Teres Hepatis Ligament Flap Plasty to Prevent Pancreatic Fistula after Tumor Enucleation

Abstract

Due to the rapid technical progresswith development of high quality imaging tools, incidental diagnosis of small pancreatic lesionsdincluding cystic and solid pathologiesdhas significantly increased in recent years. Besides solid tumors (eg, small neuroendocrine tumors), especially small cystic lesions (eg, side-branch intraductal papillary mucinous neoplasms) bear a relevant risk of malignant transformation. Therefore, surgical management is required for a considerable proportion of these findings. Because these often premalignant lesions do not necessarily require radical oncologic resection, parenchyma-sparing resections have been accepted as surgical standards, among them tumor enucleation (TE) for lesions not exceeding a diameter of 2 cm and lacking signs of malignancy. These techniques offer maximum pancreatic tissue preservation to avoid exocrine and endocrine insufficiencies, which are observed in a considerable number of patients after standard procedures such as pancreaticoduodenectomy or distal pancreatectomy. Postoperative pancreatic fistula (POPF) has been reported as the most frequent complication after TE, with a reported rate between 18% and 50%. Although POPFs after TE are mainly uncomplicated (mostly International Study Group on Pancreatic Fistula [ISGPF] grade A), they remain an unsolved and potentially long-lasting clinical problem. The versatility of the teres hepatis ligament and its use as a surgical cover structure has been described in various procedures, including filling of liver defects after hydatid cysts resection in order to prevent bile leakage, covering the gastroduodenal artery stump during pancreaticoduodenectomy, and covering the resection margin after distal pancreatectomy to prevent leakage. To our knowledge, there have been no reports on teres hepatis