Chronic pancreatitis of the pancreatic remnant is an independent risk factor for pancreatic fistula after distal pancreatectomy

Background: There is an ongoing debate about the best closure technique after distal pancreatectomy (DP). The aim of the closure is to prevent the formation of a clinically relevant post-operative pancreatic fistula (POPF). Stapler technique seems to be equal compared with hand-sewn closure of the remnant. For both techniques, a fistula rate of approximately 30% has been reported. Methods: We retrospectively analyzed our DPs between 01/2000 and 12/2010. In all cases, the pancreatic duct was over sewn with a separately stitched ligation of the pancreatic duct (5*0 PDS) followed by a single-stitched hand-sewn closure of the residual pancreatic gland. The POPF was classified according to the criteria of the International Study Group for Pancreatic Fistula (ISGPF). Univariate and multivariate analyses of potential risk factors for the formation of POPF were performed. Indications for operations included cystic tumors (n = 53), neuroendocrine tumors (n = 27), adenocarcinoma (n = 22), chronic pancreatitis (n = 9), metastasis (n = 6), and others (n = 7). Results: During the period, we performed 124 DPs (♀ = 74, ♂ = 50). The mean age was 57.5 years (18–82). The POPF rates according to the ISGPF criteria were: no fistula, 54.8% (n = 68); grade A, 24.2% (n = 30); grade B, 19.3% (n = 24); and grade C, 1.7% (n = 2). Therefore, in 21.0% (n = 26) of the cases, a clinically relevant pancreatic fistula occurred. The mean postoperative stay was significantly higher after grade B/C fistula (26.3 days) compared with no fistula/grade A fistula (13.7 days) (p < 0.05). The uni- and multivariate analyses showed chronic pancreatitis of the pancreatic remnant to be an independent risk factor for the development of POPF (p = 0.004 OR 7.09). Conclusion: By using a standardized hand-sewn closure technique of the pancreatic remnant after DP with separately stitched ligation of the pancreatic duct, a comparably low fistula rate can be achieved. Signs of chronic pancreatitis of the pancreatic remnant may represent a risk factor for the development of a pancreatic fistula after DP and therefore an anastomosis of the remnant to the intestine should be considered

Pancreatic fistula after distal pancreatectomy: Predictive risk factors and value of conservative treatment

Hypothesis Predictive factors of pancreatic fistula (PF) and the value of conservative management of PF following distal pancreatectomy (DP) are poorly known. Design Case series. Setting A university hospital referral center. Patients From 1991 to 2003, 175 patients underwent DP with routine drainage of the pancreatic stump and postoperative repeated measures in drainage fluid. Pancreatic fistula was defined as an amylase level in surgical drainage fluid more than 5-fold the serum level after postoperative day 5, or amylase-rich fluid collection. Computed tomographic scan was only done for suspicion of abdominal collection. Conservative management of PF included percutaneous drainage of abdominal collection and total parenteral nutrition or maintaining oral feeding in some patients with low-volume PF. Intervention Conservative management of PF after DP. Main Outcome Measures Incidence of PF according to indication, concomitant splenectomy, additional procedure, texture of parenchyma, location of transection (neck vs body), and technique of stump suture (stapler vs hand sewn), including elective ligation of the main duct, transfusions, and prophylactic use of octreotide. Results There was no mortality. Forty patients (23%) developed PF, which was symptomatic in 25 patients (63%); computed tomographic scan identified an abdominal collection in 26 (65%). Multivariate analysis identified 2 predictive factors for PF: no elective ligation of the main pancreatic duct (odds ratio, 2.2 [95% confidence interval, 1.0-4.7]) and transection at the body (odds ratio, 2.1 [95% confidence interval, 1.1-5.5]). If none or both predictive factors were present, the observed rate of PF was 16% and 63%, respectively. Pancreatic fistula was managed conservatively in 38 patients (95%), including percutaneous drainage in 16, and by reoperation in 2. Conclusions Pancreatic fistula following DP is more frequent in cases of pancreatic division at the body level and no elective ligation of the main duct. Routine drainage of the pancreatic stump does not prevent postoperative abdominal collections. Conservative management of PF is successful in 95% of cases

Distal Pancreatectomy - OWN Experience

The aim of the study was the retrospective analysis of early results after distal pancreatectomy (DP).Material and methods. During the period between January, 2000 and December, 2010 distal pancreatectomy was performed in 73 patients, including 32 (43.83%) male, and 41 (56.16%) female patients. Average patient age amounted to 53.92 ± 14.37 years. Surgery was performed by means of laparoscopy or the classical method.Results. The mean duration of the procedure amounted to 179.79 ± 59.90 minutes. Fifty-nine (80.82%) patients were subject to splenectomy. After the resection the pancreatic stump was hand-sewn in 69 patients. Pancreatoenterostomy was performed in 4 (5.47%) patients. Early postoperative complications occurred in 11 (15%) patients. Reoperation was required in two (2.7 %) patients. The postoperative mortality rate amounted to 2.7%. The average hospitalization period after surgery amounted to 12.72 ± 9.8 (1- 66) days.Conclusions. Distal pancreatectomy performed in a center experienced in pancreatic surgery is a safe procedure characterized by a low rate of complications and mortality