• Giuseppe Zimmitti, Roberta La Mendola, Alberto Manzoni, Valentina Sega, Valentina Malerba, Elio Treppiedi, Claudio Codignola, Lorenzo Monfardini, Marco Garatti, and Edoardo Rosso.
• Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy. gzimmitti@hotmail.com.
• Surg Endosc. 2021 Feb 1; 35 (2): 941-954.

IntroductionPostoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) remains the most frequent complication, potential precursor of more serious events, and mechanisms behind POPF development are not clear. Primary aim of the current study is to investigate correlations between patients' characteristics, including technical intraoperative data assessed by retrospective video review of laparoscopic DP (L-PD), and development of clinically relevant (CR-)POPF and major complication.MethodsPatients undergoing L-DP whose surgery video was available for review were included in this study. Retrospective video review, performed by two surgeons blinded for postoperative outcomes, was focused on pancreatic neck transection and identification of pancreatic capsule disruption (PCD)/staple line bleeding (SLB). Correlation between clinical, demographic, and intraoperative factors and CR-POPF/major complications and assessment of factors associated with PCD and SLB were investigated.ResultsOf 41 L-DP performed at our institution (June 2015-June 2020) using a triple-row stapler (EndoGIA™ Reloads with Tri-Staple™), surgery video was available for 38 patients [men/women, 13/25; median age (range) 62 (25-84) years; median BMI (range) 24 (17-42)]. PCD and SLB occurred in 15(39%) and 19(50%) patients and were concomitant in 9(24%). CR-POPF and major complications occurred in 8(21%) and 12(31%) patients, respectively. PCD, SLB, and PCD + SLB rates were significantly higher among patients with CR-POPF, compared to patients without (all p < 0.05). Among patients with PCD, pancreatic thickness at pancreatic transection site was higher (19 mm), compared to non-PCD patients (13 mm, p < 0.001). A directly proportional relation between PCD, CR-POPF, and major complication rate and pancreatic thickness was confirmed by ROC analysis (AUC = 0.949, 0.798, and 0.740, respectively).ConclusionPCD and SLB close to the staple line detected by retrospective video-review are intraoperatively detectable indicators of severe pancreatic traumatism and a potential precursors of CR-POPF following L-PD. Given the strict correlation between PCD and pancreatic thickness, alternative techniques to stapled closure for pancreatic transection may be recommended for patients with a thick pancreas and modification in postoperative care may be considered in patients with PCD/SLB.

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