Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy

Background

The appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP.

Methods

The risk factors of pancreatic fistulas were investigated in 122 DPs among 3 types of stump closure: hand-sewn suture (n = 32), bipolar scissors (n = 45), and stapler closure (n = 45).

Results

There was no significant difference in the incidence of pancreatic fistula between the 3 types of stump closure (hand-sewn suture [44%] vs bipolar scissors [37.7%] vs stapler closure [35.5%]). By using receiver operating characteristics curves, 12 mm was the best cutoff value of the thickness of the pancreas for pancreatic fistulas after DP using stapler closure. Three factors (ie, male sex, body mass index >25 kg/m², and stapler closure) were independent risk factors of pancreatic fistulas after DP with a pancreas thicker than 12 mm.

Conclusions

A pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.     

Secure placement of a peripancreatic drain after a distal pancreatectomy

Background

A peripancreatic drain that is placed after a distal pancreatectomy sometimes migrates and becomes ineffective postoperatively. We devised a new drainage method with fixation of the tip of a peripancreatic drain using a loose loop of an absorbable suture.

Methods

This retrospective study was performed on 84 consecutive patients who underwent a distal pancreatectomy followed by peripancreatic drainage with (n = 31) or without (n = 53) fixation.

Results

The fixed drain remained in place postoperatively and was removed easily when the drainage became unnecessary. Pancreatic fistula developed in 4 patients with and 11 patients without drain fixation, the incidence between the patients. None with and 7 patients without fixation required additional drainage (interventional or surgical) for pancreatic fistula, the difference being significant. Time to resolution of pancreatic fistula tended to be shorter after drain fixation than after nonfixation.

Conclusions

Fixation of the tip of a peripancreatic drain is a simple but useful technique for effective drainage after distal pancreatectomy.     

Laparoscopic distal pancreatectomy using radiofrequency energy

Introduction

The pancreatic remnant remains a significant source of morbidity during laparoscopic pancreatectomy. Previous series have relied heavily on the endoscopic stapler for transection. Our study is the first to report use of a laparoscopic radiofrequency device for pancreatic transection.

Methods

The laparoscopic Habib 4x delivers high-energy radio waves through a hand-held device consisting of 4 electrodes and allows for bloodless tissue transection. We retrospectively evaluated prospectively collected data. Fourteen patients were identified and used in our analysis.

Results

There were no conversions, blood transfusions, reoperations, or mortalities. Average length of stay was 4.6 days. There was 1 readmission. Clinically significant fistula occurred in 2 patients (14%), only one of which required an intervention.

Conclusion

Radiofrequency energy is safe and feasible for use during laparoscopic pancreatic transection. Moreover, it is technically simple to use.     

Stapler and Nonstapler Closure of the Pancreatic Remnant After Distal Pancreatectomy: Multicenter Retrospective Analysis of 388 Patients

Background

The pancreatic fistula rate following distal pancreatectomy ranges widely, from 13.3 to 64.0?%. The optimal closure method of the pancreatic remnant remains controversial, especially regarding whether to use a stapler.

Methods

All patients who underwent distal pancreatectomy in five Japanese hospitals from January 2001 to June 2009 were included in this study. All relevant, anonymized medical records were entered into an electronic case report form. Complications and pancreatic fistulas were classified according to the Clavien–Dindo classification and the International Study Group of Pancreatic Surgery grading system, respectively.

Results

Of the 388 patients, stapler closure and nonstapler closure were used after distal pancreatectomy in 224 patients (57.7?%) and 164 patients (42.3?%), respectively. Clinically relevant pancreatic fistulas (grades B and C) occurred in 47 patients (21.0?%) treated by stapler closure, which was a significantly lower rate than that for the 83 patients (50.6?%) treated by nonstapler closure. There were no surgical mortalities or in-hospital deaths. The distribution of postoperative complications was grade 1, 30.7?% (n?=?119); grade 2, 40.2?% (n?=?156); grade 3a, 0.1?% (n?=?5); grade 3b, 0.3?% (n?=?1); grade 4a, 0.3?% (n?=?1). In the multivariate analysis, diabetes mellitus, previous laparotomy, operating time, and method of stump closure were found to be independently associated with the development of a clinical pancreatic fistula.

