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Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy
The American Journal of Surgery 182 (2001) 257–259
How I do it
Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy Masanori Sugiyama, M.D., Ph.D.*, Nobutsugu Abe, M.D., Ph.D., Yumi Izumisato, M.D., Makoto Tokuhara, M.D., Ph.D., Tadahiko Masaki, M.D., Ph.D., Toshiyuki Mori, M.D., Ph.D., Yutaka Atomi, M.D., Ph.D. First Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan Manuscript received March 1, 2001; revised manuscript June 4, 2001
Abstract Background: Pancreatoenterostomic leakage after pancreatoduodenectomy may be caused partly by pancreatic juice leakage from transected branch pancreatic ducts on the pancreatic cut surface that do not drain into the main pancreatic duct after pancreatectomy. Methods: We devised a new technique of pancreatic transection using an ultrasonic dissector followed by duct-to-mucosa pancreatojejunostomy, in order to prevent pancreatoenterostomic leakage after pancreatoduodenectomy in patients with a soft pancreas and a small main pancreatic duct. During pancreatic transection, branch pancreatic ducts and blood vessels are adequately skeletonized and securely ligated. The pancreatic duct is anastomosed to the full thickness of the jejunum with four to six interrupted sutures. Results: Ten patients with a nondilated pancreatic duct (2 to 3 mm) underwent pancreatoduodenectomy by the present method. During pancreatic transection, 24 to 35 ducts including the pancreatic ducts and blood vessels were skeletonized and ligated. Postoperatively, no patients developed pancreatojejunostomic leakage. The present method may prevent pancreatoenterostomic leakage after pancreatoduodenectomy. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Pancreatoduodenectomy; Pancreatic transection; Pancreatoenterostomic leakage; Ultrasonic dissector
Despite recent advances in operative techniques and postoperative care, pancreatoenterostomic leakage is still a common and serious complication after pancreatoduodenectomy [1]. The leakage sometimes causes intraabdominal abscess or bleeding and may result in a fatal outcome. Various methods have been employed to prevent the leakage, including duct-tomucosa anastomosis, pancreatogastrostomy, pancreatic duct stenting (external drainage of pancreatic juice), fibrin glue spray, and prophylactic administration of a somatostatin analogue [1– 4]. However, these methods cannot completely eliminate the possibility of leakage, particularly when the remnant pancreas is soft with a small main pancreatic duct [5]. This may be partly due to pancreatic juice leakage from transected branch pancreatic ducts on the pancreatic cut surface that do not drain into the main pancreatic duct after pancreatectomy [6].
* Corresponding author. Tel.: ⫹81-422-47-5511; fax: ⫹81-422-479926. E-mail address: [email protected]
Using an ultrasonic dissector in pancreatic transection reportedly allows adequate skeletonization and secure ligation of the small branch pancreatic ducts and reduces the incidence of pancreatic fistula, in clinical distal pancreatectomy and experimental pancreatoenterostomy after pancreatic resection [7–9]. To prevent pancreatojejunostomic leakage after pancreatoduodenectomy in patients with a soft pancreas and a small main pancreatic duct, we devised a new technique of pancreatic transection using an ultrasonic dissector followed by duct-to-mucosa anastomosis.
Surgical technique The pancreatic neck is dissected from the superior mesenteric and portal veins. Either a broad malleable sound or gauze is passed under the pancreatic neck to protect the veins from ultrasonic injury. After clamping the pancreas with intestinal forceps proximal and distal to the transection plane, the pancreas is transected using an ultrasonic dissector (Selector; Integra Neurosciences, Plainsboro, New Jer-
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 6 9 6 - 1
258
M. Sugiyama et al. / The American Journal of Surgery 182 (2001) 257–259
Fig. 1. Pancreatic transection using an ultrasonic dissector. Three small ducts (pancreatic ducts or blood vessels; arrowheads) are adequately skeletonized near the upper border of the transection plane. The main pancreatic duct (arrow) is partially exposed in the middle portion.
