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Wang Z, Wang Y, Zhu C, Pan H, Chen S, Hu X, Zhou S, Liu H, Pang Q, Jin H. Prevention of postpancreatectomy hemorrhage after laparoscopic pancreaticoduodenectomy by wrapping ligamentum teres hepatis surrounding hepatic portal artery. Sci Rep 2024; 14:18332. [PMID: 39112624 PMCID: PMC11306217 DOI: 10.1038/s41598-024-69292-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 08/02/2024] [Indexed: 08/10/2024] Open
Abstract
Postpancreatectomy hemorrhage (PPH) is an important risk factor for postoperative complications after laparoscopic pancreaticoduodenectomy (LPD). Recent studies have reported that the use of ligamentum teres hepatis (LTH) in LPD may reduce the risk of PPH. Therefore, this study aims to investigate whether wrapping the hepatic hilar artery with the LTH can reduce PPH after LPD. We reviewed the data of 131 patients who underwent LPD in our team from April 2018 to December 2023. The patients were divided into Groups A (60 patients) and B (71 patients) according to whether the hepatic portal artery was wrapped or not. The perioperative data of the two groups were compared to evaluate the effect of LTH wrapping the hepatic hilar artery on LPD. The platelet count of Group A was (225.25 ± 87.61) × 10^9/L, and that of Group B was (289.38 ± 127.35) × 10^9/L, with a statistically significant difference (p < 0.001). The operation time of group A [300.00 (270.00, 364.00)] minutes was shorter than that of group B [330.00 (300.00, 360.00)] minutes, p = 0.037. In addition, A set of postoperative hospital stay [12.00 (10.00, 15.00)] days shorter than group B [15.00 (12.00, 19.50)] days, p < 0.001. No PPH occurred in Group A, while 8 patients in Group B had PPH (7 cases of gastroduodenal artery hemorrhage and 1 case of proper hepatic artery hemorrhage), p = 0.019. The new technique of wrapping the hepatic hilar artery through the LTH can effectively reduce the occurrence of PPH after LPD.
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Affiliation(s)
- Zhicheng Wang
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
- Graduate School of Bengbu Medical University, Bengbu, Anhui, China
| | - Yong Wang
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Chao Zhu
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Hongtao Pan
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Shilei Chen
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Xiaosi Hu
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Shuai Zhou
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Huichun Liu
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Qing Pang
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China
| | - Hao Jin
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Anhui Medical University, 1868 Dangshan Road, Hefei, 230041, Anhui, China.
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Preston WA, Collins ML, Gönen M, Murtha T, Rivera V, Lamm R, Schafer M, Yarmohammadi H, Covey A, Brody LA, Topper S, Nevler A, Lavu H, Yeo CJ, Balachandran VP, Drebin JA, Soares KC, Wei AC, Kingham TP, D’Angelica MI, Jarnagin WR. Hemorrhage Sites and Mitigation Strategies After Pancreaticoduodenectomy. JAMA Surg 2024; 159:891-899. [PMID: 38776076 PMCID: PMC11112495 DOI: 10.1001/jamasurg.2024.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/01/2024] [Indexed: 05/25/2024]
Abstract
Importance Postpancreatectomy hemorrhage is an uncommon but highly morbid complication of pancreaticoduodenectomy. Clinical evidence often draws suspicion to the gastroduodenal artery stump, even without a clear source. Objective To determine the frequency of gastroduodenal artery bleeding compared to other sites and the results of mitigation strategies. Design, Setting, and Participants This cohort study involved a retrospective analysis of data for consecutive patients who had pancreaticoduodenectomy from 2011 to 2021 at Memorial Sloan Kettering Cancer Center (MSK) and Thomas Jefferson University Hospital (TJUH). Exposures Demographic, perioperative, and disease-related variables. Main Outcomes and Measures The incidence, location, treatment, and outcomes of primary (initial) and secondary (recurrent) hemorrhage requiring invasive intervention were analyzed. Imaging studies were re-reviewed by interventional radiologists to confirm sites. Results Inclusion criteria were met by 3040 patients (n = 1761 MSK, n = 1279 TJUH). Patients from both institutions were similar in age (median [IQR] age at MSK, 67 [59-74] years, and at TJUH, 68 [60-75] years) and sex (at MSK, 814 female [46.5%] and 947 male [53.8%], and at TJUH, 623 [48.7%] and 623 male [51.3%]). Primary hemorrhage occurred in 90 patients (3.0%), of which the gastroduodenal artery was the source in 15 (16.7%), unidentified sites in 24 (26.7%), and non-gastroduodenal artery sites in 51 (56.7%). Secondary hemorrhage occurred in 23 patients; in 4 (17.4%), the gastroduodenal artery was the source. Of all hemorrhage events (n = 117), the gastroduodenal artery was the source in 19 (16.2%, 0.63% incidence in all pancreaticoduodenectomies). Gastroduodenal artery hemorrhage was more often associated with soft gland texture (14 [93.3%] vs 41 [62.1%]; P = .02) and later presentation (median [IQR], 21 [15-26] vs 10 days [5-18]; P = .002). Twenty-three patients underwent empirical gastroduodenal artery embolization or stent placement, 7 (30.4%) of whom subsequently experienced secondary hemorrhage. Twenty percent of all gastroduodenal artery embolizations/stents (8/40 patients), including 13% (3/13 patients) of empirical treatments, were associated with significant morbidity (7 hepatic infarction, 4 biliary stricture), with a 90-day mortality rate of 38.5% (n = 5) for patients with these complications vs 7.8% without (n = 6; P = .008). Ninety-day mortality was 12.2% (n = 11) for patients with hemorrhage (3 patients [20%] with primary gastroduodenal vs 8 [10.7%] for all others; P = .38) compared with 2% (n = 59) for patients without hemorrhage. Conclusions and Relevance In this study, postpancreatectomy hemorrhage was uncommon and the spectrum was broad, with the gastroduodenal artery responsible for a minority of bleeding events. Empirical gastroduodenal artery embolization/stent without obvious sequelae of recent hemorrhage was associated with significant morbidity and rebleeding and should not be routine practice. Successful treatment of postpancreatectomy hemorrhage requires careful assessment of all potential sources, even after gastroduodenal artery mitigation.
