Stapler cartridge selection according to the pancreatic characteristics in distal pancreatectomy

Introduction: Stapler closure is a popular method for stump closure in distal pancreatectomy (DP). However, research on which cartridges are suitable for different pancreatic thickness and texture is lacking. The purpose of this study was to identify the optimal stapler cartridge choice in DP according to pancreatic characteristics. Method: From November 2011 to May 2018, data were prospectively collected from 599 consecutive patients who underwent DP with 3-layer endoscopic stapler closure regardless open or laparoscopic surgery in Seoul National University Hospital and Samsung Medical Center Korea. Postoperative pancreatic fistula (POPF) was graded according to International Study Group on Pancreatic Fistula definitions. Staplers were grouped based on closed length (CL) (Group I: CL ≤ 1.5mm, II: 1.5 mm < CL < 2mm, III: CL ≥ 2mm). Distribution of pancreatic thickness was used to find the cut-off point of thickness which predicts POPF according to stapler groups. Result: POPF including biochemical leak developed in 372 (62.1%) patients (biochemical leak; n=262 [43.7%], B; n=44 [18.4%]). The numbers in each stapler group were 220 (36.7%), 169 (28.2%), and 210 (35.1%), respectively. Mean thickness was higher in POPF cases (16.5 mm vs 18.3 mm, p < 0.001). High body mass index (p=0.010) and thick pancreas (p=0.001) were independent risk factors for POPF in multivariate analysis. Pancreatic thickness was grouped into <13 mm, 13 to 22 mm, and >22 mm. In thin pancreas group (pancreatic thickness <13mm) the POPF rate was lowest with Group II (I: 53.5%, II: 21.7%, III: 36.0%, P=0.037). Conclusion: The optimal stapler cartridges with pancreatic thickness <13mm were those in Group II (CL: 1.8mm). There was no suitable cartridge for thicker pancreases. Further studies are necessary to reduce POPF rate in thick pancreases.