Brief introduction.

This is a journal club review anchored on the Probst Cochrane Review. We will discuss how to transect the pancreas, what the data says about suture vs. staple, complication rates, whether oversewing helps, and when to give splenic vaccines.

This is the anchor paper for the journal club.

The 2015 Cochrane Review found 2 RCTs; the 2025 update added a third (515 patients total) and reached the same conclusion.

DISPACT is the dominant trial — superiority design, so it cannot prove equivalence, but the message is clear: neither won.

Key limitation: wide confidence intervals cannot exclude clinically important benefit or harm in either direction.

The authors conclude the choice is left to surgeon preference and patient anatomy.

They call for a non-European multicentre trial with an equality or non-inferiority design to corroborate.

The bottom line: techniques are roughly equivalent.

The PLOS ONE 2018 meta-analysis found a modest stapler advantage (OR 0.73) but the absolute difference is small.

The Ratnayake network meta-analysis ranked teres ligament patch #1 for lowest CR-POPF, blood loss, abscesses, and 30-day mortality.

Reinforced staplers: Hamilton single-center RCT was dramatically positive (1.9% vs 20%) but HiSCO-07 and Wennerblom could not replicate in multicentre settings. HiSCO-07 subgroup: thin pancreas (<14 mm) 4.5% vs. 22.5%.

Fibrin sealants are definitively dead — consistent negative results.

Bleeding: stapler provides better hemostasis at the transection line. No large RCT has isolated bleeding as a primary endpoint for pancreatic transection.

This slide directly addresses the textbook passage.

The main pancreatic duct is not routinely identified within the stapled end — so the oversewing is a belt and suspenders approach over the staple line.

The evidence gap: we have meta-analyses showing modest benefit trends, but no dedicated RCT comparing stapler alone vs. stapler + oversewing.

Duct ligation is a separate and important point: when hand-sewing (not oversewing a stapled stump), individually ligating the main pancreatic duct is independently protective.

In the robotic era, oversewing is technically easier, which may explain why it is increasingly common.

The honest answer: it probably doesn't hurt, but we can't say it helps based on Level 1 evidence.

Critical for any distal pancreatectomy that includes splenectomy.

OPSI is rare but devastating — 50-70% mortality even with aggressive ICU care.

Ideal timing is 2 weeks preoperatively — better immune response before spleen removal.

For emergency/unplanned splenectomy: wait at least 2 weeks postoperatively, then vaccinate.

All four vaccines can be given simultaneously when timing is tight.

Most commonly missed step: long-term booster compliance. Patients need PPSV23 and MenACWY boosters every 5 years for life.

Annual influenza vaccine is also recommended.

Five messages:

1. Stapler ≈ suture — the Cochrane Review is definitive.

2. Ligate the duct when hand-sewing.

3. Oversewing is not proven.

4. Teres ligament is the only adjunct with consistent evidence.

5. Don't forget vaccines.