sey) at the lowest vibration level. During transection, small branch pancreatic ducts and blood vessels are skeletonized and tied with 4-0 or 5-0 silk sutures (Fig. 1). The main pancreatic duct is identified and cut without ligation, at the level of the transection plane (Fig. 2). The pancreatic cut surface is not oversewn. After conventional or pylorus-preserving pancreatoduodenectomy, a Roux-en-Y segment of the jejunum is approximated to the viscera assuring that the pancreas, bile duct, and stomach (or duodenum) are anastomosed in proximalto-distal order. Pancreatojejunostomy is conducted in endto-side anastomosis using two layers including duct-tomucosa and the pancreatic parenchyma-to-the jejunal seromuscular layer, even in cases with a small pancreatic duct. First, the posterior border of the pancreatic stump and the jejunal seromuscular layer are sutured using interrupted 3-0 silk sutures. Then, a small opening, equal to the pancreatic duct diameter, is made in the jejunum at the planned site of anastomosis. The pancreatic duct is then anastomosed to the jejunum (the mucosal layer and a small part of the seromuscular layer), using four to six interrupted sutures (5-0 Maxon, monofilament polyglyconate; Davis & Geck, St Louis, Missouri). A 4-Fr polyvinyl chloride tube (Sumitomo Bakelite, Tokyo, Japan) is inserted through the anastomosis into the pancreatic duct, for partial external drainage of
Fig. 2. The main pancreatic duct is skeletonized at the final stage of pancreatic transection.
pancreatic juice. The opposite end of the pancreatic tube is introduced externally through the jejunal wall. Finally, the anterior border of the pancreatic stump and the jejunal seromuscular layer are sutured.
Results Ten patients underwent conventional (n ⫽ 2) or pyloruspreserving (n ⫽ 8) pancreatoduodenectomy, using an ultrasonic dissector. Diagnoses included bile duct carcinoma (n ⫽ 6), carcinoma of the papilla of Vater (n ⫽ 2), pancreatic head carcinoma (n ⫽ 1; carcinoma involved the Santorini duct not the main pancreatic duct), and duodenal carcinoma (n ⫽ 1). On endoscopic retrograde pancreatography, the main pancreatic duct of the pancreatic neck measured 2 to 3 mm in diameter. At surgery, the remnant pancreas was soft with a normal small pancreatic duct. During pancreatic transection, 24 to 35 ducts (mean, 28) including the pancreatic ducts and blood vessels were skeletonized and ligated. Five to seven pancreatic ducts were identified microscopically in the cut surface of the resected pancreas in the 4 cases examined. The time required for pancreatic transection ranged from 19 to 50 minutes (mean 31 minutes). Postoperatively, no patients developed pancreatic fistula or prolonged (⬎7 days) discharge of a high amylase content from a perianastomotic peritoneal drain.
M. Sugiyama et al. / The American Journal of Surgery 182 (2001) 257–259
Comments After pancreatoduodenectomy, the cut surface of the remnant pancreas has several stumps of the branch pancreatic ducts. Because of their small diameters, these ducts cannot all be identified and ligated during pancreatic transection. However, stamping litmus paper on the pancreatic cut surface after stimulation with secretin may help in localizing transected branch ducts [6]. Various methods of pancreatic stump management, such as oversewing, compression by the gastric or jejunal wall, and application of fibrin glue, have been employed [1,2], but none completely seals the branch ducts. Unrecognized or unsealed branch pancreatic ducts may lead to pancreatic juice leakage and, ultimately, major anastomotic leakage. In the present study, the ultrasonic dissector allowed adequate skeletonization and secure ligation of even small branch pancreatic ducts on the pancreatic cut surface. The nonfibrotic pancreas was easy to transect with the ultrasonic dissector, in contrast to secondary chronic pancreatitis caused by pancreatic ductal obstruction [7–9]. Transection time was relatively prolonged but can be shortened by experience. No pancreatic leakages occurred in our patients with a soft remnant pancreas and a small main pancreatic duct, who have been considered to be at high risk for postoperative leakage. Duct-to-mucosa pancreatojejunostomy and pancreatic duct stenting also may have contributed to the prevention of anastomotic leakage. The present preliminary study indicates that pancreatic
259
transection using an ultrasonic dissector may prevent pancreatoenterostomic leakage after pancreatoduodenectomy for patients with a soft pancreatic remnant and a small main pancreatic duct. A randomized trial comparing the ultrasonic dissector and conventional transection in pancreatoduodenectomy is ongoing in our department.
