Biliary Complications After Pancreaticoduodenectomy: Skinny Bile Ducts Are Surgeons’ Enemies

Background

The aim of this study was to determine the incidence and predisposing factors of biliary complications (BCs) after pancreaticoduodenectomy (PD) and report our experience in managing these BCs. Pancreatic surgery, particularly PD, has benefited from improvements in operative techniques and postoperative care and is currently safer in terms of mortality. However, the morbidity associated with PD remains high, including frequent complications such as delayed gastric emptying and pancreatic fistulas. Rarer but important BCs are those that manifest as bile leaks (BLs) and biliary strictures (BSs).

Methods

Between April 2005 and December 2011, a total of 397 patients underwent PD at two centers. All data were retrospectively studied with respect to age, gender, pancreatic pathology, neoadjuvant treatment, preoperative biliary stenting, intraoperative data, postoperative pancreatic fistula, BL and BS rates, and mortality. The management of BCs was also analyzed.

Results

Thirty patients experienced a BC: 13 BLs (3.3 %) and 17 BSs (4.3 %). A thin bile duct (<5 mm), measured during surgery, was the only predisposing factor for developing a BL or a BS. The management of the BLs consisted of surveillance in six patients (46 %), percutaneous drainage of bilioma in four patients (31 %), and reintervention in three patients (23 %). No patient with a BS had surgery as the frontline treatment: the initial management consisted of an endoscopic procedure, a percutaneous procedure, or medical treatment. Four patients (23.5 %) underwent surgical treatment after failure of nonsurgical procedures.

Conclusions

The only identified predictive factor of BC, either a BS or a BL, was a thin bile duct. Although the noninvasive technique was the treatment of choice initially, reintervention was required in almost 25 % of the cases.     

Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection

Background

Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality.

Methods

Adult patients in the 2014–2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak.

Results

Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p <?0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p <?0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p?<?0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR?=?4.55; 95% CI 3.72–5.56; p <?0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p =?0.262).

Conclusion

Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.

     

200 Consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder

Introduction

Because of the potential benefit of robotics in pancreatic surgery, we review our experience at two minimally invasive pancreatic surgery centers that utilize a robotically controlled laparoscope holder to see if smaller robots that enable the operating surgeon to maintain contact with the patient may have a role in the treatment of pancreatic disease.

Methods

From March 1994 to June 2011, a total of 200 laparoscopic pancreatic procedures utilizing a robotically controlled laparoscope holder were performed.

Results

A total of 72 duodenopancreatectomies, 67 distal pancreatectomies, 23 enucleations, 20 pancreatic cyst drainage procedures, 5 necrosectomies, 5 atypical pancreatic resections, 4 total pancreatectomies, and 4 central pancreatectomies were performed. Fourteen patients required conversion to an open approach and eight a hand-assisted one. A total of 24 patients suffered a major complication. Sixteen patients developed a pancreatic leak and 19 patients required reoperation. Major complications occurred in 14 patients and pancreatic leaks occurred in 13 patients. Ten patients required conversion to a lap-assisted or open approach and six patients required reoperation.

Conclusions

Currently, a robotically assisted approach using a camera holder seems the only way to incorporate some of the benefits of robotics in pancreatic surgery while maintaining haptics and contact with the patient.     

A novel endoscopic treatment of major bile duct leak

INTRODUCTION

Bile leak is a serious complication of hepatobiliary surgery. The incidence has remained the same over the last decade despite significant improvement in the results of liver surgery.

PRESENTATION OF CASE

A 21-year-old man was a passenger in a motor vehicle and sustained a blunt abdominal trauma in a high-speed collision leading to major liver laceration. He had right lobe hepatectomy complicated by major bile leak. He was not fit for further surgery and he, therefore, had ERCP and obliteration of the leaking bile duct using a combination of metallic coil and N-butyl cyanoacrylate.

DISCUSSION

Endoscopic therapy has become the modality of choice in the treatment of biliary tract injuries. Different modalities of management of persistent bile leak such as sphincterotomy, plastic biliary stents, and nasobiliary drainage have been described. Obliteration of bile duct leak using N-butyl cyanoacrylate and coil embolization has been described but most of these reports used the percutaneous transhepatic approach.

