Anonymous User
Login / Registration

a hepatologie

Gastroenterology and Hepatology

Gastroent Hepatol 2022; 76(3): 212–217. doi: 10.48095/ccgh2022212.

Prevention of pancreatic fistula in laparoscopic left-sided pancreatectomies

Petr Moravčík1, Zdeněk Kala1, Jan Hlavsa  1, Vladimír Procházka1, Tomáš Pavlík2, Lumír Kunovský1

+ Affiliation


Introduction: Postoperative pancreatic fistula (POPF) is one of the most serious complications in pancreatobiliary surgery. The management of clinically relevant grade B and C fistulas requires interventional management or reoperation. POPF is accompanied with high mortality rate. Prevention of fistula formation is a possible solution of the problem. Methods: A retrospective observational study of patients with pathology of pancreatic body or tail, who underwent laparoscopic distal pancreatectomy or splenopancreatectomy (LDP) a tour instution between 2016 and 2021. From 2020, a set of perioperative precautions to reduce POPF has been standardised. Primary objective was to determine the total number of POPFs, the number of POPF-associated bleeds, and POPF-associated mortality in the 2016–2021 cohort. Secondary objective was to compare the outcomes of the group of patients with standardised preventive measures operated on in 2020–2021 with the group of patients without standardised measures operated on in 2016–2019. Results: In 2016–2021, we performed a total of 67 laparoscopic distal pancreatectomies. Of these, 10 patients (14.9%) had clinically relevant POPF (CR-POPF) grade B or C and we observed bio­chemical leakage in 22 cases (32.8%). There was no POPF associated bleeding or POPF associated mortality. In the 2020–2021 group of 20 patients treated with the standardised precautions, we observed no CR-POPF, and bio­chemical leakage occurred in 7 patients (35%). In contrast, in the group of patients without any standardisation of treatment (47 patients), operated on in 2016–2019, CR-POPF occurred in 10 patients (21.3%) and bio­chemical leakage in 15 patients (31.9%). Conclusion: The results of our entire cohort of patients confirm high numbers of POPFs after LDP. The results of the subgroup of patients with standardised perioperative procedures aimed at reducing POPFs showed a significant reduction in CR-POPFs, suggesting good rates of efficacy of the preventive measures introduced.


postoperative complications, surgery, pancreas, pancreatic fistula, distal pancreatectomy

To read this article in full, please register for free on this website.

Benefits for subscribers

Benefits for logged users


1. Plotkin A, Ceppa EP, Zarzaur BL et al. Reduced morbidity with minimally invasive distal pancreatectomy for pancreatic adenocarcinoma. HPB 2017; 19 (3): 279–285. doi: 10.1016/j.hpb.2017.01.014.

2. Yoshida Y, Matsumoto I, Matsumoto M et al. Transpancreatic mattress suture wit Vicryl mesh around th stupm decreases postopertive pan­creatic fistula after distal pancreatectomy. J Hepatobiliary Pancreat Sci 2019; 26 (11): 510–516. doi: 10.1002/jhbp.664.

3. Chee M, Lee CY, Lee SY et al. Short- and long-term outcomes after minimally invasive versus open spleen-saving distal pancreatectomies. J Min Access Surg 2022; 18 (1): 118–124. doi: 10.4103/jmas.JMAS_178_20.

4. Sugimoto M, Gotohda N, Kato Y et al. Risk factor analysis and prevention of postoperative pancreatic fistula after distal pancreatectomy with stapler use. J Hepatobiliary Pancreat Sci 2013; 20 (5): 538–544. doi: 10.1007/s00534-013-0596-0.

5. Bassi C, Marchegiani G, Dervenis C et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017; 161 (3): 584–591. doi: 10.1016/j.surg. 2016.11.014.

6. Yekebas EF, Wolfram L, Cataldegirmen G et al. Postpancreatectomy hemorrhage: dia­gnosis and treatment – an analysis in 1669 consecutive pancreatic resections. Ann Surg 2007; 246 (2): 269– –280. doi: 10.1097/01.sla.0000262953.77735.db.

