Department of Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA.
J Gastrointest Surg. 2012 Feb;16(2):267-74. doi: 10.1007/s11605-011-1715-3. Epub 2011 Oct 21.
Pancreatic fistula continues to be a source of significant morbidity following distal pancreatic resections. The technique of pancreatic division varies widely among surgeons, and there is no evidence that identifies a single method as superior. In our practice, the technique of distal pancreatic resection has evolved from cut-and-sew to stapled technique with green and recently white cartridge. The aim of our study was to evaluate the rate of clinically significant fistulas [International Study Group on Pancreatic Fistula (ISGPF) grade B or C] following distal pancreatectomy and to identify variables associated with a low rate of fistula development.
Clinical records of all patients who underwent distal pancreatic resections between February 1999 and July 2010 by a single surgeon were retrospectively reviewed focusing on the incidence and type of pancreatic fistula as defined by ISGPF. Study variables included age, gender, surgical approach, extent of resection, ASA classification, type of stapler cartridge, use of Seamguard™, and ISGPF classification. Statistical analysis was performed using Fisher's exact test, and univariate and multivariate logistic regression.
Sixty-four patients (median age 60, range 21-85; 54% male) underwent distal pancreatic resection (laparoscopy 50% vs. open 50%). The most common indications were pancreatic adenocarcinoma (N = 15; 23%) and neuroendocrine neoplasms (N = 14; 22%). Clinically significant pancreatic fistula developed in 24% (N = 15). The rate of fistula with cut-and-sew technique was 36% (4/11), with stapled green cartridge 31% (9/29) and only 5% (1/21) with stapled vascular cartridge. Univariate logistic regression identified vascular cartridge size (p = 0.04, OR 0.11) and open stapled technique (p = 0.05, OR 0.12) as variables significantly associated with a low fistula rate. Both vascular cartridge size (p = 0.05, OR 0.10) and open stapled technique (p = 0.04, OR 0.08) remained significant when analyzed by multivariate logistic regression. Division of pancreatic parenchyma with vascular cartridges resulted in significantly (p = 0.03, OR 9.0) lower fistula rate compared to green cartridges. The use of Seamguard™ did not affect fistula rate (16% vs. 27%; p = 0.34) nor did the performance of multivisceral resection vs. distal pancreatectomy/splenectomy alone (21% vs. 23%, p = 1.0).
The optimal technique of pancreatic division has not been conclusively established. Dividing the pancreas utilizing vascular (2.5 mm) staple cartridges significantly decreased the rate of clinically significant pancreatic fistula and we have changed our practice accordingly. A prospective randomized trial is necessary to validate these results.
胰腺残端瘘仍然是胰腺远端切除术后发生严重并发症的一个重要原因。外科医生在胰腺分割技术方面差异很大，目前尚无证据表明哪种方法具有优势。在我们的实践中，胰腺远端切除术的技术已经从传统的缝合技术发展到了吻合器切割技术，并且吻合器使用的钉仓也从绿色发展到了白色。本研究旨在评估胰腺远端切除术后发生临床显著瘘（国际胰腺瘘研究小组 [ISGPF] 分级 B 或 C）的发生率，并确定与瘘管形成发生率低相关的变量。
对 1999 年 2 月至 2010 年 7 月间由同一位外科医生实施的胰腺远端切除术的所有患者的临床记录进行回顾性分析，重点关注 ISGPF 定义的胰腺瘘的发生率和类型。研究变量包括年龄、性别、手术入路、切除范围、ASA 分级、吻合器钉仓类型、SeamguardTM 的使用情况和 ISGPF 分级。使用 Fisher 精确检验和单变量及多变量逻辑回归进行统计分析。
64 例患者（中位年龄 60 岁，范围 21-85 岁；54%为男性）接受了胰腺远端切除术（腹腔镜手术 50%，开腹手术 50%）。最常见的适应证是胰腺腺癌（N=15；23%）和神经内分泌肿瘤（N=14；22%）。发生临床显著的胰腺瘘的有 24%（N=15）。采用传统缝合技术的胰腺瘘发生率为 36%（4/11），使用绿色吻合器钉仓的发生率为 31%（9/29），而使用血管吻合器钉仓的仅为 5%（1/21）。单变量逻辑回归确定血管吻合器钉仓尺寸（p=0.04，OR 0.11）和开腹吻合器技术（p=0.05，OR 0.12）是与低瘘管发生率显著相关的变量。当进行多变量逻辑回归分析时，血管吻合器钉仓尺寸（p=0.05，OR 0.10）和开腹吻合器技术（p=0.04，OR 0.08）仍然具有显著意义。与绿色吻合器钉仓相比，使用血管吻合器钉仓（p=0.03，OR 9.0）可显著降低胰腺瘘的发生率。使用 SeamguardTM 并未影响瘘管发生率（16% vs. 27%；p=0.34），多脏器切除术与单纯胰腺远端切除/脾切除术相比（21% vs. 23%；p=1.0）也未影响瘘管发生率。
胰腺分割的最佳技术尚未得到明确确立。使用血管（2.5mm）吻合器钉仓进行胰腺分割可显著降低临床显著胰腺瘘的发生率，我们已根据这一结果改变了手术实践。有必要开展前瞻性随机试验来验证这些结果。
