The "double-fired" gastro-jejunostomy as a form of improved efficiency during Whipple procedure.

BACKGROUND: Gastro-jejunostomy (GJ) after pylorus-resecting pancreatoduodenectomy (PD) is most commonly performed in a hand-sewn fashion. Intestinal stapled anastomosis are reported to be as effective as hand-sewn in terms of patency and risk of leakage in other indications. However, the use of a stapled gastro-jejunostomy hasn't been fully assessed in PD. The aim of the present technical report is to evaluate functional outcomes of stapled GJ during PD, its associated effect on operative time and related complications. METHODS: The institutional database for pancreatic duct adenocarcinoma (PDAC) was retrospectically reviewed. Pylorus resecting open PD without vascular or multivisceral resections were considered for the analysis. The incidence of clinically significant delayed gastric emptying (DGE from the International Stufy Group of Pancreatic Surgery (ISGPS) grade B and C), other complications, operative time and overall hospitalization were evaluated. RESULTS: Over a 10-years study period, 1182 PD for adenocarcinoma were performed and recorded in the database. 243 open Whipple procedures with no vascular and with no associated multivisceral resections were available and constituted the study population. Hand-sewn (HS) anastomosis was performed in 175 (72 %), stapled anastomosis (St) in 68 (28 %). No significant differences in baseline characteristics were observed between the two groups, with the exception of a higher rate of neoadjuvant chemotherapy in the HS group (74 % St vs. 86 % HS, p = 0.025). Intraoperatively, a significantly reduced median operative time in the St group was observed (248 min St vs. 370 mins HS, p < 0.001). Post-operatively, rates of clinically relevant delayed gastric emptying (7 % St vs. 14 % HS, p = 0.140), clinically relevant pancreatic fistula (10 % St, 15 % HS, p = 0.300), median length of stay (7 days for each group, p = 0.289), post-pancreatectomy hemorrhage (4.4 % St vs. 6.3 % HS, p = 0.415) and complication rate (22 % St vs. 34 % HS, p = 0.064) were similar between groups. However, readmission rates were significantly lower after St GJ (13.2 % St vs 29.7 % HS, p = 0.008). CONCLUSION: Our results indicate that a stapled GJ anastomosis during a standard Whipple procedure is non-inferior to a hand-sewn GJ, with a comparable rate of DGE and no increase of gastrointestinal related long term complications. Further, a stapled GJ anastomosis might be associated with reduced operative times.

Evaluation of a bone's in vivo 24-hour loading history for physical exercise compared with background loading.

The present study sought to answer two research questions. First, how distinctive, as a potential osteogenic stimulus, are short-duration bouts of treadmill exercise relative to sedentary background activity? Second, how well does daily effective strain stimulus relate the loading history for one such exercise program, in comparison with other experimental loading programs, to bone formation? In vivo cortical strains were measured in the tibiotarsus of White Leghorn chickens at a late stage of skeletal growth (14-34 weeks old) under the conditions of a previous investigation of bone formation in response to an exercise program (15 min/day, treadmill gait at 60% maximum speed while carrying 20% body mass) that included sedentary background activity. These strain data were compiled into 24-hour loading histories of peak cyclic strain, demonstrating that strains were statistically different for exercise and background activities (p < 0.0001), with both the magnitude and number of cyclic strain events being greater during exercise (generally greater than 500 microstrain, 2,500 cycles/day) than during background activity (generally less than 500 microstrain, mean: 775 cycles/day). Strains during exercise accounted for more than 97% of the daily effective strain stimulus for bone adaptation, despite the fact that exercise comprised only 1% of the daily period (15 min/day). The levels of the daily effective strain stimulus were similar to those calculated for strains engendered by artificial loading of functionally isolated avian ulnae, which either maintained bone mass or resulted in a 15% increase of cortical cross-sectional area in both sets of studies. These results indicate that short-duration bouts of treadmill exercise and sedentary background activity can represent distinct osteogenic stimuli for adaptive bone modeling. They also provide experimental support for the use of a daily effective strain stimulus to quantify skeletal loading histories for differing programs of physical exercise, although the relative importance of other mechanical and nonmechanical factors requires further investigation.