Efficacy of Reinforced Stapler Versus Hand-sewn Closure of the Pancreatic Stump During Pure Laparoscopic Distal Pancreatectomy to Reduce Pancreatic Fistula.
Journal
Surgical laparoscopy, endoscopy & percutaneous techniques
ISSN: 1534-4908
Titre abrégé: Surg Laparosc Endosc Percutan Tech
Pays: United States
ID NLM: 100888751
Informations de publication
Date de publication:
01 Apr 2023
01 Apr 2023
Historique:
received:
30
06
2022
accepted:
09
01
2023
medline:
6
4
2023
pubmed:
24
2
2023
entrez:
23
2
2023
Statut:
epublish
Résumé
Laparoscopic distal pancreatectomy (L-DP) is the standard procedure for treating left-sided pancreatic tumors. Stapler closure of the pancreas is the preferred method for L-DP; however, postoperative pancreatic fistula (POPF) remains a challenging problem. The present study aimed to compare the surgical outcomes of staple closure using a reinforcing stapler (RS) and transection using an ultrasonic dissector followed by hand-sewn (HS) closure in a fish-mouth manner in pure L-DP and to determine independent perioperative risk factors for clinically relevant postoperative pancreatic fistula (CR-POPF). Among the 85 patients who underwent pure L-DP between February 2011 and August 2021, 80 of whom the pancreatic stump was closed with RS (n = 59) or HS (n = 21) were retrospectively investigated. Associations between potential risk factors and POPF were assessed using univariate analysis. The factors, of which the P value was determined to be <0.1 by univariate analysis, were entered into a multivariate regression analysis to ascertain independent predictive factors. The surgery time and estimated blood loss were not significantly different between the two groups. Overall, 13 patients (16.3%) developed CR-POPF ( B = 12 and C = 1). The rate of CR-POPF was lower in RS than in HS; however, the difference was not statistically significant (RS vs HS: 11.9% vs 28.9%, P = 0.092). Consistent with the results for CR-POPF, the rate of Clavien-Dindo IIIa or more postoperative complications and the length of hospital stay were also not significantly different between the two groups (RS vs HS: 10.2, 12% vs 14.3%, 14 d). In the univariate analysis of risk factors for CR-POPF, the pancreatic thickness at the transection site, procedure for stump closure, and estimated blood loss were associated with a significantly higher rate of CR-POPF. The multivariate analysis revealed that the pancreatic thickness at the transection site (cutoff: 12 mm) was the only independent risk factor for CR-POPF (odds ratio: 6.5l, 95% CI: 1.4-30.4, P = 0.018). The rate of CR-POPF was much lower in RS than in HS for pancreatic thickness <12 mm (RS vs HS: 4.1% vs 28.6%), whereas that was rather higher in RS than in HS for pancreatic thickness ≥12 mm (RS vs HS: 50% vs 28.6%). RS closure was superior to HS closure for pancreatic thickness <12 mm and for prevention of CR-POPF after pure L-DP. It is necessary to seek more reliable procedures for pancreatic stump closure in patients with a pancreatic thickness of ≥12 mm.
Sections du résumé
BACKGROUND
BACKGROUND
Laparoscopic distal pancreatectomy (L-DP) is the standard procedure for treating left-sided pancreatic tumors. Stapler closure of the pancreas is the preferred method for L-DP; however, postoperative pancreatic fistula (POPF) remains a challenging problem. The present study aimed to compare the surgical outcomes of staple closure using a reinforcing stapler (RS) and transection using an ultrasonic dissector followed by hand-sewn (HS) closure in a fish-mouth manner in pure L-DP and to determine independent perioperative risk factors for clinically relevant postoperative pancreatic fistula (CR-POPF).
PATIENTS AND METHODS
METHODS
Among the 85 patients who underwent pure L-DP between February 2011 and August 2021, 80 of whom the pancreatic stump was closed with RS (n = 59) or HS (n = 21) were retrospectively investigated. Associations between potential risk factors and POPF were assessed using univariate analysis. The factors, of which the P value was determined to be <0.1 by univariate analysis, were entered into a multivariate regression analysis to ascertain independent predictive factors.
RESULTS
RESULTS
The surgery time and estimated blood loss were not significantly different between the two groups. Overall, 13 patients (16.3%) developed CR-POPF ( B = 12 and C = 1). The rate of CR-POPF was lower in RS than in HS; however, the difference was not statistically significant (RS vs HS: 11.9% vs 28.9%, P = 0.092). Consistent with the results for CR-POPF, the rate of Clavien-Dindo IIIa or more postoperative complications and the length of hospital stay were also not significantly different between the two groups (RS vs HS: 10.2, 12% vs 14.3%, 14 d). In the univariate analysis of risk factors for CR-POPF, the pancreatic thickness at the transection site, procedure for stump closure, and estimated blood loss were associated with a significantly higher rate of CR-POPF. The multivariate analysis revealed that the pancreatic thickness at the transection site (cutoff: 12 mm) was the only independent risk factor for CR-POPF (odds ratio: 6.5l, 95% CI: 1.4-30.4, P = 0.018). The rate of CR-POPF was much lower in RS than in HS for pancreatic thickness <12 mm (RS vs HS: 4.1% vs 28.6%), whereas that was rather higher in RS than in HS for pancreatic thickness ≥12 mm (RS vs HS: 50% vs 28.6%).
CONCLUSIONS
CONCLUSIONS
RS closure was superior to HS closure for pancreatic thickness <12 mm and for prevention of CR-POPF after pure L-DP. It is necessary to seek more reliable procedures for pancreatic stump closure in patients with a pancreatic thickness of ≥12 mm.
