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     

Closure of the distal pancreatic stump with a seromuscular flap

We describe herein our new method for transecting the pancreas and closing its stump in distal pancreatectomy, devised to decrease the risk of pancreatic fistula formation. With this technique, the pancreas is transected in such a way that a convex stump is left, whereby the pancreatic secretions from the parenchyma near the pancreatic stump are fully drained into the main pancreatic duct. A pedicled seromuscular flap of the stomach or jejunum is then used to cover the cut surface of the pancreas. This new technique provides tight closure of the pancreatic stump after distal pancreatectomy.     

����β�г���������Ԥ��������

??Prevention and treatment for pancreatic fistula after distal pancreatectomy YANG Ming??WANG Chun-you. Department of Pancreatic Surgery, Union Hospital??Tongji Medical College??Huazhong University of Science and Technology??Wuhan 430022??China
Corresponding author: WANG Chun-you, E-mail: chunyouwang52@126.com
Abstract The incidence of pancreatic fistula after distal pancreatectomy is higher. Some of the main risk factors associated with pancreatic fistula after distal pancreatectomy include soft pancreatic texture, smaller pancreatic duct diameter and the handling of the pancreatic stump. Surgical techniques should been selected reasonably according to the pancreas texture and pathology, which is the key to decrease the incidence of pancreatic fistula. The optimal surgical method for a thick or edema pancreas is still a standardized hand-sewn closure technique of the pancreatic remnant. An anastomosis of the remnant to the intestine should be considered to prevent pancreatic fistula in the case of proximal duct obstruction associated with dilatation of the main pancreatic duct. The stapler technique should be recommended as the preferred method of pancreatic stump closure for a soft and flat pancreas. Most cases of pancreatic fistula could be cured by conservative treatment. Effective drainage plays an important role in the management of pancreatic fistula and in prevention of abdominal infection and bleeding. Pancreatic stent placement should be considered on the principle of failure of conservative treatment. Some of cases need fistulojejunostomy for refractory pancreatic fistulas.     

胰体尾切除术后胰瘘预防及处理

胰体尾切除术术后胰瘘发生率较高,主要与胰腺质地、胰管直径及胰腺残端的处理方式等有关。依据胰腺质地及病理检查结果合理选择胰腺残端处理方式是减少胰瘘发生的关键。胰腺肥厚或水肿质脆者胰瘘发生率较高,推荐残端手工缝合;如近端胰管存在梗阻并伴胰管扩张,建议行胰管-空肠吻合;对于胰腺扁平且质地柔软者,推荐使用直线切割闭合器。胰体尾切除术术后胰瘘经非手术治疗多可治愈。通畅引流可有效预防腹腔感染和出血的发生,是促进胰瘘愈合的关键。非手术治疗无效时可考虑胰管支架置入,部分难治性胰瘘病人须行窦道-空肠吻合。     

Safe and quick distal pancreatectomy using a staggered six-row stapler

BACKGROUND: The use of stapling devices for distal pancreatectomy remains controversial, due to concerns about the development of postoperative pancreatic fistula (POPF) and hemorrhage. METHODS: We report herein the usefulness of the Endo SGIA stapler (Tyco Healthcare, Norwalk, CT) for distal pancreatectomy by placing 2 triple-staggered rows, ie, 6 rows of staples in the pancreatic stump. The pancreas was divided together with both the splenic artery and vein with Endo SGIA in 7 consecutive hand-assisted laparoscopic distal pancreatectomies. RESULTS: No patients developed clinically significant POPF or postoperative hemorrhage. None of the patients had complications that may have influenced the length of hospital stay. CONCLUSION: The 6-row Endo SGIA stapler allows quick and effective prevention of POPF after distal pancreatectomy.     

