胰尾部切除术后胰腺残端闭合技术与胰瘘形成：荟萃分析和单中心经验。
Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience.
机构信息
Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
出版信息
PLoS One. 2018 Jun 13;13(6):e0197553. doi: 10.1371/journal.pone.0197553. eCollection 2018.
BACKGROUND
Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP.
METHODS
We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques.
RESULTS
8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02).
CONCLUSION
After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.
背景
胰瘘（PF）是胰十二指肠切除术后（DP）最常见和最令人担忧的并发症。然而，安全的胰腺残端闭合技术仍然存在争议。在这里，我们旨在比较 DP 中不同胰腺残端闭合技术预防 PF 的安全性。
方法
我们基于 PRISMA 进行了一项荟萃分析，纳入了比较 DP 中至少两种残端闭合技术的 PF 发生率（PFR）的所有相关研究。我们还对我们机构的 PFR 与残端闭合技术进行了回顾性分析。
结果
最初确定了 8301 项研究。其中，10 项随机对照试验（RCT）、11 项前瞻性研究和 59 项回顾性研究符合条件。吻合器闭合（26%比 31%，OR：0.73，p = 0.02）、吻合器联合缝合（30%比 33%，OR：0.70，p = 0.05）或胰腺残端吻合（14%比 28%，OR：0.51，p = 0.02）与单纯缝合闭合相比，PFR 较低。保留脾脏/脾脏切除术、腹腔镜/开腹 DP、TachoSil®、纤维蛋白样胶应用、生物可吸收吻合器增强物（Seamguard®）不影响 DP 后的 PFR。相反，自体补丁（镰状韧带/浆肌层补丁）的应用比不应用补丁（21.9%比 25.8%，OR：0.60，p = 0.006）导致更低的 PFR。在我们机构，残端闭合的三大主要技术导致的 PFR 相当（缝合：27%，吻合器：29%，或联合：24%）。然而，选择性缝合/夹闭胰腺残端的主胰管可预防严重的 PF（p = 0.02）。
结论
在 DP 后，吻合器闭合、胰腺吻合或镰状韧带/浆肌层补丁导致的 PFR 低于单纯缝合闭合。然而，这些差异很小，需要进一步的 RCT 来验证这些效果。在残端闭合时选择性闭合主胰管可能预防严重的 PF。
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