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Introduction: Pancreatic fistula is a common complication and a major source of morbidity after distal pancreatectomy (DP). We evaluated consecutive patients undergoing DP to determine if the type of stump closure could decrease fistula rates.
Methods: Retrospective review of a prospectively collected database between 2/1994 and 10/2007 identified 442 patients who underwent distal pancreatectomy. Clinicopathologic variables were reviewed. Pancreatic fistula was defined as a JP amylase >300U/L and an output>30cc on POD#5 or development of a postoperative collection up to POD 30.
Results: Distal pnacreatectomy was performed in 442 patients with a mortality of <1% and a pancreatic fistula rate of 29% (130/442). Distal pancreatectomy with splenectomy was performed in 311(70%) patients. Additional organs were resected in 99 (22%) patients and a laparoscopic procedure was performed in 12 (3%) patients. The pancreatic stump was closed with a fish-mouth suture closure in 228, of whom 69 (30%) developed a fistula. If a separate ductal ligation was performed the fistula rate was 27.6% (44/158) vs. 36% (25/70) if the duct was not ligated. A peritoneal falciform patch was used in 106, with a fistula rate of 30% (33/106). Stapled compared to stapled with staple line reinforcement had a fistula rate of 24% (10/41) vs. 33% (10/30). The pancreatic fistula rate was lowest (15%; 3/20) in patients who had a fish mouth suture closure with an omental patch. There is no significant difference in the rate of fistula formation between the groups (p=0.33).
Conclusions: In a series of 442 distal pancreatectomies the pancreatic fistula rate was 29%. Staplers with or without staple line reinforcement do not significantly reduce fistula rates after distal pancreatectomy. Reduction of pancreatic fistulas after DP remains an unsolved challenge.

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