Low-cost model for pancreatojejunostomy simulation in minimally invasive pancreatoduodenectomy

Minimally invasive pancreatoduodenectomy (MIS PD) is a well reported technique with several advantages over conventional open pancreatoduodenectomy. In comparison to distal pancreatectomy, the adoption of MIS PD has been slow due to the technical challenges involved, particularly in the reconstruction phase of the pancreatojejunostomy (PJ) anastomosis. Hence, we introduce a low-cost model for PJ anastomosis simulation in MIS PD. We fashioned a model of a cut pancreas and limb of jejunum using economical and easily accessible materials comprising felt fabric and the modelling compound, Play-Doh. Surgeons can practice MIS PJ suturing using this model to help mount their individual learning curve for PJ creation. Our video demonstrates that this model can be utilized in simulation practice mimicking steps during live surgery. Our model is a cost-effective and easily replicable tool for surgeons looking to simulate MIS PJ creation in preparation for MIS PD.

Technical insights to multivisceral resections using the da Vinci Xi

BACKGROUND

There have been few reports on the feasibility and safety of robotic multivisceral surgeries. The da Vinci Xi boasts significant upgrades that improve its applicability in combined resections. We report our early experience of multivisceral, multi-quadrant resections with the Xi system.

METHODS

Between May 2015 and August 2019, 13 multivisceral resections were performed. Patient demographics, procedural data, and perioperative outcomes were evaluated.

RESULTS

The procedures were completed at a median operative time of 290 (range, 210-535) minutes. The median postoperative length of hospital stay was 3.5 (range, 2-7) days. There was one case of readmission for anastomotic leak, but no positioning injuries, external robot arm collisions or issues arising from trocar position. There were no cases of perioperative mortality.

CONCLUSION

Multivisceral resections can be safely accomplished using the Xi. Further studies are necessary to ascertain whether there are benefits of the robotic approach over conventional laparoscopy in these complex cases.

Limited liver resections in the posterosuperior segments: international multicentre propensity score-matched and coarsened exact-matched analysis comparing the laparoscopic and robotic approaches

Background

Limited liver resections (LLRs) for tumours located in the posterosuperior segments of the liver are technically demanding procedures. This study compared outcomes of robotic (R) and laparoscopic (L) LLR for tumours located in the posterosuperior liver segments (IV, VII, and VIII).

Methods

This was an international multicentre retrospective analysis of patients who underwent R-LLR or L-LLR at 24 centres between 2010 and 2019. Patient demographics, perioperative parameters, and postoperative outcomes were analysed; 1 : 3 propensity score matching (PSM) and 1 : 1 coarsened exact matching (CEM) were performed.

Results

Of 1566 patients undergoing R-LLR and L-LLR, 983 met the study inclusion criteria. Before matching, 159 R-LLRs and 824 L-LLRs were included. After 1 : 3 PSM of 127 R-LLRs and 381 L-LLRs, comparison of perioperative outcomes showed that median blood loss (100 (i.q.r. 40–200) versus 200 (100–500) ml; P = 0.003), blood loss of at least 500 ml (9 (7.4 per cent) versus 94 (27.6 per cent); P < 0.001), intraoperative blood transfusion rate (4 (3.1 per cent) versus 38 (10.0 per cent); P = 0.025), rate of conversion to open surgery (1 (0.8 per cent) versus 30 (7.9 per cent); P = 0.022), median duration of Pringle manoeuvre when applied (30 (20–46) versus 40 (25–58) min; P = 0.012), and median duration of operation (175 (130–255) versus 224 (155–300); P < 0.001) were lower in the R-LLR group compared with the L-LLR group. After 1 : 1 CEM of 104 R-LLRs with 104 L-LLRs, R-LLR was similarly associated with significantly reduced blood loss and a lower rate of conversion to open surgery.

Conclusion

Based on a matched analysis of well selected patients, both robotic and laparoscopic access could be undertaken safely with good outcomes for tumours in the posterosuperior liver segments.

Novel method of intraoperative liver tumour localisation with indocyanine green and near-infrared imaging

INTRODUCTION

Fluorescence imaging (FI) with indocyanine green (ICG) is increasingly implemented as an intraoperative navigation tool in hepatobiliary surgery to identify hepatic tumours. This is useful in minimally invasive hepatectomy, where gross inspection and palpation are limited. This study aimed to evaluate the feasibility, safety and optimal timing of using ICG for tumour localisation in patients undergoing hepatic resection.

METHODS

From 2015 to 2018, a prospective multicentre study was conducted to evaluate feasibility and safety of ICG in tumour localisation following preoperative administration of ICG either on Day 0-3 or Day 4-7.

