Invagination Technique Research Articles

A Comparative Study between Duct-to-Mucosa and Invagination Technique for Reconstruction after Pancreaticoduodenectomy: Aprospective Study

Background: The pancreaticojejunostomy has notoriously been known to carry a high rate of operative complications,morbidity,and mortality mainly due to anastomotic leak and ensuing septic complications. Patients and methods: From January 2012 to October 2015, we presented a prospective study which included 24 patients who underwent pancreaticoduodenectomy (PD) operation through either Whipple resection or modified Whipple(pylorus-preserving).Patients were reviewed and divided into 2 groups (A,B) according to the type of pancreaticojejunostomy (PJ), (invagination vs duct-to-mucosa ). Results: 12 patients in each group were operated on: Group A patients had invagination technique for PJ ,while all the 12 patients in group B had duct –to-mucosa anastomotic technique for PJ. 1 (8.3%)case in group A developed pancreatic fistula (PF),while 3 (25%) cases in group B developed PF, and 1 case (8.3%) in group A had mild anastomotic leak which was managed conservatively,while 3 cases (25%) in group B developed moderate to severe anastomotic leak with intra-abdominal collection which required CT-guided percutaneous drainage and operative intervention. Average age was (mean ±SD) = (55 ±12),average operative time was (245 ±75) min. Conclusion: PF after PD represents a critical trigger of potentially life-threatening complications. Although the best method for dealing with the pancreatic stump after PD remains controversial, recent reports described the invagination technique todecrease the rate of PF significantly compared to the duct-to-mucosa technique. Our results appeared to be closely related to the published literature.

Safer intestinal invagination for a solid pancreatico-jejunal anastomosis in presence of a soft texture pancreatic remnant and non-dilated duct

Pancreatico-jejunal anastomosis after pancreatoduodenectomy still represents the Achilles' heel of the procedure: the failure of this anastomosis is relatively common and it is the main cause of post-operative morbidity and mortality. Studies have described different reconstruction strategies for the control of the development of post-operative pancreatic fistula, but the strategy to obtain a safer pancreatico-jejunal anastomosis is still far from satisfaction. We report a novel variation of the invagination technique based on preliminary clinical experience in 8 patients who underwent pancreatico-jejunal anastomosis after pancreatoduodenectomy in our hepatobiliopancreatic center from 2008 to 2014. The variation could obtain a safer intestinal invagination for a solid pancreatico-jejunal anastomosis even in the presence of soft pancreatic remnant.

PC8. Proximal First Anastomosis by a Simplified Graft Invagination Technique for Type A Aortic Dissection

PC8. Proximal First Anastomosis by a Simplified Graft Invagination Technique for Type A Aortic Dissection

Pancreaticojejunostomy: Images of an Invagination Technique

Pancreaticoduodenectomy is the treatment of choice for resectable periampullary tumors. Anastomosis between the remnant of the pancreas and the intestine can be fashioned by various methods. An anastomotic leak can result in sepsis and even death. The rate of these complications is reported to be 10-28.5% [1]. Two widely used techniques for fashioning a pancreatic anastomosis are practiced: end to side duct to mucosa anastomosis or telescopic invagination of the pancreas into the lumen of the bowel. Some authors have suggested that the invagination technique reduces the rate of anastomotic leaks and the rate of pancreatic fistula formation [2]. These complications directly correlate with morbidity and mortality after a Whipple procedure [3]. We would like to share with the readers interesting computerized tomography (CT) images of a pancreaticojejunostomy fashioned by a telescopic invagination anastomosis between the remnant of the pancreas and a loop of the small bowel.

A Comparison of Two Invagination Techniques for Pancreatojejunostomy after Pancreatoduodenectomy

Background. The aim of the study was to compare two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Methods. For effective prevention of the development of pancreatic leakage, we modified invagination technique that we term the “serous touch.” We analysed the diameter of the main pancreatic duct, the texture of the remnant pancreas, the method of the reconstruction, pancreatic external drainage, anastomotic procedure time, histopathological examination, and postoperative complications. Results. Fifty-two patients underwent pancreatoduodenectomy with pancreatojejunostomy using “serous touch” technique (ST group) and 52 classic pancreatojejunostomy (C group). In the ST group one patient (1.9%) was diagnosed as grade B pancreatic fistula, and no patient experienced fistula grade A or C. In the C group 6 patients (11.5%) were diagnosed as fistula grade A, 1 (1.9%) patient as fistula grade B, and 1 (1.9%) patient as fistula grade C. There was a significant statistical difference in incidents of pancreatic fistula (P < 0.05) and no statistical difference in other postoperative complications or mortality in comparison group. Anastomosis time was statistically shorter in the ST group. Conclusions. “Serous touch” technique appeared to be easy, safe, associated with fewer incidences of pancreatic fistulas, and less time consuming in comparison with classical pancreatojejunostomy.

