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A new technique for performing hepatic resections utilizing a specially designed needle
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Letters to the Editor / The American Journal of Surgery 185 (2003) 601– 607
[5] Bland KI, Scott-Conner CE, Menck H, Winchester DP. Axillary dissection in breast-conserving surgery for stage I and II breast cancer: a National Cancer Data Base study of patterns of omission and implications for survival. J Am Coll Surg 1999;188:586 –96. [6] Saphir O, Amromin G. Obscure axillary lymph-node metastasis in carcinoma of the breast. Cancer 1948;1:238 – 41. [7] Weaver DL, Krag DN, Ashikaga T, Harlow SP, O’Connell M. Pathologic analysis of sentinel and nonsentinel lymph nodes in breast carcinoma: a multicenter study. Cancer 2000;88:1099 –107. [8] Schoenfeld A, Luqmani Y, Sinnett HD, Shousha S, Coombes RC. Keratin 19 mRNA measurement to detect micrometastases in lymph nodes in breast cancer patients. Br J Cancer 1996;74:1639 – 42. [9] Lockett MA, Baron PL, O’Brien PH, et al. Detection of occult breast cancer micrometastases in axillary lymph nodes using a multimarker reverse transcriptase-polymerase chain reaction panel. J Am Coll Surg 1998;187:9 –16. [10] Heller R, Becker J, Wasselle J, et al. Detection of submicroscopic lymph node metastases in patients with melanoma. Arch Surg 1991; 126:1455– 60. [11] Osborne MP, Ormiston N, Harmer CL, et al. Breast conservation in the treatment of early breast cancer. A 20-year follow-up. Cancer 1984;53:349 –55.
A new technique for performing hepatic resections utilizing a specially designed needle To the Editor: We read with great interest the proposed method of Chang et al [1] for performing hepatic resections utilizing a specially designed straight needle (Chang’s needle). We would like to congratulate the authors for their ingenious and simple technique. This article gave us the trigger to describe our own technique, which is based on a similar concept to the technique of Chang et al. However, our method has some alterations compared with the abovementioned technique, which we think could make the technique even more suitable for major hepatic resections. Our needle device consists of three parts. An outer stainless 18-gauge sheath with a cutting edge and two inner needles. The first inner needle has a blunt end, which minimizes the trauma to the liver parenchyma during the penetration of the needle. The second inner needle ends to a wire loop resembling the one used for endoscopic polypectomy (Fig. 1). In addition, we use 1 cm Dacron patches, which are used as cushions to allow the application of more tension during knotting of the threads, without the danger of cutting through the liver parenchyma. The first step is to penetrate the whole depth of the liver parenchyma with the needle, which consists in this step of the outer sheath and the inner blunt needle. Once the needle has penetrated the liver, the blunt needle is removed and the second needle with the wire loop is introduced through the canal of the sheath. Two threads (silk 0) are put through the loop and then pulled out through the sheath. The first thread is then knotted around the edge of the liver. Before the introduction of the needle into the liver parenchyma, and before pulling the threads through the loop, the needle is passed through a Dacron patch. The needle is then introduced for the second time in the
Fig. 1. Needle-device consisting of an outer 18-gauge sheath, a blunt inner needle, and an inner needle ending to a wire loop.
same manner through the liver. After the removal of the blunt needle and the introduction of the loop, the unknotted thread, which was passed with the first needle as well as a third thread are pulled though the sheath. The second thread is then knotted. The sutures are placed along the division line in one row (Fig. 2). The liver parenchyma is then divided approximately 1 cm from the suture lines. Tubular structures detected during transection may be ligated. The reduction of blood loss during liver transection remains a major element for the successful performance of a hepatic resection. A number of methods have been applied for this purpose. The classical Pringle maneuver offers a bloodless operating field at the cost of generalized ischemia of the liver. However, this ischemia may be critical for the
Fig. 2. A, B. Penetration of the needle, which consists of the outer sheath and the inner blunt needle, through the liver parenchyma (before the insertion and after the penetration of the liver, the needle is passed through Dacron patches). C. Removal of inner blunt needle and introduction of the needle with the wire loop. D. Two threads are passed through the loop. E. Pulling of the wire loop through the sheath. F. The first thread is knotted. G. Introduction of the needle and wire loop in the same manner. The second and third threads are pulled through the sheath. H. The second thread is knotted.