Conclusions

Stapler closure is a safe, efficient alternative to standard suture closure techniques because the clinical fistula rate is significantly lower.     

Risk factors and management of intra-abdominal infection after extended radical gastrectomy

Background

This study elucidated risk factors and management for intra-abdominal infection after extended radical gastrectomy.

Methods

From 1988 to 2004, 2,076 patients with gastric cancer underwent extended radical gastrectomy at Taipei Veterans General Hospital. Risk factors for intra-abdominal infection were determined by analyzing clinicopathological factors, operative procedure, combined organ resection, operative time, blood loss, and associated disease(s). Management modalities were summarized.

Results

The overall complication rate was 18.7%. Eighty (3.9%) patients were found to have intra-abdominal infections. Age, prolonged operation time, and combined organ resection were the precipitating factors. These patients were categorized into 3 groups: intra-abdominal abscess with adequate drainage, intra-abdominal abscess without anastomotic leakage, and intra-abdominal abscess because of leakage. Adequate drainage was the primary treatment. Mortality rate was 22.5% (18), and the most common cause of mortality was intra-abdominal abscess caused by leakage.

Conclusions

Although expert surgical skills can minimize the incidence of intra-abdominal infection, management also requires experience and training.     

Risk factors for surgical complications in distal pancreatectomy

Background

Pancreatic fistula (PF) represents a major complication after distal pancreatectomy. In a consecutive series of 110 patients, risk factors for the incidence of PF and surgical morbidity were identified.

Methods

Patients having undergone distal pancreatectomy between 2003 and 2007 were identified. Clinicopathologic parameters as well as perioperative data were correlated with the incidence of PF and overall surgical morbidity using univariate and multivariate models.

Results

In 72 patients (65%), malignant disease was present. Splenectomy and multivisceral resection were performed in 84 (76%) and 47 (42%) patients, respectively. Overall major surgical morbidity was 18%, and 12 patients (11%) developed PFs. A body mass index > 25 kg/m² was the only independent significant predictive factor for PF. Malignancy, splenectomy, multivisceral resection, transfusion, comorbidity, and stapler use did not show statistical significance. For overall surgical morbidity, there was no significant indicator.

Conclusions

A body mass index > 25 kg/m² contributes to the incidence of PF after distal pancreatectomy. Other parameters did not show a significant influence on PF or on overall surgical morbidity.     

Angiographic, ultrasonographic, and macroscopic assessment of aortic growth after VCS clips, interrupted polypropylene, or running polyglycolic acid anastomosis

Background/Purpose

Lack of growth after surgery is still an unsolved issue in growing vessels. Aortic surgery is an integral part of vascular pediatric surgery. As an alternative to address this lack of growth in this scenario, we propose the use of titanium clips for vascular anastomosis.

Methods

Thirty-two domestic swine were used in this study. Animals entered the study when they were 55 days old and were subjected to an end-to-end aortic anastomosis using vasular closure stapler (VCS) clips, interrupted polypropylene, or running polyglycolic acid suture. Control group animals were sham-operated. Pigs were allowed to grow for 6 months, during which time they were subjected to serial ultrasonographic and angiographic studies to assess vascular growth.

Results

VCS clip anastomosis outcome was comparable with polypropylene or polyglycolic acid suture anastomosis. No significant differences in either longitudinal or transversal vascular growth were seen between the 3 studied suturing techniques and the control group.

Conclusions

Our vascular growth and patency results suggest that VCS clips may provide a suitable alternative to conventional suture in pediatric aortic vascular surgery.     

The burden of incisional hernia in necrotizing pancreatitis: how can we improve?

Background

Necrotizing pancreatitis (NP) patients frequently require pancreatic debridement, and have risk factors for incisional hernia (IH). However, no published data exist regarding the incidence of IH in NP. The aim of the current study was to define the incidence of and identify risk factors for developing IH after pancreatic debridement.

Methods

Hernia presence was determined by clinical examination and patient interview. Technical and clinical considerations were noted: type of incision, closure, suture material, age, body mass index (BMI), diabetes mellitus (DM), preoperative albumin, and number of operations.

Results

Sixty-three (42%) of 149 debrided patients with NP developed IH. IH patients were older (P < .05). No differences in surgical technique or clinical risk factors were seen between groups.

