Hand-sewn Suture Research Articles

CLEAN-NET: a modified laparoendoscopic wedge resection of the stomach to minimize the sacrifice of innocent gastric wall.

To avoid excessive sacrifice of the tissue surrounding the submucosal tumor in gastric wedge resection with a stapling device, we perform a "combined laparoscopic and endoscopic approach for neoplasia with a nonexposure technique" (CLEAN-NET). Herein the operative technique of CLEAN-NET is described and its short-term outcomes in 50 patients are evaluated. Between December 2015 and July 2017 CLEAN-NET was performed in 50 patients with gastric submucosal tumors. During the operation, the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. When seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. The mucosa is then transected with a stapling device to execute full-thickness resection of the specimen. Finally, the seromuscular defect is repaired by hand-sewn suture. The hospital records of the 50 patients were reviewed to assess the outcomes. The margin width was compared with those measured in another group with 19 patients, who underwent conventional wedge resection with a stapling device. The operation was completed as CLEAN-NET and the tumor was resected en-bloc without rupture in all patients. The average operation time ranged from 50 to 220min with an average of 105.4min. The post-operative course was uneventful. Microscopically the surgical margin was tumor-negative (R0 resection) in all cases. The margin width in the CLEAN-NET group was smaller than that in the wedge resection group (5.4mm ± 2.5 vs. 33.1mm ± 14.7). CLEAN-NET can be performed safely with an acceptable operation time. CLEAN-NET can be a useful option in the laparoscopic surgical treatment of gastric submucosal tumors, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided.

Is there any different risk factor for clinical relevant pancreatic fistula according to the stump closure method following left side pancreatectomy?

Background: No consistent risk factor for PF after LP according to the stump closure methods had not been revealed yet. This study investigated risk factor for PF according to the closure methods during LP. Methods: The risk factors of pancreatic fistulas were investigated in 49 underwent LPs according stump closure: hand-sewn suture (n = 19), and stapler closure (n = 30). The risk factors for PF after LP with a stapler and hand sewn were identified based on univariate and multivariate analyses. Results: There was no significant difference in the incidence of POPF between the two types of stump closure (hand-sewn suture 42.1% vs stapler closure 50.0%), CR-POPF was not different in 5.3% HS than ST 6.7% also. In ST, the pancreas was significantly thicker at the transection line in patients with CR-POPF (27 mm) in comparison to patients without CR-POPF (17 mm) and tumor were larger (58 mm vs 27 mm). In HS, longer operation time was observed in CR-POPF group (515 min vs 292 min). Wider pancreatic duct (27 mm vs 16 mm) were associated with postoperative POPF in a univariate analysis in HS. There was no difference of risk factor for POPF in ST. Conclusions: Although near the half of patients experienced POFP after LP, almost POPF were clinically insignificant in this study. Thicker pancreas and larger tumor significantly associated with the incidence of CR-POPF after LP using stapler closure and longer operation time associated with CR-POPF in hand sewn closure.

Application of inner figure-of-eight suture to laparoscopic colorectal surgery

Regardless of laparoscopic or open colorectal surgeries, intestinal anastomosis is usually an important operative procedure. Even if stapler is widely used in different intestinal surgery nowadays, hand sewn suture is an indispensable procedure in clinical practice, meanwhile after stapled anastomosis, additional hand sewn suture is usually performed to ensure the safety of anastomosis. The inner figure-of-eight suture is a single layer suture technique which has been widely used in skin, tendon, rectus and uterus for quick and secure approximation. We describe our innovative application of inner figure-of-eight suture technique for intestinal anastomosis and/or reinforcement after stapled anastomosis in laparoscopic colorectal surgery. Main steps of inner figure-of-eight suture for intestinal anastomosis on posterior wall are as follows: (1) At 4 mm from cut edge of bowel, needle enters vertically from one side and courses mucosa-serosa-opposite serosa-mucosa in parallel to the entry point. (2) The needle is brought back to first entry side of bowel at 45 degree to enter the mucosa 5 mm below the first entry point and out on opposite side mucosa horizontally. (3) Both lose ends of the suture are pulled to approximate bowel edges and knots are tied on mucosal surface, in which suture line presents figure-of-eight on mucosal surface and two parallel suture lines are seen on serosal surface. When inner figure-of-eight suture is performed on anterior wall, the procedure is similar, but needle passes from serosa-mucosa-opposite mucosa-serosa and repeated to complete the inner figure-8 suture and knots are tied on serosa. The final look is two parallel sutures at 0.5 mm in between and the figure-of-eight remains inside the lumen. We did not deliberately try to invert the bowel edges, and if anastomosis is not satisfactory at final examination, simple interrupted seromuscular suture can be carried out. From 2015 till now, we have successfully completed inner figure-of-eight sutures in 38 cases receiving intestinal anastomosis reinforcement procedure and in 24 cases receiving hand sewn anastomosis. Comparison study revealed inner figure-of-eight suture presented shorter anastomotic time and less medical cost without anastomotic leakage, stump leakage or bleeding. No anastomotic stenosis was found at enteroscopy examination during follow up. We think that inner figure-of-eight suture possesses safe and simple advantages and is a manual suture technique worthy of promotion.

