Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis

Background

Suture closure and stapler closure of the pancreatic remnant after distal pancreatectomy are the techniques used most often. The ideal choice remains a matter of debate.

Methods

Five bibliographic databases covering 1970 to July 2009 were searched.

Results

Sixteen articles met the inclusion criteria. Stapler closure was performed in 671 patients, while suture closure was conducted in 1,615 patients. The pancreatic fistula rate ranged from 0% to 40.0% for stapler closure of the pancreatic stump and from 9.3% to 45.7% for the suture closure technique. There were no significant difference between the stapler and suture closure groups with respect to the pancreatic fistula formation rate (22.1% vs 31.2%; odds ratio, .85; 95% confidence interval, .66-1.08), although there was a trend toward favoring stapler closure. In 4 studies including 437 patients, stapler closure was associated with a trend (not statistically significant) toward a reduction in intra-abdominal abscess (odds ratio, .53; 95% confidence interval, .24-1.15).

Conclusions

No significant differences occur between suture and stapler closure with respect to the pancreatic fistula or intra-abdominal abscess after distal pancreatectomy, though there is a trend favoring stapler closure.     

腹腔镜胰腺远端切除术治疗体会

目的探讨腹腔镜下胰腺远端切除术的手术适应证、安全性和可行性。方法选择2005年2月-10月住院的连续10例胰体尾占位患者,年龄(43．4±14．7)岁,男1例,女9例。9例术前诊断为囊性占位,肿瘤最大径平均4．0 cm(2．6～8．5cm);1例术前诊断为胰体尾病变伴肝转移,胰腺内分泌肿瘤可能性大。其中7例行保留脾脏胰腺远端切除术,3例行胰腺远端+脾切除术。结果10例手术均完全在腹腔镜下完成。手术时间(228±26)min,术中出血量(173±100)ml。术后胰瘘1例(10％),充分引流1个月后自行愈合;1例患者术后1个月复查发现胰腺断端旁有假性囊肿形成,直径约2 cm,观察1个月后囊肿消失。其余8例无并发症发生。术后平均住院13．5 d(12～16 d)。10例患者术后血糖均正常。10例随访2～22个月(中位数8个月),9例囊性病变患者均无复发,1例内分泌癌随访1年,肝脏转移病灶无明显变化,原发部位无肿瘤复发。结论对于病变位于胰体尾的良性肿瘤或疾病,选择腹腔镜胰腺远端切除术是安全、可行的。     

Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy

Background

The appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP.

Methods

The risk factors of pancreatic fistulas were investigated in 122 DPs among 3 types of stump closure: hand-sewn suture (n = 32), bipolar scissors (n = 45), and stapler closure (n = 45).

Results

There was no significant difference in the incidence of pancreatic fistula between the 3 types of stump closure (hand-sewn suture [44%] vs bipolar scissors [37.7%] vs stapler closure [35.5%]). By using receiver operating characteristics curves, 12 mm was the best cutoff value of the thickness of the pancreas for pancreatic fistulas after DP using stapler closure. Three factors (ie, male sex, body mass index >25 kg/m², and stapler closure) were independent risk factors of pancreatic fistulas after DP with a pancreas thicker than 12 mm.

Conclusions

A pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.     

不同闭合方式在降低胰体尾切除术后并发症的效果观察

目的探讨手工缝合和切割闭合器(Endo-GIA stapler)处理胰腺残端对胰体尾切除术后并发症的影响。方法回顾性分析南昌大学第一附属医院2014年1月至2018年8月收治的行胰体尾切除术88例病人的临床资料,根据不同闭合方式分为:手工缝合组24例、开腹闭合器组40例及腹腔镜闭合器组24例,比较三组病人在术中相关指标、术后恢复情况及并发症等方面的差异。结果三组病人在术中出血量、术后住院时间、病理良恶性、住院费用等方面差异均无统计学意义(均P>0.05),三组病人总并发症发生率及胰瘘发生率差异也无统计学意义(P>0.05)。结论切割闭合器与腹腔镜均不能降低胰体尾切除术后总并发症发生率,也不能降低胰瘘发生率。     

