Efficasy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy

Efficasy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficasy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy Teijiro Hirashita, Atsuro Fujinaga, Yuiko Nagasawa, Hiroki Orimoto, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3998411/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract Background: A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult. Methods: Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated. Results : In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay longer in the stapler group than in the UCS group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure. Conclusions: PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein. central pancreatectomy distal pancreatectomy pancreaticojejunostomy pancreatic fistula Figures Figure 1 Introduction Postoperative pancreatic fistula (POPF) is a major complication of pancreatectomy and is still the most frequently occurring complication after distal pancreatectomy (DP), with an incidence of 5–30% [ 1 – 3 ]. POPF leads to prolonged hospitalization, increased treatment costs, and death as the worst possible outcome. Many risk factors for POPF following DP have been reported, including high body mass index (BMI), prolonged operation time, large amount of blood loss, soft pancreatic texture, and pancreatic thickness [ 4 , 5 ]. Central pancreatectomy (CP) is one of the parenchyma-sparing surgeries and is recommended for benign or low-grade malignant pancreatic neoplasms in the body and neck of the pancreas because it better preserves exocrine and endocrine pancreatic function. However, CP leaves two divided pancreatic remnants, creating more opportunities for POPF formation [ 6 ]. There are many reports on various methods of pancreatic stump closure, but the most effective technique to prevent POPF is yet to be proven, and the appropriate technique for closure of the pancreatic stump during DP remains controversial [ 7 ]. Although a randomized controlled trial did not show superiority of stapler versus hand-sewn closure for POPF [ 8 ], stapler closure has recently become a standard technique because it is convenient and ideal for laparoscopic or robotic DP. However, stapler closure of the pancreatic stump can be difficult when the tumor location extends to the pancreatic neck. Several studies have reported the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for POPF in patients who have undergone DP [ 9 – 11 ]. Kawai et al. [ 12 ] reported that PJ of the pancreatic stump did not reduce POPF when they examined all patients who underwent DP. However, the usefulness of PJ of the pancreatic stump, which is limited to when stapler closure is difficult, has not been investigated. The present study investigated the relationship between methods of pancreatic stump closure and perioperative factors and also compared hand-sewn closure and PJ of the pancreatic stump when it cannot be closed with a stapler. Patients and methods Study population In total, 164 patients who underwent DP or CP in Oita University Faculty of Medicine from January 2011 to December 2023 were enrolled in this study. Patient characteristics were retrospectively collected from the patients’ charts. This study was approved by the Ethics Committee of Oita University Faculty of Medicine (approval number: 2744). Distal and central pancreatectomy A stapler was used for transection and closure of the pancreas during DP, when the pancreas was transected above or to the left of the portal vein (PV). In CP, the proximal pancreatic stump was also transected with a stapler, and PJ was performed for the distal stump. Additional treatment or covering of the pancreatic stump was not performed. When the tumor was located around the pancreatic neck or if an accurate pathological diagnosis of the stump was required due to the possibility of cancer infiltration to the stump, the pancreas was divided with ultrasonic coagulating shears (UCS). When using UCS, ligation of the main pancreatic duct and hand-sewn closure of the stump resulted in a high incidence of POPF, so PJ of the stump was performed in all cases from 2022 (Fig. 1 a, b) and was performed by board-certified expert surgeons of the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Data collection The following clinicopathological variables were included in the analysis: preoperative factors including age, sex, and BMI; operative factors including DP/CP, open/laparoscopic surgery, level of pancreatic transection (right of the PV/above or left of the PV), instruments for pancreatic transection (stapler/UCS), operation time, blood loss, and transfusion; postoperative course including POPF, complications, and postoperative hospital stay; and pathological factors, including diagnosis. POPF was defined according to the International Study Group of Pancreatic Fistula definition [ 13 ]. In this study, POPF grades B and C were defined as clinically relevant POPF (CR-POPF). These variables were compared between the stapler and UCS groups for pancreatic transection and further, between hand-sewn closure and PJ of the pancreatic stump in the UCS group. Statistical analysis All variables are expressed as the mean ± standard deviation for continuous data. Univariate analyses were performed using the Student t -test for continuous variables and chi-squared test for categorical variables. Statistical significance was defined as P < 0.05. All statistical analyses were performed with JMP Pro 17 (SAS Institute Inc., Cary, NC, USA). Results Patient characteristics The clinicopathological characteristics of the patients who underwent DP or CP are shown in Table 1. The mean patient age was 66.4 ± 15.7 years, and of these 164 patients, 78 were women and 86 were men. DP was performed in 158 patients and CP in 6 patients. The pancreas was transected to the right of the PV in 14 (9%) patients. Mean operation time was 353 ± 110 min, and mean blood loss was 517 ± 634 mL. CR-POPF occurred in 30 (18%) patients, and the mean postoperative hospital stay was 23.3 ± 18.1 days. Comparison of perioperative factors for pancreatic transection using stapler and ultrasonic dissector The pancreas was transected with a stapler in 150 patients (stapler group) and UCS in 14 patients (UCS group). There were no significant differences between the two groups in preoperative factors and diagnosis. For operative factors, however, the rate of laparoscopic surgery in the stapler group was higher than that in the UCS group. The pancreas was more frequently transected to the right of the PV in the UCS group versus stapler group. There were no significant differences in operation time and blood loss between the groups. The rate of POPF was higher (50% vs 15%, P = 0.004) and the postoperative hospital stay was longer (34.6 ± 24.1 vs 22.2 ± 17.1 days, P = 0.014) in the stapler group than those in the UCS group. Case series of patients with pancreatic stump divided with UCS Details of the patients whose pancreas was transected with UCS are shown in Table 3. Open surgery was performed in all of these patients. As described above, PJ of the pancreatic stump was performed in all cases from 2022 because hand-sewn closure of the stump resulted in a high incidence of POPF, and since then, there have been no cases of POPF. Among the cases in which PJ of the pancreatic stump was not performed were many cases with pancreatic