How i do it: microscope augmented pancreaticojejunostomy.

PURPOSE: Post-operative pancreatic fistula (POPF) is perhaps one of most dreaded pancreatoduodenectomy-related complications. Various approaches to mitigate this risk have been explored, with conflicting results and no clear consensus on the comparative superiority of any one technique. We postulate that regardless of technique, the key to reducing POPF is a robust pancreatic anastomosis with careful apposition of tissues, in particular the duct-to-mucosa anastomosis. METHOD: We describe the fashioning of a pancreatojejunostomy with an external pancreatic stent in the setting of a high-risk anastomosis with help of a 10 × magnification surgical microscope. A technical description with a short, edited video is presented.

Percutaneous pancreatic necrosectomy: a case of difficult pancreatic intubation.

A significant percentage of patients with necrotizing pancreatitis will develop an infected pancreatic necrosis that contributes to the morbidity and mortality. Infected pancreatic necrosis requires drainage and debridement. This can be performed percutaneously or surgically. Surgical management may be performed with open or minimally invasive techniques. There has been a trend toward minimally invasive surgical management in recent years. Minimally invasive management requires effective drainage through the use of large-bore drain catheters. We describe a technique that facilitates the insertion of large-bore drainage tubes within the pancreatic collections.

Lipid metabolism in omental adipose tissue during operative surgery.

BACKGROUND: Omental adipose tissue is a pure depot of visceral adipose tissue. We investigated the regulation of lipid metabolism in human omental tissue in vivo by the arterio-venous technique. MATERIALS AND METHODS: Six adults were studied while undergoing elective colonic surgery. Their omental vein was cannulated intraoperatively, and after obtaining the baseline blood samples, 50 ml of 50% dextrose solution was given intravenously and simultaneous arterio-venous samples were taken for the next 2 h. Concentration differences of lipid metabolites, glucose, and lactate were measured across the arterio-venous bed. The rates of action of hormone-sensitive lipase (HSL) and lipoprotein lipase (LPL) were calculated by stoichiometric analysis and the rate of re-esterification of nonesterified fatty acids (NEFA) was determined. RESULTS: After an overnight fast there was a significant release of NEFA and glycerol from the omental adipose tissue (P <0.05, P <0.05). Intravenous glucose load caused a significant reduction in the arterial NEFA and glycerol concentrations (P <0.05, P <0.05), but only the arterio-venous concentration of NEFA decreased significantly (P <0.05). There was no significant change in the arterio-venous concentration difference of glycerol, and the relative rate of action of HSL decreased, but not significantly (P=0.09 at 30 min; P=0.054 at 120 min). The ratio of release of NEFA to glycerol changed significantly (ANOVA; P <0.05) from 2.93:1 to 0.1:1. CONCLUSION: The net release of NEFA by omental adipose tissue is primarily regulated by their local re-esterification. The change in the rate of action of HSL and LPL plays a minor role in the net release of NEFA by omental adipose tissue.