Conclusion

The incidence of IH in NP patients requiring operative debridement is substantially higher than that in patients undergoing routine laparotomy. Innovative fascial closure techniques such as primary fascial buttress with nonsynthetic mesh should be considered.     

Morbimortalidad de la resección pancreática

Aim

Assess the postoperative morbidity rates in pancreatic resection.

Material and method

Prospective observational study which includes 117 patients who underwent surgery consecutively due to pancreatic or periampullary tumours. In 61 of the patients, cephalic pancreatectomy was carried out; 15 underwent total pancreatectomy; one underwent enucleation and 40 underwent distal pancreatectomy.

Results

Overall morbidity was 48.7% (59% for cephalic pancreatectomy, 35% for distal pancreatectomy and 46.7% for total pancreatectomy). The most frequent complications were intra-abdominal abscesses and collections (15.38%) and medical complications (13.68%). The incidence of pancreatic fistula was 9.83% for cephalic pancreatectomy and 10% for distal pancreatectomy. The reintervention incidence was 14.53%. Overall mortality was 5.12% (6.56% for cephalic pancreatectomy, 2.5% for distal pancreatectomy and 6.67% for total pancreatectomy). The presence of postoperative complications, the need for reintervention and the fact of being over 70 years of age correlated significantly with mortality.

Discussion

Pancreatic resection has high morbidity rates. Mortality is low and is practically limited to patients older than 70 years.     

Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

Introduction

High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion.

Methods

This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively.

Results

Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001).

Conclusions

Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.     

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。     

Outcomes of anal fistula surgery in patients with inflammatory bowel disease

Background

Anal fistulas in patients with Crohn's disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion.

Methods

This was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively.

Results

Between 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Paul's Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures.

Conclusions

Closure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.     

Male cryptoglandular fistula surgery outcomes: a retrospective analysis

Purpose

The purpose of this study was to evaluate cryptoglandular fistula surgery outcomes in men with common types of fistulae.

Method

A database review identified study patients. Exclusion criteria included history of previous fistula, previous anorectal surgery, inflammatory bowel disease, pelvic radiation, complex fistula, age <21 years, and absence of follow-up.

Results

Four hundred twenty-five patients met criteria for review. Mean follow-up was 5.8 years. Concurrent abscess at presentation was strongly associated with poorer outcomes. New-onset seepage is more common with seton treatment (P = 0.01), but seepage resolution occurred less commonly with fistulotomy (P <0.01).

Conclusions

Although both treatments are highly successful, men treated with primary fistulotomy are more likely to heal than seton patients. Fistulotomy patients have less early postoperative seepage than seton patients, but when this is present it is less likely to resolve. Presentation with concurrent abscess is strongly associated with poorer outcomes.     

A simple and safe pancreas transection using a stapling device for a distal pancreatectomy

Pancreatic fistula is the most common major complication to occur after distal pancreatectomy, ranging in frequency from 5% to 40%. The appropriate technique for treating the pancreatic stump still remains controversial. Thirty-six patients underwent distal pancreatectomy in Kagawa University Hospital between January 2000 and February 2007. Their hospital records were reviewed to evaluate the usefulness of a stapling closure using several types of staplers in comparison to a suture closure. They were subdivided according to the method used to close the pancreas stump: the suture group comprised 11 patients, the staple group comprised 24 patients, including 7 patients for whom was used the new endopath stapler Echelon 60 (Ethicon Endo-surgery; Johnson & Johnson, Cincinnati, OH, USA). Overall pancreatic fistula rate was 17% (6/36) in this series. In the staple group, 3 of the 24 patients (12%) developed a pancreatic fistula, whereas in the suture group, 3 of 11 patients (27%) developed a pancreatic fistula. Of the 7 patients for whom the Echelon 60 was used, none developed a pancreatic fistula. The length of postoperative hospital stay was also significantly shorter for the patients with the Echelon 60 than in the patients either with sutures or another stapling device. These findings support the advantages of using a stapler closure in distal pancreatectomy. This method, using a new stapler device, is considered to be a simple and safe alternative to the standard suture closure technique.     