References [1] Sikora SS, Posner MC. Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82:1590 –7. [2] Howard JM. Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection. J Am Coll Surg 1997;184:454 –7. [3] Mackie JA, Rhoads JE, Park CD. Pancreaticogastrostomy: a further evaluation. Ann Surg 1975;181:541–5. [4] Buchler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–31. [5] Friess H, Malfertheiner P, Isenmann R, et al. The risk of pancreaticointestinal anastomosis can be predicted preoperatively. Pancreas 1996;12:202– 8. [6] Yamaguchi K, Chijiiwa K, Shimizu S, et al. Litmus paper helps detect potential pancreatoenterostomy leakage. Am J Surg 1998;175:227– 8. [7] Kuroda Y, Tanioka Y, Suzuki Y, et al. Distal pancreatectomy using the ultrasonic dissector. J Am Coll Surg 1995;180:737– 8. [8] Kuroda Y, Tanioka Y, Matsumoto S, et al. A new technique for pancreaticogastrointestinal anastomosis without suturing the pancreatic parenchyma. J Am Coll Surg 1995;181:311–14. [9] Suzuki Y, Fujino Y, Tanioka Y, et al. Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas. Br J Surg 1999;86:608 –11.
How I do it
Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy Masanori Sugiyama, M.D., Ph.D.*, Nobutsugu Abe, M.D., Ph.D., Yumi Izumisato, M.D., Makoto Tokuhara, M.D., Ph.D., Tadahiko Masaki, M.D., Ph.D., Toshiyuki Mori, M.D., Ph.D., Yutaka Atomi, M.D., Ph.D. First Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan Manuscript received March 1, 2001; revised manuscript June 4, 2001
Abstract Background: Pancreatoenterostomic leakage after pancreatoduodenectomy may be caused partly by pancreatic juice leakage from transected branch pancreatic ducts on the pancreatic cut surface that do not drain into the main pancreatic duct after pancreatectomy. Methods: We devised a new technique of pancreatic transection using an ultrasonic dissector followed by duct-to-mucosa pancreatojejunostomy, in order to prevent pancreatoenterostomic leakage after pancreatoduodenectomy in patients with a soft pancreas and a small main pancreatic duct. During pancreatic transection, branch pancreatic ducts and blood vessels are adequately skeletonized and securely ligated. The pancreatic duct is anastomosed to the full thickness of the jejunum with four to six interrupted sutures. Results: Ten patients with a nondilated pancreatic duct (2 to 3 mm) underwent pancreatoduodenectomy by the present method. During pancreatic transection, 24 to 35 ducts including the pancreatic ducts and blood vessels were skeletonized and ligated. Postoperatively, no patients developed pancreatojejunostomic leakage. The present method may prevent pancreatoenterostomic leakage after pancreatoduodenectomy. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Pancreatoduodenectomy; Pancreatic transection; Pancreatoenterostomic leakage; Ultrasonic dissector
Despite recent advances in operative techniques and postoperative care, pancreatoenterostomic leakage is still a common and serious complication after pancreatoduodenectomy [1]. The leakage sometimes causes intraabdominal abscess or bleeding and may result in a fatal outcome. Various methods have been employed to prevent the leakage, including duct-tomucosa anastomosis, pancreatogastrostomy, pancreatic duct stenting (external drainage of pancreatic juice), fibrin glue spray, and prophylactic administration of a somatostatin analogue [1– 4]. However, these methods cannot completely eliminate the possibility of leakage, particularly when the remnant pancreas is soft with a small main pancreatic duct [5]. This may be partly due to pancreatic juice leakage from transected branch pancreatic ducts on the pancreatic cut surface that do not drain into the main pancreatic duct after pancreatectomy [6].
