PPF method. The risk of grade B/C POPF significantly decreased with the PPF method if the pancreas was thick (> 13.5 mm) or the patients were obese. CONCLUSIONS The PPF method is useful for POPF in DP and is particularly effective when a thick pancreas or obese patient is involved. Removing the drainage tube early in the PPF method may lead to early discharge.
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Affiliation(s)
- Keishi Kawasaki
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
| | - Tatsuya Hayashi
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
| | - Makoto Takahashi
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
| | - Yasuhiro Morita
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
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13
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van Bodegraven EA, De Pastena M, Vissers FL, Balduzzi A, Stauffer J, Esposito A, Malleo G, Marchegiani G, Busch OR, Salvia R, van Hilst J, Bassi C, Besselink MG, Asbun HJ. Routine prophylactic abdominal drainage versus no-drain strategy after distal pancreatectomy: A multicenter propensity score matched analysis. Pancreatology 2022; 22:797-802. [PMID: 35690539 DOI: 10.1016/j.pan.2022.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/11/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives Postoperative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy (DP). Traditionally, surgical drains are placed routinely after DP, but some question its efficacy and postulate that the use of drains may convert a self-limiting postoperative collection into a POPF. This study aimed to compare outcomes between three institutions with varying drainage strategies. METHODS The study is a retrospective propensity score-matched analysis of intraoperative prophylactic drain placement during DP (2010-2019). The primary outcome is major morbidity. Propensity score matching was used to obtain comparable groups. RESULTS Overall, 963 patients after DP were included. One center did not place a surgical drain routinely, but decided to place a drain when unsatisfactory pancreatic closure occurred. Prophylactic abdominal drains were placed in 805 patients (84%) of which 74 could be matched to 74 patients without a drain. The rate of major morbidity (8% vs 19%, p = 0.054) and radiological interventions (5% vs 12%, p = 0.147) were non-significantly lower in the no-drain group as compared to the prophylactic drain group, respectively. The rates of POPF (4% vs 16%, p = 0.014) were lower in the no-drain group. CONCLUSION In this international retrospective multicenter study, a selective no-drain strategy after DP was not associated with higher rates major morbidity or radiological interventions as compared to routine prophylactic abdominal drainage. Although the rate of POPF was lower in the no-drain group, randomized trials should confirm the safety and outcome of a no-drain strategy after DP.
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Affiliation(s)
- Eduard A van Bodegraven
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Matteo De Pastena
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Department of General and Pancreatic Surgery - the Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Frederique L Vissers
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Alberto Balduzzi
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Department of General and Pancreatic Surgery - the Pancreas Institute, University of Verona Hospital Trust, Italy
| | - John Stauffer
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - the Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery - the Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery - the Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Roberto Salvia
- Department of General and Pancreatic Surgery - the Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Jony van Hilst
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Claudio Bassi
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Department of General and Pancreatic Surgery - the Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Horacio J Asbun
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA; Miami Cancer Institute, Division of Hepatobiliary and Pancreas Surgery, Miami, USA
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14
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Elkomos BE, Elkomos PE, Salem AA, Adly PB. The outcome of bioabsorbable staple line reinforcement versus standard stapler for distal pancreatectomy: A systematic review and meta-analysis. J Minim Access Surg 2022; 18:338-345. [PMID: 35708377 PMCID: PMC9306122 DOI: 10.4103/jmas.jmas_47_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/15/2022] [Accepted: 04/22/2022] [Indexed: 01/08/2023] Open
Abstract
Background and Aim In the era of minimally invasive procedures and as a way to decrease the incidence of post-operative pancreatic fistula (POPF), the use of staplers for distal pancreatectomy (DP) has increased dramatically. Our aim was to investigate whether reinforced staplers decrease the incidence of clinically relevant PF after DP compared with staplers without reinforcement. Methods PubMed, Scopus, Web of Science and Cochrane Library were searched for eligible studies from inception to 1 November 2021, and a systematic review and a meta-analysis were done to detect the outcomes after using reinforced staplers versus standard stapler for DP. Results Seven studies with a total of 681 patients were included. The overall incidence of POPF and the incidence of Grade A POPF after DP are similar for the two groups (overall POPF, risk ratio [RR] = 0.85, 95% confidence interval [CI] = 0.71-1.01, P = 0.06; I2 = 38% and Grade A POPF, RR = 1.15, 95% CI = 0.78-1.69, P = 0.47; I2 = 49%). However, the incidence of clinically significant POPF (Grades B and C) is significantly lower in DP with reinforced staplers than DP with bare staplers (Grades B and C, RR = 0.45, 95% CI = 0.29-0.71, P = 0.0005; I2 = 17%). Nevertheless, the time of the operation, the blood loss during surgical procedure, the hospital stay after the surgery and the thickness of the pancreas are similar for both techniques. Conclusion Although staple line reinforcement after DP failed to prevent biochemical PF, it significantly reduced the rate of clinically relevant POPF in comparison to standard stapling.
