Validation of day 1 drain fluid amylase level for prediction of clinically relevant fistula after distal pancreatectomy using the NSQIP database

Background

The role of postoperative day 1 drain fluid amylase level in predicting clinically relevant postoperative pancreatic fistula is under investigation. In a previous multicenter study conducted on 338 patients undergoing distal pancreatectomy, day 1 drain fluid amylase level has been correlated to the development of a clinically relevant pancreatic fistula and an amylase value of 2,000 U/L was found to be most predictive of the development of clinically relevant postoperative pancreatic fistula. Our objective was to validate the previously established cutoff level for drain fluid amylase on postoperative day 1 after distal pancreatectomy as a predictor for clinically relevant postoperative pancreatic fistula using a different patient population from the National Surgery Quality Improvement Program database.

Application of a new collagen-based sealant for the treatment of pancreatic injury

Pancreatic injury is the most frequent serious morbidity that can occur following laparoscopic splenectomy. The presumed mechanism of injury is direct trauma to the pancreatic tail during hilar dissection or transection with endovascular staplers. It was our aim to study the direct application of topical sealants to a pancreatic injury to prevent a pancreatic leak. A porcine model of pancreatic injury in a normal pancreas was developed. Fourteen animals underwent midline laparotomy and subtotal (8 cm) distal pancreatectomy. The pancreas was sharply divided and minimal cauterization used. A (1/4)-inch round Jackson Pratt drain was secured to the pancreatic stump in all animals. The control group (n = 7) underwent no further treatment. Two groups underwent treatment with a sealant. Group 1 (n = 3) had a hydrogel applied to the pancreatic remnant. Group 2 (n = 4) had a biodegradable sealant of PEG (polyethylene glycol)-collagen formulation applied to the pancreatic stump by aerosol. During the postoperative period, animals were fed 2.2 lb/d of a high fat (10% lard) diet to stimulate pancreatic exocrine function. Total daily drain outputs were recorded, and drain amylase content and serum amylase concentration were measured on postoperative days 3, 7, and 10. A significant pancreatic leak was defined as a drain to serum amylase content of greater than 3:1. Animals were killed on day 10 and explored for undrained fluid collections. The pancreas was removed for histologic evaluation. Control and treatment groups were compared using repeated measures ANOVA of log-transformed data. All animals survived until elective necropsy. In group 1, average total drain outputs were not significantly less than the controls (125 mL versus 269; P = .66). The mean drain/serum amylase concentration on days 3, 7, and 10 were not significantly different between group 1 and the control group. Group 2 had significantly less overall average drainage output than controls (40 mL versus 269 mL; P = .0006). Furthermore, group 2 had a significant reduction in pancreatic leaks on days 3, 7, and 10 as measured by mean drain/serum amylase concentration. No undrained fluid collections were identified at autopsy. Based on our experimental porcine model, a novel collagen-based, biodegradable hydrogel can prevent a ductal leak following pancreatic injury. These encouraging data have fostered application by aerosol treatment to the hilar bed at laparoscopic splenectomy to diminish capsular disruption from mechanical injury.     

胰腺残端处理方式对胰体尾切除术后胰瘘的影响

目的探讨预防胰体尾切除术后胰瘘的胰腺残端处理方式。方法回顾性分析我院1996至2008年186例因胰腺或胰外病变行胰体尾切除术患者的临床资料,胰腺残端处理方法分别为：结扎主胰管、残端结扎、间断缝合、Prolene线连续缝合、胰腺空肠吻合及闭合器钉合六种方式,比较上述六种方式对术后胰瘘的影响并行统计学分析。结果186例患者中围手术期死亡5例（2．7％）,术后总并发症发生率34．9％（65／186）,胰瘘发生率21．0％（39／186）。8例胰腺残端结扎术后4例发生胰瘘,11例胰腺空肠吻合患者无胰瘘发生;17例Endo—GIA关闭胰腺残端者有胰瘘4例;结扎主胰管组、连续缝合组、间断缝合组胰瘘发生率分别为13．9％（5／36）、15．6％（10／64）、32．0％（16／50）,前两者与后者差别具有统计学意义（P〈0．05）。结论胰体尾切除术中残端结扎和间断缝合容易发生胰瘘,选择性缝扎主胰管或Prolene线连续缝合能降低胰瘘发生率,尤其后者更简单易行。近端胰管梗阻患者可选用胰肠吻合预防胰瘘;闭合器钉和胰腺残端要根据胰腺大小和质地选择性使用。     