Identifiants
pubmed: 36821651
doi: 10.1097/SLE.0000000000001151
pii: 00129689-202304000-00001
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
99-107Informations de copyright
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors declare no conflicts of interest.
Références
Stauffer JA, Coppola A, Mody K, et al. Laparoscopic versus open distal pancreatectomy for pancreatic adenocarcinoma. World J Surg. 2016;40:1477–1484.
de Rooij T, van Hilst J, van Santvoort H, et al. Minimally invasive versus open distal pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg. 2019;269:2–9.
Mehrabi A, Hafezi M, Arvin J, et al. A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: it’s time to randomize. Surgery. 2015;157:45–55.
Asbun HJ, Moekotte AL, Vissers FL, et al. The Miami International evidence-based guidelines on minimally invasive pancreas resection. Ann Surg. 2020;271:1–14.
Kawai M, Hirono S, Okada KI, et al. Reinforced staplers for distal pancreatectomy. Langenbecks Arch Surg. 2017;402:1197–1204.
Kawaida H, Kono H, Amemiya H, et al. Use of a reinforced triple-row stapler following distal pancreatectomy reduces the incidence of postoperative pancreatic fistula in patients with a high BMI. Anticancer Res. 2019;39:1013–1018.
Matsumoto I, Kamei K, Satoi S, et al. Efficacy of the slow firing method using a reinforced triple-row stapler for preventing postoperative pancreatic fistula during laparoscopic distal pancreatectomy. Surg Today. 2021;52:260–267.
Hamilton NA, Porembka MR, Johnston FM, et al. Mesh reinforcement of pancreatic transection decreases incidence of pancreatic occlusion failure for left pancreatectomy: a single-blinded, randomized controlled trial. Ann Surg. 2012;255:1037–1042.
Kondo N, Uemura K, Nakagawa N, et al. A multicenter, randomized, controlled trial comparing reinforced staplers with bare staplers during distal pancreatectomy (HiSCO-07 Trial). Ann Surg Oncol. 2019;26:1519–1527.
Diener MK, Seiler CM, Rossion I, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet. 2011;377:1514–1522.
Pulvirenti A, Landoni L, Borin A, et al. Reinforced stapler versus ultrasonic dissector for pancreatic transection and stump closure for distal pancreatectomy: a propensity matched analysis. Surgery. 2019;166:271–276.
Maeda K, Kuriyama N, Nakagawa Y, et al. Optimal management of peripancreatic fluid collection with postoperative pancreatic fistula after distal pancreatectomy: Significance of computed tomography values for predicting fluid infection. PLoS One. 2021;16:e0259701.
Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161:584–591.
Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–196.
Ji W, Wang Y, Wang L, et al. Modified hand-sewn closure with retroperitoneal tissue-covering method prevents pancreatic fistula in laparoscopic distal pancreatectomy. Surg Laparosc Endosc Percutan Tech. 2016;26:e95–e99.
Diener MK, Knaebel HP, Witte ST, et al. DISPACT trial: a randomized controlled trial to compare two different surgical techniques of DIStal PAnCreaTectomy - study rationale and design. Clin Trials. 2008;5:534–545.
Kawai M, Tani M, Okada K, et al. Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy. Am J Surg. 2013;206:352–359.
Probst P, Hüttner FJ, Klaiber U, et al. Stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy. Cochrane Database Syst Rev. 2015;11:Cd008688.
Reeh M, Nentwich MF, Bogoevski D, et al. High surgical morbidity following distal pancreatectomy: still an unsolved problem. World J Surg. 2011;35:1110–1117.
Chikhladze S, Makowiec F, Küsters S, et al. The rate of postoperative pancreatic fistula after distal pancreatectomy is independent of the pancreatic stump closure technique - A retrospective analysis of 284 cases. Asian J Surg. 2020;43:227–233.
Eguchi H, Nagano H, Tanemura M, et al. A thick pancreas is a risk factor for pancreatic fistula after a distal pancreatectomy: selection of the closure technique according to the thickness. Dig Surg. 2011;28:50–56.
Goh BKP, Lee CY, Koh YX, et al. Use of reinforced staplers decreases the rate of postoperative pancreatic fistula compared to bare staplers after minimally invasive distal pancreatectomies. J Laparoendosc Adv Surg Tech A . 2021;31:1124–1129.
Kurahara H, Maemura K, Mataki Y, et al. Closure of the pancreas in distal pancreatectomy: comparison between bare stapler and reinforced stapler. Hepatogastroenterology. 2014;61:2367–2370.
Nagakawa Y, Hijikata Y, Osakabe H, et al. Why does postoperative pancreatic fistula occur after hand-sewn parenchymal closure and staple closure in distal pancreatectomy? Surg Laparosc Endosc Percutan Tech. 2019;29:e15–e19.
Pannegeon V, Pessaux P, Sauvanet A, et al. Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment. Arch Surg. 2006;141:1071–1076.
Aoki T, Mansour DA, Koizumi T, et al. Preventing clinically relevant pancreatic fistula with combination of linear stapling plus continuous suture of the stump in laparoscopic distal pancreatectomy. BMC Surg. 2020;20:223.
Miyamoto R, Sano N, Maeda M, et al. Modified reinforced staple closure technique decreases postoperative pancreatic fistula after distal pancreatectomy. Indian J Surg Oncol. 2019;10:587–593.
Zimmitti G, La Mendola R, Manzoni A, et al. Investigation of intraoperative factors associated with postoperative pancreatic fistula following laparoscopic left pancreatectomy with stapled closure: a video review-based analysis: video-review for predictors of pancreatic leak. Surg Endosc. 2021;35:941–954.