By I. Asaru. Notre Dame College of Ohio.

Closing the capsule in this fashion generally controls bleeding Complete Transverse Fracture from superficial fractures buy generic priligy on-line. Alternatively order genuine priligy, applying Avitene to When a transverse fracture of the spleen has divided the the stellate fracture may successfully control all but the arterial organ into two or more segments order on line priligy, it is necessary to determine bleeders. The efficiency of this topical agent may be enhanced the viability of each segment. Any splenic fracture that significantly involves the the nonviable segments and retain the viable portion of the hilus of the spleen generally requires partial splenectomy to spleen after achieving hemostasis. Be sure Applying Topical Hemostatic Agents to identify and ligate the hilar artery that supplied the ampu- tated segment of the spleen. Most topical hemostatic agents provide a framework for deposition of platelets, which accelerates formation of a Longitudinal Fracture blood clot. Severe blunt injuries may produce a longitudinal fracture in Consequently, it is necessary to slow down the bleeding from the long axis of the spleen (Fig. Because this fracture the surface of a damaged spleen by local pressure for a few may lacerate a large number of the transverse branches of the minutes. If the oozing surface is fairly smooth, apply a 97 Operations for Splenic Trauma 879 double sheet of oxidized cellulose gauze and cover it with a dry gauze pad. Then gently remove the gauze pad while taking care not to dislodge the sheet of oxidized cellulose, which should now be adherent to the raw surface. If the bleeding surface is irregular in nature, Avitene is a much better choice than hemostatic sheets. It is highly effec- tive for oozing surfaces due to traumatized capillaries and venous sinusoids. Use a forceps to apply enough Avitene to cover the entire bleeding surface for a thickness of 3–4 mm. If bleeding breaks through one portion of the Avitene, apply an additional layer of dry Avitene. If bleeding contin- ues to break through, remove the Avitene and pursue further efforts to reduce the rate of bleeding by applying hemostatic clips or suture-ligatures. If necessary, use strips or pledgets of Splenorrhaphy Teflon felt, omental pedicle, or even oxidized cellulose gauze; insert the sutures through these pledgets to protect the Mobilizing the Spleen splenic capsule when the suture is being tied. A linear sta- Do not try to repair the spleen without completely mobiliz- pling device may also be used to close the capsule of a small, ing the spleen and the tail of the pancreas by the technique normal spleen after partial splenectomy. Adequate exposure may Absorbable Mesh Wrap also require division of the lower short gastric vessels. Be When a spleen is the site of several fractures or the capsule is careful not to cause further injury to the spleen when divid- stripped from a significant part of the surface but the hilum is ing the splenic ligaments. Place a large gauze pad against the posterior tailoring the mesh and suturing it so it provides even pressure to abdominal wall in the area of the dissection and elevate the the damaged spleen may help achieve good hemostasis. Mark the excess, splenic artery and vein between the thumb and index finger remove it, and cut it to size, leaving at least a 2 cm border all at the hilus (Fig. With the mesh on a convenient surface away from the hilus that may have been lacerated by the trauma. This suture serves as a purse string to Suturing the Splenic Capsule tighten the mesh around the spleen, applying firm, even com- For fractures that have not penetrated the full thickness of pression to the splenic pulp without occluding the hilar vessels. Use a narrow-tipped suction device to taking care not to tighten it around the splenic artery and vein provide exposure and occlude bleeding arteries by accurately (Fig. If the mesh is not tight enough, plicate it with addi- applying small- or medium-size hemostatic clips, use 4-0 or tional sutures at a convenient location. Confirm that all bleeding 5-0 vascular sutures to control bleeding veins or arteries that has been controlled and replace the spleen in its bed. Control residual oozing of blood from the sinusoids by closing the capsule with interrupted sutures of 2-0 chromic catgut on a medium-size gastrointestinal atrau- Partial Splenectomy matic needle, as illustrated in Fig. In other cases, a Dividing the Spleen continuous suture of the same material may prove to be Temporarily occlude the splenic artery with a Silastic loop. When tying these sutures, take great care not to Then aspirate all blood clots from the area of injury, espe- apply