Practical aspects of distal pancreatectomy

From 1979 to 1984, 54 pancreatectomies have been performed, including 20 distal pancreatectomies. The primary pathology was tumour (benign insulinoma 3, malignant vipoma 3, mixed endocrine tumours 3, cystadenoma 1 and cystadenocarcinoma 1), pancreatitis (acute 5, chronic 2) and trauma (2). Tumours were reliably located pre-operatively by angiography, CT and ultrasound, and pancreatic cysts (3) were accurately defined with CT and ultrasound. Radiological visualisation of the pancreatic duct with ERCP or operative pancreatography demonstrated ductal strictures in 5 cases of pancreatitis. Since the tumours are often large (up to 12 cm in diameter) and invading the mesocolon, pre-operative bowel preparation is used routinely in the event colonic resection is required. Approaching these tumours from below the transverse mesocolon allows easier identification of the vasculature. We prefer to transect the normal pancreas with a GIA stapler but to oversew the pancreatic stump with silk if the pancreas is inflamed. Enteral drainage of the stump was performed in 3 cases. Four patients died (2 with tumour and 2 with pancreatitis), all of whom developed intra-abdominal sepsis postoperatively. Three other patients had life-threatening complications (pancreatic and intra-abdominal abscess, faecal fistula and septicaemia). Risk factors predisposing to severe postoperative complications including pre-existing malnutrition (p = 0.025), infection (p = 0.014), inflammation of the gland (p = 0.016), or previous pancreaticobiliary operations (p = 0.003, Fischer's exact test). Three other patients had short-lived pancreatic fistulae which closed spontaneously, and 1 became diabetic.