My last post in Surgical Thoughts was about a new pancreatic anastomosis. Great technique, easy to perform, with good results. Now, I would like to share with you another technique used in laparoscopic pancreatic surgery by Dr. Azagra. Laparoscopic pancreatic surgery was first described by Gagner in 1994, a doctor with experience in several areas of surgery and minimally invasive surgery. The diversity of his experience was crucial to make possible those advances in surgery. Comparing laparoscopic pancreatic surgery with open surgery, complications seem to be identical according to some studies. Even though, data about ontological results comparing laparoscopic and open pancreatic surgery are still lacking. Robotic surgery might be a good help to make minimally invasive pancreatic surgery feasible. It may be like in rectal cancer surgery: robotic is probably better than open, but laparoscopic is not. Robotic surgery can be the future but more studies are necessary.
Meanwhile a great paper from Dr Azagra et al. from the "Département de chirurgie générale" of "Centre Hospitalier de Luxembourg" from Luxembourg City, was published this year about a pancreaticojejunal anastomosis technique which can make it easier to perform by laparoscopy. An analysis of 34 consecutive patients submitted to laparoscopic duodenopancreatectomy was conducted. An end-to-side pancreaticojejunostomy was perform using a posterior and anterior running suture with a resorbable, barbed, 3/0 V-Loc suture, assuring that one passage of both the posterior and anterior suture go through the Wirsung. The Wirsung is always catheterized with a silastic drain. No knots are done. Two drains are placed at the end (near both the pancreaticojejunostomy and the hepaticojejunostomy). Assisting the video available online is mandatory (access the article link at the bottom - scroll down and assist video). Very good surgical technique, great movements, great skills are shown. However, the most important about a surgical technique are the final outcomes, and the results presented are very good.
Pancreatic laparoscopic surgery can have technical advantages.
Risk factors for pancreatic fistula include a soft pancreas and a pancreatic duct smaller than 3 mm. One interesting idea the authors’ present (based in a Battal et al study) is the fact that older patients can be more suitable for laparoscopic reconstruction by having a harder pancreas. In that case the usually worst health condition of the elderly can be overtaken by this technical advantage. I believe this is to be taken into account in the future, along with operative time and surgical aggression (open vs laparoscopic). Additionally, according to Dr. Azagra et al. laparoscopic approach can have advantages namely a better assessment of both resectability and anatomical anomalies. So, in the case of having similar oncological results, minimally invasive pancreatic surgery can eventually be the future. Is it going to overtaken open surgery like in colon cancer? Is this path already being walked? Do not know.
Even with high number of soft pancreas, no type C fistula occurred.
Talking about Dr. Azagra’s study, from the 34 patients included 31 had a malignant disease. A soft pancreas was found in 25 patients (73,53%). Ten (10) patients had a Wirsung smaller than 3 mm. Pancreatic fistula rate reported was 26,47% (type A: 17,65%; type B: 8,82%; type C: 0%).
One small note to remember and summarize the types of pancreatic fistula:
Type/Grade A: no clinical impact (“transitory” fistula)
Type/Grade B: clinically significant fistula (abdominal pain, fever, leukocytosis)
Type/Grade C: potentially life-threatening fistula, possible sepsis and organ failure
No stenosis nor hemorrhage cases were reported. No mortality. Median anastomosis time was 17,3 min. Great, I think.
Important to understand is the reason why Dr. Azagra et al. decided to use the V-Loc sutures, without knots, in such a feared anastomosis. How did this idea arise? One of the reasons was the very good experience the authors had in using such suture in other digestive tract anastomosis. Again, the experience in other fields of surgery can lead to advances in other parallel surgical settings. Knowledge in other fields is never too much. From the patients included 73,53% had a soft pancreas, and although that high rate of soft pancreas the authors reported a fistula rate of 26,47%. This rate match other studies and meta-analysis data. However it is important to highlight that Dr. Azagra el al. reported no type C fistula nor mortality.
Pancreatic anastomosis with barbed self-locking sutures is feasible and safe.
As stated in my previous post, the ideal technique must be suitable for soft and hard pancreas, suitable for all sizes of Wirsung, provide a good blood supply and pancreatic juice flow, easy to learn and to perform, and have a low fistula rate. Can this be one of those techniques? Probably. The authors conclude that “minimally invasive pancreaticojejunostomy using barbed self-locking sutures is feasible and safe”. I would certainly try this in a future opportunity...
Thank you to Dr. Azagra for the great pictures.
Link to article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
#pancreas #pancreatoduodenectomy #laparoscopic #laparoscopic #V_Loc #knotless #pancreaticojunostomy #hepatobiliopancreatic #cancer #anastomosis #digestive #pancreatic_cancer
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