A novel preoperative predictor of pancreatic fistula using computed tomography after distal pancreatectomy with staple closure

Purpose

A thick pancreas has proven to be a conspicuous predictor of pancreatic fistula (PF) following distal pancreatectomy (DP) using staples. Other predictors for this serious surgical complication currently remain obscure. This study sought to identify novel predictors of PF following DP.

Methods

One hundred and twenty-two patients were retrospectively assessed to determine the correlation between PF occurrence and the clinicopathological findings and radiologic data from preoperative computed tomography (CT). CT assessments included the thickness of the pancreas (TP) and pancreatic CT number (pancreatic index; PI), calculated by dividing the pancreatic CT by the splenic CT density.

Results

Twenty-four patients (19.7%) developed a clinically relevant PF. TP was identified as an independent risk factor for PF in multivariate analyses (odds ratio 1.17; P?=?0.0095). In subgroup analyses, a lower PI in a thick pancreas was a significant predictor of PF (P?=?0.032). The combination of these two prediction parameters, known as the TP-to-PI ratio (TPIR), showed a significantly better prediction ability than TP alone (area under the receiver operating characteristic curve for the incidence of PF, TPIR 0.80 vs. TP 0.69; P?=?0.037).

Conclusion

Combining the CT number with TP substantially improves the prediction ability for the incidence of PF following DP with staple use.

     

Closure method for thick pancreas stump after distal pancreatectomy: soft coagulation and polyglycolic acid felt with fibrin glue

Purpose

Pancreatic fistula (PF) remains an obstacle to safe distal pancreatectomy (DP). A thick pancreatic parenchyma is a major risk factor for PF. In this paper, we elucidate the feasibility of the new closure method using soft coagulation and polyglycolic acid felt with fibrin glue.

Methods

In 2009–2013, 96 patients underwent DP with a novel closure method for pancreatic stump that utilized soft coagulation and polyglycolic acid felt with fibrin glue. We evaluated amylase levels in drainage fluid on postoperative days (POD) 1 and 3 and the incidence of postoperative PF according to International Study Group of Pancreatic Fistula (ISGPF) definitions.

Results

Drain amylase levels on POD1 and POD3 were 275 and 241 U/L, respectively, and ISGPF-defined Grade B/C PF rates were 16.7 %. No clinical factors were significantly associated with PF. Average pancreatic parenchymal thicknesses were similar in PF-positive and PF-negative patients (10.4?±?2.6 mm vs. 10.1?±?2.2 mm, P?=?0.639). There was no significant difference in the postoperative PF rate between patients with thick (≥12 mm) and thin (<12 mm) pancreas (11.1 vs. 18.8 %, P?=?0.544).

Conclusion

Our novel pancreatic stump closure method appears to be simple and effective, particularly in patients with thick pancreas.

     

Novel intraoperative use of the “Tensipresser” to assess factors predictive of pancreatic fistula after pancreaticoduodenectomy

Purposes

Pancreatic fistula (PF) is a challenging complication of pancreaticoduodenectomy (PD). ‘Soft pancreas’ is reported as a risk factor for PF; however, palpation by the surgeon is not an objective method of evaluating pancreatic texture. We conducted this study to investigate whether a texture analyzer called a “Tensipresser” can be used to quantify pancreatic tissue hardness and predict the development of postoperative PF.

Methods

We assessed pancreatic texture in 85 patients who underwent PD. After surgeons assessed the texture of the pancreas subjectively, the physical properties were measured on the pancreatic margin intraoperatively, by the two-bite method using the “Tensipresser”. The incidence and severity of PF were based on the definitions of the International Study Group on Pancreatic Fistula.

Results

Symptomatic PF (grade B and C) developed in 16% of the patients. Patients were divided into two groups based on the Tensipresser measurement: those with a soft and fragile pancreas with hardness?<?2070 gw/cm² and cohesiveness?<?0.65 (SF group); and all other patients (non-SF group). In the univariate and multivariate analysis, a small pancreatic duct diameter (<4 mm), no conduction of preoperative chemoradiation therapy, and inclusion in the SF group were significant predictors of PF.

Conclusion

The Tensipresser can evaluate pancreatic texture objectively, helping to define intraoperatively, those at risk of the development of PF.

