Hiroyuki Hoshino

Risk factors for failure of early recovery from pancreatoduodenectomy despite the use of enhanced recovery after surgery protocols and a physical aging score to predict postoperative risks

Enhanced recovery after surgery (ERAS) protocols are beneficial for pancreatoduodenectomy (PD). Our aim was to evaluate risk factors associated with ERAS protocol failure after PD.

The Vertical Array Reconstruction Technique in Pylorus-Preserving Pancreatoduodenectomy

Background/Aims: We describe a new reconstruction method of duodenojejunal anastomosis, the “vertical array reconstruction” (VAR) technique, following pylorus-preserving pancreatoduodenectomy (PPPD). Methods: The VAR technique aligns the stomach, duodenum, and jejunal loop vertically along the body’s longitudinal axis. It was performed in 120 consecutive patients (between June 2008 and October 2015) who underwent PPPD. We evaluated the incidence of delayed gastric emptying (DGE). Results: The incidence of DGE was 1.7% (n = 2). The proposed clinical grading classified these 2 cases of DGE as grade B. There was no DGE related to pancreatic fistula. The median duration to starting a solid diet was 3 days (range 3–5 days). The median operative time was 450 min (range 391–550 min). Conclusion: The VAR technique allows the upper digestive tract to be aligned linearly and can minimize the risk of DGE after PPPD.

Utility of Glissonean Pedicle Transection for Surgical Treatment of Severe Liver Trauma

The most common initial strategy for treatment of severe liver trauma is damage control in which hemostasis is achieved by perihepatic gauze packing and/or vascular embolization. However, we encounter patients in whom this strategy alone is not adequate. We have applied the principles of Glissonean pedicle transection, a technique that was originally devised to ensure safe and quick performance of planned hepatectomy for liver cancer, to 3 cases of severe liver trauma. We performed Glissonean pedicle ligation during damage control surgery in 2 patients and Glissonean pedicle transection during the definitive surgery in 1 patient. We describe the approaches and our experience with them, including operation times and outcomes. From our experience thus far, it seems that 8–12 h after the damage control procedure is appropriate for performing the definitive surgery. Although there are some problems posed by this strategy and cases to which it will not be applicable, the method seems to be particularly useful for cases of severe liver trauma in which the damage is extensive and involves the Glissonean pedicles near the hepatic hilus. We describe our 3 cases in detail and review our experience in light of the available literature.