Pancreatic Duct-to-mucosa versus Invagination or Complete External Drainage Anastomosis in Case of Small Pancreatic Duct after Pancreaticoduodenectomy: Comparative Historical Review

After pancreaticoduodenectomy (PD), pancreatic duct-to-mucosa anastomosis (PDM) has been usually applied which may prevent risk of pancreatic fistula (PF). In cases with a small pancreatic duct, however, PDM is difficult to complete. Procedures involving the invagination (IV) or complete external tube drainage (CED) are supposed to be alternative options for anastomosis. We retrospectively compared clinical results between PDM and IV or CED in 104 patients with a tiny pancreatic duct who underwent PD. The 77 patients undergoing PDM (the control group) and 27 patients undergoing other procedures, including 19 for CED and 8 for IV, were comparatively examined. Fatty pancreas was commonly observed in CED group. Pancreaticojejunostomy was significantly more frequently applied in CED group, and the operating time in the IV group was significantly longer than in control group (p<0.05). The anastomotic time in CED group tended to be shorter than those in control and IV groups (18 versus 29 and 37 min). The incidences of PF were not significantly different among groups (31% in control, 47% inCED and 14% in IV, respectively); however, a grade B or C level of PF was not observed in the IV group. PDM is often difficult to achieve and inadequate suturing may injure the pancreatic parenchyma in cases of very small pancreatic duct. Re-evaluation of the CED or IV procedure as an alternative option was suggested to be warranted

Usefulness of intraoperative diagnosis of hepatic tumors located at the liver surface and hepatic segmental visualization using indocyanine green-photodynamic eye imaging

Background To improve the diagnostic accuracy for hepatic tumors on the liver surface, we investigated the usefulness of an indocyanine green-photodynamic eye (ICG-PDE) system by comparison with Sonazoid intraoperative ultrasonography (IOUS) in 117 patients. Hepatic segmentation by ICG-PDE was also evaluated. Methods ICG was administered preoperatively for functional testing and images of the tumor were observed during hepatectomy using a PDE camera. ICG was injected into portal veins to determine hepatic segmentation. Results Accurate diagnosis of liver tumors was achieved with ICG-PDE in 75% of patients, lower than with IOUS (94%). False-positive and false-negative diagnosis rates for ICG-PDE were 24% and 9%, respectively. New small HCCs were detected in 3 patients. The ICG fluorescent pattern in tumors was strong staining in 41%, weak staining in 13%, rim staining in 20% and no staining in 26%. Hepatocellular carcinoma predominantly showed strong staining (61%), while rim staining predominated in cholangiocellular carcinoma (60%) and liver metastasis (55%). Hepatic segmental staining was performed in 28 patients, proving successful in 89%. Conclusion ICG-PDE is a useful tool for detecting the precise tumor location at the liver surface, identifying new small tumors, and determining liver segmentation for liver resection