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Affiliation(s)
- William A. Preston
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Micaela L. Collins
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Timothy Murtha
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Division of Surgical Oncology, Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Victor Rivera
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan Lamm
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michelle Schafer
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Hooman Yarmohammadi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Covey
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lynn A. Brody
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephen Topper
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Avinoam Nevler
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Harish Lavu
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Charles J. Yeo
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Vinod P. Balachandran
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jeffrey A. Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kevin C. Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alice C. Wei
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - T. Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael I. D’Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William R. Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Yang W, Zeng H, Jin Y. Robotic pancreaticoduodenectomy in patients with overweight or obesity: a meta-analysis protocol. BMJ Open 2024; 14:e080605. [PMID: 39019640 DOI: 10.1136/bmjopen-2023-080605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION The prevalence of overweight or obesity among patients undergoing pancreaticoduodenectomy is on the rise. The utilisation of robotic assistance has the potential to enhance the feasibility of performing minimally invasive pancreaticoduodenectomy in this particular group of patients who are at a higher risk. The objective of this meta-analysis is to assess the safety and effectiveness of robotic pancreaticoduodenectomy in individuals with overweight or obesity. METHODS AND ANALYSIS This investigation will systematically search for randomised controlled trials (RCTs) and non-randomised comparative studies that compare robotic pancreaticoduodenectomy with open or laparoscopic pancreaticoduodenectomy in patients with overweight or obesity, using PubMed, Embase and the Cochrane Library databases. The methodological quality of studies will be evaluated using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for observational studies. RevMan software (V.5.4.1) will be used for statistical analysis. The OR and weighted mean differences will be calculated separately for dichotomous and continuous data. The selection of a fixed-effects or random-effects model will depend on the level of heterogeneity observed among the included studies. ETHICS AND DISSEMINATION This study will be conducted based on data in the published literature from publicly available databases. Therefore, ethics approval is not applicable. The results will be disseminated in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023462321.
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Affiliation(s)
- Wenxiao Yang
- Business School, University of Shanghai for Science & Technology, Shanghai, China
| | - Hai Zeng
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yueling Jin
- Shanghai Science and Technology Museum, Shanghai, China
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Hang K, Wei L, Yi M, Liu H, Huang Y, Zhang H, Tan C, Li K, Xiong J. Pedicled ligament flaps during pancreatoduodenectomy are associated with reduced hemorrhage from hepatic artery and gastroduodenal artery stump during pancreatoduodenectomy: a systematic review, meta-analysis and trial sequential analysis. HPB (Oxford) 2024; 26:476-485. [PMID: 38195309 DOI: 10.1016/j.hpb.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/12/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND The aim of this study was to investigate whether pedicled ligament flaps (PLF) covering around the hepatic and gastroduodenal artery stump can provide better clinical outcomes in pancreatoduodenectomy (PD). METHODS We conducted a comprehensive search of databases (inception to January 2023) to identify studies comparing PD with or without PLF covering the skeletonized arteries. The perioperative and postoperative outcomes were compared. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated using fixed-effects models. RESULTS Ten studies were included in the qualitative synthesis. Six studies with 3538 patients met the inclusion criteria for the meta-analysis. Patients in the PLF group had a significantly lower rate of PPH from the hepatic artery or gastroduodenal artery stump (H/G PPH) (OR: 0.41; 95 % CI, 0.22-0.75; P < 0.01) and overall PPH (OR: 0.65; 95 % CI, 0.46-0.93; P = 0.02). There were no significant differences between the two groups in terms of morbidity, grade B/C postoperative pancreatic fistula (B/C POPF), delayed gastric emptying (DGE), reoperation, or mortality. CONCLUSION Prophylactic pedicled ligament flaps covering around the skeletonized arteries significantly reduced overall PPH and H/G PPH, and it seemed to have no obvious influence on other complications.
