Emerging strategies to prevent the development of pancreatic fistula after distal pancreatectomy

Abstract

Pancreatic fistula occurs in approximately 30% of patients after distal pancreatectomy. Fistula formation is multifactorial in nature, influenced by patient-specific anatomic features of the pancreas and operative techniques at the time of resection. In this article, we review past, present, and future strategies postulated to address this problem. The results of the stapler versus hand-sewn closure after distal pancreatectomy trial are presented in detail. This trial established equivalency between these 2 techniques, putting to rest a 25-year-old controversy. The implications of the stapler versus hand-sewn closure after distal pancreatectomy trial are discussed in the context of the current revolution in minimally invasive surgery, which will likely bring stapler closure to the forefront. Technologic improvements in surgical staplers are also discussed, with a focus in their applicability to pancreatic transection. Specifically, the results of a newly -published trial from Washington University in St. Louis are presented, showing improved fistula rates when stapler closure of the pancreas is reinforced with an external prosthesis. Based on these results, we postulate that stapler transection with mesh reinforcement is the best currently available method of pancreatic remnant closure. Results of ongoing trials using energy sealing devices are eagerly awaited, and further research into this area is necessary to make further progress in this field.