Vacuum-assisted closure: a new method for treating patients with giant omphalocele

Introduction

Closure of giant omphalocele can present a surgical challenge. Neither silo, skin flap, nor primary closure has been successful in treating all patients. We present a novel application of the vacuum-assisted closure (VAC) device, which allows for improved results in these difficult cases.

Methods

The VAC device (KCI, San Antonio, Tex) consisted of a sponge applied directly to the bowel and liver, covered with impermeable transparent dressing, and attached to a low negative pressure system. The sponge was changed every 3 to 5 days under local sedation.

Patients

All 3 patients had giant omphaloceles. The first infant, a 34 week gestational age (WGA) male, was initially treated with silo reduction, which disrupted after 21 days. The large mass of bowel and liver made primary closure impossible. The VAC was applied for 45 days. The viscera was easily reduced and subsequently covered with acellular dermal matrix (AlloDerm). The VAC was reapplied, and the small remaining defect was skin-grafted. The second male infant was a 34 WGA male infant who became septic after failure of prosthetic mesh closure. The VAC was applied for 22 days after removal of the mesh. The infection resolved, and the defect size was reduced, allowing for skin flap closure. Mesh infection and development of an enterocutaneous fistula in the last patient, a 37 WGA female child, were treated by mesh removal and application of the VAC for 36 days. The VAC allowed for control of the fistula output and development of a healthy granulation bed.

Results

Vacuum-assisted closure was associated with (1) rapid shrinkage and reduction of the viscera (22-45 days); (2) cleansing of the wound; (3) excellent granulation; (4) maintenance of a sterile environment; and (5) ease of use, with changes possible at the bedside.

Conclusion

The VAC device should be considered a safe and effective alternative in treating complicated cases of giant omphalocele until a more definitive closure method can be used.     

Experience performing 64 consecutive stapled intestinal anastomoses in small children and infants

Background/Purpose

Intestinal anastomosis in children has traditionally been performed using hand-sewn techniques. Little data exist evaluating the efficacy of stapled intestinal anastomoses in the infant and pediatric populations.

Methods

A review of a 5-year experience using a mechanical stapler to treat 64 consecutive children requiring intestinal anastomoses was performed. An intestinal stapler was used to complete a side-to-side functional end-to-end anastomosis. Postoperative outcomes and modifications made to the technique were identified.

Results

Since 2004, 64 children (median age, 3 months; range, newborn to 24 months) underwent procedures requiring intestinal anastomosis. Twenty-six children (41%) were 1 week or less in age. Twenty-seven children (42%) underwent a stoma closure using a stapler. Thirty-seven children (58%) underwent bowel resection and stapled anastomosis in treating a variety of surgical disorders. Complications included wound infection (n = 2) and anastomotic stricture (n = 1). No issues suggesting anastomotic dilatation and subsequent stasis/overgrowth were identified.

Conclusions

These results suggest that stapled bowel anastomosis is an effective approach applicable to a variety of surgical diseases in newborns and infants.     

Renal Vein Extension Using Gonadal Vein: A Useful Strategy for Right Kidney Living Donor Harvested Using Laparoscopy

Introduction

Vascular management of the right renal vein during laparoscopic living donor nephrectomy is still an unsolved problem. This short vessel has limited the use of right kidneys. However, the right kidney should be harvested in some instances. Based on experience in open donor nephrectomy, our unit has used the donor gonadal vein to obtain a longer renal vein in this setting.

Methods

Four consecutive living related donors with the indication for laparoscopic right nephrectomy underwent this procedure. Three donors were females and the overall average age was 48.5 years. The renal vein was controlled with a 30-mm stapler and we included 5-6 cm of the ipsilateral gonadal vein during the harvest. The donor kidney was perfused and renal vessels prepared under cold conditions. The gonadal vein was opened longitudinally and sutured to the donor right renal vein as a wide tube in 3 cases and as a spiral tube in 1 case with 6-0 monofilament suture.

Results

This procedure extended the bench work between 25 to 40 minutes permitting an 2.5- to 3.5-cm extension of the donor vein. The transplantations were performed in the usual mode and the vein enlargement enormously facilitated the implantation surgery. All recipients displayed immediate graft function; no complications were observed with this strategy.

