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Novel Approach Using Dissecting Sealer for Uncinate Process Resection During Pancreaticoduodenectomy
Novel Approach Using Dissecting Sealer for Uncinate Process Resection During Pancreaticoduodenectomy Lucas McCormack, MD, Henrik Petrowsky, MD, Pierre-Alain Clavien, MD, PhD, FACS of the duodenum and the superior mesenteric vein below the pancreas. A Kelly clamp is introduced along the vein between the neck of the pancreas and the superior mesenteric vein, and slowly brought to the porta hepatis. The neck of the pancreas is then divided with electrocautery directly over the portal vein unless there is an oncologic reason for extending resection to the left portion of the pancreas. The left pancreas is mobilized 3 to 5 mm to facilitate suture placement during later pancreaticojejunal anastomosis. Once the superior mesenteric vein is completely separated from the pancreas, it is retracted to the left to expose the retroperitoneal attachment of the uncinate process to the SMA (Fig. 1). In some cases, an earlier step including division of the Treitz ligament, mobilization of duodenojejunal junction, and retraction of the first jejunal loop under the SMA may allow better exposure of the uncinate process so that all structures that have to be resected are located on the right side of the SMA (Fig. 1). The attachment of the uncinate process to the right lateral wall of the SMA is then thermocoagulated with a DS3.0 dissecting sealer (TissueLink). The monopolar device is connected to a compatible electrosurgical generator normally used for electrocautery, with output power set at 80 to 100 watts. RF energy is focused on the tip and conveyed to the tissue by a continuous low flow saline solution to cool down the tissue. The round tip of this device allows a blunt dissection of the soft tissue in proximity with the SMA. The procedure is completed in the standard fashion with or without preservation of the pylorus. Reconstruction is performed in a standard technique using a duct-to-mucosa (end-to-side) pancreaticojejunal anastomosis. We routinely place an abdominal closed-suction drain close to the pancreatic anastomosis.
Pancreaticoduodenectomy (PD) remains one of the most challenging procedures. Although postoperative mortality has decreased dramatically during the past 2 decades in experienced centers, there is still a high complication rate of 20% to 70%.1 Advances in surgical technique have focused mostly on reducing the incidence of pancreato-digestive anastomotic leakage, with only a few data available on the prevention of intra- and postoperative bleeding.1,2 Intraabdominal bleeding remains the most frequent reason for relaparotomy after PD, even in high-volume centers, and is mostly the result of inadequate hemostasis at the time of operation.3 Although bleeding can occur anywhere in the abdomen, the retroperitoneal region is the most frequent source of bleeding after PD. One critical step of the operation requiring particular attention for adequate hemostasis is transection of the retroperitoneal attachment of the pancreatic uncinate process. Additionally, negative tumor margins are sometimes difficult to achieve in the area in close proximity to the superior mesenteric artery (SMA).2,4 There is currently no recommendation or consensus available on how the uncinate process should be transected during PD. Most surgeons use an electrocautery device with sutures or ligatures of small vessels for this specific step, a technique often associated with severe bleeding.5,6 In this article, we describe a novel technique for pancreatic head resection using a saline-linked radiofrequency (RF) device (dissecting sealer, TissueLink), which has been designed for tissue thermocoagulation and dissection during hepatectomy.7 Surgical technique
The first steps of PD are performed in a standardized fashion.8 Briefly, the pancreatic head is dissected with careful preparation of the portal vein above the first part Competing Interests Declared: None.
RESULTS Ten consecutive patients underwent standard PD with the novel approach of using a saline-linked RF device for transecting the uncinate process. RF-assisted thermocoagulation was performed without injury of any major
Received September 22, 2005; Accepted October 13, 2005. From the Department of Visceral & Transplant Surgery, University Hospital of Zurich, Zurich, Switzerland. Correspondence address: Pierre-Alain Clavien, MD, PhD, FACS, Department of Visceral & Transplant Surgery, University Hospital of Zurich, Rämistr 100, 8091 Zürich, Switzerland.
© 2006 by the American College of Surgeons Published by Elsevier Inc.
