Radiofrequency is a secure and effective method for pancreatic transection in laparoscopic distal pancreatectomy: results of a randomized, controlled trial in an experimental model

Background

Postoperative pancreatic fistula (PPF) is the most frequent and serious complication after laparoscopic distal pancreatectomy (LDP). Our goal was to compare the performance, in terms of PPF prevention, and safety of a radiofrequency (RF)-assisted transection device versus a stapler device in a porcine LDP model.

Methods

Thirty-two animals were randomly divided into two groups to perform LDP using a RF-assisted device (RF group; n = 16) and stapler device (ST group; n = 16) and necropsied 4 weeks after surgery. The primary endpoint was the incidence of PPF. Secondary endpoints were surgery/transection time, intra/postoperative complications/deaths, postoperative plasmatic amylase and glucose concentration, peritoneal liquid amylase and interleukin 6 (IL-6) concentrations, weight variations, and histopathological changes.

Results

Two clinical and one biochemical PPF were observed in the ST and RF groups respectively. Peritoneal amylase concentration was significantly higher in the RF group 4 days after surgery, but this difference was no longer present at necropsy. Both groups presented a significant decrease in peritoneal IL-6 concentration during the postoperative follow-up, with no differences between the groups. RF group animals showed a higher postoperative weight gain. In the histopathological exam, all RF group animals showed a common pattern of central coagulative necrosis of the parenchymal surface, surrounded by a thick fibrosis, which sealed main and secondary pancreatic ducts and was not found in ST group.

Conclusions

The fibrosis caused by an RF-assisted device can be at least as safe and effective as stapler compression to achieve pancreatic parenchyma sealing in a porcine LDP model.     

Robotic-Assisted Minimally Invasive Central Pancreatectomy: Technique and Outcomes

Background

Central pancreatectomy is a definitive treatment for low-grade tumors of the pancreatic neck that preserves pancreatic and splenic function at the potential expense of postoperative pancreatic fistula. We analyzed outcomes after robot-assisted central pancreatectomy (RACP) to reexamine the risk–benefit profile in the era of minimally invasive surgery.

Methods

Retrospective analysis of nine RACP performed between August 2009 through June 2010 at a single institution.

Results

The average age of the cohort was 64 (range 18–75 years) with six women (67 %). Indications for surgery included: five benign cystic neoplasm and four pancreatic neuroendocrine tumor. Median operative time was 425 min (range 305–506 min) with 190 ml median blood loss (range 50–350 ml) and one conversion to open due to poor visualization. Median tumor size was 3.0 cm (range 1.9–6.0 cm); all patients achieved R0 status. Pancreaticogastrostomy was performed in seven cases and pancreaticojejunostomy in two. The median length of hospital stay was 10 days (range 7–19). Two clinically significant pancreatic fistulae occurred with one requiring percutaneous drainage. No patients exhibited worsening diabetes or exocrine insufficiency at the 30-day postoperative visit.

Conclusions

RACP can be performed with safety and oncologic outcomes equivalent to published open series. Although the rate of pancreatic fistula was high, only 22 % had clinically significant events, and none developed worsening pancreatic endocrine or exocrine dysfunction.     

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.

     

Laparoscopic dismembered pyeloplasty: technique and results in 105 patients

Purpose

To evaluate the postoperative and functional results of the laparoscopic dismembered pyeloplasty (LDP).

Patients and methods

Between May 2000 and April 2008, we performed in our department 105 LDP. All patients presented an ureteropelvic junction obstruction with dilatation of renal calyx system with an enlarged renal pelvis. Demographic data (age, gender), perioperative and postoperative parameters, including operating time, estimated blood loss, complications, length of hospital stay, functional outcome were collected and evaluated.

Results

The mean operative time for LDP was 150 min (range 120–180 min) and the mean estimated blood loss was negligible in all patients. The mean hospital stay was 4 days (4–8). No conversion to open surgery occurred. In the follow-up, we noted a successful rate in 96.2% of the patients.

