Skip to main content

Advertisement

SpringerLink
Log in

Modified Blumgart Suturing Technique for Remnant Closure After Distal Pancreatectomy: a Propensity Score-Matched Analysis

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Despite recent advances in surgical techniques including staple closure and ultrasonic devices, the reported incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Therefore, we devised a new strategy in which the pancreatic stump is enveloped with the elevated jejunum (EJ) by a modified Blumgart anastomotic technique. Eighty-one patients who underwent open DP with splenectomy from January 2008 to December 2014 were enrolled. Comparisons were made between 42 patients who underwent placement of an EJ patch using the modified Blumgart method after scalpel transection and 39 patients who underwent scalpel transection alone, using unmatched and propensity score-matched analysis. After 25 patients from each group were selected by propensity score matching, the EJ patch technique was significantly associated with a lower incidence of clinically relevant POPF (P = 0.036). Multivariate analysis showed that the EJ patch was an independent predictor of a lower incidence of POPF (odds ratio, 0.16; 95 % confidence interval, 0.01–0.48; P = 0.017) as was the estimated remnant pancreatic volume. Addition of the EJ patch improves postoperative outcomes in patients who undergo open DP with splenectomy by scalpel transection and hand-sewn closure of the pancreatic remnant.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244:931-937.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Balcom JHT, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001;136:391-398.

    Article  PubMed  Google Scholar 

  3. Nagai S, Fujii T, Kodera Y, Kanda M, Sahin TT, Kanzaki A, Yamada S, Sugimoto H, Nomoto S, Takeda S, Morita S, Nakao A. Impact of operative blood loss on survival in invasive ductal adenocarcinoma of the pancreas. Pancreas 2011;40:3-9.

    Article  PubMed  Google Scholar 

  4. Lillemoe KD, Kaushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ. Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg 1999;229:693-698.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  5. Knaebel HP, Diener MK, Wente MN, Büchler MW, Seiler CM. Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 2005;92:539-546.

    Article  CAS  PubMed  Google Scholar 

  6. Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, Tomazic A, Bruns CJ, Busch OR, Farkas S, Belyaev O, Neoptolemos JP, Halloran C, Keck T, Niedergethmann M, Gellert K, Witzigmann H, Kollmar O, Langer P, Steger U, Neudecker J, Berrevoet F, Ganzera S, Heiss MM, Luntz SP, Bruckner T, Kieser M, Büchler MW. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 2011;377:1514-1522.

    Article  PubMed  Google Scholar 

  7. Kleeff J, Diener MK, Z'graggen K, Hinz U, Wagner M, Bachmann J, Zehetner J, Müller MW, Friess H, Büchler MW. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 2007;245:573-582.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg 2011;98:268-274.

    Article  CAS  PubMed  Google Scholar 

  9. Seeliger H, Christians S, Angele MK, Kleespies A, Eichhorn ME, Ischenko I, Boeck S, Heinemann V, Jauch KW, Bruns CJ. Risk factors for surgical complications in distal pancreatectomy. Am J Surg 2010;200:311-317.

    Article  PubMed  Google Scholar 

  10. Frozanpor F, Albiin N, Linder S, Segersvärd R, Lundell L, Arnelo U. Impact of pancreatic gland volume on fistula formation after pancreatic tail resection. JOP 2010;11:439-443.

    PubMed  Google Scholar 

  11. Ferrone CR, Warshaw AL, Rattner DW, Berger D, Zheng H, Rawal B, Rodriguez R, Thayer SP, Fernandez-del Castillo C. Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg 2008;12:1691-1697.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Yoshioka R, Saiura A, Koga R, Seki M, Kishi Y, Morimura R, Yamamoto J, Yamaguchi T. Risk factors for clinical pancreatic fistula after distal pancreatectomy: analysis of consecutive 100 patients. World J Surg 2010;34:121-125.

    Article  PubMed  Google Scholar 

  13. Harris LJ, Abdollahi H, Newhook T, Sauter PK, Crawford AG, Chojnacki KA, Rosato EL, Kennedy EP, Yeo CJ, Berger AC. Optimal technical management of stump closure following distal pancreatectomy: a retrospective review of 215 cases. J Gastrointest Surg 2010;14:998-1005.

    Article  PubMed  Google Scholar 

  14. Bilimoria MM, Cormier JN, Mun Y, Lee JE, Evans DB, Pisters PW. Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation. Br J Surg 2003;90:190-196.

    Article  CAS  PubMed  Google Scholar 

  15. Farkas G, Leindler L, Farkas Jr G Safe closure technique for distal pancreatic resection. Langenbecks Arch Surg 2005;390:29-31.

