Safe closure technique for distal pancreatic resection

Background and aims Various methods had previously been employed to manage the proximal pancreas after distal resection (mattress sutures with duct ligation; pancreato-enterostomy or stapling with stainless steel staples, etc.), with postoperative complications in 13% (6%–30%) of the cases, on average. In our practice, to reduce these complications, we applied staples made from Polysorb (Auto Suture), an absorbable lactomer.Patients/methods In the past 10 years, distal pancreatic resection in 90 patients [62 men, 28 women, mean age 52 (24–72)] years) was followed by closure of the resection surfaces with absorbable lactomer clips. Indications for distal resection (with or without splenectomy) were: focal pancreatic necrosis, spontaneous pancreatic fistulas, abscess, pseudocyst, traumatic disruption, segmental chronic obstructive pancreatitis in the tail, and benign (cystadenoma, or insulinoma) or malignant tumours.Results The postoperative period was uneventful in all these patients, without any complications (pancreatic fistula, abscess or bleeding). No morbidity or mortality occurred in the follow-up period (6 or 12 months postoperatively) with the exception of one patient who suffered a pseudocyst 6 months after surgery and was treated by cysto-jejunostomy.Conclusions The clinical results clearly demonstrated that the application of absorbable lactomer staples for closure of the transected margin of the pancreas is a safe alternative to the standard closure technique. These staples can be applied in all cases when distal pancreatic resection is indicated for benign or malignant disorders or a traumatically injured pancreatic gland.Presented at the Joint Meeting of the American Pancreatic Association and International Association of Pancreatology, 1–5 November 2000, Chicago, Illinois, USA and published in abstract form as Pancreas (2000) 21:442     

Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution

Background  Despite recent advances in laparoscopic pancreatic surgery, few studies have compared laparoscopic distal pancreatic resection (LDPR) with open distal pancreatic resection (ODPR). This study aimed to compare clinical outcomes for LDPR and ODPR performed at a single institution. Methods  For this study, 93 patients with benign pancreatic disease underwent LDPR, and 35 patients with benign pancreatic disease underwent ODPR. Patient demographic characteristics, operative times, perioperative complications, length of hospital stay, and return to normal diet were compared retrospectively between the two groups. Results  The LDPR and ODPR groups had the same demographic characteristics. The median operative time was 195 min in the LDPR group and 190 min in the ODPR group (p > 0.05). The rate of spleen preservation was higher in the LDPR group (40.8%) than in the ODPR group (5.7%) (p < 0.05) No operative mortality occurred in either group. The overall complication rate was 24.7% in the LDPR group and 29% in the ODPR group (p > 0.05). The rate of pancreas-related complications was 11.8% in the LDPR group and 17.2% in the ODPR group (p > 0.05). Pancreatic fistula developed in 8.6% of the LDPR group and in 14.3% of the ODPR group (p > 0.05). Bowel movement return to normal and resumption of normal diet were achieved 2.8 ± 1.3 days after the operation in the LDPR group and 4.5 ± 1.6 days after the operation in the ODPR group (p < 0.05). The median duration of hospital stay was 10 days for the LDPR group, which was significantly shorter than the 16 days for the ODPR group (p < 0.01). Conclusion  The use of LDPR for benign lesions of the distal pancreas is feasible and safe. The LDPR procedure is associated with operative times and complication rates similar to those for ODPR, but LDPR has the advantages of an earlier return to normal bowel movements and normal diet and shorter hospital stays than ODPR. To be presented at the 2008 Society of American Gastroinestinal Endoscopic Surgeons (SAGES) Meeting.     

Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis

Background

Suture closure and stapler closure of the pancreatic remnant after distal pancreatectomy are the techniques used most often. The ideal choice remains a matter of debate.

Methods

Five bibliographic databases covering 1970 to July 2009 were searched.

Results

Sixteen articles met the inclusion criteria. Stapler closure was performed in 671 patients, while suture closure was conducted in 1,615 patients. The pancreatic fistula rate ranged from 0% to 40.0% for stapler closure of the pancreatic stump and from 9.3% to 45.7% for the suture closure technique. There were no significant difference between the stapler and suture closure groups with respect to the pancreatic fistula formation rate (22.1% vs 31.2%; odds ratio, .85; 95% confidence interval, .66-1.08), although there was a trend toward favoring stapler closure. In 4 studies including 437 patients, stapler closure was associated with a trend (not statistically significant) toward a reduction in intra-abdominal abscess (odds ratio, .53; 95% confidence interval, .24-1.15).