Conclusion

Laparoscopic dismembered pyeloplasty, if performed by expert surgeons in high-volume centres, presents results that are comparable with open surgery, with a lower surgical trauma for the patients.     

Resection of Isolated Renal Cell Carcinoma Metastases of the Pancreas: Outcomes from the Johns Hopkins Hospital

Purpose

This study aims to assess outcomes and characteristics associated with resection of metastatic renal cell carcinoma (mRCC) to the pancreas.

Materials and Methods

From April 1989 to July 2012, a total of 42 patients underwent resection of pancreatic mRCC at our institution. We retrospectively reviewed records from a prospectively managed database and analyzed patient demographics, comorbidities, perioperative outcomes, and overall survival. Cox proportional hazards models were used to evaluate the association between patient-specific factors and overall survival.

Results

The mean time from resection of the primary tumor to reoperation for pancreatic mRCC was 11.2 years (range, 0–28.0 years). In total, 17 patients underwent pancreaticoduodenectomy, 16 underwent distal pancreatectomy, and 9 underwent total pancreatectomy. Perioperative complications occurred in 18 (42.9 %) patients; there were two (4.8 %) perioperative mortalities. After pancreatic resection, the median follow-up was 7.0 years (0.1–23.2 years), and median survival was 5.5 years (range, 0.4–21.9). The overall 5-year survival was 51.8 %. On univariate analysis, vascular invasion (hazard ratio, 5.15; p?=?0.005) was significantly associated with increased risk of death.

Conclusions

Pancreatic resection of mRCC can be safely achieved in the majority of cases and is associated with long-term survival. Specific pathological factors may predict which patients will benefit most from resection.     

Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler

Purpose

No consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler.

Methods

A total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses.

Results

Clinical PF developed in 7 of 31 (22 %) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4 ± 1.47 mm) in comparison to patients without PF (12.6 ± 0.79 mm; p = 0.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (p = 0.0215). Pancreatic thickness (p = 0.0006) and blood transfusion (p = 0.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; p = 0.036) according to a multivariate analysis with a specificity of 72 %, and a sensitivity of 85 %.

Conclusion

Pancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16 mm.     

DHEA(S)—a novel marker in Cushing’s disease

Introduction

Dehydroepiandrosterone sulfate (DHEA(S)) is a multi-functional steroid implicated in a broad range of biological effects, including obesity, diabetes, bone metabolism, neuroprotection, and anti-tumorigenesis. It has not yet undergone wider research in the context of Cushing’s disease. The objective of this study was to determine if perioperative blood levels of DHEA(S) correlate with levels of ACTH and cortisol, and therefore may be useful as a new, additional marker for the early definition of cure in patients suffering from Cushing’s disease.

Methods

Forty-two consecutive patients undergoing transsphenoidal surgery for Cushing’s disease from September 2009 to September 2010 were perioperatively monitored for ACTH, cortisol, and DHEA(S).

Results

Pre-operative blood samples revealed ACTH levels of median 65 ng/l (range 11–1,183 ng/l, standard deviation 183.76), cortisol of median 257 μg/l (range 93–803 μg/l, standard deviation 140.88), and DHEA(S) of median 2.22 mg/l (range 0.44–7.79 mg/l, standard deviation 1.82) according to the pathology of Cushing’s disease. Postoperative blood samples drawn over a 7-day time span showed a drop in median ACTH to just 14.5 % (median: 9 ng/l, range 2–44, standard deviation 12.75) of its median preoperative figure. Median cortisol levels were reduced to 6.9 % (median: 18 μg/l, range 10–190 μg/l, standard deviation 38.04) of their preoperative values and DHEA(S) levels decreased to 17 % (median: 0.38 mg/l, range 0.05–2.29, standard deviation 0.51). In persistent disease, no patient showed a drop in DHEA(S) below 38 % of its preoperative figures.

Conclusions

DHEA(S) shows the potential to become an additional marker in the diagnosis and follow-up of patients. However, it needs to be examined further, including whether DHEA(S) may also be a useful predictor of recovery of the HPA-axis after successful surgery.     