In situ cooling with ice water for the easier removal of self-expanding nitinol stents.

Background: It is yet to be determined what effects temperature has on the properties of nitinol in order to simplify the process of removing nitinol self-expanding metal stents (SEMS). Materials and methods: We describe the procedure for removal of SEMS in a total of 11 cases with 9 patients. A study involving cooling of nitinol stents in situ with ice water just before their removal was attempted. Results: All stents were removed successfully. In partially covered and in fully covered stents, the stent rigidity was noticeably reduced following cooling. Stent removal was performed by inversion, which was achieved by pulling on the stent from its distal end. No adverse events were observed during this trial. Conclusion: The higher pliability of the stents after ice-water cooling facilitates stent removal. With this method, a mobilization of all stents by the invagination technique was achieved. The separation of the uncoated stent ends from the intestinal wall by the invagination technique, as well as the mucosal vasoconstriction resulting from the cooling, lead to an easier SEMS removal and may serve to prevent severe bleeding of the mucosal wall during this process.

Treatment of fixed atlantoaxial dislocation and basilar invagination with C1-2 screw and rod reduction and fixation technique

To introduce a novel technique of reducing fixed atlantoaxial dislocation (FAAD) and basilar invagination (BI) with C1-C2 screw and rod system. From January 2009 to December 2011, 26 patients of FAAD and BI were reduced successfully with an insertion of C1 lateral mass and C2 pedicle/pars screw and rod system. The cohort had 17 females and 9 males. And their most common presenting symptoms were extremity muscle weakness, restricted neck movement and paresthesia. All of them achieved effective reduction. Among them, 18 attained complete reduction and 8 partial reduction (over 60% extent of reduction). The mean atlanto-dental interval (ADI) value was 2.1 mm postoperatively versus 8.8 mm preoperatively (t = 21.1, P < 0.01) . All of them had relieved compression of dura and medulla oblongata and cervical cord. All clinical symptoms improved. One case had pulmonary infection while another case delayed healing of incision. Both recovered well after symptomatic treatments. Bony fusion reached 100% during a mean follow-up period of 22 months. The C1-C2 screw and rod system may achieve effective reduction and fixation for FAAD and BI. Capable of preserving atlanto-occipital joints in patients without atlas assimilation, this procedure provide more solid immobilization than occipitocervical fusion in those with atlas assimilation.

Surgery of male infertility: an update

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval.Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein.Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART.In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.

Healing of two microarterial anastomoses with diameter mismatch

BackgroundThe use of fascial perforating vessels as recipients for microvascular composite tissue autotransplants has led to vessel diameter discrepancy becoming an increasingly common finding. Little evidence, however, is available to direct the choice of anastomotic technique where a discrepancy exists. We have been studying two methods of anastomosing arteries where a small-to-large discrepancy exists—a 45° section of the smaller vessel, and invaginating the smaller vessel inside the larger. As part of this work, this study examines intimal hyperplasia and healing of the two methods. Materials and methodsA previously described paired Wistar rat femoral axis model was used. Anastomoses were performed, one on each side, and specimens were harvested in groups at 24 h, 1 wk, 6 wk, and 8 mo. Inflammation, necrosis, and fibrosis in each layer of the vessel wall and intimal hyperplasia were each scored by an assessor blinded to the group and anastomotic technique. ResultsSignificant differences in healing were found. The invagination technique induced less inflammation, and caused less endothelial and medial necrosis than the oblique cut end-to-end method. Intimal hyperplasia was most pronounced at 6 wk, but no evidence of a difference in the severity of intimal hyperplasia between the two methods was found. ConclusionsThe invaginating anastomosis causes less inflammation and less vessel wall necrosis than the oblique end-to-end method in this model. This finding, alongside results from previous work, suggests that this is the better method to deal with a small-to-large microarterial diameter discrepancy in the range 1:1.5 to 1:2.5.