7. Wente MN, Veit JA, Bassi C et al. Postpan­createctomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition. Surgery 2007; 142 (1): 20–25. doi: 10.1016/j.surg.2007.02.001.

8. Chikladze S, Makowiec F, Kusters S et al. 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): 227–233. doi: 10.1016/j.asjsur.2019.03.009.

9. Diener MK, Seiler CM, Rossion I et al. Effectiveness of stapler versus handsewn closure after distal pancreactomy (DISPACT trial): a randomized, controlled multicenter trial. Lancet 2011; 377 (9776): 1514–1522. doi: 10.1016/ S0140-6736 (11) 60237-7.

10. Ferrone CR, Warshaw AL, Rattner DW et al. Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg 2008; 12 (10): 1691–1697. doi: 10.1007/s11605-008-0636-2.

11. Hackert T, Büchler MW. Remnant closure after distal pancreatectomy: current state and future perspectives. Surgeon 2012; 10 (2): 95–101. doi: 10.1016/j.surge.2011.10.003.

12. Cunha AS, Carrere N, Meunier B et al. Stump closure reinforcement with absorbable fibrin collagen sealant sponge (TachoSil) does not prevent pancreatic fistula after distal pancreatectomy: the FIABLE multicenter control­led randomized study. Am J Surg 2015; 210 (4): 739–748. doi: 10.1016/j.amjsurg.2015.04.015.

13. Ecker BL, McMillan MT, Allegrini V et al. Risk factors and mitigation strategies for pancreatic fistula after distal pancreatectomy: analysis of 2026 resections from the International, Multi-institutional Distal Pancreatectomy Study Group. Ann Surg 2019; 269 (1): 143–149. doi: 10.1097/SLA.0000000000002491.

14. Ban D, Shimada K, Konishi M et al. Stapler and nonstapler closure of the pancreatic remnant after distal pancreatectomy: multicenter retrospective analysis of 388 patients. World J Surg 2012; 36 (8): 1866–1873. doi: 10.1007/s00268-012-1595-z.

15. Asbun HJ, Van Hilst J, Tsamalaidze L et al. Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement. Surg Endosc 2020; 34 (1): 231–239. doi: 10.1007/s00464-019-06757-3.

16. Nakamura M, Ueda J, Kohno H et al. Prolonged peri-fring compression with a linear stapler prevents pancreatic fstula in laparoscopic distal pancreatectomy. Surg Endosc 2011; 25 (3): 867–871. doi: 10.1007/s00464-010-1285-6.

17. Ariyarathenam AV, Bunting D, Aroori S et al. Laparoscopic distal pancreatectomy using the modifed prolonged prefring compression technique reduces pancreatic fistula. J Laparoendosc Adv Surg Tech A 2015; 25 (10): 821–825. doi: 10.1089/lap.2015.0200.

18. Matsumoto I, Kamei K, Satoi S 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): 260–267. doi: 10.1007/s00595-021-02344-z.

19. Sugimoto M, Kendrick ML, Farnell MB et al. Realtionshio between pancretic thisckness and staple height is relevant to the occurrence od pancreatic fistula after distal pancreatectomy. HPB 2020; 22 (3): 398–404. doi: 10.1016/ j.hpb.2019.07.010.

20. Sepesi B, Moalem J, Galka E et al. The influence of staple size on fistula formation following distal pancreatectomy. J Gastrointest Surg 2012; 16 (2): 267–274. doi: 10.1007/s11605-011-1715-3.

21. Nishikawa M, Yamamoto J, Hoshikawa M et al. Stapler sizes optimized for pancreatic thickness can reduce pancreatic fistula incidence after distal pancreatectomy. Surg Today 2020; 50 (6): 623–631. doi: 10.1007/s00595-019-01929-z.

22. Hamilton NA, Porembka MR, Johnston FM et al. Mesh reinforcement of pancreatic transection decreased incidence of pancreatic occlusion failure for left pancreatectomy: a single-blinded, randomized controlled trial. Ann Surg 2012; 255 (6): 1037–1042. doi: 10.1097/SLA.0b013e31825659ef.

