Randomized clinical trial of duct‐to‐mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy

Background

The postoperative pancreatic fistula (POPF) rate for duct‐to‐mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct‐to‐mucosa versus invagination pancreaticojejunostomy.

Methods

Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct‐to‐mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay.

Results

Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct‐to‐mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct‐to‐mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct‐to‐mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028).

Conclusion

This study did not demonstrate a superiority of invagination over duct‐to‐mucosa pancreaticojejunostomy in the risk of POPF. However, in high‐risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct‐to‐mucosa. Registration number: UMIN000005890 ( http://www.umin.ac.jp ).     

Randomized Controlled Single-Center Trial Comparing Pancreatogastrostomy Versus Pancreaticojejunostomy After Partial Pancreatoduodenectomy

Background

The aim of this single-center randomized trial was to compare the perioperative outcome of pancreatoduodenectomy with pancreatogastrostomy (PG) vs pancreaticojejunostomy (PJ).

Methods

Randomization was done intraoperatively. PG was performed via anterior and posterior gastrotomy with pursestring and inverting seromuscular suture; control intervention was PJ with duct?Cmucosa anastomosis. The primary endpoint was postoperative pancreatic fistula (POPF).

Results

From 2006 to 2011, n?=?268 patients were screened and n?=?116 were randomized to n?=?59 PG and n?=?57 PJ. There was no statistically significant difference regarding the primary endpoint (PG vs PJ, 10?% vs 12?%, p?=?0.775). The subgroup of high-risk patients with a soft pancreas had a non-significantly lower pancreatic fistula rate with PG (PG vs PJ, 14 vs 24?%, p?=?0.352). Analysis of secondary endpoints demonstrated a shorter operation time (404 vs 443?min, p?=?0.005) and reduced hospital stay for PG (15 vs 17?days, p?=?0.155). Delayed gastric emptying (DGE; PG vs PJ, 27 vs 17?%, p?=?0.246) and intraluminal bleeding (PG vs PJ, 7 vs 2?%, p?=?0.364) were more frequent with PG. Mortality was low in both groups (<2?%).

Conclusions

Our randomized controlled trial shows no difference between PG and PJ as reconstruction techniques after partial pancreatoduodenectomy. POPF rate, DGE, and bleeding were not statistically different. Operation time was significantly shorter in the PG group.     

Impact of Postoperative Pancreatic Fistula on Surgical Outcome—The Need for a Classification-driven Risk Management

Background

The International Study Group of Pancreatic Fistula (ISGPF) classification allows comparison of incidence and severity of postoperative pancreatic fistula (POPF). Its post hoc character, however, does not provide a guideline for the treatment of POPF in individual patient. We therefore studied the association of POPF type A-C on secondary surgical morbidity and mortality in patients undergoing pancreatic resection.

Patients and methods

Between 3/2001-12/2007, 483 patients underwent pancreatic resections. POPF were classified according to the ISGPF classification. All patient data were entered in a clinical data management system prospectively.

Results

Patients who developed POPF had significantly more vascular but not other surgical complications than patients without POPF. Patients with POPF A had no vascular or surgical complications. Twenty one of the 29 patients with POPF C had surgical complications (17 vascular complications). Mortality attributed to surgical complications after POPF C was 5/29. A soft pancreatic consistency (OR 8.5; p?<?0.008) and a high drain lipase activity on postoperative day 3 (OR 4.4; p?=?0,065) were predictors for the development of POPF C.

Discussion

POPF C is associated with vascular complications like erosion bleeding and other surgical complications like delayed gastric emptying or pleural effusions. A soft pancreatic consistency and a high drain lipase activity on postoperative day?3 are early predictors for the development of POPF C.     

Topically Applied 2-Octyl Cyanoacrylate (Dermabond) for Prevention of Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Objective

We examined whether 2-octyl cyanoacrylate (Dermabond) topically applied to the pancreaticojejunostomy (PJ) anastomotic site after pancreaticoduodenectomy (PD) reduces the rate of postoperative pancreatic fistula (POPF).

