Systematic review and meta‐analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy. BJS 2015; 102: 4-15.

Published: 12th November 2014

Authors: H. Zhang, F. Zhu, M. Shen, R. Tian, C. J. Shi, X. Wang et al.


Established closure techniques for the pancreatic remnant after distal pancreatectomy include stapler, suture and anastomotic closure. However, controversy remains regarding the ideal technique; therefore, the aim of this study was to compare closure techniques and risk of postoperative pancreatic fistula (POPF).


A systematic review was carried out according to PRISMA guidelines for studies published before January 2014 that compared at least two closure techniques for the pancreatic remnant in distal pancreatectomy. A random‐effects model was constructed using weighted odds ratios (ORs).


Thirty‐seven eligible studies matched the inclusion criteria and 5252 patients who underwent distal pancreatectomy were included. The primary outcome measure, the POPF rate, ranged 0 from to 70 per cent. Meta‐analysis of the 31 studies comparing stapler versus suture closure showed that the stapler technique had a significantly lower rate of POPF, with a combined OR of 0·77 (95 per cent c.i. 0·61 to 0·98; P = 0·031). Anastomotic closure was associated with a significantly lower POPF rate than suture closure (OR 0·55, 0·31 to 0·98; P = 0·042). Combined stapler and suture closure had significantly lower POPF rates than suture closure alone, but no significant difference compared with stapler closure alone.


The use of stapler closure or anastomotic closure for the pancreatic remnant after distal pancreatectomy significantly reduces POPF rates compared with suture closure. The combination of stapler and suture closure shows superiority over suture closure alone.

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Kirsty McFarlane

3 years ago

Dear editors,

As the authors of the DISPACT-trial (1), we read with interest the recently published article “Systematic review and meta-analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy” by Zhang et al. (2).

In our opinion, the conclusion that stapler closure significantly reduces postoperative pancreatic fistula (POPF) rates is not vigorously supported by the data presented. There are several sources of bias, which are only peripherally discussed and completely ignored in the conclusion process. First of all, it is well known that nonrandomised studies with a small sample size introduce potential bias (3). Furthermore, the methodological quality of the individual trials is not taken into account neither in the analysis nor in the conclusions. Since critical appraisal is one of the key features in the conduct of a systematic review and meta-analysis, this should be part of every systematic review.

In addition, the results of all of the conducted subgroup analyses (study design, clinically relevant POPF, ISGPF definition of POPF) were contradictious to the results of the primary analysis, thus showing no significant difference between stapler and suture closure. The use of well-defined endpoints, such as the ISGPF definition of POPF (4), is crucial to surgical trials and this subgroup analysis is therefore highly important.

The article by Zhang et al. (2) reanimates a formerly resolved discussion with deficient methodology. Instead of repeating such trials and meta-analyses, investigators of individual studies should bundle their efforts to conduct another high-quality multicentre and multinational RCT, e.g. from the US or Asia, to finally end this discussion.

Markus K. Diener
Felix J. Hüttner
Pascal Probst
Markus W. Büchler

Department of General, Visceral and Transplantation Surgery
University of Heidelberg
69120 Heidelberg

1. Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 2011; 377: 1514-1522.
2. Zhang H, Zhu F, Shen M, Tian R, Shi CJ, Wang X, et al. Systematic review and meta-analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy. Br J Surg 2015; 102: 4-15.
3. Ioannidis JP, Haidich AB, Pappa M, Pantazis N, Kokori SI, Tektonidou MG, Contopoulos-Ioannidis DG, Lau J. 1. Comparison of evidence of treatment effects in randomized and nonrandomized studies. JAMA 2001; 286: 821-830.
4. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8-13.