Letters to the Editor / The American Journal of Surgery 185 (2003) 601– 607
survival of the reserved hepatic tissue, especially in cirrhotic patients. Furthermore, it does not suppress backflow from the hepatic veins, which may lead to significant blood loss during transection. Other alternatives include the application of partial Pringle maneuver, hepatic vein exclusion, in situ cooling of the reserved hepatic tissue, and so forth [2]. A number of devices have been introduced in order to achieve a more accurate and bloodless transection of the hepatic parenchyma, ie, water jet knife, harmonic scalpel, or CUSA. However, even these instruments usually require the application of a complete or partial Pringle maneuver. We think that our method, as well as the method described by Chang et al [1] can facilitate a significant reduction of blood loss during hepatic resection without the need for Pringle maneuver or other vascular exclusion. In addition, it leads to significant reduction of the cost of the operation. Our technique differs from that described by Chang in the following aspects: (1) In the technique described by Chang the thread is catched with a hook, which is situated near the top of the inner needle. We used instead a wire loop similar to one used for endoscopic polypectomy. We believe that this device is less traumatic compared with the hook. (2) In the technique described by Chang the needle has to penetrate twice the liver in order to make a knot. In our technique, two threads are pulled through the needle, so that the times of the needle penetrations required are reduced to the half. Furthermore, this maneuver allows the passage of two consecutive threads from the same canal, so that no liver tissue remains between the two consecutive sutures. Finally, there is no danger of cutting the previous suture when penetrating the liver for the next suture. (3) We apply Dacron patches, which are used as cushions allowing the application of increased tension during knotting of the threads without the danger of cutting through the liver surface. Charalambos Lazaridis, MD Basilios Papaziogas, MD Aris Patsas, MD Thomas Papaziogas, MD Second Surgical Clinic Aristotle University Thessaloniki, Greece doi:10.1016/S0002-9610(02)01427-7 References [1] Chang YC, Nagasue N, Lin XZ, Chen CS. Easier hepatic resections with a straight needle. Am J Surg 2001;182:260 – 4. [2] Horgan PG, Leen E. A simple technique for vascular control during hepatectomy: the half-Pringle. Am J Surg 2001;182:265–7.
The Reply: Simple is the best, especially using my needle for one of the most difficult gastrointestinal operations (ie, hepatic
605
resection). It is my pleasure to learn about Dr. Lazardis’ modification. Every modification will lead to an easier and simpler way to reach our goal. I have several comments after reading his article. First, the hook of my needle is hidden in the sheath when pulling out from the liver parenchyma to prevent the unnecessary injuries. Therefore, the criticism in the current discussion is a misunderstanding. Second, the current wire loop method pulls out two threads at the same time. If the needle penetrates into the vessels (especially the weak wall of the hepatic vein), the vessels will be widely torn, instead of ligated, when tying up the threads with each adjacent thread. Third, although Dacron patches are a good idea, they will make the procedure more complicated and may only minimally help. Even without Dacron patches, most major bleeding can be reduced to a more easily controlled level so that parenchyma transection can be safely performed. Bloodless hepatic resection is not my goal, but sometimes is a result. If there is a septic focus (eg, intrahepatic stone or liver abscess), Dacron patches will be a contraindication. Yu-Chung Chang, MD, PhD Surgical Department College of Medicine National Cheng Kung University Tainan, R.O.C., China doi:10.1016/S0002-9610(02)01414-9
Early postoperative enteral feeding increases anastomotic strength in a peritonitis model To the Editor: I read with great interest the study by Khalili et al [1] as published in The American Journal of Surgery. This paper looks at the beneficial effects of early postoperative enteral feeding on anastomotic healing. They hypothesized that early postoperative enteral feeding would change the cytokine response after surgery, mainly by decreasing TNF-␣ levels, which would increase the collagen synthesis and so anastomotic strength. They used cecal ligation and puncture model to produce acute peritonitis in rats, and then obtained chronic sepsis by treating acute phase surgically and with intravenous fluid resuscitation. They looked at the cytokine profile and anastomotic burst strength in postoperatively enteral fed group and compared it with the controls (no feeding). They found decreased TNF-␣ levels and increased anastomotic strength in early fed animals, and concluded that early postoperative enteral feeding decreased TNF-␣ levels, which resulted in increased collagen formation and better anastomotic healing. In our study [2,3], we used a chronic septic rat fecal-agar pellet model to produce chronic intraabdominal sepsis by