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Affiliation(s)
- Kuan Hang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Lijuan Wei
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Mingchao Yi
- The People's Hospital of Jianyang City, Jianyang, Sichuan Province, China
| | - Haoheng Liu
- College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, China
| | - Yang Huang
- College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, China
| | - Hao Zhang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Chunlu Tan
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Kezhou Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China
| | - Junjie Xiong
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, Sichuan Province, China.
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Zheng X, Jiang Z, Gao Z, Zhou B, Li G, Yan S, Mei X. Wrapping gastroduodenal artery stump with the teres hepatis ligament to prevent postpancreatectomy hemorrhage after pancreaticoduodenectomy. World J Surg Oncol 2023; 21:370. [PMID: 38008758 PMCID: PMC10680273 DOI: 10.1186/s12957-023-03218-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/05/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND Gastroduodenal artery (GDA) stump erosion hemorrhage is a fatal complication after pancreaticoduodenectomy. This study aimed to determine whether GDA stump wrapping with the teres hepatis ligament during pancreaticoduodenectomy decreased the incidence of postpancreatectomy hemorrhage (PPH). METHODS We reviewed 307 patients who had undergone pancreaticoduodenectomy between March 2019 and June 2022. The patients were divided into two groups according to application of GDA stump wrapping with the teres hepatis ligament: GDA wrapping group (165 patients) and no-wrapping group (142 patients). The perioperative data were compared between the groups. RESULTS The clinical characteristics were balanced between the two groups. Grades B and C PPH and GDA-stump-related hemorrhage were significantly reduced in the GDA wrapping group compared with the no-wrapping group (PPH B/C, 13.4% vs 6.1%, P = 0.029; GDA hemorrhage, 5.6% vs 0.6%, P = 0.014). No difference was observed in the incidence of clinically relevant postoperative pancreatic fistula, biliary leak, intra-abdominal abscess, delayed gastric emptying, 90-day mortality, and postoperative hospital stay between the two groups. CONCLUSION Wrapping GDA stump with the teres hepatis ligament reduced the incidence of GDA-stump-related PPH. Therefore, the wrapping technique is a simple and effective strategy to prevent PPH. Prospective studies are needed to confirm the benefit of this procedure.
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Affiliation(s)
- Xiang Zheng
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Zedong Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Zhenzhen Gao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Bo Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Sheng Yan
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China.
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China.
| | - Xiaoping Mei
- Affiliated Hospital of Jiaxing University (The First Hospital of Jiaxing), Jiaxing, China.
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Barberio M, Milizia A, Pizzicannella M, Lapergola A, Barbieri V, Benedicenti S, Rubichi F, Altamura A, Giaracuni G, Citiso S, Mita MT, Viola MG. End-to-end invaginated pancreaticojejunostomy during minimally invasive pancreatoduodenectomy: technical description and single center experience. Surg Endosc 2023; 37:7370-7375. [PMID: 37530988 DOI: 10.1007/s00464-023-10316-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/15/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Remarkable progress has been made in pancreatic surgery over the last decades with the introduction of minimally invasive techniques. Minimally invasive pancreatoduodenectomy (MIPD) remains one of the most challenging operations in abdominal surgery and it is performed in a few centers worldwide. The treatment of the pancreatic stump is a crucial step of this operation; however, the best strategy to perform pancreatic anastomosis is still debated. In this article, we describe the technical details of our original technique of modified minimally invasive end-to-end invaginated pancreaticojejunostomy (EIPJ) using video footage. METHODS In the current study, we retrospectively analyzed a pilot series of 67 consecutive cases of minimally invasive (7 robotic/60 fully laparoscopic) MIPD operated on at the General Surgery Department of the Panico Hospital, Tricase (Italy) between March 2017 and October 2022.The reconstruction phase involved an EIPJ, tailored using an intra-ductal anastomotic plastic stent. The aim of this study was to describe the technique and evaluate the short-term outcomes of patients undergoing MIPD with EIPJ. RESULTS The mean operative time to perform the EIPJ was 21.57 ± 3.32 min. Seven patients (10.5%) developed biochemical leaks and 13 (19.4%) developed clinically relevant pancreatic fistulas (grade B or C according to the definition of the International Study Group on Pancreatic Surgery). CONCLUSION The early results confirm that this anastomosis is safe, easy to perform, and effective in the hands of hepatobiliopancreatic (HBP) surgeons with experience in minimally invasive surgery.
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Affiliation(s)
- Manuel Barberio
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy.
