家猪贯穿缝合式胰肠吻合实验模型的建立

目的 建立家猪贯穿缝合式胰肠吻合的动物实验模型.方法 选取10头小型家猪,全麻后剖腹暴露胰腺,于胰腺左叶肠系膜上血管水平横断胰腺,胰腺近侧残端缝闭,远侧残端与空肠行端侧贯穿缝合式胰肠吻合,Roux-en-Y式重建消化道.结果 10头家猪行贯穿缝合式胰肠吻合手术均获成功.胰腺残端横径平均2.5 cm,胰管直径平均1.5 mm.手术时间为1.0～2.5 h,平均1.8h,其中胰肠吻合时间平均为8 min.术中平均出血量为25 ml.术后2头猪发生腹泻,1头猪发生切口感染,均经相应处理后治愈.术中未发生意外,术后未发生胰瘘,无死亡.结论 成功建立家猪贯穿缝合式胰肠吻合的实验模型.     

Binding pancreaticojejunostomy--a safe and reliable anastomosis procedure

BackgroundOver the past one hundred years, the development of pancreaticoduodenectomy (PD) has always involved the struggle against pancreatic leakage. Until now, leakage of the pancreatic anastomosis has remained a common and serious complication after PD. Various methods of dealing with the pancreatic stump for prevention of pancreatic anastomotic leakage have been described. No matter which method is used, however, pancreatic anastomotic leakage is still most likely to occur when anastomosis involves a normal and soft pancreas.MethodsTo perform a safe and reliable pancreaticoenteric anastomosis, we investigated the risk factors and potential mechanisms of occurrence of pancreatic leakage, including leakage from the needle hole and from the seam between two anastomosed structures, blood supply to the anastomosis and tension at the anastomosis. Based on these findings, we established a new pancreaticoenteric anastomosis procedure – binding pancreaticojejunostomy. The unique aspects of this procedure are as follows. The sero-muscular sheath of jejunum is bound to the invaginated pancreatic stump, so as to seal the gap between them; mucosa of the segment of jejunum that would eventually be in contact with the pancreatic stump is destroyed either chemically or by electric coagulation to promote healing. There is no needle hole on the jejunal surface of the anastomotic site.ResultsFrom 1996 to 2003, a total of 227 consecutive patients were treated with this type of pancreaticojejunostomy in this institution. None of the patients developed a pancreatic anastomotic leak.DiscussionBinding pancreaticojejunostomy is a safe and reliable anastomotic procedure to effectively minimize leakage even when the texture of the pancreas is soft and normal.     

Pancreaticogastrostomy: a pancreas-transfixing method with duct-to-mucosa anastomosis (with video)

Pancreatic fistula still remains a persistent problem after pancreaticoduodenectomy. We have devised a pancreas-transfixing suture method of pancreaticogastrostomy with duct-to-mucosa anastomosis. This technique is simple and reduces the risk of pancreatic leakage by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel technique of pancreaticogastrostomy is an effective reconstructive procedure following pancreaticoduodenectomy, especially for patients with a soft and fragile pancreas.     

胰腺残端缝合方式预防胰腺远端切除术后胰漏的动物实验

[目的]探讨不同胰腺残端缝合方式预防胰腺远端切除术后胰漏的效果.[方法]将34只实验用猪随机分为研究组与对照组,每组17只.研究组:超声刀横断胰腺,用4-0 Prolene线间断缝合胰腺残端,主胰管单独结扎;对照组:超声刀横断胰腺,用4-0 Prolene线U形交锁缝合胰腺残端,主胰管单独结扎.观察2组术后的胰漏情况,...     

Transection using bipolar scissors reduces pancreatic fistula after distal pancreatectomy

Background/Purpose

Various methods and technique for treating the surgical stump of the remnant pancreas have been reported to reduce pancreatic fistula after distal pancreatectomy (DP). However, appropriate surgical stump closure after DP is still controversial. We aimed to clarify whether using bipolar scissors in DP reduces pancreatic fistula compared to hand-sewn suture of surgical stump closure.

Methods

Between January 1989 and December 2005, handsewn suture of surgical stump closure was performed (n = 49), and bipolar scissors was prospectively performed between January 2006 and July 2007 (n = 26).