force sufficient to tear the delicate splenic capsule. Release the splenic artery, observe for a line of demarcation, and mark it with electro- cautery along the capsule. Use a narrow-tipped suction device to expose the bleed- ing points in the line of the fracture. Apply small hemostatic clips to bleeding vessels and continue the dissec- tion until the traumatized section of the spleen has been entirely severed. Then release the Silastic loop encircling the splenic artery and observe the cut edge of the splenic remnant for hemostasis. Then insert the sutures Close the abdominal incision in the usual fashion without through the Teflon felt as shown in Fig. This maneuver achieves satisfactory is suspected, place a closed-suction drain in the vicinity of hemostasis along the cut edge of the spleen. Replace the splenic remnant in its natural position after making certain that hemostasis is complete in the posterior abdominal wall and the splenic bed. Use electrocautery Postoperative Care along the posterior abdominal wall; but if there are bleeding points in the tail of the pancreas, occlude these bleeding Administer perioperative antibiotics for 12–24 h. Follow so the splenic remnant can be inspected after it has been the vital signs and the hemoglobin or hematocrit to exclude replaced in the abdomen. Patients who have 97 Operations for Splenic Trauma 881 had a splenorrhaphy or partial splenectomy should avoid Further Reading vigorous athletic activity for 4–6 weeks. The patient should wear a MedicAlert able mesh: feasibility, reliability and safety. National variation in outcomes and costs for splenic injury and the impact of trauma systems: a population-based cohort study. Partial splenic resection using phylactic antibiotics are indicated during adult life. Variation in the use of urgent sple- nectomy after blunt splenic injury in adults. If proper hemostasis has been attained during the operation, this complication is rare. Leon Pachter In most major centers, laparoscopic splenectomy is the pre- • Felty’s syndrome ferred method of elective splenectomy in all patients except • Hematologic malignancies for those with massive splenomegaly. Splenectomy typi- cally leads to normalization of platelet count in 65–85 % of patients long term. Other hematologic indications Preoperative Evaluation and Preparation include hereditary spherocytosis, myeloproliferative disor- der (chronic and acute myeloid leukemia), and autoimmune The preoperative abdominal exam is important to estimate hemolytic anemia. Massive Although laparoscopic splenectomy can be performed in splenomegaly (>25 cm) may change the operative approach select situations of splenic trauma, generally the laparo- to either anterior with 45° tilt or hand-assist (or supine lapa- scopic approach is contraindicated in emergent situations rotomy).

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It can be prevented by dissecting these two vital structures with care and precision buy generic priligy line. We have had two patients who developed gastric phytobezoars following pancreatoduodenectomy with vagotomy best order for priligy. Initiate enteral feedings by way of the jejunostomy cath- Further Reading eter after the operation is completed and continue these feed- ings until the patient is able to take a full diet by mouth cheap 90 mg priligy otc. Preoperative biliary stents in pancreatic cancer Leave the T-tube and the pancreatic catheter in place for – proceed with caution. If there has been no drainage of pancreatic juice or and some new insights into pancreaticoduodenectomy. Techniques of pancreaticojejunostomy in pan- this leak of pancreatic juice becomes complicated by an creatoduodenectomy. Long-term survival after vated and start digesting tissues in the vicinity of the anasto- pancreatoduodenectomy for pancreatic adenocarcinoma: is cure mosis. Do preoperative Initially, attempt conservative therapy by continuous irriga- biliary stents increase postpancreaticoduodenectomy complica- tion of the anastomotic site through the catheter using sterile tions? En bloc vascular the patient’s condition continues to deteriorate, relaparotomy resection for locally advanced pancreatic malignancies infiltrating to remove the remaining tail of the pancreas together with major blood vessels: perioperative outcome and long-term survival the spleen may prove lifesaving. Pancreaticoduodenectomy with or pancreaticoduodenectomies in the 1990’s: pathology, complications, without extended retroperitoneal lymphadenectomy for periampul- and outcomes. Chassin† Indications centrates on the additional features necessary to complete the pancreatic resection and should be read in conjunction with Carcinoma of the