Conclusions

No significant differences occur between suture and stapler closure with respect to the pancreatic fistula or intra-abdominal abscess after distal pancreatectomy, though there is a trend favoring stapler closure.     

Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic fistula development after distal pancreatectomy

BACKGROUND AND OBJECTIVE: Pancreatic fistula is a common complication of distal pancreatectomy (DP). Although various surgical procedures have been proposed for DP in an attempt to decrease the high incidence of pancreatic fistula, the prevention of pancreatic fistula remains a major problem in DP. Endoscopic pancreatic stenting for the treatment or prophylaxis of such a fistula has been rarely described. METHODS: We reviewed 9 patients who underwent preoperative endoscopic pancreatic stenting for the prophylaxis of pancreatic fistula development after DP. RESULTS: Preoperative endoscopic pancreatic stenting was successfully performed with a 7F stent in all the 9 patients. Two patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the 9 patients developed pancreatic fistula. The pancreatic stent was removed from 8 to 28 days (mean 11 days) postoperatively. CONCLUSIONS: Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP in selected patients.     

Local pancreatic resection with preoperative endoscopic transpapillary stenting

BACKGROUND: Pancreatic fistula, although not common, can cause serious complications after pancreatectomy. During local pancreatectomy, injury to the main pancreatic duct (in addition to the accessory and side branch ducts) increases the risk of pancreatic fistula formation. Nonetheless, local pancreatic resection maintains the advantage of preserving pancreatic parenchyma. METHODS: In this study, we reviewed the cases of 5 patients who underwent preoperative endoscopic transpapillary pancreatic stenting to help prevent refractory fistula development after local pancreatic resection. RESULTS: Stenting was successful in all 5 patients, and none developed a refractory grade C postoperative pancreatic fistula. CONCLUSIONS: These results suggest that in selected patients, preoperative endoscopic pancreatic stenting may be an effective prophylactic measure to lower the risk of refractory grade C fistula formation after local pancreatic resection.     

胰腺残端处理方式对胰体尾切除术后胰瘘的影响

目的探讨预防胰体尾切除术后胰瘘的胰腺残端处理方式。方法回顾性分析我院1996至2008年186例因胰腺或胰外病变行胰体尾切除术患者的临床资料,胰腺残端处理方法分别为：结扎主胰管、残端结扎、间断缝合、Prolene线连续缝合、胰腺空肠吻合及闭合器钉合六种方式,比较上述六种方式对术后胰瘘的影响并行统计学分析。结果186例患者中围手术期死亡5例（2．7％）,术后总并发症发生率34．9％（65／186）,胰瘘发生率21．0％（39／186）。8例胰腺残端结扎术后4例发生胰瘘,11例胰腺空肠吻合患者无胰瘘发生;17例Endo—GIA关闭胰腺残端者有胰瘘4例;结扎主胰管组、连续缝合组、间断缝合组胰瘘发生率分别为13．9％（5／36）、15．6％（10／64）、32．0％（16／50）,前两者与后者差别具有统计学意义（P〈0．05）。结论胰体尾切除术中残端结扎和间断缝合容易发生胰瘘,选择性缝扎主胰管或Prolene线连续缝合能降低胰瘘发生率,尤其后者更简单易行。近端胰管梗阻患者可选用胰肠吻合预防胰瘘;闭合器钉和胰腺残端要根据胰腺大小和质地选择性使用。     