Results

The overall rate of pancreatic fistula after DP was 22 patients (29%). There were significant differences between the hand-sewn suture group (41%) and bipolar scissors group (8%) concerning pancreatic fistula (P = 0.0164). A multivariate logistic regression analysis revealed that two factors, soft pancreas and hand-sewn suture compared to bipolar scissors, were independent risk factors of pancreatic fistula after DP (P = 0.011 and 0.0361, respectively).

Conclusions

Bipolar scissors for transection of the pancreas is a useful device to reduce pancreatic fistula after DP.     

Duodenum-preserving resection of the pancreatic head with the ultrasonic coagulating shears

Duodenum-preserving resection of the pancreatic head is a risk factor for pancreatic fistula because of the wide surface of the transected pancreas. We report on a 72-year-old woman undergoing this procedure for cystadenoma in the pancreatic head using the ultrasonic coagulating shears. The soft pancreatic parenchyma was extensively transected around the cyst with the coagulating shears. Suture of the cut stump was not necessary due to absence of bleeding. The distal pancreatic duct was well preserved for pancreatojejunostomy. We oversewed the possible opening of the main pancreatic duct on the remaining pancreas attached to the duodenum after confirming the location by intrabiliary dye injection. The postoperative course was uneventful. The draining fluid amylase level was low and there were no viscous materials from the drains. We compared histologic changes of a porcine pancreas transected with the coagulating shears or electrocautery to evaluate the sealing effect of the transected surface. The cut stump was covered by a continuing layer of thick protein coagulum in cases of coagulating shears, but by a disrupted layer of coagulating necrosis with charring in cases of electrocautery. The coagulating shears are useful for pancreatic transection in duodenum-preserving resection of the pancreatic head to prevent bleeding and pancreatic fistula from the cut surface.     

A proposed new pancreatic classification system according to segments: Operative procedure for a medial pancreatic segmentectomy

Based on anatomical considerations and our experience in performing segmental resections of the pancreas, we propose here a new pancreatic classification system that divides the pancreas into four segments: posterior, proximal, medial, and distal. We also describe the operative procedures for medial pancreatic segmentectomy, carried out in two patients. Under this new classification system, based on the clinical position of these pancreatic segments, the embryologically termed ventral pancreas is now retermed the posterior segment, while the dorsal pancreas is divided into three segments, termed: the proximal segment (the duodenum-sided segment of the dorsal pancreas that connects with the posterior pancreas), the medial segment (the segment that corresponds with the pancreatic neck), and the distal segment (the area from the left border of the superior mesenteric artery to the hilum of the spleen). Although this division of the pancreas into four segments is a new concept, the development of new and better operative procedures that enable the resection of each pancreatic segment independently has made this concept not only valuable but clinically practical.     

Benign pancreatic tumor treated with duodenum-preserving resection of the head of the pancreas. Case report

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. Authors report the case of a 70 year-old woman with microcystic cystadenoma. Computed tomography (CT) scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An endoscopic retrograde cholangiopancreatography (ERCP) showed cephalic symmetrical stenosis (diameter: 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter: 6 mm). An intra-operative biopsy of the cystic wall had been performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, of a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, duodenum-preserving resection of the head of the pancreas is a highly effective surgical procedure with low early and late morbidity and mortality due to limited surgical resections. This technique, introduced into surgical practice in 1972 by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can also be performed in cases of pancreatic benign tumors, such as microcystic cystadenoma. Advantages of this technique make DPPHR an attractive alternative to pylorus-preserving pancreatico-duodenectomy (PPPD).     

