Barbed suture for pancreatic anastomosis during pancreaticoduodenectomy decreases incidence of clinically significant pancreatic fistula

Abstract

Background: Pancreatic leak after pancreaticoduodonectomy maints to be a high cause of morbidity during pancreaticoduodenectomy, regardless of the technique. Barbed suture is being utilized in many clinical applications due to ease of use and potential higher burst strength during gastrointestinal anastomsis. To date, no studies have looked at the impace of utilizing barbed suture in pancreatic reconstruction during pancreaticoduodenecotmy. Methods: A retrospective analysis of a prospective database was reviewd off all pancreaticoduenectomy cases performed by a single surgeon from 2015–2017 at a tertiary care regional medical center. Pancreatic anastomosis was performed as a pancreaticojejunostomy in an end to side fashion, An outer layer of mattress vicryl suture was utilized first followed by inner running layer of barbed suture. No stent was utlized during anastomosis. Drain amylase was checked on POD 1 and 3. Fistula rates were recorded in accordance with the International Society of Grading of Pancreatic Fistutla descriptions. Results: A total of 32 consecutive pancreaticoduodenectomies were performed by a single surgeon. There was no difference in age, operative indication, pancreatic texture, and duct diameter between patients. 16 patients had elevated amylase levels (50%) Of these, 15/32 Grade A (46%), 1/32 Grade B (3%), 0/32 Grade C (0%). One patient required percutaneous drain placement on post operative day 14 which resolved leak. No patients required operative intervention for pancreatic fistula. Mean time to drain removal was 7 days. There were no deaths related to pancreatic fistula during the study period. Conclusion: Barbed suture utilization is a reliable and safe method of pancreaticojejunostomy creation during pancreaticoduodenectomy. This technique has a low incidence of clincally relevent pancreatic fistula and is easily producibleFigure 1Demographics, perioperative data, and complication data for minimally invasive pancreatectomyPDLPTotalDemographic dataTotal number of patients4357100 Male, No. (%)20 (46.5%)35 (61.4%)55 (55%) Female, No. (%)23 (53.5%)22 (38.6%)45 (45%)Age in years, median (range)67 (38–87)66 (40–74)66 (28–87)ASA score, No. (%) ASA II7 (16.3%)8 (17.0%)15 (15%) ASA III28 (65.1%)33 (70.2%)61 (61%) ASA IV5 (11.6%)6 (12.8%)11 (11%)BMI, median (range)26.6 (19.0–39.1)26.5 (16.8–68.6)26.5 (16.8–68.6)Perioperative data Case initiated robotically, No. (%)43 (100%)25 (43.9%)68 (68%) Convened to open9 (20.9%)6 (10.5%)15 (15%) Operative time, median (range)429.5 (290–571)206(131–375)295 (131–571) EBL in mL, median (range)500 (50–5000)200 (25–2000)325 (25–5000) Length of stay in days, median (range)8 (5–63)6 (3–20)6 (3–63) 90-day readmission, No. (%)15 (34.9%)12 (21.05%)27 (27%) 30-day mortality, No. (%)0 (0.0%)0 (0%)0 (0%) 90-day mortality, No. (%)1 (2.3%)2 (3.5%)3 (3%) Pancreatic fistula (Grade B/C)4 (9.3%)6 (10.5%)10 (10%)Oncological Factors Tumor size in mm, mean (range)28.7 (5–100)42.8 (4.2–80)36.7 (4.2–100) R0 resection, No. (%)31 (72.1%)40 (70.2%)71 (71%) R1 resection, No. (%)12 (27.9%)15 (26.3%)27 (27%) Lymph nodes harvested with specimen, mean (range)18.9 (5–39)11.2 (1–24)14.5 (1–39) Cases with positive lymph nodes, No. (%)30 (69.8%)26 (49.1%)56 (56%) Number of nodes positive, mean (range)3 (0–16)0.8 (0.0–4.0)1.7 (0–16) Positive lymph node ratio, mean (range)0.19 (0–0.76)0.09 (0–0.67)0.13 (0–0.76)Abbreviations: PD, pancreaticoduodenectomy; LP, left pancreatectomy; BMI, body mass index; EBL, estimated blood loss. Open table in a new tab . Abbreviations: PD, pancreaticoduodenectomy; LP, left pancreatectomy; BMI, body mass index; EBL, estimated blood loss.