Skip to main content
SpringerLink
Log in

Optimal Technical Management of Stump Closure Following Distal Pancreatectomy: A Retrospective Review of 215 Cases

  • SSAT Poster Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Pancreatic fistula (PF) is a major source of morbidity following distal pancreatectomy (DP). Our aim was to identify risk factors related to PF following DP and to determine the impact of technique of transection and stump closure.

Methods

We performed a retrospective review of 215 consecutive patients who underwent DP. Perioperative and postoperative data were collected and analyzed with attention to PF as defined by the International Study Group of Pancreatic Fistula.

Results

PF developed in 36 patients (16.7%); fistulas were classified as Grade A (44.4%), B (44.4%), or C (11.1%). The pancreas was transected with stapler (n = 139), cautery (n = 70), and scalpel (n = 3). PF developed in 19.8% of remnants which were stapled/oversewn and 27.7% that were stapled alone (p = 0.4). Of the 69 pancreatic remnants transected with cautery and oversewn, a fistula developed in 4.3% (p = 0.004 compared to stapled/oversewn; p = 0.006 compared to stapled/not sewn). The median length of postoperative hospital stay was significantly increased in patients who developed PF (10 vs. 6 days, p = 0.002)

Conclusion

The method of transection and management of the pancreatic remnant plays a critical role in the formation of PF following DP. This series suggests that transection using electrocautery followed by oversewing of the pancreatic remnant has the lowest risk of PF.

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

Figure 1
Figure 2

Similar content being viewed by others

References

  1. Neoptolemos JP, Russell RC, Bramhall S, et al. Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group. Br J Surg 1997;84:1370-1376.

    Article  CAS  PubMed  Google Scholar 

  2. Buchler MW, Wagner M, Schmied BM, et al. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003;138:1310-1314.

    Article  PubMed  Google Scholar 

  3. Fahy BN, Frey CF, Ho HS, et al. Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg 2002;183:237-241.

    Article  PubMed  Google Scholar 

  4. Grobmeyer SR, Pieracci FM, Allen PJ, et al. Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg 2007;204:356-364.

    Article  Google Scholar 

  5. van Heek NT, Kuhlmann KF, Scholten RJ, et al. Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg 2005;242:781-788.

    Article  PubMed  Google Scholar 

  6. Lillemoe KD, Kaushal S, Cameron JL, et al. Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg 1999;229:693-700.

    Article  CAS  PubMed  Google Scholar 

  7. Fabre JM, Houry S, Manderscheid JC, et al. Surgery for left-sided pancreatic cancer. Br J Surg 1996;83:1065-1070.

    Article  CAS  PubMed  Google Scholar 

  8. Bilimoria MM, Cormier JN, Mun Y, et al. Pancreatic leak after pancreatectomy is reduced following main pancreatic duct ligation. Br J Surg 2003;90:190-196.

    Article  CAS  PubMed  Google Scholar 

  9. Kleeff J, Diener MK, Z’graggen K, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 2007;245:573-582.

    Article  PubMed  Google Scholar 

  10. Balcom JH IV, Rattner DW, Warshaw Al, et al. 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 

  11. Rodriguez JR, Germes SS, Pandharipande PV, et al. Implications and cost of pancreatic leak following distal pancreatic resection. Arch Surg 2006;141:361-365.

    Article  PubMed  Google Scholar 

  12. Ridolfini MP, Alferi S, Gourgiotis S, et al. Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial? World J Gastroenterol 2007;13:5096-5100.

    PubMed  Google Scholar 

  13. Sheehan MK, Beck K, Creech S, et al. Distal pancreatectomy: does the method of closure influence fistula formation? Am Surg 2002;68:264-267.

    PubMed  Google Scholar 

  14. Bassi C, Butturini G, Falconi M, et al. Prospective randomized pilot study of management of the pancreatic stump following distal resection. HPB 1999;1:203-207.

    Google Scholar 

  15. Takeuchi K, Tsuzuki T, Ando T, et al. Distal pancreatectomy: is staple closure beneficial? Aust N Z J Surg 2003;73:922-925.

    Article  Google Scholar 

  16. Suzuki Y, Fujino Y, Tanioka Y, et al. 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 

  17. Ohwada S, Ogawa T, Tanahashi Y, et al. Fibrin glue sandwich prevents pancreatic fistula following distal pancreatectomy. World J Surg 1998;22:494-498.

    Article  CAS  PubMed  Google Scholar 

  18. Kuroki T, Tajima Y, Kanematsu T. Surgical management for the prevention of pancreatic fistula following distal pancreatectomy. J Hepatobiliary Pancreat Surg 2005;12:283-285.

