METHODS: The clinical data of 69 patients who underwent pancreatic body tail resection in our department from May 2011 to March 2014 were retrospectively analyzed. 35 patients were wrapped with transverse colonic mesenteric avascular zone around the pancreatic stump after intermittent suturing of pancreatic stumps with silk threads and sutured as an improved group, and 34 patients in the control group were not treated otherwise after intermittent suturing of pancreatic stumps with silk threads. RESULTS: The average surgical operation time for the treatment of pancreatic stumps in the modified group was 15.2±2.1min, and 13.2±3.2min in the control group, and the difference between the two was not statistically significant (p= 0.018); 0 pancreatic fistulas occurred in the modified group, and 9 pancreatic fistulas occurred in the control group, and the difference between the two was statistically significant (p=0.002); the average time for the placement of the drainage tubes for pancreatic stumps in the modified group after the operation was 6.1 ± 2.2 days, and 16.6 ± 3.5 days in the control group, and the difference was statistically significant (p=0.000); the average postoperative hospitalization time was 12.5 ± 2.5 days in the modified group, and the median postoperative hospitalization time was 21.5 ± 3.5 days in the control group, and the difference was statistically significant (p=0.000) CONCLUSION: Mesenteric wrapping of the avascular zone of the transverse colon and stitching of pancreatic stumps is effective for the prevent pancreatic stump leakage after pancreatic body tail resection, shorten the hospitalization time, and reduce patients’ pain. Keywords: Pancreatectomy; pancreatic fistula; stump management; transverse mesocolon The clinical study of preventing pancreatic fistula after distal pancreatectomy by wrapping and suturing pancreatic stump ( with transverse mesocolon without vessels Wang Gang-cheng, HAN Guang-sen, Cheng Yong , Liu yingjun, , Xu Yongchao,Xie Jian-guo . Department of General Surgery,Affiliated Tumor Hospital of Zhengzhou University (Henan Tumor Hospital),Zhengzhou 450008,P.R.China. [abstract]. Objective To investigate a new appropriate method to prevent pancreatic fistula after distal pancreatectomy. Methods A total of 69 patients who underwent distal pancreatectomy from May.2011 to Mar.2013 were assigned into 2 groups according to the different methods of remnamt closure , namely the modified group (35 patients) ,whose pancreas remnamt were wrapped and sutured with transverse mesocolon ,and the control group(34patients), whose pancreas remnamt were not done so ,and the therapeutic effects of the two approaches were compared. Results There were 9 patients with pancreatic fistula There were 9 patients with pancreatic fistula in control group ,no patients with pancreatic fistula in modified group , the statistical difference was significant between the two groups. In the modified group , the average time of remnamt closure was 15.2±2.1 min, the average time of keeping drainage tube near the pancreatic stump was 6.1±2.2 days, the average time of hospital stay was 6.1±2.2 days, and the average time of hospitalization was 6.1±2.2 days. The average time of remnamt closure was 15.2±2.1 min, the average time of keeping drainage tube near the pancreatic stump was 6.1±2.2 days, and the average time of hospital stay was 12.5±2.5 days. In the control group, the three parameters were 13.2±3.2 min, 16.6 ±3.5 days and 21.5±3.5 days. In the control group, the three parameters were 13.2±3.2 min, 16.6±3.5 days and 21.5±3.5 days respectively. There was no significant difference between the two groups in terms of the three spects. Conclusion It is a effective method to prevent pancreatic fistula after distal pancreatectomy, which shorten the time of hospital stay and alleviate the suffering of patients. 【Keywords】 Pancreatectomy; Pancreatic fistula; Remnamt closure; Transverse mesocolon Pancreatic body-tail resection is often part of left upper abdominal tumor surgery, postoperative pancreatic stump leakage, pancreatic leakage sinusoidal prolongation, is the main problem plaguing the surgeon, in response to the above problems, domestic and foreign Scholars use manual intensive suture, occluder closure, biogelatin closure and other methods, but there is still a high incidence of glandular stump leakage [1-4]. In our department, from May 2011 to March 2014, the use of transverse colon avascular zone mesenteric wrapping and suturing of pancreatic stump can effectively prevent pancreatic stump leakage after pancreatic body tail resection, and the clinical effect is sure, now reported as Aman拢 1 Materials and methods 1.1 General information: there were 69 cases of patients in our group, and all the patients were suggested to have no metastasis to distant organs by preoperative examination, among them, 36 cases of pancreatic-gastric body carcinoma were found by intraoperative probing in the tumors invading the Among them, 36 cases of pancreatic gastric body cancer, intraoperative investigation found that the tumor invaded