- Department of Research, Research Institute against Digestive Cancer (IRCAD), 1, Place de l'Hôpital, 67091, Strasbourg, France.
| | - Antonio Milizia
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Margherita Pizzicannella
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
- Department of Research, IHU (Institute of Image-Guided Surgery), Strasbourg, France
| | - Alfonso Lapergola
- Department of Visceral and Digestive Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Vittoria Barbieri
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Sara Benedicenti
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Francesco Rubichi
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Amedeo Altamura
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Gloria Giaracuni
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Stefania Citiso
- Clinical Trials Department, Ospedale Card. G. Panico, Tricase, Italy
| | - Maria Teresa Mita
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
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Yu Z, Wu X, Zhou X, Hu X, Lu J, Fang S, Wang L, Ruan Y, Lu Y, Li H. Ligamentum teres hepatis wrapping of the gastroduodenal artery stump for protection in total laparoscopic pancreaticoduodenectomy: a single-center experience. J Int Med Res 2023; 51:3000605231188288. [PMID: 37548354 PMCID: PMC10408334 DOI: 10.1177/03000605231188288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/29/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Hemorrhage from the stump of the gastroduodenal artery (GDA) is a significant postoperative risk with pancreaticoduodenectomy (PD). Studies have shown that wrapping the GDA stump using the omentum or the falciform ligament can help prevent bleeding. We aimed to determine whether wrapping the GDA stump with the ligamentum teres hepatis (LTH) would reduce postoperative PD hemorrhage. METHODS We retrospectively reviewed data for 148 patients who underwent laparoscopic pancreatoduodenectomy (LPD) at our hospital from November 2015 to September 2021. We compared perioperative data from 63 LPD patients without wrapping of the GDA (unwrapped group) and 85 whose GDA stumps were wrapped (wrapped group). RESULTS There were no significant differences in the groups' baseline characteristics. The postoperative GDA stump bleeding incidence was significantly lower in the wrapped group than that in the unwrapped group (7.9% vs. 0, respectively). There was also no significant difference in the incidence of other complications (intra-abdominal infection, postoperative pancreatic fistula (POPF), biliary fistula, and gastrointestinal bleeding). CONCLUSION Using the LTH to wrap the GDA stump during LPD can reduce bleeding from the GDA stump but not the incidence of other complications.
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Affiliation(s)
- Zongdong Yu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
- Health Science Center, Ningbo University, , Ningbo, China
| | - Xiang Wu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
- Health Science Center, Ningbo University, , Ningbo, China
| | - Xinhua Zhou
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Xiaodong Hu
- Health Science Center, Ningbo University, , Ningbo, China
| | - Jun Lu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shenzhe Fang
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
- Health Science Center, Ningbo University, , Ningbo, China
| | - Luoluo Wang
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Yi Ruan
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Yeting Lu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
| | - Hong Li
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Li Huili Hospital, Ningbo University, Ningbo, China
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Liu T, Saber A. Utility of Falciform Ligament in Abdominal Surgery: A Systematic Review. Am Surg 2023; 89:2705-2712. [PMID: 36444692 DOI: 10.1177/00031348221142577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE The aim of the present systematic review was to assess current trends in use of falciform ligament in abdominal surgery. BACKGROUND The falciform ligament has been proposed in surgical literature as a suitable pedicle or flap with acceptable surgical outcomes; however, it is underutilized in abdominal surgery. METHODS We performed a literature search and meta-analysis. All English studies describing use of a falciform ligament were eligible for inclusion. RESULTS Of the 547 articles mentioning use of falciform ligament, 32 full text articles were included in this review. The majority were case reports (n = 14). The mremaining papers included retrospective analysis (n = 10), randomized control trials (n = 2), reviews (n = 3), and technique descriptions (n = 6). CONCLUSION The falciform ligament appears to be a safe and easily accessible natural tissue with a variety of surgical applications. It is most useful as a pedicle flap and could have benefit in foregut surgery including hepatic, pancreatic, biliary, gastric, and esophageal operations.
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Affiliation(s)
- Tom Liu
- Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA
| | - Alan Saber
- Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA
- Department of Surgery, Newark Beth Israel Medical Center, Newark, NJ, USA
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Teres ligamentum wrap covering the pancreaticojejunostomy following pancreatoduodenectomy is associated with a lower rate of postoperative pancreas fistula: a prospective cohort study. HPB (Oxford) 2023; 25:116-123. [PMID: 36280427 DOI: 10.1016/j.hpb.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/26/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreas fistula (POPF) is a common complication after pancreatoduodenectomy (PD). A Teres Ligamentum (TL)-wrap covering the pancreaticojejunostomy (PJ) is suggested as a potential solution to reduce POPF. The aim of this study was to compare POPF incidence (grade B/C) in patients with or without a TL-wrap. METHODS A prospective cohort study was performed between January 2019-December 2021. All consecutive patients were included. Patient, tumor and surgical characteristics and postoperative complications were compared in both open and robot-assisted surgery. RESULTS A total of 118 consecutive patients were included. The first 57 patients were treated without and the following 61 patients with a TL-wrap. There were no statistically significant differences between both groups regarding patient, pre-operative treatment and surgical characteristics. The occurrence of POPF was strongly reduced in the TL-wrap group compared to patients without a TL-wrap (3.3% vs 28.1%, P < 0.001). Also mean length of hospital stay was reduced (11.5 vs 18.8 days, P = 0.030). CONCLUSION The use of a TL-wrap covering the PJ as addition to the modified Blumgart anastomosis technique is associated with a significantly reduced POPF rate and a reduced length of hospital stay. A TL-wrap is a simple addition to a PJ that may be considered to improve postoperative outcome. This association must be studied more definitively in a randomized controlled trial.
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Chung JH, Choi CW, Kim SJ, Hwang SH, Lee SH. Application of the Falciform Ligament Patch for the Prevention of Duodenal Stump Leakage After Gastrectomy: Technical Report on a Case Series. J Laparoendosc Adv Surg Tech A 2022; 33:447-451. [PMID: 36459622 DOI: 10.1089/lap.2022.0454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Duodenal stump leakage (DSL) is a serious complication after gastrectomy. In this study, we developed a novel prevention technique using a falciform ligament patch (FLP) to prevent DSL among high-risk patients after gastrectomy. Materials and Methods: From January 2019 to July 2021, 14 patients who were judged to be at high risk for DSL during preoperative examinations or surgery were included in this retrospective study, and the FLP was applied to the duodenal stump. The falciform ligament was separated from the liver after duodenal transection during gastrectomy; the end part was used to cover the duodenal stump and was fixed using nonabsorbable polypropylene sutures. Results: In total, 14 patients who underwent FLP had one or two risk factors that were identified: 5 patients, gastric cancer duodenal invasion; 4 patients, gastric outlet obstruction (GOO); 1 patient, cancer involving the distal resection margin; 1 patient, duodenal gastrointestinal stromal tumor involving the distal resection margin; 1 patient, gastric cancer duodenal invasion and GOO; and 2 patients, cancer involving the distal resection margin and GOO. FLP construction was successful, and no patient developed complications of DSL. The average hospital stay was 11.9 days, and the patients were discharged without any morbidities after surgery. Conclusions: Therefore, the FLP can be used to prevent DSL among high-risk patients after gastrectomy.
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Affiliation(s)
- Jae Hun Chung
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Sun-Hwi Hwang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Si-Hak Lee
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
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Nour HM, Peristeri DV, Ahsan A, Shafique S, Khan PM, Sajid MS. Regional vessels wrapping following pancreaticoduodenectomy reduces the risk of post-operative extra-luminal bleeding. A systematic review. Ann Med Surg (Lond) 2022; 82:104618. [PMID: 36268446 PMCID: PMC9577535 DOI: 10.1016/j.amsu.2022.104618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background Post-pancreatectomy bleeding is a potentially fatal complication which results from the erosion of the regional visceral arteries, mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether wrapping of regional vessels with omentum or falciform/teres ligament following pancreaticoduodenectomy reduces the risk of extra-luminal bleeding. Materials and method Standard medical electronic databases were searched with the help of a local librarian and relevant published randomised controlled trials (RCT) and any type of comparative trial were shortlisted according to the inclusion criteria. The summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software. Result Two RCTs and 5 retrospective studies on 4100 patients undergoing pancreaticoduodenectomy were found suitable for this meta-analysis. There were 1404 patients in the wrapping-group (WG) and 2696 patients in the no-wrapping group (NWG). In the random effects model analysis, the incidence of extra-luminal haemorrhage was statistically lower in WG [odds ratio 0.51, 95%, CI (0.31, 0.85), Z = 2.59, P = 0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant. Conclusion The wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres) following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting a greater number of patients are required to validate these findings as this study presents the combined data of two RCTs and 5 retrospective studies. Post pancreaticoduodenectomy haemorrhage can be mortality and morbidity increasing complication. The aim is to assess the effectiveness of regional vessels wrapping in decreasing post operative bleeding. Two RCTs and five retrospective studies were used to obtain the submitted data. Regional vessels wrapping was associated with reduced bleeding post pancreaticoduodenectomy.