23. Kondo N, Uemura K, Nakagawa N et al. A multicenter, randomized, controlled trial comparing reinforced staplers with bare staplers during distal pancreatectomy (HiSCO-07) trial. Ann Surg Oncol 2019; 26 (5): 1519–1527. doi: 10.1245/s10434-019-07222-0.

24. Ratnayake CB, Wells C, Hammond J et al. Net­work meta-analysis comparing techniques and outcomes of stump closure after distal pancreatectomy. Br J Surg 2019; 106 (12): 1580–1589. doi: 10.1002/bjs.11291.

25. Hassenpflug M, Hinz U, Strobel O et al. Teres ligament patch reduces relevant morbidity after distal pancreatectomy (the DISCOVER Randomized Controlled Trial). Ann Surg 2016; 264 (5): 723–730. doi: 10.1097/SLA.0000000000001913.

26. Jang JY, Shin YC, Han Y et al. Effect of polyglycolic acid mesh for prevention of pancreatic fistula following distal pancreatectomy: a randomized clinical trial. JAMA Surg 2017; 152 (2): 150–155. doi: 10.1001/jamasurg.2016.3644.

27. Meniconi RL, Caronna R, Borreca D et al. Pan­crea­to-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis. BMC Surg 2013; 13: 23. doi: 10.1186/1471-2482-13-23.

28. Uemura K, Satoi S, Motoi F et al. Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy of pancreatic stump versus hand-sewn closure after distal pancreatectomy. Br J Surg 2017; 104 (5): 536–543. doi: 10.1002/bjs.10458.

29. Adamenko O, Ferrari C, Schmidt J. Irrigation and passive drainage of pancreatic stump after distal pancreatectomy in high-risk patients: an innovative approach to reduce pancreatic fistula. Langenbecks Arch Surg 2020; 405 (8): 1233–1241. doi: 10.1007/s00423-020-02012-9.

30. Kone LB, Maker VK, Banulescu M et al. Should drains suck? A propensity score analysis of closed-suction versus closed-gravity drainage after pancreatectomy. J Gastrointest Surg 2021; 25 (5): 1224–1232. doi: 10.1007/s11605-020-04613-7.

31. Veziant J, Selvy M, Buc E et al. Evidence-based evaluation of abdominal drainage in pancreatic surgery. J Visc Surg 2021; 158 (3): 220–230. doi: 10.1016/j.jviscsurg.2020.11.001.

32. Schorn S, Vogel T, Demir E et al. Do somatostatin-analogues have the same impact on postoperative morbidity and pancreatic fistula in patients after pancreaticoduodenectomy and distal pancreatectomy? A systematic review with meta-analysis of randomized-controlled trials. Pancreatology 2020; 20 (8): 1770–1778. doi: 10.1016/j.pan.2020.10.043.

33. Fischer CP, Bass B, Fahy B et al. Transampullary pancreatic duct stenting decreases pancreatic fistula rate following left pancreatectomy. Hepatogastroenterology 2008; 55 (81): 244–248.

34. Rieder B, Krampulz D, Adolf J et al. Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy. Gastrointest Endosc 2010; 72 (3): 536–542. doi: 10.1016/j.gie.2010.04.011.

35. Wu X, Li M, Wu W et al. The role of prophylactic transpapillary pancreatic stenting in distal pan­createctomy: a meta-analysis. Front Med 2013; 7 (4): 499–505. doi: 10.1007/s11684-013-0296-9.

36. Klaiber U, Sauer P, Martin E et al. Protocol of a randomised controlled phase II clinical trial investigating PREoperative endoscopic injection of BOTulinum toxin into the sphincter of Oddi to reduce postoperative pancreatic fistula after distal pancreatectomy: the PREBOT pilot trial. BMJ Open 2020; 10 (9): e036815. doi: 10.1136/bmjopen-2020-036815.

Credited self-teaching test