The impact of new technology on hepatic resection for malignancy.

HYPOTHESIS: Relatively high morbidity rates remain problematic in hepatic resection for malignant neoplasms. Technological innovations coupled with surgical expertise can ameliorate morbidity and mortality rates. DESIGN: Medical records survey. SETTING: Tertiary care university hospital. PATIENTS: Five hundred one patients underwent liver resection at our hospital from March 1, 1988, through November 30, 1999. Three hundred twenty-one patients (64.1%) had primary carcinoma, whereas 180 (35.9%) had metastatic disease, mainly colorectal secondary disease (83.3%). Morbidity and mortality rates were compared with those of a previous series in the same setting. MAIN OUTCOME MEASURES: Special attention was paid to the impact of new technology (eg, newer imaging techniques, ultrasonic aspiration, intraoperative ultrasonography, argon beam coagulation, and autotransfusion) and improved anesthetic and surgical management on mortality and morbidity rates. RESULTS: Five patients died after liver resection and 93 patients had various complications, representing mortality and morbidity rates of 1.0% and 18.6%, respectively. These results compare favorably with the results of a previous unpublished series (mortality, 5/55 [9.1%]; morbidity, 28/55 [50.9%]). Intraoperative ultrasonography resulted in a change in operative strategy in 7 (17.5%) of a recent group of 40 patients. CONCLUSIONS: Morbidity after major hepatic resection for malignancy can be reduced considerably by applying newer technologies to preoperative and intraoperative decision making. Advanced technology also assists in reducing intraoperative risk by minimizing bleeding during resection of the hepatic parenchyma.

Subtotal pancreatoduodenectomy: use of a defunctionalized loop for pancreatic stump drainage.

BACKGROUND: Since its introduction, pancreaticoduodenal resection for periampullary cancer has undergone numerous modifications. As a result, there has been a dramatic decline in the mortality rate. However, a high morbidity rate, mainly due to pancreatic fistula formation, is still reported. OBJECTIVE: To evaluate the results of the use of a defunctionalized jejunal loop in patients undergoing pancreatoduodenectomy to minimize both the frequency and severity of anastomotic leak. SETTING: Second Surgical Department, Athens University, Aretaieon Hospital, Athens, Greece. DESIGN: A series of retrospective cases from February 1990 to December 1997. PATIENTS: One hundred five patients who underwent pancreatoduodenectomy and had the pancreatic stump drained in a defunctionalized jejunal loop. METHODS: To avoid problems related to fistula formation due to erosion of the anastomoses from activated pancreatic enzymes, a defunctionalized jejunal loop was constructed and the pancreatic stump was invaginated into the end of this loop. RESULTS: Using the defunctionalized jejunal loop, the mean (+/-SD) hospitalization was 7.57+/-1.42 days, the morbidity rate was 11.2%, and the mortality rate was 0.95%. CONCLUSIONS: A modification of pancreatoduodenectomy for the treatment of pancreatic cancer resulted in an improvement in the immediate results of subtotal pancreatoduodenectomy. Careful detachment of the posterior surface of the pancreas from the anterior surface of the portal vein and performance of pancreaticojejunal anastomosis to a defunctionalized jejunal loop results in lower mortality and morbidity rates, thus making pancreatoduodenectomy a safe procedure.