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。     

A simple and safe pancreas transection using a stapling device for a distal pancreatectomy

Pancreatic fistula is the most common major complication to occur after distal pancreatectomy, ranging in frequency from 5% to 40%. The appropriate technique for treating the pancreatic stump still remains controversial. Thirty-six patients underwent distal pancreatectomy in Kagawa University Hospital between January 2000 and February 2007. Their hospital records were reviewed to evaluate the usefulness of a stapling closure using several types of staplers in comparison to a suture closure. They were subdivided according to the method used to close the pancreas stump: the suture group comprised 11 patients, the staple group comprised 24 patients, including 7 patients for whom was used the new endopath stapler Echelon 60 (Ethicon Endo-surgery; Johnson & Johnson, Cincinnati, OH, USA). Overall pancreatic fistula rate was 17% (6/36) in this series. In the staple group, 3 of the 24 patients (12%) developed a pancreatic fistula, whereas in the suture group, 3 of 11 patients (27%) developed a pancreatic fistula. Of the 7 patients for whom the Echelon 60 was used, none developed a pancreatic fistula. The length of postoperative hospital stay was also significantly shorter for the patients with the Echelon 60 than in the patients either with sutures or another stapling device. These findings support the advantages of using a stapler closure in distal pancreatectomy. This method, using a new stapler device, is considered to be a simple and safe alternative to the standard suture closure technique.     

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.     

Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy.

OBJECTIVE: The authors used prolamine (Ethibloc, Ethicon GmBH, Norderstedt, Germany) for segmental obstruction of the pancreatic duct to prevent pancreatic fistula development after distal pancreatectomy combined with total gastrectomy for gastric malignancies. SUMMARY BACKGROUND DATA: Although the initial clinical application of prolamine was pancreatic duct obstruction for patients with pancreatitis and undergoing pancreatic transplantation and pancreaticoduodenectomy for pancreatic cancer, there are no reports on prevention of pancreatic fistula formation after distal pancreatectomy. METHODS: Prolamine (0.2 mL) was injected into the distal segment of the main duct in the remaining pancreata of 51 patients. Small pancreatic ducts on the cut surface, from which prolamine extravasates, were closed by ligation, the main duct was ligated doubly, and the transected pancreatic margin was closed 15 minutes after phenylpropanolamine hydrochloride injection. RESULTS: No patient developed a pancreatic fistula or the complication of arterial bleeding due to prolonged infection. CONCLUSION: Segmental obstruction of the pancreatic duct with prolamine is useful for preventing pancreatic fistula development after distal pancreatectomy.     

Surgical treatment of benign and borderline neoplasms of the pancreatic body

BACKGROUND: Conventional operations for benign and borderline tumors of the pancreatic body are distal pancreatectomy and enucleation. An unusual operation allowing the preservation of the proximal and distal pancreas is median pancreatectomy. METHOD: A retrospective analysis of prospectively collected data on 67 patients with nonmalignant neoplasms of the pancreatic body was performed. The operations were: 32 median pancreatectomies (22 with duct occlusion of the distal pancreas, 10 with pancreaticojejunostomy), 21 distal pancreatectomies, and 14 enucleations. The operative and long-term outcomes of the different operations were compared. RESULTS: Enucleation had a shorter operative time and less blood loss than the other operations. No mortality was observed. The pancreatic fistula rate was 50% after median pancreatectomy (59% in case of distal duct occlusion, 30% in case of pancreaticojejunostomy), 14% after distal pancreatectomy and 14% after enucleation. Diabetes appeared in 3 patients after distal pancreatectomy and 3 patients after median pancreatectomy with duct occlusion. CONCLUSIONS: When indicated, enucleation is the operation of choice for a nonmalignant neoplasm of the pancreatic body. With respect to distal resection, the higher fistula rate of median pancreatectomy with pancreaticojejunostomy could be the price for a better long-term endocrine function; median pancreatectomy with duct occlusion had worse operative results and no long-term advantages.     

Spleen-preserving laparoscopic distal pancreatectomy after division of the splenic vessels

A 37-year-old woman with a history of syncope was hospitalized with a diagnosis of hypoglycemia due to insulinoma. Computed tomography (CT) and magnetic resonance imaging revealed an enhanced solid mass, 1.5 cm in diameter, at the tail of the pancreas. Angiography via the splenic artery revealed a hypervascular mass. Because the tumor was located deep in the pancreatic parenchyma, laparoscopic distal pancreatectomy was performed. The pancreas was exposed by dissecting the greater omentum, and the tumor was located by intraoperative ultrasonography. After division of the splenic artery, the pancreas, main pancreatic duct, and splenic vein were transected with an endoscopic linear stapler. The pancreatic pedicle was divided at the splenic hilum to preserve the spleen. The postoperative course was uneventful except for the appearance of splenic infarction on a CT scan 2 weeks after surgery but without any overt symptoms. Spleen-preserving laparoscopic distal pancreatectomy by division of splenic vessels is a feasible treatment option for benign pancreatic disease.     

