A Thick Pancreas Is a Risk Factor for Pancreatic Fistula after a Distal Pancreatectomy: Selection of the Closure Technique according to the Thickness

Abstract Background To date, no stump closure technique has been shown to be superior in lowering the risk of postoperative pancreatic fistula (POPF) after pancreatectomy. The aims our study were to investigate the possibility to influence POPF risk by selection of stump closure technique according to pancreatic parenchyma thickness and to establish a thickness cut-off value for selection of a hand-sewn and stapled closure technique. Methods A retrospective analysis of consecutive patients who underwent distal pancreatectomy at a single centre was performed. Anatomical determination of the transection site (pancreatic neck, body, or tail) was based on operative report and postoperative follow-up computed tomography (CT), with the thickness measured on the most recent CT image before surgery. Patients were classified by the thickness of the transection site, and sub-classified according to stump closure technique. POPF incidence, morbidity, mortality, and baseline-characteristics were investigated between groups. Results Among the 115 cases included in the analysis, the incidence of POPF was 33%, with no difference between stapled (29.9%) and hand-sewn (37.5%) closure techniques (p=0.426), regardless of transection site thickness. Among those with a transection site <13 mm, the incidence of POPF was 4.6% in the stapler subgroup versus 45.5% in the hand-sewn subgroup (p=0.0002). Among patients with a transection site ≥13 mm, the incidence of POPF was 75% in the stapler subgroup versus 30.8% in the hand-sewn subgroup (p=0.007). Conclusions Transection in the pancreatic neck, stapler closure of thin parenchyma, and hand-sewn closure of thick parenchyma were associated with significantly lower risk of POPF.

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Risk Factors of Pancreatic Fistula in Distal Pancreatectomy Patients

Surgery Research and Practice ◽

10.1155/2019/4940508 ◽

2019 ◽

Vol 2019 ◽

pp. 1-6

Author(s):

Amyna Jiwani ◽

Tabish Chawla

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Pancreatic Fistula ◽

Distal Pancreatectomy ◽

Surgical Techniques ◽

Multivisceral Resection ◽

Postoperative Pancreatic Fistula ◽

The Body ◽

Fistula Formation ◽

Factors Associated

Introduction. Benign and malignant lesions of the pancreas located at the body and tail of the pancreas are managed by the standard procedure of distal pancreatectomy (DP). The mortality associated with this procedure is reported as less than 5% in high-volume centers. The major proportion of morbidity is comprised of pancreatic fistula with a reported incidence of 5% to 60%. The most considered risk factors associated with pancreatic fistula formation are soft pancreatic texture, diameter of the pancreatic duct <3 mm, intraoperative blood loss >1000 ml and surgical techniques. Among all these factors, the modifiable factor is the surgical technique. Several surgical techniques have been developed and modified for closure of the pancreatic remnant in the recent past in order to minimize the risk of pancreatic fistula and other complications. The main objective of the study is to analyze the factors associated with formation of pancreatic fistula after distal pancreatectomy. Patients and Methods. We performed a single-center retrospective study at Aga Khan University Hospital from January 2004 till December 2015. The perioperative and postoperative data of 131 patients who underwent pancreatic resection were recorded by using ICD 9 coding. 45 patients underwent distal pancreatectomy, out of which 38 were included in the study based on inclusion criteria. Variables were grouped into demographics, indications, operative details, and postoperative course. Statistical analysis software (SPSS) was used for analysis. Quantitative variables were presented as mean with standard deviation or median with interquartile range depending on the distribution of data. Study endpoints for the risk factor analysis were surgical morbidity and development of pancreatic fistula. Univariate logistic regressions were performed associated with study endpoints. P value less than 0.05 was considered significant. Results. Postoperative pancreatic fistula was the most common perioperative morbidity. The significant associated risk factor for pancreatic fistula was multivisceral resection as compared to spleen-preserving distal pancreatectomy (P value 0.039). However, the technique of stump closure when opted for suture techniques was seen to be associated with a higher occurrence of postoperative pancreatic fistula. The mortality rate was 2.6%. Conclusion. Postoperative pancreatic fistula is the most common complication seen after distal pancreatectomy in our series. Multivisceral resection is associated with a high incidence of pancreatic fistula and is a statistical significant predictor of pancreatic fistula.

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