CONCLUSION

In this paper, we describe the second reported case in English literature of a novel endoscopic technique using a combination of metallic coil embolization and N-butyl cyanoacrylate in a patient with major bile leak who was not a candidate for surgery as well as a third report of the late complication of coil migration to the common bile duct.     

Pancreatic Atrophy Relative to External Versus Internal Drainage of the Pancreatic Duct After Pylorus-Preserving Pancreaticoduodenectomy

Background

Atrophy of the pancreatic parenchyma, which occurs frequently after pylorus-preserving pancreaticoduodenectomy (PPPD), is often associated with pancreatic exocrine insufficiency. Many surgeons prefer to insert a drainage tube into the remnant pancreatic duct primarily to prevent pancreatic leakage at the pancreaticojejunostomy (PJ) after PPPD. Drainage methods vary widely but can be roughly classified as internal or external drainage. This study intended to evaluate their effects on pancreatic parenchymal atrophy following PPPD.

Methods

Fifty-seven patients who underwent PPPD were retrospectively divided into two groups, 28 who underwent external and 29 who underwent internal pancreatic drainage. External drainage tubes were removed 4 weeks after PPPD. The volume of the pancreatic parenchyma was serially measured on abdominal computed tomography (CT) scans before PPPD, as well as 7 days and 3, 6, and 12 months after surgery. Degree of pancreatic parenchymal atrophy was determined by calculating pancreatic volume relative to that on day 7.

Results

Univariate analysis showed that patient sex, age, body mass index, concurrent pancreatitis, pathology, and types of PJ did not significantly affect changes in pancreatic volume following PPPD. The degree of pancreatic volume atrophy did not differ significantly in the external and internal drainage groups. No patient in the external drainage group experienced drainage-related surgical complications. The incidence of PJ leak was comparable in the two groups. Postoperative pancreatic atrophy did not induce new-onset diabetes mellitus at 1 year.

Conclusions

Both external and internal pancreatic drainage methods showed similar atrophy rate of the pancreatic parenchyma following PPPD.     

Management of Anastomotic Leak: Lessons Learned from a Large Colon and Rectal Surgery Training Program

Background

Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions.

Methods

This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997–2008.

Results

Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2–1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks.

Conclusions

Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.     

Peng’s Binding Pancreaticojejunostomy After Pancreaticoduodenectomy: A French Prospective Study

Background

Pancreatic fistula (PF) is the single most important complication after pancreaticoduodenectomy. Recently, a 0% rate of PF was reported using a binding pancreaticojejunostomy with intussusception of the pancreatic stump. The aim of this study was to assess the safety of this new binding pancreaticojejunostomy in condition most susceptible to PF, i.e. soft pancreas and non-dilated main pancreatic duct.

Methods

Forty-five consecutive patients with soft pancreas and non-dilated main pancreatic duct underwent a binding pancreaticojejunostomy. Post-operative PF was defined according to the International Study Group of Pancreatic Fistula.

Results

Four patients (8.9%) developed a PF. In one case, PF developed on post-operative day 3 due to a technical deficiency. In the three other cases, pancreatic fistula developed after the tenth post-operative day; all the patients had local and/or general co-morbidities before PF occurrence.

Conclusions

Binding pancreaticojejunostomy according to Peng is a safe and secure technique that improves the rate of pancreatic fistula, especially in case of soft texture of the pancreas remnant. However, a 0% rate seems to be hard to achieve because other abdominal and general complications are frequent and can lead to secondary leakage of the pancreatic anastomosis.     

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.     

What Is the Risk of Clinical Anastomotic Leak in the Diverted Colorectal Anastomosis?

Objective

The objective of this study was to identify clinical leak in diverted colorectal anastomoses.

Design

Cohort analysis.

Setting

The study was conducted in a subspecialty practice at a tertiary care facility.

Patients

Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012.

Interventions

No intervention was applied.

Main Outcome Measures

Clinical anastomotic leak.

