Reply to Comment on “Teres Ligament Patch Reduces Relevant Morbidity After Distal Pancreatectomy (the DISCOVER Randomized Controlled Trial)”

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Reply:
We thank Dres. Chen, Chen, and Zhao for their interest and comments on our previously published randomized controlled trial (DISCOVER) on the effect of a teres ligament flap to reduce pancreas-associated morbidity after distal pancreatectomy.1 As they report their experience with beneficial outcomes of this technique consistent with our results, this underlines the potential of this simple surgical modification to improve outcomes of distal pancreatectomy. Especially as multiple other approaches aiming at the transection technique and closure modifications of the pancreatic remnant have failed in the past,2–4 there is still an urgent need to increase study activities and gain evidence on this surgical problem, as postoperative pancreatic fistula remains the most frequent and potentially dangerous complication after distal pancreatectomy.5 The technical difficulties to utilize the teres ligament mentioned by Dr Chen and colleagues may occur due to a lack of length or a small diameter of the ligament. However, we believe that in most patients, a sufficient pedicled soft tissue flap can be created to cover the resection margin. The alternative use of gastric or bowel serosa may be considered; however, there are no high-quality studies that have proven the effect of these alternative methods. The observation of fluid collections at the resection margin that the authors mention has been described and has to be differentiated from pancreatic fistula. Regardless of any coverage procedure, fluid collections are found in 40% to 50% of all patients after distal pancreatectomy. They rarely require any therapeutic intervention, but mostly resolve in the long-term follow-up.6 We certainly agree that a teres ligament coverage can also be performed in laparoscopic procedures and may show comparable benefits as in the open setting.
As the authors state that they have performed this procedure in large numbers of patients with beneficial results, we would strongly encourage them to perform a randomized controlled trial to support this statement and contribute to the scientific discussion to generate more evidence for potential changes in future clinical practice.
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