     

Clinical influence of anastomotic stricture caused by pancreatogastrointestinalstomy following pancreatoduodenectomy

Background and purpose

Pancreatic fistula after pancreatoduodenectomy (PD) is not uncommon, but few reports describe a stricture after pancreatogastrointestinalstomy. We investigated the clinical influence of anastomotic stricture caused by pancreatogastrointestinalstomy after PD.

Methods

The subjects of this prospective cohort study were 132 patients who underwent PD or pylorus-preserving PD. We reviewed the relationships between pancreatic duct dilatation of the remnant pancreas and several risk factors. We also compared pancreatic duct dilatation with pancreatic atrophy and analyzed nutrient parameters in the first postoperative year.

Results

Patients with a preoperative pancreatic duct diameter less than 3 mm had a significantly dilated postoperative pancreatic duct diameter (p = 0.0001). The average atrophy rate of the remnant pancreas was 26.3 %, with the lowest atrophy rate (7.3 %) seen in patients without pre- or postoperative pancreatic duct dilation. A normal pancreas in which pancreatic duct dilatation developed postoperatively had a high atrophy rate (34.9 %). Moreover, only patients without pre- or postoperative pancreatic dilatation gained body weight (3.9 %).

Conclusion

This study shows a significant correlation between pancreatic atrophy rate and weight loss. Atrophy of the remnant pancreas caused by anastomotic stricture influences the exocrine function of patients after PD. The anastomotic method must be improved to prevent pancreatic duct dilatation and allow for early diagnosis and management of stenotic lesions.

     

Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches

Introduction

Laparoscopic and robotic surgery of the pancreas has only recently emerged as viable treatment options for benign and malignant disease. This review seeks to evaluate the current body of evidence on these approaches to pancreaticoduodenectomy and distal pancreatectomy.

Methods

A systematic review of large published series was performed utilizing the PubMed search engine.

Results

Based on these reports, both the laparoscopic and robotic techniques for these complex procedures appear to be safe and effective, if performed by high volume experienced pancreatic surgeons. The advantages of each approach are highlighted, emphasizing the data available on the learning curve and potential dissemination.

Conclusions

Both minimally invasive approaches to pancreatic resection are safe and feasible.

     

Transvaginal primary repair of a suprasphincteric rectovaginal fistula

Introduction and hypothesis

Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.

Methods

An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.

Results

Anatomy restoration was completed without complications.

Conclusion

The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.

     

A Cohort Study for Derivation and Validation of Early Detection of Pancreatic Fistula After Pancreaticoduodenectomy

Background

Pancreatic fistula (PF) remains the most important morbidity after pancreaticoduodenectomy (PD). Early drain removal was recently recommended. However, this is not applicable to all cases because the development of severe PF may not be obvious until a later postoperative day (POD). This study aimed to discover ways to detect clinically relevant PF early during the postoperative stage after PD.

Methods

We studied 120 patients who underwent PD. Grades B/C PF classified according to the International Study Group of Pancreatic Surgery guidelines were defined as clinically relevant PF. Logistic regression was used to identify detection factors for clinically relevant PF. Receiver operating characteristic curves were used to identify the optimal cutoff value for clinically relevant PF, and the k-fold cross-validation model to validate the cutoff value.

Results

Drain amylase on POD 1 and C-reactive protein (CPR) on POD 2 were independent factors for clinically relevant PF. Drain amylase >1300 IU/l on POD 1 and CRP >12.8 g/dl on POD 2 were the best cutoff values for clinically relevant PF detection and were confirmed by k-fold cross-validation. The sensitivity and specificity values were 79 and 81 %, respectively.

Conclusions

Values of drain amylase and CRP combined were useful to distinguish clinically relevant PF.

     

Preoperative Chemoradiation for Pancreatic Adenocarcinoma Does Not Increase 90-Day Postoperative Morbidity or Mortality

Background

The impact of preoperative chemoradiation on postoperative morbidity and mortality of patients with pancreatic adenocarcinoma remains controversial.

Methods

Consecutive pancreatectomies for adenocarcinoma performed between 2011 and 2015 were prospectively monitored for 90 days by using a previously reported surveillance system to determine the association between preoperative chemoradiation and adverse events, pancreatic fistulae, readmissions, and mortality.

