Distal Pankreatektomi Sonrası Pankreas Güdüğünün Manuel Dikiş Yöntemi veya Stapler Yardımıyla Kapatılmasının Postoperatif Pankreatik Fistül Gelişimi Üzerine Etkisinin Retrospektif Analizi

Abstract

Amaç: Distal pankreatektomiyi takiben pankreatik güdüğünün manuel dikiş ve stapler yardımıyla kapatılması sık kullanılan iki tekniktir. Postoperatif pankreatik fistül oranları güdük kapama teknikleri ile ilişkili olabilir. Bu çalışma, distal pankreatektomi sonrası pankreatik fistül oranlarını belirlemek ve iki kapama yönteminin pankreas fistülü gelişimine etkisini değerlendirmek amacıyla yapıldı. Gereç ve Yöntemler: 2011-2021 yılları arasında malign ve benign pankreas patolojileri nedeniyle elektif açık veya laparoskopik distal pankreatektomi yapılan tüm hastalar retrospektif olarak değerlendirildi. Hastalar Grup HS (manuel dikiş ile kapama) ve Grup ST (stapler yardımlı kapama) olarak gruplandırıldı. Pankreas fistülü tanısı, Uluslararası Pankreas Fistülü Çalışma Grubu kılavuzlarına göre belirlendi ve derecelendirildi. Biyokimyasal kaçak oranları ve ameliyat sonrası pankreatik fistül dereceleri birincil sonuç olarak kabul edildi. Bulgular: Ortalama yaşı 51,8 ± 15,1 yıl olan 44 hasta (Grup HS'de 28 ve Grup ST'de 16) vardı. Gruplar demografik ve klinik özellikler açısından benzerdi (tüm p değerleri p>0,05). Grup HS’de biyokimyasal kaçağı olan 15 hasta, (%53,6) vardı. Grup ST'de altı hastanın (%37,5) biyokimyasal kaçağı olduğu tespit edildi. Gruplar arasındaki biyokimyasal kaçak gelişimi açısından anlamlı bir fark yoktu (p=0,305). Grup ST’de pankreas fistülü olan hasta yoktu. Buna karşın Grup HS'de Grade B postoperatif pankreas fistülü olan sadece bir olgu vardı. Pankreas fistülü açısından gruplar arasında anlamlı bir fark tespit edilmedi (p=0,999). Sonuç: Distal pankreatektomi yapılan hastalarda manuel dikiş ile kapama veya stapler ile kapama tekniklerinin biyokimyasal kaçak ve postoperatif pankreatik fistül oranları üzerinde anlamlı bir etkisi olmadığı gösterildi. Dolayısıyla, her iki pankreas güdüğü kapama yaklaşımının eşit derecede güvenli olduğu ve benzer klinik etkinlikle ile kullanılabileceği sonucuna varılmıştır.

Keywords

• Pankreatektomi
• pankreas fistülü
• dikiş
• cerrahi stapler

Retrospective Analysis of the Effect of Hand-sewn and Stapler Closure of Pancreatic Stump After Distal Pancreatectomy on the Development of Postoperative Pancreatic Fistula

Abstract

Aim: Hand-sewn (HS) and stapled closure (ST) of pancreatic stump following distal pancreatectomy are two frequently used techniques. Rates of postoperative pancreatic fistula (POPF) might be associated with stump closure techniques. This study was carried out to determine rates of POPF after distal pancreatectomy and evaluate impact of two closure methods on development of POPF. Material and Methods: All patients who underwent elective open or laparoscopic distal pancreatectomy for malignant and benign pancreatic pathologies between 2011 and 2021 were retrospectively evaluated. Patients were grouped as Groups HS and ST. POPF was diagnosed and graded according to International Study Group of Pancreatic Fistula guidelines. Rates of biochemical leak and grades of POPF were primary outcome. Results: There were 44 patients (28 in Group HS and 16 in Group ST) with a mean age of 51.8±15.1 years. Groups were similar in demographic and clinical characteristics (p>0.05). There were 15 patients (53.6%) with a biochemical leak in Group HS. In Group ST, six patients (37.5%) developed biochemical leaks. There was no significant in difference between groups in terms of biochemical leak (p=0.305). No patient in Group ST developed a pancreatic fistula. There was only one case with Grade B POPF in Group HS. We did not detect a significant difference in terms of POPF between groups (p=0.999). Conclusion: Both techniques had no significant impact on biochemical leak and POPF rates in patients who underwent distal pancreatectomy. Both pancreatic stump closure approaches are equally safe and can be used with similar clinical efficacy.