556
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.10.024
Vol. 202, No. 3, March 2006
McCormack et al
Abbreviations and Acronyms
PD ⫽ pancreaticoduodenectomy RF ⫽ radiofrequency SMA ⫽ superior mesenteric artery
artery such as the SMA or accessory hepatic artery. Transection of the sealed soft tissue containing the inferior pancreaticoduodenal arteries could be performed without the need for additional sutures. In one patient who had tumor involvement of the portal vein, the dissection sealer proved very helpful in preparing the vein from the surrounding tissue, enabling an adequate vascular resection. Transection time was less than 15 minutes in each patient. None of the patients received perioperative blood transfusion, and there was no in-hospital mortality. A major complication was observed in one patient, who underwent PD with complete resection of the extrahepatic bile duct for diffuse cholangiocarcinoma requiring three separate hepaticojejunostomies for biliary
Figure 1. Transection of the retroperitoneal attachment of the pancreatic uncinate process using dissection sealer and sharp cutting with scissors. The superior mesenteric vein is retracted to the left (blue) to expose the superior mesenteric artery and the accessory right hepatic artery (red).
Novel Approach for Uncinate Process Resection
557
reconstruction. A right hepatic abscess developed in this patient was successfully drained percutaneously and treated with antibiotics. Minor complications, including two wound infections, one urinary tract infection, and one catheter sepsis developed in some other patients. The median hospital stay was 12.5 days (range 6 to 44 days). DISCUSSION This study showed that the novel technique using RF technology enables safe, timely, and bloodless transection of the retroperitoneal attachment of the pancreatic uncinate process. So this technique may additionally reduce the risk of postoperative bleeding. Although new surgical tools such as ultrasonic activated shears or ultrasonic dissectors have been proposed for pancreatic transection to improve the safety of pancreaticojejunostomy after PD, very few data are available on how to complete resection of the pancreatic uncinate process, which represents one of the most challenging parts of this operation.9,10 Major goals of this step include meticulous and complete retroperitoneal tumor clearance and perfect bleeding control, with avoidance of any arterial injury. Traditionally, serial ligatures, sutures, and divisions of the tissue bridge between the uncinate process and the SMA have been used in this step.11 Use of a vascular clamp or a vascular stapler has been proposed, but only in the rare situation in which retroperitoneal tumor clearance is not critical (eg, chronic pancreatitis), and when the bridge of tissue to transect is not too thick.5 Additional sutures are usually required to control arterial bleeding from the right retropancreatic pedicle or other small branches of the SMA. The proposed novel approach facilitates a careful transection of the tissue bridge in a “step-by-step” fashion regardless of the thickness of the tissue and without the need for additional sutures. In contrast to the new developed cone-shaped tip, the dissecting sealer with the round tip has the advantage of allowing a blunt dissection to separate the SMA from the uncinate process, so RF energy can be applied accurately to seal small vessels in this area. A potential risk is thermal injury to major vascular structures such as the SMA or an accessory right hepatic artery. So transection of the retroperitoneal attachment of the pancreatic uncinate process should be performed only after identification of the SMA. We would like to speculate that a notable potential benefit of the RF de-
558
McCormack et al
Novel Approach for Uncinate Process Resection
vices might be to extend the resection margin by an additional 3- to 5-mm deep necrosis, which could be paramount in achieving negative resection margins in many patients.7 But we still consider a meticulous surgical technique with careful dissection of the soft tissue around the origin of the SMA the standard approach in tumors extending into this area. It is unclear whether the RF device can be recommended in other locations within the pancreas. We do not recommend this technique to transect the pancreas neck during PD because of the potential risk of postoperative pancreatic fistula associated with necrosis in the remnant pancreas.12 In contrast, this novel approach might be helpful in performing duodenum-preserving pancreas head resection or distal pancreatectomy, when no pancreaticojejunostomy is required. We have used this approach in one patient with chronic pancreatitis who underwent a Beger procedure to transect periduodenal pancreatic tissue and in another six patients with pancreatic tail