History of pancreaticojejunostomy in pancreaticoduodenectomy: development of a more reliable anastomosis technique

The history of pancreaticojejunostomy in pancreaticoduodenectomy is described. Many types of operations have been devised in search of a more reliable method of anastomosis. To perform a safe and reliable pancreaticoenteric anastomosis it is necessary to understand the organ characteristics of the pancreas. We investigated factors required for a reliable pancreaticojejunostomy and devised a new surgical technique that meets those requirements. We introduce the theoretical substantiation and clinical usefulness of our new surgical technique while reviewing the history of pancreaticojejunostomy after pancreaticoduodenectomy. The unique aspect of our method is approximation of the pancreas stump and jejunal wall by six to eight interrupted sutures. It is speculated that too many sutures and tying too tight in the anastomosis may cause ischemia and necrosis of the pancreatic stump by restricting the tissue blood flow. Our method allows us not only to reduce the number of sutures, but also to avoid some of the complicated manipulations done in any other existing methods. The newly devised pancreaticojejunostomy is an excellent surgical technique with anastomotic failure seen in only two patients and no deaths out of 162 consecutive patients.     

Distal pancreatectomy (with video)

Distal pancreatectomy is indicated for lesions in the pancreatic body and tail. Understanding of the anatomical structure of the pancreas and its surroundings is required in various situations in left upper abdominal surgery including the laparoscopic approach. Spleen-preserving distal pancreatectomy is indicated for lesions confined to the pancreas. Two major spleen-preserving procedures reported are the Warshaw procedure that conserves the spleen by blood flow from the short gastric vessels and the Kimura procedure that preserves the spleen with splenic vessels. Considering the laparoscopic approach, the surgeon may preserve splenic vessels from the median toward the splenic hilum without mobilization of the spleen. A standard distal pancreatectomy using the medial approach is presented on video. The intraoperative complications of distal pancreatectomy can be minimized by avoiding splenic capsule injury, by careful differentiation of the splenic artery from the common hepatic artery, and by secure closure of the splenic vein stump. The incidence of postoperative pancreatic fistula following distal pancreatectomy is reported to be 13% in a nationwide pancreatic cancer registry. Based on the results of an international randomized trial of hand-sewn and staple closure of the pancreatic stump, the closure method of the pancreatic stump can be the surgeon's choice.     

Complete drainage of pancreatic juice from the cut edge of the pancreas after subtotal left-side pancreatectomy

The management of the cut stump after a subtotal left-side pancreatectomy is sometimes difficult compared with that after distal pancreatic resection, which is performed at or to the left of the superior mesenteric vein. This report describes a simple and effective drainage method of leaking pancreatic juice from the cut stump after subtotal left-side pancreatectomy for pancreatic adenocarcinoma located in the body and tail. Since July 20, 1994, we have applied this method to 12 patients with carcinoma of the body and tail of the pancreas other than the present case and as yet have never experienced serious postoperative complications.     

A new technique for pancreaticogastrostomy for the soft pancreas: the transfixing suture method

Background/Purpose

Pancreatic anastomotic leakage remains a persistent problem after pancreaticoduodenectomy (PD). The presence of soft, nonfibrotic pancreatic tissue is one of the most important risk factors for pancreatic leakage. Accordingly, we devised a pancreas-transfixing suture method for pancreaticogastrostomies in patients with a soft, nonfibrotic pancreatic remnant.

Methods

The pancreas-transfixing method was applied in 103 consecutive patients after either standard PD (49 patients) or pylorus-preserving pancreaticoduodenectomy (PPPD) (54 patients) for malignant or benign disease. Of these 103 patients, 65 had a soft, nonfibrotic pancreatic remnant. For the pancreaticogastrostomy technique, an ultrasonically activated scalpel was used for transecting the pancreas. The inner layer involves a duct-to-mucosa anastomosis with an internal stent and the outer layer involves a single row of pancreas-transfixing sutures between the pancreatic remnant and the posterior gastric wall.

Results

Operative mortality was zero and morbidity was 22%. Only two patients (2%) developed pancreatic leaks; both resolved nonoperatively with the continuation of closed drainage.

Conclusions

This technique is simple and appears to reduce the risk of pancreatic leakage, possibly by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel pancreaticogastrostomy technique is an effective reconstructive procedure, especially for patients with a soft, nonfibrotic pancreas.     