Methods

Patients who underwent PD with duct-to-mucosa PJ were evaluated (n?=?124). Outcome was compared between patients who received Dermabond (n?=?75) after PD and historic patients who did not (n?=?49). Risk factors for POPF were identified.

Results

Overall and clinically relevant rates of POPF were significantly lower in patients who received Dermabond than in patients who did not (2.6?% and 1.3?% vs. 22?% and 12?%, respectively; p?=?0.001). In univariate analysis, pancreatic duct diameter ??3?mm, low serum albumin level, and no Dermabond were independent risk factors for POPF; in multivariate analysis, no Dermabond was an independent risk factor for POPF. In patients with pancreatic duct diameter ??3?mm, the rate of POPF was significantly lower in patients who received Dermabond than in patients who did not (3.5?% versus 36?%, respectively; p?=?0.0001). Patients who received Dermabond had significantly shorter hospital stays and lower re-operation and re-admission rates.

Conclusions

Topical application of Dermabond to the PJ anastomotic site after PD significantly reduced the rate of POPF, particularly in patients at risk.     

Effects of early antiplatelet therapy after splenectomy with gastro‐oesophageal devascularization

Background

This study aimed to explore the effects of early antiplatelet therapy (APT) for portal vein thrombosis (PVT) in patients with cirrhotic portal hypertension after splenectomy with gastro‐oesophageal devascularization.

Methods

We retrospectively analysed 139 patients who underwent splenectomy with gastro‐oesophageal devascularization for portal hypertension due to cirrhosis between April 2010 and December 2016. Based on the post‐operative platelet values, we used two different APT regimens: APT was started when platelet counts were increased to 200 × 10⁹/L or above (group A, n = 64) or 300 × 10⁹/L or above (group B, n = 75). We took note of the patients’ clinical symptoms, operative factors and biochemical indicators.

Results

Platelet count, mean platelet volume, D‐dimer and pancreatic fistula were closely related to the development of PVT. Early APT was an independent protective factor for PVT. The incidence of post‐operative PVT was 15.1% (21/139) overall, 4.7% (3/64) in group A and 24% (18/75) in group B; there was a significant difference between groups A and B (χ² = 10.042, P = 0.002).

Conclusion

Platelet count, mean platelet volume, D‐dimer and pancreatic fistula were independent risk factors for the development of PVT after splenectomy with gastro‐oesophageal devascularization. Selection of the appropriate timing for early APT according to the post‐operative platelet count was feasible. Moreover, the use of aspirin combined with dipyridamole was safe and effective for early prevention of PVT.     

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

Background

It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD).

Methods

A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mortality. We used the Student t, Mann–Whitney U and χ² tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression.

Results

Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003).

Conclusion

There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those undergoing PJ after PD.     

