Skip to main content
SpringerLink
Log in

Reinforced stapling does not reduce postoperative pancreatic fistula in distal pancreatectomy: a systematic review and meta-analysis

  • Review Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

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.

Key findings

There is no difference in postoperative pancreatic fistula between reinforced and standard staplers in distal pancreatectomy.

What is known and what is new?

Reinforced staples have been shown to reduce postoperative pancreatic fistula in previous meta-analyses and observational clinical trials, but an increasing number of randomized controlled trials have not reached the same conclusion.

This meta-analysis revealed that, in contrast to previous meta-analyses, reinforced stapling did nt reduce postoperative pancreatic fistula in distal pancreatectomy.

What is the implication, and what should change now?

Surgeons need to carefully consider the clinical role of reinforced staplers and find novel approaches to reduce postoperative pancreatic fistula in distal pancreatectomy.

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
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Paye F, Micelli Lupinacci R, Bachellier P et al (2015) Distal pancreatectomy for pancreatic carcinoma in the era of multimodal treatment. Br J Surg 102:229–236

    Article  CAS  PubMed  Google Scholar 

  2. de Rooij T, van Hilst J, van Santvoort H et al (2019) Minimally invasive versus open distal pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg 269:2–9

    Article  PubMed  Google Scholar 

  3. 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  PubMed Central  Google Scholar 

  4. Noorani A, Rangelova E, Del Chiaro M et al (2016) Delayed gastric emptying after pancreatic surgery: analysis of factors determinant for the short-term outcome. Front Surg 3:25

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Mendoza AS 3rd, Han HS, Ahn S et al (2016) Predictive factors associated with postoperative pancreatic fistula after laparoscopic distal pancreatectomy: a 10-year single-institution experience. Surg Endosc 30:649–656

    Article  PubMed  Google Scholar 

  6. Chang YR, Kang JS, Jang JY et al (2017) Prediction of pancreatic fistula after distal pancreatectomy based on cross-sectional images. World J Surg 41:1610–1617

    Article  PubMed  Google Scholar 

  7. Ecker BL, McMillan MT, Allegrini V et al (2019) Risk factors and mitigation strategies for pancreatic fistula after distal pancreatectomy: analysis of 2026 resections from the international, multi-institutional distal pancreatectomy study group. Ann Surg 269:143–149

    Article  PubMed  Google Scholar 

  8. Abe K, Kitago M, Shinoda M et al (2020) High risk pathogens and risk factors for postoperative pancreatic fistula after pancreatectomy; a retrospective case-controlled study. Int J Surg 82:136–142

    Article  PubMed  Google Scholar 

  9. Chong E, Ratnayake B, Lee S et al (2021) Systematic review and meta-analysis of risk factors of postoperative pancreatic fistula after distal pancreatectomy in the era of 2016 International Study Group pancreatic fistula definition. HPB (Oxford) 23:1139–1151

    Article  PubMed  Google Scholar 

  10. Rozich NS, Morris KT, Garwe T et al (2019) Blame it on the injury: trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection. J Trauma Acute Care Surg 87:1289–1300

    Article  PubMed  PubMed Central  Google Scholar 

  11. Funamizu N, Sogabe K, Shine M et al (2022) Association between the preoperative C-reactive protein-to-albumin ratio and the risk for postoperative pancreatic fistula following distal pancreatectomy for pancreatic cancer. Nutrients 14:1

    Article  Google Scholar 

  12. Diener MK, Seiler CM, Rossion I et al (2011) Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 377:1514–1522

    Article  PubMed  Google Scholar 

  13. 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 12:1691–7

    Article  PubMed  PubMed Central  Google Scholar 

  14. Jang JY, Shin YC, Han Y et al (2017) Effect of polyglycolic acid mesh for prevention of pancreatic fistula following distal pancreatectomy: a randomized clinical trial. JAMA Surg 152:150–155

    Article  PubMed  Google Scholar 

  15. Rostas JW, Richards WO, Thompson LW (2012) Improved rate of pancreatic fistula after distal pancreatectomy: parenchymal division with the use of saline-coupled radiofrequency ablation. HPB (Oxford) 14:560–564

