Pancreatogastrostomy with an elastic purse-string suture around the gastric orifice after pancreatoduodenectomy

Postoperative pancreatic fistula (POPF) is a potentially fatal complication of pancreatoduodenectomy (PD). Fixation of the remnant pancreas to the gastric wall is considered essential to prevent anastomotic leakage in patients undergoing pancreatogastrostomy (PG) after PD. PG was performed with invagination of the pancreatic stump. To limit the number of sutures in the pancreas parenchyma to three or four, we placed an elastic purse string suture around the orifice of the posterior gastric wall in an attempt to fix the gastric wall to the remnant pancreas. We performed PG using this technique in 30 patients. According to the international POPF criteria, POPF developed in three (10%) patients; as grade A in one, and grade B in two. These results demonstrate the potential advantage of performing PG after PD, by using this invaginated technique with an elastic suture.     

Fistulation method: simple and safe pancreaticojejunostomy after pancreatoduodenectomy

BACKGROUND: A pancreatic leak from the pancreaticojejunostomy after pancreatoduodenectomy has a potential risk of serious complications. We devised a simplified fistulation method for pancreaticojejunostomy. METHODS: The fistulation method, which uses a pancreatic drainage tube as a stent without pancreatic duct-to-jejunal mucosa anastomosis, was applied to 162 consecutive patients. They were divided into 3 groups according to the state of the pancreatic remnant: group 1, soft and normal parenchyma (n = 71); group 2, firm and thickened parenchyma (n = 40); group 3, hard and atrophic parenchyma (n = 51). The consistency in relation to the incidence of pancreatic leak and mortality were analyzed. Morphologic changes of the pancreatic remnant in long-term survivors of group 1 were assessed with computed tomography. RESULTS: A pancreatic leak occurred in 3 patients from group 1, in 2 patients from group 2, and in no patients from group 3 (leak rate, 3%). No operative mortality and 5 hospital deaths (3%) unrelated to a pancreatic leak were observed. The parenchyma of the pancreatic remnant was well preserved in 52% of the long-term survivors and the pancreatic duct was not dilated in 63%. CONCLUSIONS: The fistulation method can be performed safely and easily regardless of the state of the pancreatic remnant, and it provides every surgeon with a low incidence of pancreatic leak among patients.     

Effect of preoperative endoscopic biliary drainage on infectious morbidity after pancreatoduodenectomy: a case-control study

BACKGROUND: The utility of preoperative endoscopic biliary drainage (PEBD) in jaundiced patients before pancreatoduodenectomy (PD) is still debated. This is in part due to the heterogeneity of the studied population, including different tumor location, drainage techniques, and surgical procedures. The aim of the current study was to report the influence of PEBD on postoperative infectious morbidity of PD. MATERIALS AND METHODS: Between January 1996 and December 2004, 124 patients underwent a PD and 28. Twenty-eight (22.6%) of these patients underwent a PEBD. This group of patients was matched to 28 control patients who underwent PD without PEBD during the same period. The 2 groups were matched for age, sex, indication of surgery, and serum bilirubin levels. RESULTS: The specific morbidity of PEBD before surgery was 10.7% (n = 3). The postoperative overall morbidity, medical morbidity, and surgical morbidity rates were not different between the 2 groups. At the time of surgery, 89.3% (n = 25) of the patients in the PEBD group had positive bile culture in comparison to 19.4% (n = 4) in the control group (P < .001). The number of patients with 1 or more infectious complications was higher in the PEBD group (50%; n = 14) than in the control group (21.4%; n = 6) (P = .05). CONCLUSIONS: Before PD, PEBD should be routinely avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. In patients with cholangitis, requiring extensive preoperative assessment (such as liver biopsy) or neoadjuvant treatment, PEBD might still be indicated.     

Postprandial plasma gastrin and secretin concentrations after a pancreatoduodenectomy. A comparison between a pylorus-preserving pancreatoduodenectomy and the Whipple procedure

Based on the observation that patients given a pylorus-preserving pancreatoduodenectomy maintain higher gut hormonal levels than do patients who have received the classic Whipple surgical procedure, which seems most likely due to a postoperative difference in the remaining digestive tract, the postprandial plasma gastrin and secretin concentrations in patients who have received either surgery have been evaluated to examine this difference more fully. The subjects were 20 patients treated by a pylorus-preserving operation and 27 patients treated by the Whipple procedure whose concentrations were compared with those of 8 healthy control patients. The postprandial plasma gastrin concentrations were found to be similar in patients given the pylorus-preserving operation and the controls and were significantly lower in patients who underwent the Whipple procedure (p less than 0.05). Similarly, the postprandial plasma secretin concentrations did not differ in these two groups, whereas patients who underwent the Whipple procedure showed significantly lower concentrations at 60, 90, and 120 minutes (p less than 0.05). The above findings, as well as supportive data in the literature, indicate that the duodenal bulb and the gastric antrum, which are resected in the Whipple procedure and are kept in the pylorus-preserving operation, seem to play important roles in the gut hormonal release and that the pylorus-preserving operation is the superior surgical technique in terms of gastrin and secretin release.     

Effect of preoperative biliary drainage on surgical outcome after pancreatoduodenectomy

BACKGROUND: The role of preoperative biliary drainage in patients with biliary obstruction undergoing pancreatoduodenectomy remains controversial. Several authors failed to show any effect of preoperative biliary drainage, whereas others even reported an increased morbidity following pancreatoduodenectomy. METHODS: Retrospective analysis was performed in a consecutive series of 257 patients undergoing pancreatoduodenectomy between November 1993 and November 1999. RESULTS: Ninety-nine patients (38%) underwent preoperative biliary drainage for a median time period of 10 days (range 1 to 41) prior to resection. Cumulative postoperative morbidity was 47% (120 patients), the reoperation rate was 4.3% (11 patients), and mortality was 2.3% (6 patients). There was no difference in total morbidity, infectious complications, reoperation rate, mortality, or long-term survival between patients with or without preoperative biliary drainage. CONCLUSIONS: Preoperative biliary instrumentation and biliary drainage do not affect early or late outcome in patients undergoing pancreatoduodenectomy.     

Subtotal pancreatoduodenectomy: use of a defunctionalized loop for pancreatic stump drainage

BACKGROUND: Since its introduction, pancreaticoduodenal resection for periampullary cancer has undergone numerous modifications. As a result, there has been a dramatic decline in the mortality rate. However, a high morbidity rate, mainly due to pancreatic fistula formation, is still reported. OBJECTIVE: To evaluate the results of the use of a defunctionalized jejunal loop in patients undergoing pancreatoduodenectomy to minimize both the frequency and severity of anastomotic leak. SETTING: Second Surgical Department, Athens University, Aretaieon Hospital, Athens, Greece. DESIGN: A series of retrospective cases from February 1990 to December 1997. PATIENTS: One hundred five patients who underwent pancreatoduodenectomy and had the pancreatic stump drained in a defunctionalized jejunal loop. METHODS: To avoid problems related to fistula formation due to erosion of the anastomoses from activated pancreatic enzymes, a defunctionalized jejunal loop was constructed and the pancreatic stump was invaginated into the end of this loop. RESULTS: Using the defunctionalized jejunal loop, the mean (+/-SD) hospitalization was 7.57+/-1.42 days, the morbidity rate was 11.2%, and the mortality rate was 0.95%. CONCLUSIONS: A modification of pancreatoduodenectomy for the treatment of pancreatic cancer resulted in an improvement in the immediate results of subtotal pancreatoduodenectomy. Careful detachment of the posterior surface of the pancreas from the anterior surface of the portal vein and performance of pancreaticojejunal anastomosis to a defunctionalized jejunal loop results in lower mortality and morbidity rates, thus making pancreatoduodenectomy a safe procedure.     

Lung resection for bronchogenic carcinoma after pneumonectomy: a safe and worthwhile procedure.

OBJECTIVES: Patients treated surgically for lung cancer can develop either a metachronous cancer or a recurrence. The appearance of a new cancer on the remaining lung after a pneumonectomy poses unique treatment problems, and surgery is often considered contraindicated. We report on the outcome of resections for lung cancer after pneumonectomy performed for lung cancer. METHODS: We reviewed the records of patients who underwent a resection of bronchogenic carcinoma on the remaining lung from 1990 to 2002. RESULTS: There were 14 patients (13 males and 1 female) with a median age of 64 years (range 51-74). Median preoperative Fev1 was 1.45 (range 1.35-2.23), corresponding to 59% of predicted Fev1 (range 46-80%). Resection was performed between 11 and 264 months after pneumonectomy (median 35.5). The resections performed were: one wedge resection in 11 patients, two wedge resections in two patients and two segmentectomies in two other patients; one patient underwent a third resection. Diagnosis was metachronous cancer in 12 patients and metastasis in two patients. Complications occurred in three patients (21%), while operative mortality was nil. Mean hospital stay was 10.5 days (6-25). Two patients received chemotherapy (one after local recurrence, one after the third resection). Overall 1, 3 and 5 year survivals were 57, 46 and 30%, respectively (median 21 months). For patients with a metachronous cancer they were 69, 55 and 37% (median 57 months), respectively, while neither patient with a metastatic tumor survived 1 year (P=0.03). CONCLUSIONS: Limited lung resection on a single lung is a safe procedure associated with acceptable morbidity and mortality rates. In patients with a metachronous lung cancer, long-term survival with a good quality of life can be obtained with limited resection on the residual lung.     