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Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery. Curr Oncol 2022; 29:2472-2482. [PMID: 35448175 PMCID: PMC9025466 DOI: 10.3390/curroncol29040201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: To report and compare the results of endovascular and open surgical treatment for erosion bleeding of visceral arteries following pancreatitis and pancreatic surgery. Materials and Methods: This retrospective study included 65 consecutive patients (46 males, mean age 63 ± 14 years) presenting with visceral artery erosions between January 2011 and December 2020. Endpoints were technical success, freedom from reintervention, stent-graft-related complications, and 30-day and one-year mortality. Results: The causes of erosion bleeding included complications of surgical treatment for the pancreas and upper gastrointestinal tract (75%), pancreatitis (19%), and spontaneous bleeding (6%). Pancreatectomy was performed in 34 (52%) patients, representing 2% of all pancreatectomy procedures (n = 1645) performed in our hospital during the study period. A total of 37 (57%) patients underwent endovascular treatment (EVT), and 28 (43%) patients had open surgery (OS) as a primary treatment. Eight of 37 (22%) patients in the EVT group underwent stent-graft treatment of the eroded vessels and 28 (78%) coil embolization. Six (9%) patients underwent reintervention with no significant differences between EVT and OS groups (11% vs. 7%, p = 0.692). Postoperative morbidity and complications in 52% of all patients were higher in the OS group than in the EVT group (41% vs. 68%, p = 0.029). The in-hospital 30-days mortality rate for all patients was 25%, and it was higher in the OS group than in the EVT group (14% vs. 39%, p = 0.017). Conclusions: An endovascular-first strategy for treating visceral arteries erosions may be preferred to reduce the complications associated with open surgery if patients are hemodynamically stable and have no anastomotic insufficiency. Endovascular treatment may be associated with better in-hospital survival when compared to primary open surgery. Further studies are required to identify the optimal approach.
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Ausania F, Martínez-Pérez A, Senra Del Rio P, Borin A, Melendez R, Casal-Nuñez JE. Multifactorial mitigation strategy to reduce clinically relevant pancreatic fistula in high-risk pancreatojejunostomy following pancreaticoduodenectomy. Pancreatology 2021; 21:466-472. [PMID: 33454209 DOI: 10.1016/j.pan.2020.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/06/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) is the most dreadful complication of pancreaticoduodenectomy (PD) and previous literature focused on technical modifications of pancreatic remnant reconstruction. We developed a multifactorial mitigation strategy (MS) and the aim of the study is to assess its clinical impact in patients at high-risk of POPF. METHODS All patients candidate to PD between 2012 and 2018 were considered. Only patients with a high Fistula Risk Score (FRS 7-10) were included. Patients undergoing MS were compared to patients receiving Standard Strategy (SS). Clinical outcomes were compared between the two groups. Multivariate hierarchical logistic regression analyses were performed to detect independent predictors of POPF. RESULTS Out of 212 patients, 33 were finally included in MS Group and 29 in SS Group. POPF rate was significantly lower in MS Group (12.1% vs 44.8%, p = 0.005). Delayed gastric emptying, postoperative pancreatitis, complications and hospital stay were also significantly lower in MS Group. Hierarchical logistic regression analyses showed that Body Mass Index (OR = 1.196, p = 0.036) and MS (OR = 0.187, p = 0.032) were independently associated with POPF. CONCLUSION A multifactorial MS can be helpful to reduce POPF rate in patients with high FRS following PD. Personalized approach for vulnerable patients should be investigated in the future.
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Affiliation(s)
- Fabio Ausania
- HPB Surgery Unit, Department of General Surgery, Complejo Hospitalario Universitario de Vigo, Spain; HPB and Transplant Surgery, Department of General and Digestive Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Aleix Martínez-Pérez
- Minimally Invasive and Robotic Digestive Surgery Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Paula Senra Del Rio
- HPB Surgery Unit, Department of General Surgery, Complejo Hospitalario Universitario de Vigo, Spain
| | - Alex Borin
- HPB and Transplant Surgery, Department of General and Digestive Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain.
| | - Reyes Melendez
- HPB Surgery Unit, Department of General Surgery, Complejo Hospitalario Universitario de Vigo, Spain
| | - Josè Enrique Casal-Nuñez
- HPB Surgery Unit, Department of General Surgery, Complejo Hospitalario Universitario de Vigo, Spain
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Andreasi V, Partelli S, Crippa S, Balzano G, Tamburrino D, Muffatti F, Belfiori G, Cirocchi R, Falconi M. A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy. HPB (Oxford) 2020; 22:1227-1239. [PMID: 32631806 DOI: 10.1016/j.hpb.2020.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD. METHODS Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals. RESULTS Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620). DISCUSSION Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Cirocchi
- Department of General Surgery and Surgical Oncology, University of Perugia, Hospital of Terni, Terni, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Takahashi Y, Kobayashi A, Seki H. Successful use of ligamentum teres hepatis for perforated duodenal ulcer following omentectomy: a case report. J Surg Case Rep 2020; 2020:rjaa196. [PMID: 32760488 PMCID: PMC7394140 DOI: 10.1093/jscr/rjaa196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 12/25/2022] Open
Abstract
Our patient was a 59-year-old woman with past history of hysterectomy, bilateral salpingo-oophorectomy, regional lymphadenectomy and omentectomy performed for advanced ovarian cancer. She was experiencing abdominal pain over the past 2 days and visited our hospital owing to pain exacerbation. Contrast-enhanced computed tomography revealed free air around the liver, ascites and duodenal perforation; thus, emergent abdominal surgery was performed. The 5-mm duodenal perforation at the anterior wall of the duodenal bulb was sutured with absorbable thread. We used ligamentum teres hepatis (LTH) as a patch for the sutured site as the greater omentum could not be used. The postoperative course was uneventful, and she was discharged on postoperative Day 8. There were no complications 1 month after surgery. Although the greater omentum is conventionally used for upper gastrointestinal perforation, the LTH was a plausible alternative with good indication in our case.
