An Evidence-Based Beneficial Shortcut for Distal Pancreatic Resection
Mené entre 2016 et 2019 sur 316 patients présentant des tumeurs du corps ou de la queue du pancréas et devant subir une pancréatectomie distale, cet essai randomisé compare, du point de vue de l'incidence d'une fistule pancréatique et/ou d'une hémorragie intra-abdominale, deux techniques d'isolation de la veine splénique du parenchyme pancréatique
Pancreatic surgery is major surgery, which should be centralized into units with adequate expertise, experience, and facilities. Operative technique modifications in major surgery can be challenging to implement in clinical practice. Surgeons are often used to their established routines and thus reluctant to any changes and even potential improvements. For example, distal pancreatectomy is often performed by dissection and isolation of the splenic vein from the pancreatic parenchyma prior to ligation.In this issue of JAMA Surgery, Yamada et al report a large multicenter phase 3 randomized clinical trial, the Combined Resection vs Separated Resection After Mobilization of Splenic Vein During Distal Pancreatectomy (COSMOS-DP) trial, comparing combined division of the splenic vein with pancreatic parenchyma with separate splenic vein division in distal pancreatectomy. This trial of 316 eligible patients with a primary end point of grade B or C pancreatic fistula incidence demonstrated noninferiority of the combined division. There were no significant differences between the groups in the percentage of patients requiring staple-line hemostasis or the incidence of pancreatic injury. At present, with any kind of technique of pancreatic resection, the risk for pancreatic fistula remains. Therefore, close perioperative follow-up is needed, as was recommended by the authors. Furthermore, various prophylactic measures to reduce the risk of leakage should be considered. The authors were unable to show differences in the operation time. However, from a clinical perspective, it is fair to assume that dissecting the splenic vein concurrently with pancreatic parenchyma instead of first dissecting the splenic vein separately saves some precious operating room time.
JAMA Surgery , éditorial, 2020