Results

Among 209 consecutive patients who underwent pancreatectomy, 159 (76 %) experienced at least one adverse event within 90 postoperative days. Patients who received preoperative chemoradiation (n?=?137, 66 %) were more likely to have borderline resectable/locally advanced tumors, to have received induction chemotherapy, and to require vascular resection at pancreatectomy than those who did not receive chemoradiation (all P?<?0.05). Nonetheless, there were no significant differences in the rates of severe complications, readmission, or mortality between these groups (all P?>?0.05). Among patients who underwent pancreatoduodenectomy, the rate of pancreatic fistula was similar between those who received chemoradiation and those who did not (P?=?0.96). In contrast, those who received chemoradiation prior to distal pancreatectomy had a lower rate of pancreatic fistula (P?<?0.01).

Conclusion

Preoperative chemoradiation is not associated with an increase in 90-day morbidity or mortality, and it may reduce the rate of pancreatic fistula following distal pancreatectomy.

     

Risk factors of postoperative pancreatic fistula after distal pancreatectomy using a triple-row stapler

Purpose

Postoperative pancreatic fistula (POPF) is one of the major complications in patients who undergo distal pancreatectomy (DP). Recently, dividing the pancreas by stapler is a commonly performed technique, however, POPF still occurs. Therefore, the purpose of this study was to investigate the risk factors for POPF after DP using a triple-row stapler.

Methods

A total of 75 patients underwent DP using a triple-row stapler (Endo GIA? Reloads with Tri-Staple? Technology 60 mm; COVIDIEN, North Haven, CT, USA) at Yamanashi University from December 2012 to December 2016. The clinical risk factors for POPF after DP using a triple-row stapler were identified based on univariate and multivariate analyses.

Results

Clinical POPF (ISGPF Grade B and C) was seen in 7 of 75 patients (9.3%). The body mass index (BMI) was significantly higher in the patients with POPF (26.8 ± 0.5 kg/m²) compared with the patients without POPF (21.4 ± 0.4 kg/m²; a cut-off value; 25.7 kg/m²). In addition, the patients with POPF were significantly younger than the patients without POPF (56.4 ± 5.6 vs 67.0 ± 1.5; a cut-off value was 57.0 years old).

Conclusions

BMI and age were found to be significant risk factors for POPF after DP using a triple-row stapler.

     

Distal Pancreatectomy Combined with Multivisceral Resection Is Associated with Postoperative Complication Rates and Survival Comparable to Those After Standard Procedures

Background

For pancreatic tumors located in the body or tail of the pancreas, distal pancreatectomy (DP) remains the surgical procedure of choice to achieve radical tumor removal. Purpose of this study was to evaluate outcome and overall survival of patients who underwent DP combined with multivisceral resection (MVR).

Methods

Retrospective single-center case-matched analysis. Between January 1994 and June 2014, 494 consecutive patients were entered into a prospective database, and 126 patients undergoing DP + MVR (cases) were matched with 126 patients undergoing DP (controls) for gender, age, and underlying final diagnosis.

Results

There were no significant differences in patient demographics. Rates of postoperative pancreatic fistula (POPF) (36 (28.6%) vs. 29 (23.0%); p?=?0.388) and postpancreatectomy hemorrhage (PPH) (7 (5.5%) vs. 5 (3.9%); p?=?0.769) did not reveal any significant differences. Although operative time (237.8?±?57.9 vs. 203.5?±?34.5; p?<?0.001) and the necessity for intraoperative transfusions (18 (14.3%) vs. 5 (4.0%); p?<?0.001) was significantly higher, the number of patients with major complications (the Clavien-Dindo ≥?3) was not increased (27 (19.8%) vs. 20 (15.9%); p?=?0.332) in the DP + MVR group. Midterm survival analysis indicated no significant difference for adenocarcinoma and neuroendocrine tumors for either group.

Conclusion

DP + MVR is a feasible and safe surgical procedure to achieve radical tumor removal and can offer beneficial survival outcomes. Although operative time and intraoperative transfusions are enhanced, POPF, PPH, or major complications (the Clavien-Dindo ≥?3) are not significantly increased after DP + MVR. DP + MVR can therefore be recommended in selected patients for resection of extended tumors within the concept of interdisciplinary strategies.

     

Operative Behandlung der ulnaren Seitenbandläsion am Daumengrundgelenk

Objective

Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb.

Indications

Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures.

Contraindications

Abrasions, wound-healing disturbance, skin disease, osteoarthritis.

