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

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Abstract

Purpose

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

Methods

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

Results

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

Conclusion

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

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Data Availability

Data will be available upon request.

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Authors and Affiliations

  1. Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France

    Théophile Guilbaud, Olivier Picaud, Thibaud Vicenty, Georges Farvacque, Charles Vanbrugghe, Stéphane Berdah, Vincent Moutardier & David Jérémie Birnbaum

  2. Center of Epidemiology and Health Economy, Direction de La Recherche en Santé, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France

    Cindy Faust & Karine Baumstarck

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Contributions

Study conception and design: DJB and TG. Acquisition of data: DJB, TG, TV, and GF. Analysis and interpretation of data: DJB, TG, CVB, OP, CF, and KB. Drafting of manuscript: DJB and TG. Critical revision of manuscript: DJB, TG, VM, and SB.

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Correspondence to David Jérémie Birnbaum.

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Supplementary Information

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Supplementary file 1 (DOCX 22 KB)

ESM 1

Supplementary Figure 1. Late PPH location after pancreaticoduodenectomy (A, C) and distal pancreatectomy (B, D). A, B. Late PPH location after pancreatic resection in no “flooring” method group. C, D. Late PPH location after pancreatic resection in “flooring” method group. HA, hepatic artery; GDA, gastroduodenal artery; SMA, superior mesenteric artery; SA, Splenic artery. (PNG 2797 kb)

High resolution image (TIFF 574 kb)

ESM 2

Supplementary Figure 2. Postoperative abdominal CT scan following PD (A, B) and DP (C, D). A. After PD, the pedicled falciform/round ligament flap is “flooring” (yellow area) the skeletonized major vessels near the pancreaticojejunostomy (*). B. A Late PPH (red area) following PD is contained by the falciform/round flap (yellow area). C. After DP, the pedicled falciform/round ligament flap is “flooring” (yellow area) the skeletonized major vessels near the pancreatic stump (**). D. A Late PPH (red area) following PD is contained by the falciform/round flap (yellow area) (PNG 3629 kb)

High resolution image (TIFF 833 kb)

ESM 3

Supplementary Figure 3. Surgical technic for the falciform/round ligament “flooring” method during laparoscopic distal pancreatectomy. A, B. The falciform/round ligament flap was pedicled. It was mobilized by dividing it near the umbilicus and incising its anterior peritoneal reflections along the posterior rectus sheath and the undersurface of the diaphragm. C. the falciform/round ligament flap was brought to the operative field and is spread out widely on the major vessels near the pancreatic stump (yellow area, such as the common hepatic artery (CHA), superior mesenteric vein (SMV), portal vein, and stumps of the splenic artery/vein. (PNG 3440 kb)

High resolution image (TIF 911 kb)

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Guilbaud, T., Faust, C., Picaud, O. et al. The falciform/round ligament “flooring,” an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence. Langenbecks Arch Surg 408, 192 (2023). https://doi.org/10.1007/s00423-023-02915-3

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