Results

Two hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14 %) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5 %) patients within 30 days of surgery (early leaks) and in 21 (9 %) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing.

Conclusions

In diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.     

Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review

Background

In the setting of difficult dissection of Calot’s triangle during laparoscopic cholecystectomy, conversion is commonly advocated. An alternative approach aimed at preventing bile duct injury is laparoscopic partial cholecystectomy (LPC). The safety and efficacy of this procedure are unclear.

Methods

A systematic review of the literature was performed independently by three researchers. The outcomes were conversion rate, hospital length of stay (LOS), bile duct injury, bile leak, symptomatic gallstones in the remnant gallbladder, need for reoperation, postoperative endoscopic retrograde cholangiopancreaticography (ERCP), percutaneous intervention, and mortality.

Results

The review included 15 publications, which reported on 625 patients. Four different operative techniques could be distinguished. Conversion to open (partial) cholecystectomy was performed in 10.4 % of the cases. The median LOS was 4.5 days (range, 0–48 days). The most common complication was postoperative bile leak, which occurred in 66 patients (10.6 %). One case of bile duct injury occurred. During the follow-up period, 2.2 % of the patients experienced recurrent symptoms of gallstones. Eight patients (2.7 %) underwent reoperation. Postoperative ERCP was performed for 26 (7.5 %) of 349 patients. A percutaneous intervention was performed for 5 (1.4 %) of 353 patients. Three deaths were described in the reviewed series (1 of pulmonary sepsis and 2 of myocardial infarctions). A rough comparison showed that fewer bile leaks, less need for ERCP, and less recurrent symptoms of gallstones seemed to occur when the cystic duct and gallbladder remnant were closed.

Conclusions

Literature concerning LPC is scarce. Four different LPC techniques can be distinguished. When a difficult gallbladder is encountered during LC, LPC seems to be a safe and feasible alternative to conversion. Closing of the cystic duct, gallbladder remnant, or both seems to be preferable.     

Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery

Background

Endoscopic ultrasound (EUS)-guided drainage is widely used to manage pancreatic pseudocysts. Several studies have reported the use of EUS-guided drainage for pancreatic fistula and stasis of pancreatic juice caused by stricture of the pancreatic duct after pancreatic resection.

Methods

At the authors’ hospital, 262 patients underwent surgery involving pancreatic resection from April 2005 to March 2010. In 90 of these patients (34%), a grade B or C postoperative pancreatic fistula developed that required additional treatment. The authors performed EUS-guided transmural drainage (EUS-TD) for six patients (2.1%) with a pancreatic fistula or dilation of the main pancreatic duct visible by EUS. Percutaneous drainage was provided for 18 patients (6.8%). The success rates for EUS-TD and percutaneous drainage were compared in a retrospective analysis.

Results

In all six cases, EUS-TD was performed successfully without complications. Five of the six patients were successfully treated with only one trial of EUS-TD. The final technical success rate was 100% for both EUS-TD and percutaneous drainage. Both the short- and long-term clinical success rates for EUS-TD were 100% and those for percutaneous drainage were 61.1 and 83%, respectively. The differences in these rates were not significant (short-term success, P?=?0.091 vs. long-term success, P?=?0.403). However, the time to clinical success was significantly shorter with EUS-TD (5.8?days) than with percutaneous drainage (30.4?days; P?=?0.0013) in the current series.

Conclusions

The EUS-TD approach appears to be a safe and technically feasible alternative to percutaneous drainage and may be considered as first-line therapy for pancreatic fistulas visible by EUS.     

Verification of Early Removal of the Chest Tube after Absorbable Mesh-based Pneumostasis Subsequent to Video-assisted Major Lung Resection for Cancer

Background

We previously reported that the combined use of absorbable mesh and fibrin glue is superior to the use of fibrin glue alone to stop intraoperative air leaks. However, concern remains about whether mesh-based pneumostasis can induce the recurrence of air leaks after chest tube removal.