Excision or exclusion of left atrial appendage?

Stroke is one of the leading causes of mortality and morbidity today. In the majority of the cases, stroke results from cardiac emboli predominantly in patients with atrial fibrillation. Theoretically, the most likely site for generation of thrombus formations as a prerequisite for emboli and stroke is the left atrial appendage (LAA). Here, the three characteristics of Virchow's triad are realized, especially flow abnormalities, besides those of the vessel wall and constituents in blood [1]. Therefore, it makes theoretical sense to exclude the LAA in order to prevent stroke as recommended in the ACC/AHA Guidelines [2] during mitral valve surgery and MAZE procedures, although some authors argue that LAA exclusion is not the whole story [3] of stroke prevention and that strokes occur also after LAA occlusion, related to unsuccessful exclusion [4] or other sources. In this issue, Hernandez-Estefania report on a special technique for LAA occlusion including invagination and double-suture technique [5]. A purse-string suture is used to delineate the rim of the orifice which is facilitated by the invagination of the LAA. Although this might help to better define the borders of the os of the LAA, a clearly defined ridge is not present at the anterior and inferior borders of the LAA os [6]. Furthermore, the rim of the os is smooth [6]. Thus, there may be few firm tissues to anchor securely the sutures for occlusion. In addition, the oval area of the os is tugged together by the sutures, potentially creating tension forces in the tissue tending to reset the oval shape of the os. These are the factors that might cause some kind of re-opening of the LAA orifice years after the operation [4]. Whether this occurs with the proposed LAA occlusion technique remains to be seen. Therefore, long-term follow-up is needed to decide whether this is an effective technique for LAA occlusion. A more definite approach would be the complete excision of the LAA. Since our negative results years after direct suture closure of the LAA [7], we switched our technique to complete excision of LAA. The LAA atriotomy is closed between two 4–5 mm wide strips of Teflon felt to reinforce the fragile tissue, using a mattress suture followed by a continuous over and over suture to definitely close the resection line. The excision technique was reported to yield the most successful results compared with exclusion by suture or stapling [4]. In that report, 27% of patients in the excision group showed a residual stump of >1 cm, but the author did not find thrombus material in the residual stump at follow-up investigation, indicating that this residual stump at the base may not generate thrombus formation. Taken together, it would be appropriate for the proposed occlusion technique to stand the test of time for final judgment of its effectiveness. The most successful technique still remains the excision of the LAA.

Combined invagination and duct-to-mucosa techniques with modifications: a new method of pancreaticojejunal anastomosis

Soft pancreatic texture and a small main pancreatic duct are thought to be the most significant risk factors for the occurrence of pancreatic fistula (PF), a common and serious complication after pancreaticoduodenectomy (PD). This is in part due to the technical difficulties of pancreaticojejunostomy (PJ) posed by a soft gland with a normal-sized duct. To deal with this problem, we developed a new anastomotic technique which combines the two most widely used techniques, namely, the invagination technique and the duct-to-mucosa technique, with a modification of the suture route and insertion of a temporary stent tube. Between January 2003 and December 2009, ninety-two consecutive patients underwent PD in which the new PJ technique was used. Charts and follow-up data of these patients were reviewed for operative details, early postoperative events, and outcomes at 6 months after the operation. PF was defined by the International Study Group on Pancreatic Fistula (ISGPF) guidelines and graded (A, B or C) according to the clinical procedures and outcome. In this group of 92 patients, there was only 1 early death from acute renal failure. PF was observed in 11 patients (12.0%), 8 in grade A, 1 in grade B, and 2 in grade C. For the 2 patients in grade C, PF was surgically managed. There were no early or late deaths attributable to PF. Six months after the operation, all of the patients were free of PJ-related symptoms except for 2, who were found to have steatorrhea. Our modified technique is simple and safe in PD. Present data suggest that this technique produces excellent early and medium-term results.

