***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Pancreatic fistula is a major form of morbidity following pancreatic resection . We conducted a nonr and omized clinical trial comparing the sealing and s and wich techniques of spraying fibrin glue to prevent pancreatic fistula following distal pancreatectomy . The pancreas was transected with a scalpel to identify and suture the main pancreatic duct and its small branches . In the sealing group , fibrin glue was sprayed over the closed pancreatic stump and sutures . Alternatively , in the s and wich group fibrin glue was sprayed so as to cover and join the cut surface of the pancreatic remnant , which was then held closed with sutures . Altogether 111 patients were included in the study ( 90 with gastric cancer , 10 with esophageal cancer , and 11 with pancreatic cancer ) . Patients were nonr and omly assigned to the s and wich or the sealing group . Morbidity was 21.8 % for the patients in the s and wich group versus 33.9 % in the sealing group . Pancreatic fistulas occurred in 9.0 % of the s and wich group versus 26.8 % of the sealing group . The incidence of fistula was thus significantly lower in the s and wich group . The incidence of fistula was also significantly lower in the s and wich group for gastric malignancy patients undergoing extended radical lymphadenectomy down to the paraaortic lymph nodes combined with left adrenalectomy . Of the patients with gastric malignancy , pancreatic fistulas occurred in 9.3 % of the s and wich group versus 25.5 % of the sealing group . The fibrin glue s and wich technique is simple and reliable and should be valuable for complementing other prophylactic methods of preventing pancreatic fistula BACKGROUND A pancreatic fistula is one of the most serious complications in distal pancreatectomy with en bloc celiac axis resection ( DP-CAR ) , because the pancreatic transection is performed on the right side of the portal vein , which results in a large cross-section surface , and because post-pancreatectomy hemorrhage is hard to treat by interventional radiology . Therefore , a procedure to decrease the incidence of postoperative pancreatic fistula is urgently needed . METHODS Twenty-six consecutive patients who underwent DP-CAR between April 2008 and August 2012 were review ed retrospectively . The first 13 consecutive patients underwent DP-CAR with no anastomosis , and the subsequent 13 consecutive patients were treated with Roux-en-Y pancreaticojejunostomy ( PJ ) in a duct-to-mucosa fashion . RESULTS Extremely high amylase levels ( > 4000 IU/l ) of all drainage fluid specimens on postoperative day ( POD ) 1 , 3 and 4 were detected more frequently in cases with no anastomosis ( n = 7 ) compared to those with PJ ( n = 1 ) ( P = 0.056 ) . CONCLUSION The incidence of grade B/C pancreatic fistulas was 15.4 % in cases with isolated Roux-en-Y anastomosis of the pancreatic stump performed in a duct-to-mucosa fashion , and we are currently examining whether this anastomosis method reduces the pancreatic fistula rate in a multicenter , r and omized controlled trial for distal pancreatectomy patients ( Clinical Trials.gov NCT01384617 ) BACKGROUND The purpose of this study was to analyze the short-term outcome and to determine risk factors after  distal pancreatectomy ( DP ) .  METHODS This prospect i ve single-center study included 61 patients undergoing DP with splenic preservation in 6 ( 10 % ) . The diagnoses included pancreatic adenocarcinoma ( n = 9 ) , neuroendocrine neoplasms ( n = 17 ) , benign neoplasm ( n = 26 ) , pseudocyst ( n = 4 ) , chronic pancreatitis ( n = 2 ) , and other diagnoses ( n = 3 ) . Twelve clinical factors were studied . The chi-square test was used for univariate analysis . RESULTS The median duration of the postoperative hospital stay was 10 days ( range , 5 - 155 days ) . Two patients ( 3 % ) died postoperatively ; 12 patients ( 20 % ) had one or more intra-abdominal complications with reoperation necessary in 3 patients ( 5 % ) : 6 pancreatic fistula ( 10 % ) , 11 intra-abdominal collection s ( 18 % ) , 1 postoperative hemorrhage ( 2 % ) . Univariate analysis showed that a body mass index > 25 kg/m 2 was the only risk factor for intra-abdominal complication ( P = .003 ) . CONCLUSIONS DP is associated with an intra-abdominal morbidity rate of 20 % , which is increased for patients with a body mass index > 25 kg/m 2 HYPOTHESIS Advances in specialized centers for pancreatic diseases have improved surgical morbidity and outcome . In the past , postoperative local complications ( pancreatic fistulae ) were causing most of the mortality . Now , more patients experience postoperative complications related to their comorbidity . DESIGN To report a prospect i ve audit of a single center 's experience with pancreatic resection during an 8-year period . SETTING Tertiary referral center focused on pancreatic diseases . PATIENTS AND INTERVENTIONS Six hundred seventeen consecutive patients underwent pancreatectomy between November 1 , 1993 , and August 31 , 2001 . The series included 468 pancreatic head resections ( 76 % ) , 25 total pancreatectomies ( 4 % ) , 88 left-sided resections ( 14 % ) , and 36 others ( 6 % ) . MAIN OUTCOME MEASURES Morbidity after pancreatic resection . RESULTS Postoperative in-hospital mortality was 1.6 % , and the additional operation rate was 4.1 % . Four patients died of surgical complications and 6 of systemic complications . Systemic morbidity was 18 % and consisted primarily of cardiopulmonary complications ( 13 % ) . The most frequent postoperative complication was delayed gastric emptying ( 14 % ) , which caused significant prolongation of the hospital stay . No patients died of a postoperative pancreatic fistula , which occurred in 3.2 % , and no completion pancreatectomies were necessary . CONCLUSIONS Pancreatic resections can be performed with considerable safety and a low rate of pancreatic complications . More patients die of systemic complications than in the past , which increases the dem and for precise preoperative patient selection . Completion pancreatectomy should no longer be considered in patients with a pancreatic fistula Pancreaticoduodenectomy  ( PD )  is still a difficult procedure with significant morbidity . We report 150 consecutive PDs performed during a 3-year period . All the cases have been prospect ively evaluated with regard to the surgical outcome . Mortality in this series was 3/150 ( 2 % ) with a re-operation rate of 5/150 ( 3.3 % ) ; surgical complications were experienced in 57/150 ( 38 % ) . The most frequent complications were collection s in 25/150 ( 16.6 % ) and pancreatic fistulas in 16/150 ( 10.7 % ) . The majority of these complications were conservatively managed : only one abscess and one fistula due to an anastomotic dehiscence required re-operation . The complication most responsible for mortality was haemorrhage secondary to arterial pseudoaneurysms in patients with severe post-operative pancreatitis . The continued high morbidity of PDs is compensated by the ability to treat complications non-operatively , result ing in a surgical risk that should now be considered medium to low in high volume centres Background Pancreatic fistula continues to be a source of significant morbidity following distal pancreatic resections . The technique of pancreatic division varies widely among surgeons , and there is no evidence that identifies a single method as superior . In our practice , the technique of distal pancreatic resection has evolved from cut- and -sew to stapled technique with green and recently white cartridge . The aim of our study was to evaluate the rate of clinical ly significant fistulas [ International Study Group on Pancreatic Fistula ( ISGPF ) grade B or C ] following distal pancreatectomy and to identify variables associated with a low rate of fistula development . Methods Clinical records of all patients who underwent distal pancreatic resections between February 1999 and July 2010 by a single surgeon were retrospectively review ed focusing on the incidence and type of pancreatic fistula as defined by ISGPF . Study variables included age , gender , surgical approach , extent of resection , ASA classification , type of stapler cartridge , use of Seamguard ™ , and ISGPF classification . Statistical analysis was performed using Fisher ’s exact test , and univariate and multivariate logistic regression . Results Sixty-four patients ( median age 60 , range 21–85 ; 54 % male ) underwent