ABSTRACT
Background & Aim: Roux-en-Y hepaticojejunostomy (RYHJ) is the most common treatment done for benign biliary strictures and as a part of for post CDC excision biliary drainage. In the long term follow up, RYHJ stenosis is a dreaded complication, both for the patients and the attending surgeon, in view of the complexity and difficulty in its management. This is traditionally managedby a combination of medical, radiological and open surgical techniques. There are only a few reports describing the management of strictured biliary anastomosis by a laparoscopic technique. The aim of the present study is to describe our experience of laparoscopic re- establishment of biliary continuity(Re-do hepatico-jejunostomy) Methods: Retrospective analysis of prospectively collected data of RYHJ stenosis post benign biliary stricture (BBS) repair and choledochal cyst (CDC) excision, treated by laparoscopic re-do RYHJ, between January 2018 to December 2018 in the department of GI Surgery, GB Pant Institute & Maulana Azad Medical College. Results: 6 patients underwent laparoscopic Re-do RYHJ during the study period. 4 patients developed RYHJ stenosis post open BBS repair and 2 after open CDC excision. The presenting complaints was repeated episodes of fever with jaundice, refractory to medical management. Three patients also had hepatolithiasis.
ABSTRACT
Background: Pancreaticoduodenectomy is a standard procedure for periampullary tumours. Pancreatic anastomosis is the Achilles heel of the procedure with a significant leak rate and the associated high morbidity. We adopted a modified pancreatic stump drainage with pancreato-gastrostomy - pancreatic stump mobilization with invagination into the lumen of the stomach via posterior gastrotomy and fixation with two U shaped sutures to the posterior wall of the stomach traversing across the pancreatic parenchyma. Materials and Methods: We did a retrospective analysis of a prospectively maintained database of patients who underwent Laparoscopic Whipple’s pancreaticoduodenectomy (WPD) from November 2017 to March 2019 in our department, a tertiary referral centre of Northern India. A total of 34 patients underwent totally laparoscopic Whipple’s pancreatoduodenectomy with the modified Pancreatogastrostomy. Results: A total of 34 patients underwent totally laparoscopic WPD during this study period. The median age was 50 years (27 to 70 years) with 17 male and 17 female patients. Of these patients, 23 patients had their tumours arising from the ampulla, 6 from the duodenum, 3 from the pancreas, 1 SCN head of pancreas and 1 from the distal common bile duct. All patients had R0 resection with a median lymph node yield of 13 (6-19). 9 patients had stage 1 disease, 10 patients had stage 2 disease and 14 patients had stage 3 disease. 31 patients had moderately differentiated adenocarcinoma while 2 patients had well-differentiated tumour morphology. 14 patients had pancreato-biliary differentiation with the remaining 19 patients having intestinal differentiation. The overall number of significant complications according to Clavien-Dindo classification was 17.6% (Grade 3 and higher) . Conclusion: Laparoscopic WPD is a feasible procedure in the hands of a well-trained laparoscopic surgeon. Modified P-G as described, simplifies the pancreatic drainage with a low incidence of post-operative pancreatic fistula and its attendant complications.
ABSTRACT
Background: The minimally invasive surgery (MIS) in GBC is being increasingly performed with superior short term results and non-inferior oncological outcomes. Most of the studies on minimally invasive radical cholecystectomy (MIRC) included patients with GBC limited to the gall bladder. Bile duct or adjacent viscera has been resected only in a very few studies. One of the reasons perhaps for not imbibing MIS in advanced GBC is the innate complexity of resection of the involved adjacent organs and need performing a bilioenteric anastomosis. Aim of this study is to assess safety, feasibility and short-term outcomes of locally advanced GBC patients who underwent MIRC with adjacent bile duct or viscera resection. Methods: Retrospective analysis of prospectively maintained data of 11 patients who underwent MIRC with adjacent viscera resection for suspected case of GBC in a single surgical unit between January 2017 to December 2019 at Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, a tertiary referral teaching institute. Results: During the study period 11 patients underwent adjacent viscera resection along with MIRC.Ten patients had Common bile duct (CBD) excision (4 choledochal cyst and 6 direct tumor infiltration), four patients had gastroduodenal resection (3 sleeve duodenectomy and 1 distal gastrectomy with proximal duodenectomy) and three patients had colonic resection (2 sleeve resection and 1 segmental resection). Seven patients had single organ resection (3 CBD and 4 CDC), 2 of them had double organ (CBD & duodenum, duodenum & colon) and 2 patients had triple organ resection (CBD, duodenum and colon). Conclusion: The minimally invasive approach inGBC patients who need extrahepatic adjacent viscera resection was found to be feasible and safe with favourable perioperative and oncological outcomes.Further studies are needed from high-volume centres engaged in minimally invasive hepatobiliary surgery.
ABSTRACT
Background: Standard treatment for choledochal cyst (CDC) is excision of cyst with biloenteric reconstruction. Most common methods of reconstruction following CDC excision are Roux en y hepaticojejunostomy (RYHJ) and Hepaticoduodenostomy (HD). Although HD has been employed in paediatric population, its use in adult patients has been limited. Aim: The aim of the study was to analyse our experience of patients who underwent laparoscopic excision of CDC and to compare the short term and long term outcomes following HD versus RYHJ as a method of reconstruction in adults. Methods: This is a retrospective analysis of prospectively collected data of 65 patients who underwent laparoscopic cyst excision from January 2016 to March 2021in a single surgical unit at GB Pant Institute of Post graduate Medical Education and Research, New Delhi. Following CDC excision HD was our preferred as method of biliary reconstruction. Patients with restricted duodenal mobility and thin friable duct underwent RYHJ.Short-term outcomes included operative time,blood loss, length of hospital stay and complications such as anastomotic leakage and post operative bleeding.Long-term outcomes included anastomotic stricture formation and need for redo biliary reconstruction. Results: Total 65 patient underwent laparoscopic CDC excision. Mean age was 31.66 ± 12.77years and male: female ratio was 1:5.4. Type I cyst was the most common (60/65=92.3%) with mean size of 2.59 ±0.78cm. Laparoscopic HD was feasible in 87% (57/65) of patients. RYHJ was done in 8 patients. Outcome in laparoscopic HD vs RYHJ group: Mean blood loss was 54.22±8.9ml vs 92±16 mL, mean operative time was 182±41.6 vs 240±52.2 mL, mean hospital stay was 4±2.1 vs 5±3.2 days. There was no difference in anastomotic leak rate (3 vs 1, p=0.42) or post-operative bleeding rate between the two groups.There was no perioperative mortality. Conclusion: Laparoscopic HD was feasible in most of the adult CDC patients with better short term and comparable long term results.It may be used as the preferred biliary reconstruction method during laparoscopic CDC excision in adults as it is technically easier, requires single anastomosis and also accessible for future endoscopic intervention.