Ductal branch-oriented minimal pancreatectomy: Two cases of successful treatment

Two patients with intraductal papillary-mucinous adenoma of the pancreas were successfully treated by ductal branch-oriented minimal pancreatectomy. We propose this novel less invasive ductal branch-oriented pancreatectomy, as indicated for benign ductal ectasia of the pancreas. The cystically dilated branch duct is identified by intraoperative ultrasonography, intraoperative balloon pancreatography, and injection of indigocarmine into the cyst. The cystically dilated branch is resected from the surrounding pancreas together with minimal removal of the pancreatic parenchyma. The communicating duct and cutting margins are tightly ligated to prevent pancreatic juice leakage and fistula. A drainage tube is placed in the main pancreatic duct whenever possible. Histopathologic examination of the transected branch duct is necessary to check for mucosal extension of dysplastic epithelium. This ductal branch-oriented minimal pancreatectomy is the least invasive pancreatectomy and a suitable operation for branch-type ductal ectasia of the pancreas, which is usually benign. Received for publication on Jan. 5, 1998; accepted on April 3, 1998     

胰体尾切除术后胰瘘的防治

目的探讨胰体尾切除术后胰瘘的防治。方法回顾性分析2007年1月至2014年5月间83例行胰体尾切除术病人的术前基本资料、术中操作及术后治疗等临床资料,对其中并发胰瘘的19例病人临床资料进行分析。结果行胰体尾切除术的83例病人中,术后并发胰瘘19例,发生率为22．9％,16例经保守治疗痊愈,有效率为84．2％,2例病人行放射治疗后治愈,1例死亡,死亡率为1．2％。单纯缝扎和切割闭合器处理胰腺断端后胰瘘发生率分别为21．6％和23．9％。结论胰体尾切除术后胰瘘的发生率仍然很高,术中正确处理胰腺断端及加强术后管理是预防胰体尾切除术后胰瘘的关键。胰瘘的治疗在于通畅引流、加强营养支持,并积极寻找新的治疗方法。     

MANAGEMENT OF TRANSECTED PANCREAS IN CHILDREN

The pancreas is the fourth most commonly injured intra-abdominal organ in children who sustain blunt abdominal trauma. Appropriate management of the injured pancreas has been controversial. With the advent of the computerized tomography scan, paediatric surgeons have tended to manage pancreatic injuries non-operatively. However. if pseudocysts develop. non-operative management may necessarily entail a long hospital course involving total parenleral nutrition. drainage procedures and attendant morbidity. The critical element in planning therapy is to determine the status of the pancreatic duct. We have recently encountered five children who suffered blunt pancreatic injury where the main pancreatic duct was determined to have been transected. These children underwent spleen preserving distal pancreatectomy with resultant shorter hospital stays and minimal long-term morbidity. We suggest that in children with pancreatic injury where the main pancreatic duct has been transected early operative management rather than non-operative therapy is the procedure of choice. Endoscopic retrograde cholangiopancreatography should be used to determine the status of the pancreatic duct. This modality can be both diagnostic and therapeutic in appropriate circumstances.     

Distal pancreatectomy: does the method of closure influence fistula formation?

The appropriate closure of the pancreatic remnant after distal pancreatectomy is still debated. Suture techniques, stapled closure, and pancreaticoenteric anastomosis all have their supporters. In this study we have reviewed our data from distal pancreatectomy to determine whether the type of remnant closure or underlying pathologic process had any relation to postoperative fistula formation. We performed a retrospective chart review of patients undergoing distal pancreatectomy at our institution between 1993 and 2001. The charts were reviewed for morbidity and mortality. These were then related to the type of closure of the pancreatic stump. From 1993 to 2001 a total of 86 patients underwent distal pancreatectomy. Data were available on 85 patients. Indications for surgery were pancreatic tumor (69%), pancreatitis (14%), trauma (7%), and extra pancreatic disease (9%). Pancreatic fistula occurred in 14 per cent (N = 12), intra-abdominal abscess in 8 per cent (N = 7), and wound infection in 2 per cent (N = 2). There was no mortality in the series. The incidence of pancreatic fistula formation was not related to method of closure of the pancreatic remnant nor to the underlying pathologic process. Postoperative pancreatic fistulas will close spontaneously even without total parenteral nutrition.     