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Affiliation(s)
- Beshoy Effat Elkomos
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
| | | | - Amir Ali Salem
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
| | - Philobater Bhgat Adly
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
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15
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Maeda K, Kuriyama N, Yuge T, Ito T, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Mizuno S. Risk factor analysis of postoperative pancreatic fistula after distal pancreatectomy, with a focus on pancreas-visceral fat CT value ratio and serrated pancreatic contour. BMC Surg 2022; 22:240. [PMID: 35733145 PMCID: PMC9215066 DOI: 10.1186/s12893-022-01650-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In pancreaticoduodenectomy, the pancreas-visceral fat CT value ratio and serrated pancreatic contour on preoperative CT have been revealed as risk factors for postoperative pancreatic fistulas. We aimed to evaluate whether they could also serve as risk factors for postoperative pancreatic fistulas after distal pancreatectomy. METHODS A total of 251 patients that underwent distal pancreatectomy at our department from 2006 to 2020 were enrolled for the study. We retrospectively analyzed risk factors for postoperative pancreatic fistulas after distal pancreatectomy using various pre and intraoperative factors, including preoperative CT findings, such as pancreas-visceral fat CT value ratio and serrated pancreatic contour. RESULTS The study population included 147 male and 104 female participants (median age, 68 years; median body mass index, 21.4 kg/m2), including 64 patients with diabetes mellitus (25.5%). Preoperative CT evaluation showed a serrated pancreatic contour in 80 patients (31.9%), a pancreatic thickness of 9.3 mm (4.0-22.0 mm), pancreatic parenchymal CT value of 41.8 HU (4.3-22.0 HU), and pancreas-visceral fat CT value ratio of - 0.41 (- 4.88 to - 0.04). Postoperative pancreatic fistulas were developed in 34.2% of the patients. Univariate analysis of risk factors for postoperative pancreatic fistulas showed that younger age (P = 0.005), high body mass index (P = 0.001), absence of diabetes mellitus (P = 0.002), high preoperative C-reactive protein level (P = 0.024), pancreatic thickness (P < 0.001), and high pancreatic parenchymal CT value (P = 0.018) were significant risk factors; however, pancreas-visceral fat CT value ratio (P = 0.337) and a serrated pancreatic contour (P = 0.122) did not serve as risk factors. Multivariate analysis showed that high body mass index (P = 0.032), absence of diabetes mellitus (P = 0.001), and pancreatic thickness (P < 0.001) were independent risk factors. CONCLUSION The pancreas-visceral fat CT value ratio and serrated pancreatic contour evaluated using preoperative CT were not risk factors for postoperative pancreatic fistulas after distal pancreatectomy. High body mass index, absence of diabetes mellitus, and pancreatic thickness were independent risk factors, and a close-to-normal pancreas with minimal fat deposition or atrophy is thought to indicate a higher risk of postoperative pancreatic fistulas after distal pancreatectomy.
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Affiliation(s)
- Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.,Regional Medical Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Takuya Yuge
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Using a Reinforced Stapler Decreases the Incidence of Postoperative Pancreatic Fistula After Distal Pancreatectomy: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:1969-1979. [PMID: 35525852 DOI: 10.1007/s00268-022-06572-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is no consensus on the pancreatic transection during distal pancreatectomy (DP) to reduce postoperative pancreatic fistula (POPF). This meta-analysis aimed to evaluate the effects of a reinforced stapler on the postoperative outcomes of DP. METHODS We systematically searched electronic databases and bibliographic reference lists in The PubMed/MEDLINE, Google Scholar, Cochrane Library's Controlled Trials Registry and Database of Systematic Reviews, Embase, and Scopus. Review Manager Software was used for pooled estimates. RESULTS Seven eligible studies published between 2007 and 2021 were included with 553 patients (267 patients in the reinforced stapler group and 286 patients in the standard stapler group). The reinforced stapler reduced the POPF grade B and C (OR = 0.33; 95% CI [0.19, 0.57], p < 0.01). There was no difference between the reinforced stapler group and standard stapler group in terms of mortality rate (OR = 0.39; 95% CI [0.04, 3.57], p = 0.40), postoperative haemorrhage (OR = 0.53; 95% CI [0.20, 1.43], p = 0.21), and reoperation rate (OR = 0.91; 95% CI [0.40, 2.06], p = 0.82). CONCLUSIONS Reinforced stapling in DP is safe and seems to reduce POPF grade B/C with similar mortality rates, postoperative bleeding, and reoperation rate. The protocol of this systematic review with meta-analysis was registered in PROSPERO (ID: CRD42021286849).
