Invagination Technique Research Articles

Novel invagination procedure for pancreaticojejunostomy using double purse string sutures: A technical note.

Postoperative pancreatic fistula (POPF) is one of the most serious complications after pancreaticoduodenectomy (PD), and the choice of pancreaticojejunostomy (PJ) is considered a key factor affecting the occurrence of POPF. Numerous anastomotic methods and their modifications have been proposed, and there is no method that can completely avoid the occurrence of POPF. Based on our team's experience in pancreatic surgery and a review of relevant literature, we describe a novel invagination procedure for PJ using double purse string sutures, which has resulted in favourable outcomes. To describe the precise procedural steps, technical details and clinical efficacy of the novel invagination procedure for PJ. This study adopted a single-arm retrospective cohort study methodology, involving a total of 65 consecutive patients who underwent PD with the novel invagination procedure for PJ, including the placement of a pancreatic stent, closure of the residual pancreatic end, and two layers of purse-string suturing. Baseline data included age, sex, body mass index (BMI), pancreatic texture, pancreatic duct diameter, operation time, and blood loss. Clinical outcomes included the operation time, blood loss, and incidence of POPF, postoperative haemorrhage, delayed gastric emptying, postoperative pulmonary infection, postoperative abdominal infection, and postoperative pulmonary infection. The mean age of the patients was 59.12 (± 8.08) years. Forty males and 25 females were included, and the mean BMI was 21.61 kg/m2 (± 2.74). A total of 41.53% of patients had a pancreatic duct diameter of 3 mm or less. The mean operation time was 263.83 min (± 59.46), and the mean blood loss volume was 318.4 mL (± 163.50). Following the surgical intervention, only three patients showed grade B POPF (4.62%), while no patients showed grade C POPF. Five patients (5/65, 7.69%) were diagnosed with postoperative haemorrhage. Six patients (6/65, 9.23%) experienced delayed gastric emptying. Four patients (4/65, 6.15%) developed postoperative pulmonary infection, while an equivalent number (4/65, 6.15%) exhibited postoperative abdominal infection. Additionally, two patients (2/65, 3.08%) experienced postoperative pulmonary infection. The novel invagination technique for PJ is straightforward, yields significant outcomes, and has proven to be safe and feasible for clinical application.

Duct-to-mucosa versus invagination pancreaticogastrostomy reconstruction after pancreaticodudenectomy: a comparative study

Background Pancreaticoduodenectomy (PD) is the most used standard operation for both benign and malignant diseases in the pancreatic head. Panc. Fistula following pancreaticoduodenectomy is relatively common and remains a major cause of mortality and morbidity. Aim To evaluate the early outcome of the main two techniques of pancreatic duct anastomosis with the stomach (duct-to mucosa vs. invagination) in patients who undergo pancreaticodudenectomy. Patients and methods This is a prospective randomized study was conducted on 50 patients with elective PD with two schedule techniques of pancreatic anastomoses with the stomach divided in two groups: group A (duct-to mucosa technique) and group B (invagination technique) performed in the department of the Hepato-pancreaticobiliary surgery, National Liver Institute, Menoufia University form October 2019 to October 2021. Results This study showed that, postoperative pancreatic fistula (POPF) developed in 1 (4%) case in group A and 5 (20%) cases in group B. regarding Delayed Gastric Empting (DGE), 15 (60.00%) patients had no DGE, 5 (20.00%) patients had grade A, 4 (16.00%) had grade B,1 (4.00%) had grade C among group A while, among group B, 20 (80.00%) patients had no DGE, 5 (20.00%) patients had grade A, with no significant difference (P = 0.126). Also, there was no statistically significant difference between the two groups regarding diagnostic tools, preoperative drainage as well tumor size, type of tumor regarding histopathological examination as the majority of examined specimens were adenocarcinoma. Conclusion Our study concluded that were Duct-to-mucosa pancreaticogastrostry is safer anastomosis. Following pancreatico duodenectomy other than invagination technique.

