Optimal technical management of stump closure following distal pancreatectomy: A retrospective review of 215 cases

Background: Pancreatic fistula (PF) is a major source of morbidity following distal pancreatectomy (DP). Our aim was to identify risk factors related to PF following DP and to determine the impact of technique of transection and stump closure. Methods: We performed a retrospective review of 215 consecutive patients who underwent DP. Perioperative and postoperative data were collected and analyzed with attention to PF as defined by the International Study Group of Pancreatic Fistula. Results: PF developed in 36 patients (16.7%); fistulas were classified as Grade A (44.4%), B (44.4%), or C (11.1%). The pancreas was transected with stapler (n=139), cautery (n=70), and scalpel (n=3). PF developed in 19.8% of remnants which were stapled/oversewn and 27.7% that were stapled alone (p=0.4). Of the 69 pancreatic remnants transected with cautery and oversewn, a fistula developed in 4.3% (p=0.004 compared to stapled/oversewn; p=0.006 compared to stapled/not sewn). The median length of postoperative hospital stay was significantly increased in patients who developed PF (10 vs. 6 days, p=0.002)Conclusion: The method of transection and management of the pancreatic remnant plays a critical role in the formation of PF following DP. This series suggests that transection using electrocautery followed by oversewing of the pancreatic remnant has the lowest risk of PF.