Surgical technique

Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury.

Postoperative treatment

Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months.

Results

Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.

     

Surgical Management of Gastrogastric Fistula After Roux-en-Y Gastric Bypass: 10-Year Experience

Background

Gastrogastric fistula (GGF) occurs in 1–6% of patients who undergo Roux-en-Y gastric bypass (RYGB) for morbid obesity. The pathophysiology may be related to gastric ischemia, fistula, or ulcer.

Objectives

The purposes of the study are to describe the principles of management and to review the literature of this uncommon complication.

Setting

The setting of this study is University Hospital, France.

Materials and Methods

We conducted a retrospective review of all patients’ records with a diagnosis of GGF after RYGB between January 2004 and November 2014.

Results

During the study period, 1273 patients had RYGB for morbid obesity. Fifteen patients presented with a symptomatic GGF (1.18%). The average interval from surgery to presentation was 28 months (22–62). A history of marginal ulcer or anastomotic leak was present in nine patients (60%). The most common presentation was weight regain (80%), followed by pain (73.3%). Two types of fistulas were identified, an exclusively GGF (high) and a gastro-jejuno-gastric fistula (low). High GGF, frequently associated with dilatation of the gastric pouch, was treated by a sleeve of the pouch and sleeve resection of the remnant stomach (nine patients). Low GGF was treated with gastric resection coupled with a revision of the gastrojejunal anastomosis (six patients). All patients were treated laparoscopically with no conversion to laparotomy. The average length of postoperative hospital stay was 5.2 days (range 3–10).

Conclusion

GGF after RYGB is a rare complication. Its pathophysiology remains unclear. Surgical management is the definitive treatment.

     

Comparison of postoperative early and late complications between pancreas-sparing duodenectomy and pancreatoduodenectomy

Purpose

Pancreas-sparing duodenectomy (PSD) represents an alternative procedure to pancreatoduodenectomy (PD) for patients with duodenal neoplasms.

Methods

The postoperative early and late complications of 21 patients who underwent PSD between 1992 and 2014 were compared with those of 44 patients with soft pancreatic parenchyma who underwent PD between 2009 and 2014.

Results

The median operation time and blood loss were less in the PSD group than in the PD group (P < 0.001). The overall incidence of early complications was less in the PSD group than in the PD group (PSD with ampullectomy vs. PSD without ampullectomy vs. PD; 45.5 vs. 20.0 vs. 56.8 %). The incidence of pancreatic fistula formation and overall incidence of late complications were also less in the PSD group than in the PD group (P = 0.031, 0.020). There were no complications related to the pancreatic endocrine or exocrine functions in the PSD group.

Conclusion

PSD is a less-invasive procedure and has the advantage over PD of preserving the pancreas.

     

Arthroskopische subakromiale Dekompression

Objective

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.

Indications

All types of outlet impingement after 3 months of conservative treatment.

Contraindications

Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.

Surgical technique

Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.

Postoperative management

Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.

Results

Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.

     

Classification of remnant stomach shape after distal gastrectomy with Billroth-I reconstruction and a comparison of the postoperative outcomes

Purpose

To classify the shape of the remnant stomach after Billroth-I (B-I) reconstruction and evaluate the relationship between the shape of the remnant stomach and the postoperative clinical outcomes.

Methods

One hundred and ninety-five consecutive patients with gastric cancer underwent distal gastrectomy with B-I reconstruction between May 2006 and October 2014. We retrospectively reviewed their medical records and radiological findings. Finally, the shapes of the remnant stomach of 150 patients were classified as either straight type (type A) or stagnant type (type B). The clinical outcomes were compared with respect to the types of remnant stomach.

Results

The incidence of anastomotic leakage was significantly higher in the type A group than in the type B group (9.4 vs. 1.5%, p?=?0.044). The body weight change ratio after surgery was significantly lower in the type B group than in the type A group [p?=?0.0068, two-way repeated measures analysis of variance (ANOVA)], while the serum albumin levels showed marginally significant improvement in the type B group compared with the type A group (p?=?0.0542, two-way repeated measures ANOVA).

Conclusion

The shape of the remnant stomach after distal gastrectomy with B-I reconstruction might influence the degree of anastomotic leakage and long-term nutritional status.