    Article  PubMed  Google Scholar 

  19. Kawai M, Tani M, Yamaue H. Transection using bipolar scissors reduced pancreatic fistula after distal pancreatectomy. J Hepatobiliary Pancreat Surg 2008;15:366-372.

    Article  PubMed  Google Scholar 

  20. Jimez R, Mavanur A, Macaulay W. Staple line reinforcement reduced postoperative pancreatic stump leak after distal pancreatectomy. J Gastroint Surg 2007;11:345-349.

    Article  Google Scholar 

  21. Ferrone C, Warshaw A, Rattner D, et al. Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg 2008;12:1691-1698.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  23. Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection: the importance of definitions. Dig Surg 2004;21:54-59.

    Article  PubMed  Google Scholar 

  24. Goh B, Ten Y, Chung YA, et al. Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula. Arch Surg 2008;143:956-965.

    Article  PubMed  Google Scholar 

  25. Bilimoria MM, Evans DB, Lee JE, et al. Pancreatic closure after distal pancreatectomy: relationship to postoperative pancreatic fistula. Presented at the 53rd Annual Cancer Symposium of the Society of Surgical Oncology, New Orleans, LA, March 16-19, 2000.

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

    Article  PubMed  Google Scholar 

  27. Büchler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–131.

    Article  PubMed  Google Scholar 

  28. Pederzoli P, Bassi C, Falconi M, et al. Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Br J Surg 1994;81:265–269.

    Article  CAS  PubMed  Google Scholar 

  29. Montorsi M, Zago M, Mosca F, et al. Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery 1995;117:26–31.

    Article  CAS  PubMed  Google Scholar 

  30. Friess H, Beger HG, Sulkowski U, et al. Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis. Br J Surg 1995;82:1270–1273.

    Article  CAS  PubMed  Google Scholar 

  31. Lowy AM, Lee JE, Pisters PWT, et al. Prospective randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 1997;226:632–641.

    Article  CAS  PubMed  Google Scholar 

  32. Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy?: Results of a prospective, randomized placebo-controlled trial. Ann Surg 2000;232:419-429.

    Article  CAS  PubMed  Google Scholar 

  33. Tang CN, Tsui KK, Ha JP, et al. Laparoscopic distal pancreatectomy: a comparative study. Hepatogastroenterology 2007;54:265-271.

    CAS  PubMed  Google Scholar 

  34. Pierce RA, Spitler JA, Hawkins WG, et al. Outcomes analysis of laparoscopic resection of pancreatic neoplasms. Surg Endosc 2007;21:579-586.

    Article  CAS  PubMed  Google Scholar 

  35. Pryor A, Means JR, Pappas TN. Laparoscopic distal pancreatectomy with splenic preservation. Surg Endosc 2007;21:2326-2330.

    Article  CAS  PubMed  Google Scholar 

  36. Abu Hilal M, Jain G, Kasasbeh F, et al. Laparoscopic distal pancreatectomy: critical analysis of preliminary experience from a tertiary referral centre. Surg Endosc 2009; doi:10.1007/s00464-009-0499-y.

    Google Scholar 

  37. Patterson EJ, Gagner M, Salky B, et al. Laparoscopic pancreatic resection: single-institution experience of 19 patients. J Am Coll Surg 2001;193:281-287.

    Article  CAS  PubMed  Google Scholar 

  38. Velanovich V. Case-control comparison of laparoscopic versus open distal pancreatectomy. J Gastrointest Surg 2006;10:95-98.

    Article  PubMed  Google Scholar 

  39. Kooby DA, Gillespie T, Bentrem D, et al. Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 2008;248:438-446.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Thomas Jefferson University, 1100 Walnut Street, MOB Suite 500, Philadelphia, PA, 19107, USA

    Lisa J. Harris, Hamid Abdollahi, Timothy Newhook, Patricia K. Sauter, Albert G. Crawford, Karen A. Chojnacki, Ernest L. Rosato, Eugene P. Kennedy, Charles J. Yeo & Adam C. Berger

Authors
  1. Lisa J. Harris
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hamid Abdollahi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Timothy Newhook
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Patricia K. Sauter
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Albert G. Crawford
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Karen A. Chojnacki
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ernest L. Rosato
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Eugene P. Kennedy
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Charles J. Yeo
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Adam C. Berger
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Adam C. Berger.

Additional information

Poster presentation at the 50th Annual Meeting of the Society of Surgery of the Alimentary Tract (Chicago, IL, USA, June 2009)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Harris, L.J., Abdollahi, H., Newhook, T. et al. Optimal Technical Management of Stump Closure Following Distal Pancreatectomy: A Retrospective Review of 215 Cases. J Gastrointest Surg 14, 998–1005 (2010). https://doi.org/10.1007/s11605-010-1185-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-010-1185-z

Keywords

Search

Navigation