POPF have been reported and have guided strate­gies for its management and prevention. A short list of risk factors for the development of POPF includes pancreatic texture, pathology, duct size, age, intraoperative blood loss, and others [2]. A number of technical factors have also been inves­tigated. Few of these, however, have been dem­onstrated to have an effect on the overall inci­dence of POPF, understandably to the frustration of surgeons and their patients [3]. This chapter considers proposed interventions for the reduc­tion of POPF that have been evaluated in the preoperative, intraoperative, and postoperative settings.

among patients undergoing distal pancreatecto­my, as well as only marginally increased hospital costs, versus robust increases in hospital costs between patients who had grade B and C fistula following pancreaticoduodenectomy [8].

al fibrin sealant administration in the octreotide group [13].

Stenting of the main pancreatic duct at the am­pulla has been investigated as a method to pre­vent postoperative fistula formation after distal pancreatectomy. This again has a clear anatomic rationale, as decompression of the pancreatic tree via drainage across the ampulla would have the effect of decreasing pressure against the pancre­atic stump, thereby reducing the likelihood of leakage from the resection margin. Retrospective data from several centers initially demonstrated some success with the technique. One small se­ries published in 2008 noted a 20 % incidence of mild pancreatitis but no instances of pancreatic leak among ten patients who underwent distal pancreatectomy with prior endoscopic placement of transampullary stent [14]. A second retrospec­tive series involved the intraoperative placement of transampullary stents. In this series, the sur­geons identified the transected duct at the resec­tion margin of the distal pancreatectomy and subsequently advanced a pediatric feeding tube into the duodenum. The transected end of the duct was then ligated. The authors were able to demonstrate an association of intraoperative stent placement with decreased pancreatic fistula rates as well as decreased overall length of stay [15].

atectomy [23]. Indeed, numerous studies have re­ported somewhat favorable results with creation of an anastomosis at the distal pancreatic stump [24]. A large series by Kleef et al. [25] examined 302 patients undergoing distal pancreatectomy with an overall fistula rate of 12 %. Data were gathered prospectively, and four main techniques of pancreatic stump management were described: (1) pancreaticojejunostomy; (2) seromuscular patch; (3) suture of the duct with polydioxanone (PDS) stitch followed by parenchymal closure with PDS suture, with or without collagen patch; (4) closure with a stapler, primarily with a vas­cular load. In this series, a stapled anastomosis was associated with a higher rate of fistula for­mation. As this was a retrospective, single-center review, certain subgroup analyses such as a strict comparison of patient characteristics between the various closure techniques were not reported [25]. Additionally, the use of nonvascular stapler loads, which the authors suggest were occasion­ally used, may be quite significant. One single­center study suggested that the rate of pancreatic fistula was much lower when a vascular (2.5 mm) cartridge was utilized instead of a standard car­tridge or a hand-sewn technique [26]. More re­cently, a large multicenter trial was conducted to answer the question of whether a stapled or hand­sewn technique prevented POPF. The DISPACT trial randomized patients into a stapled or hand­sewn closure of the pancreatic stump. The prima­ry endpoints included combined mortality and/or the detection of pancreatic fistula prior to post­operative day #7. Secondary endpoints included detection of pancreatic fistula up until postopera­tive day #30. No difference in fistula rates was described between the two groups. Additionally, outcomes among a range of clinical factors were similar. A post hoc analysis was conducted within the trial to determine the factors associated with the development of pancreatic fistula and did not reveal any factor to be causative in a multivariate analysis [27].

Ligation of the main pancreatic duct, where technically feasible, has been reported to dra­matically reduce the incidence of pancreatic duct leak in some studies, with conflicting reports in others. The main limitation of data addressing

Mostly, any deviation from the expected clini­cal course in a patient who has undergone distal pancreatectomy should prompt consideration of a pancreatic leak. Pancreatic leaks may present in a latent fashion, or be clinically evident early after resection. If a drain has been left in place, ret­rospective data suggest that features of the drain prior to its removal should not be reassuring with regard to the subsequent consideration of pan­creatic fistula when a patient presents postopera­tively with fever and abdominal pain. The pre­ceding data in this chapter underscore the wide variety of strategies that have been employed to prevent pancreatic exocrine complications after distal pancreatectomy and the very limited suc­cess that any single strategy has enjoyed. Indeed, a recent survey of hepatopancreatobiliary sur­geons worldwide demonstrated that there is little consensus on the management of patients with POPF [40].