TY - JOUR
AU - White, S A
AB - Sir We read with interest the large case series of laparoscopic pancreatic resections reported by Rosok and colleagues. Pancreatic leak and fistulation can still be a problem after laparoscopic pancreatic surgery. There are several methods of dividing the pancreas but in most instances this is done by means of a mechanical stapling device; in our centre the Echelon™ 60-cm reticulating stapler (Ethicon Endosurgery, Cincinnati, Ohio, USA) is used, a 45-cm cartridge being too short to span the width of the pancreas. Despite this, it is often difficult to determine which cartridge to use for division of the pancreatic parenchyma: white, blue, gold or green. These range from 2·0 to 4·8 mm (1–2 mm in the deployed form) and in most instances when the gland is thick or fibrous we prefer the 4·8-mm cartridge (green). Likewise we prefer to divide the splenic artery and splenic vein individually, separately from stapling the pancreatic parenchyma. This is performed using locking laparoscopic clips (Hem-o-lok®; Weck Closures, Research Triangle Park, North Carolina, USA). Although pancreatic fistulas occurred in 17 patients in Rosok and colleagues' series, it is not clear how many occurred since 2005 when they started to use a fibrinogen/thrombin-coated sponge (TachoSil®; Nycomed, Zurich, Switzerland) to seal the pancreatic resection margin1. In our experience TachoSil® is very difficult to apply when used laparoscopically as there is no ideal delivery system; the sponge is prone to cracking and fragmentation when being manipulated as a dry sponge and introduced either down the laparoscopic ports or through a wound exit site. An alternatively strategy is to use Tisseel® (Baxter Healthcare, Deerfield, Illinois, USA) which is licensed as both a sealant and haemostat. There is also now a Duplocath MIS® (Baxter Healthcare) spray system available so this can be used laparoscopically. As distinct from TachoSil® it contains not just fibrinogen and thrombin but also aprotonin. We understand that in the presence of a pancreatic fistula or leak activated proteolytic pancreatic enzymes may lead to rapid degradation of fibrin, unless a protease inhibitor (such as aprotonin) is added2. Therefore, Tachosil® may not reduce the risk of bleeding or pancreatic fistulas at all. In light of this we use Tisseel® and in our early experience have recognized no pancreatic fistulas after laparoscopic distal pancreatectomy3. References 1 Oláh A , Issekutz A, Belágyi T, Hajdú N, Romics L Jr. Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy . Br J Surg 2009 ; 96 : 602 – 607 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Marczell AP . Indications for fibrin sealing in pancreatic surgery with special regard to occlusion nonanastomosed stump with fibrin sealant . Surg Technol Int 2000 ; VIII : 32 – 36 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 3 Robinson S , Sen G, Saif R, Jacob M, Charnley R, French J et al. Management of the pancreatic stump after laparoscopic distal pancreatectomy . HPB 2010 ; 12 ( Suppl 1 ): 204 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Single-centre experience of laparoscopic pancreatic surgery (Br J Surg 2010; 97; 902–909)
JF - British Journal of Surgery
DO - 10.1002/bjs.7319
DA - 2010-11-04
UR - https://www.deepdyve.com/lp/oxford-university-press/single-centre-experience-of-laparoscopic-pancreatic-surgery-br-j-surg-Ikd8PYAxRD
SP - 1891
EP - 1892
VL - 97
IS - 12
DP - DeepDyve
ER -