胰腺中段切除术后胰瘘分析

目的 分析胰腺中段切除术对胰瘘发生的影响,并总结胰腺残端处理经验.方法 对2003年4月至2009年12月共40例行胰腺中段切除术的胰腺肿瘤患者资料进行回顾性分析,其中良性肿瘤36例(MSP组)、恶性肿瘤4例.并与同期行胰十二指肠切除术的44例(PD组)和行胰颈体尾切除术的26例(EDP组)患者进行疗效及胰瘘对照分析.结果 MSP组患者平均手术时间为222 min,明显短于PD组(P＜0.05);术中平均出血量316 ml,明显少于其他两组(P＜0.05).MSP组在术后营养状况、血糖控制方面均占优势(P＜0.05).通过术后随访,MSP组患者的内外分泌功能保留更为良好,仅出现新发糖尿病1例,无需要补充胰酶病例,且无肿瘤复发.虽然MSP组胰瘘发生率最高(42%),但与PD组和EDP组相比,患者的总体住院时间并未延长;其胰瘘程度及胰瘘患者的住院时间与另两组的差异无统计学意义(P＞0.05).结论 对于胰腺中段的良性或低度恶性肿瘤,胰腺中段切除术是一种安全可行的手术方式.虽然双残端引起胰瘘发生率升高,但其显著的临床疗效降低了高胰瘘风险.合理的残端处理至关重要.     

Risk factors for surgical complications in distal pancreatectomy

Background

Pancreatic fistula (PF) represents a major complication after distal pancreatectomy. In a consecutive series of 110 patients, risk factors for the incidence of PF and surgical morbidity were identified.

Methods

Patients having undergone distal pancreatectomy between 2003 and 2007 were identified. Clinicopathologic parameters as well as perioperative data were correlated with the incidence of PF and overall surgical morbidity using univariate and multivariate models.

Results

In 72 patients (65%), malignant disease was present. Splenectomy and multivisceral resection were performed in 84 (76%) and 47 (42%) patients, respectively. Overall major surgical morbidity was 18%, and 12 patients (11%) developed PFs. A body mass index > 25 kg/m² was the only independent significant predictive factor for PF. Malignancy, splenectomy, multivisceral resection, transfusion, comorbidity, and stapler use did not show statistical significance. For overall surgical morbidity, there was no significant indicator.

Conclusions

A body mass index > 25 kg/m² contributes to the incidence of PF after distal pancreatectomy. Other parameters did not show a significant influence on PF or on overall surgical morbidity.     

Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy

Background

The appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP.

Methods

The risk factors of pancreatic fistulas were investigated in 122 DPs among 3 types of stump closure: hand-sewn suture (n = 32), bipolar scissors (n = 45), and stapler closure (n = 45).

Results

There was no significant difference in the incidence of pancreatic fistula between the 3 types of stump closure (hand-sewn suture [44%] vs bipolar scissors [37.7%] vs stapler closure [35.5%]). By using receiver operating characteristics curves, 12 mm was the best cutoff value of the thickness of the pancreas for pancreatic fistulas after DP using stapler closure. Three factors (ie, male sex, body mass index >25 kg/m², and stapler closure) were independent risk factors of pancreatic fistulas after DP with a pancreas thicker than 12 mm.

Conclusions

A pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.     

Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy

BACKGROUND/PURPOSE: The prevention of pancreatic fistula is still a major problem in distal pancreatectomy (DP). We have recently adopted preoperative endoscopic pancreatic stenting with the aim of preventing the leakage of pancreatic juice from the resection plane of the remnant pancreas after DP. We reviewed ten patients who underwent this intervention. METHODS: One to 6 days before surgery, the patients underwent an endoscopic transpapillary pancreatic stent (7 Fr., 3 cm) placement. The perioperative short-term outcomes were assessed. RESULTS: Preoperative endoscopic pancreatic stenting was successfully performed in all ten patients. Two (20%) patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the ten patients developed pancreatic fistula. The pancreatic stent was removed 8-28 days (mean, 11 days) postoperatively. CONCLUSIONS: Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP.     

胰十二指肠切除和胰体尾切除术后胰瘘预测的研究

目的: 探讨2017年中华医学会外科学分会胰腺外科学组的术后胰瘘预测评分的应用价值。方法: 本研究回顾性分析2014年1月至2016年12月我院249胰十二指肠切除术（pancreaticoduodenectomy, PD）及156例胰体尾切除术（distal pancreatectomy, DP）病人的资料。对可能与术后胰瘘发生有关的因素进行分析。根据预测评分中胰腺质地、肿瘤病理、胰管直径以及术中出血量4项指标进行评分。同时应用受试者工作特征（receiver operating characteristic, ROC）曲线分析此评分对病人术后胰瘘发生的灵敏度和特异度。结果: 249例PD病人中31例（12.4%）发生术后胰瘘。单因素分析结果显示,胰腺质地、肿瘤病理、胰管直径以及术中失血量是术后胰瘘发生的危险因素。ROC曲线结果显示,曲线下面积为0.894,P<0.001,95%CI：0.839~0.949。预测评分的灵敏度和特异度分别为83.9%和77.1%。156例DP病人中44例（28.2%）发生术后胰瘘。单因素分析结果显示,胰管直径以及术中出血量是术后胰瘘发生的危险因素。ROC曲线结果显示,曲线下面积为0.567,P=0.190,95%CI：0.467~0.668。预测评分的灵敏度和特异度分别为84.1%和27.7%。结论: 2017年中华医学会外科学分会胰腺外科学组术后胰瘘预测评分能准确地预测PD术后胰瘘的发生,但对DP术后胰瘘的预测没有作用。DP术后胰瘘的预测有待进一步研究。     