the tail of pancreatic body or the splenic hilar, 29 cases of total gastric + tail of pancreatic body splenectomy, 7 cases of partial gastric (proximal gastric) + tail of pancreatic body splenectomy; 11 cases of gastrointestinal mesenchymal tumors, during the intraoperative exploration, 7 cases originated from the stomach, and the tumors had a close relationship with the tail of pancreatic body splenectomy, and part of stomach + tail of pancreatic body splenectomy; 4 cases originated from the splenic flexure colon, and the tumors had a close relationship with the tail of pancreatic body splenectomy, and the left half of colon + tail of pancreatic body splenectomy; and In 9 cases, the tumor was closely related to the spleen of the tail of the pancreas, and left hemicolon + tail of pancreas splenectomy was performed; 13 cases of pancreatic cystic adenocarcinoma, and tail of pancreas splenectomy was performed. After pancreatic body-caudal splenectomy, the pancreatic stump was divided into a modified group and a control group according to whether or not the pancreatic stump was embedded with transverse colonic mesentery. In the modified group, the pancreatic stump was embedded in the transverse colon mesentery, of which 21 cases were male and 14 cases were female, with ages ranging from 35 to 82 years old, and the average age was 61.3 years old. There were 16 cases of total gastric + pancreatic body-tail splenectomy, 5 cases of left hemicolon + pancreatic body-tail splenectomy, 8 cases of partial gastric + pancreatic body-tail splenectomy, and 6 cases of pancreatic body-tail + splenectomy. In the control group, the pancreatic stumps were treated according to the conventional treatment, and the pancreatic stumps were not encapsulated with transverse colonic mesentery, of which, 19 cases were male and 15 cases were female, with the age ranging from 37 to 79 years old, and the average age was 58.6 years old. There were 13 cases of total stomach + pancreatic body-tail splenectomy, 8 cases of left hemicolon + pancreatic body-tail splenectomy, 6 cases of partial stomach + pancreatic body-tail splenectomy, and 7 cases of pancreatic body-tail + splenectomy. All patients were routinely treated with growth inhibitor for one week after surgery, and 6mg per day was continuously pumped. All patients underwent pancreatic body-tail resection, with no preoperative history of pancreatitis, soft pancreas, no dilatation of pancreatic ducts, pancreatic ducts of pancreatic stumps were not ligated exclusively, and surgical operations were completed by the same group of physicians. χ2=6.775 Table 1.Comparison of patients’ basic information 1.2 Surgical methods: Modified group: after pancreatic body-tail splenectomy with suture ligation of splenic arteries, modified group was applied with “7” number silk thread (or “7” number silk thread), which was used in all cases. In the modified group, after splenectomy of the tail of the pancreas, the modified group should use “No. 7” silk thread (or absorbable thread with 2 zeros) to suture the pancreatic stump longitudinally intermittently, with the distance between the edge of the needle (the hole of the needle from the broken edge of the pancreas) of about 1.0cm and the distance between the needles of about 5mm, and then tie 3 slip knots as far as possible, and then tighten the knots gradually. After the suture was completed, the closest transverse colon without large blood vessels in the mesenteric area covered with wrapped pancreatic stump, the same with all the use of “7” silk thread (or 2 zero absorbable thread), intermittent longitudinal suture pancreatic stump, the needle edge distance of about 1.5cm, the needle spacing of about 3-5mm. two edges of the pancreas transverse each sewing a needle and knot, and then to the opposite side of the The pancreas is then tied around the pancreatic stump as shown in Figures 1 and 2. Two drainage tubes were placed near the pancreatic stump as shown in Figures 1 and 2. Figure 1 Pancreatic stump after suturing Figure 2 Pancreatic stump wrapped around the mesentery Control group: according to the conventional method, after splenectomy of the tail of the pancreas and suturing the splenic artery, the pancreatic stump was treated in the same way as that of the modified group before the pancreatic stump was wrapped around the mesentery. No other special treatment was performed. Two drainage tubes were placed near the pancreatic stump. 1.3 Diagnostic methods of pancreatic fistula 1.3.1 According to the diagnostic criteria of pancreatic leakage after pancreatic surgery by Bassi [5] and others: 3 d or more after surgery. Abdominal drainage fluid amylase measurement value is greater than normal, serum amylase measurement value of the upper limit of three times; can be divided into three levels: level I, only abdominal drainage fluid amylase elevation, no corresponding symptoms and signs; level II, abdominal drainage fluid amylase elevation. Grade II, elevated amylase in the abdominal drainage fluid, accompanied by typical clinical symptoms. And began to appear signs of organ insufficiency, need to use antibiotics, nutritional support and abdominal drainage; Grade III. The patient’s condition is serious. Septicemia and organ dysfunction occur, and may even lead to death, often requiring surgical intervention. Based on the above diagnostic criteria, the patients in this group were diagnosed as pancreatic fistula on the 3rd day after operation, and the amylase value of the abdominal drainage fluid on the 3rd day after operation was more than 3 times of the normal serum amylase value, meanwhile, the contents of the drainage tube were grayish-white in nature. 