A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreaticoduodenectomy

This retrospective study compares the results of pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) in our institution, which has extensive experience in both techniques. Between the years of June 1995 and June 2001, 214 patients underwent pancreaticoduodenectomy (PD) at our institution. Of these 177 had PG and 97 had pancreatojejunostomy (PJ). There were 117 (54.6%) males and 97 (45.3%) females with a mean age of 64.2 ± 12.4 years. Indications for surgery were pancreatic adenocarcinoma in 101 (47.2%), ampullary adenocarcinoma in 36 (16.9%), distal bile duct adenocarcinoma in 22 (10.2%), duodenal adenocarcinoma in 9 (4.2%), and miscellaneous causes in 46 (21.4%) of patients. Preoperatively, significant differences in the groups were that the patients undergoing PJ were significantly younger than those undergoing PG. Also noted preoperatively, was that the patients undergoing PG had a significantly lower direct bilirubin than those undergoing PJ. With regard to intraoperative parameters, operative time was significantly shorter in the PJ group when compared to the PG group. When the patients who did not develop fistula (N = 186) were compared to those who developed fistula (N = 28) the significant differences were that the patients who developed fistula were more likely to have hypertension preoperatively and a higher alkaline phosphatase. They also showed a significantly higher drain amylase and were likely to have surgery for ampullary, distal bile duct or duodenal carcinoma rather than pancreatic adenocarinoma. In addition, those patients who developed fistula had a significantly longer postoperative stay, a larger number of intraabdominal abscesses and leaks at the biliary anastomosis. Thirty-day mortality was significantly higher in the PJ group compared to the PG (4 vs. 0, P = 0.041). There was a significantly larger number of bile leaks in the PJ group when compared to the PG (6 vs. 1, P = 0.048). In addition, the PJ group required a significantly larger number of new CT guided drains to control infection (8 vs. 2,P = 0.046) and the PJ group required a larger number of re-explorations to control infection or bleeding (5 vs. 0, P = 0.018). However, the pancreatic fistula rate was not different between the two groups (12% [PG] vs. 14% [PJ]). This retrospective analysis shows that safety of PG can be performed safely and is associated with less complications than PJ and proposes PG as a suitable and safe alternative to PJ for the management of the pancreatic remnant following PD.     

Value of monitoring postoperative intra‐abdominal drainage fluid for the diagnosis of postoperative pancreatic fistula: Results of a prospective study in 134 patients

Objective: To evaluate the value of monitoring postoperative intra‐abdominal drainage in the diagnosis and treatment of postoperative pancreatic fistula (POPF). Methods: Intra‐abdominal drainage adjacent to the pacreaticoenteric anastomosis was prospectively collected from 134 patients accepted for pancreatic surgery in our department between November 2005 and August 2007 to determine the concentration of amylase and bacteriology. Also, the clinical outcome of each patient was recorded. The international study group definition was used to diagnose POPF. Results: The overall incidence of POPF was 39.6% in 53 patients diagnosed as POPF, among which 50 patients (37.3%, 50/134) were graded as I/II of POPF. The rising trend of the amylase level in the drainage fluid (P = 0.001), the texture of the pancreatic remnant (P = 0.042), and the amylase level on the 3rd and 7th postoperative days demonstrated good diagnostic values in univariate analysis (P < 0.001). The amylase value in drains on the 3rd postoperative day (POD3) and the 7th postoperative day (POD7) were the predicting factors (P < 0.001) of POPF by multivariate analysis. Conclusions: The amylase values in drains on the 3rd postoperative day and on the 7th postoperative day (POD7) were both valuable factors in the diagnoses of POPF. It is very important to monitor the dynamic change of amylase concentration in the drainage, not the result of a single test. These clinical factors could help us to detect the incidence of POPF earlier.     

Short‐ and long‐term outcomes following redo valvular surgery

Aim

We reviewed our experience in redo valvular surgery to evaluate trends in short‐ and long‐term outcomes.

Methods

We reviewed 414 patients (mean age, 62.8 ± 13.6 years) who underwent redo valvular surgery in the past 25 years. A total of 301 patients (54.2%) underwent first‐time redo valvular surgeries; 178 (32.1%) were second redos, 60 (10.8%) were third redos, and 16 were fourth redos (2.9%). The mean follow‐up period was 6.8 ± 6.3 years.

Results

Hospital mortality was 5.8%. New York Heart Association (NYHA) class III/IV (P = 0.0007, odds ratio = 4.403) and hemodialysis (P = 0.0383, odds ratio = 7.196) were risk factors for hospital death. Long‐term survival rates at 15 and 20 years were 64.7% ± 4.3% and 59.1% ± 5.0%, respectively. Predictors of late death were first time redo (P = 0.0076, hazard ratio = 0.422) and age younger than 61 years (P = 0.0005, hazard ratio = 0.229). There were significant differences in long‐term survival between NYHA classes I/II and III/IV (log‐rank test, P = 0.0419) and between the time from redo surgery (log‐rank test, P = 0.0189) and age (log‐rank test, P = 0.0001).