    Article  PubMed  Google Scholar 

  16. Sadek S, Holdsworth R, Cuschieri A. Experience with pancreatic banding: results of a simple technique for dealing with the pancreatic remnant after distal partial pancreatectomy. Br J Surg 1988;75:486-487.

    Article  CAS  PubMed  Google Scholar 

  17. Wagner M, Gloor B, Ambühl M, Worni M, Lutz JA, Angst E, Candinas D. Roux-en-Y drainage of the pancreatic stump decreases pancreatic fistula after distal pancreatic resection. J Gastrointest Surg 2007;11:303-308.

    Article  CAS  PubMed  Google Scholar 

  18. Suzuki Y, Fujino Y, Tanioka Y, Hori Y, Ueda T, Takeyama Y, Tominaga M, Ku Y, Yamamoto YM, Kuroda Y. Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas. Br J Surg 1999;86:608-611.

    Article  CAS  PubMed  Google Scholar 

  19. Moriura S, Kimura A, Ikeda S, Iwatsuka Y, Ikezawa T, Naiki K. Closure of the distal pancreatic stump with a seromuscular flap. Surg Today 1995;25:992-994.

    Article  CAS  PubMed  Google Scholar 

  20. Kluger Y, Alfici R, Abbley B, Soffer D, Aladgem D. Gastric serosal patch in distal pancreatectomy for injury: a neglected technique. Injury 1997;28:127-129.

    Article  CAS  PubMed  Google Scholar 

  21. Ohwada S, Ogawa T, Tanahashi Y, Nakamura S, Takeyoshi I, Ohya T, Ikeya T, Kawashima K, Kawashima Y, Morishita Y. Fibrin glue sandwich prevents pancreatic fistula following distal pancreatectomy. World J Surg 1998;22:494-498.

    Article  CAS  PubMed  Google Scholar 

  22. Thaker RI, Matthews BD, Linehan DC, Strasberg SM, Eagon JC, Hawkins WG. Absorbable mesh reinforcement of a stapled pancreatic transection line reduces the leak rate with distal pancreatectomy. J Gastrointest Surg 2007;11:59-65.

    Article  PubMed  Google Scholar 

  23. Fujii T, Sugimoto H, Yamada S, Kanda M, Suenaga M, Takami H, Hattori M, Inokawa Y, Nomoto S, Fujiwara M, Kodera Y. Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study. J Gastrointest Surg 2014;18:1108-1115.

    Article  PubMed  Google Scholar 

  24. Carter TI, Fong ZV, Hyslop T, Lavu H, Tan WP, Hardacre J, Sauter PK, Kennedy EP, Yeo CJ, Rosato EL. A dual-institution randomized controlled trial of remnant closure after distal pancreatectomy: does the addition of a falciform patch and fibrin glue improve outcomes? J Gastrointest Surg 2013;17:102-109.

    Article  PubMed  Google Scholar 

  25. Montorsi M, Zerbi A, Bassi C, Capussotti L, Coppola R, Sacchi M; Italian Tachosil Study Group. Efficacy of an absorbable fibrin sealant patch (TachoSil) after distal pancreatectomy: a multicenter, randomized, controlled trial. Ann Surg 2012;256:853-859.

    Article  PubMed  Google Scholar 

  26. Oláh A, Issekutz A, Belágyi T, Hajdú N, Romics L Jr. Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy. Br J Surg 2009;96:602-607.

    Article  PubMed  Google Scholar 

  27. Kanda M, Fujii T, Sahin TT, Kanzaki A, Nagai S, Yamada S, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Morita S, Nakao A. Invasion of the splenic artery is a crucial prognostic factor in carcinoma of the body and tail of the pancreas. Ann Surg 2010;251:483-487.

    Article  PubMed  Google Scholar 

  28. Sahin TT, Fujii T, Kanda M, Nagai S, Kodera Y, Kanzaki A, Yamamura K, Sugimoto H, Kasuya H, Nomoto S, Takeda S, Morita S, Nakao A. Prognostic implications of lymph node metastases in carcinoma of the body and tail of the pancreas. Pancreas 2011;40:1029-1033.

    Article  PubMed  Google Scholar 

  29. Fujii T, Yamada S, Suenaga M, Kanda M, Takami H, Sugimoto H, Nomoto S, Nakao A, Kodera Y.Preoperative internal biliary drainage increases the risk of bile juice infection and pancreatic fistula after pancreatoduodenectomy: a prospective observational study. Pancreas 2015;44:465-470.

    Article  PubMed  Google Scholar 

  30. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M; International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8-13.