1.3.2 Clinical manifestations of drainage tube drainage contents The drainage tube contents of the presence of pancreatic leakage, the color is usually gray-brown, thicker, no odor, as infected pus-like liquid, drainage laboratory bacterial culture without bacterial growth. The contents of drainage tubes without pancreatic leakage showed light yellow liquid, clear. 1.4 Statistical methods SPSS13.0 statistical software was used to process the data, the comparison of the means of the samples of the two groups was performed by t-test, and the count data such as the incidence of pancreatic leakage was performed by χ2-test, and the difference was considered to be statistically significant at p<0.05< span="">. 2 Results The average surgical operation time for pancreatic stump treatment in the modified group was 15.2±2.1min, and that in the control group was 13.2±3.2min, and the difference between the two was not statistically significant (p=0.018); 0 cases of pancreatic fistula occurred in the modified group, and the postoperative drainage tubes’ drainage fluid was light red and gradually changed to light yellow, and the drainage fluid assayed for amylase was in the normal range, and none of them had pancreatic leakage. Nine patients in the control group postoperative postoperative drainage tube drainage fluid was light red gradually changed to gray-white, higher than the upper limit of the normal serum amylase measurement value of three times, confirmed as pancreatic fistula, the difference between the two is statistically significant (p = 0.002); improved group abdominal drainage tube yellowish drainage fluid is less than 20 ml per day, removal of the drainage tube postoperative pancreatic stump drainage tube placed in the average of 6.1 ± 2.2 days; the control group The drain was removed when the grayish-white drainage fluid from the abdominal drain was less than 20 ml per day. The average time for placing the postoperative pancreatic stump drain in the control group was 16.6 ± 3.5 days. Two patients in the control group developed left upper abdominal fluid accumulation after removal, and the patients developed left upper abdominal pain and fever, and were again drained by indwelling drain tube under CT-guidance by abdominal puncture, and the time of placing the drain tube again was 8 days and 10 days, respectively. The difference between the two groups was statistically significant (p=0.000); the average postoperative hospital stay in the modified group was 12.5±2.5 days, and the average postoperative hospital stay in the control group was 21.5±3.5 days, and the difference between the two groups was statistically significant (p=0.000) 3 Discussion: The organs of the left epigastric region are relatively more centralized, and tumors originating from different tissues can easily invade the pancreas and spleen. Combined pancreatic body-tail splenectomy is the main component of combined organ resection for left upper abdominal tumors. The biggest complication of pancreatic body-tail resection is the occurrence of pancreatic leakage, which in the mild case manifests as persistent leakage of pancreatic fluid, which is prolonged, and persistent grayish drainage from the local drainage tube, which is difficult to remove. In severe cases, there is local pain, fever, bleeding, and even the possibility of severe pancreatitis. The occurrence of pancreatic leakage not only increases the physical pain of patients, but also increases the economic burden of patients. The main reasons for the occurrence of pancreatic leakage in pancreatic body tail resection are: 1. Pancreatic tissue is brittle, lacks toughness, and the integrity of the suture is poor. When sewing the pancreatic tissue, it is easy for the suture line to cut the pancreatic tissue, and the integrity of the pancreatic tissue is easily damaged, resulting in the leakage of pancreatic fluid.2. Difficulty in finding the pancreatic duct. Many surgeons believe that after resection of the tail of the pancreatic body, the main pancreatic duct is finally found and ligated to prevent pancreatic leakage. However, in fact, if the pancreatic duct in the tail of the pancreatic body is not dilated and the diameter of the duct is very thin, it is very difficult to find the main pancreatic duct during the operation, on the other hand, the tail of the pancreatic body may only have a netted grade 3 small pancreatic duct, which leads to the exudation of some of the pancreatic fluid.3.Pancreatic trauma is exposed and lacks