Linear Stapling Device with Pre-attached Bioabsorbable Polyglycolic Acid Felt Reduces Postoperative Pancreatic Fistula After Distal Pancreatectomy

Discussion

There are two possible reasons for POPF in DP after division of the pancreas using staples; one is the stapling error of the main pancreatic duct at the pancreatic stump and the other is the tearing of the pancreatic parenchyma at the pancreatic stump. From the experiences of pressure tolerance studies using porcine or bovine pancreases, the major cause of POPF after staple applications is the tearing of the pancreatic parenchyma at the pancreatic stump (7). To avoid tearing the pancreatic parenchyma using a stapler with PGA felt, gentle compression of the parenchyma to 1.75-2.0-2.25 mm thickness would be the first priority. According to the instruction manual, the applicable thickness of the tissue should be 1.95 to 2.7 mm. The thickness of the adult human pancreatic body typically exceeds 3.0 mm. We went ahead and applied this stapler to the division of the pancreas because the pancreatic parenchyma is relatively soft. To the best of our knowledge, no technical difficulties during use of the stapler with PGA felt have been reported.

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Figure 2.

The operative schemas of the case with laparoscopic distal pancreatectomy (DP) are demonstrated. (A) The parenchyma of the pancreas just above the portal/superior mesenteric vein was isolated and controlled with tape. (B) The pancreas was closed using staplers with polyglycolic acid (PGA) felt. (C) When the stapler with PGA felt is removed, the tip of the PGA felt is not divided. Gentle handling of stapler is especially needed during the removal of the stapler from the pancreas.

Kawai et al. reported that a pancreas thickness greater than 12 mm significantly increased POPF after DP using stapler closure (8). The thickness of the pancreatic parenchyma should be one of the important considerations during the applications of staples; however, the softness of pancreatic parenchyma is another consideration. For example, a very soft pancreas of more than 13-mm thickness would be safely compressed, while a hard pancreas of 11-mm thickness could not be compressed. For the safe compression of pancreatic parenchyma using staplers, both the thickness and softness of the pancreas should be taken into consideration simultaneously.

To avoid tearing of pancreatic parenchyma, the maintenance of pancreatic capsule during the division of the pancreas is another important concern. As a matter of course, the pancreatic capsule is thinner than those of other organs, such as the digestive tract or the liver. Some authors have emphasized that prolonged peri-firing compression of staplers could prevent POPF (9). However, our earlier trial showed the opposite (7). As we mentioned in this report, the time required for the procedure should not be the main concern; rather, the maintenance of the capsule and the care taken not to tear the parenchyma should be the paramount concerns.

Kurahara et al. (10) and Hamilton et al. (11) reported that mesh reinforcement of the pancreatic transection decreased POPF; however, details of the material of mesh or thickness of the staples were not discussed in these papers. Yet, these details are very important for the establishment of the ideal stapling system for DP. The reinforcement of the pancreatic transection line using anything else should be an important concept to maintain the pancreatic capsule and to avoid tearing of pancreatic parenchyma; however, the applicable thickness of the tissue would vary according to the thickness of reinforcement materials. Taking into consideration the original thickness of the pancreas, the development of a cartridge with PGA felt that has thicker staples is important for use in this challenging field. However, the deeper the staples go, the greater the risk of error in the stapling of the main pancreatic duct. Further in-depth research is needed for the establishment of the ideal staplers for DP.