Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience.

Elke Tieftrunk,Helmut Friess,Güralp O Ceyhan,Florian Scheufele,Ihsan Ekin Demir,Lenika Calavrezos,Mine Sargut,Stephan Schorn,Rebekka Schirren,Aldo Scarpa

doi:10.1371/journal.pone.0197553

Abstract

BackgroundPancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP.MethodsWe performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques.Results8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02).ConclusionAfter DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.

Highlights

Perioperative morbidity and mortality rates after pancreatic resection have continuously diminished over the past two decades in parallel with concentration of pancreatic resections in “pancreatic surgical centers” [1, 2]
The major three techniques of stump closure resulted in comparable PFR
After distal pancreatectomy (DP), stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone

Summary

Introduction

Perioperative morbidity and mortality rates after pancreatic resection have continuously diminished over the past two decades in parallel with concentration of pancreatic resections in “pancreatic surgical centers” [1, 2]. Stump closure after DP has been reported to be mainly performed by six different techniques: 1) manual/hand sutures on the stump to close the draining pancreatic duct [3], 2) stapler-based transsection and concomitant closure of the stump [3], 3) combination of stapler-based resection with manual sutures along the stapler line [4], 4) pancreatico-enteric or -gastric anastomosis [6], 5) application of fibrin/coagulation factor-like bio-sealants [7], 6) placement of autologous patches like falciform ligament [8] or seromuscular seals [9] on the pancreatic stump.

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