Background: Resection of the capsule of the pancreas is part of the radical operation for the treatment of gastric cancer proposed by the Japanese Gastric Cancer Association. It is unclear; however, if resection of the capsule is a safe procedure or even if it is necessary. This study aims to assess in patients treated for gastric cancer the occurrence of: (a) pancreatic fistula, and (b) metastasis to the pancreatic capsule.
Methods: We studied 80 patients (mean age 61 years, 42 males) submitted to gastrectomy and lymphadenectomy with resection of the pancreatic capsule by hydrodissection. Patients with anastomotic leakage, pancreatic disease, tumoral invasion of the pancreas, or submitted to concomitant splenectomy were excluded. The tumor was located in the distal third of the stomach in 61% of the patients, in the middle third in 27%, and proximally in 12%. Total gastrectomy was performed in 27% of the cases and partial gastrectomy in 73%. In all patients, amylase activity in the drainage fluid was measured on day 2. Subsequent measurements were performed in alternated days until normalization if initial measurement was abnormal. Pancreatic fistula was defined as amylase levels greater than 600. In 25 of these patients (mean age 53 years, 16 males) the pancreatic capsule was histologically analyzed for metastasis.
Results: Pancreatic fistula was diagnosed in 8 (10%) patients. The mean amylase level was 5863. Normalization of amylase levels was achieved within 7 days in all patients. No clinical complications of pancreatic fistula, such as intraabdominal abscesses, were noticed. In only one case, the surgeon suspected of pancreatic injury during removal of the capsule. Pancreatic fistula was associated to younger age (p=0.03), but not to gender (p=0.1), tumor location (p=0.6) and type of gastrectomy (p=0.8). Metastasis to the pancreatic capsule was not identified.
Conclusion: Resection of the pancreatic capsule must be discouraged due to subclinical pancreatic fistula in a significant number of the cases and absence of metastasis to the capsule.