    Article  PubMed  Google Scholar 

  31. Dindo D, Demartines N, Clavien PA. Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240:205-213.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Fujii T, Kanda M, Nagai S, Suenaga M, Takami H, Yamada S, Sugimoto H, Nomoto S, Nakao A, Kodera Y. Excess Weight Adversely Influences Treatment Length of Postoperative Pancreatic Fistula: A Retrospective Study of 900 Patients. Pancreas 2015;44:971-976.

    Article  PubMed  Google Scholar 

  33. Kanda M, Fujii T, Takami H, Suenaga M, Inokawa Y, Yamada S, Kobayashi D, Tanaka C, Sugimoto H, Koike M, Nomoto S, Fujiwara M, Kodera Y. Novel diagnostics for aggravating pancreatic fistulas at the acute phase after pancreatectomy. World J Gastroenterol 2014;20:8535-8544.

    Article  PubMed Central  PubMed  Google Scholar 

  34. Bonjer HJ, Hop WC, Nelson H, Sargent DJ, Lacy AM, Castells A, Guillou PJ, Thorpe H, Brown J, Delgado S, Kuhrij E, Haglind E, Påhlman L; Transatlantic Laparoscopically Assisted vs Open Colectomy Trials Study Group. Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 2007;142:298-303.

    Article  PubMed  Google Scholar 

  35. Thorpe H, Jayne DG, Guillou PJ, Quirke P, Copeland J, Brown JM; Medical Research Council Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer Trial Group. Patient factors influencing conversion from laparoscopically assisted to open surgery for colorectal cancer. Br J Surg 2008;95:199-205.

    Article  CAS  PubMed  Google Scholar 

  36. Reeve BB, Smith AW, Arora NK, Hays RD. Reducing bias in cancer research: application of propensity score matching. Health Care Financ Rev. 2008;29:69-80.

    PubMed Central  PubMed  Google Scholar 

  37. D'Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 1998;17:2265-2281.

    Article  PubMed  Google Scholar 

  38. Austin PC. Some methods of propensity-score matching had superior performance to others: results of an empirical investigation and Monte Carlo simulations. Biom J 2009;51:171-184.

    Article  PubMed  Google Scholar 

  39. Hamilton NA, Porembka MR, Johnston FM, Gao F, Strasberg SM, Linehan DC, Hawkins WG. Mesh reinforcement of pancreatic transection decreases incidence of pancreatic occlusion failure for left pancreatectomy: a single-blinded, randomized controlled trial. Ann Surg 2012;255:1037-1042.

    Article  PubMed Central  PubMed  Google Scholar 

  40. Kleespies A, Rentsch M, Seeliger H, Albertsmeier M, Jauch KW, Bruns CJ. Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection. Br J Surg 2009;96:741-750.

    Article  CAS  PubMed  Google Scholar 

  41. Grobmyer SR, Kooby D, Blumgart LH, Hochwald SN. Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications. J Am Coll Surg 2010;210:54-59.

    Article  PubMed  Google Scholar 

  42. Tokunaga J, Imanaka Y. Influence of length of stay on patient satisfaction with hospital care in Japan. Int J Qual Health Care 2002;14:493-502.

    Article  PubMed  Google Scholar 

  43. Kondo A, Zierler BK, Isokawa Y, Hagino H, Ito Y. Comparison of outcomes and costs after hip fracture surgery in three hospitals that have different care systems in Japan. Health Policy 2009;91:204-210.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors are grateful to Leon Sakuma, BA, of the Kawasaki University of Medical Welfare, for providing the illustrations.

Grant support

No grant support was provided for this study.

Author information

Authors and Affiliations

  1. Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan

    Tsutomu Fujii, Suguru Yamada, Hiroyuki Sugimoto, Masashi Hattori, Mitsuro Kanda, Hideki Takami, Goro Nakayama, Shuji Nomoto, Michitaka Fujiwara, Akimasa Nakao & Yasuhiro Kodera

  2. Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan

    Kenta Murotani

Authors
  1. Tsutomu Fujii
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Suguru Yamada
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kenta Murotani
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hiroyuki Sugimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Masashi Hattori
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mitsuro Kanda
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hideki Takami
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Goro Nakayama
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Shuji Nomoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Michitaka Fujiwara
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Akimasa Nakao
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Yasuhiro Kodera
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tsutomu Fujii.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fujii, T., Yamada, S., Murotani, K. et al. Modified Blumgart Suturing Technique for Remnant Closure After Distal Pancreatectomy: a Propensity Score-Matched Analysis. J Gastrointest Surg 20, 374–384 (2016). https://doi.org/10.1007/s11605-015-2980-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-015-2980-3

Keywords

Search

Navigation