Magnetic Anastomosis Rings to Create Portacaval Shunt in a Canine Model of Portal Hypertension.

PURPOSE: This study evaluated a novel magnetic compression technique (magnamosis) for creating a portacaval shunt in a canine model of portal hypertension, relative to traditional manual suture. METHODS: Portal hypertension was induced in 18 dogs by partial ligation of the portal vein (baseline). Six weeks later, extrahepatic portacaval shunt implantation was performed with either magnetic anastomosis rings, or traditional manual suture (n = 9, each). The two groups were compared for operative time, portal vein pressure, and serum biochemical indices. Twenty-four weeks post-implantation, the established anastomoses were evaluated by color Doppler imaging, venography, and gross and microscopic histological examinations. RESULTS: Anastomotic leakage did not occur in either group. The operative time to complete the anastomosis for magnamosis (4.12 ± 1.04 min) was significantly less than that needed for manual suture (24.47 ± 4.89 min, P < 0.01). The portal vein pressure in the magnamosis group was more stable than that in the manual suture group. The blood ammonia level at the end of the 24-week post-implantation observation period was significantly lower in the magnamosis group than in the manual suture group. Gross and microscopic histological examinations revealed that better smoothness and continuity of the vascular intima had been achieved via magnamosis than with manual suture. CONCLUSION: Magnamosis was superior to manual suture for the creation of a portacaval shunt in this canine model of portal hypertension.

Perioperative outcome of elderly versus younger patients undergoing major hepatic or pancreatic surgery.

OBJECTIVE: The aim of this study was to determine the safety of elderly cancer patients (≥70 years) undergoing hepatic resection (HR) or pancreaticoduodenectomy (PD) in comparison with younger adults (<70 years). METHODS: A total of 1,012 consecutive patients undergoing HR or PD were included. The incidence and severity of morbidity were documented within 30 days postoperatively and compared between elderly and younger groups. Risk factors associated with postoperative morbidity were investigated by multivariate logistic regression analysis. RESULTS: Elderly patients (n=111, 11.0%) had more comorbidities and worse preoperative general condition and liver function versus younger patients (n=901, 89.0%), and thus were more likely to develop infectious (eg, systemic sepsis and urinary tract infection, both p<0.01) and technical-associated complications (intraperitoneal bleeding and biliary/pancreatic fistula, p=0.029 and p=0.074, respectively). However, the incidence and severity of complications were comparable between elderly and younger patients in the whole cohort, and also in HR and PD surgery groups separately. Preoperative hemoglobin (odds ratio [OR] 1.4, p=0.007) and intraoperative blood transfusion (OR 1.9, p=0.002), rather than age, were independently associated with postoperative morbidity. Hepatitis (OR 2.9, p=0.001), preoperative hemoglobin (OR 1.6, p=0.036), and pancreatic versus hepatic surgery (OR 2.3, p=0.005) were independently associated with postoperative infectious. For elderly patients only, American Society of Anesthesiologists (ASA) score III (OR 2.1, p=0.033) and intraoperative blood transfusion (OR 3.2, p=0.030) were independently associated with postoperative morbidity. CONCLUSION: HR and PD can be safely performed in selected elderly patients versus younger patients. Elderly patients with ASA score III or above should be cautiously selected for major surgeries.

Mass Continuous Suture versus Layered Interrupted Suture in Transverse Abdominal Incision Closure after Liver Resection.