Prevention of pancreatic fistula with a new synthetic,absorbable sealant: evaluation in a dog model

BACKGROUND: Pancreatic fistula complicates up to 15% to 25% of pancreatic resections, especially with soft, normal pancreas, and is most common after distal pancreatectomy. A new synthetic, absorbable hydrogel sealant has recently been developed and tested for sealing of human aorta, bronchi, and dura; it is FDA approved as a lung sealant in humans. Our objective was to test the efficacy of the sealant in preventing pancreatic leaks in a dog model of distal pancreatectomy. STUDY DESIGN: Ten dogs underwent bilateral distal pancreatectomy under general anesthesia. Animals were randomized to receive application of the sealant to the pancreatic stumps (n = 5) or no treatment (n = 5). The transected pancreatic duct was not ligated, and the end of the pancreas was neither oversewn nor stapled; closed-suction drains were placed in proximity to the pancreatic stumps before abdominal closure. All animals received normal chow starting on the second postoperative day. Drainage was collected for volume and amylase determination twice daily for 14 days, after which the animals were sacrificed. Pancreatic tissue was collected from the area of transection and was formalin fixed for histopathology. RESULTS: There was no perioperative mortality. Fluid recovered from closed-suction drains in all animals was uniformly amylase-rich. Over the 14-day study period, daily volume of pancreatic drainage was significantly different between control animals and animals treated with sealant (p < 0.001). By postoperative day 6, the total mean pancreatic drainage in dogs treated with sealant was 25 +/- 5 mL/drain (versus 91 +/- 26 mL/drain in untreated dogs; p < 0.05). This is the point at which we remove the drains in our clinical practice. Examination at 14 days revealed intact sealant at the pancreatic stumps in the treatment group, and histopathology showed a characteristic benign histiocyte reaction to the sealant but no other qualitative differences in the degree of inflammation between control and treatment animals. There were no undrained collections or abscesses. CONCLUSIONS: A new synthetic hydrogel sealant prevents the formation of significant pancreatic fistulae after distal pancreatectomy in the dog and may be suitable for clinical application.     

Distal pancreatectomy: does the method of closure influence fistula formation?

The appropriate closure of the pancreatic remnant after distal pancreatectomy is still debated. Suture techniques, stapled closure, and pancreaticoenteric anastomosis all have their supporters. In this study we have reviewed our data from distal pancreatectomy to determine whether the type of remnant closure or underlying pathologic process had any relation to postoperative fistula formation. We performed a retrospective chart review of patients undergoing distal pancreatectomy at our institution between 1993 and 2001. The charts were reviewed for morbidity and mortality. These were then related to the type of closure of the pancreatic stump. From 1993 to 2001 a total of 86 patients underwent distal pancreatectomy. Data were available on 85 patients. Indications for surgery were pancreatic tumor (69%), pancreatitis (14%), trauma (7%), and extra pancreatic disease (9%). Pancreatic fistula occurred in 14 per cent (N = 12), intra-abdominal abscess in 8 per cent (N = 7), and wound infection in 2 per cent (N = 2). There was no mortality in the series. The incidence of pancreatic fistula formation was not related to method of closure of the pancreatic remnant nor to the underlying pathologic process. Postoperative pancreatic fistulas will close spontaneously even without total parenteral nutrition.     

Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? results of a prospective randomized trial

Despite substantial improvements in perioperative mortality, complications, and specifically the development of a pancreatic fistula, remain a common occurrence after pancreaticoduodenectomy. It was the objective of this study to evaluate the role of fibrin glue sealant as an adjunct to decrease the rate of pancreatic fistula after pancreaticoduodenectomy. One hundred twenty-five patients were randomized after pancreaticoduodenal resection only if, in the opinion of the surgeon, the pancreaticojejunal anastomosis was at high risk for development of a pancreatic anastomotic leak. After completion of the pancreaticojejunal anastomosis, the patients were randomized to topical application of fibrin glue sealant to the surface of the anastomosis or no such application. The primary postoperative end points in this study were pancreatic fistula, total complications, death, and length of hospital stay. A total of 59 patients were randomized to the fibrin glue arm, whereas 66 patients were randomized to the control arm and did not receive fibrin glue application. The pancreatic fistula rate in the fibrin glue arm of the study was 26% vs. 30% in the control group (p = not significant [NS]). The mean length of postoperative stay for all patients randomized was similar (fibrin glue = 12.2 days, control = 13.6 days) and the mean length of stay for patients in whom pancreatic fistula developed was also not different (fibrin glue = 18.9 days, control = 21.7 days). There were no differences with respect to total complications or specific complications such as postoperative bleeding, infection, or delayed gastric emptying. These data demonstrate that the topical application of fibrin glue sealant to the surface of the pancreatic anastomosis in this patient population undergoing high-risk pancreaticojejunal anastomosis did not reduce the incidence of pancreatic fistula or total complications after pancreaticodudodenectomy. There seems to be no benefit regarding the use of this substance in this setting. Presented at the Forty-Fifth Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation). This work was supported in part by the Haemacure Company and Baxter Health Care.     

Application of Polyethylene Glycolic Acid Felt with Fibrin Sealant to Prevent Postoperative Pancreatic Fistula in Pancreatic Surgery

Objective

The purpose of this nonrandomized retrospective study was to report our new procedures using polyethylene glycolic acid (PGA) felt with fibrin sealant to prevent severe pancreatic fistula in patients undergoing pancreatic surgery.

Methods

From 2000 to 2008, 54 and 63 patients underwent pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), respectively. Of those patients, we applied PGA felt with fibrin sealant to 18 PD patients and 26 DP patients. In PD patients, the PGA felt was wrapped around the pancreatic suture site, while in DP patients, the PGA felt was wrapped around the predictive division site. The pancreaticojejunostomy site in PD patients and the cut stump in DP patients were coated with fibrin sealant. We compared the occurrence rates for severe postoperative pancreatic fistula (POPF) that occurred after PD or DP both with and without our new procedures.

Results

Before introduction of our procedures, severe POPF developed in 14 of 36 PD patients (39%) and 10 of 37 DP patients (27%). In contrast, after introduction of our procedures, the incidence of POPF was only one in both of 18 PD (6%; P?=?0.016) and 26 DP (4%; P?=?0.017) patients.

Conclusion

In summary, our procedure using PGA felt with fibrin sealant may reduce the risk of severe POPF.     

Comparison of ultrasonically activated scalpel versus conventional division for the pancreas in distal pancreatectomy

Purpose: The goal of this study was to compare the benefits and complications of using an ultrasonically activated scalpel and conventional division of the pancreas in patients undergoing a distal pancreatectomy. Methods: A retrospective review was performed of all patients who underwent distal pancreatectomy at the Department of Surgery, Koshigaya Municipal Hospital. In the ultrasonically activated scalpel (US) group (n = 11), the pancreas was divided using coagulation shears. The stump of the pancreas was left open without parenchymal suturing. In the conventional surgical division (CV) group (n = 20), the pancreas was cut with a knife and the stump was oversewn with interrupted mattress sutures. The main pancreatic duct was ligated in all patients in both groups. The postoperative courses in the two groups were then compared in terms of postoperative serum amylase levels and the incidence of pancreatic fistulas. Results: The postoperative serum amylase levels were significantly lower in the US group than in the CV group (P < 0.01 on the day of operation). The incidence of pancreatic fistulas was also significantly lower in the US group (0%) than in the CV group (30%) (P = 0.04). Conclusions: The use of the ultrasonically activated scalpel was found to reduce the incidence of pancreatic fistula in distal pancreatectomy. Furthermore, the use of this device without any clamping or parenchymal suturing may reduce the damage to the remnant pancreas. Received: December 22, 2000 / Accepted: March 9, 2001     

Effect of BioGlue® on the Incidence of Pancreatic Fistula Following Pancreas Resection

Background Despite numerous modifications of surgical technique, pancreatic fistula remains a serious problem and occurs in about 10% of patients following pancreas resection. BioGlue is a new sealant that creates a flexible mechanical seal within minutes independent of the body’s clotting mechanism. Hypothesis Application of BioGlue sealant will reduce the incidence of pancreatic fistula following pancreas resection. Methods A retrospective cohort study was performed with 64 patients undergoing pancreas resection. BioGlue sealant was applied to the pancreatic anastomosis (Whipple) or resection margin (distal pancreatectomy) in 32 cases. Factors that could affect the rate of postoperative pancreatic fistula were recorded. Pancreatic fistula was defined as greater than 50 ml of drain output with an amylase content greater than three times normal serum value after postoperative day 10. To improve the sensitivity of our study, we also examined pancreatic fistula with a strict definition of any drain output on or after postoperative day 3 with a high amylase content and graded the fistulas in terms of clinical severity. Grade A leaks were defined as subclinical. Grade B leaks required some response such as making the patient nil per os, parenteral nutrition, octreotide, antibiotics, or a prolonged hospital stay. Grade C leaks were defined as serious and life threatening. They were associated with hemorrhage, sepsis, resulted in deterioration of other organ systems, and mandated intensive care. Comparisons between the two groups were made using the chi-square test or Fisher’s exact test for categorical variables and by the Wilcoxon rank-sum test for continuous variables. P values of 0.05 or less were deemed statistically significant. Results There were no differences between the patients who received BioGlue and the control cohort in terms of comorbid conditions, tumor location, texture of the pancreas, size of the pancreatic duct, or surgical technique. By the common definition, pancreatic fistula occurred in 6% (control) vs. 22% (BioGlue). By the strict definition, a fistula occurred in 41% (control) vs. 60% (BioGlue). In the control group, ten were subclinical (grade A) and two were clinically apparent leaks (grade B). In the BioGlue group, seven were subclinical (grade A), five were clinically apparent (grade B), and three were severe (grade C). There were no statistically significant differences in the incidence or severity grades of postoperative pancreatic fistulas between the two groups. Conclusion Application of BioGlue sealant probably does not reduce the incidence of pancreatic fistula following pancreas resection.     

The lasso technique for laparoscopic distal pancreatectomy

Background Laparoscopic distal pancreatectomy with or without splenectomy is becoming an acceptable alternative to open resection for selected pancreatic lesions. One of the difficulties with this approach is manipulating the pancreas with laparoscopic instruments to avoid unnecessary injury to the pancreas, and yet obtain adequate margins. The described technique accomplishes these goals. Methods Data from all patients who underwent laparoscopic distal pancreatectomy (always with splenectomy) were reviewed for age, gender, laparoscopic completion of the resection, postoperative complications, length of hosptial stay, and pathology. The essential component of the technique is use of a Penrose drain around the neck or proximal body of the pancreas as a “lasso” for atraumatic manipulation. This technique is described in detail. Results A total of 11 patients have undergone laparoscopic distal pancreatectomy with splenectomy using the lasso technique. Two patients (18%) underwent conversion to an open laparotomy: the because of bleeding from the pancreatic parenchyma and the other due to local invasion of a pancreatic adenocarcinoma. The average operating time was 162 ± 39 min, and the median length of hosptial stay was 3 days. There were two (18%) pancreatic leaks, both of which were treated conservatively with resolution. Pathologic examination, found six cystic neoplasms, two neuroendocrine tumors, two masses of chronic pancreatitis, and one adenocarcinoma. Conclusions The lasso technique simplifies intraoperative manipulation of the pancreas during laparoscopic distal pancreatectomy. It allows for safe manipulation of the pancreas and may expand the indications for the laparoscopic approach to pancreatic resection. This article contains a supplementary video. Presented in part at the 2004 Scientific Session of the Society of American Gastrointestinal Endoscopic Surgeons, (SAGES), Denver, Colorado, 31 March to 2 April, 2004     

Pancreaticojejunostomy with invagination of the punched pancreatic remnant after medial pancreatectomy and enucleation for multiple metastases of renal cell carcinoma: Report of a case

We report the successful resection of multiple pancreatic metastases of renal cell carcinoma (RCC), achieved by performing medial pancreatectomy and enucleation, preserving as much of the pancreatic parenchyma as possible. Most of the distal remnant pancreas was placed into the jejunal lumen and all three cut surfaces were covered to prevent pancreatic leakage. The postoperative course was uneventful, without any sign of pancreatic fistula. The patient is well without any evidence of recurrence or impairment of exocrine or endocrine pancreatic functions 1 year after surgery. Considering the unusual behavior of RCC metastasis and the difficulty in predicting the pattern of recurrence, we should devise the optimal surgical strategy to provide cancer-free surgical margins and preserve as much of the pancreatic parenchyma as possible.     

The use of a fibrin tissue sealant during laparoscopic partial nephrectomy

OBJECTIVE: To assess the feasibility and efficacy of commercially available fibrin tissue sealant as a haemostatic agent and collecting-system sealant during hand-assisted laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Fifteen consecutive patients underwent LPN for enhancing renal masses suspicious for renal cell carcinoma via a transperitoneal approach and with the use of a hand-assistance device. Monopolar electrocauterization and argon-beam coagulation were initially used to slow bleeding from the resection site. Through a laparoscopic applicator, Tisseel(TM) fibrin sealant (Baxter Inc., Deerfield, IL) was applied to the transected partial nephrectomy bed while the surgeon's hand maintained adequate compression and partial haemostasis. No further haemostatic measures were required in any patient; the patients were evaluated for acute and delayed bleeding or urinary extravasation. RESULTS: In all cases electrocauterization and argon-beam coagulation followed by the application of Tisseel was successful in obtaining strict haemostasis of the surgical bed, with no evidence of bleeding during or after surgery on immediate and extended follow-up. In addition, there was no evidence during or after surgery of any urinary leak. There were no immediate or delayed complications in any of the patients; a short-term outpatient follow-up (12-60 weeks) revealed no additional problems. CONCLUSIONS: Conventional haemostatic measures of electrocauteriztion and argon-beam coagulation combined with commercial fibrin sealant allows successful haemostasis during LPN. In addition to haemostatic properties, fibrin sealants appear to have sealing properties that may help to prevent complications of urinary leakage by helping to seal or close the small defects in the urinary collecting system. The use of this compound may facilitate the ability of the urological laparoscopist during LPN.     

远端胰腺切除术中两种胰腺残端封闭技术对比研究

目的 对比远端胰腺切除术中两种胰腺残端封闭技术的疗效,为胰腺外科手术医生选择合理的胰腺残端封闭技术提供参考。方法 回顾性分析2012-01-01至2013-09-30因“胰体尾占位性病变”在第二军医大学附属长海医院胰腺外科行开放的远端胰腺切除术的部分病人资料,分为切割闭合器组（99例）和手工缝合组（57例）,对比两组之间术中、术后及随访情况。结果 两组病人性别、年龄、体重指数、手术时间、术中出血、术中输血量、引流液淀粉酶值及胰瘘、术后输血率、术后体温（T）≥38℃、术后心率≥100次/min、术后再次手术、术后住院天数、术后30 d内再住院率及术后30 d内病死率差异均无统计学意义;术后输血量和总住院费用手工缝合组均少于切割闭合器闭合组,两组之间差异有统计学意义（P<0.05）。结论 建议胰腺外科医生在行开放的远端胰腺切除术时优先考虑选用手工缝合的方法来封闭保留侧胰腺残端。     

直线切割闭合器在胰体尾切除术中的作用

目的研究胰体尾切除术中传统手工缝合和直线切割闭合器处理胰腺残端对术后并发症的影响。方法回顾性分析2003年1月至2006年12月间109例接受胰体尾切除术患者的临床资料。结果109例患者中53例患者在开腹手术中手工缝合封闭胰腺残端;56例患者使用直线切割闭合器切断并封闭胰腺组织,其中31例在开腹手术中使用直线切割闭合器,25例在腹腔镜手术中使用腹腔镜直线切割闭合器。直线切割闭合器组患者的术后胰瘘以及腹腔感染发生率分别为21．4％和8．9％,低于手工缝合组的41．5％和28．3％（P=0．024和P=0．009）,但在手术持续时间、术后输血、术后再出血以及住院费用方面均无显著性差异。结论使用切割闭合器可以降低术后腹腔感染和胰瘘发生率。     

保留脾脏的胰体尾部良性肿瘤切除

目的探讨保留脾脏胰体尾切除的可行性和安全性以及并发症预防。方法回顾性分析总结2009年1月至2011年12月行保留脾脏胰体尾切除术5例资料,其中保留脾脏血管的开腹保脾胰体尾切除3例,切断(或切除)脾脏血管的保脾胰体尾切除术1例,腔镜下保脾胰体尾部切除术1例。结果本组无手术死亡,术后均未发生胰瘘、脾梗死、脾脓肿及脾出血等。随访3～6月,无并发症发生。结论胰体尾部良性肿瘤,应首选保留脾脏的胰体尾切除方法,手术安全,效果好,且避免了脾脏的不必要切除。     

Distal pancreatectomy with duct-to-mucosa pancreaticogastrostomy: a novel technique for preventing postoperative pancreatic fistula

Background

Management of the pancreatic remnant after distal pancreatectomy remains a clinically relevant problem and a significant clinical challenge. We evaluated the safety and efficacy of duct-to-mucosa pancreaticogastrostomy for preventing pancreatic fistula development after distal pancreatectomy.

Methods

Twenty-one patients underwent distal pancreatectomy using the duct-to-mucosa pancreaticogastrostomy and the clinical data were collected prospectively. Pancreatic fistula was defined and classified according to the international study group definition.

Results

The median surgical time was 236 minutes, with a median intraoperative blood loss of 250 mL. Morbidity was 5% and mortality was nil. The postoperative pancreatic fistula rate of clinically relevant grade B or C fistulae was 0%, although the biochemical grade A fistula rate was 29%. Delayed gastric emptying developed in only 1 patient (5%).

Conclusions

Duct-to-mucosa pancreaticogastrostomy may be a safe and effective technique for preventing pancreatic fistula development after distal pancreatectomy when performed by experienced surgeons who are skilled in this technique.     

Laparoscopic distal pancreatectomy

Background: Advanced laparoscopic techniques have been adapted to various surgical pathologies, including pancreatic tumors, with the potential benefits of attenuated surgical trauma, faster recovery, and improved cosmesis. Laparoscopic pancreatic surgery is technically demanding, and thus has not yet gained widespread acceptance. The aim of this study was to review our preliminary experience with laparoscopic distal pancreatectomy for benign and malignant pancreatic pathologies.Methods: A retrospective chart review of consecutive patients with benign and malignant pancreatic tumors who underwent laparoscopic distal pancreatectomy in a university-affiliated department of surgery between 1997 and 2003 was performed. Data relative to demographic and clinical characteristics, indications for surgery, surgical procedure, and postoperative course were recorded.Results: Laparoscopic distal pancreatectomy was attempted for 12 patients with benign (n = 8) and malignant (n = 4) pancreatic tumors and successfully completed laparoscopically in 75%, of these cases. Six early postoperative complications (two abscesses, two instances of diabetes mellitus, two pancreatic leaks) developed in three patients. The spleen was successfully preserved in 58% of the cases.Conclusions: This preliminary experience suggests that laparoscopic distal pancreatectomy is a feasible and safe procedure with a morbidity rate comparable with that for the conventional open procedure. However, laparoscopic surgery for malignant pancreatic tumors remains controversial. Larger series with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the treatment of pancreatic pathologies.Presented as a poster at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, Colorado, 31 March 3–April, 2004     

