Robotic distal pancreatectomy with a modified transpancreatic mattress suture-based stump management strategy is associated with lower clinically relevant POPF than reinforced stapling: a propensity score-matched cohort study.

BACKGROUND

The optimal stump-closure method to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) in robot-assisted distal pancreatectomy (RDP) remains unsettled. We evaluated whether a modified transpancreatic mattress suture (mTMP) strategy was associated with reduced CR-POPF compared with reinforced stapler closure.

METHODS

107 consecutive RDPs at a single center (June 2020-October 2024) were grouped by stump-closure method (stapler, n = 50; mTMP, n = 57). The mTMP strategy comprised main duct ligation, stump coagulation, polyglycolic acid reinforcement, fibrin sealant, and transpancreatic mattress suturing. The primary outcome was CR-POPF (ISGPS 2016 grades B/C). Confounding was addressed with 1:1 propensity score matching on 10 covariates (38 matched pairs) and multivariable logistic regression, with a prespecified subgroup analysis in thick-pancreas patients (>12 mm, 31 pairs).

RESULTS

After matching, the mTMP strategy was associated with lower CR-POPF (15.8% vs 42.1%, P=0.011) and fewer major complications (5.3% vs 26.3%, P=0.012). On multivariable analysis, stapler closure and age ≤60 years independently predicted CR-POPF. In the thick-pancreas subgroup, CR-POPF remained lower with the mTMP strategy (16.1% vs 48.4%, P = 0.024).

CONCLUSIONS

The mTMP strategy showed an association with lower CR-POPF than reinforced stapling, including in thick-pancreas patients. These findings are hypothesis-generating and warrant prospective validation.