pancreas diseases : PancreasWeb 28/06/06

Ever since surgical resection has been part of the armamentarium against pancreatic disease, pancreatic leak has been its foremost complication in terms of frequency and associated morbidity. The rate of pancreatic leak is more common, albeit less dramatic, after distal pancreatectomy than after pancreatoduodenectomy. Occurrence of a pancreatic leak is associated with fistula, sterile or infected collections, or peritonitis, which may lead to patient re-operation or even death. This increase in morbidity has significant financial implications, doubling the overall cost of the procedure, as shown in the economic assessment recently published by Dr. Rubén Rodríguez et al.. The money that could be saved by reducing the occurrence rate of this complication has warranted a wealth of trials aiming at controlling pancreatic leak thanks to pharmacological, technical or technological means. The suppressive effect on exocrine secretion from the pancreas of the hormone somatostatin and its synthetic analogues has been used in a number of prospective randomized trials in an attempt to prevent pancreatic leaks after pancreatic resection. Although this pharmacological strategy has been found beneficial in a recent meta-analysis, its efficiency is still a matter of debate and was not observed in several studies [1,2]. From a technical/technological point of view, there does not seem to be an advantage in using stapling rather than a hand-sewn suture for the closure of the pancreatic stump after distal pancreatectomy [3]. Several other strategies, such as fibrin-glue sealing of the stump or anastomosis, sealing of the parenchyma of the pancreatic stump with a radio-frequency device, patching the pancreatic stump with an omental plug or a patch taken from the falciform ligament, the use of an ultrasonic or harmonic scalpel for tissue dissection, have been described as successful, but still remain anecdotic [4]. Some authors have even advocated the preoperative endoscopic placement of a stent inside the pancreatic duct or performance of a sphincterotomy to prevent the occurence of a leak thanks to pancreatic decompression. This strategy was successful in a small series of patients, but triggered acute pancreatitis in some [5]. Finally, it is ironic that the most sophisticated approaches may not necessarily be the most effective, since a recent article showed that identification and suture ligation of the pancreatic duct after distal pancreatectomy decreased the rate of occurrence of a pancreatic leak from 34% to 9.6% [6], which equals a saving of 3,400 US$ per patient according to the study of Dr. Rubén Rodríguez.

by Thierry Berney, MD, MSc,