Prevention value of four treatments of pancreatic stump for pancreatic fistula after distal pancreatectomy: a Meta-analysis / 中华消化外科杂志

ABSTRACT

Objective To systematically evaluate the clinical effects of four treatments of pancreatic stump including stapler closure,hand-sutured closure,stapler with hand-sutured closure,and manual anastomosis on the prevention of postoperative pancreatic fistula after distal pancreatectomy.Methods Databases including PubMed,Embase,the Cochrane Library,CBM,CNKI,and VANFUN were searched for from January 1979 to January 2019 with the key words including "distal pancreatectomy,left pancreatectomy,distal pancreatic resection,left pancreatic resection,pancreatic fistula,fistula,leak,stapler,suture,anastomosis,胰腺远端切除 术,胰体尾切除术,闭合器,手工缝合,吻合,胰瘘”.Patients undergoing dissection of distal pancreas with Endo-GIA stapler were allocated into stapler group,patients undergoing hand-sutured closure of pancreatic stump after dissection of distal prancreas with electrotome or ultrasonic scalpel were allocated into hand-sutured closure group,patients undergoing dissection of distal pancreas with Endo-GIA stapler and hand-sutured closure of pancreatic stump were allocated into stapler with hand-sutured closure group,patients undergoing pancreaticojejunostomy or pancreatogastrostomy after dissection of distal pancreas were allocated into manual anastomosis group,respectively.Two reviewers independently screened literatures,extracted data and assessed the risk of bias.Count data were described as odds ratio (OR) and 95％ confidence interval (95％ CI).The heterogeneity of the studies included was analyzed using the I2 test.Funnel plot was used to test potential publication bias if the studies included ≥ 5,and no test was needed if the studies included ＜5.Results (1) Document retrievala total of 10 available prospective studies were included.There were 1 363 patients,including 565 in the stapler group,484 in the hand-sutured closure group,182 in the stapler with hand-sutured closure group,and 132 in the manual anastomosis group.(2) Results of Meta-analysis.① There was no statistically significant difference in postoperative fistula after distal pancreatectomy between the stapler group and the handsutured closure group (OR =0.75,95％CI0.45-1.25,P＞0.05).Further study showed that there was no statistically significant difference in the incidence of grade B and C postoperative fistula between the two groups (OR=0.45,95％CI0.14-1.52,P＞0.05).The left-right asymmetry was presented in the funnel plot based on the 8 studies,suggesting that publication bias may exsited.② There was no statistically significant difference in postoperative fistula after distal pancreatectomy between the stapler group and the stapler with hand-sutured closure group (OR =0.96,95％ CI0.48-1.91,P ＞ 0.05).③ There was no statistically significant difference in postoperative fistula after distal pancreatectomy between the stapler with hand-sutured closure group and manual anastomosis group (OR =0.80,95％ CI0.49-1.32,P＞ 0.05).④ There was no statistically significant difference in postoperative fistula after distal pancreatectomy between the manual anastomosis group and the stapler group (OR=0.73,95％CI0.39-1.34,P＞0.05).Further study showed that there was no statistically significant difference in the incidence of grade B and C postoperative fistula between the two groups (OR =0.60,95％CI0.21-1.68,P＞0.05).The bilateral symmetry was presented in the funnel plot based on the 5 studies,suggesting that publication bias had little influence on results of Meta-analysis.⑤ There was no statistically significant difference in postoperative fistula after distal pancreatectomy between the manual anastomosis group and the handsutured closure group (OR=0.24,95％CI0.08-0.74,P＜0.05).The bilateral symmetry was presented in the funnel plot,suggesting that publication bias had little influence on results of Meta-analysis.Conclusions Compared with hand-sutured closure,pancreaticojejunostomy or pancreatogastrostomy after distal pancreatectomy can help to reduce the incidence of postoperative pancreatic fistula.However,there was equivalent prevention value of stapler,hand-sutured closure,and stapler with hand-sutured closure for postoperative fistula after distal pancreatectomy.The manual anastomosis group has equivalent prevention value with stapler group.