Immunocytochemical Detection of Islet Hormones in the Digestive System ofProtopterus annectens

The presence, distribution, and interrelationships of the four typical pancreatic islet hormones were investigated in the digestive system ofProtopterus annectensby single and double immunohistochemical methods. Insulin-, glucagon-, and somatostatin-immunoreactive (IR) elements were detected in both the pancreas and the gut. Pancreatic polypeptide (PP)-IR endocrine cells were always present in the gut, but were only present in the pancreas of a few specimens. Some of the latter cells also seemed to react with glucagon antiserum. In the pancreas the immunopositive cells were organized into islets of different sizes, and their organizations were studied by the double immunohistochemical techniques. In the few large islets insulin-IR cells were present in the central zone, glucagon- and PP-IR cells at the periphery, and somatostatin-IR cells intermingled with both the peripheral and the central endocrine cells. In the smaller islets, the number and the staining intensity of glucagon- and PP-IR endocrine cells varied markedly. In the gut, insulin-, somatostatin-, and PP-IR cells were of the open type; glucagon-containing cells were very few and had no luminal contact. They were differently distributed along the intestinal epithelium. Somatostatin-IR nerve fibers and somatostatin-IR neuron cell bodies were also observed in the intestinal wall. The organization of pancreatic endocrine cells inP. annectensis similar to that observed in the majority of teleosts even if a different topographical association can be found. Furthermore, islets of different sizes seem to display a different metabolic turnover, and the detection of pancreatic PP-immunoreactivity varied according to the specimens utilized. In the intestinal portion insulin-IR cells, in addition to PP-, glucagon- and somatostatin-IR cells are present: this suggests that intestinal insulin-like immunoreactivity may be more widespread than previously supposed.     

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

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

Risk factor analysis and prevention of postoperative pancreatic fistula after distal pancreatectomy with stapler use

Background

Postoperative pancreatic fistula (POPF) is a major, intractable complication after distal pancreatectomy (DP). Risk factor evaluation and prevention of this complication are important tasks for pancreatic surgeons.

Methods

One hundred and six patients who underwent DP using a stapler for pancreatic division were retrospectively investigated. The relationship between clinicopathological factors and the incidence of POPF was statistically analyzed.

Results

Clinically relevant, Grade B or C POPF by International Study Group of Pancreatic Fistula criteria occurred in 52 patients (49.1 %). Age, American Society of Anesthesiologists score, body mass index, and concomitant gastrointestinal tract resection did not influence the incidence of POPF. Use of a double-row stapler and a thick pancreatic stump were significant risk factors for POPF in multivariate analysis. Compression index was also shown to be an important factor in cases in which the pancreas was divided by a stapler.

Conclusions

The most important risk factor for POPF after DP was suggested to be the thickness of the pancreatic stump, reflecting the volume of remnant pancreas. A triple-row stapler seemed to be superior to a double-row stapler in preventing POPF. However, triple-row stapler use in a thick pancreas is considered to be a future problem to be solved.     

The double duct sign in patients with malignant and benign pancreatic lesions

BACKGROUND: The double duct sign, a simultaneous stenosis of the common bile duct and the pancreatic duct by endoscopic retrograde cholangiopancreatography (ERCP), has been reported to predict the presence of pancreatic cancer with a high degree of certainty. METHODS: To test the specificity of the double duct sign for pancreatic cancer in patients with malignant and benign pancreatic lesions, we have reviewed all ERCP films obtained during a 24-month period (n = 1209) and corresponding clinical follow-up data obtained during a period of 4 years. RESULTS: Forty-three patients were identified as having a double duct stenosis on ERCP, 15% of whom did not have pancreatic carcinoma. In 4 patients chronic pancreatitis was confirmed by serial histologic sections of the surgical specimen. Data on the lengths of the stenotic segment in either the pancreatic duct or the bile duct did not contribute to a better discrimination between benign and malignant disease. CONCLUSION: The specificity of the double duct sign in predicting the presence of pancreatic cancer appears to be lower than previously reported. Better discrimination between malignant and benign disease of the pancreas will be difficult to achieve with existing imaging techniques.     

Abolishment of oral trypsin inhibitor stimulation of the rat exocrine pancreas after duodeno-jejunal resection.

