Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases

Abstract

Objective: The objective of this study was to identify potential risk factors for mortality and morbidity after distal pancreatectomy, with special focus on the formation of pancreatic fistula.

Summary background data: Distal pancreatectomy can be performed with low mortality and acceptable morbidity rates. Pancreatic fistulas, occurring in 10% to 20% of cases, remain a problem that contributes significantly to morbidity, length of stay, and overall costs.

Methods: From November 1993 to February 2006, perioperative and postoperative data of 302 consecutive patients were recorded. Univariate and multivariate analyses of potential risk factors for morbidity and for the formation of pancreatic fistula were performed. The surgical techniques used for closure were categorized into 4 groups: 1) anastomosis, 2) seromuscular patch, 3) closure by suture, and 4) closure using a stapling device.

Results: Indications for resection were pancreatic tumors in 62% of patients, nonpancreatic tumors in 23%, chronic pancreatitis in 12%, and others in 3%. The spleen was preserved in 24% of patients. The morbidity and mortality rates for distal pancreatectomy in this series were 35% and 2%, respectively. The prevalence of pancreatic fistula was 12%. Univariate and multivariate analyses indicated that closure using a stapling device and an operating time >or=480 minutes were associated with a higher incidence of pancreatic fistula (odds ratio = 2.6 and 4.2, respectively). Overall morbidity was mainly influenced by the extent of resection (multivisceral vs. conventional; odds ratio = 1.7).

Conclusion: Pancreatic leak remains a common complication after distal pancreatectomy. Our series suggests that stapler closure of the pancreatic remnant is associated with a significantly higher fistula rate.

Figures

FIGURE 1. Stapler dissection of the pancreas. Example of a stapler dissection of the pancreas during distal pancreatectomy. The pancreas is looped (white vessel loop, A). B–D, Dissection of the pancreas on the left lateral side of the superior mesenteric vein/portal vein axis using 2 cartridges of an ETS Flex 45 cutter, as described in Methods. SV, splenic vein; SCN, serous cystic neoplasm.

FIGURE 2. Different techniques for closure of the pancreatic remnant. A, Closure of the pancreatic remnant using single stitches of 5-0 PDS. B, Closure of the pancreatic remnant using an ETS Flex 45 cutter with a white vascular cartridge. Note the double row of closely placed staples (arrows and inset). C, Covering of the pancreatic remnant (in this case, following stapler closure) by laying a fibrinogen/thrombin-coated collagen patch (TachoSil) onto the transected end. SMV, superior mesenteric vein; SV, splenic vein.