distal pancreatic resection ( laparoscopy 50 % vs. open 50 % ) . The most common indications were pancreatic adenocarcinoma ( N = 15 ; 23 % ) and neuroendocrine neoplasms ( N = 14 ; 22 % )  . Clinical ly significant pancreatic fistula developed in 24 % ( N = 15 ) . The rate of fistula with cut- and -sew technique was 36 % ( 4/11 ) , with stapled green cartridge 31 % ( 9/29 ) and only 5 % ( 1/21 ) with stapled vascular cartridge . Univariate logistic regression identified vascular cartridge size ( p = 0.04 , OR 0.11 ) and open stapled technique ( p = 0.05 , OR 0.12 ) as variables significantly associated with a low fistula rate . Both vascular cartridge size ( p = 0.05 , OR 0.10 ) and open stapled technique ( p = 0.04 , OR 0.08 ) remained significant when analyzed by multivariate logistic regression . Division of pancreatic parenchyma with vascular cartridges result ed in significantly ( p = 0.03 , OR 9.0 ) lower fistula rate compared to green cartridges . The use of Seamguard ™ did not affect fistula rate ( 16 % vs. 27 % ; p = 0.34 ) nor did the performance of multivisceral resection vs. distal pancreatectomy/splenectomy alone ( 21 % vs. 23 % , p = 1.0 ) . Conclusion The optimal technique of pancreatic division has not been conclusively established . Dividing the pancreas utilizing vascular ( 2.5 mm ) staple cartridges significantly decreased the rate of clinical ly significant pancreatic fistula and we have changed our practice accordingly . A prospect i ve r and omized trial is necessary to vali date these results BACKGROUND We previously demonstrated that pancreatic transection with a reinforced staple line results in significantly lower fistula rates than when stapling without reinforcement . ( J Gastrointest Surg . 2007;11:345 - 349 ) . Criticism of this initial study focused on the small size of the treated group ( N = 13 ) . We report four more years of experience with this technique with a larger sample size . METHODS This was a before-after trial . Patients included had distal pancreatectomies with stapled stump closure . The main intervention analyzed was staple-line reinforcement with Seamguard . The experimental group consisted of a consecutive series of stapled pancreatectomies with reinforcement performed from 2005 to 2010 . The control group was a consecutive series of stapled pancreatectomies without reinforcement performed between 2003 and 2005 ( previously published ) . The main outcome measure was pancreatic fistula . RESULTS 54 patients were included ; 36 in the experimental group and 18 in the control group . Mean age was 62 ; 50 % were males . The most common diagnoses were adenocarcinoma ( 31 % ) , cystic neoplasm ( 24 % ) , and neuroendocrine tumor ( 22 % ) . There were no mortalities . Postoperative pancreatic leak rate was 39 % in the control group , and 8 % in the experimental group ( P = 0.01 ) . Seven of ten patients with leak required additional drain placement . Development of pancreatic leak result ed in prolonged hospital stays ( 12 vs eight days , P < 0.007 ) . CONCLUSION We demonstrate sustained success of reinforced stapling for pancreatic stump closure . Our technique is straightforward and results in reduced morbidity and cost . Our results suggest that surgical drains may not be needed when this technique is applied Background Surgery is of increasing importance in the treatment and outcome of diseases of the pancreas worldwide . The incidence of pancreatic cancer ( 7—11/ 100,000 per year ) has risen over the last years and surgical resection remains the only option for definite cure . Twenty-five percent of all resections are left of the superior mesenteric vein ( distal pancreatectomy ) and the appropriate closure technique for the pancreatic remnant remains unclear . Pancreatic fistulas are the most common ( 0—40 % ) and relevant postoperative complication . The optimal surgical strategy for pancreatic resection needs to be identified from the large number of surgical 
    Output:
    
Neither stapler nor scalpel resection followed by h and -sewn closure of the pancreatic remnant for distal pancreatectomy showed any benefit compared to the other method in terms of postoperative pancreatic fistula , overall postoperative mortality or operation time .