* Corresponding author. Tel.: ⫹81-422-47-5511; fax: ⫹81-422-479926. E-mail address: [email protected]
Using an ultrasonic dissector in pancreatic transection reportedly allows adequate skeletonization and secure ligation of the small branch pancreatic ducts and reduces the incidence of pancreatic fistula, in clinical distal pancreatectomy and experimental pancreatoenterostomy after pancreatic resection [7–9]. To prevent pancreatojejunostomic leakage after pancreatoduodenectomy in patients with a soft pancreas and a small main pancreatic duct, we devised a new technique of pancreatic transection using an ultrasonic dissector followed by duct-to-mucosa anastomosis.
Surgical technique The pancreatic neck is dissected from the superior mesenteric and portal veins. Either a broad malleable sound or gauze is passed under the pancreatic neck to protect the veins from ultrasonic injury. After clamping the pancreas with intestinal forceps proximal and distal to the transection plane, the pancreas is transected using an ultrasonic dissector (Selector; Integra Neurosciences, Plainsboro, New Jer-
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 6 9 6 - 1
258
M. Sugiyama et al. / The American Journal of Surgery 182 (2001) 257–259
Fig. 1. Pancreatic transection using an ultrasonic dissector. Three small ducts (pancreatic ducts or blood vessels; arrowheads) are adequately skeletonized near the upper border of the transection plane. The main pancreatic duct (arrow) is partially exposed in the middle portion.
sey) at the lowest vibration level. During transection, small branch pancreatic ducts and blood vessels are skeletonized and tied with 4-0 or 5-0 silk sutures (Fig. 1). The main pancreatic duct is identified and cut without ligation, at the level of the transection plane (Fig. 2). The pancreatic cut surface is not oversewn. After conventional or pylorus-preserving pancreatoduodenectomy, a Roux-en-Y segment of the jejunum is approximated to the viscera assuring that the pancreas, bile duct, and stomach (or duodenum) are anastomosed in proximalto-distal order. Pancreatojejunostomy is conducted in endto-side anastomosis using two layers including duct-tomucosa and the pancreatic parenchyma-to-the jejunal seromuscular layer, even in cases with a small pancreatic duct. First, the posterior border of the pancreatic stump and the jejunal seromuscular layer are sutured using interrupted 3-0 silk sutures. Then, a small opening, equal to the pancreatic duct diameter, is made in the jejunum at the planned site of anastomosis. The pancreatic duct is then anastomosed to the jejunum (the mucosal layer and a small part of the seromuscular layer), using four to six interrupted sutures (5-0 Maxon, monofilament polyglyconate; Davis & Geck, St Louis, Missouri). A 4-Fr polyvinyl chloride tube (Sumitomo Bakelite, Tokyo, Japan) is inserted through the anastomosis into the pancreatic duct, for partial external drainage of
Fig. 2. The main pancreatic duct is skeletonized at the final stage of pancreatic transection.
pancreatic juice. The opposite end of the pancreatic tube is introduced externally through the jejunal wall. Finally, the anterior border of the pancreatic stump and the jejunal seromuscular layer are sutured.