Operative risk factors for clinically relevant-postoperative pancreatic fistula after pancreaticoduodenectomy: a prospective multicenter cohort study

Background Pancreatic fistula remains the most dangerous complication after pancreatoduodenectomy (PD). This study aimed to identify the operative risk factors for clinically relevant-postoperative pancreatic fistula (CR-POPF) after PD. Methods This prospective multicenter cohort study investigated the association between CR-POPF and operative risk factors in 107 patients who underwent PD at three tertiary centers from August 2017 to July 2022. Results The incidence of CR-POPF was 26.2%. With univariate analysis, soft pancreatic texture, pancreatic duct diameter (≤3 mm), right-sided pancreatic transection, absorbable suture, pancreatico-enteric anastomosis invagination technique, non-stented pancreatic drainage, internal pancreatic drainage, long anastomotic time (>40 min), and R1 resection margin were risk factors for CR-POPF. Multivariate analysis identified four independents risk factors for CR-POPF: (1) soft pancreatic texture (OR 0.219; 95% CI 0.061–0.792; P<0.021), (2) small main pancreatic duct diameter (OR 0.280; 95% CI 0.086–0.910; P<0.034), (3) right-sided pancreatic transection (OR 0.168; 95% CI 0.032–0.881; P<0.035), and (4) non-stented pancreatic drainage (OR 3.771; 95% CI 1.147–12.401; P<0.029). Conclusion The incidence of CR-POPF after PD is reduced significantly by left-sided pancreatic transection and pancreatic drainage. Soft pancreatic texture and small main pancreatic duct diameter are independent risk factors for CR-POPF, and clinically postoperative prophylactic measures should be implemented as soon as possible.

Histoire de la vaginoplastie : évolution technique et sociologique

Technical advances in gender-affirming genital surgery have allowed the modern surgeon to create a vagina, vulva and clitoris from a male sex. This surgery, commonly known as vaginoplasty, should in fact be identified as aidopoiesis, since it is not a question of improving an already existing vagina but of creating a female sex. Numerous technical advances made since 1930 throughout the world now offer a safe and proven surgical strategy for female genital gender affirmation. Most of these techniques are derived from advances in intersex genital surgery. The first vaginoplasties described in the context of gender affirmation were performed in Berlin in the 1930s. After the Second World War, the greatest advances in vaginoplasty were made in Denmark. It was not until Geroges Burou in Casablanca and Harold Gillies, aided by Ralph Millard in England, in the mid-fifties that the modern technique of invagination of the penile skin took over from neo-vaginal grafting techniques. The creation of the clitoris from the glans penis and a more aesthetic vulva were the major advances from the 1970s. Other flap or intestinal transplant techniques were also developed, often to correct the failure of penile skin invagination. Some of the patients who benefited from these early technical advances, such as Lili Elbe and Christine Jorgensen later on, helped to make this surgery, which had long remained taboo, popular with the general public. Pioneers such as the gynaecologist Georges Burou in Casablanca have contributed, with the greatest discretion, to the well-being of gender-affirmed people by improving these techniques. Today, this hard-won heritage cannot be ignored by surgeons interested in vaginoplasty.

Penile Invagination and Corporal Excavation for Penile Prosthesis Placement in Severe Corporal Fibrosis

ABSTRACT Introduction The penile prosthesis is a standard treatment for men with erectile dysfunction refractory to vacuum, medical, or injection therapies. In patients with virgin tissue planes and normal anatomy, prosthesis placement can be technically straight forward and associated with minimal morbidity. Patients with corporal fibrosis present a unique surgical challenge for implantation and there is no standardized approach to care. Selection of the appropriate surgical technique can vary depending on the extent of corporal fibrosis and surgeon experience. In this case, our patient's corporal fibrosis resulted from two episodes of prolonged priapism as well as two distal shunts and a failed attempt at inflatable penile prosthesis placement resulting in a prolonged wound infection. Objective We present our unique surgical approach for penile prosthesis implantation in the most severe cases of corporal fibrosis. Methods Video demonstration of corporal excavation and penile prosthesis placement via a perineal incision with complete penile invagination. Results Comprehensive pre-operative planning guided our decision to utilize a malleable prosthesis given the severe degree of corporal fibrosis and higher risk of complications with a three-piece IPP. Our penile invagination technique allowed us to achieve complete longitudinal corporal exposure while avoiding multiple incisions or overlapping incisions near the corporotomy and cylinders. Tachosil or other biologic grafts should be available for use in cases where primary corporotomy closure is not possible. Conclusions We demonstrated that penile invagination, corporal excavation, and implantation with a malleable prosthesis is a safe and effective treatment for patients with the most severe corporal fibrosis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific

Usefulness of vein graft for arterial anastomosis with diameter mismatch in head and neck reconstruction

Considerable progress has resulted in microvascular free flaps becoming a cornerstone in the management of head and neck cancer. An important determinant of the success of free flap reconstruction is the proper choice of vessels, but the literature shows that donor-recipient diameter mismatch in arterial anastomosis is common, and can increase the rates of thrombosis and flap loss.1 The invagination technique and the oblique cut method are commonly used in the management of arteries with a large:small diameter ratio of 1.5:1 or less.

One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysis.

Performing 1-stage urethroplasty in patients with urethral strictures caused by lichen sclerosus (LS) is hotly debated among reconstructive urologists due to conflicting reports of success. Therefore, the objective of this study was to determine the pooled incidence of stricture recurrence following 1-stage buccal mucosal graft (BMG) urethroplasty in patients with LS, to determine the impact of surgical technique on recurrence and to compare recurrence risk between patients with and without LS after 1-stage repairs. A systematic review was conducted in accordance with PRISMA criteria. The primary outcome was pooled incidence of recurrence, which was calculated using a Der-Simonian-Laird binary random effects model with a Freeman-Tukey arcsine transformation. A total of 21 studies were included, of which 15 provided data for comparative analyses. Pooled data from 625 LS patients revealed a stricture recurrence rate of 10% (95% CI 6-14). Among studies with longer followup (≥24 months), this increased to 18%. Among patients with penile urethral involvement, studies utilizing a penile skin incision had significantly higher pooled recurrence rates than those utilizing penile invagination (p=0.004). Across all studies, there was no evidence to suggest a difference in pooled recurrence rate between patients with and without LS (p=0.36). However, across only long-term studies, recurrence risk was significantly higher for patients with LS (OR 1.83, p=0.05). One-stage BMG urethroplasty is likely a viable surgical option for patients with LS-related strictures; however, high-quality data are limited. Future multi-institutional, long-term prospective studies are needed to assess durability of 1-stage repair.

Choosing a method to perform an esophageal-intestinal anastomosis after complete removal of the stomach

The paper reviews various methods of performing esophageal-intestinal anastomoses with complete removal of the stomach (gastrectomy). The main methods of manual and stapler stitching of the esophagus with the jejunum are described. Special attention is paid to detailing of techniques for the most commonly performed esophageal-intestinal anastomoses, with a comparative assessment of the reliability of manual and stapler anastomoses. Given the large number of proposed methods to perform esophageal-intestinal anastomoses, it can be stated that no universal anastomosis yet exists. In laparotomy, a stapler suture is most commonly used to perform an esophageal-intestinal anastomosis with circular crosslinking devices, while the manual version implies one of the invagination techniques, or muff-like anastomosis (the Tsatsanidi K.N., Bondar G.V., Davydov M.I. procedure). With laparoscopic access, the anastomosis is performed with linear endoscopic crosslinking devices. The choice of a technique to perform an esophageal-intestinal joint remains with the operating surgeon and depends on his/hers experience, skills, individual intraoperative situation, and equipment of the operating unit.

A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate?