ductal adenocarcinoma, including two cases of DP with celiac axis resection, and it is possible that many cases involved more difficult surgery. Comparison of perioperative factors between hand-sewn closure (HS group) and pancreaticojejunostomy of the pancreatic stump (PJ group) PJ of the pancreatic stump was performed on 7 patients, 4 with DP and 3 with CP. The BMI of the PJ group was lower than that of the HS group. The PJ group had shorter operation time (312 ± 82 vs 479 ± 126 min, P = 0.012) and less blood loss (286 ± 360 vs 921 ± 510 mL, P = 0.019) than the HS group. The rate of POPF was zero in the PJ group, and the rates of both POPF and complications in the PJ group were significantly lower than those in the HS group. The length of postoperative hospital stay was also significantly shorter in the PJ group versus HS group (16.0 ± 4.4 vs 53.1 ± 20.9 days, P = 0.001). Discussion This study showed a higher incidence of CR-POPF and longer postoperative hospital stay when the pancreas was divided using UCS. One reason for this result is that UCS were only used in special situations. PJ of the pancreatic stump after using UCS decreased the rate of CR-POPF. As PJ was performed for the pancreatic stump to the right of the PV and the pancreas and jejunum used for anastomosis are opposite that in the usual PJ in pancreaticoduodenectomy (PD), the difficulty of this procedure may be higher than that for the usual PJ in PD. However, no CR-POPF occurred after PJ of the pancreatic stump in this patient series. Pancreatic juice was drained to both the duodenum and the jejunum, and all PJ procedures on the stump were performed by board-certified expert surgeons. These may be the reasons for the good outcomes obtained following PJ of the stump. Several approaches to pancreatic stump closure have been described in the literature, but the most effective method to prevent CR-POPF remains to be proven. In a large series by Ferrone et al. [ 7 ], different closure techniques were compared between hand-sewn closure, stapler with or without staple line reinforcement, use of free falciform patches, and pancreatic duct ligation, but there was no significant difference in the rates of CR-POPF. The DISPACT trial [ 8 ], in which two groups of patients were randomly assigned to stapler or hand-sewn closure of the pancreatic stump, showed no difference in the rates of CR-POPF. Stapler closure of the pancreatic stump is technically easy and has become popular with many surgeons as the performance of minimally invasive surgery has spread. The incidence of overall POPF in the DISPACT trial was 32%, which was a higher rate than those in other recent studies. Stapler techniques such as pre-firing compression of the pancreas have improved the rate of POPF in DP [ 14 , 15 ]. Good results with the use of artificial patches or fibrin-glue sealant have also been described in small series, but thus far, large series have failed to prove their efficacy [ 16 , 17 ]. Although transection at the pancreatic neck is suggested to be more reasonable [ 18 ], pancreatic transection may be performed to the right of the PV depending on the location of the tumor in DP or CP. Stapler closure of the pancreatic stump is not suitable in such a situation, and the surface of the pancreatic stump is often wider. The pancreatic stump is usually closed by ligating or suturing the main pancreatic duct and suturing the pancreatic parenchyma, but the incidence of POPF is very high under these poor conditions [ 19 ]. In the present series, the rate of POPF was higher in the UCS group than in the stapler group, partly because surgical conditions such as pancreatic transection performed to the right of the PV and near the tumor in the patients in the UCS group were worse. Several studies have reported the effect of PJ of the pancreatic stump. Wagner et al. [ 10 ] examined the efficacy of PJ of the pancreatic stump compared to hand-sewn closure, and they found a zero rate of CR-POPF in the PJ group compared to a 20% rate of PF in the hand-sewn group. Meniconi et al. [ 11 ] also reported the superiority of PJ, which had a zero rate of CR-POPF compared to hand-sewn closure. Kawai et al. [ 12 ] reported on a prospective, randomized, multicenter study of PJ versus stapler closure of the pancreatic stump during DP. The rate of CR-POPF in the PJ group tended to be lower than that in the stapler closure group for patients with a thicker pancreas, although no statistical significance was shown. Furthermore, PJ did not increase postoperative complications including those of intra-abdominal abscess and ileus, although PJ of the pancreatic stump may have some risks due to intestinal division and contamination with intestinal juice. However, CR-POPF after PJ may become more severe due to activation of pancreatic enzymes and bacterial contamination. Despite this possibility, our series showed good results similar to those of previous reports, and PJ was effective because of decompression of the main pancreatic duct, especially when hand-sewn closure results in a high rate of CR-POPF in poor conditions. CP is one of the parenchyma-sparing surgeries and is recommended for benign or low-grade malignant pancreatic neoplasms in the body and neck of the pancreas. The size of the remnant pancreas suggests that exocrine and endocrine functions are better preserved. However, CP leaves two divided pancreatic remnants, increasing the opportunities for CR-POPF. Previous meta-analyses showed higher incidences of CR-POPF following CP than after PD or DP [ 20 , 21 ]. The reported rate of CR-POPF in CP ranged from 26 to 63% [ 20 – 22 ]. Sho et al. [ 23 ] reported a low rate of POPF of 8% in CP when using double PJ. In our series, we performed CP in 6 patients, with and without PJ performed for the proximal pancreatic stump in 3 patients each. CR-POPF occurred in 2 (66%) patients without PJ and no patients with PJ. Thus, PJ for the proximal pancreatic stump as an alternative to closure may also be useful in CP. This study has some limitations. These are the results of a retrospective non-randomized analysis of a small group of patients. Furthermore, recent improvements in the perioperative course may be related to many other factors, such as changes in the operative instruments used, surgeons, and postoperative management. It will thus be important to confirm these data in a larger series of patients. In conclusion, PJ of the pancreatic stump during DP or CP reduces the incidence of CR-POPF compared with hand-sewn closure, especially when the pancreas is transected to the right of the PV. Declarations Ethics approval The protocol for this study was approved by the Ethics Committee of the study center (Oita University, approval number: 2744) and complies with the Declaration of Helsinki and its later amendments. Consent to participate All participants provided informed consent for participation in this study and for the use of their medical records through an optout form. Conflict of interest The authors declare that they have no conflict of interest. Authors’ contributions Study conception and design: TH, AF, YN, HO, SA, MK, TK, YK, TM, YE, MI. Acquisition of data: TH, AF, YN, HO, SA, MK, TK, YK, TM, YE, MI. Analysis and interpretation of data: TH, AF. Drafting of manuscript: TH, AF. Critical revision of manuscript: MI. All authors read and approved the final manuscript before submission. References de Rooij T, van Hilst