P. J. Arnold1, A. D. Meagher1, J. Belchos1, 3, C. Robbins1, D. Ortiz1, 2, I. Ferries3, J. L. Hartwell1 1Indiana University School Of Medicine, Department Of Surgery, Indianapolis, IN, USA 2Sidney & Lois Eskenazi Hospital, Indianapolis, IN, USA 3Ascension St. Vincent Hospital, Indianapolis, IN, USA
Introduction:
Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in cases of adult splenectomy following trauma are reported to occur in 1-3% of cases. Incidence of this complication leads to increased mortality rates, length-of-stays (LOS), and costs for patients. In cases where no previous pancreatic injury was noted, we hypothesized that the use of sutures in splenic hilum ligation instead of staples reduced the rate of incidence.
Methods:
Adult trauma patients (age ≥17 years) that underwent non-elective splenectomy from 2010-2020 were retrospectively evaluated from the hospital trauma registries of all three adult Level 1 trauma centers in the state of Indiana: Indiana University Methodist Hospital, Eskenazi Hospital, and Ascension St. Vincent Hospital. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 hours of hospital admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. Clinically relevant POPF (Grade B and Grade C) were defined and identified based on the 2016 update of the International Study Group of Pancreatic Fistula.
Results:
Between 2010 and 2020, 419 adult splenectomies following trauma were conducted at Level 1 trauma centers in the state of Indiana; 278 passed exclusion criteria and were included in our analysis. CR-POPF developed in 14 cases (5.0%). Sutures alone across hilar structures were used in 200 cases, 7 of which developed CR-POPF (3.5%). Staples alone were used in 46 cases, 4 of which developed CR-POPF (9.5%). A combination of staples and sutures was used in 28 cases, 3 of which developed CR-POPF (10.7%). 4 cases did not report their technique, but POPF did not develop in any of these patients. Controlling for demographic and clinical factors, the use of sutures alone was associated with a lower rate of CR-POPF compared to the use of any staples, either alone or combined with sutures (p=.060). Patients that developed CR-POPF had a mean LOS of 38.09 days, compared to 18.04 days in patients that did not (p=.005).
Conclusion:
In our 10-year retrospective review of POPF, we find the complication to be rare but morbid, with statistically significant (p<.01) prolonged length of hospital stays that require multiple imaging studies and interventions, leading to increased costs. We identified a protective effect of borderline significance (p<.10) when sutures alone are used in splenic hilum ligation compared to any form of staples, alone or in combination. We propose a new institutional norm that CR-POPF develop in 5.0% of traumatic splenectomies and conclude that further study of optimal technique for emergent splenectomy is warranted.