Results Ten patients underwent conventional (n ⫽ 2) or pyloruspreserving (n ⫽ 8) pancreatoduodenectomy, using an ultrasonic dissector. Diagnoses included bile duct carcinoma (n ⫽ 6), carcinoma of the papilla of Vater (n ⫽ 2), pancreatic head carcinoma (n ⫽ 1; carcinoma involved the Santorini duct not the main pancreatic duct), and duodenal carcinoma (n ⫽ 1). On endoscopic retrograde pancreatography, the main pancreatic duct of the pancreatic neck measured 2 to 3 mm in diameter. At surgery, the remnant pancreas was soft with a normal small pancreatic duct. During pancreatic transection, 24 to 35 ducts (mean, 28) including the pancreatic ducts and blood vessels were skeletonized and ligated. Five to seven pancreatic ducts were identified microscopically in the cut surface of the resected pancreas in the 4 cases examined. The time required for pancreatic transection ranged from 19 to 50 minutes (mean 31 minutes). Postoperatively, no patients developed pancreatic fistula or prolonged (⬎7 days) discharge of a high amylase content from a perianastomotic peritoneal drain.
M. Sugiyama et al. / The American Journal of Surgery 182 (2001) 257–259
Comments After pancreatoduodenectomy, the cut surface of the remnant pancreas has several stumps of the branch pancreatic ducts. Because of their small diameters, these ducts cannot all be identified and ligated during pancreatic transection. However, stamping litmus paper on the pancreatic cut surface after stimulation with secretin may help in localizing transected branch ducts [6]. Various methods of pancreatic stump management, such as oversewing, compression by the gastric or jejunal wall, and application of fibrin glue, have been employed [1,2], but none completely seals the branch ducts. Unrecognized or unsealed branch pancreatic ducts may lead to pancreatic juice leakage and, ultimately, major anastomotic leakage. In the present study, the ultrasonic dissector allowed adequate skeletonization and secure ligation of even small branch pancreatic ducts on the pancreatic cut surface. The nonfibrotic pancreas was easy to transect with the ultrasonic dissector, in contrast to secondary chronic pancreatitis caused by pancreatic ductal obstruction [7–9]. Transection time was relatively prolonged but can be shortened by experience. No pancreatic leakages occurred in our patients with a soft remnant pancreas and a small main pancreatic duct, who have been considered to be at high risk for postoperative leakage. Duct-to-mucosa pancreatojejunostomy and pancreatic duct stenting also may have contributed to the prevention of anastomotic leakage. The present preliminary study indicates that pancreatic
259
transection using an ultrasonic dissector may prevent pancreatoenterostomic leakage after pancreatoduodenectomy for patients with a soft pancreatic remnant and a small main pancreatic duct. A randomized trial comparing the ultrasonic dissector and conventional transection in pancreatoduodenectomy is ongoing in our department.
References [1] Sikora SS, Posner MC. Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82:1590 –7. [2] Howard JM. Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection. J Am Coll Surg 1997;184:454 –7. [3] Mackie JA, Rhoads JE, Park CD. Pancreaticogastrostomy: a further evaluation. Ann Surg 1975;181:541–5. [4] Buchler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–31. [5] Friess H, Malfertheiner P, Isenmann R, et al. The risk of pancreaticointestinal anastomosis can be predicted preoperatively. Pancreas 1996;12:202– 8. [6] Yamaguchi K, Chijiiwa K, Shimizu S, et al. Litmus paper helps detect potential pancreatoenterostomy leakage. Am J Surg 1998;175:227– 8. [7] Kuroda Y, Tanioka Y, Suzuki Y, et al. Distal pancreatectomy using the ultrasonic dissector. J Am Coll Surg 1995;180:737– 8. [8] Kuroda Y, Tanioka Y, Matsumoto S, et al. A new technique for pancreaticogastrointestinal anastomosis without suturing the pancreatic parenchyma. J Am Coll Surg 1995;181:311–14. [9] Suzuki Y, Fujino Y, Tanioka Y, et al. Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas. Br J Surg 1999;86:608 –11.