Stapler and nonstapler closure of the pancreatic remnant after distal pancreatectomy: multicenter retrospective analysis of 388 patients.

Background: The pancreatic fistula rate following distal pancreatectomy ranges widely, from 13.3 to 64.0 %. The optimal closure method of the pancreatic remnant remains controversial, especially regarding whether to use a stapler.
Methods: All patients who underwent distal pancreatectomy in five Japanese hospitals from January 2001 to June 2009 were included in this study. All relevant, anonymized medical records were entered into an electronic case report form. Complications and pancreatic fistulas were classified according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery grading system, respectively.
Results: Of the 388 patients, stapler closure and nonstapler closure were used after distal pancreatectomy in 224 patients (57.7 %) and 164 patients (42.3 %), respectively. Clinically relevant pancreatic fistulas (grades B and C) occurred in 47 patients (21.0 %) treated by stapler closure, which was a significantly lower rate than that for the 83 patients (50.6 %) treated by nonstapler closure. There were no surgical mortalities or in-hospital deaths. The distribution of postoperative complications was grade 1, 30.7 % (n = 119); grade 2, 40.2 % (n = 156); grade 3a, 0.1 % (n = 5); grade 3b, 0.3 % (n = 1); grade 4a, 0.3 % (n = 1). In the multivariate analysis, diabetes mellitus, previous laparotomy, operating time, and method of stump closure were found to be independently associated with the development of a clinical pancreatic fistula.
Conclusions: Stapler closure is a safe, efficient alternative to standard suture closure techniques because the clinical fistula rate is significantly lower.