Methods

We reviewed our prospective database of selected patients (n?=?206) who underwent video-assisted major lung resection for cancer. Exclusion criteria included simultaneous combined resection, induction radiotherapy, entire intrathoracic adhesion, or a history of prior ipsilateral thoracotomy. We sealed any intraoperative air leaks with absorbable mesh and fibrin glue and then carried out prophylactic chest-tube drainage for 1?day.

Results

Intraoperative air leaks were detected in 133 (65%) patients. Overall, air leaks were not detected postoperatively in 186 (91%) patients, allowing chest tube removal on the day after the operation. The mean length of time for chest tube drainage was 1.2?days. A prolonged air leak (>7?days) was observed in one (0.5%) patient, and this leak resolved by itself. After chest tube removal, an air leak recurred in six (2.9%) patients during the 30?day follow-up period, necessitating chest tube reinsertion. Although the recurrence was observed more frequently after segmentectomy than after lobectomy (p?=?0.04), the recurrence was not observed more frequently in patients who had an intraoperative air leak than in patients who did not (p?=?0.3).

Conclusion

Early removal of the chest tube after pneumostasis with absorbable mesh is verified in selected patients who underwent video-assisted major lung resection for cancer. However, further attempts should be made to prevent air leaks after anatomical segmentectomy.     

Chen’s U-Suture Technique for End-to-End Invaginated Pancreaticojejunostomy Following Pancreaticoduodenectomy

Background and Purpose

Internationally, postoperative pancreatic fistula (POPF) remains a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). In order to reduce the incidence of POPF, a number of technical modifications for pancreato-enteric anastomosis after PD have been proposed. In 1995, we established a new technique with transpancreatic transverse U-sutures for end-to-end invaginated pancreaticojejunostomy after a PD, and the preliminary results were quite encouraging. This study aims to review a new surgical approach, the Chen’s U-stitch technique, for end-to-end invaginated pancreaticojejunostomy, which involves two to four transpancreatic transverse U-sutures, and to evaluate the effectiveness of this approach with reducing the incidence of POPF formation.

Methods

To evaluate this new approach, during 2002–2012, a total of 264 patients who received the new Chen’s U-stitch technique after a PD were included in this study. Postoperative morbidity and mortality, including the incidence of POPF, were analyzed.

Results

Postoperative morbidity was 22.3 % (59/264) and mortality was 0 % (0/264). The POPF rate was 3.4 % (9/264) for Grade A, 0.8 % (2/264) for Grade B, and 0 % (0/264) for Grade C.

Conclusions

This new surgical technique (Chen’s U-stitch), which involves an end-to-end invaginated pancreaticojejunostomy with two to four transpancreatic transverse U-sutures, provides excellent outcomes at reducing the incidence of POPF after PD.     

Primary closure versus T-tube drainage in laparoscopic common bile duct exploration: a meta-analysis of randomized clinical trials

Purpose

To compare the safety and effectiveness of primary closure with those of T-tube drainage in laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis.

Methods

A comprehensive search was performed in the PubMed, EmBase, and Cochrane Library databases. Only randomized controlled trials comparing primary closure with T-tube drainage in LCBDE were considered eligible for this meta-analysis. The analyzed outcome variables included postoperative mortality, overall morbidity, biliary complication rate, biliary leak rate, reoperation, operating time, postoperative hospital stay, time to abdominal drain removal, and retained stone. All calculations and statistical tests were performed using ReviewerManager 5.1.2 software.

Results

A total of 295 patients (148 patients with primary closure and 147 patients with T-tube drainage) from three trials were identified and analyzed. No deaths occurred in any of the trials. Primary closure showed significantly better results in terms of morbidity (risk ratio (RR), 0.51; 95% confidence interval (CI), 0.30 to 0.88), biliary complication without a combination of retained stone (RR, 0.44; 95% CI, 0.20 to 0.97), reoperation (RR, 0.16; 95% CI, 0.03 to 0.87), operating time (mean difference (MD), ?20.72; 95% CI, ?29.59 to ?11.85), postoperative hospital stay (MD, ?3.24; 95% CI, ?3.96 to ?2.52), and time to abdominal drainage removal (MD, ?0.45; 95% CI, ?0.86 to ?0.04). Statistically significant differences were not found between the two methods in terms of biliary leak, biliary complication, and retained stones.

