Comment on "Teres Ligament Patch Reduces Relevant Morbidity After Distal Pancreatectomy (the DISCOVER Randomized Controlled Trial)"

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To the Editor:
The paper “Teres ligament patch reduces relevant morbidity after distal pancreatectomy (the DISCOVER randomized controlled trial)1” presented a simple and feasible technique for preventing postoperative pancreatic fistula (POPF). We have also been exploring this technique in Peking Union Medical College Hospital. Our results of dozens of cases suggest that this technique reduces POPF rate and are consistent with the DISCOVER trial. We would like to share our experiences of this procedure with some more technical details.
After mobilization of the teres ligament, we prefer to use intermittent stitches that go through the entire pancreatic margin and the ligament, so that they stick more closely together and the ligament covers the entire pancreatic stump. Four to six stitches are generally needed to complete the suture. It occurs to us that this full-layer suture performs better in preventing POPF and in reducing volume of postoperative drains.
In some cases, as Dr Hassenpflug et al also mentioned in their paper, the teres ligament might not be long enough to reach the pancreatic stump. In our experiences, we would cut and mobilize the teres ligament from the umbilical region right after entry into the abdomen. That would create a longer pedicle and reduce tension. In other cases, the pancreatic remnant is much thicker than the teres ligament. Complete coverage may be difficult for a relatively thin ligament and this may affect the sealing results. Using larger sealing materials such as gastric or jejunum wall may solve this problem, but in our practice, we tend to avoid using these as patches. The sealing effect is achieved by local adhesion. Minor amount of pancreatic fluid may accumulate around the surgical site before the adhesion completes. Exposing another part of gastrointestinal tract may increase the risk for postoperative gastric or jejunum fistula and other unwanted complications.
We have also performed several teres ligament patching Surgeries under laparoscopic procedure. It takes a little longer to complete the suture, but overall surgical time does not increase (unpublished data). Instead of intermittent stitches, a run-up suture with a barbed suture may help to reduce the surgical time while maintaining the tension between the pancreatic remnant and the teres ligament.
Sealing the pancreatic stump with teres ligament and other autologus tissues has only been explored in small cohorts and received different conclusions. This study by Dr Hassenpflug et al provided a high-quality evidence that will guide the practice of all pancreatic surgeons. Laparoscopic surgeries should be evaluated and more standardized suturing techniques should be developed in future studies.
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