Comparing effects of intraoperative fluid and vasopressor infusion on intestinal microcirculation

Several studies have revealed that vasopressor may be more appropriate for treating intraoperative hypotension and preventing hypervolemia. This study compared the effects of vasopressor infusion and fluid supplementation on intestinal microcirculation during treating intraoperative hypotension. Thirty-two rats were randomly divided into the following four groups: Light Anesthesia group (LA, 0.8–1% isoflurane); Deep Anesthesia group (DA, 1.5–1.8% isoflurane); Fluid DA group (1.5–1.8% isoflurane and fluid supplementation); and Norepinephrine DA group (1.5–1.8% isoflurane and norepinephrine infusion). At 240 min, perfused small vessel density (PSVD) of the mucosa did not differ significantly between the Fluid DA and Norepinephrine DA groups [26.2 (3.2) vs 28.9 (2.5) mm/mm2, P = 0.077], and tissue oxygen saturation of the mucosa was lower in the Fluid DA groups than in the Norepinephrine DA groups [ 48 (7) vs 57 (6) %, P = 0.02]. At 240 min, TSVD and PSVD of the seromuscular layer were higher in the Norepinephrine DA group than in the Fluid DA group. Fluid administration was higher in the Fluid DA group than in the Norepinephrine DA group [66 (25) vs. 9 (5) μL/g, P = 0.001]. Our results showed that norepinephrine can resuscitate intraoperative hypotension related microcirculatory alteration and avoid fluid overload.

Simplified Minimally Invasive Surgical Approach for Prophylactic Laparoscopic Gastropexy in 21 Cases

ABSTRACT The objective of this study was to describe the operative technique and outcome of a simplified laparoscopic gastropexy approach in dogs. Twenty-one dogs undergoing prophylactic laparoscopic gastropexy with a simple continuous barbed suture without incising the seromuscular layer of the stomach and transversus abdominis muscle were reviewed. In 20 cases, additional procedures were performed (18 ovariectomies and 2 prescrotal castrations); 1 dog had two prior episodes of gastric dilation without volvulus and underwent gastropexy with a prophylactic intent. The gastropexy procedure had a median duration of 33 min (range 19–43 min). V-Loc 180 absorbable and the V-Loc PBT nonabsorbable suturing devices were used in 8 and 13 dogs, respectively. Minor intraoperative complications occurred in four cases: broken suture (1), needle dislodgement (2), and folded needle (1). Minor complications included self-limiting wound complications (3), abdominal discomfort (2), vomiting (1), and inappetence (2). Postoperative abdominal ultrasound performed after a median of 8 mo (6–36 mo) confirmed permanent adhesion at the gastropexy site in all dogs. One dog developed a fistula (1 yr postoperatively) and another a granuloma (3 mo postoperatively), both at the gastropexy site. Prophylactic laparoscopic gastropexy may be performed with knotless unidirectional barbed suture without creating an incision on the abdominal wall and stomach.

MODIFIED HEIDELBERG TECHNIQUE FOR PANCREATIC ANASTOMOSIS

ABSTRACT Background : Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described. Aim: To present a novel technique based on slight modifications of the original Heidelberg technique, as new pancreatojejunostomy technique for reconstruction of pancreatic stump after pancreatoduodenectomy and present initial results. Method: The technique was used for patients with soft or hard pancreas and with duct size smaller or larger than 3 mm. The stitches are performed with 5-0 double needle prolene at the 2 o’clock, 4 o’clock, 6 o’clock, 8 o’clock, 10 o’clock, and 12 o’clock, positions, full thickness of the parenchyma. A running suture is performed with 4-0 single needle prolene on the posterior and anterior aspect the pancreatic parenchyma with the jejunal seromuscular layer. A plastic stent, 20 cm long, is inserted into the pancreatic duct and extended into the jejunal lumen. Two previously placed hemostatic sutures on the superior and inferior edges of the remnant pancreatic stump are passed in the jejunal seromuscular layer and tied. Results : Seventeen patients underwent pancreatojejunostomy after pancreatoduodenectomy for different causes. None developed grade B or C pancreatic fistula. Biochemical leak according to the new definition (International Study Group on Pancreatic Surgery) was observed in four patients (23.5%). No mortality was observed. Conclusion : Early results of this technique confirm that it is simple, reliable, easy to perform, and easy to learn. This technique is useful to reduce the incidence of pancreatic fistula after pancreatoduodenectomy.