胰体尾切除术后胰瘘防治研究进展

胰体尾切除术(DP)较胰十二指肠切除术后胰瘘发生率更高,胰瘘的有效防治是保障胰体尾切除术后安全的关键。诸多危险因素可以导致DP术后胰瘘的发生,具体划分为非技术因素和技术因素两个部分。但目前关于DP术后胰瘘危险因素的分析多为回顾性研究,且研究结果差异性较大,目前尚无统一的DP术后胰瘘的危险因素或预测模型。胰瘘的预防和治疗一直是胰腺外科关注的热点和焦点。预防DP术后胰瘘包括诸多措施,如胰腺断面处理方式及主胰管结扎等,胰瘘发生后的基础治疗主要有抑酸,抑酶,抗炎等。DP术后如何减少胰瘘,仍然是一个挑战。     

Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation

Background

Preoperative endoscopic pancreatic sphincterotomy (EPS) has been proposed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) or enucleation (EN). The use of EPS as a curative treatment for POPF has been scarcely reported. We reported 10 consecutive patients who were successfully treated by EPS for a prolonged POPF.

Study design

Ten patients underwent EPS for prolonged POPF (median duration = 40 days, range 20-114; median daily output = 80 mL, range 50-250) after 6 DPs, 2 ENs, and 2 medial pancreatectomies.

Results

EPS was performed in all patients, with stent insertion in 4. No patient developed a specific complication because of EPS. POPF healed within a median delay of 4 days (range 1-12). One patient underwent a repeated endoscopy to treat stent malposition. The median delay of discharge after EPS was 13 days (range 8-15). With a 20-month median follow up, 1 patient developed early transient POPF recurrence because of spontaneous stent migration.

Conclusions

EPS is indicated for prolonged POPF after DP or EN because it is highly feasible, shortens healing, and is well tolerated.     

保留十二指肠的胰头切除术

目的 总结保留十二指肠的胰头切除术(DPRHP)的经验。方法 回顾分析我院1995年7月至2002年8月以来实施该术式9例的临床资料，对该术式的适应证、手术方法和并发症进行探讨，对术后生存质量进行评价。结果 患者手术死亡率为0，胰瘘发生率44.4%，无胰腺假性囊肿及腹腔脓肿形成，随访中无新发糖尿病患者。结论 DPRHP是一种安全、有效、能够保证患者生存质量的术式。     

胰体尾切除术后胰瘘的相关性因素分析

目的探讨胰体尾切除术后胰瘘发生的相关性因素。方法回顾性总结了82例行胰体尾切除的患者术前、术中操作以及术后并发症和死亡率发生的情况,并分析和术后胰瘘发生的相关性因素。结果术后有36名患者出现并发症占43.9%（36/82）。其中胰瘘是最常见的并发症,发生率为37.8%（31/82）。其中是否结扎主胰管和术后胰瘘的发生具有明显的相关性（P=0.010）,而性别、年龄、是否并存糖尿病、胰腺的质地、术中失血量、是否预防性应用奥曲肽、是否用生物胶封闭胰腺断端、术后低蛋白血症和是否联合其它脏器切除均和胰瘘的发生无明显的相关性。结论胰体尾切除术后最常见的并发症仍然是胰瘘,术中单独结扎胰管可以减少胰瘘的发生率。     