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) remains a major cause of morbidity in patients undergoing pancreatic surgery. Controversy exists as to whether there is any difference in CR-POPF with a Duct-to-Mucosa (DTM) versus an Invagination (IG) pancreaticojejunostomy (PJ). MethodsDemographic, perioperative, intraoperative, and postoperative data were captured from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2014–2017 databases. Potential confounders were included in a logistic regression and a propensity score model. The primary outcome was CR-POPF. ResultsA total of 12,361 pancreaticojejunal anastomoses were performed with 11,168 patients undergoing DTM (90%) and 1193 undergoing IG (10%) after pancreaticoduodenectomy. Amongst all patients, there was no significant difference in CR-POPF between DTM and IG on multivariate (OR = 0.95, p = 0.64) or propensity score analysis (OR = 0.99, p = 0.93). After stratification by pancreatic gland texture and duct size, there was a decrease in CR-POPF with DTM amongst patients with duct size greater than 6 mm on multivariate analysis (OR = 0.35, p = 0.009) and propensity score analysis (OR = 0.40, p = 0.018). There were no significant differences in any other strata. ConclusionDTM or IG technique are not associated with CR-POPF for patients with average size pancreatic ducts; however, DTM is preferable in patients with large pancreatic duct diameter (>6 mm).

Comparison of Blumgart Anastomosis with Duct-to-Mucosa Anastomosis and Invagination Pancreaticojejunostomy After Pancreaticoduodenectomy: A Single-Center Propensity Score Matching Analysis

The Blumgart anastomosis is a method of pancreaticojejunostomy after pancreaticoduodenectomy (PD) which combines the principle of duct-to-mucosa anastomosis with an invagination technique of the pancreas. Retrospective study involving consecutive patients who underwent pancreaticoduodenectomy for pancreatic head cancer. Data predictive of pancreatic fistula and postoperative outcomes were collected. The patients were divided into three groups and were compared based on the type of pancreatic anastomosis performed: Blumgart anastomosis (BA), duct-to-mucosa anastomosis (DtoM), and invagination pancreaticojejunostomy (PJ). The primary endpoint was to determine the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). The secondary endpoints were to determine whether postoperative pancreatic fistula grade C (POPF C) and/or severe complications occurred as well as to determine the reoperation rate and 30- and 90-day mortality. A propensity score matching analysis was used. Using propensity score matching (PSM), the occurrence of CR-POPF was not significantly different between the BA (21.6%) and the other pancreatic anastomoses (all 31.1%, DtoM = 27.0%; PJ = 35.1%). However, the BA significantly reduced (1) severe complications (0 versus 35.1%; P < 0.001) and 90-day mortality (0% versus 12.2%; P = 0.028) with respect to all anastomoses; (2) severe complications (0% versus 29.7%; P < 0.001), POPF grade C (0% versus 16.2%; P = 0.025), and reoperation (2.7% versus 16.2%; P = 0.056) with respect to DtoM; and (3) severe complications (0% versus 40.5%; P < 0.001) and 90-day mortality (0% versus 13.5%; P = 0.054) with respect to PJ. Applying the PSM analysis for the first time, the present study seemed to suggest that the BA succeeded in minimizing severe complications after PD.

Conventional versus invagination stripping varicose veins: which is better?

Background: Varicose veins are dilated, tortuous veins. It is an extremely common condition causing substantial morbidity. Prevalence of varicose veins ranges between 5% to 30% in adult population. Surgery is preferred over conservative treatment in symptomatic primary varicosis of the great saphenous vein (GSV). This study aims to compare the efficacy of GSV stripping by invagination technique in comparison to the conventional method in terms of time taken to strip the vein, the length of vein stripped, post-operative pain, area of bruising and intra-operative blood loss.Methods: The study was conducted in Dr. D. Y. Patil Medical College, Hospital and Research Centre located in Pimpri, Pune between July 2017 to September 2019.It is a prospective comparative Study. Subjects were randomly divided into 2 groups alternately where group A and B were operated by conventional and invagination techniques respectively and their outcomes were compared.Results: The mean age of the cases in Group A (conventional stripping) was 52 years and in group B (Invagination stripping) was 53 years. Blood loss was significantly more in conventional stripping compared to invagination stripping (p&lt;0.001). The post-operative (after 1 week) mean VAS of the cases in Group A was 3.1 and 2.3 respectively while in group B it was 2.9 and 2.1 respectively. Time taken to get back to activity was significantly more in conventional stripping compared to invagination stripping (p&lt;0.001).Conclusions: From this study we concluded that Invagination stripping is a suitable alternative to time honoured conventional varicose vein stripping with added advantage of less blood loss, less postoperative pain and shorter time span to get back to work.