Conclusions

The hospital mortality rate for redo valve surgery has improved. Early referral for redo surgery can contribute to improving early and late outcomes.     

Body mass index and complications following major gastrointestinal surgery: a prospective,international cohort study and meta‐analysis

Aim

Previous studies reported conflicting evidence on the effects of obesity on outcomes after gastrointestinal surgery. The aims of this study were to explore the relationship of obesity with major postoperative complications in an international cohort and to present a meta‐analysis of all available prospective data.

Methods

This prospective, multicentre study included adults undergoing both elective and emergency gastrointestinal resection, reversal of stoma or formation of stoma. The primary end‐point was 30‐day major complications (Clavien–Dindo Grades III–V). A systematic search was undertaken for studies assessing the relationship between obesity and major complications after gastrointestinal surgery. Individual patient meta‐analysis was used to analyse pooled results.

Results

This study included 2519 patients across 127 centres, of whom 560 (22.2%) were obese. Unadjusted major complication rates were lower in obese vs normal weight patients (13.0% vs 16.2%, respectively), but this did not reach statistical significance (P = 0.863) on multivariate analysis for patients having surgery for either malignant or benign conditions. Individual patient meta‐analysis demonstrated that obese patients undergoing surgery for malignancy were at increased risk of major complications (OR 2.10, 95% CI 1.49–2.96, P < 0.001), whereas obese patients undergoing surgery for benign indications were at decreased risk (OR 0.59, 95% CI 0.46–0.75, P < 0.001) compared to normal weight patients.

Conclusions

In our international data, obesity was not found to be associated with major complications following gastrointestinal surgery. Meta‐analysis of available prospective data made a novel finding of obesity being associated with different outcomes depending on whether patients were undergoing surgery for benign or malignant disease.     

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.

     

Pancreaticojejunostomy Sleeve Reconstruction After Pancreaticoduodenectomy in Laparoscopic and Open Surgery

Introduction:

Laparoscopic procedures for pancreatic surgery have been significantly improved recently; however, only a limited number of successful laparoscopic or laparoscopy-assisted pancreaticoduodenectomy (PD) have been reported. The limitations could be attributed to the complexity of the reconstruction procedures under laparoscopic observation and the high incidence of complications. Postoperative pancreatic fistula (POPF) has been regarded traditionally as the most frequent major complication and is a potentially serious and life-threatening event. It remains the single most important cause of morbidity after PD and contributes significantly to prolonged mortality. Several modified methods of pancreas anastomosis were introduced to prevent POPF. However, few methods with a satisfactory leakage rate have yet to be seen. Collating principle of theoretical mechanics, we introduce a new method of reconstruction by performing an asymmetric sleeving-joint pancreaticojejunostomy (SJPJ). The aim of this study is to summarize the results of a new technique that is designed to decrease the POPF.

Methods:

From January 2004 to December 2010, SJPJ was performed on 86 patients undergoing PD by 1 surgeon: a laparoscopic reconstruction was completed in 9 cases, a hand-assisted laparoscopic reconstruction in 2 cases, and an open SJPJ reconstruction in 75 cases.

Discussion:

We used SJPJ, an asymmetric pancreaticojejunostomy (PJ). The time of operation ranged from 300 minutes to 640 minutes. Postoperatively there were no major morbidities and no deaths. Although POPF was observed in the laparoscopic SJPJ group with pancreatic adenocarcinoma, 3 patients developed POPF in the open SJPJ group with ampullary adenocarcinoma (n=1) and pancreatic adenocarcinoma (n=2). The POPF rate was 9.30% in the open SJPJ group and 9.10% in the laparoscopic SJPJ group. The SJPJ procedure facilitates PJ, both laparoscopically and in open surgery. It is safe, effective, and feasible in experience hands.     