J, van Santvoort H et al (2019) Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg 269:2–9 Zhou J, Lv Z, Zou H et al (2020) Up-to-date comparison of robotic-assisted versus open distal pancreatectomy: a PRISMA-compliant meta-analysis. Medicine (Baltimore) 99:e20435 Lai EC, Tang CN (2013) Current status of robot-assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a comprehensive review. Asian J Endosc Surg 6:158–164 van Bodegraven EA, den Haring FET, Pollemans B et al (2023) Nationwide validation of the distal fistula risk score (D-FRS). Langenbecks Arch Surg 409:14 Van Buren G 2nd, Bloomston M, Schmidt CR et al (2017) A prospective randomized multicenter trial of distal pancreatectomy with and without routine intraperitoneal drainage. Ann Surg 266:421–431 Bi S, Liu Y, Dai W et al (2023) Effectiveness and safety of central pancreatectomy in benign or low-grade malignant pancreatic body lesions: a systematic review and meta-analysis. Int J Surg 109:2025–2036 Ferrone CR, Warshaw AL, Rattner DW et al (2008) Pancreatic fistula rates after 462 distal pancreatectomies. Stapler do not decrease fistula rates. J Gastrointest Surg 12:1691–1698 Diener MK, Seiler CM, Rossion I et al (2011) Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 377:1514–1522 Kleeff J, Diener MK, Z’graggen K et al (2007) Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 245:573–582 Wagner M, Gloor M, Ambühl M et al (2007) Roux-en-Y drainage of the pancreatic stump decreases pancreatic fistula after distal pancreatic resection. J Gastrointest Surg 11:303–308 Meniconi RL, Caronna R, Borreca D , Schiratti M, Chirletti P (2013) Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis. BMC Surg 2:13–23 Kawai M, Hirono S, Okada K et al (2016) Randomized controlled trial of pancreaticojejunostomy versus stapler closure of the pancreatic stump during distal pancreatectomy to reduce pancreatic fistula. Ann Surg 264:180–187 Bassi C, Marchegiani G, Dervinis C et al (2017) The 2016 update of the international study group (ISGPF) definition and grading of postoperative pancreatic fistula: 11 years after. 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J Am Coll Surg 221:e15–e19 Tables Table 1 Patient characteristics ( n = 164) Characteristics Value Preoperative factors Age, years 66.4 ± 15.7 Sex (female/male) 78 (48%)/86 (52%) BMI, kg/m 2 23.1 ± 4.6 Diagnosis Pancreatic cancer/Others 67 (41%)/97 (59%) Operative factors DP/CP 158 (96%)/6 (4%) Open/Laparoscopy 80 (49%)/84 (51%) Pancreatic transection (right of PV/above or left of PV) 14 (9%)/150 (91%) Pancreatic transection (stapler/UCS) 150 (91%)/14 (9%) Operation time, min 353 ± 110 Blood loss, mL 517 ± 634 Transfusion 26 (16%) Postoperative course POPF (≥ grade B) 30 (18%) Clavien-Dindo (≥ grade 3) 32 (20%) Postoperative hospital stay, days 23.3 ± 18.1 BMI body mass index, DP distal pancreatectomy, CP central pancreatectomy, UCS ultrasonic coagulating shear, POPF postoperative pancreatic fistula Table 2 Perioperative factors of pancreatic transection using a stapler vs. ultrasonic coagulation shears (UCS) Stapler (n=150) UCS (n=14) P value Preoperative factors Age, years 65.7 ± 16.1 74.1 ± 4.9 0.055 Sex (female/male) 71 (47%)/79 (53%) 7 (50%)/7 (50%) 0.849 BMI, kg/m 2 23.1 ± 4.7 22.7 ± 2.7 0.776 Diagnosis Pancreas cancer/Others 60 (40%)/90 (60%) 6 (43%)/8 (57%) 0.835 Operative factors DP/CP 149 (99%)/1 (1%) 9 (64%)/5 (36%) <0.001 Open/Laparoscopy 66 (44%)/84 (56%) 14/0 <0.001 Pancreatic transection (right of PV/above or left of PV) 1 (1%)/149 (99%) 13 (93%)/1 (7%) <0.001 Operation time, min 349 ± 108 395 ± 134 0.130 Blood loss, mL 509 ± 644 602 ± 538 0.599 Transfusion 22 (15%) 4 (29%) 0.417 Postoperative course POPF (≥ grade B) 23 (15%) 7 (50%) 0.004 Complications (≥ Clavien-Dindo III) 25 (17%) 7 (50%) 0.007 Postoperative hospital stay, days 22.2 ± 17.1 34.6 ± 24.1 0.014 BMI body mass index; DP distal pancreatectomy; CP central pancreatectomy; PV portal vein; POPF postoperative pancreatic fistula Table 3 Case series of pancreatic stumps divided with an ultrasonic dissector Case Age/Sex Diagnosis Operation Pancreato-jejunostomy of pancreatic stump Operation time (min) Blood loss (mL) POPF (≥ grade B) Complication Postoperative hospital stay (days) 1 75/F PDAC DP No 455 830 B PF 61 2 75/M PDAC DP Yes 449 240 None none 19 3 72/M PDAC DP-CAR No 556 1380 B PF 46 4 78/F IPMC DP No 466 1210 B PF 62 5 72/M PDAC DP No 469 1260 C PF 93 6 73/M PDAC DP-CAR No 585 1320 B PF 39 7 62/M PanNET CP No 455 310 B PF 39 8 71/M Stenosis of MPD CP No 267 140 B PF 32 9 74/M IPMA CP Yes 237 110 None None 10 10 70/F RCC metastasis DP Yes 306 80 None None 11 11 77/M IPMA CP Yes 296 170 None Chylous ascites 18 12 83/M ITPN CP Yes 359 1090 None Ascites 18 13 78/F RCC metastasis DP Yes 199 100 None None 14 14 77/F PDAC DP Yes 337 190 None None 22 PDAC pancreatic ductal adenocarcinoma; IPMC intraductal papillary mucinous carcinoma, PanNET pancreatic neuroendocrine tumor; MPD main pancreatic duct; IPMA intraductal papillary mucinous adenoma; RCC renal cell carcinoma; ITPN intraductal tubulopapillary neoplasm; DP distal pancreatectomy ; DP-CAR distal pancreatectomy with celiac axis resection; CP central pancreatectomy; POPF postoperative pancreatic fistula Table 4 Comparison of perioperative factors between hand-sewn closure and pancreaticojejunostomy (PJ) of the pancreatic stump Hand-sewn closure (n=7) PJ of the pancreatic stump (n=7) P value Preoperative factors Age, years 71.9 ± 4.9 76.3 ± 4.0 0.090 Sex (female/male) 4/3 2/4 0.592 BMI, kg/m 2 24.4 ± 2.0 20.8 ± 2.1 0.010 Diagnosis Pancreas cancer/Others 4/3 2/5 0.276 Operative factors DP/CP 5/2 4/3 0.576 Open/Laparoscopy 7/0 7/0 1.000 Operation time, min 479 ± 126 312 ± 82 0.012 Blood loss, mL 921 ± 510 283 ± 360 0.019 Transfusion 3/4 7/0 0.007 Postoperative course POPF (≥ grade B) 7 (100%) 0 <0.001 Complication (≥ Clavien-Dindo III) 7 (100%) 0 <0.001 Postoperative hospital stay, days 53.1 ± 20.9 16.0 ± 4.4 0.001 BMI body mass index, DP distal pancreatectomy, CP central pancreatectomy, POPF postoperative pancreatic fistula Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Apr, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 13 Apr, 2024 Reviews received at journal 12 Apr, 2024 Reviewers agreed at journal 07 Apr, 2024 Reviewers agreed at journal 17 Mar, 2024 Reviewers invited by journal 16 Mar, 2024 Editor assigned by journal 02 Mar, 2024 Submission checks completed at journal 29 Feb, 2024 First submitted to journal 28 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3998411","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275536098,"identity":"e7767f1a-00c9-4a73-9471-c58c4cf83743","order_by":0,"name":"Teijiro 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Masafumi","middleName":"","lastName":"Inomata","suffix":""}],"badges":[],"createdAt":"2024-02-29 03:46:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3998411/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3998411/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-024-03335-7","type":"published","date":"2024-04-30T19:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51974003,"identity":"c32b700d-8148-4796-9f98-9445f9bac307","added_by":"auto","created_at":"2024-03-04 19:05:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":131887,"visible":true,"origin":"","legend":"\u003cp\u003eSchematics of pancreaticojejunostomy of the pancreatic stump. a: Distal pancreatectomy. b: Central