Toshihiro Ohya

Fibrin Glue Sandwich Prevents Pancreatic Fistula following Distal Pancreatectomy

Pancreatic fistula is a major form of morbidity following pancreatic resection. We conducted a nonrandomized clinical trial comparing the sealing and sandwich techniques of spraying fibrin glue to prevent pancreatic fistula following distal pancreatectomy. The pancreas was transected with a scalpel to identify and suture the main pancreatic duct and its small branches. In the sealing group, fibrin glue was sprayed over the closed pancreatic stump and sutures. Alternatively, in the sandwich group fibrin glue was sprayed so as to cover and join the cut surface of the pancreatic remnant, which was then held closed with sutures. Altogether 111 patients were included in the study (90 with gastric cancer, 10 with esophageal cancer, and 11 with pancreatic cancer). Patients were nonrandomly assigned to the sandwich or the sealing group. Morbidity was 21.8% for the patients in the sandwich group versus 33.9% in the sealing group. Pancreatic fistulas occurred in 9.0% of the sandwich group versus 26.8% of the sealing group. The incidence of fistula was thus significantly lower in the sandwich group. The incidence of fistula was also significantly lower in the sandwich group for gastric malignancy patients undergoing extended radical lymphadenectomy down to the paraaortic lymph nodes combined with left adrenalectomy. Of the patients with gastric malignancy, pancreatic fistulas occurred in 9.3% of the sandwich group versus 25.5% of the sealing group. The fibrin glue sandwich technique is simple and reliable and should be valuable for complementing other prophylactic methods of preventing pancreatic fistula.

Results of duct-to-mucosa pancreaticojejunostomy for pancreaticoduodenectomy Billroth I type reconstruction in 100 consecutive patients.

BACKGROUND This study retrospectively analyzed 100 consecutive patients who underwent pancreaticoduodenectomy (PD) and pylorus-preserving PD (PPPD) with a Billroth I type reconstruction and pancreaticojejunostomy by duct-to-mucosal anastomosis using a continuous running suture. STUDY DESIGN Seventy patients underwent PD and 30 patients PPPD for pancreatic cancer in 33, bile duct cancer in 28, ampullary or duodenal tumor in 22, chronic pancreatitis in 8, and other gastrointestinal cancer in 9. Postoperative pancreatic anastomotic leakage was diagnosed from skin excoriation around the drain site, and was defined as a high concentration of amylase in drainage fluid or leakage demonstrated on x-ray. RESULTS The mortality rate was 2% overall (2.8% in PD, 0% in PPPD). The morbidity rate was 23% overall (12.8% in PD, 46.7% in PPPD). Pancreatic anastomotic leakage was 4.0% overall (2.8% in PD, 6.7% in PPPD).. The incidence in the ampullary or duodenal tumors was 9.1% overall (0% in PD, 14.3% in PPPD). Biliary leakage occurred in four patients, 4.0% overall (4.3% in PD, 3.3% in PPPD), intraabdominal hemorrhage in 2% (2.8% in PD, 0% in PPPD), and lethal anastomotic leakage in one patient, overall rate 1% (1.4% in PD, 0% in PPPD). Delayed gastric emptying had the highest morbidity and was seen exclusively in PPPD (39.3%). CONCLUSIONS A simple continuous running suture and parachuting for duct-to-mucosal pancreaticojejunostomy makes pancreaticoduodenectomy a safe procedure, even in a Billroth I type reconstruction.

Concomitant major hepatectomy and inferior vena cava reconstruction

The development of techniques for liver transplantation and preservation has led to several surgical innovations for the resection of hepatic malignancies that invade the inferior vena cava (IVC) and the hepatic venous confluence. The resection of hepatic malignancies invading the IVC has become technically feasible and relatively safe since the introduction of total hepatic vascular exclusion (HVE), with or without bypass. The more aggressive approach, involving concomitant hepatic and IVC resection and subsequent replacement of the IVC using autologous or synthetic materials, has also been adopted. If a subtotal hepatectomy could not be performed, total hepatectomy with liver transplantation was a valuable option. But there is no agreement on the management of these tumors in a cirrhotic liver, so the choice of operative procedures used for these patients remains debatable. We reviewed the records of eight hepatic malignancies, including histologically proven five hepatocellular carcinomas (HCC) in cirrhotic livers, and the records of patients with metastatic carcinoma in noncirrhotic livers who underwent concomitant hepatic resection and IVC reconstruction.

