Review question

Is surgical tissue adhesive able to reduce postoperative pancreatic fistula after pancreatic surgery?

Background

Postoperative pancreatic fistula is a complication that may follow major surgery for cancer or inflammation of the pancreas, a digestive gland situated at the back of the upper abdomen. The surgery involves disconnecting the pancreas from the nearby gut, and then reconnecting this to allow pancreatic juice containing digestive enzymes to enter the digestive system after surgical removal of the head of the pancreas. The pancreatic stump is often left to heal itself after surgical removal of the tail of the pancreas. A fistula occurs when the reconnection or stump does not heal properly, creating a leak of pancreatic juice from the pancreas to the abdominal tissues. This delays recovery from surgery and often requires further treatment to ensure complete healing. The role of fibrin sealants (surgical tissue adhesives) to reduce postoperative pancreatic fistula after pancreatic surgery is controversial.

Study characteristics

We searched for all relevant, well-conducted studies up to April 2018. We included eleven studies which were divided into three comparisons. First, seven of the eleven studies randomized 860 participants undergoing surgical removal of the tail of the pancreas to either fibrin sealant use (428 participants) or no fibrin sealant use (432 participants) for pancreatic stump closure reinforcement. Second, three studies randomized 251 participants undergoing the ‘Whipple’ operation (surgical removal of the head of the pancreas) to fibrin sealant use (115 participants) or no fibrin sealant use (136 participants) for pancreatic stump reconstruction reinforcement. Third, two studies randomized 351 participants undergoing the ‘Whipple’ operation to fibrin sealant use (188 participants) and no fibrin sealant use (163 participants) for pancreatic duct blockage.

Key results

Application of fibrin sealants to pancreatic stump closure reinforcement after surgical removal of the tail of the pancreas

Fibrin sealants may have little to no difference in postoperative pancreatic fistula or postoperative death when fibrin sealants are used on stump closure reinforcement after surgical removal of the tail of the pancreas.

Application of fibrin sealants to pancreatic anastomosis reinforcement after ‘Whipple’ operation

We are uncertain whether fibrin sealants improve postoperative pancreatic fistula when used for pancreatic anastomosis reinforcement after the ‘Whipple’ operation. Fibrin sealants may have little to no difference on postoperative death.

Application of fibrin sealants to pancreatic duct occlusion after ‘Whipple’ operation

Postoperative pancreatic fistula was not reported in any of the studies. Fibrin sealants may have little to no difference in postoperative death when applied to a pancreatic duct occlusion after ‘Whipple’ operation.

Fibrin sealants may have little or no benefit on postoperative pancreatic fistula in people undergoing surgical removal of the tail of the pancreas. We cannot tell from our results whether fibrin sealants have an important effect on postoperative pancreatic fistula after the ‘Whipple’ operation because the sample size was small and the results were imprecise.

Quality of the evidence

Most of the included studies had some shortcomings in terms of how they were conducted or reported. Overall, the quality of the evidence varied from very low to moderate.