Rate of Clinically Significant Postoperative Pancreatic Fistula in Pancreatic Neuroendocrine Tumors

Background

In 2005, the International Study Group of Pancreatic Fistula (ISGPF) developed a definition and grading system for postoperative pancreatic fistula (POPF). The authors sought to determine the rate of POPF after enucleation and/or resection of pancreatic neuroendocrine tumors (PNET) and to identify clinical, surgical, or pathologic factors associated with POPF.

Methods

A retrospective analysis of pancreatic enucleations and resections performed from March 1998 to April 2010. We defined a clinically significant POPF as a grade B that required nonoperative intervention and grade C.

Results

One hundred twenty-two patients were identified; 62 patients had enucleations and 60 patients had resections of PNET. The rate of clinically significant POPF was 23.7?% (29/122). For pancreatic enucleation, the POPF rate was 27.4?% (17/62, 14 grade B, 3 grade C). The pancreatic resection group had a POPF rate of 20?% (12/60, 10 grade B, 2 grade C). This difference was not significant (p?=?0.4). In univariate analyses, patients in the enucleation group with hereditary syndromes (p?=?0.02) and non-insulinoma tumors (p?=?0.02) had a higher POPF rate. Patients in the resection group with body mass index (BMI)?>?25 (p?p?p?=?0.02) had a higher POPF rate. Multivariate analyses revealed that hereditary syndromes were able to predict POPF in the enucleation group, while having BMI?>?25 and increasing lesion size were also associated with POPF in the group undergoing resection.

Conclusions

We found a clinically significant POPF rate after surgery in PNET to be 23.7?% with no difference by the type of operation. Our POPF rate is comparable to that reported in the literature for pancreatic resection for other types of tumors. Certain inherited genetic diseases—von Hippel–Lindau disease (VHL) and MEN-1—were associated with higher POPF rates.     

Pancreaticogastrostomy versus pancreaticojejunostomy

Background

It has long been debated whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is the better choice for reconstruction after pancreaticoduodenectomy. The purpose of this study is to evaluate the two techniques.

Methods

Randomized controlled trials (RCTs) comparing PG with PJ published from January 1995 to January 2014 were searched electronically using PubMed, Medline, and Cochrane Library. Published data of these RCTs were analyzed using either fixed-effects model or random-effects model.

Results

Seven RCTs were included in this meta-analysis, with a total of 1121 patients (562 in PG, 559 in PJ). The incidence of postoperative pancreatic fistula and intra-abdominal fluid collection were significantly lower in PG than in PJ (respectively: odds ratio = 0.53 [0.37, 0.74], P < 0.001; odds ratio = 0.48 [0.30, 0.76], P < 0.01), no significant difference could be found for delayed gastric emptying, hemorrhage, morbidity, reoperation rate, and mortality.

Conclusions

The evidence from RCTs suggests that PG technique is associated with a lower rate of postoperative pancreatic fistula and intra-abdominal fluid collection than PJ.     

Schematic Pancreatic Configuration: A Risk Assessment for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Introduction

Postoperative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). Preoperative risk assessment of POPF is desirable in careful preparation for operation. The aim of this study was to assess simple and accurate risk factors for clinically relevant POPF based on a schematic understanding of the pancreatic configuration using preoperative multidetector computed tomography.

Methods

Three hundred and eighteen consecutive patients who underwent PD in the National Cancer Center Hospital East between November 2006 and March 2013 were investigated. Pre-, intra-, and postoperative clinicopathological findings as well as pancreatic configuration data were analyzed for the risk of clinically relevant POPF. POPF was defined according to the International Study Group of Pancreatic Fistula classification. POPF grade A occurred in 52 patients (16.4 %), grade B in 84 (26.4 %), and grade C in 6 (1.9 %).

