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Introduction: Recent advances in operative technique and post-operative care have resulted in low mortality following distal pancreatectomy (DP). However, rates of pancreatic fistula (PF) remain as high as 40%. This study was performed to determine trends for pancreatic remnant closure and identify potential risk factors for PF at our institution.
Methods: Data from every patient undergoing DP from 2007 to present were retrospectively reviewed. Primary outcome was PF, classified according to ISGPF. Other variables included patient demographics, neoadjuvant therapy, operative details, complications, and pathologic examination. Differences in variables by PF status were assessed with Chi-square, Fisher exact, and t-tests as appropriate. A p-value < 0.05 was considered significant.
Results: 89 patients underwent DP during the study interval, 79% of which had pathologically confirmed malignancy with the most common being pancreatic ductal (21%) and renal cell (17%). Mean age was 61 years, 79% were Caucasian, 50% were male, and 1/3 were obese (BMI>30). Only 25% received chemotherapy and 11% radiation. Operatively, 74% had concomitant splenectomy, 48% had at least one other procedure, and 95% had a drain. Pancreatic transection was accomplished by: electrocautery alone (12.4%), transection and oversewn (39.3%), stapled (36.0%), stapled and oversewn (12.4%). Mean hospital length of stay was 8.3 days, but increased by 3 full days if PF was present (10.2 vs 6.9 days). Overall PF rate was 43%, with 2/3 requiring percutaneous intervention. PF rate was no different in the electrocautery alone (37.1%), transection and oversewn (36.4%), and stapled (40.6%) groups. However, the rate of PF was nearly double in the stapled and oversewn cohort (72.7%) with no difference if omentum was used to cover the remnant.
Conclusions: The ideal closure method for the pancreatic remnant following DP remains unknown. These data demonstrate that PF incidence rises with increased manipulation of the pancreatic remnant. Thus, when utilizing a stapled closure, separate ligation of the pancreatic duct should be avoided.