Keywords

• Pancreatectomy
• pancreatic fistula
• suturing
• surgical staplers

References

1. Nagakawa Y, Hijikata Y, Osakabe H, Matsudo T, Soya R, Sahara Y, 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(2): e15-e19. https://doi.org/10.1097/SLE.0000000000000604.
2. Aoki T, Mansour DA, Koizumi T, Matsuda K, Kusano T, Wada Y, 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(1): 223. https://doi.org/10.1186/s12893-020-00876-8.
3. Matsumoto I, Takeyama Y, Kamei K, Satoi S, Nakata Y, Ishikawa H, et al. Transpancreatic mattress suture with vicryl mesh around the stump during distal pancreatectomy: a novel technique for preventing postoperative pancreatic fistula. J Am Coll Surg. 2016; 223(2): e1-5. https://doi.org/10.1016/j.jamcollsurg.2016.03.027.
4. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. International study group on pancreatic surgery (ISGPS). The 2016 update of the international study group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017; 161(3): 584-91. https://doi.org/10.1016/j.surg.2016.11.014.
5. Yoshida Y, Matsumoto I, Matsumoto M, Kawaguchi K, Murase T, Kamei K, et al. Transpancreatic mattress suture with Vicryl mesh around the stump decreases postoperative pancreatic fistula after distal pancreatectomy. J Hepatobiliary Pancreat Sci. 2019; 26(11): 510-6. https://doi.org/10.1002/jhbp.664.
6. Tieftrunk E, Demir IE, Schorn S, Sargut M, Scheufele F, Calavrezos L, et al. Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience. PLoS One. 2018; 13(6): e0197553. https://doi.org/10.1371/journal.pone.0197553.
7. Kondo N, Uemura K, Nakagawa N, Okada K, Kuroda S, Sudo T, et al. Hiroshima surgical study group of clinical oncology. a multicenter, randomized, controlled trial comparing reinforced staplers with bare staplers during distal pancreatectomy (HiSCO-07 Trial). Ann Surg Oncol. 2019; 26(5): 1519-27. https://doi.org/10.1245/s10434-019-07222-0.
8. Wang W, Qian H, Lin J, Weng Y, Zhang J, Wang J. Has the pancreatic fistula already occurred in the operation? An intraoperative predictive factor of clinical relevant-postoperative pancreatic fistula after the distal pancreatectomy. Surg Open Sci. 2019; 1(1): 38-42. https://doi.org/10.1016/j.sopen.2019.04.003.