Letters to the Editor / The American Journal of Surgery 185 (2003) 601– 607
[5] Bland KI, Scott-Conner CE, Menck H, Winchester DP. Axillary dissection in breast-conserving surgery for stage I and II breast cancer: a National Cancer Data Base study of patterns of omission and implications for survival. J Am Coll Surg 1999;188:586 –96. [6] Saphir O, Amromin G. Obscure axillary lymph-node metastasis in carcinoma of the breast. Cancer 1948;1:238 – 41. [7] Weaver DL, Krag DN, Ashikaga T, Harlow SP, O’Connell M. Pathologic analysis of sentinel and nonsentinel lymph nodes in breast carcinoma: a multicenter study. Cancer 2000;88:1099 –107. [8] Schoenfeld A, Luqmani Y, Sinnett HD, Shousha S, Coombes RC. Keratin 19 mRNA measurement to detect micrometastases in lymph nodes in breast cancer patients. Br J Cancer 1996;74:1639 – 42. [9] Lockett MA, Baron PL, O’Brien PH, et al. Detection of occult breast cancer micrometastases in axillary lymph nodes using a multimarker reverse transcriptase-polymerase chain reaction panel. J Am Coll Surg 1998;187:9 –16. [10] Heller R, Becker J, Wasselle J, et al. Detection of submicroscopic lymph node metastases in patients with melanoma. Arch Surg 1991; 126:1455– 60. [11] Osborne MP, Ormiston N, Harmer CL, et al. Breast conservation in the treatment of early breast cancer. A 20-year follow-up. Cancer 1984;53:349 –55.
A new technique for performing hepatic resections utilizing a specially designed needle To the Editor: We read with great interest the proposed method of Chang et al [1] for performing hepatic resections utilizing a specially designed straight needle (Chang’s needle). We would like to congratulate the authors for their ingenious and simple technique. This article gave us the trigger to describe our own technique, which is based on a similar concept to the technique of Chang et al. However, our method has some alterations compared with the abovementioned technique, which we think could make the technique even more suitable for major hepatic resections. Our needle device consists of three parts. An outer stainless 18-gauge sheath with a cutting edge and two inner needles. The first inner needle has a blunt end, which minimizes the trauma to the liver parenchyma during the penetration of the needle. The second inner needle ends to a wire loop resembling the one used for endoscopic polypectomy (Fig. 1). In addition, we use 1 cm Dacron patches, which are used as cushions to allow the application of more tension during knotting of the threads, without the danger of cutting through the liver parenchyma. The first step is to penetrate the whole depth of the liver parenchyma with the needle, which consists in this step of the outer sheath and the inner blunt needle. Once the needle has penetrated the liver, the blunt needle is removed and the second needle with the wire loop is introduced through the canal of the sheath. Two threads (silk 0) are put through the loop and then pulled out through the sheath. The first thread is then knotted around the edge of the liver. Before the introduction of the needle into the liver parenchyma, and before pulling the threads through the loop, the needle is passed through a Dacron patch. The needle is then introduced for the second time in the
Fig. 1. Needle-device consisting of an outer 18-gauge sheath, a blunt inner needle, and an inner needle ending to a wire loop.
same manner through the liver. After the removal of the blunt needle and the introduction of the loop, the unknotted thread, which was passed with the first needle as well as a third thread are pulled though the sheath. The second thread is then knotted. The sutures are placed along the division line in one row (Fig. 2). The liver parenchyma is then divided approximately 1 cm from the suture lines. Tubular structures detected during transection may be ligated. The reduction of blood loss during liver transection remains a major element for the successful performance of a hepatic resection. A number of methods have been applied for this purpose. The classical Pringle maneuver offers a bloodless operating field at the cost of generalized ischemia of the liver. However, this ischemia may be critical for the
Fig. 2. A, B. Penetration of the needle, which consists of the outer sheath and the inner blunt needle, through the liver parenchyma (before the insertion and after the penetration of the liver, the needle is passed through Dacron patches). C. Removal of inner blunt needle and introduction of the needle with the wire loop. D. Two threads are passed through the loop. E. Pulling of the wire loop through the sheath. F. The first thread is knotted. G. Introduction of the needle and wire loop in the same manner. The second and third threads are pulled through the sheath. H. The second thread is knotted.