pancreas (see Chap. Contraindications Documentation Basics Distant metastases Findings Absence of an experienced surgical team Patient who lacks alertness and intelligence to manage diabetes Operative Technique Invasion of portal or superior mesenteric vein Incision Preoperative Preparation Except for extremely stocky patients, we use a long midline incision from the xiphoid to a point 10 cm below the See Chap. Operative Strategy Evaluation of Pathology, Determination of Resectability, Initial Mobilization Complete omentectomy is generally performed as part of a total pancreatectomy. Division of the splenic, short gastric, The technique followed here is identical to that described in right gastric, and gastroduodenal arteries leaves the gastric Figs. For this reason, do not divide the left gastric artery at its removed with the specimen (Figs. Rather, divide it along the lesser curvature distal to the point where the branches to the proximal stomach and esophagus arise. This chapter con- Splenectomy and Truncal Vagotomy With the stomach and omentum retracted in a cephalad direction, identify the splenic artery along the superior sur- C. Make an incision in the Ligate the gastric side of the vessel with 2-0 or 3-0 silk and avascular lienophrenic fold of the peritoneum (Fig. Elevate the tail of the until all of the short gastric vessels have been divided pancreas together with the spleen. Expose Now redirect attention to the tail and body of the pan- the posterior surface of the spleen and identify the splenic creas, which is covered by a layer of posterior parietal peri- artery and veins at this point. Insert moist gauze pads into the bed of the border of the pancreas and then again along the inferior elevated spleen. As the pancreas is elevated from costal margin and place it in the region of the sternum. Apply the posterior abdominal wall, follow the posterior surface traction in a cephalad and anterior direction, exposing the of the splenic vein to the point where the inferior mesen- abdominal esophagus. Incise the peritoneum over the teric vein enters; then divide this vessel between 2-0 silk abdominal esophagus. Follow the splenic artery to its point rate the crus of the diaphragm from the esophagus (Fig. Carefully dissect the junction Mobilizing the Distal Pancreas of the splenic and portal veins away from the posterior wall of the pancreas. After 2 cm of the terminal portion of Identify the proximal short gastric vessel, and insert the the splenic vein has been cleared (Fig. Apply a ligature to the distal end and an atrau- matic bulldog clamp to the proximal end and divide the duct. Freeing the Uncinate Process Cholecystectomy and Division of the Hepatic Duct Retract the spleen, pancreas, and duodenum to the patient’s right. Gentle dissection discloses three or four venous The hepatic duct, portal vein, and hepatic artery have already branches between the posterior surface of the pancreatic been stripped of overlying peritoneum and lymph nodes. It bladder by dissecting it out of the liver bed from above down is now possible gently to retract the portal vein to the right. Obtain complete hemostasis in the liver bed At this point the superior mesenteric artery can generally be with electrocautery. Be certain that Expose the ligament of Treitz by elevating the transverse hemostasis is complete. Divide the jejunum as previously described and suction-drainage catheter in the right upper quadrant of the remove the specimen (Fig. The hepaticojejunostomy is performed first, as Postoperative Care described in Chap. At a point about 50 cm downstream from the hepatico- The principles of postoperative care described in Chap. Frequently no more than 10–20 units are required following total pancreatectomy is regulation of the resulting per day. The greatest danger is hypoglycemia due to one of the longer-acting insulin products. Perform blood glucose relatives should be carefully instructed about the symptoms determinations every 3–4 h for the first few days. Especially Repeated measurements of the gastric pH are vital to pre- during the early postoperative period, the diabetes is quite vent postoperative gastric hemorrhage. Use intravenous H2 brittle, and an overdose of only a few units of insulin may blockers to keep the gastric pH at 5 or above. Leakage from biliary anastomosis Mesenteric venous thrombosis Hepatic failure Complications Hypoglycemia or hyperglycemia Postoperative gastric bleeding due to stress ulceration or a marginal ulcer 834 C. Chassin† Indications Operative Strategy Resectable malignant tumors located to the left of superior Choice of Operative Approach mesenteric vessels Benign tumors that cannot be locally excised (e. Careful dissection