Flowchart of the systematic review and meta-analysis.

<p>The boxes to the right indicate the number of excluded studies with the specified reasons.</p

Impact of spleen-preservation and laparoscopic approach on PF rates after DP.

<p><b>A.</b> Forrest plot of studies that provided comparative data on overall (upper plot) and clinically relevant (grade B/C, lower plot) PF rates after either spleen-preserving or spleen-resecting DP. <b>B.</b> The Forrest plot of studies that compared overall (upper plot) and clinically relevant (grade B/C, lower plot) PF rates after laparoscopic vs. open DP, showing no difference in PF probability after either approach. Bottom right: Funnel plot of the included studies in the comparison of laparoscopic vs. open DP with regard to PF rates. Studies that were associated with high PF rates after laparoscopic DP seem to be lacking.</p

Anastomosis of the pancreatic stump during DP is superior to suture, but not to stapling, for reducing fistula rates.

<p><b>A.</b> Forrest plot of studies that compared anastomosis (i.e. pancreatico-gastrostomy or–enterostomy) of the pancreatic stump to stapler closure with regard to overall (upper plot) and clinically relevant (grade B/C, lower plot) postoperative PF rates after DP. RCTs: randomized controlled trials. <b>B.</b> The Forrest plot of studies that compared anastomosis to suture closure of the pancreatic stump show a beneficial effect of anastomosis for reducing overall (upper plot) and clinically relevant (grade B/C, lower plot) postoperative PF rates after DP. Bottom: funnel plot of included studies in the comparison of anastomosis vs. suture with regard to PF rates after DP.</p

Stapler closure of the pancreatic remnant during distal pancreatectomy/DP is associated with less frequent pancreatic fistula/PF formation.

<p>Forrest plot of studies that provided quantitative data on the PF rates after handsewn/suture vs. stapler closure of the pancreatic stump during DP. 95%CI: 95% confidence interval. RCTs: randomized controlled trials. Grading of PF as B or C in the eligible studies was according to the ISGPF definition [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0197553#pone.0197553.ref016" target="_blank">16</a>]. Bottom right: funnel plot of included studies.</p

Retrospective analysis of our institutional experience on PF rates and stump closure techniques during DP (Department of Surgery, TU München, 2007–2015).

<p><b>A.</b> Three different techniques of stump closure were applied for closure of the pancreatic remnant, where suture closure dominated. The overall PF rate was 27% (Grade A: 11%, Grade 2: 11%, Grade 3: 5% according to the ISGPS definition from 2005 [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0197553#pone.0197553.ref016" target="_blank">16</a>]). <b>B.</b> The overall PF rate, but also the grade of the PF did not differ between DPs performed via any of the three techniques. n.s.: not significant. <b>C.</b> We also analyzed whether targeted, i.e. extra closure of the main pancreatic duct (e.g. via sutures or clipping) prior to suturing of the whole stump during DP influenced PF grade. Indeed, duct suturing or clipping prior to stump suture decreased the proportion of higher grade PF. <b>D.</b> The beneficial effect of pancreatic duct closure on reduction of higher grade PF was most obvious for closure with the monofilamentous PDS^® sutures.</p