BACKGROUND: Abdominal incision closure technique seriously influences patient prognosis. Most studies have focused on the different suture techniques and materials on midline incision, while little data are available in wide transverse or oblique incisions after liver resection (LR). The aim of the present study is to compare the two major incision suture methods after LR in our institute: Mass continuous suture (group P) and layered interrupted suture (group S). STUDY DESIGN: 258 patients undergoing LR with abdominal transverse or oblique incisions were prospectively enrolled. They were divided into two groups according to different abdominal incision suture methods and compared with the preoperative, intraoperative parameters, and postoperative wound complications. RESULTS: There were 118 patients in group P and 140 patients in group S, which was similar in general condition, primary disease, liver, and renal function. Incision length, total operation time, intraoperative blood loss, or perioperative antibiotics use were not different between the two groups. However, abdominal incision closure time and interval time for stitches removing after operation was significantly shorter in group P than group S (both p < 0.001). After a median follow-up of 16 months, the incidence of wound infection and fat liquefaction was more than two times higher in group S than group P, which, however, was not statistically different. Moreover, there was no difference in wound disruption or incisional hernia between the two groups. CONCLUSIONS: Although similar in occurrence of postoperative wound complications, mass continuous suture with polydioxanone seemed to be more timesaving in incision closure and motivated in wound healing.

Choledochojejunostomy with an innovative magnetic compressive anastomosis: How to determine optimal pressure?

AIM: To investigate the optimal magnetic pressure and provide a theoretical basis for choledochojejunostomy magnetic compressive anastomosis (magnamosis). METHODS: Four groups of neodymium-iron-boron magnets with different magnetic pressures of 0.1, 0.2, 0.3 and 0.4 MPa were used to complete the choledochojejunostomy magnamosis. Twenty-six young mongrel dogs were randomly divided into five groups: four groups with different magnetic pressures and 1 group with a hand-suture anastomosis. Serum bilirubin levels were measured in all groups before and 1 wk, 2 wk, 3 wk, 1 mo and 3 mo after surgery. Daily abdominal X-ray fluoroscopy was carried out postoperatively to detect the path and the excretion of the magnet. The animals were euthanized at 1 or 3 mo after the operation, the burst pressure was detected in each anastomosis, and the gross appearance and histology were compared according to the observation. RESULTS: The surgical procedures were all successfully performed in animals. However, animals of group D (magnetic pressure of 0.4 MPa) all experienced complications with bile leakage (4/4), whereas half of animals in group A (magnetic pressure of 0.1 MPa) experienced complications (3/6), 1 animal in the manual group E developed anastomotic stenosis, and animals in group B and group C (magnetic pressure of 0.2 MPa and 0.3 MPa, respectively) all healed well without complications. These results also suggested that the time required to form the stoma was inversely proportional to the magnetic pressure; however, the burst pressure of group A was smaller than those of the other groups at 1 mo (187.5 ± 17.7 vs 290 ± 10/296.7 ± 5.7/287.5 ± 3.5, P < 0.05); the remaining groups did not differ significantly. A histologic examination demonstrated obvious differences between the magnamosis groups and the hand-sewn group. CONCLUSION: We proved that the optimal range for choledochojejunostomy magnamosis is 0.2 MPa to 0.3 MPa, which will help to improve the clinical application of this technique in the future.

Association of Preoperative Biliary Drainage with Postoperative Morbidity after Pancreaticoduodenectomy.

Background. The advantages or disadvantages of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) remain unclear. Methods. A prospectively maintained database was queried for 335 consecutive patients undergoing standard PD surgery between 2009 and 2013. Clinical data and postoperative complications of the 47 patients receiving PBD and 288 patients with early surgery were compared. A matching analysis was also performed between patients receiving or not receiving PBD (no-PBD). Results. The indication for PBD was severe obstructive jaundice (81%) and cholangitis (26%) at the time of PBD. 47 PBD patients had higher bilirubin level than 288 no-PBD patients preoperatively (363.2 µmol/L versus 136.0 µmol/L, p < 0.001). Although no significant difference of any complications could be observed between the two groups, positive intraoperative bile culture and wound infection seemed to be moderately increased in PBD compared to no-PBD patients (p = 0.084 and 0.183, resp.). In the matched-pair comparison, the incidence of wound infection was three times higher in PBD than no-PBD patients (14.9% versus 4.3%, p = 0.080). Conclusions. PBD seems to moderately increase the risk of postoperative wound and bile duct infection. Therefore, PBD should be selectively performed prior to PD.