Experimental investigation of two techniques of arterial microanastomosis used to manage a small-to-large diameter discrepancy

A limiting factor in the use of perforators as recipient vessels is the small-to-large diameter mismatch often encountered. Mismatches less than 1:1.5 may be managed by dilatation of the smaller vessel and by differentially-spaced suture bites. Beyond this ratio, little evidence exists to direct the choice of end-to-end anastomotic technique. Following in silico work and the characterisation of a rodent superficial caudal epigastric/femoral artery model, we conducted an experimental series examining two techniques - an oblique section of the smaller vessel and invaginating the smaller vessel inside the larger. A paired design was used. To test for a difference in patency of >5% required a total of 156 animals (312 anastomoses). Side and technique were randomised. Two investigators performed the anastomoses. A single revision was permitted. Anastomoses were timed and patency was tested at one hour, one week and at six weeks. There was no significant difference in patency at each of the three time points (p = 0.8026, 0.2963 and 0.8137). The invagination technique was significantly faster to perform (p < 0.0001). There was a significant association between the investigator and both patency and the time taken to complete an anastomosis. Independent of the investigator, a revision was more likely to be necessary with the oblique end-to-end technique, and a revision having been performed showed a highly significant association with an anastomosis having failed at 1 h (p < 0.0001, OR 33.333). In the management of microarterial size discrepancy between 1:1.5 and 1:2.5, an invaginating anastomosis is faster to perform and produces comparable patency in a rat model.

Assessment of stump invagination versus simple ligation in open appendicectomy

Introduction: Operation of appendix is very common abdominal surgery that is done by general surgeons. Some surgeon prefer to invaginate the appendix stump while others don&rsquo;t. Aim of the study was to compare the technique of ligation and invagination of the appendix stump with simple ligation of the appendix stump during appendicectomy for acute appendicitis. Methods: A prospective comparative study of 150 appendicectomies were done in the Department of General Surgery, Nepalgunj medical college (NGMC),Nepalgunj,Nepal from June 2001-May 2007in unit III. All patients with uncomplicated and complicated acute appendicitis who underwent open appendicectomy and had appendicular stump for ligation and invagination or simple ligation, were divided into two groups. In group-I ligation with invagination and in group-II, simple ligation of appendix stump was carried out. Patients were followed up for 3-6 months to check the development of complications Results: Both groups were similar with respect to age and sex. Invagination of the stump after ligation of the stump was done in 70 patients while simple ligation was done in 80 cases. The incidence of postoperative pyrexia (18.57% and 22.5%), wound infection (27.15% and 30.0%) and postoperative paralytic ileus (25.71% and 27.5%) was in group-I and group-II respectively. Conclusions: Simple ligation of appendix stump is as safe a procedure as ligation and invagination of appendix stump during appendicectomy. DOI: http://dx.doi.org/10.3126/joim.v32i1.3994Journal of Institute of Medicine, April, 2010; 32:1 pp.7-10

Assessment of stump invagination versus simple ligation in open appendicectomy

Introduction: Operation of appendix is very common abdominal surgery that is done by general surgeons. Some surgeon prefer to invaginate the appendix stump while others don&rsquo;t. Aim of the study was to compare the technique of ligation and invagination of the appendix stump with simple ligation of the appendix stump during appendicectomy for acute appendicitis. Methods: A prospective comparative study of 150 appendicectomies were done in the Department of General Surgery, Nepalgunj medical college (NGMC),Nepalgunj,Nepal from June 2001-May 2007in unit III. All patients with uncomplicated and complicated acute appendicitis who underwent open appendicectomy and had appendicular stump for ligation and invagination or simple ligation, were divided into two groups. In group-I ligation with invagination and in group-II, simple ligation of appendix stump was carried out. Patients were followed up for 3-6 months to check the development of complications Results: Both groups were similar with respect to age and sex. Invagination of the stump after ligation of the stump was done in 70 patients while simple ligation was done in 80 cases. The incidence of postoperative pyrexia (18.57% and 22.5%), wound infection (27.15% and 30.0%) and postoperative paralytic ileus (25.71% and 27.5%) was in group-I and group-II respectively. Conclusions: Simple ligation of appendix stump is as safe a procedure as ligation and invagination of appendix stump during appendicectomy. DOI: http://dx.doi.org/10.3126/joim.v32i1.3994Journal of Institute of Medicine, April, 2010; 32:1 pp.7-10

Pancreatic Leakage After Pancreaticoduodenectomy

To evaluate the impact of the length of the isolated jejunal loop and the type of pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy. One hundred thirty-two consecutive patients who underwent a pancreaticoduodenectomy were studied according to the length of the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and the type of pancreaticojejunostomy (invagination vs duct to mucosa). The use of the long isolated jejunal loop was associated with a significantly lower pancreatic leakage rate compared with the use of a short isolated jejunal loop (4.34% vs 14.2%, P < 0.05). In addition, the use of duct-to-mucosa technique was associated with significantly lower incidence of postoperative pancreatic fistula compared with the invagination technique (4.2% vs 14.5%, P < 0.05). Finally, patients with a short isolated jejunal loop compared with patients with a long loop had increased morbidity (50.7% vs 27.5%, P < 0.05) and prolonged hospital stay (16.3 +/- 1.9 days vs 10.2 +/- 2.3 days, P < 0.05). Overall mortality rate was 1.5%. The use of a long isolated jejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreased pancreatic leakage rate after pancreaticoduodenectomy.

Pancreatogastrostomy with an elastic purse-string suture around the gastric orifice after pancreatoduodenectomy

Postoperative pancreatic fistula (POPF) is a potentially fatal complication of pancreatoduodenectomy (PD). Fixation of the remnant pancreas to the gastric wall is considered essential to prevent anastomotic leakage in patients undergoing pancreatogastrostomy (PG) after PD. PG was performed with invagination of the pancreatic stump. To limit the number of sutures in the pancreas parenchyma to three or four, we placed an elastic purse string suture around the orifice of the posterior gastric wall in an attempt to fix the gastric wall to the remnant pancreas. We performed PG using this technique in 30 patients. According to the international POPF criteria, POPF developed in three (10%) patients; as grade A in one, and grade B in two. These results demonstrate the potential advantage of performing PG after PD, by using this invaginated technique with an elastic suture.

Utilización de la tecnología láser en el tratamiento de las estenosis ureterointestinales

Ureteral-intestinal anastomosis represent on important problem in patients undergoing radical cystectomy with urinary diversion using intestinal segments, either small or large intestine. With the incorporation of laser technology in urology, new therapeutic possibilities have been opened for the section of these ureteral intestinal stenosis. Various types of laser had been employed to perform the incision, Nd:YAG, KTP:YAG, Ho:YAG, Er:YAG, and Th:YAG. The experience is limited in terms of use and results don't give clear therapeutic orientation. The section of ureteral-intestinal stenosis with laser has advantages and disadvantages, but the application of this energy source with various techniques of endoscopic section, such as the Lovaco's technique of endoluminal invagination and endoureterotomy gives satisfactory results in the short-midterm.

Modified Technique of Pancreaticojejunal Anastomosis with Invagination Following Pancreaticoduodenectomy: A Cohort Study

Leakage from pancreatic anastomoses remains the single most important morbidity after pancreaticoduodenectomy and contributes to prolonged hospitalization and mortality. This observational cohort study reported the surgical outcome of a modified invagination technique of pancreaticojejunostomy after pancreaticoduodenectomy. Between December 2001 and December 2007, a total of 52 consecutive patients underwent elective pancreaticoduodenectomy for benign or malignant pathologies of the pancreas or the periampullary region in a tertiary referral center. All patients underwent our modified invagination technique of pancreaticojejunostomy regardless of the characteristics of the pancreatic stump. Data were collected prospectively. The mean hospital stay was 12.6 +/- 3.2 days. The incidence of overall surgical complications was 9.6%. No patient developed pancreatic fistula. One patient (1.9%) died of respiratory failure on postoperative day 7. We reported our pancreaticojejunostomy anastomosis technique with a pancreatic fistula rate of 0% and low intra-abdominal complication rate. The favorable results of this technique warrant further investigation in large prospective cohort studies and prospective randomized controlled studies.

Complications after pancreaticoduodenectomy: intraabdominal abscess

The development of intraabdominal abscess (IAA) following pancreaticoduodenectomy (PD) is an important problem. It is a common cause of readmission to the hospital following discharge. Rates of IAA do not appear to depend on whether the pancreas is anastomosed to the stomach or jejunum, nor whether a duct-to-mucosa or invagination technique is used. Most surgeons favor the use of closed-suction drains after PD. The use of fibrin glue sealant does not appear to reduce the rate of IAA. The use of preoperative biliary stenting increases wound infection rates, but not IAA rates. The use of internal and external pancreatic duct stents with PD to prevent IAA have yielded mixed results.

MP-22.11: Penile invagination technique in full length buccal mucosa urethroplasty

Full length urethral strictures are difficult to treat. We describe our method of penile invagination to access the entire penile urethra during full length buccal mucosa urethroplasty.