Conclusions

Vein extension with the gonadal vein was a simple, safe method to enlarge the renal vein among right living donor kidneys procured using laparoscopy.     

Intraperitoneal drainage after pancreatic resection: a review of the evidence

Background

Despite a growing body of literature supporting the limited use of prophylactic intra-abdominal drainage for many procedures, drain placement after pancreatic resection remains commonplace and highly controversial.

Materials and methods

Literature available in the PubMed was systematically reviewed by searching using combinations of keywords and citations in review articles regarding prophylactic drainage after pancreatic resection, early removal of intraoperatively placed drains after pancreatic resections, and risk factors and predictive tools for pancreatic fistula.

Results

Prospective randomized studies on prophylactic drainage after pancreaticoduodenectomy or distal pancreatectomy have not shown any benefit in decreasing pancreatic fistula, total complications, length of hospital stay, or readmission rates. Frequency of complications was significantly higher in patients receiving routine drainage. This was recently supported by retrospective studies; however, patients with risk factors for pancreatic fistula (soft pancreatic texture, prolonged operative times, and increased blood loss) were more likely to have prophylactic intra-abdominal drainage. Alternatively, if a drain is placed, prospective randomized studies demonstrate that early removal is safe in patients with postoperative day 1 drain amylase values <5000 U/L and associated with a lower rate of fistula.

Conclusions

The current literature supports a strategy of selective drainage and early drain removal after pancreatic resection in low-risk patients.     

Operative management of massive hernias with associated distended bowel

Introduction

Hernia patients with a history of recurrent bowel obstructions, chronic bowel dysmotility, and bowel distension have few options for return to a “normal” life. Return of the bowel and adhesiolysis seems the logical surgical solution, but the return of a swollen distended bowel into the abdominal cavity would put patients at a high risk for the development of abdominal compartment syndrome. Hernia repair with large pieces of mesh under tenuous skin flaps to incorporate the bowel into the abdominal cavity has its own set of devastating complications, including mesh infection, extrusion, and fistula formation.

Methods

Here we present 4 patients who underwent successful treatment with a combined small bowel resection for volume reduction and simultaneous components separation hernia repair for autogenous closure without mesh.

Results

All patients had successful abdominal wall closure without major complications and were tolerating enteral feedings upon discharge.

Conclusions

A combined approach of small bowel resection and separation of parts hernia repair is a feasible and successful means for approaching challenging abdominal wall defects with chronically distended bowel. A vicious cycle in which postoperative elevation in intra-abdominal pressure leads to severe systemic consequences can be averted. Moreover, bowel function can be restored and excellent cosmesis achieved, leading to significant improvements in patients' quality of life.     

Use of a non-cross-linked porcine dermal scaffold in abdominal wall reconstruction

Background

Reconstruction of complex abdominal wall defects is challenging. The use of prosthetic mesh can be associated with surgical site infection, fistula formation, and adhesions. This study presents our experience using a non-cross-linked porcine dermal scaffold (NCPDS) in abdominal wall reconstruction.

Methods

Patients undergoing abdominal wall reconstruction with NCPDS between May 2006 and January 2008 underwent a retrospective chart review. Demographics, indications for NCPDS placement, surgical technique, complications, and follow-up data were evaluated.

Results

Sixteen patients were identified in whom NCPDS was implanted into complex abdominal wall defects. These included 13 planned and 3 emergency surgeries. Indications for surgery included delayed reconstruction of giant ventral hernia secondary to decompressive laparotomy and open management of abdominal trauma, recurrence of large incisional hernia, temporary coverage of open abdomen secondary to intra-abdominal catastrophes, and open abdominal closure owing to compartment syndrome secondary to necrotizing fasciitis. In all, NCPDS was positioned in a subfascial underlay technique. Forty-four percent required a combination of components separation and NCPDS insertion. At a mean follow-up period of 16.5 months, the majority had desirable outcomes. Complications included seroma (21%), superficial wound dehiscence (7%), recurrence (7%), and infection (7%). Two patients died from multiorgan failure unrelated to NCPDS placement. The material only had to be removed in 1 patient because of wound infection and superficial wound dehiscence.

Conclusions

NCPDS seems to be a safe and effective alternative to prosthetic mesh in the reconstruction of complicated abdominal wall defects.