Conclusions

Independent risk factors for POPF grade B/C included main pancreatic duct diameter (MPDd) < 2 mm (P = 0.001), parenchymal thickness ≥ 8 mm (P = 0.018), not performing portal vein/superior mesenteric vein resection (P = 0.004), and amylase level of drainage fluid on postoperative day 3 ≥ 375 IU/L (P < 0.001). Pancreatic configuration data including MPDd and parenchymal thickness were good indicators of clinically relevant POPF.     

A grading system can predict clinical and economic outcomes of pancreatic fistula after pancreaticoduodenectomy: results in 755 consecutive patients

Aim  

Postoperative pancreatic fistula (POPF) has a wide range of clinical and economical implications due to the difference of the associated complications and management. The aim of this study is to verify the applicability of the International Study Group of Pancreatic Fistula (ISGPF) definition and its capability to predict hospital costs.     

Association of Insulin‐like Growth Factor‐1, Bone Mass and Inflammation to Low‐energy Distal Radius Fractures and Fracture Healing in Elderly Women Attending Emergency Care

Objective

Elderly patients suffer fractures through low‐energy mechanisms. The distal radius is the most frequent fracture localization. Insulin‐like growth factor‐1 (IGF1) plays an important role in the maintenance of bone mass and its levels decline with advancing age and in states of malnutrition. Our aim was to investigate the association of IGF1 levels, bone mass, nutritional status, and inflammation to low‐energy distal radius fractures and also study if fracture healing is influenced by IGF1, nutritional status, and inflammation.

Methods

Postmenopausal women, 55 years or older, with low‐energy distal radius fractures occurring due to falling on slippery ground, indoors or outdoors, were recruited in the emergency department (ED) and followed 1 and 5 weeks after the initial trauma with biomarkers for nutritional status and inflammation. Fractures were diagnosed according to standard procedure by physical examination and X‐ray. All patients were conservatively treated with plaster casts in the ED. Patients who needed interventions were excluded from our study. Fracture healing was evaluated from radiographs. Fracture healing assessment was made with a five‐point scale where the radiological assessment included callus formation, fracture line, and stage of union. Blood samples were taken within 24 h after fracture and analyzed in the routine laboratory. Bone mineral density (BMD) was measured by dual‐energy X‐ray absorptiometry (DXA).

Results

Thirty‐eight Caucasian women, aged 70.5 ± 8.9 years (mean ± SD) old, were recruited. Nutritional status, as evaluated by albumin (40.3 ± 3.1 g/L), IGF1 (125.3 ± 39.9 μg/L), body mass index (26.9 ± 3.6 kg/m²), arm diameter (28.9 ± 8.9 cm), and arm skinfold (2.5 ± 0.7 cm), was normal. A positive correlation was found between IGF1 at visit 1 and the lowest BMD for hip, spine, or radius (r = 0.39, P = 0.04). High sensitive C‐reactive protein (hsCRP) and leukocytes were higher at the fracture event compared to 5 weeks later (P = 0.07 and P < 0.001, respectively). Fracture healing parameters (i.e. callus formation, fracture line, and stage of union) were positively correlated with the initial leukocyte count and to difference in thrombocyte count between visit 1 and 3.

Conclusions

In elderly women with low‐energy distal radius fractures, an association between IGF1 and lowest measures of BMD was found, indicating that low IGF1 could be an indirect risk factor for fractures. Fracture healing was associated with initial leukocytosis and a lower thrombocyte count, suggesting that inflammation and thrombocytes are important components in fracture healing.

     

One-layer pancreaticojejunostomy using reinforcing sutures in pancreaticoduodenectomy: A single surgeon’s experience with 122 cases

BackgroundDiscussions about pancreaticojejunostomy (PJ), which can reduce the incidence of postoperative pancreatic fistula (POPF) in pancreaticoduodenectomy (PD), are ongoing. Here we introduce the surgical technique of PJ performed at our hospital and analyze its safety and advantages.MethodsWe retrospectively analyzed 122 patients who underwent one-layer PJ using reinforcing sutures in PD. PJ was performed with reinforcing sutures on the pancreatic stump, including the insertion of a soft silastic catheter for internal drainage followed by suturing of the pancreas and jejunum with one layer.ResultsOf the 122 patients who underwent PJ with this technique, 62 (50.8%) developed POPF. However, 37 (30.3%) had grade A that did not affect the hospital course. Critical POPF occurred in 25 patients: grade B in 20 (16.4%) and grade C in 5 (4.1%). There was no significant difference in the critical POPF patient group according to the pancreas related disease related to pancreatic texture.ConclusionAlthough this technique cannot prevent POPF, we noted no significant difference in POPF versus other surgical techniques. In addition, this technique, which was designed to increase pancreatic texture, is practical and simple for PJ. Therefore, the inexperienced hepatobiliary and pancreatic surgeon can perform it without major complications.     

Combined treatment for facial rejuvenation using an optimized pulsed light source followed by a fractional non‐ablative laser

Background

Combination laser treatments can potentially increase the effectiveness of treatment without the additional downtime associated with another procedure.

Objective

To assess the effectiveness and safety of combining non‐ablative fractional treatments with optimized intense pulsed light.

Methods and Materials

Ten subjects (Group A) received full face treatments with a non‐ablative fractional either followed or preceded by an optimized intense pulsed light source. Twenty‐six subjects (Group B) received only full face treatments with the same non‐ablative, fractional laser device.

Results

For Group A, the overall average Fitzpatrick Wrinkle Scale for all patients improved from 6.3 ± 1.1 at baseline to 5.9 ± 0.8 one month following one treatment for an average improvement of 0.4 ± 0.6 (P < 0.10 paired t‐test n = 9). The average pigment improvement score was 1.8 ± 0.9 on a 4‐point scale. In Group B, the average Fitzpatrick Wrinkle Scale improved from 6.0 ± 1.6 at baseline to 5.2 ± 1.4 at 3 months for an average improvement of 0.8 ± 0.7 (P < 0.001, n = 26 paired t‐test). The average pigment improvement score was 1.4 ± 1.0 (P < 0.001, t‐test, n = 26). Adverse events were similar in the two groups.

Conclusion

The combination of an optimized intense pulsed light source with a non‐ablative fractional laser during the same treatment session is safe and effective. Lasers Surg. Med. 45:405–409, 2013. © 2013 Wiley Periodicals, Inc.     

Adjuvant radiotherapy after radical prostatectomy shows no ability to improve rates of overall and cancer‐specific survival in a matched case‐control study

OBJECTIVE

To assess the effect of adjuvant radiotherapy (aRT) on the rate of cancer‐specific and overall survival after radical prostatectomy (RP) in a group of patients with a long‐term follow‐up, as there is controversy about the benefit of aRT after RP for prostate cancer when endpoints beyond biochemical and local recurrence are considered.

PATIENTS AND METHODS

Within a study cohort of 752 patients treated with RP, 118 (15.7%) received aRT; these patients were matched with controls who did not receive aRT after RP. Exact matches were made for pT stage, RP Gleason sum, surgical margin status, age (±10 years), year of surgery (±10 years) and delivery of hormonal therapy. Kaplan‐Meier and life‐table analyses were used to assess overall and cancer‐specific survival

RESULTS

The median (range) follow‐up was 11.4 (0.1–41) years. The 10‐ and 20‐year overall survival after RP in those with no aRT were, respectively, 81.1% and 44.8%, vs 75.5% and 40.0% in the aRT group (P = 0.1). The corresponding probabilities for cause‐specific survival were, respectively, 97.3% and 89.0% vs 86.3% and 69.3% (P < 0.001). There was no statistically significant difference in the overall and cause‐specific survival between the groups after matching (hazard ratio 0.9, log rank P = 0.6; and 2.1, log rank P = 0.1, respectively).

CONCLUSIONS

Our analysis showed that, in a matched case‐control study, aRT has no effect on overall and cancer‐specific survival. Further randomized long‐term studies are necessary to confirm these results.