tumors who underwent distal pancreatectomy, resulting in excellent bleeding control and uneventful postoperative courses. A current focus in most health care systems is cost reduction. The cost related to use of this RF device has to be balanced with costs associated with prolonged operating time, red blood cell transfusion requirements, and postoperative complications. So before introduction of this novel device for routine use during PD, its efficacy or superiority over other techniques should be properly tested, optimally through a randomized controlled trial, to define the most effective and cost-efficient strategy. In conclusion, this study showed that the novel approach using a dissecting sealer device facilitates a safe, simple, and effective resection of the uncinate process during PD, with excellent bleeding control. Additional studies are needed to demonstrate the oncologic advan-
J Am Coll Surg
tages in terms of better retroperitoneal tumor clearance in patients with pancreatic head tumors and the cost effectiveness of routine use of such device in pancreatic surgery. REFERENCES 1. Schafer M, Mullhaupt B, Clavien PA. Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis. Ann Surg 2002;236:137–148. 2. Stojadinovic A, Brooks A, Hoos A, et al. An evidence-based approach to the surgical management of resectable pancreatic adenocarcinoma. J Am Coll Surg 2003;196:954–964. 3. Martignoni ME, Wagner M, Krahenbuhl L, et al. Effect of preoperative biliary drainage on surgical outcome after pancreatoduodenectomy. Am J Surg 2001;181:52–59; discussion 87. 4. Leach SD, Lee JE, Charnsangavej C, et al. Survival following pancreaticoduodenectomy with resection of the superior mesentericportal vein confluence for adenocarcinoma of the pancreatic head. Br J Surg 1998;85:611–617. 5. Ahmad SA, Lowy AM, McIntyre BC, Matthews JB. Pancreaticoduodenectomy. J Gastrointest Surg 2005;9:138–143. 6. Varty PP, Yamamoto H, Farges O, et al. Early retropancreatic dissection during pancreaticoduodenectomy. Am J Surg 2005; 189:488–491. 7. Poon RT, Fan ST, Wong J. Liver resection using a saline-linked radiofrequency dissecting sealer for transection of the liver. J Am Coll Surg 2005;200:308–313. 8. Clavien PA, Rudiger HA. A simple technique of portal vein resection and reconstruction during pancreaticoduodenectomy. J Am Coll Surg 1999;189:629–634. 9. Tanaka T, Matsugu Y, Fukuda Y. Use of ultrasonically activated shears improves the safety of pancreaticojejunostomy after pancreaticoduodenectomy. Arch Surg 2002;137:1258– 1261. 10. Sugiyama M, Abe N, Izumisato Y, et al. Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy. Am J Surg 2001;182:257–259. 11. Richelme H, Michetti C, Birtwisle Y, Bourgeon A. [Section of the right retropancreatic pedicle during duodeno-pancreatectomy of the head. Technical modality] Ann Chir 1986;40:401–404. 12. Strasberg SM, McNevin MS. Results of a technique of pancreaticojejunostomy that optimizes blood supply to the pancreas. J Am Coll Surg 1998;187:591–596.
Pancreaticoduodenectomy (PD) remains one of the most challenging procedures. Although postoperative mortality has decreased dramatically during the past 2 decades in experienced centers, there is still a high complication rate of 20% to 70%.1 Advances in surgical technique have focused mostly on reducing the incidence of pancreato-digestive anastomotic leakage, with only a few data available on the prevention of intra- and postoperative bleeding.1,2 Intraabdominal bleeding remains the most frequent reason for relaparotomy after PD, even in high-volume centers, and is mostly the result of inadequate hemostasis at the time of operation.3 Although bleeding can occur anywhere in the abdomen, the retroperitoneal region is the most frequent source of bleeding after PD. One critical step of the operation requiring particular attention for adequate hemostasis is transection of the retroperitoneal attachment of the pancreatic uncinate process. Additionally, negative tumor margins are sometimes difficult to achieve in the area in close proximity to the superior mesenteric artery (SMA).2,4 There is currently no recommendation or consensus available on how the uncinate process should be transected during PD. Most surgeons use an electrocautery device with sutures or ligatures of small vessels for this specific step, a technique often associated with severe bleeding.5,6 In this article, we describe a novel technique for pancreatic head resection using a saline-linked radiofrequency (RF) device (dissecting sealer, TissueLink), which has been designed for tissue thermocoagulation and dissection during hepatectomy.7 Surgical technique
The first steps of PD are performed in a standardized fashion.8 Briefly, the pancreatic head is dissected with careful preparation of the portal vein above the first part Competing Interests Declared: None.
