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Division of the Pancreas During Distal Pancreatectomy: a Reliable and Simple Technique Which Results in a Very Low Fistula Rate
John Stauffer*1, Marc Mesleh2, Horacio J. Asbun1
1General Surgery, Mayo Clinic, Jacksonville, FL; 2General Surgery, Advocate Christ Medical Center, Oak Lawn, IL
Background:
Pancreatic fistula (PF) is the Achilles heel of pancreatic surgery. It is commonly reported to occur in the range of 10-50% of the time after distal pancreatectomy (DP). Many different techniques have been used and described in great detail, all in an effort to decrease the occurrence of PF as this is the driver of most of the major complications seen after this procedure. This report describes the technique and outcomes of a gradual stepwise compression technique using a linear stapler with staple line reinforcement for pancreatic transection during open or laparoscopic DP which has resulted in a very low PF rate.
Methods:
Over a 5-year period (Sept 2008 to Sept 2013), 136 patients underwent DP using the gradual stepwise compression technique with linear stapler and staple line reinforcement by two surgeons. The gradual stepwise compression technique involves a circumferential control of the pancreas at the appropriate location with application of a linear cutting stapling device with staple line reinforcement material applied to the jaws. The stapler is then closed in a very slow and methodical fashion over the course of a 3-5 minute period. The stapler is then fired and the staple line is inspected. The splenic vasculature is generally included with an en bloc stapling technique.
A laparoscopic, hand assist, and open approach was used in 121 (89%), 9 (6.6%), and 6 (4.4%) of the patients respectively. There were 64 (47%) males and 72 (53%) females with an average BMI of 28.2 +-5.9. The average estimated blood loss was 245mL and operative time was 210 minutes. Indications for surgery include pancreatic adenocarcinoma, other neoplastic, cystic disease, and neuroendocrine, and benign in 38 (28%), 28 (21%), 27 (20%), 25 (18%), and 18 (13%) respectively. The average length of stay was 5.2 days.
Results:
Pancreatic fistula was seen in a total of 16 (11.8%) patients including Grade A, B, and C in 9 (6.6%), 2 (1.5%), and 5 (3.7%). 90-Day minor and major morbidity was seen in 32 (23%) and 19 (13.7%) patients respectively. There were no mortalities.
Discussion:
Division of the pancreas during DP using a gradual stepwise compression technique as described above results in a very low clinically significant PF rate (5.2%). This correlated to low morbidity with minimal recovery time for this patient group and is a very reliable and simple method of closure of the pancreatic remnant during open or laparoscopic distal pancreatectomy.
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