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Polyglycolic Acid Mesh in Distal Pancreatectomy: A Tool for Preventing Postoperative Pancreatic Fistula?

Postoperative pancreatic fistula (POPF) is the most frequent and serious complication following distal pancreatectomy. Various approaches, including different closure methods, transection devices, intestinal serosal patches, fibrin glue, and drainage procedures have been proposed as potential means of preventing POPF.1 Polyglycolic acid (PGA) is a biodegradable thermoplastic polymer being used to facilitate wound healing in tissues ranging from oral mucosa and pleura to dura mater. Polyglycolic acid is hypothesized to induce inflammation and adhesion formation and through this mechanism prevent POPF. Previous case series evaluating the use of PGA mesh for preventing POPF are limited by the retrospective nature and the lack of standardized surgical technique.2-4 Jang et al5 performed a randomized clinical trial comparing distal pancreatic transection with a stapling device, fibrin glue application, and with and without additional stump wrapping with PGA mesh. The primary outcome was the incidence of clinically significant POPF, defined as International Study Group grade B or C.6 Patient-related risk factors, such as age, body mass index, and pancreatic histology, were controlled through randomization. In comparison with the control group, the authors found that members of the intervention group who received PGA mesh demonstrated a significantly decreased incidence of clinically significant POPF (11.4% vs 28.3%, P = .04).5 These results are compatible with 3 previous retrospective studies.2,4,7 Postoperative pancreatic fistula is the Achilles heel of pancreatic surgery, and little progress has been made in addressing this problem. Although the International Study Group has standardized the reporting of POPF in the literature, surgeons’ practices vary across the world with regard to obtaining routine amylase levels and abdominal computerized tomography. Given this reality, some “clinically significant” POPF in the study might not be detected in real-life practice; therefore, the applicability of these results remain unknown. One concern regarding this technique is whether the PGA mesh will contribute to infection and a delay in resolution of fistula if this occurs. Experimental models in mice have shown an increased susceptibility to infection with the use of PGA mesh wrap following splenectomy.8 While study results are demonstrating a lower overall POPF rate and consequently less infectious sequelae, it is worth considering whether the PGA mesh itself might act as a nidus for infection. Although the investigators have executed an elegant study design, standardizing the complexities and nuisances of surgery is difficult. No information regarding the stapler size or details of how the PGA mesh is secured on the pancreatic stump is provided. Was fibrin glue applied to all cases, and what is the likelihood that this is adequate to secure fixation? How is the mesh exactly placed on the gland, and what additional technical steps are required to prepare the stump for mesh application? In conclusion, the researchers are to be congratulated on successful completion of what is, to our knowledge, the first randomized clinical trial evaluating the efficacy of PGA mesh wrapping in preventing POPF. Polyglycolic acid mesh represents a possible solution to the main complication following pancreatic resection. Although the study design had minor biases, the intervention is worth further investigation considering the minimal associated risk.