RESULTS Ten consecutive patients underwent standard PD with the novel approach of using a saline-linked RF device for transecting the uncinate process. RF-assisted thermocoagulation was performed without injury of any major
Received September 22, 2005; Accepted October 13, 2005. From the Department of Visceral & Transplant Surgery, University Hospital of Zurich, Zurich, Switzerland. Correspondence address: Pierre-Alain Clavien, MD, PhD, FACS, Department of Visceral & Transplant Surgery, University Hospital of Zurich, Rämistr 100, 8091 Zürich, Switzerland.
© 2006 by the American College of Surgeons Published by Elsevier Inc.
556
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.10.024
Vol. 202, No. 3, March 2006
McCormack et al
Abbreviations and Acronyms
PD ⫽ pancreaticoduodenectomy RF ⫽ radiofrequency SMA ⫽ superior mesenteric artery
artery such as the SMA or accessory hepatic artery. Transection of the sealed soft tissue containing the inferior pancreaticoduodenal arteries could be performed without the need for additional sutures. In one patient who had tumor involvement of the portal vein, the dissection sealer proved very helpful in preparing the vein from the surrounding tissue, enabling an adequate vascular resection. Transection time was less than 15 minutes in each patient. None of the patients received perioperative blood transfusion, and there was no in-hospital mortality. A major complication was observed in one patient, who underwent PD with complete resection of the extrahepatic bile duct for diffuse cholangiocarcinoma requiring three separate hepaticojejunostomies for biliary
Figure 1. Transection of the retroperitoneal attachment of the pancreatic uncinate process using dissection sealer and sharp cutting with scissors. The superior mesenteric vein is retracted to the left (blue) to expose the superior mesenteric artery and the accessory right hepatic artery (red).
Novel Approach for Uncinate Process Resection
557
reconstruction. A right hepatic abscess developed in this patient was successfully drained percutaneously and treated with antibiotics. Minor complications, including two wound infections, one urinary tract infection, and one catheter sepsis developed in some other patients. The median hospital stay was 12.5 days (range 6 to 44 days). DISCUSSION This study showed that the novel technique using RF technology enables safe, timely, and bloodless transection of the retroperitoneal attachment of the pancreatic uncinate process. So this technique may additionally reduce the risk of postoperative bleeding. Although new surgical tools such as ultrasonic activated shears or ultrasonic dissectors have been proposed for pancreatic transection to improve the safety of pancreaticojejunostomy after PD, very few data are available on how to complete resection of the pancreatic uncinate process, which represents one of the most challenging parts of this operation.9,10 Major goals of this step include meticulous and complete retroperitoneal tumor clearance and perfect bleeding control, with avoidance of any arterial injury. Traditionally, serial ligatures, sutures, and divisions of the tissue bridge between the uncinate process and the SMA have been used in this step.11 Use of a vascular clamp or a vascular stapler has been proposed, but only in the rare situation in which retroperitoneal tumor clearance is not critical (eg, chronic pancreatitis), and when the bridge of tissue to transect is not too thick.5 Additional sutures are usually required to control arterial bleeding from the right retropancreatic pedicle or other small branches of the SMA. The proposed novel approach facilitates a careful transection of the tissue bridge in a “step-by-step” fashion regardless of the thickness of the tissue and without the need for additional sutures. In contrast to the new developed cone-shaped tip, the dissecting sealer with the round tip has the advantage of allowing a blunt dissection to separate the SMA from the uncinate process, so RF energy can be applied accurately to seal small vessels in this area. A potential risk is thermal injury to major vascular structures such as the SMA or an accessory right hepatic artery. So transection of the retroperitoneal attachment of the pancreatic uncinate process should be performed only after identification of the SMA. We would like to speculate that a notable potential benefit of the RF de-