Laparoscopic pancreaticoduodenectomy: experience of 22 cases

Background

Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center.

Methods

From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed.

Results

Mean operative time was 392 (range, 327–570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12–35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14–20).

Conclusions

The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.     

Pancreatic Anastomotic Leakage after Pancreaticoduodenectomy. Risk factors, Clinical predictors, and Management (Single Center Experience)

Background

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers.

Methods

This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected.

Results

A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m² (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture.

Conclusions

Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.     

Oncological Feasibility of Laparoscopic Distal Pancreatectomy for Adenocarcinoma: A Single-Institution Comparative Study

Background

Laparoscopic distal pancreatectomy (LDP) is performed increasingly for pancreatic pathology in the body and tail of the pancreas. However, only few reports have compared its oncological efficacy with open distal pancreatectomy (ODP). We compared these two techniques in patients with pancreatic ductal adenocarcinoma.

Methods

From a prospectively maintained database, all patients who underwent either LDP or ODP for adenocarcinoma in the body and tail of the pancreas between January 2008 and December 2011 were compared. Data were analysed using SPSS^® v19 utilising standard tests. A p value <0.05 was considered significant.

Results

Of 101 patients who underwent distal pancreatectomy, 22 had histologically confirmed adenocarcinoma (LDP n = 8, ODP n = 14). Both groups were well matched for age and the size of tumour (22 vs. 32 mm, p = 0.22). Intraoperative blood loss was 306 ml compared with 650 ml for ODP (p = 0.152). A longer operative time was noted for LDP (376 vs. 274 min, p < 0.05). Total length of stay was shorter for LDP compared with ODP (8 vs. 12 days, p = 0.05). The number of postoperative pancreatic fistulas were similar (LDP n = 2 vs. ODP n = 3, p = 0.5). Complete resection (R0) was achieved in 88 % of LDP (n = 7) compared with 86 % of ODP (n = 12). The median number of lymph nodes harvested was 16 for LDP versus 14 for ODP. Overall 3-year survival also was similar: LDP = 82 %, ODP = 74 % (p = 0.89).

Conclusions

From an oncological perspective, LDP is a viable procedure and its results are comparable to ODP for ductal adenocarcinomas arising in the body and tail of the pancreas.     

Analysis of endoloops and endostaples for closing the appendiceal stump during laparoscopic appendectomy

Purpose

An inadequate closure of the appendiceal stump can lead to intra-abdominal surgical site infections. The aim of this study was to assess the efficiency of different closure techniques by focusing on the intraoperative and postoperative complications versus cost.

Methods

From June 2011 to June 2013, 333 patients from two different hospitals undergoing laparoscopic appendectomy were included in this study. The patients were divided into two groups based on the technique used for appendiceal stump closure: there were 104 patients in the stapler group and 229 in the loop group.

Results

Among the 333 patients who underwent laparoscopic appendectomy, there were two (0.6 %) intraoperative complications and 22 (6.6 %) postoperative complications. There were no significant differences between the groups with respect to the intraoperative and postoperative complications. The length of the operation was 7 min shorter when the endoloop was used (p = 0.014). The mean costs of the operation were significantly lower when the loop was used (€ 554.93) compared to the stapler (€ 900.70) (p = 0.000).

Conclusions

There is no clinical evidence supporting the routine use of endoscopic staplers. The appendiceal stump can be secured safely with the use of endoloops in the majority of patients. Surgeons have to be more selective when choosing how to perform closure, and an endostapler should be used only in cases where it is clinically indicated.     

Centralization of Services and Reduction of Adverse Events in Pancreatic Cancer Surgery

Background

The perioperative period is critical in the outcome for patients with pancreatic cancer. The aim of the present analysis was to examine adverse events in patients dying under surgical care in relation to changes in the organization of pancreatic cancer surgery.

