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Why Does Postoperative Pancreatic Fistula Occur After Hand-sewn Parenchymal Closure and Staple Closure in Distal Pancreatectomy?

Nagakawa, Yuichi, MD, PhD, FACS; Hijikata, Yosuke, MD; Osakabe, Hiroaki, MD; Matsudo, Takaaki, MD; Soya, Ryoko, MSc; Sahara, Yatsuka, MD; Takishita, Chie, MD; Shirota, Tomoki, MD, PhD; Kobayashi, Nao, MD; Nakajima, Tetsushi, MD; Hosokawa, Yuichi, MD; Ishizaki, Tetsuo, MD, PhD, FACS; Katsumata, Kenji, MD, PhD, FACS; Tsuchida, Akihiko, MD, PhD, FACS

Surgical Laparoscopy Endoscopy & Percutaneous Techniques: April 2019 - Volume 29 - Issue 2 - p e15–e19
doi: 10.1097/SLE.0000000000000604
Online Articles: Technical Reports

Hand-sewing (HS) and stapling are common parenchymal closure techniques after distal pancreatectomy. However, these methods cannot completely prevent postoperative pancreatic fistula (POPF). The mechanisms of POPF formation after closure are unknown. We performed distal pancreatectomy in mongrel dogs to identify the mechanisms of POPF formation after HS and staple closure. We measured the closed pancreatic duct burst pressures and examined the histology of the remnant pancreas. The after staple-closure burst pressures depended on stapler height; lower pressures were associated with greater stapler heights. Post-HS closure burst pressures were significantly higher than those at each stapler height (P<0.01). Post-HS closure pathologic findings showed extensive necrosis (day 3), and some regenerated pancreatic duct stumps (day 5). Necrosis was not observed around the stapled tissues. Although HS completely closes the pancreatic ducts, stump necrosis and blood flow disturbances may cause POPF. With stapler closure, pancreatic fluid leakage may occur even with appropriate stapler heights.

Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan

The author declares no conflicts of interest.

Reprints: Yuichi Nagakawa, MD, PhD, FACS, Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan (e-mail:

Received May 26, 2018

Accepted October 1, 2018

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