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BACKGROUND: Pancreatic stump leak is the major source of morbidity after distal pancreatectomy. We hypothesized that a duct-to-mucosa pancreaticogastrostomy after distal pancreatectomy (DP-PG) can decrease pancreatic fistula (PF) rates when compared to hand-sewn or staple closure. Since 2008, we conducted the nonrandomized cohort study with a prospective DP-PG group, forming our experimental group, and a retrospective control group undergoing hand-sewn closure. The aim of this study is to analyze the safety and efficacy of this method.
METHODS: DP-PG was intended to prevent PF after DP in 30 patients between April 2008 and November 2011. A historical control group was composed of 30 consecutive patients undergoing hand-sewn closure between January 2005 and March 2008. Main outcome measure was incidence of PF which was defined and graded according to the International Study Group on Pancreatic Surgery (ISGPS) classification. Secondary measures were complications which were assessed by the Clavien classification and postoperative hospital length of stay. Two groups were compared using Kruskal-Wallis test or chi-square tests.
RESULTS: Overall, a cohort of 60 patients underwent DP between 2005 and 2011. In the DP-PG group (n=30), none PF was observed in 19 patients (63%), Grade A was 10 (33%), Grade B was 1 (3%), and Grade C was none. In the control group (n=30), none PF was observed in 17 patients (57%), Grade A was 7 (23%), Grade B was 5 (17%), and Grade C was 1 (3%). Therefore the clinically-relevant PF (ISGPS Grade B/C) rate was significantly lower in the DP-PG group (3%) comparing to the control group (20%; P=0.01). Re-operation was required for one patient in both groups, but no one was due to PF. The mortality was zero in both groups. The operative time was slightly longer in the DP-PG group (median, 237 min) comparing to the control group (198min, P=0.05). The Clavien III-V severe complications were observed in 2 patients (7%; none for PF) in the DP-PG group, but in 4 patients (13%) in the control group. Development of a pancreatic leak resulted in prolonged hospital stays: 20 days in the DP-PG group vs. 29 days in the control group (P=0.03). The advantage of this technique is that pancreatic juice leaking from smaller branches on the cut surface which cannot be drained through the remnant main duct directly passes into the stomach and also allows decompress the intraductal pressure through the anastomosis.
CONCLUSIONS: Drainage through the pancreatic stump provided by duct-to-mucosa pancreaticogastrostomy after distal pancreatectomy (DP-PG) appears to have abruptly reduced clinically-relevant PF (ISPGS Grade B/C) rate and hospital stay. The economic impact of lower leak rates is reflected in lower morbidity rate and significantly shorter hospital stays. The results of our study should be validated in a randomized controlled trial.