Postoperative pancreatic fistula (POPF) is the most frequent and serious complication after distal pancreatectomy (DP) and often leads to other postoperative complications. Numerous studies have been conducted to clarify the risk factors for POPF after DP, and to also determine effective prophylactic treatments. In this article, we review the current evidence on the risk factors for POPF after DP, and also provide new evidence to support the currently implemented prophylactic measures against POPF after DP. The patient-related and surgery-related risk factors and risk factors specific to staplers are discussed. Several studies have suggested that a thick pancreas is a risk factor for POPF using a stapler and that a higher stapler height or pancreatoenteric anastomosis might be useful for preventing POPF when transecting a thick pancreas. Various methods, such as stapler closure, procedures that may be performed in addition to stapler closure, pancreatoenteric anastomosis, pancreatic transection devices, laparoscopic surgery, pancreatic stenting, stump coverage, and somatostatin analogs, have been tested and in comparison with conventional procedures in case–control studies and randomized, controlled trials. Although some studies have shown the superiority of these methods to the conventional procedures, a consensus on precautionary measures that can be taken against POPF remains to be established. Further investigation is necessary to develop a reliable strategy for preventing POPF and to improve the outcomes of patients after DP.
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