J Gastric Cancer.  2018 Jun;18(2):134-141. 10.5230/jgc.2018.18.e15.

Pancreatic Compression during Lymph Node Dissection in Laparoscopic Gastrectomy: Possible Cause of Pancreatic Leakage

• Ida S
• Hiki N
• Ishizawa T
• Kuriki Y
• Kamiya M
• Urano Y
• Nakamura T
• Tsuda Y
• Kano Y
• Kumagai K
• Nunobe S
• Ohashi M
• Sano T

• KMID: 2414533
• DOI: http://doi.org/10.5230/jgc.2018.18.e15

Abstract

PURPOSE
Postoperative pancreatic fistula is a serious and fatal complication of gastrectomy for gastric cancer. Blunt trauma to the parenchyma of the pancreas can result from an assistant's forceps compressing and retracting the pancreas, which in turn may result in pancreatic juice leakage. However, no published studies have focused on blunt trauma to the pancreas during laparoscopic surgery. Our aim was to investigate the relationship between compression of the pancreas and pancreatic juice leakage in a swine model.
MATERIALS AND METHODS
Three female pigs were used in this study. The pancreas was gently compressed dorsally for 15 minutes laparoscopically with gauze grasped with forceps. Pancreatic juice leakage was visualized by fluorescence imaging after topical administration of chymotrypsin-activatable fluorophore in real time. Amylase concentrations in ascites collected at specified times was measured. In addition, pancreatic tissue was fixed with formalin, and the histology of the compressed sites was evaluated.
RESULTS
Fluorescence imaging enabled visualization of pancreatic juice leaking into ascites around the pancreas. Median concentrations of pancreatic amylase in ascites increased from 46 U/L preoperatively to 12,509 U/L 4 hours after compression. Histological examination of tissues obtained 4 hours after compression revealed necrotic pancreatic acinar cells extending from the surface to deep within the pancreas and infiltration of inflammatory cells.
CONCLUSIONS
Pancreatic compression by the assistant's forceps can contribute to pancreatic juice leakage. These findings will help to improve the procedure for lymph node dissection around the pancreas during laparoscopic gastrectomy.

Keyword

Blunt injury; Laparoscopy; Optical imaging; Pancreatic juice; Swine

MeSH Terms

Acinar Cells
Administration, Topical
Amylases
Ascites
Female
Formaldehyde
Gastrectomy*
Hand Strength
Humans
Laparoscopy
Lymph Node Excision*
Lymph Nodes*
Optical Imaging
Pancreas
Pancreatic Fistula
Pancreatic Juice
Stomach Neoplasms
Surgical Instruments
Swine
Wounds, Nonpenetrating
Amylases
Formaldehyde

Figure

• 

  Fig. 1 Fluorescent imaging of the pancreas. The upper panels show a chymotrypsin probe (A, B), and the lower panels show the administration of ICG (C-E). Gross appearance in natural color (A). Image obtained through light-blocking glasses 2 minutes after administration of the chymotrypsin probe (B). Before (C), immediately after (D), and 2 hours after administration of ICG. The black dotted lines (A) indicate the borders of the pancreas. The white arrows (B) indicate ascites containing pancreatic juice. The white arrowheads (E) indicate pooled ICG fluorescence. ICG = indocyanine green.

• 

  Fig. 2 Pancreatic amylase concentrations in ascites at specified times (n=3).

• 

  Fig. 3 Macroscopic and histopathological images of pancreatic tissues. Before (A), during (B), and immediately after compression (C). Normal pancreas (D) and injured pancreas (E). The injured pancreas (E) shows necrotic changes in acinar cells with inflammatory infiltrates in the pancreatic parenchyma. The white dotted circle (C) indicates the compressed area. Scale bar, 50 μm.

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