胰腺残端处理方式对胰体尾切除术后胰瘘的影响

目的探讨预防胰体尾切除术后胰瘘的胰腺残端处理方式。方法回顾性分析我院1996至2008年186例因胰腺或胰外病变行胰体尾切除术患者的临床资料,胰腺残端处理方法分别为：结扎主胰管、残端结扎、间断缝合、Prolene线连续缝合、胰腺空肠吻合及闭合器钉合六种方式,比较上述六种方式对术后胰瘘的影响并行统计学分析。结果186例患者中围手术期死亡5例（2．7％）,术后总并发症发生率34．9％（65／186）,胰瘘发生率21．0％（39／186）。8例胰腺残端结扎术后4例发生胰瘘,11例胰腺空肠吻合患者无胰瘘发生;17例Endo—GIA关闭胰腺残端者有胰瘘4例;结扎主胰管组、连续缝合组、间断缝合组胰瘘发生率分别为13．9％（5／36）、15．6％（10／64）、32．0％（16／50）,前两者与后者差别具有统计学意义（P〈0．05）。结论胰体尾切除术中残端结扎和间断缝合容易发生胰瘘,选择性缝扎主胰管或Prolene线连续缝合能降低胰瘘发生率,尤其后者更简单易行。近端胰管梗阻患者可选用胰肠吻合预防胰瘘;闭合器钉和胰腺残端要根据胰腺大小和质地选择性使用。     

胰体尾切除术后并发胰瘘的防治

目的 探讨胰体尾切除术后胰瘘的预防及治疗措施.方法 回顾性分析2000-2009年124例胰体尾部切除病例,包括胰腺恶性肿瘤86例,胰腺假性囊肿及良性肿瘤12例,胃肠肿瘤侵犯胰体尾18例,慢性胰腺炎合并胰体尾囊肿3例,外伤5例.以单纯间断褥式缝合(A组)处理胰腺残端63例;以改良的主胰管缝扎+间断褥式交锁缝合(B组)处理胰腺残端61例.所有患者均放置负压引流,术后均常规应用生长抑素.结果 A组63例中22例术后发生胰瘘,发生率为34.9％,其中高流量胰瘘10例,低流量胰瘘12例;B组61例中9例术后发生胰瘘,发生率为14.7％,无高流量胰瘘.两组胰瘘患者中,A组住院天数明显延长(P＜0.01),术后医疗费用明显增加(P＜0.01).结论 主胰管缝扎+间断褥式交锁缝合的手术方法可减少术后胰瘘的发生,有助于减少住院天数及术后医疗费用.     

Breast sarcomas: current and future perspectives

Breast sarcomas are rare neoplasms of the breast that need to be clearly distinguished from the very common breast carcinomas and treated in a multidisciplinary manner modelled after treatment paradigms in other sarcoma locations. An increasing need to differentiate sarcoma sub-types based on molecular characteristics that will also be depicted in differential treatment sensitivities and development of specifically targeted therapies are equally valid in sarcomas in general and in breast sarcomas in particular.Of special interest in breast are sarcomas developing after breast irradiation for a previous breast carcinoma, a scenario that is increasingly common, given the increasing trends of breast conservation in the surgical treatment of breast carcinoma that necessitates the adjuvant use of radiotherapy.     

Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy

BACKGROUND: Appropriate closure of the pancreatic remnant after distal pancreatectomy is still debated. A variety of procedures have been recommended to reduce the frequency of pancreatic fistula. This review quantitatively compares the available techniques. METHODS: Original articles and abstracts published up to the end of June 2004 were searched without language restriction in the Cochrane Controlled Trials Register, Medline and Embase. Three reviewers independently assessed each study's eligibility and quality, and extracted the data. A random effects model was performed using weighted odds ratios. RESULTS: Only ten of 262 articles could be included, two randomized clinical trials and eight observational studies. Reported postoperative morbidity varied from 13.3 to 64 per cent. The primary outcome measure, pancreatic fistula rate, occurred within the range 0-60.9 per cent. Meta-analysis of the six studies comparing stapler versus hand-sutured closure showed a non-significant combined odds ratio for occurrence of a pancreatic fistula of 0.66 (95 per cent confidence interval 0.35 to 1.26, P = 0.21) in favour of stapler closure. CONCLUSIONS: The quality and quantity of information extracted from the available trials are insufficient to enable any firm conclusion to be drawn on the optimal surgical technique of pancreatic stump closure; there is a trend in favour of the stapling technique.     

Laparoscopic distal pancreatectomy and open distal pancreatectomy: a nonrandomized comparative study

Although laparoscopic distal pancreatectomy (LDP) is technically feasible, its benefits remain uncertain. The purpose of this study was to compare the clinical results of LDP and open distal pancreatectomy (ODP). The medical records of 14 consecutive patients who underwent LDP were reviewed and compared with those of 19 patients who underwent ODP. All patients were treated for benign or borderline malignant disease of the pancreas. Operation time was longer for LDP than for ODP (290.7 vs. 213.8 min, P=0.0022), and postoperative analgesics were administered less frequently for patients who underwent LDP. Patients treated by LDP had earlier recovery of bowel function, shorter time to oral intake, and shorter postoperative hospital stay than those treated by ODP. No difference in morbidity or inflammatory response was observed between the 2 groups. LDP for benign or borderline malignant disease of the pancreas provides benefits without increasing morbidity.     