pancreatectomy. \u003cem\u003ePV\u003c/em\u003e portal vein, \u003cem\u003eGDA\u003c/em\u003e gastroduodenal artery, \u003cem\u003eCBD\u003c/em\u003e common bile duct\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3998411/v1/29e510b67712350085298f94.jpg"},{"id":56042816,"identity":"a75054e6-636b-4851-85f9-6a6e23ce57d6","added_by":"auto","created_at":"2024-05-07 20:07:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":671666,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3998411/v1/d87b1adc-f90e-409b-81c7-3aecbe36eefa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficasy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostoperative pancreatic fistula (POPF) is a major complication of pancreatectomy and is still the most frequently occurring complication after distal pancreatectomy (DP), with an incidence of 5\u0026ndash;30% [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. POPF leads to prolonged hospitalization, increased treatment costs, and death as the worst possible outcome. Many risk factors for POPF following DP have been reported, including high body mass index (BMI), prolonged operation time, large amount of blood loss, soft pancreatic texture, and pancreatic thickness [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCentral pancreatectomy (CP) is one of the parenchyma-sparing surgeries and is recommended for benign or low-grade malignant pancreatic neoplasms in the body and neck of the pancreas because it better preserves exocrine and endocrine pancreatic function. However, CP leaves two divided pancreatic remnants, creating more opportunities for POPF formation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are many reports on various methods of pancreatic stump closure, but the most effective technique to prevent POPF is yet to be proven, and the appropriate technique for closure of the pancreatic stump during DP remains controversial [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although a randomized controlled trial did not show superiority of stapler versus hand-sewn closure for POPF [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], stapler closure has recently become a standard technique because it is convenient and ideal for laparoscopic or robotic DP. However, stapler closure of the pancreatic stump can be difficult when the tumor location extends to the pancreatic neck.\u003c/p\u003e \u003cp\u003eSeveral studies have reported the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for POPF in patients who have undergone DP [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Kawai et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported that PJ of the pancreatic stump did not reduce POPF when they examined all patients who underwent DP. However, the usefulness of PJ of the pancreatic stump, which is limited to when stapler closure is difficult, has not been investigated.\u003c/p\u003e \u003cp\u003eThe present study investigated the relationship between methods of pancreatic stump closure and perioperative factors and also compared hand-sewn closure and PJ of the pancreatic stump when it cannot be closed with a stapler.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eIn total, 164 patients who underwent DP or CP in Oita University Faculty of Medicine from January 2011 to December 2023 were enrolled in this study. Patient characteristics were retrospectively collected from the patients\u0026rsquo; charts. This study was approved by the Ethics Committee of Oita University Faculty of Medicine (approval number: 2744).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDistal and central pancreatectomy\u003c/h2\u003e \u003cp\u003eA stapler was used for transection and closure of the pancreas during DP, when the pancreas was transected above or to the left of the portal vein (PV). In CP, the proximal pancreatic stump was also transected with a stapler, and PJ was performed for the distal stump. Additional treatment or covering of the pancreatic stump was not performed. When the tumor was located around the pancreatic neck or if an accurate pathological diagnosis of the stump was required due to the possibility of cancer infiltration to the stump, the pancreas was divided with ultrasonic coagulating shears (UCS). When using UCS, ligation of the main pancreatic duct and hand-sewn closure of the stump resulted in a high incidence of POPF, so PJ of the stump was performed in all cases from 2022 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, b) and was performed by board-certified expert surgeons of the Japanese Society of Hepato-Biliary-Pancreatic Surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe following clinicopathological variables were included in the analysis: preoperative factors including age, sex, and BMI; operative factors including DP/CP, open/laparoscopic surgery, level of pancreatic transection (right of the PV/above or left of the PV), instruments for pancreatic transection (stapler/UCS), operation time, blood loss, and transfusion; postoperative course including POPF, complications, and postoperative hospital stay; and pathological factors, including diagnosis. POPF was defined according to the International Study Group of Pancreatic Fistula definition [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this study, POPF grades B and C were defined as clinically relevant POPF (CR-POPF). These variables were compared between the stapler and UCS groups for pancreatic transection and further, between hand-sewn closure and PJ of the pancreatic stump in the UCS group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll variables are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous data. Univariate analyses were performed using the Student \u003cem\u003et\u003c/em\u003e-test for continuous variables and chi-squared test for categorical variables. Statistical significance was defined as \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were performed with JMP Pro 17 (SAS Institute Inc., Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinicopathological characteristics of the patients who underwent DP or CP are shown in Table 1. The mean patient age was 66.4 ± 15.7 years, and of these 164 patients, 78 were women and 86 were men.\u0026nbsp;DP was performed in 158 patients and CP in 6 patients. The pancreas was transected to the right of the PV in 14 (9%) patients.