Surgery xxx (2020) 1
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Surgery
journal homepage: www.elsevier.com/locate/surg
Letter to the Editor
Re: Management of the pancreatic transection plane
after left (distal) pancreatectomy: Expert consensus
guidelines by the International Study Group of
Pancreatic Surgery (ISGPS)
To the Editor,
We read with interest the next expert consensus guideline from
the International Study Group of Pancreatic Surgery (ISGPS) titled
“Management of the Pancreatic Transection Plane After Left (Distal)
Pancreatectomy.”1 The authors are to be congratulated on another
notable contribution to an issue where there has been considerable
variation in practice and outcome.
Statement 8-1 of the guidelines state that “additional coverage
of the pancreatic stump with an autologous patch decreases the
POPF [postoperative pancreatic fistula] rate after left pancreatec-
tomy. Quality assessment: moderate; Recommendation: condi-
tional; Agreement: weak.”1 We note that this appears to be based
on 2 low-powered randomized controlled trials (RCTs),2,3 but there
is a recently published network meta-analysis (NMA)4 on this topic
that provides a greater quality of evidence. This NMA indicated that
an autologous patch (round ligament or seromuscular patch)
closure after a suture or stapled closure of the pancreatic stump
was associated with the least rate of clinically relevant POPF.
Sixteen RCTs were reviewed systematically, and an NMA approach
used 8 different techniques of stump closure after distal pancrea-
tectomy.4 Note that studies evaluating laparoscopic approaches,
stenting, and intraperitoneal drainage were excluded. Autologous
patching of the pancreatic stump had the least clinically relevant
POPF rate, volume of intraoperative blood loss, intra-abdominal ab-
scesses, overall complication rate, and 30-day mortality.
Network meta-analysis is now a well-established method and
can be superior to pairwise meta-analyses when multiple arms
are available for comparison.5,6 The methodology uses Bayesian
modeling to form indirect and direct comparisons allowing for
simultaneous comparative outputs from randomized datasets
while maintaining randomization.7 A network meta-analysis of
RCTs constitutes the greatest level of evidence (level 1a) compared
with that offered by an expert consensus alone (level 5a). The weak
agreement regarding Statement 8-1 appears to reflect the poor
quality evidence base used in the guideline.1 It is not a surprise
that despite large absolute differences, the RCTs were not statisti-
cally powered to show a difference for contrasting absolute rates
of clinically relevant POPF (patch 6% versus no patch 14%3 and patch
22% versus no patch 33%2). This type II error is addressed by the
NMA.5,6 These two underpowered RCTs were also conducted before
the ISGPF definition of POPF when there was not distinction be-
tween POPF and clinically relevant POPF. Although the NMA agrees
with Statement 8-1, it would appear that the quality assessment,
recommendation, and level of agreement might have been
different if the best available evidence had been used.
https://doi.org/10.1016/j.surg.2020.04.058
0039-6060/© 2020 Elsevier Inc. All rights reserved.
Conflict of interest/Disclosure
Each author confirms that this manuscript is original and has
not been previously published nor under consideration by another
journal. All authors have substantially contributed to the concep-
tion, drafting and/or critical revision of this manuscript and we
have no conflicts of interest, financial or otherwise, to disclose
Funding/support
None.
References
1. Miao Y, Lu Z, Yeo CJ, et al. Management of the pancreatic transection plane after
left (distal) pancreatectomy: expert consensus guidelines by the International
Study Group of Pancreatic Surgery (ISGPS). Surgery. 2020 Apr 2.
2. Hassenpflug M, Hinz U, Strobel O, et al. Teres ligament patch reduces relevant
morbidity after distal pancreatectomy (the DISCOVER Randomized Controlled
Trial). Ann Surg. 2016;264:723e730.
3. Olah A, Issekutz A, Belagyi T, et al. Randomized clinical trial of techniques for
closure of the pancreatic remnant following distal pancreatectomy (Br J Surg
2009; 96: 602-607). Br J Surg. 2009;96:1222.
4. Ratnayake C, Wells C, Hammond J, et al. Network meta-analysis comparing tech-
niques and outcomes of stump closure after distal pancreatectomy. Br J Surg.
2019;12:1580e1589.
5. Faltinsen EG, Storebø OJ, Jakobsen JC, et al. Network meta-analysis: the highest
level of medical evidence? BMJ Evid Based Med. 2018;23:56e59.
6. Leucht S, Chaimani A, Cipriani AS, et al. Network meta-analyses should be the
highest level of evidence in treatment guidelines. Eur Arch Psychiatry Clinic Neu-
rosci. 2016;266:477e480.
7. Cipriani A, Higgins JPT, Geddes JR, Salanti G. Conceptual and technical challenges
in network meta-analysis. Ann Intern Med. 2013;159:130e137.
Chathura B.B. Ratnayake, MBChB*
Department of Surgery, Faculty of Medical and Health Sciences,
University of Auckland, New Zealand
HPB Unit, Department of General Surgery, Auckland City Hospital,
New Zealand
Colin H. Wilson, MBBS, FRCS, PhD
HPB and Transplant Unit, Freeman Hospital, Newcastle, UK
John A. Windsor, BSc, MBChB, MD, FRACS, FACS
Department of Surgery, Faculty of Medical and Health Sciences,
University of Auckland, New Zealand
HPB Unit, Department of General Surgery, Auckland City Hospital,
New Zealand
Sanjay Pandanaboyana, MBBS, MS, FRCS, MPhil
HPB and Transplant Unit, Freeman Hospital, Newcastle, UK
*
Corresponding author.
E-mail address: crat791@aucklanduni.ac.nz (C.B.B. Ratnayake).
Accepted 29 April 2020