Influence of preoperative biliary drainage on postoperative morbidity and mortality after pancreatoduodenectomy

Pancreatoduodenectomy is the only potentially curative treatment for peripapillary tumors. However, postoperative mortality remains as high as 5% and as many as 50% of patients have postoperative morbidity. Preoperative endoscopic retrograde cholangiopancreatography and placement of a biliary drainage stent aim to achieve a precise diagnosis, reduce jaundice and improve the results of surgery for biliary malignancies, but the effectiveness of preoperative biliary drainage in the prevention of postoperative infections is controversial. A retrospective analysis was performed in a series of 58 patients with periampullary tumors who underwent pancreatoduodenectomy and the relationship between preoperative biliary drainage and postoperative complications was examined. Biliary drainage (25.8%) before pancreatoduodenectomy was significantly associated with more frequent biliary and pancreatic anastomotic leakage (60% with drainage versus 20.9% without drainage), higher postoperative morbidity, and greater mean postoperative length of hospital stay (33.3 days with drainage versus 21.6 without drainage). No significant difference was found between the two groups in postoperative mortality at 30 days (13.7%). The effectiveness of biliary drainage before surgery in patients with pancreatic and peripancreatic lesions has not been well established, but we believe that this procedure should be avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. Prospective randomized studies are required to clarify the indications for preoperative biliary drainage in these patients.     

Needle biopsy of testes: a safe outpatient procedure

A total of 287 testes biopsies were performed in the office under local anesthesia, using a modified needle and technique to collect the tissue which was then fixed in Bouin's solution. Adequate tissue was obtained in all specimens for histopathologic diagnosis. In 3 patients small hematomas developed and were treated conservatively. Five patients complained of orchialgia, but none required narcotic analgesia. No sperm antibodies, extravasation, or serious complications were encountered. We believe this technique is safe, simple, and cost-effective.     

The insulin infusion test: a safe procedure?

One hundred and thirty insulin infusion tests (dose 0.05 u kg-1h-1) were carried out in 87 patients with peptic ulcer or after a vagotomy. During the test ECG tracings were taken and blood was sampled for blood glucose and serum potassium determination. In 31% of the tests electrocardiographic changes were seen. The cardiovascular effects were supraventricular and ventricular ectopic beats, ST-T changes and U waves. In 2 tests there were potentially dangerous arrhythmias. A significant relationship was seen between ECG abnormalities and the age of the patients. Such a relationship was not present between ECG changes and glucose and potassium values. It is concluded that the insulin infusion test is probably safer than the conventional Hollander test, but constant monitoring is still required.     

Minicholecystectomy: a safe, cost-effective day surgery procedure

OBJECTIVE: To document effectiveness of minicholecystectomy as a safe, cost-effective day surgery procedure with rapid return to work. DESIGN: Review of medical records. SETTING: Small community hospital. PATIENTS: A total of 1207 patients who underwent minicholecystectomies from January 1, 1986, through December 31, 1997. INTERVENTION: Minicholecystectomy. MAIN OUTCOME MEASURES: Complications, length of hospital stay, cost, and time until return to work. RESULTS: Of the 1207 patients who underwent minicholecystectomy, 74% were admitted for day surgery, 88% of whom were discharged in less than 12 hours, 9.3% in 24 hours or less, and 1.7% in greater than 24 hours; 0.3% were readmitted within 2 weeks. The complication rate was 0.2%; 2 cases required laparotomy, with no common duct injuries. The cost of the procedure was S435; the average time it took working patients to return to work was 11.4 days. CONCLUSIONS: Minicholecystectomy is a safe, inexpensive day surgery method of cholecystectomy with minimal time off work after surgery.     

Update: varicocelectomy--a safe outpatient procedure

One hundred ninety-two males with palpable varicoceles and subfertility who underwent varicocelectomy were studied. Fifty-five patients underwent inpatient varicocelectomy and 137 ambulatory varicocelectomy. We have shown that ambulatory varicocelectomy is safe and effective. Surgical success is not compromised. Most importantly, outpatient varicocelectomy is extremely cost-effective. The average cost of ambulatory varicocelectomy was less than 25 per cent that of an equivalent inpatient procedure, with a mean cost of $372 and $1,536 per person, respectively.     