\u0026nbsp;Mean operation time was 353 ± 110 min, and mean blood loss was 517 ± 634 mL. CR-POPF occurred in 30 (18%) patients, and the mean postoperative hospital stay was 23.3 ± 18.1 days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of perioperative factors for pancreatic transection using stapler and ultrasonic dissector\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe pancreas was transected with a stapler in 150 patients (stapler group) and UCS in 14 patients (UCS group). There were no significant differences between the two groups in preoperative factors and diagnosis. For operative factors, however, the rate of laparoscopic surgery in the stapler group was higher than that in the UCS group. The pancreas was more frequently transected to the right of the PV in the UCS group versus stapler group. There were no significant differences in operation time and blood loss between the groups. The rate of POPF was higher (50% vs 15%, P = 0.004) and the postoperative hospital stay was longer (34.6 ± 24.1 vs 22.2 ± 17.1 days, P = 0.014) in the stapler group than those in the UCS group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase series of patients with pancreatic stump divided with UCS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDetails of the patients whose pancreas was transected with UCS are shown in Table 3. Open surgery was performed in all of these patients. As described above, PJ of the pancreatic stump was performed in all cases from 2022 because hand-sewn closure of the stump resulted in a high incidence of POPF, and since then, there have been no cases of POPF. Among the cases in which PJ of the pancreatic stump was not performed were many cases with pancreatic ductal adenocarcinoma, including two cases of DP with celiac axis resection, and it is possible that many cases involved more difficult surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of perioperative factors between hand-sewn closure (HS group) and pancreaticojejunostomy of the pancreatic stump (PJ group)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePJ of the pancreatic stump was performed on 7 patients, 4 with DP and 3 with CP. The BMI of the PJ group was lower than that of the HS group. The PJ group had shorter operation time (312 ± 82 vs 479 ± 126 min, P = 0.012) and less blood loss (286 ± 360 vs 921 ± 510 mL, P = 0.019) than the HS group. The rate of POPF was zero in the PJ group, and the rates of both POPF and complications in the PJ group were significantly lower than those in the HS group. The length of postoperative hospital stay was also significantly shorter in the PJ group versus HS group (16.0 ± 4.4 vs 53.1 ± 20.9 days, P = 0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed a higher incidence of CR-POPF and longer postoperative hospital stay when the pancreas was divided using UCS. One reason for this result is that UCS were only used in special situations. PJ of the pancreatic stump after using UCS decreased the rate of CR-POPF. As PJ was performed for the pancreatic stump to the right of the PV and the pancreas and jejunum used for anastomosis are opposite that in the usual PJ in pancreaticoduodenectomy (PD), the difficulty of this procedure may be higher than that for the usual PJ in PD. However, no CR-POPF occurred after PJ of the pancreatic stump in this patient series. Pancreatic juice was drained to both the duodenum and the jejunum, and all PJ procedures on the stump were performed by board-certified expert surgeons. These may be the reasons for the good outcomes obtained following PJ of the stump.\u003c/p\u003e \u003cp\u003eSeveral approaches to pancreatic stump closure have been described in the literature, but the most effective method to prevent CR-POPF remains to be proven. In a large series by Ferrone et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], different closure techniques were compared between hand-sewn closure, stapler with or without staple line reinforcement, use of free falciform patches, and pancreatic duct ligation, but there was no significant difference in the rates of CR-POPF. The DISPACT trial [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], in which two groups of patients were randomly assigned to stapler or hand-sewn closure of the pancreatic stump, showed no difference in the rates of CR-POPF. Stapler closure of the pancreatic stump is technically easy and has become popular with many surgeons as the performance of minimally invasive surgery has spread. The incidence of overall POPF in the DISPACT trial was 32%, which was a higher rate than those in other recent studies. Stapler techniques such as pre-firing compression of the pancreas have improved the rate of POPF in DP [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Good results with the use of artificial patches or fibrin-glue sealant have also been described in small series, but thus far, large series have failed to prove their efficacy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough transection at the pancreatic neck is suggested to be more reasonable [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], pancreatic transection may be performed to the right of the PV depending on the location of the tumor in DP or CP. Stapler closure of the pancreatic stump is not suitable in such a situation, and the surface of the pancreatic stump is often wider. The pancreatic stump is usually closed by ligating or suturing the main pancreatic duct and suturing the pancreatic parenchyma, but the incidence of POPF is very high under these poor conditions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In the present series, the rate of POPF was higher in the UCS group than in the stapler group, partly because surgical conditions such as pancreatic transection performed to the right of the PV and near the tumor in the patients in the UCS group were worse.\u003c/p\u003e \u003cp\u003eSeveral studies have reported the effect of PJ of the pancreatic stump. Wagner et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] examined the efficacy of PJ of the pancreatic stump compared to hand-sewn closure, and they found a zero rate of CR-POPF in the PJ group compared to a 20% rate of PF in the hand-sewn group. Meniconi et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] also reported the superiority of PJ, which had a zero rate of CR-POPF compared to hand-sewn closure. Kawai et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported on a prospective, randomized, multicenter study of PJ versus stapler closure of the pancreatic stump during DP. The rate of CR-POPF in the PJ group tended to be lower than that in the stapler closure group for patients with a thicker pancreas, although no statistical significance was shown. Furthermore, PJ did not increase postoperative complications including those of intra-abdominal abscess and ileus, although PJ of the pancreatic stump may have some risks due to intestinal division and contamination with intestinal juice. However, CR-POPF after PJ may become more severe due to activation of pancreatic enzymes and bacterial contamination. Despite this possibility, our series showed good results similar to those of previous reports, and PJ was effective because of decompression of the main pancreatic duct, especially when hand-sewn closure results in a high rate of CR-POPF in poor conditions.\u003c/p\u003e \u003cp\u003eCP is one of the parenchyma-sparing surgeries and is recommended for benign or low-grade malignant pancreatic neoplasms in the body and neck of the pancreas. The size of the remnant pancreas suggests that exocrine and endocrine functions are better preserved. However, CP leaves two divided pancreatic remnants, increasing the opportunities for CR-POPF. Previous meta-analyses showed higher incidences of CR-POPF following CP than after PD or DP [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The reported rate of CR-POPF in CP ranged from 26 to 63% [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Sho et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported a low rate of POPF of 8% in CP when using double PJ. In our series, we performed CP in 6 patients, with and without PJ performed for the proximal pancreatic stump in 3 patients each. CR-POPF occurred in 2 (66%) patients without PJ and no patients with PJ. Thus, PJ for the proximal pancreatic stump as an alternative to closure may also be useful in CP.