Pancreatic fistula after distal pancreatectomy: risk factors analysis

Distal pancreatectomy represents the standard surgical procedure for the body and tail pancreatic tumors. This operation is associated with a high number of postoperative complications, especially pancreatic fistula. The purpose of this paper is to analyse the risk factors that predispose to the pancreatic fistula after distal pancreatectomy and to present the proposed methods of prevention for this complication.     

A novel preoperative predictor of pancreatic fistula using computed tomography after distal pancreatectomy with staple closure

Purpose

A thick pancreas has proven to be a conspicuous predictor of pancreatic fistula (PF) following distal pancreatectomy (DP) using staples. Other predictors for this serious surgical complication currently remain obscure. This study sought to identify novel predictors of PF following DP.

Methods

One hundred and twenty-two patients were retrospectively assessed to determine the correlation between PF occurrence and the clinicopathological findings and radiologic data from preoperative computed tomography (CT). CT assessments included the thickness of the pancreas (TP) and pancreatic CT number (pancreatic index; PI), calculated by dividing the pancreatic CT by the splenic CT density.

Results

Twenty-four patients (19.7%) developed a clinically relevant PF. TP was identified as an independent risk factor for PF in multivariate analyses (odds ratio 1.17; P?=?0.0095). In subgroup analyses, a lower PI in a thick pancreas was a significant predictor of PF (P?=?0.032). The combination of these two prediction parameters, known as the TP-to-PI ratio (TPIR), showed a significantly better prediction ability than TP alone (area under the receiver operating characteristic curve for the incidence of PF, TPIR 0.80 vs. TP 0.69; P?=?0.037).

Conclusion

Combining the CT number with TP substantially improves the prediction ability for the incidence of PF following DP with staple use.

     

Umbilical cord blood research: current and future perspectives

Umbilical cord blood (UCB) banking has become a new obstetrical trend. It offers expectant parents a biological insurance policy that can be used in the event of a child or family member's life-threatening illness and puts patients in a position of control over their own treatment options. However, its graduation to conventional therapy in the clinical realm relies on breakthrough research that will prove its efficacy for a range of ailments. Expanding the multipotent cells found within the mononuclear fraction of UCB so that adequate dosing can be achieved, effectively expanding desired cells ex vivo, establishing its safety and limitations in HLA-mismatched recipients, defining its mechanisms of action, and proving its utility in a wide variety of both rare and common illnesses and diseases are a few of the challenges left to tackle. Nevertheless, the field is moving fast and new UCB-based therapies are on the horizon.     

Sperm cell biology: current perspectives and future prospects

Major advances in biomolecular techniques as well as in the sensitivity and accuracy of mass spectrometers are transform-ing the scientific landscape by fuelin...     

Intraoperative myocardial protection: current trends and future perspectives

BACKGROUND: The results of contemporary coronary artery bypass graft surgery (CABG) are excellent. However, recently changing trends in the population at risk have necessitated new measures to minimize perioperative morbidity and mortality. METHODS: We reviewed cardioplegic innovations developed, evaluated, and currently employed at the Toronto Hospital. In addition, we conducted an evaluation of novel cardioplegic formulations, with an eye towards future clinical applications. RESULTS: At the Toronto Hospital, we demonstrated that blood provided better protection than crystalloid cardioplegia. Subsequently, we found that a terminal infusion of warm blood cardioplegia repleted myocardial adenosine triphosphate (ATP) levels and improved postoperative ventricular function. Recently, we reported that tepid (29 degrees C) cardioplegia reduced lactate and acid production during cardioplegic arrest, and improved postoperative ventricular function. Combining antegrade and retrograde cardioplegic delivery reduced lactate production, preserved ATP stores, and improved metabolic recovery after cross-clamp release. Cardioplegic flows of at least 200 mL/min were required to washout detrimental metabolic end-products and improve ventricular function. To further optimize myocardial protection, attempts have been made to harness the beneficial effects of ischemic preconditioning using adenosine. Similarly, insulin cardioplegia has been employed in order to enhance ventricular performance by stimulating early postoperative aerobic metabolism. Finally L-arginine, a nitric oxide donor has been demonstrated to be beneficial in experimental studies and may represent a further option for the enhancement of intraoperative myocardial protection. CONCLUSIONS: Despite continued improvements in cardioplegic techniques, low output syndrome following high-risk CABG remains an ongoing concern. The development of novel additives with various protective properties may provide added protection, allowing for a reduction morbidity and mortality following CABG.     