9. Matsumoto I, Kamei K, Satoi S, Murase T, Matsumoto M, Kawaguchi K, 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. 2022; 52(2): 260-7. https://doi.org/10.1007/s00595-021-02344-z.
10. Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet. 2011; 377(9776): 1514-22. https://doi.org/10.1016/S0140-6736(11)60237-7.
11. Qu C, Yang YM. Manual suture or stapler closure: management of pancreatic stump during distal pancreatectomy. Zhonghua Wai Ke Za Zhi. 2020; 58(7): 494-8. https://doi.org/10.3760/cma.j.cn112139-20200410-00289.
12. Futagawa Y, Takano Y, Furukawa K, Kanehira M, Onda S, Sakamoto T, et al. Comparison of outcomes with hand-sewn versus stapler closure of pancreatic stump in distal pancreatectomy. Anticancer Res. 2017; 37(5): 2515-21. https://doi.org/10.21873/anticanres.11593.
13. Chikhladze S, Makowiec F, Küsters S, Riediger H, Sick O, Fichtner-Feigl S, Hopt UT, Wittel UA. 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(1): 227-33. https://doi.org/10.1016/j.asjsur.2019.03.009.
14. Pulvirenti A, Landoni L, Borin A, De Pastena M, Fontana M, Pea A, et al. Reinforced stapler versus ultrasonic dissector for pancreatic transection and stump closure for distal pancreatectomy: A propensity matched analysis. Surgery. 2019; 166(3): 271-6. https://doi.org/10.1016/j.surg.2019.02.016.
15. Miyamoto R, Sano N, Maeda M, Inagawa S, Ohkohchi N. Modified reinforced staple closure technique decreases postoperative pancreatic fistula after distal pancreatectomy. Indian J Surg Oncol. 2019; 10(4): 587-93. https://doi.org/10.1007/s13193-019-00958-x.
16. Watanabe N, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uesaka K. The impact of stump closure techniques on pancreatic fistula stratified by the thickness of the pancreas in distal pancreatectomy. Dig Surg. 2020; 37(4): 340-7. https://doi.org/10.1159/000505061.
17. Kang MK, Kim H, Byun Y, Han Y, Choi YJ, Kang JS, et al. Optimal stapler cartridge selection to reduce postoperative pancreatic fistula according to the pancreatic characteristics in stapler closure distal pancreatectomy. HPB (Oxford). 2021; 23(4): 633-40. https://doi.org/10.1016/j.hpb.2020.09.004.
18. Illuminati G, Cerasari S, Pasqua R, Nardi P, Fratini C, Frey S, Iannelli A, Marini P. Results of standard stapler closure of pancreatic remnant after distal spleno-pancreatectomy for adenocarcinoma. Front Surg. 2020; 7: 596580. https://doi.org/10.3389/fsurg.2020.596580.
19. Pueyo-Périz E, Téllez-Marquès C, Radosevic A, Morató O, Visa L, Ilzarbe L, et al. Radiofrequency-assisted transection of the pancreas vs stapler in distal pancreatectomy: a propensity score matched cohort analysis. Sci Rep. 2022; 12(1): 7486. https://doi.org/10.1038/s41598-022-11583-0.
20. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240(2): 205-13. https://doi.org/10.1097/01.sla.0000133083.54934.ae.
21. Wang W, Qian H, Lin J, Weng Y, Zhang J, Wang J. Has the pancreatic fistula already occurred in the operation? An intraoperative predictive factor of clinical relevant-postoperative pancreatic fistula after the distal pancreatectomy. Surg Open Sci. 2019; 1(1): 38-42. https://doi.org/10.1016/j.sopen.2019.04.003.
22. Zimmitti G, La Mendola R, Manzoni A, Sega V, Malerba V, Treppiedi E, 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(2): 941-54. https://doi.org/10.1007/s00464-020-07912-x.
23. Ozyazici S, Erdogan O. Risk factors of postoperative clinically relevant pancreatic fistula following distal pancreatectomy with stapler closure. J Coll Physicians Surg Pak. 2021; 31(10): 1214-8. https://doi.org/10.29271/jcpsp.2021.10.1214.
24. Kawabata Y, Nishi T, Tanaka T, Yano S, Tajima Y. Distal pancreatectomy utilizing a flexible stapler closure eliminates the risk of pancreas-related factors for postoperative pancreatic fistula. Eur Surg Res. 2013; 50(2): 71-9. https://doi.org/10.1159/000349977.
25. Goh BK, Tan YM, Chung YF, Cheow PC, Ong HS, Chan WH, et al. Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution. Arch Surg. 2008; 143(10): 956-65. https://doi.org/10.1001/archsurg.143.10.956.
26. Wennerblom J, Ateeb Z, Jönsson C, Björnsson B, Tingstedt B, Williamsson C, et al. Reinforced versus standard stapler transection on postoperative pancreatic fistula in distal pancreatectomy: multicentre randomized clinical trial. Br J Surg. 2021; 108(3): 265-70. https://doi.org/10.1093/bjs/znaa113.
27. Landoni L, De Pastena M, Fontana M, Malleo G, Esposito A, Casetti L, et al. A randomized controlled trial of stapled versus ultrasonic transection in distal pancreatectomy. Surg Endosc. 2022; 36(6): 4033-41. https://doi.org/10.1007/s00464-021-08724-3.
28. Jia B, Chen Q, Jiang P, Liu Y. An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. Surg Today. 2022; 1-8. https://doi.org/10.1007/s00595-022-02470-2.
29. Oweira H, Mazotta A, Mehrabi A, Reissfelder C, Rahbari N, Betzler A, et al. Using a reinforced stapler decreases the incidence of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis. World J Surg. 2022; 46(8): 1969-79. https://doi.org/10.1007/s00268-022-06572-3.
30. Goh BKP, Lee CY, Koh YX, Teo JY, Kam JH, Cheow PC, et al. 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(10): 1124-9. https://doi.org/10.1089/lap.2020.0754.
31. Miao Y, Lu Z, Yeo CJ, Vollmer CM Jr, Fernandez-Del Castillo C, Ghaneh P, et al. International Study Group of Pancreatic Surgery (ISGPS). Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2020; 168(1): 72-84. https://doi.org/10.1016/j.surg.2020.02.018.
32. Asbun HJ, Moekotte AL, Vissers FL, Kunzler F, Cipriani F, Alseidi A, et al. International Study Group on Minimally Invasive Pancreas Surgery (I-MIPS). The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection. Ann Surg. 2020; 271(1): 1-14. https://doi.org/10.1097/SLA.0000000000003590.