The effects of a neutrophil elastase inhibitor (ONO-5046.Na) and neutrophil depletion using a granulotrap (G-1) column on lung reperfusion injury in dogs

BACKGROUND Activated neutrophils are reported to be closely involved in ischemia-reperfusion injury after lung transplantation. We investigated the beneficial effects of a new recombinant specific neutrophil elastase inhibitor, ONO-5046.Na, and an extracorporeal-type granulotrap (G-1) column on ischemia-reperfusion lung injury, by using an in situ warm lung ischemia model in dogs. METHODS Warm ischemia was induced for 3 hours by clamping the pulmonary arteries and veins. The left main bronchus was bisected and reanastomosed prior to reperfusion. The left lung was collapsed for 3 hours. A total of 27 adult mongrel dogs were divided into three groups: the control group (n = 9) treated with a saline vehicle; the ONO group (n = 9), in which ONO-5046.Na was continuously administrated from before induced ischemia and to ending 2 hours after reperfusion; and the G-1 group (n = 9), in which a G-1 column was applied for 90 minutes starting 30 minutes before reperfusion under passive bypass support. RESULTS Circulating neutrophils in the G-1 group decreased significantly (p<.05) compared to preischemia, and significantly decreased compared with the other groups after reperfusion. Oxygenation was improved actually and pulmonary vascular resistance was kept lower level after the administration of ONO-5046.Na. The increase of lung weight was significantly ameliorated in both the G-1 and ONO groups. In the histopathological study, lungs from the control group demonstrated diffuse alveolar edema, neutrophil infiltration, massive alveolar exudate and hemorrhage, and thickening of the interstitium. Lungs from the G-1 group showed mild swelling of the alveolar wall and neutrophil infiltration. Lungs from the ONO group showed virtually no abnormalities. CONCLUSION This study demonstrated that a neutrophil elastase inhibitor and neutrophil depletion prevented lung reperfusion injury. These treatments may prevent ischemia and reperfusion injury in lung transplantation.

Efficacy of hypothermic perfusion using University of Wisconsin solution in extended hepatectomy with hepatic inflow occlusion in a canine model

This study was designed to elucidate the efficacy of University of Wisconsin (UW) solution for preventing liver injury, when used as a hypothermic perfusate infused into the systemic circulation during extended hepatectomy with hepatic inflow occlusion. Adult mongrel dogs (9.5–17.5 kg, n= 14) were subjected to 75% hepatectomy under 60 min hepatic inflow occlusion. The animals were divided into two groups. The UW group (n= 7) underwent hypothermic perfusion using 4°C UW solution (core temperature of the liver: 12.3±0.2°C). The control group designated as the Ringers lactate (LR) group (n= 7) underwent hypothermic perfusion using 4°C LR solution. The perfusate was introduced into the systemic circulation via the hepatic vein. Blood from the hepatic vein was sampled, and alanine amino‐transferase, purine nucleoside phosphorylase activities and the ammonia concentration were measured. The 7 day survival rate was higher in the UW group than in the LR group. The parameters of liver function were less significantly altered in the UW group than in the LR group. The plasma ammonia concentration was significantly (P<0.05) lower 6h after reperfusion in the UW group than in the LR group. A small volume of hypothermic perfusion of the liver using UW solution was safe if it returned to systemic circulation. Hypothermic perfusion of the liver using UW solution may be effective for preventing hepatic tissue injury during extended hepatectomy with hepatic vascular occlusion.