Short-term perioperative outcomes after robot-assisted and laparoscopic distal pancreatectomy

Robotic surgery offers potential technical advantages that may facilitate pancreatic resection. The aim of this study was to evaluate the learning curve and short-term perioperative outcomes in patients who underwent laparoscopic and robot-assisted distal pancreatectomy. All perioperative variables were evaluated and compared retrospectively between laparoscopic (LDP) (n = 23) and robot-assisted (RDP) (n = 11) distal pancreatectomy. The mean total operative time was shorter in LDP (194 vs. 225 min; p = 0.017). All other perioperative criteria were similar between LDP and RDP patients (blood loss, transfusion rate, conversion, pancreatic fistula, postoperative morbidity, and duration of hospitalization). Non-adjusted CUSUM curve for composite events including operative time, conversion, postoperative morbidity and reoperation rates showed that the RDP learning curve corresponded to the first seven consecutive patients. During early experience, RDP was associated with longer operative time but similar short-term perioperative outcomes compared to conventional distal pancreatectomy.     

远端胰腺切除术后发生胰瘘的危险因素分析

目的 探讨远端胰腺切除术（distal pancreatectomy,DP）后发生术后胰瘘（postoperative pancreatic fistula,POPF）的危险因素。方法 回顾性分析2014年1月至2018年10月在西南医科大学附属医院肝 胆外科接受诊治的81例胰腺远端肿瘤性病变行DP的临床资料,对可能导致POPF的相关因素进行单因素 分析和Logistic回归分析。结果 81例患者DP术后发生生化漏13例,B级胰瘘9例,C级胰瘘3例。单因 素分析显示POPF可能与手术时间、术中失血量及内脏脂肪面积有关（P＜0.05）;Logistic回归分析显示, 手术时间（OR 1.060,95%CI 1.021～1.102,P=0.003）及内脏脂肪面积（OR 1.116,95%CI 1.046～1.190, P=0.001）是 POPF的独立危险因素。结论 手术时间和内脏脂肪面积是DP术后发生临床胰瘘的独立危险 因素。对内脏脂肪面积较大的患者需采取积极预防措施。     

胰体尾切除术后胰瘘的相关性因素分析

目的探讨胰体尾切除术后胰瘘发生的相关性因素。方法回顾性总结了82例行胰体尾切除的患者术前、术中操作以及术后并发症和死亡率发生的情况,并分析和术后胰瘘发生的相关性因素。结果术后有36名患者出现并发症占43.9%（36/82）。其中胰瘘是最常见的并发症,发生率为37.8%（31/82）。其中是否结扎主胰管和术后胰瘘的发生具有明显的相关性（P=0.010）,而性别、年龄、是否并存糖尿病、胰腺的质地、术中失血量、是否预防性应用奥曲肽、是否用生物胶封闭胰腺断端、术后低蛋白血症和是否联合其它脏器切除均和胰瘘的发生无明显的相关性。结论胰体尾切除术后最常见的并发症仍然是胰瘘,术中单独结扎胰管可以减少胰瘘的发生率。     

Hormones and prostate cancer: current perspectives and future directions

Prostate cancer is the most commonly diagnosed non-skin cancer in men in most western countries. Despite the high morbidity and mortality from prostate cancer, its etiology remains obscure. Although compelling laboratory data suggest a role for androgens in prostate carcinogenesis, most epidemiologic data on humans are inconclusive. To provide insights and directions for future epidemiologic research on hormones and prostate cancer, this review focuses on current perspectives of serum-based studies and polymorphisms in relevant hormone-related genes. We highlight the importance of methodologic studies and investigations of hormone levels in the prostatic tissue to help clarify the often-contradictory data on serologic studies. We recommend careful analysis and cautious interpretation of studies of genetic markers, including repeats and single nucleotide polymorphisms (SNPs), as false positive and negative results may arise in many current and future studies with limited statistical power and non-representative samples from the population. The review also highlights the reasons to perform functional analyses of SNPs, a critical and often under-appreciated component of molecular epidemiologic investigations.The time is ripe for large-scale multidisciplinary investigations that incorporate molecular genetics, biochemistry, histopathology, and endocrinology into traditional epidemiologic studies. Such collaboration will lead to a deeper understanding of the etiologic pathways of prostate cancer, ultimately yielding better preventive, diagnostic, and therapeutic strategies.