     

Laparoscopic Hiatal Hernia Repair with Falciform Ligament Buttress

Background

Using synthetic mesh to buttress the crural repair during laparoscopic hiatal hernia repair may be associated with dysphagia and esophageal erosions, while a biologic mesh is expensive and does not decrease long-term recurrence rates. This study documents outcomes of laparoscopic paraesophageal hernia repairs using the falciform ligament to reinforce the crural repair.

Methods

This is a prospective study of laparoscopic paraesophageal hernia repairs with a falciform ligament buttress. Preoperatively and at 6 and 12 months postoperatively, medications, radiologic studies, and symptom severity and frequency scores were recorded. Patients with a hiatal defect greater than 5 cm were included, while patients with recurrent hiatal hernia repairs or prior gastric surgery were excluded. Symptom scores were compared pre- and postoperatively with a p?<?0.05 considered significant.

Results

One hundred four patients were included with a mean age of 62.4 years, and 57 patients underwent an upper gastrointestinal series at least 12 months from the initial operation with a mean follow-up of 20.6 months. The mean symptom severity score decreased from 14.32?±?0.93 to 4.75?±?0.97 (p?<?0.001), mean symptom frequency score decreased from 14.99?±?0.97 to 5.25?±?0.99 (p?<?0.001), and mean total symptom score decreased from 29.31?±?1.88 to 10.00?±?1.95 (p?<?0.001). Five patients developed recurrent hiatal hernias on upper gastrointestinal series, but only three required operative intervention.

Conclusions

Laparoscopic paraesophageal hernia repair with a falciform ligament buttress is a viable option for a durable closure. Ongoing follow-up will continue to illuminate the value of this approach to decrease morbidity and recurrence rates for hiatal hernia repair.

     

Repair of a vesicouterine fistula following cesarean section

Introduction and hypothesis

Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta.

Methods

A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video.

Results

No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage.

Conclusions

Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.

     

Extravesical robotic ureteral reimplantation for ureterovaginal fistula

Introduction

We present a video describing the technical considerations for performing an extravesical robotic ureteral reimplantation.

Methods

A 55-year old woman presented with urinary incontinence secondary to a ureterovaginal fistula after robotic-assisted hysterectomy. After failure of more conservative measures, she proceeded to a robotic ureteral reimplantation. Following port placement, the ureter is identified at the level of the iliac vessels and dissected circumferentially. The ureter is dissected free to the level of the ureterovaginal fistula, transected, and the distal remnant ligated. The ureter is spatulated, a cystotomy created, and a running anastomosis with mucosa-to-mucosa apposition performed over a stent. Care is taken to ensure it is tension free. The integrity of the anastomosis is tested with retrograde filling of the bladder. Postoperatively, a drainage catheter is left to allow for adequate healing. Follow-up imaging is performed to ensure a patent anastomosis.

Results

The patient had an uncomplicated postoperative course. A cystogram showed adequate healing at 10 days, and the stent was removed at 6 weeks. A follow-up renal ultrasound 6 weeks later showed no hydronephrosis.

Conclusions

Extravesical robotic ureteral reimplantation is a useful technique for managing ureterovaginal fistula; here we highlight pertinent technical considerations.

     

Fistelreifung: Vorhersage durch intraoperative Flussmessung

Background

The autogenous arteriovenous fistula (AVF) is the access of choice for hemodialysis therapy. Its timely and successful creation is particularly important to avoid hemodialysis catheters; however, according to the literature primary failure occurs in 20–50?% of newly created AVF.

Objective

To identify factors influencing AVF maturation and thus identify predictors of successful fistula creation.

Methods

We report on a prospective cohort study of 41 patients undergoing the first upper extremity AVF placement. Primary endpoint of the study was successful fistula maturation after 6 weeks and several constitutional, demographic, hemodynamic and technical factors were investigated.

Results

The most significant predictive parameter for fistula maturation was flow volume measured in the access vein during surgery. The receiver operating characteristic (ROC) curve analysis showed a cut-off value of 170 ml/min for the blood flow volume with the best possible sensitivity (85?%) and maximum specificity (80?%) for prediction of fistula failure within 6 weeks.

Conclusion

Intraoperative transit time flow measurement is easy to perform and can be used anytime to reliably predict successful AVF maturation.

     

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

Introduction and hypothesis

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

Methods

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

Results

The patient’s postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

Conclusions

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.