RESULTS

Among 32 patients, a total of 46 lesions were resected: 23 were hepatocellular carcinomas (HCCs), 12 were colorectal liver metastases (CRLM) and 11 were benign lesions. ICG FI identified 38 (82.6%) lesions prior to resection. The majority of HCCs were homogeneous fluorescing lesions (56.6%), while CLRM were homogeneous (41.7%) or rim-enhancing (33.3%). The majority (75.0%) of the lesions not detected by ICG FI were in cirrhotic livers. Most (84.1%) of ICG-positive lesions detected were < 1 cm deep, and half of the lesions ≥ 1 cm in depth were not detected. In cirrhotic patients with malignant lesions, those given ICG on preoperative Day 0-3 and Day 4-7 had detection rates of 66.7% and 91.7%, respectively. There were no adverse events.

CONCLUSION

ICG FI is a safe and feasible method to assist tumour localisation in liver surgery. Different tumours appear to display characteristic fluorescent patterns. There may be no disadvantage of administering ICG closer to the operative date if it is more convenient, except in patients with liver cirrhosis.

Systematic review of the outcomes of surgical resection for intermediate and advanced Barcelona Clinic Liver Cancer stage hepatocellular carcinoma: A critical appraisal of the evidence

AIM

To perform a systematic review to determine the survival outcomes after curative resection of intermediate and advanced hepatocellular carcinomas (HCC).

METHODS

A systematic review of the published literature was performed using the PubMed database from 1^st January 1999 to 31^st Dec 2014 to identify studies that reported outcomes of liver resection as the primary curative treatment for Barcelona Clinic Liver Cancer (BCLC) stage B or C HCC. The primary end point was to determine the overall survival (OS) and disease free survival (DFS) of liver resection of HCC in BCLC stage B or C in patients with adequate liver reserve (i.e., Child’s A or B status). The secondary end points were to assess the morbidity and mortality of liver resection in large HCC (defined as lesions larger than 10 cm in diameter) and to compare the OS and DFS after surgical resection of solitary vs multifocal HCC.

RESULTS

We identified 74 articles which met the inclusion criteria and were analyzed in this systematic review. Analysis of the resection outcomes of the included studies were grouped according to (1) BCLC stage B or C HCC, (2) Size of HCC and (3) multifocal tumors. The median 5-year OS of BCLC stage B was 38.7% (range 10.0-57.0); while the median 5-year OS of BCLC stage C was 20.0% (range 0.0-42.0). The collective median 5-year OS of both stages was 27.9% (0.0-57.0). In examining the morbidity and mortality following liver resection in large HCC, the pooled RR for morbidity [RR (95%CI) = 1.00 (0.76-1.31)] and mortality [RR (95%CI) = 1.15 (0.73-1.80)] were not significant. Within the spectrum of BCLC B and C lesions, tumors greater than 10 cm were reported to have median 5-year OS of 33.0% and multifocal lesions 54.0%.

CONCLUSION

Indication for surgical resection should be extended to BCLC stage B lesions in selected patients. Further studies are needed to stratify stage C lesions for resection.

Malignant Transformation Arising Within Unusual and Rare Hepatic Lesions: Fibropolycystic Disease Form of Ductal Plate Malformation and Biliary Adenofibroma

Cholangiocarcinoma is the second most common hepatobiliary cancer following hepatocellular carcinoma, and 20% to 25% are intrahepatic. We describe 2 cases of intrahepatic cholangiocarcinoma arising within unusual and rare hepatic lesions, fibropolycystic liver disease form of ductal plate malformation and biliary adenofibroma, whose association with malignancy is rarely reported in the literature.

Surgical management decreases disease recurrence risk in recurrent pyogenic cholangitis

BACKGROUND

Recurrent pyogenic cholangitis (RPC) has a high risk of disease recurrence. We present our experience with RPC and examine the factors associated with disease recurrence.

METHODS

We performed a retrospective review of all patients with RPC treated at two tertiary institutions between January 1990 and December 2013. Patients with liver atrophy and/or abscess were categorized as being associated with parenchymal disease (PD).

RESULTS

We studied 157 patients with a median age of 59.0 (interquartile range (IQR): 47.0-70.0) years and a median follow-up duration of 71.0 (IQR: 26.0-109.0) months. There were 64 (40.8%) and 93 (59.2%) patients with and without associated PD, respectively. Disease recurrence rate was 43.9% in our overall cohort through the course of follow-up. Surgical treatment was an independent prognostic factor for decreased disease recurrence risk (hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.18-0.87, P = 0.021). Stratified analysis revealed that liver resection was prognostic for lower risk of disease recurrence among patients with PD (HR 0.38, 95% CI 0.15-0.94, P = 0.036), while biliary bypass was prognostic for lower risk of disease recurrence among patients without PD (HR 0.30, 95% CI 0.15-0.61, P = 0.001). The overall post-operative complication rate among surgically treated patients was 31.1%, and the presence of bilobar stones was found to be independently associated with higher odds of post-operative complications (odds ratio 3.51, 95% CI 1.26-9.81, P = 0.017).

CONCLUSION

Surgical treatment is associated with decreased recurrence risk in RPC, but with significant post-operative morbidity. Where surgery is deemed appropriate, patients with and without PD are likely to benefit from liver resection and biliary bypass, respectively.