Laparoscopic Pyloromyotomy: A Modified Simple Technique

Background: A modified laparoscopic pyloromyotomy (LP) technique may provide an alternative to treating infantile hypertrophic pyloric stenosis (IHPS) by improving operative timing with reduction of postoperative complication rates, compared with a three-port trocar system.Methods: Thirty-three infants were treated with IHPS at a single-centre between January 2002 and December 2011. The local surgical incision to the pylorus was performed according to Ramstedt’s pyloromyotomy; but with a two-port trocar system (umbilical and right lower abdominal crease ports), following a controlled stab wound into the epigastric region and a 3mm incision to allow introduction of ophthalmic knife. With the aid of atraumatic forceps and camera guidance, the ophthalmic knife was used to carefully incise the seromuscular layer, which allows improved manual tactile sensation compared to ergonomic laparoscopic spreaders. A Benson pyloric spreader was then used to further separate the pyloric muscle layer to complete the procedure.Results: In all 33 infants treated, LP was safely performed with no evidence of duodenal or mucosal perforation with complete pyloromyotomy achieved in each case. The postoperative course was rather uneventful apart from an umbilical wound infection.Conclusion: This modified approach is simple, safe and allows improved operative timing, whilst increasing surgeon’s confidence by tactile sensation.

Pancreatico-Gastric Anastomosis with and without Sutures – Experimental Swine Model

Objectives. The aim of our study is to identify a surgical technical that has the lowest rate of pancreatic fistulas in pancreatico-gastric anastomosis following duodenopancreatectomies. We studied pancreatico-gastric anastomosis performed with stitches compared to the ones performed without stitches. Methods. Our experimental model is based on ten piglets, which were divided into 2 groups. In the first group (n=5) the pancreatico-gastric anastomosis was done using double purse-string threads one passed through the gastric seromuscular layer and one through the gastric mucosa. In the second group (n=5) the pancreatico-gastric anastomosis was performed using sutures through the stomach and pancreas. Results. Postoperative amylasemia was higher in the second group. In the first group no pancreatico-gastric fistulas were observed, whereas pancreatic necrosis was observed only at a superficial level of the pancreatic stump. In the second group, two cases had developed fistulas, both bordered by large areas of coagulation necrosis accompanied by pancreatic duct hyperplasia. Duration of the anastomosis was shorter for the first group. Conclusions. In conclusion, the pancreatico-gastric anastomosis performed using two purse-string suture is a feasible, safe and fast process.

Dipping Technique for Ureteroileal Anastomosis in Orthotopic Ileal Neobladder: 20-Year Experience in 670 Patients—No Stenosis with Preservation of the Upper Tract

Objectives. Many techniques were described for ureteroileal anastomosis in orthotopic bladder substitution, ranging from nonrefluxing to refluxing techniques, all aiming at preservation of the upper tract. We describe our technique of dipping the ureter into the ileal pouch, which is simple and had no complications. Patients and Methods. Our technique implies dipping the ureter in the lateral side of the pouch, in right and left corners, with two rows of four sutures fixing the seromuscular layer of the ureter to the seromuscular layer of the ileal pouch. The procedure was applied in both normal ureteric calibre and dilated ureter. Total number of procedures done was 1,340 ureters in 670 patients after radical cystectomy for invasive carcinoma of the bladder of urothelial and nonurothelial cancer. Results. Followup of patients every six months and onward did not show stenosis in the ureteroileal anastomotic site. Filling of the ureter with contrast dye on ascending pouchogram was observed in patients who had considerably dilated ureters at the time of cystectomy. Normal ureter did not show clinical reflux but radiological filling of the ureter when the intravesical pressure exceeded the leak point pressure. Time to perform the dipping technique was 5–7 minutes for each site. Conclusion. Dipping technique for ureteroileal anastomosis in orthotopic ileal neobladder avoids the incidence of stenosis, preserves the upper tract, is a fast procedure, stands the evaluation in long-term followup, and was practiced successfully for twenty years.