Despite recent improvements in surgical technique, the morbidity of distal pancreatectomy remains high, with pancreatic fistula being the most significant postoperative complication. A systematic review of randomized controlled trials (RCTs) dealing with surgical techniques in distal pancreatectomy was carried out to summarize up-to-date knowledge on this topic. The Cochrane Central Registry of Controlled Trials, Embase, Web of Science, and Pubmed were searched for relevant articles published from 1990 to December 2013. Ten RCTs were identified and included in the systematic review, with a total of 1286 patients being randomized (samples ranging from 41 to 450). The reviewers were in agreement for application of the eligibility criteria for study selection. It was not possible to carry out meta-analysis of these studies because of the heterogeneity of surgical techniques and approaches, such as varying methods of pancreas transection, reinforcement of the stump with seromuscular patch or pancreaticoenteric anastomosis, sealing with fibrin sealants and pancreatic stent placement. Management of the pancreatic remnant after distal pancreatectomy is still a matter of debate. The results of this systematic review are possibly biased by methodological problems in some of the included studies. New well designed and carefully conducted RCTs must be performed to establish the optimal strategy for pancreatic remnant management after distal pancreatectomy.

Department of Surgery Faculty of Medicine and University Hospital Hradec Králové Sokolská 581 500 05 Hradec Králové Czech Republic

Department of Surgery Faculty of Medicine and University Hospital Hradec Králové Sokolská 581 500 05 Hradec Králové Czech Republic ; Department of Field Surgery Military Health Science Faculty Hradec Králové Defence University Brno Třebešská 1575 500 01 Hradec Králové Czech Republic

Zobrazit více v PubMed

Büchler MW, Wagner M, Schmied BM, et al. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Archives of Surgery. 2003;138(12):1310–1314. PubMed

DeOliveira ML, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Annals of Surgery. 2006;244(6):931–937. PubMed PMC

Ferrone CR, Warshaw AL, Rattner DW, et al. Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. Journal of Gastrointestinal Surgery. 2008;12(10):1691–1697. PubMed PMC

Nathan H, Cameron JL, Goodwin CR, et al. Risk factors for pancreatic leak after distal pancreatectomy. Annals of Surgery. 2009;250(2):277–281. PubMed

Pratt W, Maithel SK, Vanounou T, Callery MP, Vollmer CM., Jr. Postoperative pancreatic fistulas are not equivalent after proximal, distal, and central pancreatectomy. Journal of Gastrointestinal Surgery. 2006;10(9):1264–1279. PubMed

Reeh M, Nentwich MF, Bogoevski D, et al. High surgical morbidity following distal pancreatectomy: still an unsolved problem. World Journal of Surgery. 2011;35(5):1110–1117. PubMed

Callery MP, Pratt WB, Vollmer CM., Jr. Prevention and management of pancreatic fistula. Journal of Gastrointestinal Surgery. 2009;13(1):163–173. PubMed

Čečka F, Jon B, Šubrt Z, Ferko A. Clinical and economic consequences of pancreatic fistula after elective pancreatic resection. Hepatobiliary & Pancreatic Diseases International. 2013;12(5):533–539. PubMed

Balcom JH, IV, 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. Archives of Surgery. 2001;136(4):391–398. PubMed

Sauvanet A, Partensky C, Sastre B, et al. Medial pancreatectomy: a multi-institutional retrospective study of 53 patients by the French Pancreas Club. Surgery. 2002;132(5):836–843. PubMed

Seth TN. The activation of pancreatic juice by enterokinase. Biochemical Journal. 1924;18(6):1401–1416. PubMed PMC

Čečka F, Jon B, Šubrt Z, Ferko A. The effect of somatostatin and its analogs in the prevention of pancreatic fistula after elective pancreatic surgery. European Surgery: Acta Chirurgica Austriaca. 2012;44(2):99–108.

Jon B, Čečka F, Šubrt Z, et al. A novel approach for reinforcing the pancreatic remnant in laparoscopic distal pancreatectomy: an experimental study on a porcine model. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2010;20(2):e50–e53. PubMed

Harris LJ, Abdollahi H, Newhook T, et al. Optimal technical management of stump closure following distal pancreatectomy: a retrospective review of 215 cases. Journal of Gastrointestinal Surgery. 2010;14(6):998–1005. PubMed

Kleeff J, Diener MK, Z’graggen K, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Annals of Surgery. 2007;245(4):573–582. PubMed PMC

Sheehan MK, Beck K, Creech S, Pickleman J, Aranha GV. Distal pancreatectomy: does the method of closure influence fistula formation? American Surgeon. 2002;68(3):264–267. PubMed

Fahy BN, Frey CF, Ho HS, Beckett L, Bold RJ. Morbidity, mortality, and technical factors of distal pancreatectomy. American Journal of Surgery. 2002;183(3):237–241. PubMed

Okano K, Kakinoki K, Yachida S, Izuishi K, Wakabayashi H, Suzuki Y. A simple and safe pancreas transection using a stapling device for a distal pancreatectomy. Journal of Hepato-Biliary-Pancreatic Surgery. 2008;15(4):353–358. PubMed