A study on predictive factors for anastomotic leakage in enteropancreatic anastomosis in a tertiary centre in Andhra Pradesh

Background: This study aimed to identify various factors influencing occurrence of post-operative pancreatic fistula.Methods: Only those patients who underwent standard pancreatojejunostomy anastomosis in duct to mucosa technique using vicryl 4-0 sutures (double layer- interrupted fashion) were included in the study. Patients who had duct size ≤3 mm underwent papillary like main pancreatic duct invaginated technique of pancreaticojejunostomy (fish mouth type).Results: In 40 patients, 10 patients (25%) developed postoperative pancreatic fistula. 5 (12.5%) patients had grade A pancreatic fistula and 5 patients had CR–POPF [grade B–3(7.5%), grade C–2(5%)]. Pancreatic fistula in relation with duct size has attained statistical significance. When all the four factors were put together and given fistula risk score, it correlated well with the occurrence of fistula. Fistula risk score has high negative predictive value. Of 40 patients, 13 patients fall into low risk zone, out of which 1 patient developed grade A fistula. 26 patients fall into moderate risk zone, out of which 4 patients developed grade A, 3 patients developed grade B and 1 patient developed grade C fistula. One patient fall into high risk zone and developed grade C fistula.Conclusions: We found in our study that, post-operative pancreatic fistulae could be modestly predicted using fistula risk score. However, the latter had high negative predictive value and thus could be used to prognosticate risk of non-development of fistula than predicting its severity.

Pancreaticogastrostomy after pancreaticoduodenectomy without suturing the pancreas.

The aim of the present paper was to describe a new and easy technique for performing pancreaticogastrostomy (PG) through simple pancreatic invagination by a single binding suture without suturing the pancreatic parenchyma. The present study included all consecutive patients who underwent elective pancreaticoduodenectomy from 2007 to 2015. The intraoperative and postoperative outcomes after PG (PG group) were compared with those of patients who underwent pancreaticojejunostomy (PJ) (PJ group). Out of 270 patients, 88 PG and 182 PJ patients were assessed. The rate of clinically significant PF was similar between the PG and PJ groups (10.2% vs. 13.2%, respectively; p = 0.487), despite the risk of pancreatic fistula being higher in the PG group. There were no significant differences in the intraoperative and postoperative outcomes or mortality between the groups. This easy invagination technique for PG is simple, safe and reproducible with a low risk of postoperative pancreatic fistula.

Modified Pancreatojejunostomy in Pancreaticoduodenectomy for the Treatment of Periampullary Tumor: 8 Years of Surgical Experience.

BackgroundWe modified the anastomosis surgical method based on the Blumgart anastomosis in pancreaticoduodenectomy. This study aimed to compare patient outcomes with regards to clinically relevant postoperative pancreatic fistula (CR-POPF) and other postoperative complications among patients receiving traditional anastomosis, classical Blumgart anastomosis, and our modified-Blumgart anastomosis.Material/MethodsData were reviewed from 229 consecutive patients with periampullary tumors who underwent pancreaticoduodenectomy administered by a single surgeon at the Tianjin Medical University Cancer Institute and Hospital between January 2010 and December 2017. Subsequently, clinical factors potentially associated with CR-POPF were analyzed.ResultsDuring the study period, the incidence of overall CR-POPF was 31 out of 229 patients (13.5%). Using Blumgart anastomosis (BA), the incidence of CR-POPF was lower at 15 out of 148 patients (10.1%), significantly lower than that of traditional anastomosis (invagination technique or “duct-to-mucosa” anastomosis) (15 out of 148 patients versus 16 out of 81 patients, P=0.042). Compared with classical Blumgart anastomosis (c-B), our modified-Blumgart anastomosis (m-BA) method had similar outcomes in terms of CR-POPF (9 out of 73 patients versus 6 out of 75 patients, P=0.383), CR-POPF-related intra-abdominal hemorrhage rate (0 out of 73 patients versus 1 out of 75 patients, P=0.322), and median length of postoperative hospital stay (19 days versus 19 days, P=0.752). There were no fatalities as a result of CR-POPF in the BA group.ConclusionsUpon review of a single surgeon’s experience over 8 years, Blumgart anastomosis might be more effective in the prevention of CR-POPF than traditional anastomosis. Our modified-Blumgart anastomosis method maintained a low rate of morbidity and mortality but with simplified procedures that can be easily put into practice. This technique can be used widely with excellent safety for pancreatojejunostomy as a part of pancreaticoduodenectomy.