Letters to the Editor / The American Journal of Surgery 185 (2003) 601– 607
survival of the reserved hepatic tissue, especially in cirrhotic patients. Furthermore, it does not suppress backflow from the hepatic veins, which may lead to significant blood loss during transection. Other alternatives include the application of partial Pringle maneuver, hepatic vein exclusion, in situ cooling of the reserved hepatic tissue, and so forth [2]. A number of devices have been introduced in order to achieve a more accurate and bloodless transection of the hepatic parenchyma, ie, water jet knife, harmonic scalpel, or CUSA. However, even these instruments usually require the application of a complete or partial Pringle maneuver. We think that our method, as well as the method described by Chang et al [1] can facilitate a significant reduction of blood loss during hepatic resection without the need for Pringle maneuver or other vascular exclusion. In addition, it leads to significant reduction of the cost of the operation. Our technique differs from that described by Chang in the following aspects: (1) In the technique described by Chang the thread is catched with a hook, which is situated near the top of the inner needle. We used instead a wire loop similar to one used for endoscopic polypectomy. We believe that this device is less traumatic compared with the hook. (2) In the technique described by Chang the needle has to penetrate twice the liver in order to make a knot. In our technique, two threads are pulled through the needle, so that the times of the needle penetrations required are reduced to the half. Furthermore, this maneuver allows the passage of two consecutive threads from the same canal, so that no liver tissue remains between the two consecutive sutures. Finally, there is no danger of cutting the previous suture when penetrating the liver for the next suture. (3) We apply Dacron patches, which are used as cushions allowing the application of increased tension during knotting of the threads without the danger of cutting through the liver surface. Charalambos Lazaridis, MD Basilios Papaziogas, MD Aris Patsas, MD Thomas Papaziogas, MD Second Surgical Clinic Aristotle University Thessaloniki, Greece doi:10.1016/S0002-9610(02)01427-7 References [1] Chang YC, Nagasue N, Lin XZ, Chen CS. Easier hepatic resections with a straight needle. Am J Surg 2001;182:260 – 4. [2] Horgan PG, Leen E. A simple technique for vascular control during hepatectomy: the half-Pringle. Am J Surg 2001;182:265–7.
The Reply: Simple is the best, especially using my needle for one of the most difficult gastrointestinal operations (ie, hepatic
605
resection). It is my pleasure to learn about Dr. Lazardis’ modification. Every modification will lead to an easier and simpler way to reach our goal. I have several comments after reading his article. First, the hook of my needle is hidden in the sheath when pulling out from the liver parenchyma to prevent the unnecessary injuries. Therefore, the criticism in the current discussion is a misunderstanding. Second, the current wire loop method pulls out two threads at the same time. If the needle penetrates into the vessels (especially the weak wall of the hepatic vein), the vessels will be widely torn, instead of ligated, when tying up the threads with each adjacent thread. Third, although Dacron patches are a good idea, they will make the procedure more complicated and may only minimally help. Even without Dacron patches, most major bleeding can be reduced to a more easily controlled level so that parenchyma transection can be safely performed. Bloodless hepatic resection is not my goal, but sometimes is a result. If there is a septic focus (eg, intrahepatic stone or liver abscess), Dacron patches will be a contraindication. Yu-Chung Chang, MD, PhD Surgical Department College of Medicine National Cheng Kung University Tainan, R.O.C., China doi:10.1016/S0002-9610(02)01414-9
Early postoperative enteral feeding increases anastomotic strength in a peritonitis model To the Editor: I read with great interest the study by Khalili et al [1] as published in The American Journal of Surgery. This paper looks at the beneficial effects of early postoperative enteral feeding on anastomotic healing. They hypothesized that early postoperative enteral feeding would change the cytokine response after surgery, mainly by decreasing TNF-␣ levels, which would increase the collagen synthesis and so anastomotic strength. They used cecal ligation and puncture model to produce acute peritonitis in rats, and then obtained chronic sepsis by treating acute phase surgically and with intravenous fluid resuscitation. They looked at the cytokine profile and anastomotic burst strength in postoperatively enteral fed group and compared it with the controls (no feeding). They found decreased TNF-␣ levels and increased anastomotic strength in early fed animals, and concluded that early postoperative enteral feeding decreased TNF-␣ levels, which resulted in increased collagen formation and better anastomotic healing. In our study [2,3], we used a chronic septic rat fecal-agar pellet model to produce chronic intraabdominal sepsis by