Evolving Technique for Puestow-Type Procedure for Chronic Pancreatitis: The Combined Roux-en-Y Proximal End-to-Side and Distal Longitudinal Pancreatojejunostomy.

BACKGROUND The goal of surgical procedures in chronic pancreatitis is to establish drainage of the duct throughout the gland as well as resect any inflammatory masses if present. Conventionally, for patients with a dilated pancreatic duct without inflammatory masses, a drainage procedure in the form of a longitudinal pancreatojejunostomy (or Partington-Rochelle modification of the Puestow procedure) is the procedure of choice. CASE REPORT In present case, a patient with chronic pancreatitis was evaluated for surgical management, but extensive intraductal and parenchymal pancreaticolithiasis throughout the entire gland considerably restricted access to the duct. A novel combined Roux-en-Y partial longitudinal pancreatojejunostomy of the body and tail with an end-to-side pancreatojejunostomy of the head was fashioned to facilitate drainage of the entire pancreas, without resection of any parenchyma. The patient's immediate postoperative course was uncomplicated, and at her 30-day follow-up, she had been without pain and had been tolerating a diet, with additional pancreatic enzyme supplementation. CONCLUSIONS Roux-en-Y partial longitudinal pancreatojejunostomy (or modified Puestow procedure) should be considered a viable option for the surgical management of chronic pancreatitis with extensive pancreaticolithiasis, with good short-term outcomes. It underscores the importance of leveraging anatomic limitations to expand the choice of drainage procedure for chronic pancreatitis. This procedure should be considered in those patients with significant pancreaticolithiasis, where clear visualization of the main pancreatic duct is limited, precluding a lengthy pancreatojejunostomy.

Prolonged (≥24 Hours) Normothermic (≥32 °C) Ex Vivo Organ Perfusion: Lessons From the Literature.

For 2 centuries, researchers have studied ex vivo perfusion intending to preserve the physiologic function of isolated organs. If it were indeed possible to maintain ex vivo organ viability for days, transplantation could become an elective operation with clinicians methodically surveilling and reconditioning allografts before surgery. To this day, experimental reports of successfully prolonged (≥24 hours) organ perfusion are rare and have not translated into clinical practice. To identify the crucial factors necessary for successful perfusion, this review summarizes the history of prolonged normothermic ex vivo organ perfusion. By examining successful techniques and protocols used, this review outlines the essential elements of successful perfusion, limitations of current perfusion systems, and areas where further research in preservation science is required.

Institutional Marfan syndrome surgical volume influences mitral valve surgical strategy in patients with Marfan syndrome.

BACKGROUND/AIM: The goal of this study was to evaluate trends in mitral valve (MV) operations performed on patients with Marfan syndrome (MfS) and determine the influence of an institution's MfS and MV surgical volume on MV surgical strategy in the US. METHODS: The Nationwide Inpatient Sample was queried from 1998 to 2011 and a total of 1126 patients with MfS were identified who underwent MV operations meeting our inclusion criteria. Linear regression was performed to assess trends of MV repair (MVr) rates over time. Patients were stratified into tertiles depending on the institution's annual MfS and MV surgical volumes. Multivariate analysis was used to determine the impact of institutional MV and MfS surgical volume on whether a patient received an MV replacement (MVR). RESULTS: The MVR rate was 60% for the entire cohort. There was a decreasing trend of MVR rates during the study period (82% in 1998-99 vs 49% in 2010-2011, P < .05). Multivariate analysis revealed that patients operated on at high (odds ratio [OR], 0.65; P < .05) and medium (OR, 0.66; P < .05) volume MfS centers were less likely to undergo MVR when compared to lower-volume MfS centers. In contrast, MV volume was not a significant predictor of surgical strategy in this cohort. CONCLUSION: The national MVR rate in the MfS population is higher than published reports. Data from this study suggest that MfS patients with indications for MV surgery should be referred to high-volume MfS surgical centers to have the best opportunity for MVr.

Hospital Volume and Outcomes of Robot-Assisted Lobectomies.

BACKGROUND: The positive impact of hospital operative volume on outcomes following video-assisted thoracoscopic surgery has been established. The goal of this study was to determine whether or not this volume/outcome relationship translates to robot-assisted thoracoscopic surgery (RobATS) lobectomy. METHODS: Patients who underwent RobATS lobectomy were identified between 2008 and 2013 in the Healthcare Cost and Utilization Project National Inpatient Sample database. Hospital volume, as well as demographic, clinical, and health-care system-related factors were selected as potential predictors of outcomes. Outcome variables included length of stay (LOS), inpatient mortality, and complications. Hospitals were designated by quartiles according to annual case volume, with very low-volume defined as the first quartile and high-volume defined as the fourth quartile. Regression analyses were used to identify independent predictors of the outcomes of interest. RESULTS: A total of 8,253 RobATS lobectomies were identified. Compared with very low-volume centers, patients at high-volume hospitals had a shorter mean LOS (5.8 vs 6.5 days; P = .001) and decreased mortality rate (0.5% vs 1.9%; P < .001) but more complications (28.1% vs 27.6%; P = .025). In multivariable analysis, high hospital volume was prognostic for decreased mortality (OR, 0.134; P< .001) and shorter LOS (0.2 days; SE, 0.05; P<.001). Hospital volume was not prognostic for any complications, including pulmonary, cardiovascular, intraoperative, or infectious complications. CONCLUSIONS: Undergoing lobectomy at high-volume RobATS centers confers favorable mortality and LOS outcomes compared with very low-volume centers. In this relatively early phase of adoption of RobATS, the long-term clinical impact of differences in LOS as well as the lack of clinical impact on the incidence of complications remain to be determined more definitively. However, the beneficial effect of volume on mortality suggests a need for the careful adoption of this promising technology.