Takeuchi K, Tsuzuki Y, Ando T, et al. Distal pancreatectomy: is staple closure beneficial? ANZ Journal of Surgery. 2003;73(11):922–925. PubMed

Iannitti DA, Coburn NG, Somberg J, Ryder BA, Monchik J, Cioffi WG. Use of the round ligament of the liver to decrease pancreatic fistulas: a novel technique. Journal of the American College of Surgeons. 2006;203(6):857–864. PubMed

Carter TI, Fong ZV, Hyslop T, et al. A dual-institution randomized controlled trial of remnant closure after distal pancreatectomy: does the addition of a falciform patch and fibrin glue improve outcomes? Journal of Gastrointestinal Surgery. 2013;17(1):102–109. PubMed

Abe N, Sugiyama M, Suzuki Y, et al. Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic fistula development after distal pancreatectomy. American Journal of Surgery. 2006;191(2):198–200. PubMed

Rieder B, Krampulz D, Adolf J, Pfeiffer A. Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy. Gastrointestinal Endoscopy. 2010;72(3):536–542. PubMed

Frozanpor F, Lundell L, Segersvärd R, Arnelo U. The effect of prophylactic Transpapillary pancreatic stent insertion on clinically significant leak rate following distal pancreatectomy: results of a prospective controlled clinical trial. Annals of Surgery. 2012;255(6):1032–1036. PubMed

Farrokhyar F, Karanicolas PJ, Thoma A, et al. Randomized controlled trials of surgical interventions. Annals of Surgery. 2010;251(3):409–416. PubMed

Mahid SS, Hornung CA, Minor KS, Turina M, Galandiuk S. Systematic reviews and meta-analysis for the surgeon scientist. British Journal of Surgery. 2006;93(11):1315–1324. PubMed

Diener MK, Seiler CM, Rossion I, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. The Lancet. 2011;377(9776):1514–1522. PubMed

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. British Journal of Surgery. 2005;92(5):539–546. PubMed

Zhou W, Lv R, Wang X, Mou Y, Cai X, Herr I. Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis. American Journal of Surgery. 2010;200(4):529–536. PubMed

Makino I, Kitagawa H, Nakagawara H, et al. The management of a remnant pancreatic stump for preventing the development of postoperative pancreatic fistulas after distal pancreatectomy: current evidence and our strategy. Surgery Today. 2013;43(6):595–602. PubMed

Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection: the importance of definitions. Digestive Surgery. 2004;21(1):54–59. PubMed

Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13. PubMed

Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. The Cochrane Collaboration; March 2011. www.cochrane-handbook.org.

Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Medicine. 2009;6(7)e1000100 PubMed PMC

Suzuki Y, Kuroda Y, Morita A, et al. Fibrin glue sealing for the prevention of pancreatic fistulas following distal pancreatectomy. Archives of Surgery. 1995;130(9):952–955. PubMed

Suzuki Y, Fujino Y, Tanioka Y, et al. Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas. British Journal of Surgery. 1999;86(5):608–611. PubMed

Bassi C, Butturini G, Falconi M, Salvia R, Sartori N, Caldiron E. Prospective randomised pilot study of management of the pancreatic stump following distal resection. HPB. 1999;1:203–207.

Suc B, Msika S, Fingerhut A, et al. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Annals of Surgery. 2003;237(1):57–65. PubMed PMC

Oláh A, Issekutz Á, Belágyi T, Hajdú N, Romics L., Jr. Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy. British Journal of Surgery. 2009;96(6):602–607. PubMed

Hamilton NA, Porembka MR, Johnston FM, et al. Mesh reinforcement of pancreatic transection decreases incidence of pancreatic occlusion failure for left pancreatectomy: a single-blinded, randomized controlled trial. Annals of Surgery. 2012;255(6):1037–1042. PubMed PMC

Montorsi M, Zerbi A, Bassi C, Capussotti L, Coppola R, Sacchi M. Efficacy of an absorbable fibrin sealant patch (TachoSil) after distal pancreatectomy: a multicenter, randomized, controlled trial. Annals of Surgery. 2012;256(5):853–860. PubMed

Frozanpor F. Reply to letter: ‘The effect of prophylactic transpapillary pancreatic stent insertion on clinically significant leak rate following distal pancreatectomy: results of a prospective controlled clinical trial’. Annals of Surgery. 2014 PubMed

Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM., Jr. Clinical and economic validation of the international study group of pancreatic fistula (ISGPF) classification scheme. Annals of Surgery. 2007;245(3):443–451. PubMed PMC

Hassenpflug M, Bruckner T, Knebel P, Diener MK, Buchler MW, Werner J. DISCOVER trial- Distal resection of the pancreas with or without coverage of the pancreatic remnant: study protocol of a randomised controlled trial. Trials. 2013;14, article 430 PubMed PMC

Impact of postoperative complications on clinical and economic consequences in pancreatic surgery

Intra-abdominal drainage following pancreatic resection: A systematic review

DRAPA trial--closed-suction drains versus closed gravity drains in pancreatic surgery: study protocol for a randomized controlled trial