\u003c/p\u003e \u003cp\u003eThis study has some limitations. These are the results of a retrospective non-randomized analysis of a small group of patients. Furthermore, recent improvements in the perioperative course may be related to many other factors, such as changes in the operative instruments used, surgeons, and postoperative management. It will thus be important to confirm these data in a larger series of patients.\u003c/p\u003e \u003cp\u003eIn conclusion, PJ of the pancreatic stump during DP or CP reduces the incidence of CR-POPF compared with hand-sewn closure, especially when the pancreas is transected to the right of the PV.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval \u0026nbsp;\u003c/strong\u003eThe protocol for this study was approved by the Ethics Committee of the study center (Oita University, approval number: 2744) and complies with the Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate \u0026nbsp;\u003c/strong\u003eAll participants provided informed consent for participation in this study and for the use of their medical records through an optout form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest \u0026nbsp;\u003c/strong\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u0026nbsp; Study conception and design: TH, AF, YN, HO, SA, MK, TK, YK, TM, YE, MI. Acquisition of data: TH, AF, YN, HO, SA, MK, TK, YK, TM, YE, MI. Analysis and interpretation of data: TH, AF. Drafting of manuscript: TH, AF. Critical revision of manuscript: MI. All authors read and approved the final manuscript before submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ede Rooij T, van Hilst J, van Santvoort H et al (2019) Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg 269:2\u0026ndash;9\u003c/li\u003e\n\u003cli\u003eZhou J, Lv Z, Zou H et al (2020) Up-to-date comparison of robotic-assisted versus open distal pancreatectomy: a PRISMA-compliant meta-analysis. Medicine (Baltimore) 99:e20435\u003c/li\u003e\n\u003cli\u003eLai EC, Tang CN (2013) Current status of robot-assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a comprehensive review. Asian J Endosc Surg 6:158\u0026ndash;164\u003c/li\u003e\n\u003cli\u003evan Bodegraven EA, den Haring FET, Pollemans B et al (2023) Nationwide validation of the distal fistula risk score (D-FRS). Langenbecks Arch Surg 409:14\u003c/li\u003e\n\u003cli\u003eVan Buren G 2nd, Bloomston M, Schmidt CR et al (2017) A prospective randomized multicenter trial of distal pancreatectomy with and without routine intraperitoneal drainage. Ann Surg 266:421\u0026ndash;431\u003c/li\u003e\n\u003cli\u003eBi S, Liu Y, Dai W et al (2023) Effectiveness and safety of central pancreatectomy in benign or low-grade malignant pancreatic body lesions: a systematic review and meta-analysis. Int J Surg 109:2025\u0026ndash;2036\u003c/li\u003e\n\u003cli\u003eFerrone CR, Warshaw AL, Rattner DW et al (2008) Pancreatic fistula rates after 462 distal pancreatectomies. Stapler do not decrease fistula rates. J Gastrointest Surg 12:1691\u0026ndash;1698\u003c/li\u003e\n\u003cli\u003eDiener MK, Seiler CM, Rossion I et al (2011) Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 377:1514\u0026ndash;1522\u003c/li\u003e\n\u003cli\u003eKleeff J, Diener MK, Z\u0026rsquo;graggen K et al (2007) Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 245:573\u0026ndash;582\u003c/li\u003e\n\u003cli\u003eWagner M, Gloor M, Amb\u0026uuml;hl M et al (2007) Roux-en-Y drainage of the pancreatic stump decreases pancreatic fistula after distal pancreatic resection. J Gastrointest Surg 11:303\u0026ndash;308\u003c/li\u003e\n\u003cli\u003eMeniconi RL, Caronna R, Borreca D , Schiratti M, Chirletti P (2013) Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis. BMC Surg 2:13\u0026ndash;23\u003c/li\u003e\n\u003cli\u003eKawai M, Hirono S, Okada K et al (2016) Randomized controlled trial of pancreaticojejunostomy versus stapler closure of the pancreatic stump during distal pancreatectomy to reduce pancreatic fistula. Ann Surg 264:180\u0026ndash;187\u003c/li\u003e\n\u003cli\u003eBassi C, Marchegiani G, Dervinis C et al (2017) The 2016 update of the international study group (ISGPF) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161:584\u0026ndash;591\u003c/li\u003e\n\u003cli\u003eNakamura M, Ueda J, Kohno H et al (2011) Prolonged peri-firing compression with a linear stapler prevents pancreatic fistula in laparoscopic distal pancreatectomy. Surg Endosc 25:867\u0026ndash;871\u003c/li\u003e\n\u003cli\u003eHirashita T, Ohta M, Yada K et al (2018) Effect of pre-firing compression on the prevention of pancreatic fistula in distal pancreatectomy. Am J Surg 216:506\u0026ndash;510\u003c/li\u003e\n\u003cli\u003eTieftrunk E, Demir IE, Schorn S et al (2018) Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: meta-analysis and single-center experience. PLoS One 13:e0197553\u003c/li\u003e\n\u003cli\u003eMungroop TH, van der Heijde N, Busch OR et al (2021) Randomized clinical trial and meta-analysis of the impact of a fibrin sealant patch on pancreatic fistula after distal pancreatectomy: CPR trial. BJS Open 5:zrab001\u003c/li\u003e\n\u003cli\u003eHirono S, Kawai M, Okada KI et al (2021) Division of the pancreas at the neck reduces postoperative pancreatic fistula in laparoscopic distal pancreatectomy: comparison of pancreatic division at the body. Pancreatology 21:480\u0026ndash;486\u003c/li\u003e\n\u003cli\u003eChandrashekhar SH, Ismail S, Jonnada PK, Senadhipan B, Karunakaran M, Barreto SG (2023) Extended distal pancreatectomy in pancreatic cancer: is it justified? A systematic review of literature. Future Oncol 19:873\u0026ndash;885\u003c/li\u003e\n\u003cli\u003eXiao W, Zhu J, Peng L, Hong L, Sun G, Li Y (2018) The role of central pancreatectomy in pancreatic surgery: a systematic review and meta-analysis. HPB (Oxford) 20:896\u0026ndash;904\u003c/li\u003e\n\u003cli\u003eDragomir MP, Sabo AA, Petrescu GED, Li Y, Dumitrascu T (2019) Central pancreatectomy: a comprehensive, up-to-date meta-analysis. Langenbecks Arch Surg 404:945\u0026ndash;958\u003c/li\u003e\n\u003cli\u003eLee DH, Han Y, Byun Y, Kim H, Kwon W, Jang JY (2020) Central pancreatectomy versus distal pancreatectomy and pancreaticoduodenectomy for benign and low grade malignant neoplasms: a retrospective and propensity score-matched study with long-term functional outcomes and pancreas volumetry. Ann Surg Oncol 27:1215\u0026ndash;1224\u003c/li\u003e\n\u003cli\u003eSho M, Akahori T, Nagai M et al (2015) Central pancreatectomy with double pancreaticojejunostomy. J Am Coll Surg 221:e15\u0026ndash;e19\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u0026nbsp; Patient characteristics (\u003cem\u003en\u003c/em\u003e = 164)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e66.4\u0026nbsp;\u0026plusmn; 15.