Methods

From 1996 to 2005, 1,033 patients with pancreatic cancer, mean age of 71 years (range 21–97 years) died under surgical care. The incidence, mortality, and number of operations for pancreatic cancer remained stable across the time period, but the proportion of patients undergoing surgery in the five specialist cancer centers increased from 50 to 80 % (p < 0.001). Prior to death 260 (25 %) patients underwent operation and 96 (9 %) had endoscopic retrograde cholangiopancreatography (ERCP). There was a significant rise in ERCP (p = 0.03) and a decrease in non-resectional operations (p = 0.001).

Results

Since 1996, 52 (15 %) patients in whom 90 adverse events were recorded died following surgical intervention: 28 adverse events related to the perioperative period with 15 due to direct procedure complications such as bleeding or anastomotic leak; 13 were attributed to decision making around the choice or timing of the procedure. The postoperative mortality after curative pancreatic resection reduced from 3.5 to 1.8 %. Identified adverse events fell significantly in patients who died relating to the operative period (median of 3 per annum [1994–2000] to 1 per annum [2001–2005]) (p = 0.014) and medical care (3–0) (p = 0.003).

Conclusions

Continuous peer review audit has demonstrated a reduction in the number of adverse events in patients dying with pancreatic cancer under surgical care as increased numbers of patients treated in specialist cancer centers.     

Monitoring c-reactive protein after laparoscopic colorectal surgery excludes infectious complications and allows for safe and early discharge

Background

Early detection of infectious complications is urgently needed in the era of DRG-based compensation. This work assessed the diagnostic accuracy of c-reactive protein (CRP) level in the detection of infectious complications after laparoscopic colorectal resection.

Methods

Laparoscopic colorectal resections were identified from a prospective database. Complications were graded according to the Dindo–Clavien classification. Surgical site infections were defined according to the Centers of Disease Control. CRP level was routinely measured until postoperative day (POD) 7. Uni- and multivariate analysis were performed. Diagnostic accuracy was evaluated using receiver operating curves.

Results

355 patients were operated for diverticulosis (88.7 %), neoplasia (6.8 %), and other causes (4.5 %). Mean age and body mass index were 59.8 ± 13.7 years and 26.5 ± 15 kg/m². Left, right, and total laparoscopic colectomies were performed in 316, 33, and 6 patients. Complications occurred in 85 patients and 16 patients (4.5 %) were reoperated. Fifty-one patients (14.4 %) suffered from infectious complications at a median of 6 POD, while 9 anastomoses leaked (2.7 %). In multivariate analysis, presence of an abscess at surgery was predictive of an infectious complication (OR 2.5, 95 % CI 1.1–5.3), as were a body mass index >30 kg/m² and operative time >160 min in a bootstrap analysis. Overall, CRP peaked on POD 2 and declined thereafter. Most infectious complications were apparent starting on POD 6. A CRP <56 mg/l on POD 4 had a negative predictive value of 100 % (95 % CI 94.9–100 %) to rule out infectious complications. Above 56 mg/l, sensitivity was 100 % (95 % CI 0.8–1) and specificity 49 % (95 % CI 0.4–0.6) for the development of infectious complications in the absence of clinical signs. This translated into a remarkable diagnostic accuracy of 78 % (95 % CI 0.7–0.9).

Conclusion

Monitoring CRP level in laparoscopic colorectal surgery demonstrated a high diagnostic accuracy for infectious complications, thus allowing for safe and early discharge.     

Pure laparoscopic middle pancreatectomy: single-center experience with 13 cases

Background

Laparoscopic pancreatic surgery is performed with increasing frequency, but laparoscopic middle pancreatectomy (LMP) is rarely described. This study aimed retrospectively to describe the authors’ unicentrically and prospectively collected data at a specialized center.

Methods

Since July 2011, 13 patients have undergone LMP. In this study, all their demographics and operative and postoperative data were studied from a prospectively maintained database.

