Disparities in the management and prophylaxis of surgical site infection and pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Pancreatoduodenectomy (PD) carries a high morbidity. Over time, pancreatic surgeons have altered their perioperative management in efforts to reduce morbidity rates, thereby creating major technical and management variations. We aim to evaluate the practice patterns of hepato-pancreato-biliary (HPB) surgeons across multiple regions worldwide. METHODS: Between May and August 2015, an anonymous 25-item survey questionnaire was electronically distributed to the International Hepato-Pancreato-Biliary Association members regarding practice patterns and perioperative care of patients undergoing PD. Responses were analyzed based on three variables: geographical region, institution type and volume status. RESULTS: Among 285 participants, the majority were high-volume surgeons (80.4%) at academic institutions (56.1%) from the United States (34.7%), Europe (28.1%) and Asia (14.3%). North American surgeons are more likely to limit prophylactic antibiotic within 24 h postoperatively (P < 0.001), whereas European surgeons more often culture bile intraoperatively (P = 0.024). There are significant variations between different institution types and HPB surgeons based on case volume. Very-high volume surgeons (>50 cases/year) are more likely to routinely culture intraoperative bile (64% vs. 33.3-37.5%) and close incision with subcuticular sutures (42.5% vs. 15.3-25.9%). CONCLUSIONS: Our survey demonstrated significant heterogeneity in perioperative management between HPB surgeons across different regions worldwide. Further studies are warranted to assess the impact of these variations on outcomes of patients undergoing PD. Efforts should be directed towards standardization of perioperative management of PD.

Using a Single Internal Mammary Artery as Retrograde and Antegrade Flow for Bilateral Deep Inferior Epigastric Artery Perforator Reconstruction: A Case Report.

Deep inferior epigastric artery perforator (DIEP) flaps have become an attractive option for autologous breast reconstruction. The internal mammary artery (IMA) is the usual artery of choice for reconstruction. Unfortunately, there are certain situations when the IMA may not be suitable for usage as in previous radiation or diminutive size. Several options have been documented, such as using the thoracodorsal vessels. In this case report, we report usage of the distal and proximal ends of a contralateral single mammary artery to supply antegrade and retrograde flow to bilateral DIEP flaps. With increasing complexity of patient populations, the use of alternate approaches to recipient vessel in DIEP reconstruction becomes essential for effective outcomes.

Laparoscopic Left Gastric Artery Aneurysm Resection.

Aneurysmal degeneration of the visceral branches of the abdominal aorta is a rare and potentially life-threatening disease entity. Visceral artery aneurysms (VAAs) are exceedingly rare and have a prevalence of 0.1 to 2%. The left gastric artery aneurysm (LGAA) is even more rare and accounts for less than 4% of all VAAs. There is scarce literature on treatment of LGAA by embolization; however, to date successful laparoscopic repair of an LGAA has not been described. We describe the successful treatment of an LGAA by laparoscopic ligation and resection in a 68-year-old male patient.