title: Use of the round ligament of the liver to decrease pancreatic fistulas: a novel technique.
abstract: BACKGROUND
  The reported pancreatic anastomosis fistula rate for pancreaticoduodenectomy, distal pancreatectomy, or enucleation is 2% to 27%. We hypothesized that reinforcement with a vascular pedicle would decrease the number of fistulas. We report a novel technique: the use of the round ligament of the liver to reinforce the pancreatic anastomosis after resection.
  
  
  METHODS
  Patients undergoing resection from January 1, 2000 until August 8, 2005, at a tertiary referral center, were followed in a retrospective cohort study. The round ligament of the liver was disconnected from the abdominal wall, from the umbilicus to the liver. After pancreatic resection, it was sutured to the anastomosis or closure. A pancreatic fistula was defined as follows: Jackson-Pratt (JP) drainage>50 mL/d, after the fifth postoperative day, with amylase>3 times the serum level; reexploration for a fistula; postoperative pseudocyst; or death from sepsis with a presumed fistula.
  
  
  RESULTS
  In 95 patients, we were able to mobilize the round ligament and use it as a vascular pedicle. The overall fistula rate for the series was 5.3% (5 of 95) and for pancreaticoduodenectomy it was 8.8% (5 of 57). There were no fistulas within the distal pancreatectomy and enucleation group (n=38). Importantly, there was no mortality from pancreatic fistula in the studied patients and no need for operative intervention for a fistula.
  
  
  CONCLUSIONS
  We present a novel technique to prevent pancreatic fistula. Although randomized trials are necessary, it appears that the use of the round ligament as a vascular pedicle for reinforcing the pancreatic anastomoses and resections results in a very low number of pancreatic fistulas.
authors.affiliation: Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Iannitti
authors.forename: Natalie G
authors.initials: NG
authors.lastname: Coburn
authors.forename: Joy
authors.initials: J
authors.lastname: Somberg
authors.forename: Beth A
authors.initials: BA
authors.lastname: Ryder
authors.forename: Jack
authors.initials: J
authors.lastname: Monchik
authors.forename: William G
authors.initials: WG
authors.lastname: Cioffi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects; D005260:Female; D006801:Humans; D008022:Ligaments / Q000098:blood supply / Q000637:transplantation*; D008099:Liver; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods*; D010185:Pancreatic Fistula / Q000209:etiology / Q000517:prevention & control*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods*; D013524:Surgical Flaps