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

BMC Surgery

Robert Grützmann¹  Jürgen Weitz¹  Hans-Detlev Saeger¹  Peggy Kross¹  Felix Rückert²  Stephan Kersting¹  Marius Distler¹ 

[1] Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU, Dresden, Germany;Department of Surgery, University Hospital Mannheim, Mannheim, Germany

关键词: Pancreas surgery;    Chronic pancreatitis;    Pancreatic fistula;    Distal pancreatectomy;   

Others  :  1118410
DOI  :  10.1186/1471-2482-14-54

 received in 2013-05-31, accepted in 2014-08-05,  发布年份 2014

【 摘 要 】

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.

【 授权许可】

   
2014 Distler et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]Lillemoe KD, Kaushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ: Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg 1999, 229(5):693-698. discussion 698–700
• [2]Knaebel HP, Diener MK, Wente MN, Büchler MW, Seiler CM: Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 2005, 92(5):539-546.
• [3]Blansfield JA, Rapp MM, Chokshi RJ, Woll NL, Hunsinger MA, Sheldon DG, Shabahang MM: Novel method of stump closure for distal pancreatectomy with a 75% reduction in pancreatic fistula rate. J Gastrointest Surg 2012, 16(3):524-528.
• [4]Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, Tomazic A, Bruns CJ, Busch OR, Farkas S, Belyaev O, Neoptolemos JP, Halloran C, Keck T, Niedergethmann M, Gellert K, Witzigmann H, Kollmar O, Langer P, Steger U, Neudecker J, Berrevoet F, Ganzera S, Heiss MM, Luntz SP, Bruckner T, Kieser M, Büchler MW: Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 2011, 377(9776):1514-1522.
• [5]Carter TI, Fong ZV, Hyslop T, Lavu H, Tan WP, Hardacre J, Sauter PK, Kennedy EP, Yeo CJ, Rosato EL: A Dual-Institution Randomized Controlled Trial of Remnant Closure after Distal Pancreatectomy: Does the Addition of a Falciform Patch and Fibrin Glue Improve Outcomes? J Gastrointest Surg 2012. Jul 14. [Epub ahead of print]
• [6]Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M: International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005, 138(1):8-13.
• [7]Rueckert F, Distler M, Hoffmann S, Hoffmann D, Pilarsky C, Dobrowolski F, Saeger HD, Gruetzmann R: Quality of life in patients after pancreaticoduodenectomy for chronic pancreatitis. J Gastrointest Surg 2011, 15(7):1143-1150.
• [8]Ferrone CR, Warshaw AL, Rattner DW, Berger D, Zheng H, Rawal B, Rodriguez R, Thayer SP, Fernandez-del CC: Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg 2008, 12(10):1691-1697. discussion 1697–8
• [9]Gurusamy KS, Koti R, Fusai G, Davidson BR: Somatostatin analogues for pancreatic surgery. Cochrane Database Syst Rev 2012. Jun 13;6:CD008370.]
• [10]Fernández-Cruz L, Martínez I, Gilabert R, Cesar-Borges G, Astudillo E, Navarro S: Laparoscopic distal pancreatectomy combined with preservation of the spleen for cystic neoplasms of the pancreas. J Gastrointest Surg 2004, 8(4):493-501.
• [11]Pannegeon V, Pessaux P, Sauvanet A, Vullierme MP, Kianmanesh R, Belghiti J: Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment. Arch Surg 2006, 141(11):1071-1076. discussion 1076
• [12]Bilimoria MM, Cormier JN, Mun Y, Lee JE, Evans DB, Pisters PW: Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation. Br J Surg 2003, 90(2):190-196.
• [13]Howard TJ, Stonerock CE, Sarkar J, Lehman GA, Sherman S, Wiebke EA, Madura JA, Broadie TA: Contemporary treatment strategies for external pancreatic fistulas. Surgery 1998, 124(4):627-632. discussion 632–3
• [14]Rückert F, Kersting S, Fiedler D, Distler M, Dobrowolski F, Pilarsky C, Saeger HD, Grützmann R: Chronic pancreatitis: early results of pancreatoduodenectomy and analysis of risk factors. Pancreas 2011, 40(6):925-930.
• [15]Kleeff J, Diener MK, Z‘graggen K, Hinz U, Wagner M, Bachmann J, Zehetner J, Müller MW, Friess H, Büchler MW: Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 2007, 245(4):573-582.
• [16]Henry SL, Crawford JL, Puckett CL: Risk factors and complications in reduction mammaplasty: novel associations and preoperative assessment. Plast Reconstr Surg 2009, 124(4):1040-1046.
• [17]Jones DR, Copeland GP, de Cossart L: Comparison of POSSUM with APACHE II for prediction of outcome from a surgical high-dependency unit. Br J Surg 1992, 79(12):1293-1296.
• [18]Sheehan MK, Beck K, Creech S, Pickleman J, Aranha GV: Distal pancreatectomy: does the method of closure influence fistula formation? Am Surg 2002, 68(3):264-267. discussion 267–8