胰体尾切除术后胰瘘的防治

目的探讨胰体尾切除术后胰瘘的防治。方法回顾性分析2007年1月至2014年5月间83例行胰体尾切除术病人的术前基本资料、术中操作及术后治疗等临床资料,对其中并发胰瘘的19例病人临床资料进行分析。结果行胰体尾切除术的83例病人中,术后并发胰瘘19例,发生率为22．9％,16例经保守治疗痊愈,有效率为84．2％,2例病人行放射治疗后治愈,1例死亡,死亡率为1．2％。单纯缝扎和切割闭合器处理胰腺断端后胰瘘发生率分别为21．6％和23．9％。结论胰体尾切除术后胰瘘的发生率仍然很高,术中正确处理胰腺断端及加强术后管理是预防胰体尾切除术后胰瘘的关键。胰瘘的治疗在于通畅引流、加强营养支持,并积极寻找新的治疗方法。     

带血管蒂空肠浆肌瓣对胰腺切除和缝合的改进

目的　探讨一种降低全胃切除联合远端胰腺切除术后胰漏发生的术式。　方法　 1996年 3月～ 2 0 0 2年 12月 ,2 9例远端胰腺切除时 ,胰腺断端稍外凸 ,呈“ >”形 ,然后结扎主胰管 ,创面止血 ,利用代胃空肠制作带血管蒂浆肌瓣 ,用纤维蛋白胶将浆肌瓣与胰腺残端贴敷后丝线缝合 ,以保护胰腺残端。　结果　无胰漏、腹腔感染或脓肿及胰腺假性囊肿发生。　结论　带血管蒂空肠浆肌瓣有利于促进胰断面愈合 ,能有效地预防胰漏。     

Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients

OBJECTIVE: To evaluate the efficacy, amount of hemorrhage, biliary leakage, complications, and postoperative evolution after fibrin glue sealant application in patients undergoing liver resection. SUMMARY BACKGROUND DATA: Fibrin sealants have become popular as a means of improving perioperative hemostasis and reducing biliary leakage after liver surgery. However, trials regarding its use in liver surgery remain limited and of poor methodologic quality. PATIENTS AND METHODS: A total of 300 patients undergoing hepatic resection were randomly assigned to fibrin glue application or control groups. Characteristics and debit of drainage and postoperative complications were evaluated. The amount of blood loss, measurements of hematologic parameters liver test, and postoperative evolution (particularly involving biliary fistula and morbidity) was also recorded. RESULTS: Postoperatively, no differences were observed in the amount of transfusion (0.15 +/- 0.66 vs. 0.17 +/- 0.63 PRCU; P = 0.7234) or in the patients that required transfusion (18% vs. 12%; P = 0.2), respectively, for the fibrin glue or control group. There were no differences in overall drainage volumes (1180 +/- 2528 vs. 960 +/- 1253 mL) or in days of postoperative drainage (7.9 +/- 5 vs. 7.1 +/- 4.7). Incidence of biliary fistula was similar in the fibrin glue and control groups, (10% vs. 11%). There were no differences regarding postoperative morbidity between groups (23% vs. 23%; P = 1). CONCLUSIONS: Application of fibrin sealant in the raw surface of the liver does not seem justified. Blood loss, transfusion, incidence of biliary fistula, and outcome are comparable to patients without fibrin glue. Therefore, discontinuation of routine use of fibrin sealant would result in significant cost saving.