Impact of Pancreatic Gland Volume on Fistula Formation After Pancreatic Tail Resection

Farshad Frozanpor; Nils Albiin; Stefan Linder; Ralf Segersvärd; Lars Lundell; Urban Arnelo

doi:10.6092/1590-8577/3430

Farshad Frozanpor Division of Surgery, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset. Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet/Karolinska University Hospital. Stockholm, Sweden
Nils Albiin Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet/Karolinska University Hospital. Stockholm, Sweden
Stefan Linder Division of Surgery, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset. Stockholm, Sweden
Ralf Segersvärd Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet/Karolinska University Hospital. Stockholm, Sweden
Lars Lundell Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet/Karolinska University Hospital. Stockholm, Sweden
Urban Arnelo Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet/Karolinska University Hospital. Stockholm, Sweden

DOI: https://doi.org/10.6092/1590-8577/3430

Keywords: Pancreatectomy, Pancreatic Fistula, Surgical Stapling

Abstract

Context Resection of the body and tail of the pancreas (distal pancreatectomy) is associated with high postoperative morbidity, most of which is due to leakage from the pancreatic transection surface. Objective The aim of the current study was to analyze factors which may affect the risk of pancreatic fistula formation. Patients All consecutive distal pancreatectomies prospectively registered in our hospital database from 1999 to 2007 were included. Clinically relevant pancreatic fistula grades B and C, defined according to the International Study Group on Pancreatic Fistula (ISGPF) definition were assessed. Main outcome measures The impact of patient, tumor, surgery, and radiology-related factors on the risk of pancreatic fistula formation were assessed by univariate and multivariate analyses. Results A distal pancreatectomy was performed in 51 patients (median age: 59 years; range: 26-76 years), 22 of whom had malignant and 29 benign or premalignant disease. Pancreatic fistulas were diagnosed in 17 (33.3%) of the patients. An additional three patients had a local abscess without apparent but assumed pancreatic leakage. Multivariate analysis showed that pancreatic fistulas occurred more frequently after hand suturing of the transection area versus the use of a stapler (69.2% vs. 21.1%; OR: 40.4, 95% CI: 3.36-486; P=0.004) and a large volume of the pancreatic remnant (greater, or equal to, 34 cm³) increased the subsequent risk of pancreatic fistula (57.1% vs. 20.8%; OR: 6.14, 95% CI: 1.14-39.0; P=0.035). Conclusions Development of pancreatic fistula after distal pancreatectomy remains a challenge. The volume of the remaining pancreas and the technique of closure of the transected pancreas were found to affect this risk, thus allowing future preventive measures to be explored and evaluated in clinical trials.

Image: 3D volume rendering image of the pancreas with the remaining pancreas shown in blue.

Downloads

Download data is not yet available.

References

Fahy BN, Frey CF, Ho HS, Beckett L, Bold RJ. Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg 2002; 183:237-41. [PMID 11943118]

Cullen JJ, Sarr MG, Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. Am J Surg 1994; 168:295-8. [PMID 7524375]

Yang YM, Tian XD, Zhuang Y, Wang WM, Wan YL, Huang YT. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol 2005; 11:2456-61. [PMID 15832417]

Mathur A, Pitt HA, Marine M, Saxena R, Schmidt CM, Howard TJ, et al. Fatty pancreas: a factor in postoperative pancreatic fistula. Ann Surg 2007; 246:1058-64. [PMID 18043111]

Knaebel HP, Diener MK, Wente MN, Buchler MW, Seiler CM. Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 2005; 92:539-46. [PMID 15852419]

Adams DB. The pancreatic anastomosis: the danger of a leak, which anastomotic technique is better? J Gastrointest Surg 2009; 13:1182-3. [PMID 19333663]

Andren-Sandberg A, Wagner M, Tihanyi T, Lofgren P, Friess H. Technical aspects of left-sided pancreatic resection for cancer. Dig Surg 1999; 16:305-12. [PMID 10449975]

Adam U, Makowiec F, Riediger H, Trzeczak S, Benz S, Hopt UT. Distal pancreatic resection: indications, techniques and complications. Zentralbl Chir 2001; 126:908-12. [PMID 11753802]

Cogbill TH, Moore EE, Morris JA Jr, Hoyt DB, Jurkovich GJ, Mucha P Jr, et al. Distal pancreatectomy for trauma: a multicenter experience. J Trauma 1991; 31:1600-6. [PMID 1749029]

Kleeff J, Diener MK, Z'graggen K, Hinz U, Wagner M, Bachmann J, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 2007; 245:573-82. [PMID 17414606]

Lillemoe KD, Kaushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ. Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg 1999; 229:693-8. [PMID 10235528]

Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001; 136:391-8. [PMID 11296108]

Fernandez-del Castillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990s. Arch Surg 1995; 130:295-9. [PMID 7887797]

Büchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z'graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003; 138:1310-4. [PMID 14662530]

Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346:1128-37. [PMID 11948273]

Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg 2006; 244:10-5. [PMID 16794383]

Hines OJ, Reber HA. Pancreatic surgery. Curr Opin Gastroenterol 2005; 21:568-72.

Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg 2009; 249:635-40. [PMID 19300225]

Balzano G, Zerbi A, Cristallo M, Di Carlo V. The unsolved problem of fistula after left pancreatectomy: the benefit of cautious drain management. J Gastrointest Surg 2005; 9:837-42. [PMID 15985241]

Nathan H, Cameron JL, Goodwin CR, Seth AK, Edil BH, Wolfgang CL, et al. Risk factors for pancreatic leak after distal pancreatectomy. Ann Surg 2009; 250:277-81. [PMID 19638926]

Ridolfini MP, Alfieri S, Gourgiotis S, Di Miceli D, Rotondi F, Quero G, et al. Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial? World J Gastroenterol 2007; 13:5096-100. [PMID 17876875]

Ferrone CR, Warshaw AL, Rattner DW, Berger D, Zheng H, Rawal B, et al. Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg 2008; 12:1691-7. [PMID 18704597]

Kajiyama Y, Tsurumaru M, Udagawa H, Tsutsumi K, Kinoshita Y, Akiyama H. Quick and simple distal pancreatectomy using the GIA stapler: report of 35 cases. Br J Surg 1996; 83:1711. [PMID 9038547]

Olah A, Issekutz A, Belagyi T, Hajdu N, Romics L Jr. Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy. Br J Surg 2009; 96:602-7. [PMID 19434697]

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; 90:190-6. [PMID 12555295]

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; 141:1071-6. [PMID 17116799]

Wagner M, Gloor B, Ambühl M, Worni M, Lutz JA, Angst E, Candinas D. Roux-en-Y drainage of the pancreatic stump decreases pancreatic fistula after distal pancreatic resection. J Gastrointest Surg 2007; 11:303-8. [PMID 17458602]

Okabayashi T, Kobayashi M, Sugimoto T, Namikawa T, Okamoto K, Hokimoto N, Araki K. Postoperative pancreatic fistula following distal pancreatectomy for pancreatic neoplasm; can pancreatic fistula be prevented? Hepatogastroenterology 2004; 51:1838-41. [PMID 15532838]

Ohwada S, Ogawa T, Tanahashi Y, Nakamura S, Takeyoshi I, Ohya T, et al. Fibrin glue sandwich prevents pancreatic fistula following distal pancreatectomy. World J Surg 1998; 22:494-8. [PMID 9564295]

Velanovich V. The use of tissue sealant to prevent fistula formation after laparoscopic distal pancreatectomy. Surg Endosc 2007; 21:1222. [PMID 17484008]

Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138:8-13. [PMID 16003309]

Dinter DJ, Aramin N, Weiss C, Singer C, Weisser G, Schoenberg SO, et al. Prediction of anastomotic leakage after pancreatic head resections by dynamic magnetic resonance imaging (dMRI). J Gastrointest Surg 2009; 13:735-44. [PMID 19057965]

Sheehan MK, Beck K, Creech S, Pickleman J, Aranha GV. Distal pancreatectomy: does the method of closure influence fistula formation? Am Surg 2002; 68:264-7. [PMID 11893105]

Mabrut JY, Fernandez-Cruz L, Azagra JS, et al. Laparoscopic pancreatic resection: results of a multicenter European study of 127 patients. Surgery 2005; 137:597-605. [PMID 15962401]

Kooby DA, Gillespie T, Bentrem D, Nakeeb A, Schmidt MC, Merchant NB, et al. Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 2008; 248:438-46. [PMID 18791364]

Taylor C, O'Rourke N, Nathanson L, Martin I, Hopkins G, Layani L, et al. Laparoscopic distal pancreatectomy: the Brisbane experience of forty-six cases. HPB (Oxford) 2008; 10:38-42. [PMID 18695757]

Borja-Cacho D, Al-Refaie WB, Vickers SM, Tuttle TM, Jensen EH. Laparoscopic distal pancreatectomy. J Am Coll Surg 2009; 209:758-65. [PMID 19959046]

Fischer CP, Bass B, Fahy B, Aloia T. Transampullary pancreatic duct stenting decreases pancreatic fistula rate following left pancreatectomy. Hepatogastroenterology 2008; 55:244-8. [PMID 18507117]