Metachronous cholangiocarcinoma 13 years post resection of choledochal cyst-is long-term follow-up useful?: a case study and review of the literature

BACKGROUND

Patients with congenital choledochal cyst are at risk of the development of hepatobiliary malignancy, with recommended treatment of choledochal cyst being surgical excision. The development of cholangiocarcinoma more than 10 years after excision of choledochal cysts is rare, with less than 21 cases reported in the literature from 1972 to 2014. This is the first reported case of metachronous recurrence after a previously excised adenocarcinoma within a choledochal cyst.

CASE PRESENTATION

Herein, we review the case of a patient with cholangiocarcinoma arising 13 years post excision of a Todani type 1 choledochal cyst and discuss the theories of carcinogenesis and long-term management of patients with choledochal cysts. The long-term development of a malignancy must be considered in these patients.

CONCLUSIONS

Reviewing all published cases to date, regular follow-up post resection did not improve on the resectability and long-term survival of these patients. Patients presenting with symptoms did not prejudice against resectability. Despite curative resection, median survival was dismal. Optimal long-term follow-up strategies for these patients remain to be elucidated.

Learning curve in laparoscopic liver surgery: a fellow's perspective

The learning curve for laparoscopic liver surgery is infrequently addressed in current literature. In this paper, we explored the challenges faced in embarking on laparoscopic liver surgery in a unit that did predominantly open liver surgery. In setting up our laparoscopic liver surgery program, we adopted skills and practices learnt during fellowships at various high volume centers in North America and Australia, with modifications to suit our local patients' disease patterns. We started with simple minor resections in anterolateral segments to build confidence, which allowed us to train the surgical and nursing team before progressing to more difficult resections. Inter institutional collaboration and exchange of skills also enabled the synergistic development of techniques for safe progression to more complex surgeries. Multimedia resources and international guidelines for laparoscopic liver surgery are increasingly accessible, which further guide the practice of this emerging field, as evidence continues to validate the laparoscopic approach in well selected cases.

Eosinophilic cholangiopathy: the diagnostic dilemma of a recurrent biliary stricture. Should surgery be offered for all?

A 63-year-old man presented with the initial diagnosis of autoimmune pancreatitis with obstructive jaundice. CT of the abdomen revealed an oedematous pancreas and dilated common bile duct (CBD), without gallstones. After failure of initial retrograde cholangiopancreatography, a percutaneous biliary catheter was inserted with good drainage. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) revealed a 2 cm distal CBD stricture. A biliary stent was inserted past the stricture. Biopsy of the stricture, brush cytology of the bile duct and fine needle aspiration of pancreatic head under endoscopic ultrasound guidance were negative for malignancy. Autoimmune screen was negative as well. However, the patient represented with cholangitis requiring repeat ERCP and insertion of a second biliary stent. He finally underwent cholecystectomy with excision of the distal CBD and Roux-En-Y hepaticojejunostomy. Histology revealed diffuse eosinophilic cholecystitis and cholangitis. A retrospective review of the blood results showed persistent eosinophilia in full blood count measurements from presentation and persisting throughout the treatment period.

Rare cause of acute surgical abdomen with free intraperitoneal air: Spontaneous perforated pyometra. A report of 2 cases

BACKGROUND

The acute abdomen accounts for up to 40% of all emergency surgical hospital admissions and a large proportion are secondary to gastrointestinal perforation. Studies have shown the superiority of the abdominal CT over upright chest radiographs in demonstrating free intraperitoneal air. Spontaneous perforated pyometra is a rare cause of the surgical acute abdomen with free intraperitoneal air. Only 38 cases have been reported worldwide.

CASE REPORT

We report 2 cases of spontaneously perforated pyometra in our hospital's general surgery department. Both underwent exploratory laparotomy: one had a total hysterectomy and bilateral salpingo-oophorectomy, while the other had an evacuation of the uterine cavity, primary repair of uterine perforation and a peritoneal washout. A literature search was conducted and all reported cases reviewed in order to describe the clinical presentations and management of the condition. Of the 40 cases to date, including 2 of our cases, the most common presenting symptoms were abdominal pain (97.5%), fever (37.5%) and vomiting (25.0%). The main indication for exploratory laparotomy was pneumoperitoneum (97.5%).

CONCLUSIONS

Pyometra is an unusual but serious condition in elderly women presenting with an acute abdomen. A high index of suspicion is needed to make the appropriate diagnosis.

Inguinal Hernias: A Current Review of an Old Problem

The repair of groin hernias are amongst the most commonly performed procedures by the general surgeon today, with almost as many types of repairs as there are hernias.

Inguinal hernias account for 75% of all abdominal wall hernias with a lifetime risk of 27% in men and 3% in women1. Repair techniques have evolved from open suture methods to mesh repairs done either open or laparoscopically, translating to improved patient care and decreasing complications associated with hernia repair.

This article is intended to provide an overview of the presentation and latest evidence based guidelines for the management of inguinal hernias.