Results

The study included eight women and five men with a mean age of 51 (range 27–75 years) and a body mass index of 26 kg/m² (range 22–32 kg/m²). The main indications were neuroendocrine tumor (n = 7), intraductal papillary mucinous neoplasia (n = 2), solid pseudopapillary tumor (n = 2), and other (n = 2). The median duration of surgery was 190 min (range 120–285 min), and the mean blood loss was 100 ml (range 50–800 ml). Only one conversion was performed (8 %). The postoperative outcomes showed no mortality. Clinically significant pancreatic fistula (B and C) were found in 30 % of the cases. Bleeding was observed in two patients (15 %) and reintervention in three patients (23 %). The median hospital stay was 24 days (range 14–53 days), with no readmissions. The long-term follow-up evaluation showed no endocrine insufficiency and only one endocrine insufficiency (8 %).

Conclusions

LMP is a safe surgical procedure allowing a minimally invasive approach for low malignant-potential lesions and offering a postoperative outcome comparable with that of the open approach.     

Arthroskopische und offene Arthrolyse bei sekundären Schultersteifen

Purpose

The purpose of this study was to compare results after arthrolysis in cases of secondary shoulder stiffness. The hypothesis was that patients with posttraumatic/-operative shoulder stiffness benefit less than patients with shoulder stiffness due to subacromial syndrome.

Materials and Methods

A total of 82 patients with the median age of 54 years (range, 23–82 years) were followed up 14 months (median; range, 3–40 months) after operative arthrolysis. Three groups could be differentiated: group l (n=25) arthroscopic arthrolysis in patients with shoulder stiffness due to subacromial syndrome, group ll (n=31) arthroscopic arthrolysis in patients with posttraumatic/-operative shoulder stiffness, and group lll (n=26) open arthrolysis in patients with posttraumatic and -operative shoulder stiffness. Pre- and postoperative Simple Shoulder Test (SST) and Constant Murley score (CMS) results were compared.

Results

The SST score improved significantly in all groups postoperatively. In group l, the adjusted CMS increased significantly from a median 30% (range, 18–36%) to 81% (range, 47–100%), in group ll from 29% (range, 16–51%) to 68% (range, 14–100%) and in group lll from 35% (range, 18–71%) to 76% (range, 31–100%). Group l improved significantly more in the categories “pain” and “activities of daily living” than group lll, which in turn improved more than group ll.

Conclusions

In case of secondary shoulder stiffness, arthrolysis based on pathology resulted in significantly improved shoulder function. Statistically significant in the subjective scores and by the trend in the CMS, patients with shoulder stiffness due to subacromial syndrome benefit more than the other groups.     

Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage

Background

Peripancreatic fluid collections (PFCs) occur in up to 30 % of patients following partial pancreatic resections. Traditionally, postoperative PFCs are managed via percutaneous drainage (PD). EUS-guided transgastric drainage has been shown to be effective for the management of PFCs secondary to acute pancreatitis. However, there are limited data on the use of EUS-guided drainage (EUSD) for the management of postoperative PFCs.

Objective

To compare the safety and efficacy of PD versus EUSD of PFCs in patients who have undergone partial pancreatic resections.

Design

Retrospective analysis of patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy at MSKCC between January 2008 and December 2010. Patients were identified using an electronic medical records query in addition to a prospectively maintained pancreatic surgery complications database.

Setting

Single, academic, tertiary referral center.

Patients

Twenty-three patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy were retrospectively identified.

Interventions

CT-guided PD versus endoscopic ultrasound-guided drainage (EUSD)

Main outcome measures

Outcomes included technical success, clinical success, number of interventions, and complications. Technical success was defined as successful localization of the PFC by fine-needle aspiration and placement of a drainage catheter or stent. Clinical success was defined as radiographic resolution of the PFC and removal of the drain or stent, without the need for an alternative drainage procedure or surgery.