Impact of Modified duct to mucosa (Buchler) vs Binding PJ(Pengs) pancreaticojejunostomy on the functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy - a Randomised control study

Introduction: Many studies suggest PJ is better than PG in terms of long-term functional status. However, there are no clear recommendations regarding the specific PJ technique to be used, considering both the immediate and long-term outcome. Studies have proven Pengs PJ, a kind of invagination technique, to be better in terms of fistula rate for soft pancreas with small ducts. However, it has been criticized to cause exocrine and endocrine deficiencies because of accelerated atrophy of the remnant pancreas, adding to the burden of treatment. This happens due to an invagination kind of anastomosis which avoids the ductal bite that keeps the duct open from becoming stenotic as compared to duct to mucosa PJ. Method: At Asian Institute of Gastroenterology, Hyderabad, 27 patients were randomized using randomization allocation software-13 in binding and 14 in buchler PJ technique. The patients were followed-up for one year postoperatively for steatorrhoea, fecal elastase and OGTT. MRI triphasic+ MRCP (pancreatic protocol)- Anastamotic narrowing, Duct diameter, Remnant Pancreatic volume, Dixon sequences, DWI-ADC, fat content were noted. Result: 2/13 in binding group and 3/14 in buchler group had steatorrhoea. 7/12 in binding group and 8/12 in buchler group had deranged glucose tolerance tests. None were statistically different. There was no difference in fecal elastase levels. There was no difference in pancreatic morphological changes on MRI in both groups. Conclusion: The anastomosis of choice for soft pancreas with small duct post pancreaticoduodenectomy would be Pengs PJ as our study failed to show poor long-term results.

FAILURE OF COLORECTAL ANASTOMOSIS. CLINICAL ANALYSIS

Failure of colorectal anastomosis was found in 1 case after 30 stapler operations and in 6 cases after 60 manual anastomoses. All the anastomoses were formed by two rows of sutures and were subperitoneal. The diagnosis of failure was mad on the basis of clinical data. One patient died. The errors in diagnosis of colorectal anastomosis failure are discussed. Visualization of a failure area by means of contrast enema and CT is essential. From 2013 to 2017 in Chernivtsi Oncological Center 90 operations were performed for rectal cancer with colorectal anastomoses. The first row of sutures was applied from the inner part of mucosa. In 25 cases invagination technique was applied. Anastomoses were made by 5 surgeons with a high level of professional work. One failure occurred on 11 day after formation of stepler anastomosis, by means of manual anastomoses failure appeared on 5-9 days. Conservative therapy was given to 2 patients. Transversostomy was performed in 4 patients, and lparotomy with resection of anastomosis – in 1 patient. In all cases surgeons were not informed about the size of dehiscence and level of drainage of subperitoneal abscess. In such situation transversostomy may be dangerous and subperitoneal abscess leads to peritonitis.

Selection of pancreaticojejunostomy technique after pancreaticoduodenectomy: duct-to-mucosa anastomosis is not better than invagination anastomosis: A meta-analysis.