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eSex (female/male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e78 (48%)/86 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e23.1 \u0026plusmn; 4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003ePancreatic cancer/Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e67 (41%)/97 (59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eOperative factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eDP/CP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e158 (96%)/6 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eOpen/Laparoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e80 (49%)/84 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003ePancreatic transection (right of PV/above or left of PV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e14 (9%)/150 (91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003ePancreatic transection (stapler/UCS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e150 (91%)/14 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eOperation time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e353 \u0026plusmn; 110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e517 \u0026plusmn; 634\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e26 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative course\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003ePOPF (\u0026ge;\u0026nbsp;grade B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e30 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003eClavien-Dindo (\u0026ge;\u0026nbsp;grade 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e32 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"70.01763668430335%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.98236331569665%\" valign=\"top\"\u003e\n \u003cp\u003e23.3 \u0026plusmn; 18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e body mass index, \u003cem\u003eDP\u003c/em\u003e distal pancreatectomy, \u003cem\u003eCP\u003c/em\u003e central pancreatectomy, \u003cem\u003eUCS\u003c/em\u003e ultrasonic coagulating shear, \u003cem\u003ePOPF\u003c/em\u003e postoperative pancreatic fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u0026nbsp; Perioperative factors of pancreatic transection using a stapler\u0026nbsp;vs. ultrasonic coagulation shears (UCS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003eStapler\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003eUCS\u003c/p\u003e\n \u003cp\u003e(n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e65.7 \u0026plusmn; 16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e74.1 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eSex (female/male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e71 (47%)/79 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e7 (50%)/7 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.849\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e23.1 \u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e22.7 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.776\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003ePancreas cancer/Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e60 (40%)/90 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e6 (43%)/8 (57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.835\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eOperative factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eDP/CP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e149 (99%)/1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e9 (64%)/5 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eOpen/Laparoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e66 (44%)/84 (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e14/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003ePancreatic transection (right of PV/above or left of PV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1%)/149 (99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e13 (93%)/1 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eOperation time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e349 \u0026plusmn; 108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e395 \u0026plusmn; 134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e509 \u0026plusmn; 644\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e602 \u0026plusmn; 538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.599\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e22 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e4 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.417\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative course\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003ePOPF (\u0026ge;\u0026nbsp;grade B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e23 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e7 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003eComplications (\u0026ge;\u0026nbsp;Clavien-Dindo III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e25 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e7 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.650998824911866%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e22.2 \u0026plusmn; 17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91891891891892%\" valign=\"top\"\u003e\n \u003cp\u003e34.6 \u0026plusmn; 24.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.511163337250293%\" valign=\"top\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e body mass index; \u003cem\u003eDP\u003c/em\u003e distal pancreatectomy; \u003cem\u003eCP\u003c/em\u003e central pancreatectomy; \u003cem\u003ePV\u003c/em\u003e portal vein; \u003cem\u003ePOPF\u003c/em\u003e postoperative pancreatic fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"954\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"89.10994764397905%\" colspan=\"9\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u0026nbsp; Case series of pancreatic stumps divided with an ultrasonic dissector\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.890052356020943%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003eAge/Sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePancreato-jejunostomy of pancreatic stump\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eOperation time\u003c/p\u003e\n \u003cp\u003e(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003ePOPF\u003c/p\u003e\n \u003cp\u003e(\u0026ge;\u0026nbsp;grade B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003eComplication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative hospital stay\u003c/p\u003e\n \u003cp\u003e(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e75/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e455\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e75/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003enone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e72/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP-CAR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e556\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e1380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e78/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eIPMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e1210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e72/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e469\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e1260\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e73/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP-CAR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e585\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e1320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e62/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePanNET\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e455\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e71/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eStenosis of MPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e74/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eIPMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e70/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eRCC metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e77/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eIPMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003eChylous ascites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e83/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eITPN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e1090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003eAscites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e78/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eRCC metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.9748427672955975%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.966457023060797%\" valign=\"top\"\u003e\n \u003cp\u003e77/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003ePDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003eDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.836477987421384%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.90985324947589%\" valign=\"top\"\u003e\n \u003cp\u003e337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.918238993710692%\" valign=\"top\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.853249475890985%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.89308176100629%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.90146750524109%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePDAC\u003c/em\u003e pancreatic ductal adenocarcinoma; \u003cem\u003eIPMC\u003c/em\u003e intraductal papillary mucinous carcinoma, \u003cem\u003ePanNET\u003c/em\u003e pancreatic neuroendocrine tumor; \u003cem\u003eMPD\u003c/em\u003e main pancreatic duct; \u003cem\u003eIPMA\u003c/em\u003e intraductal papillary mucinous adenoma; \u003cem\u003eRCC\u003c/em\u003e renal cell carcinoma; \u003cem\u003eITPN\u003c/em\u003e intraductal tubulopapillary neoplasm; \u003cem\u003eDP\u003c/em\u003e distal pancreatectomy\u003cem\u003e; DP-CAR\u003c/em\u003e distal pancreatectomy with celiac axis resection; \u003cem\u003eCP\u003c/em\u003e central pancreatectomy; \u003cem\u003ePOPF\u003c/em\u003e postoperative pancreatic fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u0026nbsp; Comparison of perioperative factors between hand-sewn closure\u0026nbsp;and pancreaticojejunostomy (PJ)\u0026nbsp;of the pancreatic\u0026nbsp;stump\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003eHand-sewn closure (n=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003ePJ of the\u0026nbsp;pancreatic\u0026nbsp;stump\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(n=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e71.9 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e76.3 \u0026plusmn; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eSex (female/male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e4/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e2/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.592\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e24.4 \u0026plusmn; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e20.8 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003ePancreas cancer/Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e4/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e2/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.276\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eOperative factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eDP/CP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e5/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e4/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.576\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eOpen/Laparoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e7/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e7/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eOperation time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e479 \u0026plusmn;\u0026nbsp;126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e312 \u0026plusmn;\u0026nbsp;82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e921\u0026nbsp;\u0026plusmn;\u0026nbsp;510\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e283 \u0026plusmn;\u0026nbsp;360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e3/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e7/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative course\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003ePOPF (\u0026ge;\u0026nbsp;grade B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e7 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003eComplication (\u0026ge;\u0026nbsp;Clavien-Dindo III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e7 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.38745387453874%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91020910209102%\" valign=\"top\"\u003e\n \u003cp\u003e53.1\u0026nbsp;\u0026plusmn;\u0026nbsp;20.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.247232472324722%\" valign=\"top\"\u003e\n \u003cp\u003e16.0 \u0026plusmn;\u0026nbsp;4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.45510455104551%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e body mass index, \u003cem\u003eDP\u003c/em\u003e distal pancreatectomy, \u003cem\u003eCP\u003c/em\u003e central pancreatectomy, \u003cem\u003ePOPF\u003c/em\u003e postoperative pancreatic fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"central pancreatectomy, distal pancreatectomy, pancreaticojejunostomy, pancreatic fistula","lastPublishedDoi":"10.21203/rs.3.rs-3998411/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3998411/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eA stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003ePatients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay longer in the stapler group than in the UCS group.\u003cstrong\u003e \u003c/strong\u003ePJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003ePJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.\u003c/p\u003e","manuscriptTitle":"Efficasy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-04 19:04:57","doi":"10.21203/rs.3.rs-3998411/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-13T07:43:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-12T15:48:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6479ca14-d739-410e-87b9-8249c6556d9f","date":"2024-04-07T13:48:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7d7dc421-cde3-49d0-b817-c29b3e3cd9cb","date":"2024-03-17T07:17:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-16T13:51:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-02T10:36:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-29T06:59:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-02-29T03:34:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"fa68b9d7-bd56-476f-ba62-4d42537ae679","owner":[],"postedDate":"March 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-05-07T20:00:06+00:00","versionOfRecord":{"articleIdentity":"rs-3998411","link":"https://doi.org/10.1007/s00423-024-03335-7","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2024-04-30 19:57:29","publishedOnDateReadable":"April 30th, 2024"},"versionCreatedAt":"2024-03-04 19:04:57","video":"","vorDoi":"10.1007/s00423-024-03335-7","vorDoiUrl":"https://doi.org/10.1007/s00423-024-03335-7","workflowStages":[]},"version":"v1","identity":"rs-3998411","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3998411","identity":"rs-3998411","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}