Yi Miao1, Zipeng Lu2, Charles J Yeo3, Charles M Vollmer4, Carlos Fernandez-Del Castillo5, Paula Ghaneh6, Christopher M Halloran6, Jörg Kleeff7, Thijs de Rooij8, Jens Werner9, Massimo Falconi10, Helmut Friess11, Herbert J Zeh12, Jakob R Izbicki13, Jin He14, Johanna Laukkarinen15, Cees H Dejong16, Keith D Lillemoe5, Kevin Conlon17, Kyoichi Takaori18, Luca Gianotti19, Marc G Besselink8, Marco Del Chiaro20, Marco Montorsi21, Masao Tanaka22, Maximilian Bockhorn13, Mustapha Adham23, Attila Oláh24, Roberto Salvia25, Shailesh V Shrikhande26, Thilo Hackert27, Tooru Shimosegawa28, Amer H Zureikat29, Güralp O Ceyhan30, Yunpeng Peng2, Guangfu Wang2, Xumin Huang2, Christos Dervenis31, Claudio Bassi25, John P Neoptolemos27, Markus W Büchler27. 1. Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China. Electronic address: miaoyi@njmu.edu.cn. 2. Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China. 3. Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. 4. Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 5. Massachusetts General Hospital, Harvard Medical School, Boston, MA. 6. Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom. 7. Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany. 8. Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands. 9. Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany. 10. Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy. 11. Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany. 12. Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX. 13. Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 14. Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD. 15. Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland. 16. Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands. 17. Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. 18. Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan. 19. School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy. 20. Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. 21. Humanitas University and Research Hospital IRCCS, Milan, Italy. 22. Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan. 23. Department of Digestive & HPB Surgery, Hospital Edouard Herriot, HCL, UCBL1, Lyon, France. 24. The Petz Aladar Hospital, Gyor, Hungary. 25. Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy. 26. Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India. 27. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. 28. Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan. 29. Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA. 30. Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey. 31. Medical School, University of Cyprus, Nicosia, Cyprus.
Abstract
BACKGROUND: The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS: Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS: Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION: Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.
BACKGROUND: The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS: Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS: Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION: Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.
Authors: Giuseppe Zimmitti; Roberta La Mendola; Alberto Manzoni; Valentina Sega; Valentina Malerba; Elio Treppiedi; Claudio Codignola; Lorenzo Monfardini; Marco Garatti; Edoardo Rosso Journal: Surg Endosc Date: 2020-09-10 Impact factor: 4.584