Background:One of the most clinically significant current discussions is the optimal pancreaticojejunostomy (PJ) technique for pancreaticoduodenectomy (PD). We performed a meta-analysis to compare duct-to-mucosa and invagination techniques for pancreatic anastomosis after PD.Methods:A systematic search of PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to June 1, 2018 was performed. Randomized controlled trials (RCTs) comparing duct-to-mucosa versus invagination PJ were included. Statistical analysis was performed using RevMan 5.3 software.Results:Eight RCTs involving 1099 patients were included in the meta-analysis. The rate of postoperative pancreatic fistula (POPF) was not significantly different between the duct-to-mucosa PJ (110/547, 20.10%) and invagination PJ (98/552, 17.75%) groups in all 8 studies (risk ratio, 1.13; 95% CI, 0.89–1.44; P = .31). The subgroup analysis using the International Study Group on Pancreatic Fistula criteria showed no significant difference in POPF between duct-to-mucosa PJ (97/372, 26.08%) and invagination PJ (78/377, 20.68%). No significant difference in clinically relevant POPF (CR-POPF) was found between the 2 groups (55/372 vs 40/377, P = .38). Additionally, no significant differences in delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, operation time, or length of stay were found between the 2 groups. The overall morbidity and mortality rates were not significantly different between the 2 groups.Conclusion:The duct-to-mucosa technique seems no better than the invagination technique for pancreatic anastomosis after PD in terms of POPF, CR-POPF, and other main complications. Further studies on this topic are therefore recommended.

P3.16-038 Experience of 180 Bronchial Sleeve Resections for Malignant Tumors

Sleeve lobectomy can expand the indications to radical organ-saving operations and avoiding pneumonectomy increase the number of operated ones, and also significantly improve the quality of life and rehabilitation conditions of patients, which is of special importance for persons with limited functional reserves. One surgical team performed 180 bronchial sleeve resections for malignant neoplasms of the lung. In all cases an invagination technique was used to form an anastomosis per 1 cartilage semicircle. There were 168 (93,3%) patients with primary tumors and 12 (6,7%) with solid metastatic lesions. Non-small cell lung cancer (NSCLC) was performed in 149 (88.7%) cases, carcinoid tumors - in 19 (11.3%) cases. Ia stage was diagnosed in 7.4%, Ib stage in 6.7%, IIa in 25.5%, IIb in 16.1%, IIIa in 37.6% and IIIb - 6.7% of cases. There were 80.6% (145) males and 19.4% (35) females. The average age of patients was 56.9 (from 18 to 82 years). 21 variants of bronchoplastic reconstructions was performed, lobectomy - in145 (80,6%) patients, bilobectomy – in 24 (13,3%), segmentectomy – in 6 (3,3%), isolated resection of bronchus – in 5 (2,8%) patients. In common 63 (35%) bronchoangioplasty interventions were performed. Resection of the pulmonary artery was performed in 49 cases (40 - circular, 9 - edge), vena cava resection - in 9 patients (6 - circular, 3 - edge), segmental arteries were resected in 5 patients (3 - circular, 2 - edge). In all cases of NSCLC extended ipsilateral mediastinal lymph node dissection was performed. Complications were noted in 35 patients (19.4%): pneumonia (6.1%), atelectasis of the lobe (0.6%), insufficiency of bronchial sutures (3.9%), granulation stenosis of bronchial anastomosis (1.1 %), PE (1.7%), chylothorax (1.1%), recurrent nerve paresis (1.1%), cardiac rhythm disturbances (1.7%), hemothorax (1.7%), AMI (0.6%). Postoperative mortality was in 3.9% cases. The cause of death in 3 patients was massive PE, in 1 - AMI, in 3 - failure of bronchial sutures. Long-term results were obtained in 128 patients. The one-year observed survival rate in patients after reconstructive resections was 90.6%, 3-year - 57.4%, 5-year - 42.4% (with median 48.8 months). One-year recurrence-free survival was 89.1%, 3-year - 63.8%, 5-year - 51.6% Median relapse-free survival was 55.2 months. Using the invagination technique for the bronchial anastomoses is characterized by the simplicity of technical execution and is accompanied by satisfactory immediate and long-term results.

Pancreaticojejunostomy by Duct to Mucosa and Invagination Techniques Result in Similar Mortality and Pancreatic Fistula Rates

Zettervall, Sara L. MD, MPH; Holzmacher, Jeremy L. MD; Rivas, Lisbi MD; Olafson, Samantha N.; Lin, Paul P. MD, FACS; Vaziri, Khashayar MD, FACS Author Information

The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery.

Purpose:Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery.Materials and Methods:In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups.Results:Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis.Conclusions:The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.