Predictive Factors Associated with Postoperative Pancreatic fistula after Laparoscopic Distal Pancreatectomy: A 10-year Single Institution Experience

Arturo III Mendoza, MD, Ho-Seong Han, MD, PhD, Soyeon Ahn, PhD, Yoo-Seok Yoon, MD, PhD, Jai Young Cho, MD, Young Rok Choi, MD. Seoul National Univeristy Bundang Hospital

Background. Laparoscopic distal pancreatectomy (LDP) is becoming a treatment modality option for benign and borderline tumors of the pancreas. However, the incidence of postoperative pancreatic fistula remains a substantial morbidity contributing to length of hospital stay and overall costs. In a consecutive series of 143 patients, predictive factors associated with pancreatic fistula after laparoscopic distal pancreatectomy were identified.

Methods. A retrospective single-center review of patients who underwent LDP between January 2003 and December 2013 was conducted. Patient demographics and clinico-pathologic parameters were analyzed to evaluate the association for the occurence of PF.

Results. Among the 143 consecutive patients, indications were benign disease in 117 (81.8%) and malignant tumors in 26 (18.2 %). Of the benign tumors, intraductal papillary mucinous neoplasm (IMPN) had the highest incidence of 18.2% (n=26) followed by solid pseudopapillary neoplasm (SPN) (16.1%, n=23). Pancreatic fistula occurred in 25 (17%) patients. Ten (40%) of the 25 patients had clinically significant (grade B) type. No grade C was observed in the present study. Univariate and multivariate analyses indicated that pancreatic parenchymal thickness (>12mm) was associated with a higher incidence of postoperative pancreatic fistula (Odd ratio (OR) 2.635; p<0.001). A 12mm cut-off value for pancreatic thickness was defined based on the median thickness in the series of patients observed. Pancreatic texture alone was not a statistically significant risk factor for PF (OR 1.62; p=0.303), however when combined with pancreatic thickness (thick and soft), it became a significant predictive factor for PF as well (OR 2.85; p<0.001).

Conclusion. Pancreas thickness more than 12mm significantly increases the incidence of pancreatic fistula after LDP using stapled closure. Pancreatic texture alone is not an independent risk factor for PF, however when combined with a thick parenchyma (>12mm), a “soft” pancreas is significantly at risk of developing a pancreatic fistula.