改良保留十二指肠之胰头全切除术10例临床分析

目的：总结改良保留十二指肠之胰头全切除术（DPTPHR）治疗胰头部良性或低度恶性病变的诊治经验。方法：对2005年6月至2009年5月间10例行改良DPTPHR病人的资料作回顾性分析。结果：全组中男3例,女7例,平均年龄52岁,手术时间平均340min,术中失血量平均485mL。术后诊断包括导管内乳头状黏液瘤、实性假乳头状瘤、胰岛素瘤、动静脉畸形各1例,浆液性囊腺瘤、神经内分泌瘤、胰头肿块型慢性胰腺炎各2例。全组中,术后发生感染、并发大出血1例,胰瘘4例,反复呕吐1例;未发生胆瘘或十二指肠缺血。随访8～56个月,无死亡病例,无肿瘤复发。结论：改良的DPTPHR是治疗胰头部良性或低度恶性病变的较安全的术式之一。     

联合腹腔干切除在胰体尾癌扩大根治术中的应用

目的 探讨胰体尾联合腹腔干切除在胰体尾癌扩大根治术中的应用及其效果。方法 回顾分析2003-2007年上海交通大学医学院附属瑞金医院普外科10例胰体尾联合腹腔干切除的临床资料。 结果 胰体尾肿块直径平均（5.0±1.3）cm,中位手术时间320（225～420） min,术中中位出血量900 （500～1500） mL;其中3例行肝总动脉重建。术后4例发生胰漏、乳糜漏、腹腔积液、感染等并发症;其中1例死于术后相关并发症。5例术后出现肝功能异常。9例术后住院时间平均（28.8±13.6）d,术后中位存活时间15个月。术后10例均有轻度腹泻（<5次/d）,多于术后2～6个月自行好转。6例术前有腰背痛、腹痛,其中5例术后疼痛明显缓解。结论 联合腹腔干切除的胰体尾癌扩大根治术是可行、安全的,能够提高胰体尾癌的手术切除率,一定程度延长病人术后生存时间,改善生存质量。     

Transection using bipolar scissors reduces pancreatic fistula after distal pancreatectomy

BACKGROUND/PURPOSE: Various methods and technique for treating the surgical stump of the remnant pancreas have been reported to reduce pancreatic fistula after distal pancreatectomy (DP). However, appropriate surgical stump closure after DP is still controversial. We aimed to clarify whether using bipolar scissors in DP reduces pancreatic fistula compared to hand-sewn suture of surgical stump closure. METHODS: Between January 1989 and December 2005, handsewn suture of surgical stump closure was performed (n = 49), and bipolar scissors was prospectively performed between January 2006 and July 2007 (n = 26). RESULTS: The overall rate of pancreatic fistula after DP was 22 patients (29%). There were significant differences between the hand-sewn suture group (41%) and bipolar scissors group (8%) concerning pancreatic fistula (P = 0.0164). A multivariate logistic regression analysis revealed that two factors, soft pancreas and hand-sewn suture compared to bipolar scissors, were independent risk factors of pancreatic fistula after DP (P = 0.011 and 0.0361, respectively). CONCLUSIONS: Bipolar scissors for transection of the pancreas is a useful device to reduce pancreatic fistula after DP.     

Intraperitoneal drainage after pancreatic resection: a review of the evidence

Background

Despite a growing body of literature supporting the limited use of prophylactic intra-abdominal drainage for many procedures, drain placement after pancreatic resection remains commonplace and highly controversial.

Materials and methods

Literature available in the PubMed was systematically reviewed by searching using combinations of keywords and citations in review articles regarding prophylactic drainage after pancreatic resection, early removal of intraoperatively placed drains after pancreatic resections, and risk factors and predictive tools for pancreatic fistula.

Results

Prospective randomized studies on prophylactic drainage after pancreaticoduodenectomy or distal pancreatectomy have not shown any benefit in decreasing pancreatic fistula, total complications, length of hospital stay, or readmission rates. Frequency of complications was significantly higher in patients receiving routine drainage. This was recently supported by retrospective studies; however, patients with risk factors for pancreatic fistula (soft pancreatic texture, prolonged operative times, and increased blood loss) were more likely to have prophylactic intra-abdominal drainage. Alternatively, if a drain is placed, prospective randomized studies demonstrate that early removal is safe in patients with postoperative day 1 drain amylase values <5000 U/L and associated with a lower rate of fistula.

Conclusions

The current literature supports a strategy of selective drainage and early drain removal after pancreatic resection in low-risk patients.