558
McCormack et al
Novel Approach for Uncinate Process Resection
vices might be to extend the resection margin by an additional 3- to 5-mm deep necrosis, which could be paramount in achieving negative resection margins in many patients.7 But we still consider a meticulous surgical technique with careful dissection of the soft tissue around the origin of the SMA the standard approach in tumors extending into this area. It is unclear whether the RF device can be recommended in other locations within the pancreas. We do not recommend this technique to transect the pancreas neck during PD because of the potential risk of postoperative pancreatic fistula associated with necrosis in the remnant pancreas.12 In contrast, this novel approach might be helpful in performing duodenum-preserving pancreas head resection or distal pancreatectomy, when no pancreaticojejunostomy is required. We have used this approach in one patient with chronic pancreatitis who underwent a Beger procedure to transect periduodenal pancreatic tissue and in another six patients with pancreatic tail tumors who underwent distal pancreatectomy, resulting in excellent bleeding control and uneventful postoperative courses. A current focus in most health care systems is cost reduction. The cost related to use of this RF device has to be balanced with costs associated with prolonged operating time, red blood cell transfusion requirements, and postoperative complications. So before introduction of this novel device for routine use during PD, its efficacy or superiority over other techniques should be properly tested, optimally through a randomized controlled trial, to define the most effective and cost-efficient strategy. In conclusion, this study showed that the novel approach using a dissecting sealer device facilitates a safe, simple, and effective resection of the uncinate process during PD, with excellent bleeding control. Additional studies are needed to demonstrate the oncologic advan-
J Am Coll Surg
tages in terms of better retroperitoneal tumor clearance in patients with pancreatic head tumors and the cost effectiveness of routine use of such device in pancreatic surgery. REFERENCES 1. Schafer M, Mullhaupt B, Clavien PA. Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis. Ann Surg 2002;236:137–148. 2. Stojadinovic A, Brooks A, Hoos A, et al. An evidence-based approach to the surgical management of resectable pancreatic adenocarcinoma. J Am Coll Surg 2003;196:954–964. 3. Martignoni ME, Wagner M, Krahenbuhl L, et al. Effect of preoperative biliary drainage on surgical outcome after pancreatoduodenectomy. Am J Surg 2001;181:52–59; discussion 87. 4. Leach SD, Lee JE, Charnsangavej C, et al. Survival following pancreaticoduodenectomy with resection of the superior mesentericportal vein confluence for adenocarcinoma of the pancreatic head. Br J Surg 1998;85:611–617. 5. Ahmad SA, Lowy AM, McIntyre BC, Matthews JB. Pancreaticoduodenectomy. J Gastrointest Surg 2005;9:138–143. 6. Varty PP, Yamamoto H, Farges O, et al. Early retropancreatic dissection during pancreaticoduodenectomy. Am J Surg 2005; 189:488–491. 7. Poon RT, Fan ST, Wong J. Liver resection using a saline-linked radiofrequency dissecting sealer for transection of the liver. J Am Coll Surg 2005;200:308–313. 8. Clavien PA, Rudiger HA. A simple technique of portal vein resection and reconstruction during pancreaticoduodenectomy. J Am Coll Surg 1999;189:629–634. 9. Tanaka T, Matsugu Y, Fukuda Y. Use of ultrasonically activated shears improves the safety of pancreaticojejunostomy after pancreaticoduodenectomy. Arch Surg 2002;137:1258– 1261. 10. Sugiyama M, Abe N, Izumisato Y, et al. Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy. Am J Surg 2001;182:257–259. 11. Richelme H, Michetti C, Birtwisle Y, Bourgeon A. [Section of the right retropancreatic pedicle during duodeno-pancreatectomy of the head. Technical modality] Ann Chir 1986;40:401–404. 12. Strasberg SM, McNevin MS. Results of a technique of pancreaticojejunostomy that optimizes blood supply to the pancreas. J Am Coll Surg 1998;187:591–596.