Conclusion

The current meta-analysis indicates that primary closure of the common bile duct is safer and more effective than T-tube drainage for LCBDE. Therefore, we do not recommend routine performance of T-tube drainage in LCBDE.     

Pancreatic fistula following distal pancreatectomy: How to prevent

Aim-Background

Pancreatic fistula (PF) is a major cause of morbidity after distal pancreatic resection, ranging in frequency between 15% and 40%, regardless of whether the procedure is performed laparoscopically or by open surgery. The peri-operative outcomes have been examined in a single retrospective review with efforts focused on the management of PFs.

Methods

We reviewed our database for patients undergoing Distal Pancreatectomy (DP) between January 1997 and May 2012. We retrospectively evaluated the indications, surgical procedure and the postoperative course. The pancreas was transected with cautery or lancet and the resection line was oversewn with silk or vicryl 3-0 sutures. The pancreatic duct was identified and ligated with prolene 4-0 sutures.

Results

Fifty-four patients underwent DP. One month after surgery, one patient with advanced oesophageal cancer and another with pancreatic adenocarcinoma died in the intensive care unit (ICU) due to sepsis and respiratory failure respectively. PF occurred in 37% of the patients. All patients with a pancreatic leak were successfully managed non-operatively. In three cases, a percutaneous drainage catheter was placed under computed tomography (CT) guidance.

Conclusions

Postpancreatectomy fistula remains common but is followed by a low mortality rate. Conservative management of PF, including percutaneous drainage for symptomatic abdominal collections, is successful in most cases. The method of stump closure continues to present a clinical challenge.     

Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital

Background

Anastomotic leakages are severe complications of upper gastrointestinal surgery with serious morbidity and mortality. Until recently, only abscess drainage was possible. Since 2007, removable and repositionable covered metal self-expandable stents (RReCoMSeS) have been used in our hospital to cover leaks.

Methods

Patients with postsurgical gastrointestinal leaks treated with RReCoMSeS between January 2007 and March 2010 were retrospectively evaluated and described.

Results

Twenty-six patients were treated with RReCoMSeS (totally covered Choo/Hanaro and partially covered Endoflex stents). Included patients had anastomotic leaks after esophagectomy (15) and bariatric surgery (11). Overall successful sealing of the leak occurred in 81 % (including multiple procedures). In total 33 RReCoMSeS were used (mean 1.3 stents and 1.7 procedures per patient). Twenty-one of 33 RReCoMSeS succeeded in sealing the leak (64 %). Migration occurred in 24 % RReCoMSeS, and 9 % disintegrated. One stent (3 %) caused a perforation.

Conclusions

RReCoMSeS are a safe alternative for treating postsurgical leaks in the upper gastrointestinal tract. In 81 % of patients and with 64 % of the inserted stents, leaks were sealed successfully, with few complications. Fewer stents per patient were needed thanks to their repositionability. Stent migration is a major problem.     

Performing simple and safe dunking pancreaticojejunostomy using mattress sutures in pure laparoscopic pancreaticoduodenectomy

Background

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic resection, laparoscopic pancreaticoduodenectomy still presents major technical difficulties, such as when performing pancreatic–enteric anastomosis.

Methods

Laparoscopic dunking pancreaticojejunostomy using mattress sutures was performed in 15 consecutive patients with a soft pancreas and a nondilated pancreatic duct between October 2011 and December 2012.

Results

According to the International Study Group on Pancreatic Fistula criteria, 3 patients developed PF (grade A), whereas the remaining 12 patients did not.

Conclusions

Dunking pancreaticojejunostomy using mattress sutures is considered to be a feasible and safe method for performing pure laparoscopic pancreaticoduodenectomy.     

Application of Polyethylene Glycolic Acid Felt with Fibrin Sealant to Prevent Postoperative Pancreatic Fistula in Pancreatic Surgery

Objective

The purpose of this nonrandomized retrospective study was to report our new procedures using polyethylene glycolic acid (PGA) felt with fibrin sealant to prevent severe pancreatic fistula in patients undergoing pancreatic surgery.

Methods

From 2000 to 2008, 54 and 63 patients underwent pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), respectively. Of those patients, we applied PGA felt with fibrin sealant to 18 PD patients and 26 DP patients. In PD patients, the PGA felt was wrapped around the pancreatic suture site, while in DP patients, the PGA felt was wrapped around the predictive division site. The pancreaticojejunostomy site in PD patients and the cut stump in DP patients were coated with fibrin sealant. We compared the occurrence rates for severe postoperative pancreatic fistula (POPF) that occurred after PD or DP both with and without our new procedures.

Results

Before introduction of our procedures, severe POPF developed in 14 of 36 PD patients (39%) and 10 of 37 DP patients (27%). In contrast, after introduction of our procedures, the incidence of POPF was only one in both of 18 PD (6%; P?=?0.016) and 26 DP (4%; P?=?0.017) patients.

Conclusion

In summary, our procedure using PGA felt with fibrin sealant may reduce the risk of severe POPF.     

Drainage Volume After Pancreaticoduodenectomy Is a Warning Sign of Chyle Leakage That Inversely Correlates With a Diagnosis of Pancreatic Fistula

Background

Chyle leakage is a rare complication of pancreaticoduodenectomy (PD), and its association with pancreatic fistula has not been established. The aim of this study was to (1) evaluate the incidence, management, and risk factors of chyle leakage after PD; (2) determine if there is a relation between chyle leakage and diagnosis of pancreatic fistula; and (3) predict chyle leakage with drainage volume early.

Methods

A total of 222 patients underwent PD or pylorus-preserving PD. We used the clinical database registry system of the Gangnam Severance Hospital, Yonsei University Health System to establish a retrospective cohort with clinicopathologic data.

Results

Altogether, 24 patients (10.8 %) developed chyle leakage. Chyle leakage was identified at a median 5 days after surgery and a mean 2 days after enteral intake. The mean drain triglyceride level was 315 mg/dl. Early enteral intake was independently associated with chyle leakage. Chyle leakage was inversely correlated with a diagnosis of pancreatic fistula with marginal significance (odds ratio 0.27; 95 % confidence interval 0.66–1.09). The receiver operating characteristic curve of the volume on postoperative day 4 demonstrated an area under the curve of 0.740 (p = 0.0001). Drainage >335 ml indicated possible chyle leakage.

Conclusions

Chyle leakage after PD is associated with early enteral intake. It was inversely correlated with a diagnosis of pancreatic fistula because of the dilution effect of drainage volume on the concentration of drained amylase. Because early diagnosis helps with appropriate management, prediction/suspicion of chyle leakage based on drainage volume may be useful.     

Laparoscopic Roux limb Placement over a Fistula Defect Without Mucosa-to-Mucosa Anastomosis: a Modified Technique for Surgical Management of Chronic Proximal Fistulas After Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure. A chronic fistula at the esophago-gastric junction (EGJ) is a rare but life-threatening complication of this procedure whose causes are still unclear and management is still controversial.

Methods

A 41-year-old woman with a body mass index (BMI) of 38 developed an EGJ leak 6 days post-LSG. Despite initial control with conservative measures, the leak persisted and resulted in a left pleural abscess and a broncho-pleural fistula requiring thoracotomy with resection of the abscessed lung parenchyma. Endoscopic and drainage procedures failed to prevent subdiaphragmatic recurring collection due to the persistent fistula. Nineteen months after LSG, a Roux limb was placed on the EGJ and sutured side to side around the fistula defect, without mucosa-to-mucosa anastomosis.

Results

The postoperative course was uneventful and, 20 months later (39 months post-LSG), the patient is well with a BMI of 27.

Conclusions

Laparoscopic apposition of a Roux-en-Y limb without mucosa-to-mucosa anastomosis as an efferent path to drain the undebrided fistula defect can effectively treat chronic leaks at the EGJ after LSG.