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Stapler and Nonstapler Closure of the Pancreatic Remnant After Distal Pancreatectomy: Multicenter Retrospective Analysis of 388 Patients

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Abstract

Background

The pancreatic fistula rate following distal pancreatectomy ranges widely, from 13.3 to 64.0 %. The optimal closure method of the pancreatic remnant remains controversial, especially regarding whether to use a stapler.

Methods

All patients who underwent distal pancreatectomy in five Japanese hospitals from January 2001 to June 2009 were included in this study. All relevant, anonymized medical records were entered into an electronic case report form. Complications and pancreatic fistulas were classified according to the Clavien–Dindo classification and the International Study Group of Pancreatic Surgery grading system, respectively.

Results

Of the 388 patients, stapler closure and nonstapler closure were used after distal pancreatectomy in 224 patients (57.7 %) and 164 patients (42.3 %), respectively. Clinically relevant pancreatic fistulas (grades B and C) occurred in 47 patients (21.0 %) treated by stapler closure, which was a significantly lower rate than that for the 83 patients (50.6 %) treated by nonstapler closure. There were no surgical mortalities or in-hospital deaths. The distribution of postoperative complications was grade 1, 30.7 % (n = 119); grade 2, 40.2 % (n = 156); grade 3a, 0.1 % (n = 5); grade 3b, 0.3 % (n = 1); grade 4a, 0.3 % (n = 1). In the multivariate analysis, diabetes mellitus, previous laparotomy, operating time, and method of stump closure were found to be independently associated with the development of a clinical pancreatic fistula.

Conclusions

Stapler closure is a safe, efficient alternative to standard suture closure techniques because the clinical fistula rate is significantly lower.

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References

  1. Lillemoe KD, Kaushal S, Cameron JL et al (1999) Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg 229:693–700

    Article  PubMed  CAS  Google Scholar 

  2. Knaebel HP, Diener MK, Wente MN et al (2005) Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 92:539–546

    Article  PubMed  CAS  Google Scholar 

  3. Balzano G, Zerbi A, Cristallo M et al (2005) The unsolved problem of fistula after left pancreatectomy: the benefit of cautious drain management. J Gastrointest Surg 9:837–842

    Article  PubMed  Google Scholar 

  4. Rodriguez JR, Germes SS, Pandharipande PV et al (2006) Implications and cost of pancreatic leak following distal pancreatic resection. Arch Surg 141:361–366

    Article  PubMed  Google Scholar 

  5. Pachter HL, Pennington R, Chassin J et al (1979) Simplified distal pancreatectomy with the Auto Suture stapler: preliminary clinical observations. Surgery 85:166–170

    PubMed  CAS  Google Scholar 

  6. Kajiyama Y, Tsurumaru M, Udagawa H et al (1996) Quick and simple distal pancreatectomy using the GIA stapler: report of 35 cases. Br J Surg 83:1711

    Article  PubMed  CAS  Google Scholar 

  7. Fahy BN, Frey CF, Ho HS et al (2002) Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg 183:237–241

    Article  PubMed  Google Scholar 

  8. Takeuchi K, Tsuzuki Y, Ando T et al (2003) Distal pancreatectomy: is staple closure beneficial? ANZ J Surg 73:922–925

    Article  PubMed  Google Scholar 

  9. Lorenz U, Maier M, Steger U et al (2007) Analysis of closure of the pancreatic remnant after distal pancreatic resection. HPB 9:302–307

    Article  PubMed  CAS  Google Scholar 

  10. Okano K, Kakinoki K, Yachida S et al (2008) A simple and safe pancreas transection using a stapling device for a distal pancreatectomy. J Hepatobiliary Pancreat Surg 15:353–358

    Article  PubMed  Google Scholar 

  11. Misawa T, Shiba H, Usuba T et al (2008) Safe and quick distal pancreatectomy using a staggered six-row stapler. Am J Surg 195:115–118

    Article  PubMed  Google Scholar 

  12. Bilimoria MM, Cormier JN, Mun Y et al (2003) Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation. Br J Surg 90:190–196

    Article  PubMed  CAS  Google Scholar 

  13. Pannegeon V, Pessaux P, Sauvanet A et al (2006) Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment. Arch Surg 141:1071–1076

    Article  PubMed  Google Scholar 

  14. Nathan H, Cameron JL, Goodwin CR et al (2009) Risk factors for pancreatic leak after distal pancreatectomy. Ann Surg 250:277–281

    Article  PubMed  Google Scholar 

  15. Yoshioka R, Saiura A, Koga R et al (2010) Risk factors for clinical pancreatic fistula after distal pancreatectomy: analysis of consecutive 100 patients. World J Surg 34:121–125. doi:10.1007/s00268-009-0300-3

    Article  PubMed  Google Scholar 

  16. Ridolfini MP, Alfieri S, Gourgiotis S et al (2007) Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial? World J Gastroenterol 13:5096–5100

    PubMed  Google Scholar 

  17. Sledzianowski JF, Duffas JP, Muscari F et al (2005) Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy. Surgery 137:180–185

