Randomized Controlled Trial of Pancreaticojejunostomy versus Stapler Closure of the Pancreatic Stump During Distal Pancreatectomy to Reduce Pancreatic Fistula.

OBJECTIVES: The aim of this study was to evaluate in a multicenter randomized controlled trial (RCT) whether pancreaticojejunostomy (PJ) of pancreatic stump decreases the incidence of pancreatic fistula after distal pancreatectomy (DP) compared with stapler closure. BACKGROUND: Several studies reported that PJ of pancreatic stump reduces the incidence of pancreatic fistula after DP. However, no RCT has confirmed the efficacy of PJ of pancreatic stump. METHODS: One hundred thirty-six patients scheduled for DP were enrolled in this study between June 2011 and March 2014 at 6 high-volume surgical centers in Japan. Enrolled patients were randomized to either stapler closure or PJ. The primary endpoint was the incidence of pancreatic fistula based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01384617). RESULTS: Sixty-one patients randomized to stapler and 62 patients randomized to PJ were analyzed by intention-to-treat. Pancreatic fistula occurred in 23 patients (37.7%) in the stapler closure group and 24 (38.7%) in the PJ group (P = 0.332) in intention-to-treat analysis. The incidence of clinically relevant pancreatic fistula (grade B or C) was 16.4% for stapler closure and 9.7% for PJ (P = 0.201). Mortality was zero in both groups. In a subgroup analysis for thickness of pancreas greater than 12 mm, the incidence of clinically relevant pancreatic fistula occurred in 22.2% of the patients in the stapler closure group and in 6.2% of the PJ group (P = 0.080). CONCLUSIONS: PJ of the pancreatic stump during DP does not reduce pancreatic fistula compared with stapler closure.

[Discrepancies in the histological grade of submucosal gastric carcinoma between biopsy and postoperative resected specimens].

BACKGROUND AND AIMS: This study was designed to evaluate the discrepancies in the histological grade of submucosal (SM) gastric carcinoma between biopsy and resected specimens graded using the Japanese classification of gastric carcinoma (JCGC) and TNM classifications. SAMPLES AND METHODS: This study comprised 250 consecutive paired biopsy and curative gastrectomy resection specimens from SM gastric carcinomas obtained between 1995 and 2011. RESULTS: Of the 250 SM gastric carcinomas, 47 (19%) were smaller than 1.5 cm. Of 32 biopsy specimens diagnosed as differentiated type according to the JCGC classification, only 1 (3.1%) was eventually diagnosed as undifferentiated type according to the resected specimen. In contrast, of 25 biopsy specimens diagnosed as differentiated type according to the TNM classification, 2 (8.0%) were eventually diagnosed as undifferentiated type according to the resected specimens. These specimens were all mixed-type carcinomas. CONCLUSIONS: Mixed-type gastric carcinoma is associated with a high incidence of histological discrepancy between biopsy and resected specimens in both JCGC and TNM classification. For mixed-type gastric carcinoma in particular, the treatment strategy selected from the limited treatments options available should be based on the histological grade according to biopsy specimens.