Single Anastomosis Duodeno-Ileal Switch (SADIS): A Systematic Review of Efficacy and Safety.

Owing to the possibility of weight regain after the long-term follow-up of gastric bypass patients and because of the high morbidity of biliopancreatic diversion with duodenal switch, single-anastomosis duodeno-ileal switch (SADIS) has emerged as a rescue procedure in bariatric surgery. The purpose of this review is to summarize the literature data on SADIS. University Hospital, NY. A comprehensive literature review was performed through October 2016 to identify English studies on SADIS performed in human subjects. Outcomes of interest were technical considerations, postoperative complications, weight loss outcome, comorbidity resolution rate, and nutritional deficiency after SADIS. A total of 12 studies including 581 SADIS patients (217 males and 364 females) were included. SADIS was a primary procedure in 508 patients (87.4%) and a conversion procedure in 73 patients (12.6%). The length of common limb was 300cm in 54.2%, 250cm in 23%, and 200cm in 13.4% of patients. Anastomosis technique was a linear stapler in 26.7% and a hand sewn suture technique in 73.3% of patients. Diarrhea was the most common complication (1.2%). The average %EWL was 30% at 3months, 55% at 6months, 70% at 1year, and 85% at 2years. Co-morbidity resolution rate was 74.1% for type 2 diabetes mellitus, 96.3% for hypertension, 68.3% for dyslipidemia, 63.3% for obstructive sleep apnea, and 87.5% for GERD. Overall, vitamin A, selenium, and iron deficiency were the most common nutritional deficiencies with the possibility of the protein malnutrition in up to 34% of the patients when measured. As a modified bariatric procedure, SADIS has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients. When measured, there was a high prevalence of macro-nutrient deficiencies following SADIS. There is a high technical variability, and long-term data are required before any meaningful conclusion can be made.

Biomechanical characterization of a novel ring connector for sutureless aortic anastomosis.

The surgical treatment for aortic diseases remains a challenge for any cardiac surgeon. The use of sutureless ring connector in aortic anastomosis can simplify the procedure and shorten anastomosis time. Therefore, we developed a novel device for sutureless aortic anastomosis. A series of experiments were carried out for tensile and leakproof-capacity assessments to verify the feasibility of the ring connector by using fresh swine aorta samples. In in vivo test, the ring connector was implanted in 6 swine with follow-up of 6 months. Radiographic and pathological studies of the aorta were performed. In the tensile tests, the strength was 32.7±5.9 Newton (N) in the sutureless anastomosis group, compared with 73.3±12.5 N in the control group by traditional manual suture. In the leakproof-capacity assessment, no sign of either leakage or bursting was evident at 280 mmHg of internal pressure in the aorta samples. In in vivo tests, it took 9.47±0.3 minutes for the sutureless anastomosis, compared with 15.58±1.39 minutes for hand-sewn suturing. Insertion was easy and rapid. Radiographic and pathological studies were performed at first month, third month and sixth month after surgery, each time obtained from the two swine, showed patency of the anastomosis and no signs of stenosis, blood leakage, migration or pseudoaneurysm formation, except one paralyzed swine developed of thrombo-occlusion at the site of the sutureless anastomosis. The result indicates that this novel ring connector offers considerable promise for sutureless aortic anastomosis.

Our experience with laparoscopic partial gastrectomy by the 'lift-and-cut method' for gastric gastrointestinal stromal tumor with maximal preservation of the remnant stomach.

Wedge resection is the most commonly used method in laparoscopic partial gastrectomy for gastric gastrointestinal stromal tumor (GIST). However, this method can involve inadvertent resection of additional gastric tissue and cause gastric deformation. To minimize the volume of resected gastric tissue, we have developed a laparoscopic partial gastrectomy with seromyotomy which we call the 'lift-and-cut method' for gastric GIST. Here, we report a case series of this surgery. First, the seromuscular layer around the tumor is cut. Because the mucosa and submucosa are extensible, the tumor is lifted toward the abdominal cavity. After sufficient lifting, the gastric tissue under the tumor is cut at the submucosal layer with a linear stapler (thus 'lift-and-cut method'). Finally, the defect in the seromuscular layer is closed with a hand-sewn suture. From April 2011 to December 2015, 28 patients underwent laparoscopic partial gastrectomy by this method at Osaka Red Cross Hospital. Average operation time was 126min (range 65-302min) and average blood loss was 10ml (range 0-200ml). No intraoperative complications including tumor rupture or postoperative complications regarded as Clavien-Dindo Grade II or higher occurred. All patients took sufficient solid diet at discharge. Median postoperative hospital stay was 7days (range 5-21days). On median follow-up of 26.6months (range 6-54months), no recurrence was reported. Laparoscopic partial gastrectomy by the lift-and-cut method is safe and simple, and widely applicable for gastric GIST.

The Use of a Mechanical Stapler in Jejunal Free Flaps in Laryngopharyngectomy Defects.

The Use of a Mechanical Stapler in Jejunal Free Flaps in Laryngopharyngectomy Defects.

A5266 - A Prospective Randomized Controlled Trial in Laparoscopic Sleeve Gastrectomy (LSG): Buttressing versus Hand-sewn suturing in staple line reinforcement

A5266 - A Prospective Randomized Controlled Trial in Laparoscopic Sleeve Gastrectomy (LSG): Buttressing versus Hand-sewn suturing in staple line reinforcement

Economic Comparison of Hand-Sutured and Coupler-Assisted Microvascular Anastomoses

Background Compared with hand-sewn anastomoses, microvascular anastomotic coupling devices (MACDs) provide equivalent flap survival and reduced operative time. To date, an economic analysis of MACDs has not been reported. The objective of this study was to evaluate the economics of a venous anastomosis performed using a coupling device compared with a hand-sewn anastomosis. Methods Economics were modeled for a single free tissue transfer (FTT) requiring one venous anastomosis performed with either hand-sewn sutures or with a coupler-assisted anastomosis using the GEM COUPLER. Fixed and variable costs incurred with each anastomotic technique were identified with an activity-based cost analysis. Price lists were retrieved from suppliers to quantify disposable costs and capital expenditures. Two literature reviews were executed to identify microsurgical operating room (OR) costs and operating time reductions with coupler-assisted anastomoses. Results For each venous anastomosis, the use of the anastomotic coupler increased disposable costs by $284.40 compared with a hand-sutured anastomosis. Total fixed and variable OR costs were $30.82 per minute. Operating time was reduced by a mean of 16.9 minutes with a coupler-assisted anastomosis, decreasing OR costs by $519.29. Total savings of $234.89 were generated for each coupler-assisted anastomosis, recuperating the device's capital expenditure after 13 uses. Conclusion Compared with a hand-sewn venous anastomosis, an MACD produces savings with each case and quickly recoups the device's capital expenditure. Despite its limitations and simplicity, this study provides a practical economic analysis that can help inform purchasing decisions, particularly for smaller volume centers where the economic rationale may be less clear.

Intussusception causing postoperative intestinal obstruction following free jejunum transfer in adults: two case reports and review of the literature.

Intussusception is a rare cause of postoperative intestinal obstruction in adults. We experienced two cases of bowel obstruction due to the jejuno-jejunal intussusception after harvest of a free jejunum graft for reconstruction after cervical esophagectomy. Bowel obstruction occurred early in the postoperative course, and reoperations were needed in both cases. In both case, the anastomotic site was resected and re-anastomosed in a side-to-side fashion. Recurrence of intussusception has not been observed. In the literature, such a complication has been documented in two case series and a case report. The reported incidence of postoperative intussusception of the case series was 2.8% and 7.4%, respectively. The jejuno-jejunal anastomoses were performed with end-to-end fashion by two layered hand-sewn suture (Albert-Lembert method) in all cases reported. In order to prevent the occurrence of postoperative intussusception, we recommend to harvest a free jejunal graft as far from the Treitz ligament as possible and to avoid reconstruction by an Albert-Lembert end-to-end anastomosis.

An Assessment of the Clinical and Economic Impact of Establishing Ileocolic Anastomoses in Right-Colon Resection Surgeries Using Mechanical Staplers Compared to Hand-Sewn Technique.

Purpose. To estimate and compare clinical outcomes and costs associated with mechanical stapling versus hand-sewn sutured technique in creation of ileocolic anastomoses after right sided colon surgery. Methods. A previously conducted meta-analysis was updated for estimates of anastomotic leak rates and other clinical outcomes. A value analysis model was developed to estimate cost savings due to improved outcomes in a hypothetical cohort of 100 patients who underwent right colon surgery involving either mechanical stapling or hand-sewn anastomoses. Cost data were obtained from publicly available literature. Results. Findings from the updated meta-analysis reported that the mechanical stapling group had lower anastomotic leaks 2.4% (n = 11/457) compared to the hand-sewn group 6.1% leaks (n = 44/715). Utilizing this data, the value analysis model estimated total potential cost savings for a hospital to be around $1,130,656 for the 100-patient cohort using mechanical stapling instead of hand-sewn suturing, after accounting for incremental supplies cost of $49,400. These savings were attributed to lower index surgery costs, reduced OR time costs, and reduced reoperation costs driven by lower anastomotic leak rates associated with mechanical stapling. Conclusion. Mechanical stapling can be considered as a clinically and economically favorable option compared to suturing for establishing anastomoses in patients undergoing right colon surgery.

PCN1 - Meta-Analysis of Anastomotic Leak Rates Following Hand-Sewn Suture Versus Stapled Anastomoses During Right Colon Surgery

PCN1 - Meta-Analysis of Anastomotic Leak Rates Following Hand-Sewn Suture Versus Stapled Anastomoses During Right Colon Surgery

Comparison of endoscopic band ligation and endoclip closure of colonic perforation: Technical feasibility and efficacy in an ex vivo pig model

Recent reports have indicated several instances of successful treatment of bowel perforation by using endoscopic band ligation (EBL) when treatment with endoclipping is unsuccessful, but this salvage method has not been investigated in any prospective model. Herein we aimed to compare the technical feasibility and efficacy of EBL and endoclip use in intraluminal closure of colon perforation, in an ex vivo model. Standardized colonic perforations were created using fresh porcine colon and subsequently closed by full-thickness interrupted sutures, endoclip (QuickClip2(TM)), or EBL. Each closure site was tested with compressed air by using a digital pressure monitor for evaluating leak pressure. No significant differences were noted between the endoclip and EBL in leak pressures. Mean (± SD) pressures for air leakage from the perforations closed using the different devices were as follows: normal colon samples, 52.0 ± 13.2 mmHg; perforations closed with hand-sewn sutures, 32.3 ± 8.3 mmHg; perforations closed with endoclipping, 53.5 ± 22.7 mmHg; and perforations closed with EBL, 50.4 ± 12.5 mmHg. Time taken for closure by EBL was significantly less than that for closure by endoclipping (3.2 ± 1.7 min vs 6.8 ± 1.3 min, P < 0.01). Further, the number of devices used to achieve complete closure in the EBL group was lower than that with endoclipping (1.6 ± 0.5 vs 3.7 ± 0.8, P < 0.01). Endoluminal closure of a 1.5-cm colon perforation with EBL decreased procedure time and was not inferior in leak pressure compared with endoclipping in this ex vivo porcine model.

Comparison of hand-sewn and stapled anastomoses in surgeries of gastrointestinal tumors based on clinical practice of China

BackgroundThere is a lack of studies comparing stapled suturing and hand-sewn suturing in the surgeries of gastrointestinal tumors based on the clinical practice of Chinese surgeons.MethodsData were retrospectively collected from 499 patients who underwent surgery to remove gastrointestinal tumors from January 2008 to December 2009. The patients were divided into two groups according to the method of digestive tract reconstruction: 296 patients received stapled suturing and 203 patients received hand-sewn suturing. The operation time, postoperative hospital stay, postoperative recovery and complications of the patients were evaluated and compared between the two groups.ResultsThe stapling procedure took shorter operative time compared to the hand-sewn procedure for gastric carcinoma, colorectal cancer and esophageal carcinoma (P < 0.05). There was no significant difference between the two groups in postoperative hospital stay (P > 0.05). Patients receiving stapled suturing also showed shorter recovery for gastric cancer, colorectal cancer, and shorter time to recovery of normal gastrocolorectal motility compared with patients in the hand-sewn group (P < 0.05). However, there was no difference between the two groups in terms of normal time to commencing liquid diet for esophageal cancer patients (P > 0.05). We also found that the stapled procedure showed a lower incidence of anastomotic leakage, anastomotic hemorrhage and stump leakage in treating colorectal cancer or gastric carcinoma compared with the hand-sewn procedure (P < 0.05).ConclusionsApplication of the stapler in treating gastrointestinal tumors demonstrated better effects on patients in terms of surgical operation time, recovery time to normal functions, and occurrence of complications compared to hand-sewn anastomosis, especially in gastric carcinoma and colorectal cancer.

Feasibility of pure EFTR using an innovative new endoscopic suturing device: the Double-arm-bar Suturing System (with video)

Endoscopic full-thickness resection (EFTR) requires a reliable full-thickness suturing device and an endoscopic counter-traction device to prevent the collapse of the digestive tract. The present study aimed to assess the reliability of newly developed flexible endoscopy suturing devices and the feasibility of pure EFTR. A total of 30 EFTRs were performed and allocated to three groups (N=10 for each group). The full-thickness sutures were placed using over-the-scope clips (OTSCs), hand-sewn sutures, or the Double-arm-bar Suturing System (DBSS). Air leak tests were conducted in the three groups. The times required for the placement of one OTSC suture and single-stitch simple interrupted sutures (hand-sewn and DBSS sutures, respectively) were also compared. All 30 full-thickness sutures were completely and successfully placed. Regarding the air leak tests, the Mann-Whitney U test showed significant differences between OTSC and hand-sewn sutures (p=0.003). There was also a significant difference between OTSC and DBSS sutures (p=0.023). There was no significant difference between hand-sewn and DBSS sutures (p=0.542). A significant difference was found in the suture time for single-stitch simple interrupted sutures among the OTSC, hand-sewn, and DBSS sutures. The Mann-Whitney U test revealed a significant difference between OTSC and hand-sewn sutures (p=0.0001). There was no significant difference between OTSC and DBSS sutures (p=0.533), while a significant difference was found between hand-sewn and DBSS sutures (p=0.0001). Pure EFTR is feasible if the mechanical counter traction system is used to expand a small operative field and DBSS is used to make full-thickness sutures. The high safety of full-thickness resection and full-thickness suturing allows for clinical applications of this method.

Double layer versus Single layer Gastro-intestinal anastomosis in gastric cancer surgery in Mymensingh Medical College Hospital

Introduction: In gastric cancer surgery, gastrojejunostomy is one of the most important procedures. Anastomosis between different parts of the stomach and the intestine is a basic technical component in all gastrointestinal procedure. Backgrounds and aims: This study evaluated complications of gastrojejunostomy in gastric cancer surgery with two methods: single-layer and double-layer anastomosis. Materials and methods: This study was carried out in the department of surgery in Mymensingh Medical College Hospital from January 1, 2009 to December 31, 2012. 100 patients with carcinoma stomach who needed gastrojejunostomy were included in this study. These patients with average age of 43.22 years were divided in two groups (50 in each group); single-layer and double-layer anastomosis. In single-layer anastomosis gastrojejunostomy was performed in interrupted method with absorbable suture (2/0 vicryl). Double-layer anastomosis was carried out with continuous suture (2/0 silk, 2/0 catgut). Possible post-operative complications like anastomotic leakage, pelvic abscess, abdominal sepsis, anastomotic stenosis and wound infection were evaluated. Results: In the single-layer group, 4 patients (8%) developed anastomotic leakage, wound infection and only 2 patients (4%) developed abdominal sepsis, pelvic abscess and anastomotic bleeding. No patient developed anastomotic stricture. In double-layer group, 2 (4%) patients developed anastomotic leakage, only 1 (2%) patient had pelvic abscess, abdominal sepsis and anastomotic bleeding but wound infection in 2 (4%) patients. Conclusion: Gastrojejunostomy with single-layer hand-sewn suture technique is safe without serious complications in comparison to double-layer suture technique. More-over operation time is less and cost is less in single-layer method.DOI: http://dx.doi.org/10.3329/cbmj.v2i2.16695 Community Based Medical Journal 2013 July: Vol.02 No 02: 30-34

Single-port laparoscopic total mesorectal excision with transanal resection (transabdominal transanal resection) for low rectal cancer: Initial experience with 22 cases