    Article  PubMed  Google Scholar 

  16. Okada K, Kawai M, Tani M et al (2014) Isolated Roux-en-Y anastomosis of the pancreatic stump in a duct-to-mucosa fashion in patients with distal pancreatectomy with en-bloc celiac axis resection. J Hepatobiliary Pancreat Sci 21:193–198

    Article  PubMed  Google Scholar 

  17. Mungroop TH, van der Heijde N, Busch OR et al (2021) Randomized clinical trial and meta-analysis of the impact of a fibrin sealant patch on pancreatic fistula after distal pancreatectomy: CPR trial. BJS Open 5:1

    Article  Google Scholar 

  18. Ratnayake CBB, Wells C, Hammond J et al (2019) Network meta-analysis comparing techniques and outcomes of stump closure after distal pancreatectomy. Br J Surg 106:1580–1589

    Article  CAS  PubMed  Google Scholar 

  19. 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  CAS  PubMed  Google Scholar 

  20. Oweira H, Mazotta A, Mehrabi A et al (2022) Using a reinforced stapler decreases the incidence of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis. World J Surg 46:1969–1979

    Article  PubMed  Google Scholar 

  21. Elkomos BE, Elkomos PE, Salem AA et al (2022) The outcome of bioabsorbable staple line reinforcement versus standard stapler for distal pancreatectomy: a systematic review and meta-analysis. J Minim Access Surg 18:338–345

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kondo N, Uemura K, Nakagawa N et al (2019) A multicenter, randomized, controlled trial comparing reinforced staplers with bare staplers during distal pancreatectomy (HiSCO-07 Trial). Ann Surg Oncol 26:1519–1527

    Article  PubMed  Google Scholar 

  23. Wennerblom J, Ateeb Z, Jönsson C et al (2021) Reinforced versus standard stapler transection on postoperative pancreatic fistula in distal pancreatectomy: multicentre randomized clinical trial. Br J Surg 108:265–270

    Article  CAS  PubMed  Google Scholar 

  24. Merdrignac A, Garnier J, Dokmak S et al (2022) Effect of the use of reinforced stapling on the occurrence of pancreatic fistula after distal pancreatectomy. Ann Surg 276:769–775

    Article  PubMed  Google Scholar 

  25. Shea BJ, Reeves BC, Wells G et al (2017) AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 358:j4008

    Article  PubMed  PubMed Central  Google Scholar 

  26. Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097

    Article  PubMed  PubMed Central  Google Scholar 

  27. 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 

  28. Bassi C, Marchegiani G, Dervenis C et al (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 161:584–591

    Article  PubMed  Google Scholar 

  29. 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  PubMed Central  Google Scholar 

  30. Jadad AR, Moore RA, Carroll D et al (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12

    Article  CAS  PubMed  Google Scholar 

  31. Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25:603–605

    Article  PubMed  Google Scholar 

  32. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13

    Article  PubMed  PubMed Central  Google Scholar 

  33. Higgins JPT, editor (2011) Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration

  34. Jia B, Chen Q, Jiang P et al (2022) An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. Surg Today 52:1430–1437

    Article  PubMed  Google Scholar 

  35. Ishida J, Toyama H, Asari S et al (2023) Use of a short cartridge stapler is beneficial in pancreatic transection at the neck during laparoscopic distal pancreatectomy. Surg Today 53:153–157

    Article  PubMed  Google Scholar 

  36. Palmeri M, Furbetta N, Di Franco G et al (2023) Comparison of different pancreatic stump management strategies during robot-assisted distal pancreatectomy. Int J Med Robot 19:e2470

    Article  PubMed  Google Scholar 

  37. Hayashibe A, Ogino N (2018) Clinical study for pancreatic fistula after distal pancreatectomy with mesh reinforcement. Asian J Surg 41:236–240

    Article  PubMed  Google Scholar 

  38. Miyamoto R, Sano N, Maeda M et al (2019) Modified reinforced staple closure technique decreases postoperative pancreatic fistula after distal pancreatectomy. Indian J Surg Oncol 10:587–593

