- Email: [email protected]
Use of staplers to divide the pancreas during pancreatoduodenectomy: is it justified?
HPB
DOI:10.1111/j.1477-2574.2008.00021.x
LETTER TO THE EDITOR
Use of staplers to divide the pancreas during pancreatoduodenectomy: is it justified? We write with reference to the increasing trend for using stapling devices for the dissection and division of the uncinate process and pancreatic head behind the portal vein.1 The advantages of such devices over other methods of dividing the pancreas in distal or subtotal pancreatectomy have not been proven,2 and better outcomes have been reported for the hand-sewing technique.3 The importance of nodal dissection along the superior mesenteric artery during pancreatoduodenectomy is well known, and it is this margin that remains the most common positive margin in R1 resections.4 Furthermore, the prognostic implications of the nodes along the uncinate margin have been reported.5 Stapler division may contribute to reductions in operating time and blood loss, but a critical volume of tissue is necessary for the stapler to be applied. This would compromise margin clearance and nodal yield along the uncinate process. A recent report from an anatomical cadaver-based study has also pointed out that the stapling technique carries a risk for incomplete tumour resection.6 We believe that such staplers should be used with caution in pancreatoduodenectomy in malignant conditions and that further studies are required before this technique can be widely accepted.
References 1. Kleeff J, Friess H, Büchler MW. (2007) Dissection of the uncinate process and pancreatic head behind the portal vein using endovascular staplers. J Hepatobiliary Pancreat Surg 14:480–483. 2. Knaebel HP, Diener MK, Wente MN, Büchler MW, Seiler CM. (2005) Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 92:539–546. 3. Kleeff J, Diener MK, Z’graggen K, Hinz U, Wagner M, Bachmann J et al. (2007) Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 245:573–582. 4. Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH et al. (2007) Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Ann Surg 246:52–60. 5. Rowsell CH, Hanna S, Hsieh E, Law C, Khalifa MA. (2007) Improved lymph node retrieval in Whipple specimens as a result of implementation of a new uncinate margin protocol. HPB 9:388–391. 6. Baqué P, Iannelli A, Delotte J, de Peretti F, Bourgeon A. (2008) Division of the right posterior attachments of the head of the pancreas with a linear stapler during pancreaticoduodenectomy: vascular and oncological considerations based on an anatomical cadaver-based study. Surg Radiol Anat: DOI: 10.1007/s00276-008-0353-2.
Conflicts of interest None declared.
Parul J. Shukla Department of Gastrointestinal & HepatoPancreatoBiliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
Ganesh Nagarajan Department of Gastrointestinal & HepatoPancreatoBiliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
Savio G. Barretto Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
HPB 2009, 11, 90
© 2009 International Hepato-Pancreato-Biliary Association
DOI:10.1111/j.1477-2574.2008.00021.x
LETTER TO THE EDITOR
Use of staplers to divide the pancreas during pancreatoduodenectomy: is it justified? We write with reference to the increasing trend for using stapling devices for the dissection and division of the uncinate process and pancreatic head behind the portal vein.1 The advantages of such devices over other methods of dividing the pancreas in distal or subtotal pancreatectomy have not been proven,2 and better outcomes have been reported for the hand-sewing technique.3 The importance of nodal dissection along the superior mesenteric artery during pancreatoduodenectomy is well known, and it is this margin that remains the most common positive margin in R1 resections.4 Furthermore, the prognostic implications of the nodes along the uncinate margin have been reported.5 Stapler division may contribute to reductions in operating time and blood loss, but a critical volume of tissue is necessary for the stapler to be applied. This would compromise margin clearance and nodal yield along the uncinate process. A recent report from an anatomical cadaver-based study has also pointed out that the stapling technique carries a risk for incomplete tumour resection.6 We believe that such staplers should be used with caution in pancreatoduodenectomy in malignant conditions and that further studies are required before this technique can be widely accepted.
References 1. Kleeff J, Friess H, Büchler MW. (2007) Dissection of the uncinate process and pancreatic head behind the portal vein using endovascular staplers. J Hepatobiliary Pancreat Surg 14:480–483. 2. Knaebel HP, Diener MK, Wente MN, Büchler MW, Seiler CM. (2005) Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 92:539–546. 3. Kleeff J, Diener MK, Z’graggen K, Hinz U, Wagner M, Bachmann J et al. (2007) Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 245:573–582. 4. Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH et al. (2007) Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Ann Surg 246:52–60. 5. Rowsell CH, Hanna S, Hsieh E, Law C, Khalifa MA. (2007) Improved lymph node retrieval in Whipple specimens as a result of implementation of a new uncinate margin protocol. HPB 9:388–391. 6. Baqué P, Iannelli A, Delotte J, de Peretti F, Bourgeon A. (2008) Division of the right posterior attachments of the head of the pancreas with a linear stapler during pancreaticoduodenectomy: vascular and oncological considerations based on an anatomical cadaver-based study. Surg Radiol Anat: DOI: 10.1007/s00276-008-0353-2.
Conflicts of interest None declared.
Parul J. Shukla Department of Gastrointestinal & HepatoPancreatoBiliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
Ganesh Nagarajan Department of Gastrointestinal & HepatoPancreatoBiliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
Savio G. Barretto Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
HPB 2009, 11, 90
© 2009 International Hepato-Pancreato-Biliary Association