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Linear staplers in pancreatic surgery
The American Journal of Surgery 187 (2004) 796
Letter to the Editor Linear staplers in pancreatic surgery To the Editor: I would like to respond to the recent Letter to the Editor in the June 2003 issue of The American Journal of Surgery by Drs. Evans and Pisters [1] in regard to my previously published “How I do it” paper entitled, “Novel applications of Endo GIA linear staplers during pancreaticoduodenectomy and total pancreatectomy [2]. The “How I do it” paper was not intended (nor was it implied) to be an in-depth step-by-step description of how to perform a pancreaticoduodenectomy or total pancreatectomy (including any description of the dissection and exposure of the mesenteric vessels during such procedures). Instead, it was intended to be a description of how I specifically utilize linear staplers during pancreatic surgery. The portion of my paper with which Dr. Evans and Pisters contended most was the section describing the division of the uncinate process. In their letter, they stated that “Dr. Povoski describes the use of the Endo GIA linear stapler for the dissection of the uncinate process and pancreatic head from the superior mesenteric-portal vein confluence and the right lateral border of the superior mesenteric artery (SMA).” However, nowhere in the paper do I use the word “dissection.” Instead, it is clearly stated in my paper as division of the uncinate process, and not as dissection of the uncinate process. Specifically, it states that “the remaining attachments of the uncinate process of the pancreatic head to the posterior areolar tissue attachments of the retroperitoneum and to the vascular branches of the superior mesenteric vein and artery are then divided parallel to the superior mesenteric vein and artery and portal vein.” Division of these previously mentioned retroperitoneal tissues with a linear stapler does not imply anything with regard to the process of proper anatomic and oncologic dissection of the mesenteric/portal vessels prior to division of adjoining retroperitoneal tissue planes. Nor is it stated anywhere in the paper that linear staplers are a substitute for proper anatomic and oncologic dissection. This fact is easily apparent to me, and I assume to most others reading my paper. Being a surgical oncologist, I whole-heartedly agree with Drs. Evans and Pisters about the importance of proper anatomic and oncologic dissection during any cancer operation, including the retroperitoneal dissection during pancreaticoduodenectomy. However, utilization of such linear staplers for division of tissues adjacent to the uncinate process does not imply “nonanatomic retroperitoneal dissection.”
In their letter, Drs. Evans and Pisters discuss the oncologic importance of surgical margins during pancreaticoduodenectomy. I strongly agree with them and I appreciate its importance. However, in their criticism of my paper, they fail to mention that this was addressed in my previous paper by the statement: “In those cases involving a pancreatic neoplasm located in the uncinate process, it should be left to the surgeon’s discretion whether this maneuver should be utilized so as not to compromise the posterior surgical margin of resection.” Therefore, I believe we agree on this issue (and do not disagree, as they suggest). It is apparent that Drs. Evans and Pisters were troubled by my statement that “great care is taken to palpate the superior mesenteric artery before and after closing the jaws of the stapler.” This statement does not mean or imply that I advocate simply palpating the SMA, as they put it, in order to adequately identify the SMA. Instead, palpating the SMA before and after closing the jaws of the linear stapler and before firing the device is just good common sense to assure that one has not inadvertently captured any tissue within the jaws of the linear stapler that was not intended for division, including the SMA. Once again, division does not imply dissection. I hope that I have clarified the misconceptions of Drs. Evans and Pisters regarding my “How I do it” paper. With a more critical understanding of the paper’s intent, I truly believe that they would find that we have no disagreements concerning proper anatomic and oncologic dissection. Stephen P. Povoski, M.D. Division of Surgical Oncology Arthur G. James Cancer Hospital & Richard J. Solove Research Institute The Ohio State University Columbus, Ohio doi:10.1016/j.amjsurg.2003.11.033
References [1] Evans DB, Pisters PWT. Novel applications of EndoGIA linear staplers during pancreaticoduodenectomy and total pancreatectomy (letter). Am J Surg 2003;185:606 –7. [2] Povoski SP. Novel applications of Endo GIA linear staplers during pancreaticoduodenectomy and total pancreatectomy. Am J Surg 2001; 182:77– 80.