    Article  PubMed  PubMed Central  Google Scholar 

  39. Murata Y, Maeda K, Ito T et al (2023) Efficacy of reinforced stapler versus hand-sewn closure of the pancreatic stump during pure laparoscopic distal pancreatectomy to reduce pancreatic fistula. Surg Laparosc Endosc Percutan Tech 33:99–107

    Article  PubMed  Google Scholar 

  40. Kurahara H, Maemura K, Mataki Y et al (2014) Closure of the pancreas in distal pancreatectomy: comparison between bare stapler and reinforced stapler. Hepatogastroenterology 61:2367–2370

    PubMed  Google Scholar 

  41. Wallace CL, Georgakis GV, Eisenberg DP et al (2013) Further experience with pancreatic stump closure using a reinforced staple line. Conn Med 77:205–210

    PubMed  Google Scholar 

  42. Goh BKP, Lee CY, Koh YX et al (2021) Use of reinforced staplers decreases the rate of postoperative pancreatic fistula compared to bare staplers after minimally invasive distal pancreatectomies. J Laparoendosc Adv Surg Tech A 31:1124–1129

    Article  PubMed  Google Scholar 

  43. Kawaida H, Kono H, Amemiya H et al (2019) Use of a reinforced triple-row stapler following distal pancreatectomy reduces the incidence of postoperative pancreatic fistula in patients with a high BMI. Anticancer Res 39:1013–1018

    Article  PubMed  Google Scholar 

  44. Jimenez RE, Mavanur A, Macaulay WP (2007) Staple line reinforcement reduces postoperative pancreatic stump leak after distal pancreatectomy. J Gastrointest Surg 11:345–349

    Article  PubMed  Google Scholar 

  45. Maggino L, Malleo G, Bassi C et al (2019) Decoding Grade B pancreatic fistula: a clinical and economical analysis and subclassification proposal. Ann Surg 269:1146–1153

    Article  PubMed  Google Scholar 

  46. Lee SC, Hong TH, Kim OH et al (2020) A novel way of preventing postoperative pancreatic fistula by directly injecting profibrogenic materials into the pancreatic parenchyma. Int J Mol Sci 21:1

    Google Scholar 

  47. Hassenpflug M, Hinz U, Strobel O et al (2016) Teres ligament patch reduces relevant morbidity after distal pancreatectomy (the DISCOVER Randomized Controlled Trial). Ann Surg 264:723–730

    Article  PubMed  Google Scholar 

  48. Williamsson C, Ansari D, Andersson R et al (2017) Postoperative pancreatic fistula-impact on outcome, hospital cost and effects of centralization. HPB (Oxford) 19:436–442

    Article  PubMed  Google Scholar 

  49. Kawai M, Hirono S, Okada K et al (2016) Randomized controlled trial of pancreaticojejunostomy versus stapler closure of the pancreatic stump during distal pancreatectomy to reduce pancreatic fistula. Ann Surg 264:180–187

    Article  PubMed  Google Scholar 

  50. Uemura K, Satoi S, Motoi F et al (2017) Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy versus handsewn closure after distal pancreatectomy. Br J Surg 104:536–543

    Article  CAS  PubMed  Google Scholar 

  51. Frozanpor F, Lundell L, Segersvärd R et al (2012) The effect of prophylactic transpapillary pancreatic stent insertion on clinically significant leak rate following distal pancreatectomy: results of a prospective controlled clinical trial. Ann Surg 255:1032–1036

    Article  PubMed  Google Scholar 

  52. Sarr MG (2003) The potent somatostatin analogue vapreotide does not decrease pancreas-specific complications after elective pancreatectomy: a prospective, multicenter, double-blinded, randomized, placebo-controlled trial. J Am Coll Surg 196:556–64

    Article  PubMed  Google Scholar 

  53. Gans SL, van Westreenen HL, Kiewiet JJ et al (2012) Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula. Br J Surg 99:754–760

    Article  CAS  PubMed  Google Scholar 

  54. Yamashita S, Ishizawa T, Ichida A et al (2016) Advantages and disadvantages of prophylactic abdominal drainage in distal pancreatectomy. World J Surg 40:1226–1235