Pseudocysts of the tail (selected) of the splenic artery and vein is required (see references). Chronic pancreatitis localized to the body and tail Laparoscopic distal pancreatectomy is being performed in Trauma some centers and is described in the chapter which follows. The greatest danger when resecting the body and tail of In patients suspected of having a gastrinoma, the diagnosis the pancreas arises when a malignancy in the body obscures should be confirmed by serial serum gastrin levels before the junction between the splenic and portal veins. If elevation of the tail and body of the pancreas together with the tumor should result in a tear at the junction of the Pitfalls and Danger Points splenic and portal veins and this accident occurs before the tumor has been completely liberated, it may be extremely Lacerating splenic or portal vein difficult to repair the lacerated portal vein. If an accident of this type should occur, it is necessary to find the plane between the neck of the pancreas and the portal vein and then divide the pancreas across its neck while manually occluding the lacerated vein. If the tumor extends beyond this junc- blood vessel deep to this layer of peritoneum is the inferior tion, it is probably inoperable. After completing this Avoiding Pancreatic Fistula incision, insert the index finger behind the pancreas, and use the fingertip to elevate the peritoneum along the superior We have used the 55 mm linear stapling device for years to margin of the pancreas (Fig. Incise this layer of perito- accomplish closure of the cut end of the remaining pancreas neum with scissors, avoiding the sometimes convoluted after resecting the body and tail of this organ.

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Some surgeons routinely employ a prokinetic agent during the immediate postoperative period after this procedure discount 90mg priligy with visa. Fortunately buy priligy 60 mg on line, long-term delayed gastric emptying is reported Treatment far less frequently purchase priligy 60mg with amex. Neoadjuvant Chemoradiation Neoadjuvant chemoradiation protocols may be employed in an attempt to downstage tumors and improve resection rates Islet Cell Tumors and, ultimately, long-term outcomes. Their clinical presentation may be subtle, Operative Management and localization of the tumor once the endocrinopathy has been defined is even more challenging. A number of modali- Surgical resection provides the only hope for cure of this dis- ties are utilized. Most patients are treated with a pylorus - preserving prise a good initial approach. Those seen with sampling (portal and splenic veins and venous tributaries chronic pancreatitis rarely do so and may require drainage. Long-term success rates for percu- cytochemistry evaluation of islet cell tumors routinely yields taneous endoscopic and endoluminal decompression have the presence of various other islet cell products in addition to been approximately 70 %. These data are comparable to the the primary one associated with the endocrinopathy in indi- known operative success rates for external drainage of pseu- vidual patients. In other words, a patient with an insulinoma docysts established decades ago, which typically were about is likely to have somatostatin and possibly glucagon or gas- 70 % as well. Although some endoscopic and some interven- trin in the islets present within the insulinoma. In view of the tional studies have reported slightly higher success rates, added specificity of octreotide scanning, it is most recom- long-term follow-up has been scant. These modalities may reveal lesions not material that is unlikely to be adequately drained through found using conventional imaging techniques. It poses a for both procedures is their ability to access the duodenal wall, risk for secondary infection after being exposed to microor- which is the most common site of extrapancreatic gastrinoma. Once diagnosed, the problem of intraoperative localiza- The options for providing operative drainage include cysto- tion remains. Intraoperative ultrasonography plays a major gastrostomy and Roux-en-Y cyst jejunostomy. The so-called gastrinoma triangle is bounded by a verti- the pancreatic pseudocyst is also an option and is generally cal line drawn between the pylorus and the third portion of reserved for cysts in the body and tail of the pancreas. The apex of the triangle is the hilum of the obtain an intraoperative frozen section biopsy specimen of the liver, which is a reasonable starting point for assessing the wall of the cyst to rule out the presence of a cystic neoplasm. For all other islet cell tumors, With regard to cystic neoplasms, the presence of a cystad- the primary site is