The effect of long-term oral trypsin inhibitor administration on the exocrine pancreas was studied in unoperated rats and in rats operated on by a 30% proximal small intestinal resection. The following observations were made: in unoperated rats sacrificed 18 hours after the last trypsin inhibitor ingestion there was an increase of the wet weight of pancreas, increase of the pancreatic protein, and an increase of pancreatic and intestinal trypsin(ogen) and of pancreatic amylase by comparison with the controls. In operated rats, treated and examined in an identical way, no influences on the exocrine pancreas were found. It is suggested that the abolishment of the trypsin inhibitor effects on the exocrine pancreas in operated rats reflects the removal of the site of production of one or more intestinal hormone(s) or factor(s) responsible for these effects. In unoperated rats examined 4 hours after the last trypsin inhibitor ingestion a reduction of the pancreatic trypsinogen and amylase and an increase of the intestinal amylase were found, indicating a secretory response of the pancreas to the intraluminal trypsin inhibitor; the low values of intestinal trypsin found in these rats probably reflect inhibition of rat trypsin by the bovine lung trypsin inhibitor.     

Pancreatico-jejunostomy with a biodegradable pancreatic stent and without stitches through the pancreas

Previous experimental studies have shown that multiple puncturing and stitching of the pancreas results in an increased pancreatic injury response. Furthermore, post-operative pancreatitis, which still is a largely under-diagnosed condition, appears to be an important mediator of many post-operative complications after pancreatic head resection. Stenting has been suggested to improve both short-term and long-term outcome after pancreaticojejunostomy. We have recently developed a biodegradable, radiopaque self-expanding stent, which has experimentally been shown suitable for pancreatobiliary applications. In this pilot study we tested the new technique for pancreatico-jejunostomy in 3 patients. In this novel anastomosis technique with a biodegradable stent the pancreatic stump is first sunk into the jejunum and tightened with a purse string in the bowel serosa, without any stitches through the pancreatic tissue, and the patency of the pancreatic duct is secured with a biodegradable stent against the compression of the tightened purse-string. The creation of anastomosis was possible as planned in all 3 patients. They all recovered without complications. The stent was seen in x-ray in all 3 during hospitilization, was found to have disappeared by 1 month in 2 patients, but was still in place at 3 months in 1 patient. The initial experiences described herein encourage progression to a phase I safety study, and later possibly to a phase II randomized trial to test the efficacy of the new method.     

Double duct-to-mucosa pancreaticojejunostomy for bifid pancreatic duct

We report a pancreaticojejunostomy with double duct-to-mucosa anastomotic technique after pyloruspreserving pancreaticoduodenectomy for chronic pancreatitis with bifid pancreatic duct. A 49-year-old Japanese man was diagnosed preoperatively as having chronic pancreatitis with common bile duct stricture and pseudocyst of the pancreatic head. In a pancreaticoduodenectomy, the main pancreatic duct (7mm in diameter) and a secondary pancreatic duct (4mm in diameter) were identified intraoperatively at the transected surface. Pancreatography showed the main pancreatic duct as well as thesecondary pancreatic duct that drained the remaining dorsal pancreas, allowing us to diagnose bifid pancreatic duct. The pancreaticojejunostomy was performed in an end-to-side manner to create double duct-to-mucosa anastomoses and to approximate the pancreatic parenchyma and jejunal seromuscular layers. Although bifid pancreatic duct is a rare anatomical anomaly, it behooves every surgeon who performs pancreatic resections to be aware of this entity and the techniques for dealing with it.     

Ligamentum teres hepatis patch enhances the healing of pancreatic fistula after distal pancreatectomy

Pancreatic fistula is one of the most common complications after the distal pancreatectomy. Many methods have been tried to solve the problem, but no one is optimal, especially for the soft pancreatic stump cases. This study used ligamentum teres hepatis as a patch to cover the pancreatic stump. Between October 2010 and December 2012, seventy-seven patients who had undergone distal pancreatectomy with a soft pancreatic stump were divided into two groups: group A (n=39, patients received conventional ligated main pancreatic duct method) and group B (n=38, patients underwent a coverage procedure). Patients in group A had a longer recovery from postoperative pancreatic fistula than those in group B (16.4±3.5 vs 10.8±1.6 days, P<0.05). The coverage procedure with ligamentum teres hepatis is a safe, effective and convenient method for patients with a soft pancreas remnant during distal pancreatectomy.