Results

PD was initially performed in 14 patients and EUSD initially in 9 patients. Three patients with initial PD had recurrence of PFC after removal of the external drain and underwent subsequent EUSD. The mean size of the fluid collections was 10.0 cm in the PD group and 8.9 cm in the EUSD group. Technical success was achieved in all patients in both groups. Clinical success was achieved in 11 of 14 (79 %) patients in the PD group compared with 11 of 11 (100 %) in the EUSD group, with one patient in the EUSD group lost to follow-up. One patient with initial PD required two additional percutaneous procedures before complete PFC resolution. Five EUSD patients required repeat endoscopy for stent revision or necrosectomy. The median number of interventions was two [range 1–5] in the PD group and two [range 1–5] in the EUSD group. The median number of days the drainage catheters were in place was 44.5 [range 2–87] in the PD group versus 57 [range 32–217] in the EUSD group. There were no procedure-related complications in either group. Adverse events in the PD group included splenic artery stump bleeding, pleural effusion, cysto-colonic and cysto-cutaneous fistulae, and persistent catheter site pain. One patient in the EUSD group developed a small-bowel obstruction and bleeding gastric ulcer.

Limitations

Retrospective, nonrandomized study and small numbers.

Conclusions

EUSD of postoperative PFCs appears to be safe and technically feasible. This technique appears to be as successful as PD for the management of PFCs with the advantage of not requiring an external drainage apparatus and should be considered as a therapeutic option in this group of patients. Further evaluation, with analysis of cost and quality of life, should be considered in a prospective, randomized trial.     

Surgical treatment for nonspecific esophageal motility disorders

Purpose

Nonspecific esophageal motility disorder (NEMD) is a vague category that includes patients with poorly defined contraction abnormalities observed during esophageal manometry. This study investigated the therapeutic effects of the video-assisted thoracoscopic surgery (VATS) approach using long myotomy and fundopexy for NEMD.

Methods

The VATS approach using myotomy and fundopexy was performed for 4 patients of NEMD between 2005 and 2008. A total of 4 patients with NEMD that underwent treatment at our institution were analyzed retrospectively.

Results

The patients included 2 males and 2 females with a median age of 48 years (range 21–74 years). The median duration of NEMD symptoms was 58 months (range 4–108 months). Dysphagia was a primary symptom in all patients. Chest pain was a primary symptom in 3 of 4 patients (75 %). Treatment with medication was attempted before the operation. The median operative time was 344.5 min (range 210–476 min). The median time before starting oral feeding was 2.5 days (range 2–22 days). All patients achieved a significant improvement of their previous condition.

Conclusions

The VATS approach using myotomy and fundopexy for NEMD is a good treatment in cases resistant to medication and balloon dilation.     

Effects of the closing speed of stapler jaws on bovine pancreases

Background

The division of the pancreatic parenchyma using a stapler is important in pancreatic surgery, especially for laparoscopic surgery. However, this procedure has not yet been standardized.

Methods

We analyzed the effects of the closing speed of stapler jaws using bovine pancreases for each method. Furthermore, we assigned 10 min to the slow compression method, 5 min to the medium-fast compression method, and 30 s to the rapid compression (RC) method. The time allotted to holding (3 min) and dividing (30 s) was equal under each testing situation.

Results

We found that the RC method showed a high-pressure tolerance compared with the other two groups (rapid, 126 ± 49.0 mmHg; medium-fast, 55.5 ± 25.8 mmHg; slow, 45.0 ± 15.7 mmHg; p < 0.01), although the histological findings of the cut end were similar. The histological findings of the pancreatic capsule and parenchyma after the compression by staple jaws without firing also were similar.

Conclusions

RC may provide an advantage as measured by pressure tolerance. A small series of distal pancreatectomy with a stapler that compares the speed of different stapler jaw closing times is required to prove the feasibility of these results after the confirmation of the advantages of the RC method under various settings.     

Laparoscopic transgastric endolumenal cystogastrostomy and pancreatic debridement

Background

Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach.

Methods

We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed.

Results

From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18–71), average body mass index = 29.1 kg/m², 77 % had an ASA score ≥3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0–360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4–50). Median follow-up was 2 months (range = 0–62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections.

Conclusion

This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity.