Method Of Stump Closure Research Articles

Decreasing Pancreatic Leak After Distal Pancreatectomy: Saline-coupled Radiofrequency Ablation in a Porcine Model

Despite marked improvements in pancreatic surgery, the high incidence and morbidity of pancreatic leak after resection has remained unchanged. The objective of this study was to evaluate the role of saline-coupled radiofrequency ablation (TissueLink) as an alternative to traditional methods of stump closure in an animal model of distal pancreatectomy. Forty swine were randomized after pancreatic transection and remnant stump was either oversewn in a traditional fashion (control) or treated with the device alone (TissueLink). Animals were killed and necropsied at 3 or 5 weeks postoperatively. Primary endpoints were the development of a pancreatic fistula defined as dye extravasation from the remnant duct, presence of undrained amylase-rich fluid collections/abscess, and greater than threefold drain/serum amylase after the third postoperative day. The incidence of pancreatic leak in the TissueLink group was 5.5 vs 42% in the control group (p = 0.01). There were no differences in operative time or other clinical parameters measured. Histologic analysis of the remnant pancreatic stumps confirmed our results. These data support our hypothesis that saline-coupled radiofrequency ablation leads to obliteration of ducts with a resultant decrease in pancreatic leak and subsequent complications. This technology may play a substantial role in preventing this dreaded complication in the clinical setting.

Analysis of stapling versus endoloops in appendiceal stump closure

The effectiveness of various appendiceal stump closure methods has not been evaluated systematically. The aim of this study was to compare the morbidity of stump closure by stapling or use of endoloops. A non-concurrent cohort study of prospectively acquired data was performed. The primary outcome variable was the rate of intra-abdominal surgical-site infection. Secondary outcome measures were complications, duration of intervention, hospital stay, rate of readmission to hospital and the difference in direct costs of the operation. Staples were used in 60.5 per cent and endoloops in 39.5 per cent of 6486 patients operated on for suspected appendicitis between January 1995 and December 2003. Among 4489 patients with acute appendicitis the rate of intra-abdominal surgical-site infection was 0.7 per cent in the stapler group and 1.7 per cent in the endoloop group (P = 0.004). The rate of readmission to hospital was 0.9 and 2.1 per cent respectively (P = 0.001). Application of a stapler for transection and closure of the appendiceal stump in patients with acute appendicitis lowered the risk of postoperative intra-abdominal surgical-site infection and the need for readmission to hospital.

Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling?

This metaanalysis aimed to compare endoscopic linear stapling and loop ligatures used to secure the base of the appendix. Randomized controlled trials on appendix stump closure during laparoscopic appendectomy were systematically searched and critically appraised. The results in terms of complication rates, operating time, and hospital stay were pooled by standard metaanalytic techniques. Data on 427 patients from four studies were included. The operative time was 9 min longer when loops were used (p = 0.04). Superficial wound infections (odds ratio [OR], 0.21; 95% confidence interval (CI), 0.06-0.71; p = 0.01) and postoperative ileus (OR, 0.36; 95% CI, 0.14-0.89; p = 0.03) were significantly less frequent when the appendix stump was secured with staples instead of loops. Of 10 intraoperative ruptures of the appendix, 7 occurred in loop-treated patients (p = 0.46). Hospital stay and frequency of postoperative intraabdominal abscess also were comparable in loop-treated and staple-treated patients. The clinical evidence on stump closure methods in laparoscopic appendectomy favors the routine use of endoscopic staplers.

Morbidity, mortality, and technical factors of distal pancreatectomy

Background: Pancreatic leak is a major source of morbidity associated with pancreatic surgery. We sought to identify disease and technique-dependent factors associated with morbidity and mortality after distal pancreatectomy. Methods: Retrospective review of patients who underwent distal pancreatectomy during a 5-year period. Clinical, technical, and pathologic data were correlated with operative morbidity or mortality. Results: Fifty-one patients underwent distal pancreatectomy for primary pancreatic disease, extrapancreatic malignancy, or trauma. Overall perioperative mortality and morbidity rates were 4% and 47%, respectively. Pancreatic leak was the most common complication, occurring in 26% of patients. Overall complications and pancreatic leaks occurred more often after distal pancreatectomy for trauma and in patients with a sutured pancreatic stump closure. Conclusions: Distal pancreatectomy can be performed with a low rate of mortality, though pancreatic leak is a common cause of morbidity. The urgency of the procedure and the method of pancreatic stump closure may influence postoperative morbidity.

An improved method of bronchial stump closure for prevention of bronchopleural fistula in pulmonary resection.

We performed 880 pulmonary resections from January 1982 to June 1988 using Sweet's procedure for closure of the bronchial stump, in which 39 patients (4.4%) developed bronchial fistulas. Bronchoscopic studies showed that bronchopleural fistulas were located mainly at the corner of the stump. This indicates that the corner is the point with the highest tension when Sweet's procedure is employed. In some cases, stumps were injured by suture materials, resulting in bronchopleural fistulas. Since July 1988, bronchial stumps have been closed by using two pairs of teflon pledgets with additional interrupted sutures. From July 1988 to April 1990, 288 patients were treated by this new method, and only one of them developed bronchopleural fistula. This new method prevents injury of the stump by suture material and reduces the tension at the bronchial stump for a long time. Thus, pulmonary resections can be safely employed even after anti-cancer chemotherapy and/or radiation therapy.

Management of the difficult duodenal stump

Leakage from the duodenal stump has been the most feared complication of the Billroth II reconstruction following gastric resection. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. One hundred and forty-seven (74%) patients had duodenal ulcers; 28 (14%) had gastric ulcers; and 25 (13%) had a variety of other inflammatory conditions. The most common indication for operation was acute hemorrhage (51%), followed by perforation (24%), intractability (15%), and obstruction (10%). Conventional duodenal closures were performed in 160 (80%) patients, Nissen's closure in 25 (13%), Bancroft's closure in 6 (3%), and tube duodenostomy in 9 (5%). Duodenal leaks occurred in four (2.5%) patients with conventional closures and in three (33%) patients with tube duodenostomies. No leaks occurred in patients with Nissen's or Bancroft's closures. The hospital mortality rate for the series was 9.5%; however, no patient who developed a duodenal leak died. We conclude that Nissen's and Bancroft's closures were safe and effective, but that tube duodenostomy did not reliably prevent uncontrolled leakage.

Closure of an aortic stump: A new method

The traditional methods for closure of an aortic stump following removal of an infected aortic graft are attended by an abnormal stress on the suture line, which may lead to aortic stump blowout and exsanguination. Herein is described a new method for aortic stump closure, creating parallel opposing vector forces, which has the theoretical advantage of creating a functional bifurcation which can direct the flow of blood into the renal arteries.

One Hundred and Ten Consecutive Cases of Pulmonary Resection for Tuberculosis: A New Method of Bronchial Stump Closure

A perusal of all the publications on the subject, however, reveals that the incidence of bronchopleural fistula, which is one of the most disastrous complications, appears to be high. It occurred in about 8 per cent to 10 per cent of the numerous cases of pulmonary resections for tuberculosis reported by different authors (Table I). Because of the seriousness and frequency of this complication, there are physicians, internists and surgeons alike who still hesitate in advising pulmonary resection to patients who need it. The purpose of this paper is threefold: 1. To discuss etiological factors in connection with bronchopleural fistulae. 2. To describe a new technique of bronchial closure. 3. To report 11 consecutive cases of pulmonary resection for tuberculsis.