    Article  PubMed  Google Scholar 

  55. Mangieri CW, Kuncewitch M, Fowler B et al (2020) Surgical drain placement in distal pancreatectomy is associated with an increased incidence of postoperative pancreatic fistula and higher readmission rates. J Surg Oncol 122(4):723–8

    Article  PubMed  Google Scholar 

  56. Van Buren G, Bloomston M, Schmidt CR et al (2017) A prospective randomized multicenter trial of distal pancreatectomy with and without routine intraperitoneal drainage. Ann Surg 266:421–31

    Article  PubMed  Google Scholar 

  57. Allen PJ, Gonen M, Brennan MF et al (2014) Pasireotide for postoperative pancreatic fistula. N Engl J Med 370:2014–2022

    Article  PubMed  Google Scholar 

  58. Elliott IA, Dann AM, Ghukasyan R et al (2018) Pasireotide does not prevent postoperative pancreatic fistula: a prospective study. HPB (Oxford) 20:418–422

    Article  PubMed  Google Scholar 

  59. Young S, Sung ML, Lee JA et al (2018) Pasireotide is not effective in reducing the development of postoperative pancreatic fistula. HPB (Oxford) 20:834–840

    Article  PubMed  Google Scholar 

  60. Miao Y, Lu Z, Yeo CJ et al (2020) Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 168:72–84

    Article  PubMed  Google Scholar 

  61. Kim H, Jang JY, Son D et al (2016) Optimal stapler cartridge selection according to the thickness of the pancreas in distal pancreatectomy. Medicine (Baltimore) 95:e4441

    Article  PubMed  Google Scholar 

  62. Landoni L, De Pastena M, Fontana M et al (2022) A randomized controlled trial of stapled versus ultrasonic transection in distal pancreatectomy. Surg Endosc 36:4033–4041

    Article  PubMed  Google Scholar 

  63. Guzman EA, Nelson RA, Kim J et al (2009) Increased incidence of pancreatic fistulas after the introduction of a bioabsorbable staple line reinforcement in distal pancreatic resections. Am Surg 75:954–957

    Article  PubMed  Google Scholar 

  64. Wolf SE, Ridgeway CA, Van Way CW et al (1996) Infectious sequelae in the use of polyglycolic acid mesh for splenic salvage with intraperitoneal contamination. J Surg Res 61:433–436

    Article  CAS  PubMed  Google Scholar 

  65. Kang MK, Kim H, Byun Y et al (2021) Optimal stapler cartridge selection to reduce post-operative pancreatic fistula according to the pancreatic characteristics in stapler closure distal pancreatectomy. HPB (Oxford) 23:633–640

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

This study was supported by the INTERNATIONAL COOPERATION Project of the Chengdu Science and Technology Bureau (No. 2019-GH02-00020-HZ), the Sichuan Provincial Science and Technology Department Project (No. 23NSFSC0850) and the Sichuan Science and Technology Program (2023YFS0168).

Open access statement

This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

Author information

Author notes

  1. Ning Xia and Jiao Li contributed equally to this work.

Authors and Affiliations

  1. Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China

    Ning Xia, Xing Huang, Bole Tian & Junjie Xiong

  2. 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

    Jiao Li

  3. Disaster Medical Center, Sichuan University, Chengdu, China

    Jiao Li

  4. Nursing Key Laboratory of Sichuan Province, Chengdu, China

    Jiao Li

Authors
  1. Ning Xia
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jiao Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xing Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Bole Tian
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Junjie Xiong
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conception and design: NX, JL, XH, JJX; administrative support: BT; provision of study materials or patients: NX, JL; collection and assembly of data: NX, JL; data analysis and interpretation: NX, JL, JJX; manuscript writing: all authors; final approval of manuscript: all authors.

Corresponding author

Correspondence to Junjie Xiong.

Ethics declarations

Conflict of interest

All authors have completed the ICMJE uniform disclosure form. The authors have no conflicts of interest to declare.

Ethical approval

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Xia, N., Li, J., Huang, X. et al. Reinforced stapling does not reduce postoperative pancreatic fistula in distal pancreatectomy: a systematic review and meta-analysis. Updates Surg 75, 2063–2074 (2023). https://doi.org/10.1007/s13304-023-01691-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-023-01691-5

Keywords

Search

Navigation