almost always within the pancreatic paren- enoma in a cyst surrounding the pancreas has been recog- chyma. In this regard, we simply advise careful evaluation of nized as a possibility for decades. More recently, the the uncinate process and the inferior border of the pancreas important distinction between serous and mucinous adeno- as the superior mesenteric vein progresses underneath it. Serous cystadenomas are rarely Each of these sites is somewhat remote until adequate dis- malignant, but mucinous cystadenomas are considered to be section has been performed. If there is any evi- with recognized mucinous cystadenomas are candidates for dence of extension beyond the capsule or if lymph node resection at all times. In addition, several trinoma metastatic to the liver may be present in a patient for investigators have suggested measuring tumor markers decades. Spontaneous closure pancreas and the related cystic papillary neoplasms are again should be anticipated in more than 98 % of patients. Diagnosis Dehiscence of the gastrointestinal anastomoses represents is suspected when copious mucus is seen exuding from the the least frequent of all complications. Resection is indicated; total pan- by following the normal precepts of intestinal anastomotic createctomy is rarely employed even though the disease may technique. For that reason clear Complications of Pancreatic Surgery dissection of these structures is recommended. Unfortunately, superior mesenteric vein and portal vein injuries may occur Any pancreatic resection carries an associated risk of pancre- simply because of dense adhesion to these structures due to atic fistula. In the past, this complication was considered to be chronic pancreatitis or to invasion of these structures by the cause of the high mortality rate associated with these carcinoma. Pancreaticoduodenectomy adds the risk of bile and gastrointestinal anastomotic leakage. Because of the rich vas- Acknowledgment This chapter was contributed by William H. Nealon cular anatomy in the area of the head of the pancreas, major in the previous edition. The dissection planes include the superior mesenteric vein, portal vein, com- Further Reading mon hepatic artery, and superior mesenteric artery. Duodenum- cular supply or venous drainage to the intestine (superior mes- preserving head resection in chronic pancreatitis changes the natural enteric artery and portal vein). Thus, necrosis of the liver and course of the disease: a single-center 26-year experience. National failure to operate on early stage pancreatic age in the area of the pancreaticojejunostomy and the hepati- cancer. Cystic tumors of the pancreas: imaging and reached well below 5 % and in capable hands may be 2–3 %. Regression of liver fibrosis after believe that the correlation of pancreatic fistula to mortality biliary drainage in patients with chronic pancreatitis and stenosis of in the past was related to the coexistence of abdominal sep- the common bile duct. Extended drainage versus resection in surgery for chronic pancreatitis: a prospective random- ture of the pancreas is essentially normal and soft (as in ized trial comparing the longitudinal pancreaticojejunostomy com- resection for trauma); it is consequently poorly prepared to bined with local pancreatic head excision with the pylorus-preserving hold a stitch. Results of total most series is a relatively harmless complication, and spon- pancreatectomy for adenocarcinoma of the pancreas. Chemical splanchnicectomy in patients with unresectable Bile fistula may be more lethal than pancreatic fistula. Intraductal papillary mucinous pancreas, duodenum, small bowel, colon, and rectum. Chassin† Indications laparoscopy helps with accurate staging and minimizes nontherapeutic laparotomy for cancer of the pancreas. Carcinoma of ampulla, head of pancreas, distal bile duct, or Prescribe perioperative antibiotics. When a patient suffering from obstructive Postoperative sepsis jaundice has been found to have operable ampullary or pan- Postoperative acute pancreatitis creatic cancer, refer the patient to an appropriate center of Postoperative marginal ulcer with bleeding expertise. Operative Strategy Preoperative Preparation The operation may be conceptualized as consisting of three Correct hypoprothrombinemia with vitamin K. Chassin Obvious disease outside the surgical field precludes resec- Gastric Stress Ulcers or Gastritis. After surgery, use an H -2 tion; if none is found, the pancreas is mobilized to determine blocker or proton pump inhibitor to maintain the gastric pH at if local invasion (most commonly into the portal vein) ≥5. Full mobilization is performed before cal patients who are at risk of developing stress bleeding.