Comparison of the Functional Outcome after Pylorus-preservingPancreatoduodenectomy: Pancreatogastrostomy and Pancreatojejunostomy

To determine if there is any differencein pancreatic function after pylorus-preserving pancreatoduodenectomy(PPPD) according to the type of pancreatoenterostomy[pancreatojejunostomy (P-J) or pancreatogastrostomy (P-G)], weevaluated the long-term functional status of 34 patients who underwentPPPD and survived for more than 1 year without clinical evidence ofrecurrence. Altogether 20 patients underwent P-J and 14 P-G. To comparethe two groups, we analyzed the (1) general nutritional status; (2)quality of life using three scoring systems; (3) gastrointestinalsymptoms; and (4) pancreatic exocrine function by the stool elastase Itest and endocrine function by oral glucose tolerance test (GTT). AfterPPPD, body weight decreased in both groups, with no difference betweenthe two groups. No statistical differences were found in tricepsskinfold thickness or serum protein/albumin. Regarding the quality oflife and postoperative gastrointestinal symptoms, there were nodifferences between the two groups except steatorrhea. There were 4mild and 15 severe cases of pancreatic exocrine insufficiency amongthose who underwent P-J, whereas all of the patients who underwent P-Gshowed severe pancreatic insufficiency. On GTT, excluding preoperativediabetes patients, 43.8% (7/16) of the P-J group had abnormal resultsafter surgery, whereas, 75.0% (9/12) of the PG group had an abnormalpostoperative GTT (p = 0.11). Severe exocrine andendocrine pancreatic insufficiency developed after PPPD in both the P-Jand P-G groups, but there was more functional deterioration in the P-Ggroup than in the P-J group. General nutritional status and quality oflife were not affected by the pancreatoenterostomy method in eithergroup.     

Percutaneous pancreatic pseudocyst drainage: a combined sonographic-endoscopic procedure

Certain pancreas-pseudocysts can be effectively drained either transgastrically or transduodenally using endoscopic procedures. Applicable methods include repeated fine needle punctures, insertion of a drainage tube or the percutaneous pseudocyst-drainage according to Hancke. The percutaneous sonographic pancreas-pseudocyst drainage represents an alternative or an adjunct to the classical surgical cyst drainage employing a cysto-jejunostomy or cysto-gastrostomy. The indications are analog to the surgical cysto-enterostomy, whereas the optimal method for each individual patient should be decided by interdisciplinary consultation. The following report presents 21 case studies of pancreas-pseudocysts which were treated conservatively using ultrasonographical procedures.     

Percutaneous tracheostomy: a safe procedure in the morbidly obese

BACKGROUND: Percutaneous dilational tracheostomy (PDT) is becoming a widely accepted technique that has replaced open tracheostomy (OT) in many hospitals. One of the remaining relative contraindications is morbid obesity. There are no published case series of its use in this patient population. We reviewed our experience with PDT in the morbidly obese and compared it to OT in this patient population. Our hypothesis is that PDT and OT have a similar frequency of adverse events. STUDY DESIGN: We reviewed charts of all morbidly obese patients (body mass index [BMI]>or=35, calculated as kg/m2) undergoing either PDT or OT at our institution during a 58-month period. Variables examined included age, gender, BMI, diagnosis, bedside or operating room, and bronchoscopy-assisted. We recorded all procedural complications and all tracheostomy-related complications that occurred for 30 days postprocedure or death. Primary adverse end points were defined as procedures that started percutaneous and converted to open; any reoperation related to the initial tracheostomy; malpositioning of tracheostomy resulting in patient morbidity, loss of airway control, and bleeding requiring surgical intervention. Secondary adverse end points occurred when a tracheostomy tube was dislodged or malfunctioned, as in the case of a cuff leak, and any bleeding that occurred more than 24 hours after insertion. RESULTS: From January 1, 2000, until September 30, 2004, our institution performed 1,062 tracheostomies. One hundred forty-three patients had a BMI>or=35. Eighty-nine patients underwent PDT and 53 patients underwent OT. Sixty-seven of the PDTs were performed at the bedside and 22 were performed in the operating room. All OTs were performed in the operating room. Five (6.5%) primary end points were recorded for PDTs (4 conversions to open, 1 malpositioning). Three (6.5%) primary end points were reported for OTs (malpositioning resulting in hypoxia, bleeding requiring surgical intervention, aborted attempt at open). CONCLUSIONS: PDT is a safe procedure to perform on morbidly obese patients.     

Second-generation lithotripsy: a safe, noninvasive, ambulatory procedure

A total of 600 patients underwent 696 treatments of extracorporeal shockwave lithotripsy (ESWL) during the period between June and November 1987. Our progressively increasing experience with the second-generation device shows that this new unit is as effective as the conventional one, and reveals several advantages. The focusing of the stone is easier; therapy time is shorter; general or regional anesthesia is no longer necessary; distal ureteral stones can be disintegrated, and adjuvant procedures are easily performed during the ESWL session. Of the last 400 patients of our series, 76% were treated on an outpatient basis without any major complications.