Further experience with pancreatic stump closure using a reinforced staple line.

BACKGROUND: We previously demonstrated that pancreatic transection with a reinforced staple line results in significantly lower fistula rates than when stapling without reinforcement. (J Gastrointest Surg. 2007;11:345-349). Criticism of this initial study focused on the small size of the treated group (N = 13). We report four more years of experience with this technique with a larger sample size. METHODS: This was a before-after trial. Patients included had distal pancreatectomies with stapled stump closure. The main intervention analyzed was staple-line reinforcement with Seamguard. The experimental group consisted of a consecutive series of stapled pancreatectomies with reinforcement performed from 2005 to 2010. The control group was a consecutive series of stapled pancreatectomies without reinforcement performed between 2003 and 2005 (previously published). The main outcome measure was pancreatic fistula. RESULTS: 54 patients were included; 36 in the experimental group and 18 in the control group. Mean age was 62; 50% were males. The most common diagnoses were adenocarcinoma (31%), cystic neoplasm (24%), and neuroendocrine tumor (22%). There were no mortalities. Postoperative pancreatic leak rate was 39% in the control group, and 8% in the experimental group (P = 0.01). Seven of ten patients with leak required additional drain placement. Development of pancreatic leak resulted in prolonged hospital stays (12 vs eight days, P < 0.007). CONCLUSION: We demonstrate sustained success of reinforced stapling for pancreatic stump closure. Our technique is straightforward and results in reduced morbidity and cost. Our results suggest that surgical drains may not be needed when this technique is applied.

Effect of early enteral tube feeding on patient outcome following pancreaticoduodenectomy.

OBJECTIVE: Morbidity after pancreaticoduodenectomy (PD) is nearly 50%. In this study we analyzed if early enteral nutrition via feeding tube (FT) contributes to better patient outcomes. MATERIALS AND METHODS: Patients undergoing PD from 2003-2010. FTs were placed routinely before August 2006, and omitted thereafter. Short-term outcome measures included: time to start of oral diet, need for total parenteral nutrition (TPN), morbidity and mortality, pancreatic fistula, complications from FT, hospital length of stay, and disposition. Long-term outcome measures included time to start adjuvant therapy, and survival. RESULTS: N = 59 (25 had FT, 34 did not). Adenocarcinoma was found in 88%. Early institution of tube feeding had no positive impact on any of the outcome measures. There were three FT-related complications. CONCLUSIONS: Our results demonstrate that FT placement does not improve short-term or long-term outcomes after PD. Moreover, major complications can result from FT placement. We do not advocate the routine use of FT after PD.

Staple line reinforcement reduces postoperative pancreatic stump leak after distal pancreatectomy.

Pancreatic stump leak is the major source of morbidity after stapled distal pancreatectomy. We hypothesized that reinforcement of the stapler system with a buttress mat can improve leak rates when compared to standard stapling alone. We performed 13 consecutive distal pancreatectomies using our reinforced stapler system, forming our experimental group. A historical control group was composed of 18 patients undergoing stapled pancreatic closure without reinforcement. The main outcome measure was pancreatic leak in the postoperative period. Pancreatic leaks included fistulas and fluid collections (sterile or infected). Hospital length of stay was recorded as a secondary measure. Postoperative pancreatic leak rate was zero in the experimental group, but 39% in the control group (P = 0.025). Development of a pancreatic leak resulted in prolonged hospital stays: 13.6 vs 8.3 days (P < 0.03). We conclude that staple line reinforcement is a simple and effective method of reducing pancreatic stump leakage after distal pancreatectomy. The economic impact of lower leak rates is reflected in significantly shorter hospital stays. The results of our study should be validated in a randomized controlled trial.