    Article  PubMed  CAS  Google Scholar 

  18. Ferrone CR, Warshaw AL, Rattner DW et al (2008) Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg 12:1691–1698

    Article  PubMed  Google Scholar 

  19. Seeliger H, Christians S, Angele MK et al (2010) Risk factors for surgical complications in distal pancreatectomy. Am J Surg 200:311–317

    Article  PubMed  Google Scholar 

  20. Kleeff J, Diener MK, Z’Graggen K et al (2007) Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 245:573–582

    Article  PubMed  Google Scholar 

  21. Goh BK, Tan YM, Chung YF et al (2008) Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution. Arch Surg 143:956–965

    Article  PubMed  Google Scholar 

  22. Sierzega M, Niekowal B, Kulig J et al (2007) Nutritional status affects the rate of pancreatic fistula after distal pancreatectomy: a multivariate analysis of 132 patients. J Am Coll Surg 205:52–59

    Article  PubMed  Google Scholar 

  23. Zhou W, Lv R, Wang X et al (2010) Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis. Am J Surg 200:529–536

    Article  PubMed  Google Scholar 

  24. Bassi C, Dervenis C, Butturini G et al (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13

    Article  PubMed  Google Scholar 

  25. Shimada K, Yamamoto J, Kosuge T (2000) Complete drainage of pancreatic juice from the cut edge of the pancreas after subtotal left-side pancreatectomy. Hepatogastroenterology 47:1156–1158

    PubMed  CAS  Google Scholar 

  26. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed  Google Scholar 

  27. Hashimoto Y, Traverso LW (2010) Incidence of pancreatic anastomotic failure and delayed gastric emptying after pancreatoduodenectomy in 507 consecutive patients: use of a web-based calculator to improve homogeneity of definition. Surgery 147:503–515

    Article  PubMed  Google Scholar 

  28. Wente MN, Veit JA, Bassi C et al (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142:20–25

    Article  PubMed  Google Scholar 

  29. Wente MN, Bassi C, Dervenis C et al (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142:761–768

    Article  PubMed  Google Scholar 

  30. Kawai M, Tani M, Terasawa H et al (2006) Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg 244:1–7

    Article  PubMed  Google Scholar 

  31. Yamamoto M, Hayashi MS, Nguyen NT et al (2009) Use of Seamguard to prevent pancreatic leak following distal pancreatectomy. Arch Surg 144:894–899

    Article  PubMed  Google Scholar 

  32. Suzuki Y, Fujino Y, Tanioka Y et al (1999) Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas. Br J Surg 86:608–611

    Article  PubMed  CAS  Google Scholar 

  33. Sugo H, Mikami Y, Matsumoto F et al (2000) Distal pancreatectomy using the Harmonic Scalpel. Surgery 128:490–491

    Article  PubMed  CAS  Google Scholar 

  34. Ohwada S, Ogawa T, Tanahashi Y et al (1998) Fibrin glue sandwich prevents pancreatic fistula following distal pancreatectomy. World J Surg 22:494–498. doi:10.1007/s002689900423

    Article  PubMed  CAS  Google Scholar 

  35. Abe N, Sugiyama M, Suzuki Y et al (2008) Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy. J Hepatobiliary Pancreat Surg 15:373–376

    Article  PubMed  Google Scholar 

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Acknowledgments

This study was supported by a Grant-in-Aid for Cancer Research from the Ministry of Health, Welfare, and Labor of Japan (21-7-5). We acknowledge Tomoo Kosuge for inspiring this study. In addition, we thank the following investigators for data collection: Kiyoshi Yoshikawa, Rintaro Koga, Ryuji Yoshioka, Kazunari Sasaki, and Takashi Mizuno.

Conflict of interest

The authors have no direct or indirect commercial or financial incentive associated with publishing this article.

Author information

Authors and Affiliations

  1. Department of Hepatobiliary-Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan

    Daisuke Ban

  2. Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Central Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan

    Kazuaki Shimada

  3. Division of Digestive Surgery, National Cancer Center Hospital East, Kashiwa, Japan

    Masaru Konishi

  4. Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan

    Akio Saiura

  5. Department of Digestive Surgery, Toranomon Hospital, Tokyo, Japan

    Masaji Hashimoto

  6. Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan

    Katsuhiko Uesaka

Authors
  1. Daisuke Ban
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  2. Kazuaki Shimada
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  3. Masaru Konishi
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  4. Akio Saiura
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  5. Masaji Hashimoto
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  6. Katsuhiko Uesaka
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Corresponding author

Correspondence to Kazuaki Shimada.

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Ban, D., Shimada, K., Konishi, M. et al. Stapler and Nonstapler Closure of the Pancreatic Remnant After Distal Pancreatectomy: Multicenter Retrospective Analysis of 388 Patients. World J Surg 36, 1866–1873 (2012). https://doi.org/10.1007/s00268-012-1595-z

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  • DOI: https://doi.org/10.1007/s00268-012-1595-z

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