Ultrasonic dissection does not add time benefit over conventional dissection techniques in pancreatic surgery

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Key study points:

1. Ultrasonic dissection conferred no additional operative time benefit over conventional dissection techniques in surgery of the pancreatic head.

2. Ultrasonic dissection seems to be equivalent to conventional techniques with a possible tendency towards improved tissue and blood vessel sealing.

Primer: Ultrasonic dissection systems cut and coagulate tissue simultaneously and have been employed for use in in both open and endoscopic surgery for some time. They are also highly focused and confer minimal damage to surrounding tissue. Surgeries for the pancreatic head masses (pancreaticoduodectomy (PD) and pylorus-preserving pancreaticoduodectomy (PPPD)) are time consuming in that they require careful hand dissection of tissues and vessels to develop appropriate tissue planes and adequate hemostasis. Usually performed at high volume centers, median operative time for PD is still around 5.5 hours. Ultrasonic dissection devices, commonly utilized in laparoscopic surgery, may be able to achieve quick tissue dissection and hemostasis simultaneously and can significantly reduce operative time. This study is a multicenter effort to explore the potential increases in efficiency that can be achieved with ultrasonic dissection, focusing specifically on operative time, intraoperative blood loss, complications, and post-operative morbidity.

Background reading:

1. Schmidbauer S, Hallfeldt KK, Sitzmann G, et al. Experience with ultrasound scissors and blades (UltraCision) in open and laparoscopic liver resection. Ann Surg. 2002;235:27–30.

2. Suzuki Y, Fujino Y, Tanioka Y, et al. Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas. Br J Surg. 1999;86:608–611.

This [randomized, controlled, single-blind multicenter] study: included 101 patients randomized to either dissection with ultrasonic device or conventional dissection from three different countries undergoing PD or PPPD between March 2009 and May 2011. Primary endpoint was duration of surgery, and secondary endpoints included intraoperative blood loss, units of blood transfused, and post-op morbidity. The use of the ultrasonic device did not significantly decrease operative times (316 minutes with ultrasonic device vs 319 minutes with conventional surgery, P = .95), but also did not increase the costs of the procedure. There were no significant differences in any of the secondary outcomes.   

In sum: Contrary to other previously published retrospective studies, this study has found that ultrasonic dissection techniques do not confer an operative time benefit in PD or PPPD of the pancreatic head. There does not seem to be any difference between ultrasonic dissection and conventional dissection in operative time, cost, or intra-operative/post-operative morbidity and mortality. These findings are similar to those comparing ultrasonic to conventional dissection techniques in left hemicolectomy or total gastrectomy. One weakness of the trial is that it had a high exclusion rate due to suboptimal preoperative staging. There was a tendency with ultrasonic dissection towards better tissue sealing and hemostasis with regards to fewer pRBCs given, less severe hemorrhagic grades, and lower fistula rates and grades, but none of these were statistically significant.

Click to read the study in [Annals of Surgery]

 By [AH]

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