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Affiliation(s)
- Yusuke Takahashi
- Department of Digestive Surgery, Nagano Municipal Hospital, Nagano, Japan
| | - Akira Kobayashi
- Department of Digestive Surgery, Nagano Municipal Hospital, Nagano, Japan
| | - Hitoshi Seki
- Department of Digestive Surgery, Nagano Municipal Hospital, Nagano, Japan
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Flooring the Major Vessels with Falciform Ligament to Prevent Post-Pancreatectomy Hemorrhage. World J Surg 2020; 44:3478-3485. [PMID: 32533254 DOI: 10.1007/s00268-020-05637-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND One of the most severe pancreatic surgery complications is post-pancreatectomy hemorrhage (PPH). This study's aim was to evaluate the efficacy of flooring the major vessels with falciform ligament in preventing PPH after pancreatoduodenectomy (PD). METHODS This study was a retrospective review of 500 consecutive patients who underwent PD between Jan 2010 and Dec 2019 at Hiroshima University. Morbidities, including postoperative pancreatic fistula (POPF) or PPH and 90-day mortality, were analyzed. The study cohort was divided into two groups based on the time of surgery (2010-2016 and 2017-2019), i.e., before and after implementation of falciform ligament flooring method. The patient characteristics, operative parameters, clinicopathological factors, morbidity, and mortality were compared between the two periods. RESULTS Morbidity and mortality rates in the entire cohort were 21% and 1.4%, respectively. The incidence of Grade B/C POPF and PPH was 9.0% and 3.8%, respectively. There was no significant difference between the two periods with respect to Grade B/C POPF, morbidity rate, and mortality rate; however, the rate of Grade B/C PPH significantly decreased from 5.2 to 1.6% p = .027. On multivariate analysis, the absence of the falciform ligament flooring method was an independent PPH risk factor p = .003. CONCLUSIONS Falciform ligament flooring method may help decrease the incidence of PPH after PD.
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A Technical Tip of Aortic Stump Reinforcement with Plication of the Falciform Ligament of the Liver. Ann Vasc Surg 2020; 68:549-552. [PMID: 32416312 DOI: 10.1016/j.avsg.2020.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The residual stump after excision of an infected aortic graft may be subject to acute disruption-blowout-because of recurrence of infection or fatigue due to the mechanical stress. We present an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump. METHODS We excised the falciform ligament by giving attention to avoid any bleeding from the liver. The aortic stump was reinforced with synthetic, monofilament, nonabsorbable polypropylene sutures and the falciform ligament of the liver was plicated inside the stump and further sutured with polypropylene sutures. RESULTS After 5 months, he is in excellent condition. His laboratory examination is normal, he has stopped taking antibiotics, gained his initial weight, and recovered full activity. CONCLUSIONS We presented an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump after excision of an infected aortobiiliac synthetic graft. This technique can be an alternative option in patients with weak arterial wall or extended bacterial local infection in the retroperitoneal area which renders the aortic wall tissue extremely stiff to be folded and sutured. This technique may enhance the mechanical integrity of the stump.
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Müssle B, Oehme F, Schade S, Sommer M, Bogner A, Hempel S, Pochhammer J, Kahlert C, Distler M, Weitz J, Welsch T. Drain Amylase or Lipase for the Detection of POPF-Adding Evidence to an Ongoing Discussion. J Clin Med 2019; 9:jcm9010007. [PMID: 31861508 PMCID: PMC7019284 DOI: 10.3390/jcm9010007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 01/08/2023] Open
Abstract
Objectives: A postoperative pancreatic fistula (POPF) is defined as a threefold increase in the amylase concentration in abdominal drains on or after the third postoperative day (POD). However, additional lipase fluid analysis is widely used despite lacking evidence. In this study, drain amylase and lipase levels were compared regarding their value in detecting POPF. Methods: We conducted a retrospective study including all patients who underwent pancreatic resections at our center between 2005 and 2016. Drain fluid analysis was performed from day 2 to 5. Results: 990 patients were included in the analysis. Overall, 333 (34%) patients developed a POPF. The median amylase and lipase concentrations at POD 3 in cases with POPF were 11.55 µmol/(s·L) (≈13 ×-fold increase) and 39 µmol/(s·L) (≈39 ×-fold increase), respectively. Seven patients with subsequent POPF (2%) were missed with amylase analysis on POD 3, but detected using 3-fold lipase analysis. The false-positive rate of lipase was 51/424 = 12%. A cutoff lipase value at POD 3 of > 4.88 yielded a specificity of 94% and a sensitivity of 89% for development of a POPF. Increased body mass index turned out as risk factor for the development of POPF in a multivariable model. Conclusions: Threefold-elevated lipase concentration may be used as an indicator of a POPF. However, the additional detection of POPF using simultaneous lipase analysis is marginal. Therefore, assessment of lipase concentration does not provide added clinical value and only results in extra costs.
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Affiliation(s)
- Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Stephanie Schade
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Marian Sommer
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Julius Pochhammer
- Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
- Correspondence: ; Tel.: +49-(0)351-458-18283
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Desai GS, Pande PM. Gastroduodenal artery: single key for many locks. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:281-291. [PMID: 31099488 DOI: 10.1002/jhbp.636] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Gastroduodenal artery (GDA) commonly arises from common hepatic artery, a branch of celiac axis. It holds a unique anatomical position that connects the foregut and midgut due to its intimate communications with foregut and midgut arterial supply. Its numerous anatomical variations have a significant impact on planning and performance of hepatopancreaticobiliary (HPB) surgery. Its close relation to the first part of duodenum, common bile duct and head of pancreas makes it susceptible for inadvertent bleeding during or after surgery, or due to various HPB pathologies. Also, a large number of vascular interventions rely on GDA and its branches. Careful preoperative planning is the key and a detailed knowledge and awareness of its variant anatomy is of paramount importance, be it liver resections, liver transplant, biliary and pancreatic resections and pancreatic transplant or transarterial procedures involving these arteries. GDA can also be a cause of gastrointestinal hemorrhage due to true or pseudoaneurysms and anatomy has significant implications on its management. The article provides a succinct review on relevance of GDA anatomy and variations and highlights that preoperative planning and intraoperative awareness of variations is the key to performance of safe HPB surgery and interventions.
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Affiliation(s)
- Gunjan S Desai
- Department of Gastrointestinal Surgery, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
| | - Prasad M Pande
- Department of Gastrointestinal Surgery, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
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Werey F, Browet F, Mauvais F. Falciform ligament wrap during laparoscopic pancreatoduodenectomy. J Visc Surg 2018; 156:50-54. [PMID: 30497984 DOI: 10.1016/j.jviscsurg.2018.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- F Werey
- Service de chirurgie viscérale et digestive, centre hospitalier de Beauvais, avenue Léon-Blum, 40319 Beauvais cedex, France; Service de chirurgie digestive, centre hospitalier universitaire Amiens, avenue René-Laënnec, 80054 Amiens cedex 1, France
| | - F Browet
- Service de chirurgie viscérale et digestive, centre hospitalier de Beauvais, avenue Léon-Blum, 40319 Beauvais cedex, France; Service de chirurgie digestive, centre hospitalier universitaire Amiens, avenue René-Laënnec, 80054 Amiens cedex 1, France; Unité de recherche clinique simplification des soins chez les patients complexes (SSPC), université de Picardie Jules-Vernes, avenue René-Laënnec, 80054 Amiens cedex 1, France.
| | - F Mauvais
- Service de chirurgie viscérale et digestive, centre hospitalier de Beauvais, avenue Léon-Blum, 40319 Beauvais cedex, France; Service de chirurgie digestive, centre hospitalier universitaire Amiens, avenue René-Laënnec, 80054 Amiens cedex 1, France; Unité de recherche clinique simplification des soins chez les patients complexes (SSPC), université de Picardie Jules-Vernes, avenue René-Laënnec, 80054 Amiens cedex 1, France
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Zizzo M, Ugoletti L, Morini A, Manenti A, Lococo F, Pedrazzoli C. Pancreaticojejunostomy with or without reinforcement after pancreaticoduodenectomy: surgical technique of ligamentum teres hepatis wrap around pancreaticojejunostomy. World J Surg Oncol 2018; 16:181. [PMID: 30193582 PMCID: PMC6129004 DOI: 10.1186/s12957-018-1484-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/31/2018] [Indexed: 01/08/2023] Open
Abstract
In a previous issue of the Journal, Zhong et al. reported a retrospective study that compared the perioperative outcomes of the mesh-reinforced pancreaticojejunostomy with conventional pancreaticojejunostomy. They concluded that mesh-reinforced pancreaticojejunostomy was a safe and effective technique, as it provided a safe anchor site for suture, thus reducing the risk of pancreatic leakage. Considering these encouraging results, we present a further simple technique using ligamentum teres hepatis wrap around pancreatojejunostomy for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy.
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Affiliation(s)
- Maurizio Zizzo
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy. .,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Lara Ugoletti
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Andrea Morini
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Antonio Manenti
- Department of General Surgery, University of Modena and Reggio Emilia - Polyclinic, 41124, Modena, Italy
| | - Filippo Lococo
- Department of Oncology and Advanced Technologies, Thoracic Surgery Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Claudio Pedrazzoli
- Department of Oncology and Advanced Technologies, Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
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