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved.
Letter to the Editor Linear staplers in pancreatic surgery To the Editor: I would like to respond to the recent Letter to the Editor in the June 2003 issue of The American Journal of Surgery by Drs. Evans and Pisters [1] in regard to my previously published “How I do it” paper entitled, “Novel applications of Endo GIA linear staplers during pancreaticoduodenectomy and total pancreatectomy [2]. The “How I do it” paper was not intended (nor was it implied) to be an in-depth step-by-step description of how to perform a pancreaticoduodenectomy or total pancreatectomy (including any description of the dissection and exposure of the mesenteric vessels during such procedures). Instead, it was intended to be a description of how I specifically utilize linear staplers during pancreatic surgery. The portion of my paper with which Dr. Evans and Pisters contended most was the section describing the division of the uncinate process. In their letter, they stated that “Dr. Povoski describes the use of the Endo GIA linear stapler for the dissection of the uncinate process and pancreatic head from the superior mesenteric-portal vein confluence and the right lateral border of the superior mesenteric artery (SMA).” However, nowhere in the paper do I use the word “dissection.” Instead, it is clearly stated in my paper as division of the uncinate process, and not as dissection of the uncinate process. Specifically, it states that “the remaining attachments of the uncinate process of the pancreatic head to the posterior areolar tissue attachments of the retroperitoneum and to the vascular branches of the superior mesenteric vein and artery are then divided parallel to the superior mesenteric vein and artery and portal vein.” Division of these previously mentioned retroperitoneal tissues with a linear stapler does not imply anything with regard to the process of proper anatomic and oncologic dissection of the mesenteric/portal vessels prior to division of adjoining retroperitoneal tissue planes. Nor is it stated anywhere in the paper that linear staplers are a substitute for proper anatomic and oncologic dissection. This fact is easily apparent to me, and I assume to most others reading my paper. Being a surgical oncologist, I whole-heartedly agree with Drs. Evans and Pisters about the importance of proper anatomic and oncologic dissection during any cancer operation, including the retroperitoneal dissection during pancreaticoduodenectomy. However, utilization of such linear staplers for division of tissues adjacent to the uncinate process does not imply “nonanatomic retroperitoneal dissection.”
In their letter, Drs. Evans and Pisters discuss the oncologic importance of surgical margins during pancreaticoduodenectomy. I strongly agree with them and I appreciate its importance. However, in their criticism of my paper, they fail to mention that this was addressed in my previous paper by the statement: “In those cases involving a pancreatic neoplasm located in the uncinate process, it should be left to the surgeon’s discretion whether this maneuver should be utilized so as not to compromise the posterior surgical margin of resection.” Therefore, I believe we agree on this issue (and do not disagree, as they suggest). It is apparent that Drs. Evans and Pisters were troubled by my statement that “great care is taken to palpate the superior mesenteric artery before and after closing the jaws of the stapler.” This statement does not mean or imply that I advocate simply palpating the SMA, as they put it, in order to adequately identify the SMA. Instead, palpating the SMA before and after closing the jaws of the linear stapler and before firing the device is just good common sense to assure that one has not inadvertently captured any tissue within the jaws of the linear stapler that was not intended for division, including the SMA. Once again, division does not imply dissection. I hope that I have clarified the misconceptions of Drs. Evans and Pisters regarding my “How I do it” paper. With a more critical understanding of the paper’s intent, I truly believe that they would find that we have no disagreements concerning proper anatomic and oncologic dissection. Stephen P. Povoski, M.D. Division of Surgical Oncology Arthur G. James Cancer Hospital & Richard J. Solove Research Institute The Ohio State University Columbus, Ohio doi:10.1016/j.amjsurg.2003.11.033
References [1] Evans DB, Pisters PWT. Novel applications of EndoGIA linear staplers during pancreaticoduodenectomy and total pancreatectomy (letter). Am J Surg 2003;185:606 –7. [2] Povoski SP. Novel applications of Endo GIA linear staplers during pancreaticoduodenectomy and total pancreatectomy. Am J Surg 2001; 182:77– 80.
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved.