Is Sutureless Pancreaticogastrostomy More Effective than Single-Layer Duct-to-Mucosa Pancreaticojejunostomy in Pancreaticoduodenectomy?

OBJECTIVE: The present study aimed to assess the safety of pancreatic anastomosis after pancreaticoduodenectomy (PD) and to compare the results of sutureless pancreatogastrostomy (PG) with those of single-layer duct-to-mucosa pancreatojejunostomy (PJ) after PD in patients with malignant disease of the pancreatic head and of the periampullary region. MATERIALS AND METHODS: The study included 173 consecutive patients undergoing PD from May 2009 to December 2015 at a single surgical center. Single-layer duct-to-mucosa PJ was performed in 52 patients and sutureless PG in the remaining 123. The primary endpoint was the safety of the procedures, which was assessed as the occurrence of complications during hospitalization. Postoperative pancreatic fistula (POPF) was classified as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. RESULTS: We found that the incidence of POPF was 11.52%. With regard to POPF, the present study showed no significant difference in the two groups (p=0.043). The incidence of Grade C POPF was significantly higher in the PJ group than in the PG group (p=0.001), which was been reflected in the form of a higher rate of postoperative hemorrhage (p=0.001), intra-abdominal abscess (p=0.012), and septic shock (p=0.012) events in the PJ group. CONCLUSION: The evaluation of short-term outcomes demonstrates that suturelessPG is a feasible and safe technique, associated with lower life-threatening complications than single-layer duct-to-mucosa PJ. If long-term functional outcomes confirm similar results, sutureless PG could become a valid alternative for pancreatic anastomosis after PD in patients with soft pancreas and high morbidity.

Prognostic factors related to surgical outcome of liver metastases of breast cancer.

PURPOSE: The role of hepatectomy for patients with liver metastases of breast cancer (LMBC) remains controversial. The purpose of this study is to share our experience with hepatic resection in a relatively unselected group of patients with LMBC and analyse the prognostic factors and indications for surgery. METHODS: In 2000 to 2006, 42 female patients with a mean age of 58.2 years (range, 39 to 69 years) with LMBC diagnosed by means of abdominal ultrasound, computed tomography and/or magnetic resonance imaging in the hospital. They were considered for surgery because of limited comorbidities, presence of seven or fewer liver tumors and absence of (or limited and stable) extrahepatic disease on preoperative imaging. Patients' demographics, metastatic characteristics as well as clinical and operative parameters were being studied. Overall actuarial 1-, 3-, and 5-year survival rates were calculated since the hepatic resection onwards using the Kaplan-Meier method. RESULTS: Metastatic tumor size of ≤4 cm (p=0.03), R0 resection (p=0.02), negative portal lymph nodes (p=0.01), response to chemotherapy (p=0.02), and positive hormone receptor status (p=0.03) were associated with better survival outcomes on univariate analysis. However, it did not show survival benefits on multivariate analysis. The disease-free survival and overall survival are 29.40 and 43 months, respectively. The 1-, 3- and 5-year survival rates were 84.61%, 64.11%, and 38.45%, respectively. CONCLUSION: Selected patients with isolated LMBC may benefit from surgical management; although, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis. Improvements in preoperative staging and progressive application of new multimodality treatments will be the key to improved survival rates in this severe disease. The careful selection of patients is associated with a satisfactory long-term survival rate.

Anatomical preconditions for operative-technical errors in right trisectionectomy.

OBJECTIVE: Certain anatomical variations may represent preconditions for technical operation errors in right trisectionectomy. These variations include: the confluence of the common bile duct, the length of the left hepatic duct, the localization of the bile duct confluence for segments 2 and 3 of the umbilical portion of the left portal vein and the peculiarities of the afferent and efferent blood supply of these two segments. The aim of the present study is to identify and discuss such preconditions. MATERIALS AND METHODS: The anatomical variations of the common bile duct confluence were analyzed by intraoperative cholangiography in 112 patients undergoing liver resections and in 32 preparations after left hepatectomy. The variations of the afferent and efferent blood supply were morphologically examined in 43 liver resections. RESULTS: Seven types of anatomical variations of the common bile duct confluence were detected through intraoperative cholangiography, and three were extracted from the available literature. Three anatomical types (central, peripheral, and combined) of bile drainage from segment 4 were established. The mean distance between the bile duct confluence for segments 2 and 3 and the main hepatic duct confluence, i. e., the length of the left hepatic duct, was 3.68 cm. The anatomical peculiarities of the afferent and efferent arterial and venous supply of segments 2 and 3 were presented and discussed with respect to their roles in a safe right trisectionectomy. CONCLUSION: Surgeons' sound knowledge of anatomical variations of the biliary tract and hepatic blood vessels coupled with increased experience and technique refinements could contribute to better outcomes in right trisectionectomy.

Accessory hepatic lobe.

PURPOSE: The aim of the present communication was to describe an accessory hepatic lobe in two patients and to outline the significance of the timely identification of this very rare anatomic variation for the clinical practice. METHODS: In the course of right hemihepatectomy, accessory liver lobes were detected in two patients. Their diagnosis was confirmed by histopathology and cholangiography. RESULTS: Both accessory hepatic lobes arose from the left liver segments. The first lobe was detected in a 56-year-old male operated on for a retroperitoneal liposarcoma. It amounted to 15% of the standard liver volume and was attached to liver segments 2 and 3 by a stalk. The second accessory lobe was found out in 45-year-old female operated on for a colon cancer and synchronous liver metastases. It was less than 15 g in weight and attached to the main liver by a mesentery as its bile duct drained into an extrahepatic duct. CONCLUSIONS: The accessory hepatic lobes require timely diagnosis. They should be kept in mind in cases with acute surgical abdomen.

Six rare biliary tract anatomic variations: implications for liver surgery.

OBJECTIVE: The variations in the anatomy of the biliary tract need to be recognized in modern liver surgery. The purpose of this clinical and anatomical study is to describe several novel biliary tract variations and to outline their practical importance for liver resections and transplantations. MATERIALS AND METHODS: Over the previous 10 years, the anatomic variations of the bile ducts were examined during 600 intraoperative cholangiographies, 104 segmentectomies and 54 hemihepatectomies in patients with liver diseases. The intraoperative anatomies of the right and left hepatic ducts and the common hepatic duct confluence were analyzed. RESULTS: Twenty-two variations occurred in 59.5% of the patients. Six variations were described for the first time: an accessory right hepatic duct in which a cystic duct drained; a tetrafurcation from the right anterior hepatic duct, right posterior hepatic duct and bile ducts for Segments 2 and 3 with aberrant bile drainage from Segment 4 into the bile duct for Segment 8; an aberrant bile drainage from Segments 6 and 7 into the common hepatic duct; an accessory bile duct for Segment 6 that drained into the bile duct for Segment 3; a tetrafurcation from the right anterior hepatic duct and the bile ducts for Segments 6, 3 and 2 with bile from Segment 7 draining into the bile duct for Segment 2; and an accessory bile duct for the left hemiliver that drained bile from the Type 4 small accessory hepatic lobe (according to Caygill & Gatenby) into the common hepatic duct. CONCLUSION: These newly described biliary tract variations should be recognized by liver surgeons to avoid unwanted postoperative complications.

Segmental liver resection for colorectal metastases.

BACKGROUND: The question, whether to perform either a segmental, or a major liver resection if both procedures are technically feasible, continues to be under debate. METHODS: Outcomes from 188 liver resections for colorectal cancer liver metastases in the Naval Hospital of Varna in 2000-2007 were reviewed. All surviving patients were followed-up for a minimum of 2 years. Morbidity, mortality, mean blood loss, mean blood transfusion, disease-free survival and overall survival rates of the patients undergoing segmental liver resection (group one, n=76) and major liver resection (group two, n=112) were statistically compared. RESULTS: No patients died in group one while 7 patients (3.7%) died in the early postoperative period in group two. There were 18 postoperative complications in group one (23%) and 38 in group two (33%) (p less than 0.05). The mean blood loss was 1,245 +/- 128 mL in group two and 423 +/- 232 mL in group one (p less than 0.001) while the mean blood transfusion requirement was 2 units (0-18 units) for patients with major liver resections and 0.5 unit (0-3 units) for those with segmentectomies (p less than 0.006). There were no statistically significant differences in disease-free survival (p=0.545) and overall survival rates (p=0.750) between both groups. CONCLUSION: Segmental resection enables sufficient liver volume conservation. It results in lower perioperative morbidity and mortality rates and more seldom postoperative failure. Thus it warrants disease-free and overall survival rates similar to those following the major resection.

Manometric study in ulcerative colitis patients with modified ileal pouch--anal anastomosis.

BACKGROUND AND AIMS: Sphincter-saving operations and construction of intestinal reservoirs aim at additional improvement quality of life of patients with restorative proctocolectomy. The conventional ileoanal anastomosis affects the function of the anal sphincters. There is a need for operative techniques that provide sufficient intraluminal anal pressure and thus a better postoperative continence and quality of life. MATERIALS AND METHODS: Ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy was carried out in 42 consecutive ulcerative colitis patients (age range: 19-55 years and mean age of 35.52 years). There were 17 males (40.48%) and 25 females (59.52%). IPAA was performed at dentate line, according to a standard method, in 20 patients (47.62% of the cases; mean age of 35.20 years), 19 of which were in 1986-1995 and one patient in 1998. In 1996-2002, however, IPAA was performed after plicating the demucosed segment of rectal residual in 22 patients (52.38% of the cases; mean age of 35.82 years). This modification consisted in strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of rectal residual. The basal anal-canal and squeeze pressures were recorded prior to the operation as well as 1 month afterwards and then every 6 months for 2 years. Kelly-Hohlschneider's continence scores after Herold's modification were applied in 14 consecutive patients. RESULTS: Thanks to strengthening the internal anal sphincter by this segment, the basal pressure increased from a preoperative value of 68+/-6 mmHg up to 80+/-6 mmHg at the end of the second postoperative year (P<0.001). This favourable effect could be explained with the additional contractile potential of the plicated rectal segment resulting from the interference of the contractile potential of the internal anal sphincter with that of the smooth muscle cuff. CONCLUSION: The modified IPAA creates a novel and probably functionally active anatomical substrate. The basal anal-canal pressure is maintained sufficiently high through the tone of the smooth muscle cuff and internal anal sphincter. Our preliminary results suggest that the presented technique for performing IPAA may contribute to better functional results.

Results from the application of extramucous valvular pyloroplasty.

BACKGROUND/AIMS: A method for pyloroplasty with complete reconstruction of the pyloric area is presented. METHODOLOGY: The method had been preliminarily tested in dogs and then clinically applied in 28 peptic ulcer patients. The task was solved by pneumatic preparation and ring-shaped removal of pylorus musculature within a zone of 3.0-3.5 cm the integrity of the underlying mucous muff was preserved and the latter was invaginated into the lumen. Thus a circular mucous-submucous valve in the region of the gastroduodenal ligament was formed. Due to the preserved anatomical integrity, innervation and blood supply of this mucous-submucous layer after its pleating created a zone wide like a normal pylorus between the stomach and duodenum. RESULTS: The duration of the postoperative follow-up was between 6 months and 10 years. The newly created valve looked like a normal pylorus. It was 6 mm thick and 11 mm high and protruded into the lumen. The submucous layer was doubled, richly vascularized, and the muscular layers were continuous. CONCLUSIONS: This operative technique could successfully be applied in gastric surgery for preventing the dumping syndrome and gastric reflux when pyloroplasty is required.

Anal canal pressure after ileal pouch-anal anastomosis with strengthened internal anal sphincter.

INTRODUCTION: The aim of sphincter-saving operative techniques and creation of intestinal reservoirs is to improve the quality of life for patients with restorative prococolectomy. METHODS: In this study, 48 consecutive patients (19 males and 29 females of ages between 19 and 55 years; mean age, 35.52 years) with ulcerative colitis and familial adenomatous polyposis underwent ileal pouch-anal anastomosis after proctocolectomy in 1986 to 2002. In 26 patients (54.17 percent of the cases), 10 males and 16 females, ileal pouch-anal anastomosis was performed after a modified surgical technique for strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of residual rectum. Basal resting anal canal pressure and pressure after voluntary contraction were recorded preoperatively, one month after surgery, and every six months for two years. RESULTS: One month after the operation manometric results showed significantly higher values of resting pressure in patient with a plicated rectal segment than values measured preoperatively (P < 0.001). This effect was absent after the standard ileal pouch-anal anastomosis. With the rectal plication technique, basal pressure increased from a preoperative value of 69 +/- 6 mmHg up to 80 +/- 6 mmHg at the end of the second postoperative year (P < 0.001). CONCLUSIONS: We concluded that ileal pouch-anal anastomosis with rectal plication perhaps improved sphincter function. The operative technique did not affect anal squeeze pressure. Patients quality of life was improved for those undergoing the modified ileal pouch-anal anastomosis.

Smooth muscle sphincteroplasty in colostomy.

PURPOSE: The present work elaborated on Schmidt's idea of an effective smooth muscle sphincteroplasty. The aim of the study was to analyze the effects on the patients with a lower quadrant colostomy constructed after abdominoperineal extirpation of a modified smooth muscle sphincteroplasty combined with colon irrigations. METHODS: Seventy-two rectal cancer patients (39 men and 33 women, median age, 54.5 years) with smooth muscle sphincteroplasty and 20 controls with conventional colostomy using colon irrigations (11 men and 9 women, median age, 63.2 years) were examined. A modified smooth muscle wrap of the colostomy with a free graft of a 4-cm-long colon segment without mucosa was applied. In this precolostomy segment a high intraluminal pressure was achieved. The functional capacity and anatomic integrity of the transplanted smooth muscle graft were examined manometrically, electromyographically, and histomorphologically. The functional activity of the colostomy was assessed by periodic recording of the number of "spontaneous" and "directed" defecations.RESULTS. In the patients with smooth muscle sphincteroplasty, the basal intraluminal pressure of the precolostomy segment two years after operation measured 29.7 mmHg. After dilatation of the transplant, these pressures reached up to 43 mmHg ( P < 0.001). The weekly "spontaneous" stools were 3 to 5 times less frequent than in the controls ( P < 0.001). CONCLUSIONS: The modified smooth muscle sphincteroplasty offers operative-technical opportunities for increasing intraluminal pressure in the precolostomy colon segment. Its combination with colonic irrigations facilitates control of the evacuatory rhythm and "spontaneous" stools in colostomy patients, thus improving their quality of life.