BackgroundTotal mesorectal excisions (TME) with transanal resection and coloanal anastomosis (CAA) represent one of the standard surgical treatments for low rectal cancers. We report our initial experiences with trans-abdominal trans-anal resections (TATAR) with TME, performed using a single-port laparoscopic surgeries (SPLS) approach for low rectal cancers. MethodsBetween June 2009 and April 2011, 22 low rectal cancer patients underwent SPLS TATAR with TME. SPLS was performed transumbilically or through predetermined stoma sites. Conventional laparoscopic instruments were used, and the intracorporeal procedures and range of operation did not differ. After a full laparoscopic TME to the pelvic floor muscles, the specimen was pulled through the anus. CAA was completed with transanal hand sewn sutures. Patient and tumor characteristics and operative, pathologic, and postoperative outcomes were studied. ResultsSPLS TATAR with TME was successful in all patients. No additional incisions for trocars or conversions to open surgery were performed. The median incision length, operative time, and postoperative length of stay were 2.0 cm (range: 1.5–2.5), 260 min (range: 190–380), and 6 days (range: 4–16), respectively. The median number of harvested lymph nodes was 22 (range: 9–42). The median distal margin from the tumor was 2.0 cm (range: 0.3–4.0). No intraoperative complications were noted. ConclusionsSPLS TATAR with TME was safe and feasible. In addition to cosmetic advantages, oncologic requirements for specimens, including adequate margins and sufficient lymph node harvesting could be fulfilled entirely. However, the technique and oncologic safety warrant further evaluation and prospective randomized studies.

New flexible endoscopic full-thickness suturing device: a triple-arm-bar suturing system

A reliable full-thickness suturing device is necessary for pure natural orifice transluminal endoscopic surgery (NOTES). The present study focused on assessing the reliability of a new suturing device. A total of 60 single sutures were tested to close 5-cm incisions in 8-cm square pieces of resected swine stomach. Each incision was sutured by an over-the-scope clip (OTSC; n = 20), a single hand-sewn stitch (n = 20), or a single triple-arm-bar suturing system (TBSS) stitch. The maximum pulling force durability (MPD) of each suture was tested. To assess the reliability of the TBSS for endoscopic full-thickness resection (EFTR), 60 EFTRs of 50 mm diameter were performed on excised swine stomachs. After EFTR, full-thickness sutures were made using 3-stitch OTSCs (n = 20), 10-stitch hand-sewn sutures (n = 20), or 10-stitch TBSS sutures (n = 20). Outcomes were the MPD test for both single stitch and multiple stitch applications and the suturing time for single-stitch sutures. In the single-stitch MPD tests, there were significant differences between OTSCs and hand-sewn sutures (P = 0.0002) and between OTSCs and TBSS sutures (P = 0.0001), but no significant difference between hand-sewn and TBSS sutures. The multiple-stitch sutures revealed significant differences between OTSCs and hand-sewn sutures (P = 0.0039), and between OTSCs and TBSS sutures (P = 0.013). There was no significant difference between hand-sewn and TBSS sutures. There were significant differences in suture times between OTSC, hand-sewn sutures, and TBSS sutures (P < 0.05). Both single-stitch and multiple-stitch sutures using TBSS have similar strength to hand-sewn sutures. TBSS is a reliable suturing device.

Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis

BackgroundDifferent methods of pancreatic stump closure after distal pancreatectomy (DP) have been described to decrease the incidence of pancreatic fistula (PF) which still represents one of the most common complications in pancreatic surgery. We retrospectively compared the pancreato-jejunostomy technique with the hand-sewn closure of the pancreatic stump after DP, and analyzed clinical outcomes between the two groups, focusing on PF rate.MethodsThirty-six patients undergoing open DP at our institution between May 2005 and December 2011 were included. They were divided in two groups depending on pancreatic remnant management: in 24 cases the stump was closed by hand-sewn suture (Group A), while in 12 earlier cases a pancreato-jejunostomy was performed (Group B). We analyzed postoperative data in terms of mortality, morbidity and length of hospital stay between the two groups.ResultsPF occurred in 7 of 24 (29.1%) cases of group A (control group) compared to zero fistula rate in group B (anastomosis group) (p=0.005). Operative time was significantly higher in the anastomosis group (p=0.024). Mortality rate was 0% in both groups. Other postoperative outcomes such as hemorrhages, infections, medical complications and length of hospital stay were not significant between the two groups.ConclusionDespite a higher operative time, the pancreato-jejunostomy after DP seems to be related to a lower incidence of PF compared to the hand-sewn closure of the pancreatic remnant.

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

BackgroundThe appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP. MethodsThe 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). ResultsThere 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. ConclusionsA pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.