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| Abstract |
Background : Despite marked improvements in pancreatic surgery, the high incidence of pancreatic fistula and high morbidity after resection persists. Purposes : The objective of this study was to eval...uate the role of electrosurgical and stapling devices as an alternative to traditional methods of stump closure in an animal model of distal pancreatectomy. Methods : Four devices were used for transection of the pancreatic body : a bi-polar thermofusion system attached to an automatic irrigation function (BI, n = 3), a bi-polar tissue sealer (BS, n = 3), an ultrasonic scissor (US, n = 3), and an endoscopic stapling device (ES, n = 3). For each group, burst pressure was tested using an electronic manometer, with a focus on the location (s) of the first disruption (s). Histological examination was performed for the dissected surfaces. The transection line, including staples, was embedded in a polyester resin, and histological examination was performed for these polished sections of the resin. Results : Pressure was significantly higher for BI (P < 0.01) than that for the other devices. In contrast, thermal denaturation of the pancreas parenchyma was observed at a depth of approximately 1 mm from the dissected portion for BS, while it extended beyond 15 mm for BI. The staple line was the first disruption point for all of ES cases. Conclusions : The pellicle of the pancreas is likely to be deficient after a surgical operation. If the pellicle is preserved, the strength of the pellicle may be insufficient for complete closure with high stapling mechanical pressure or the protein coagulation of usually used electrosurgical devices.
【背景】膵臓に関する手術手技の進歩にも関わらず，膵切離後膵液瘻の発生頻度は減少しておらず，依然として最も重大な合併症である．【目的】この研究の目的は近年従来の膵管結紮，膵実質切離に変わって，鏡視下手術の普及と共に一般に行われるようになった，膵の高周波電気器機と吻合器での切離方法を動物実験によって評価し最適な切離方法を検討する事にある．【方法】4つの器機を用いて膵体部での切離を行った．使用した器具は①bi-polar thermofusion system(BiClamp®)に自動irrigation装置を装着した器機(BI)(n = 3)，②bi-polar tissue sealer(ENSEAL®)(BS)(n = 3)，③ultrasonic scissor(Harmonic ACE®)(US)(n = 3)，④endoscopic stapling device(ECHELON ENDOPATH®)(ES)(n = 3)である．ブタを用いて全麻下に，肝，膵，脾そして十二指腸を一回に摘出し膵体部の切断を4種の器具を用いて行った．十二指腸乳頭の膵管開口部より背側膵管にカニュレーションを行い膵切離断端の耐圧力を測定した．また高周波電気器機での切離断端のみではなく，吻合器での切離断端もpolyester resin樹脂化標本の研磨切片からStaplerでの切離線の組織学的評価を行った．【結果】切離断端の膵管耐圧力はBIで約10mmの膵をthermofusion後に尾側で切断する方法のみで高い耐圧能を認め，他の方法と比較して有意な差を認めた(P < 0.01)．組織学的にはBIでは15mm程度の熱変性を認めたのに対してBSやUSでは熱変性の深さは1mm程度であった．Staple切離線の組織所見では各々のstapleは正常に閉鎖した形となっていたが，stapleは膵実質に食い込んでおり切離面に開存した膵管を認めた．【結語】膵臓断端の十分な閉鎖は高周波電気器機や吻合器では得られなかった．適切な膵切離には膵の被膜の形態を考慮した閉鎖方法を検討する必要があると考えられた．show more
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