Diagnosis of postoperative pancreatic fistula.

BACKGROUND: Pancreatic fistula (PF) is a major source of morbidity after pancreatectomy. The International Study Group on Pancreatic Fistula (ISGPF) defines postoperative fistula by an amylase concentration in the abdominal drain of more than three times the serum value on day 3 or more after surgery. However, this definition fails to identify some clinical fistulas. This study examined the association between lipase measured in abdominal drainage fluid and PF. METHODS: Amylase and lipase levels in the abdominal drain were measured 3 days after pancreatic resection. Grade B and C fistulas were classified as clinical fistulas, regardless of whether the measured amylase concentration was considered positive or negative. The PF group included patients with a clinical fistula and/or those with positive amylase according to the ISGPF definition. RESULTS: Sixty-five patients were included. The median level of lipase was higher in patients with positive amylase than in those with negative amylase: 12,176 versus 64 units/l (P < 0·001). The lipase level was 16,500 units/l in patients with a clinical fistula and 224 units/l in those without a clinical fistula (P = 0·001). Patients with a PF had a higher lipase concentration than those without: 7852 versus 64 units/l (P < 0·001). A lipase level higher than 500 units/l yielded a sensitivity of 88 per cent and a specificity of 75 per cent for PF. For clinical fistulas the sensitivity was 93 per cent and specificity 77 per cent when the threshold for lipase was 1000 units/l. CONCLUSION: Lipase concentration in the abdominal drain correlated with PF. A threshold of 1000 units/l yielded a high sensitivity and specificity for the diagnosis of clinical PF.

Minimally invasive endogastric removal of migrated gastric band after endoscopic failure: how I do it.

Intragastric band migration is a rare and late complication of laparoscopic -adjustable gastric banding and should be recognized by all digestive surgeons. Endoscopic removal is most commonly performed, but surgery is an alternative in cases of endoscopic failure. Many different procedures have been reported. We show here (see Video) a fully laparoscopic endogastric procedure through two 5-mm antral gastrotomies. This technique can also be used to remove benign endogastric tumors. The procedure is safe and provides a large endogastric operative area, with no particular morbidity. Endogastric removal through a fully laparoscopic approach should be considered as the first alternative to endoscopic approach.

A review of available prosthetic material for abdominal wall repair.

Abdominal wall incisional and inguinal hernia repair can call for utilization of implants or prostheses as an alternative to simple suture techniques. The various implants can be synthetic, biologic or mixed: their physicochemical properties condition the mechanical results and the long-term outcome of the repair. The increasing number of available materials allows the surgeon to choose between a wide variety depending on the indication, the site of implantation, the surgical approach and whether the operative field is contaminated or not. With regard to evidence-based medicine, while several synthetic implants have been shown to be superior in efficacy to simple suture, other studies are underway to develop the indications for bioprostheses, in particular in contaminated fields. This review of the literature summarizes the current knowledge on synthetic and biologic implants (physicochemical characteristics, forms, indications).