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17
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Fatal pancreatic fistula after laparoscopic distal pancreatectomy for intraductal papillary mucinous carcinoma with pancreaticobiliary maljunction and sphincterotomized papilla: a case report. Surg Case Rep 2021; 7:239. [PMID: 34757521 PMCID: PMC8581099 DOI: 10.1186/s40792-021-01324-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022] Open
Abstract
Background Pancreatic juice is constantly activated by contaminated bile in patients with pancreaticobiliary maljunction (PBM). Here, we report a case of laparoscopic distal pancreatectomy for a patient with PBM and sphincterotomized papilla, resulting in fatal pancreatic fistula. Case presentation A 79-year-old man was diagnosed with pancreatic intraductal papillary mucinous neoplasm and common bile duct stones. Endoscopic sphincterotomy was performed prior to surgery. The pancreatic duct was simultaneously visualized when the contrast agent was injected into the common bile duct. Sudden bleeding was observed from the abdominal drain on postoperative day (POD) 6. Emergent stent graft placement and coil embolization were performed for bleeding from the splenic artery. On POD 9, the drainage fluid changed to yellowish in color with bile contamination. For internal drainage of the digestive fluid, endoscopic retrograde biliary tube and pancreatic drainage tube were placed. On POD 24, second emergent coil embolization was performed for bleeding from the left gastric artery. On POD 25, open abdominal drainage was performed. On POD 32, third emergent coil embolization was performed for bleeding from the gastroduodenal artery. Subsequently, remnant pancreatic resection was performed. On POD 39, massive bleeding was again observed from the abdominal drain. Emergency arterial portography revealed bleeding in the right wall of the superior mesenteric vein. The patient died of hemorrhagic shock on the same day. Conclusions The extreme risk of severe pancreatic fistula after distal pancreatectomy should be considered in patients with PBM and sphincterotomized papilla. In this extraordinary situation, surgeons should promptly decide whether to resect the remnant pancreas to prevent losing the patient.
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Maeda K, Kuriyama N, Nakagawa Y, Ito T, Hayasaki A, Gyoten K, Fujii T, Iizawa Y, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Mizuno S. Optimal management of peripancreatic fluid collection with postoperative pancreatic fistula after distal pancreatectomy: Significance of computed tomography values for predicting fluid infection. PLoS One 2021; 16:e0259701. [PMID: 34752498 PMCID: PMC8577730 DOI: 10.1371/journal.pone.0259701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/23/2021] [Indexed: 01/08/2023] Open
Abstract
Peripancreatic fluid collections have been observed in most patients with postoperative pancreatic fistula after distal pancreatectomy; however, optimal management remains unclear. This study aimed to evaluate the management and outcomes of patients with postoperative pancreatic fistula and verify the significance of computed tomography values for predicting peripancreatic fluid infections after distal pancreatectomy. We retrospectively investigated 259 consecutive patients who underwent distal pancreatectomy. Grade B postoperative pancreatic fistula patients were divided into two subgroups (B-antibiotics group and B-intervention group) and outcomes were compared. Predictive factor analysis of peripancreatic fluid infection was performed. Clinically relevant postoperative pancreatic fistulas developed in 88 (34.0%) patients. The duration of hospitalization was significantly longer in the B-intervention (n = 54) group than in the B-antibiotics group (n = 31; 41 vs. 17 days, p < 0.001). Computed tomography values of the infected peripancreatic fluid collections were significantly higher than those of the non-infected peripancreatic fluid collections (26.3 vs. 16.1 Hounsfield units, respectively; p < 0.001). The outcomes of the patients with grade B postoperative pancreatic fistulas who received therapeutic antibiotics only were considerably better than those who underwent interventions. Computed tomography values may be useful in predicting peripancreatic fluid collection infection after distal pancreatectomy.
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Affiliation(s)
- Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
- Regional Medical Support Center, Mie University Hospital, Tsu, Mie, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yuki Nakagawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Kelly ME. This month on Twitter. Br J Surg 2021; 108:znab225. [PMID: 34089581 DOI: 10.1093/bjs/znab225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 11/14/2022]
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