closure. After resection of pancreatic tissue, it is difficult to eliminate extravasation of pancreatic fluid no matter how tight the sutures are. Uncertainty in the current management of pancreatic stump to prevent pancreatic leakage. The main traditional management methods for pancreatic stumps are hand suturing, occluder closure, and biogelatin closure. Manual suture and occluder closure cannot completely close the pancreatic wound, and it is difficult to close the secondary pancreatic ducts, which cannot completely avoid the occurrence of pancreatic fistula. Lin Hai et al. found that hand suture and pancreatic stump with occluder application had a high rate of pancreatic leakage by comparing different resection methods of pancreatic body tail [6]. There is also some uncertainty in the closure of the pancreatic stump with bioprotein glue, how is the affinity of bioprotein glue with pancreatic tissue? Can it be evenly applied to the pancreatic stump trauma? How many days after surgery protein glue absorption? How much pressure can the pancreatic duct and pancreatic fluid withstand? Clinical reports have reported that there is still a certain chance of pancreatic leakage when the pancreatic stump is closed with biogelatin [7]. Cao Hong et al. also confirmed that it is difficult to avoid the occurrence of pancreatic leakage by collecting Meta-analysis of cases, regardless of the line of manual suture, occluder closure of the pancreatic section, and biogelatin closure [8]. Advantages of mesenteric wrapping of the avascular zone of the transverse colon and suturing the pancreatic stump to prevent pancreatic leakage. The biggest disadvantage of the various methods currently used in the clinic is the inability to close the pancreatic stump leading to pancreatic extravasation. Transverse colon nonvascularized membrane wrapping and suturing of the pancreatic stump can make up for this deficiency. After the pancreatic stump was sutured, the transverse colon avascular zone mesentery was used to wrap the pancreatic stump, which enabled the transverse colon mesentery to adhere to the pancreatic trauma and inhibit the extravasation of pancreatic fluid. The transverse colon mesentery was tied around the pancreatic stump to block the extravasation of pancreatic fluid from any invasive surface of the pancreatic stump. Although the transverse colonic mesentery is relatively weak, it is flexible and tensile, and the suture line is not easy to cut the mesenteric tissue and protects the pancreatic tissue. In addition, the transverse colonic mesentery has vitality and will not be necrotic and fall off because of suture, so the effect is certain. Thirty-five patients in the modified group utilized the mesentery of the avascular area of the transverse colon to wrap and suture the pancreatic stump to prevent pancreatic leakage without a single case of pancreatic leakage, and there was no colonic dysfunction. In comparison to the control group, there were 9 cases of pancreatic leakage. The method of transverse colon avascular zone mesentery wrapping and suturing pancreatic stump to prevent pancreatic leakage is simple, and the transverse colon mesentery is easy to take, does not need special freeing, and does not affect the operation time. There was no statistically significant difference in the processing time of pancreatic stumps between the two groups. The colon function was not affected after utilizing the transverse colonic mesentery, and none of the 35 patients in the observation group had colon dysfunction. Foreign scholars have also achieved significant results in a similar approach, Walters et al [9] put the sickle ligament with the tip of the covered and circumferential fixed on the section of the pancreatic stump. Retrospective study of 23 cases of distal pancreatectomy patients, only 2 cases (8.7%) of pancreatic leakage, no abdominal abscess and other complications occurred, effectively reducing the incidence of pancreatic leakage. As an in vivo biofilm to prevent and repair all kinds of anastomotic leaks, the tipped omentum has obvious advantages [8-12], and domestic scholars prevent pancreatic leaks by wrapping the omentum around the pancreatic stump through animal experiments, and it can also prevent pancreatic stump leaks efficiently [13], but for the patients who have had simultaneous resections of the omentum, such as those with the tail of the pancreas combined with the total gastric and distal gastric resections, it is impossible to perform the wrapping of the omentum around the pancreatic stump, and the transverse mesentery wrap around the pancreatic stump is not a bad choice for the pancreatic leak. Transverse mesenteric mesocolon wrapping around the pancreatic stump is a good choice. In conclusion, the use of transverse mesenteric wrap around the pancreatic stump significantly reduces the incidence of pancreatic fistula and shortens the hospitalization time; this method is effective, relatively simple in surgical operation, and does not increase any surgical risk, so it is worth promoting and applying in clinical practice.