Role of automatic staplers in the aetiology of bronchopleural fistula.

The incidence of bronchopleural fistula in 130 patients who had pneumonectomies has been reviewed. Patients were divided into two groups according to the type of automatic stapler used to close the bronchus. From January 1979 to February 1982 the parallel jaw stapler (TA-55) was used in 71 patients (group 1). The new hinged jaw stapler (Premium TA-55) was used in 59 patients from March 1982 to April 1984 (group 2). The incidence of bronchopleural fistula was 4.2% in group 1 and 15.2% in group 2 (p less than 0.05). The two staplers were tested on a cadaveric bronchial preparation. Radiographs were subsequently taken of the stapled segments. These showed that with the Premium TA-55 closure of staples was not uniform, being incomplete near the hinge unlike the old style TA stapler, which achieves complete and uniform closure of the staples. It is concluded that this undoubtedly contributes to the significantly higher incidence of bronchopleural fistula, and that the new hinged jaw stapler in its present design is not recommended for use during pneumonectomy.     

Spleen-preserving pancreatectomy for cystic pancreatic neoplasms.

Cystic neoplasms of the pancreas are an uncommon entity comprising fewer than 1 per cent of all pancreatic neoplasms. The guidelines for management of these tumors, specifically, the extent of resection, are unclear. Formerly, a distal pancreatectomy including the spleen was performed for tumors in the tail of the pancreas. The importance of preserving the spleen has been well documented; however, there are few reports of spleen-preserving pancreatectomy for cystic neoplasms of the distal pancreas. We report two patients who underwent spleen-preserving pancreatectomy for mucinous cystic neoplasms in the tail of the pancreas. Both patients were female, ages 39 and 65 years. Preoperative preparation included administration of vaccinations and subcutaneous somatostatin. Operative technique emphasized division of the splenic artery and vein beyond the tip of the distal pancreas without mobilization of the spleen. The pancreas was transected with a vascular stapler. Fibrin glue was applied to the margin of the pancreas. The operative blood loss, duration of operation, and postoperative hospital stay were 150 and 250 mL, 150 and 180 minutes, and 7 and 9 days, respectively. The pathology revealed both lesions to be mucinous cystic neoplasms. The patients recovered and at 6-month follow-up were without complaints and in good health. Spleen-preserving pancreatectomy is rapid and associated with minimal morbidity. This procedure should be considered in the surgical management of cystic neoplasms in the tail of the pancreas.     

胰腺损伤的诊断和治疗(附32例报告)

本文报告胰腺损伤32例,均经手术治疗。其中胰腺挫伤小网膜腔行腹腔引流术13例,胰腺挫裂伤行清创缝合及引流术10例,胰腺十二指肠联合伤行十二指肠憩室化手术2例,均治愈。7例胰腺横断伤中,行近端胰腺缝合及远端胰切除加脾切除术或远端胰空肠Roux-en-Y吻合术各3例,均治愈;1例行胰腺对端吻合术,术后因胰瘘、胰源性腹膜死亡。     

带血管蒂空肠浆肌瓣对胰腺切除和缝合的改进

目的　探讨一种降低全胃切除联合远端胰腺切除术后胰漏发生的术式。　方法　 1996年 3月～ 2 0 0 2年 12月 ,2 9例远端胰腺切除时 ,胰腺断端稍外凸 ,呈“ >”形 ,然后结扎主胰管 ,创面止血 ,利用代胃空肠制作带血管蒂浆肌瓣 ,用纤维蛋白胶将浆肌瓣与胰腺残端贴敷后丝线缝合 ,以保护胰腺残端。　结果　无胰漏、腹腔感染或脓肿及胰腺假性囊肿发生。　结论　带血管蒂空肠浆肌瓣有利于促进胰断面愈合 ,能有效地预防胰漏。