Implementation of robotic pancreaticoduodenectomy at a community tertiary care hospital utilizing a comprehensive curriculum.

BACKGROUND: We evaluated the outcomes of a robotic pancreaticoduodenectomy (RPD) program implemented at a community tertiary care hospital. METHODS: A retrospective review of 65 RPD cases compared surgical outcomes and performance to benchmark data. RESULTS: Postoperative complications occurred in 31% (20) of patients vs. ≤73% (variance -42), with grade IV complications in 3% (2) vs. ≤5% (variance -2). Postoperative pancreatic fistula type B frequency was 12% (8) vs. ≤15% (variance -3). One 90-day mortality occurred (1.5% vs. 1.6%). Failure to rescue rate was 7% vs. ≤9% (variance -2), and R1 resection rate was 2% vs. ≤39% (variance -37). There was a downward trend of operative time (rho â€‹= â€‹-0.600, P â€‹< â€‹0.001), with a learning curve of 27 cases. Median hospital length of stay was 6 days vs. ≤15 days (variance -9). CONCLUSION: Our comprehensive RPD training program resulted in improved operative performance and outcomes commensurate with benchmark thresholds.

Gemcitabine transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma.

BACKGROUND/AIMS: Transcatheter arterial chemoembolization (TACE) has been shown to increase survival in patients with unresectable hepatocellular carcinoma (HCC), however toxicity from commonly used agents limits its use in unresectable disease. Gemcitabine is a well tolerated chemotherapeutic agent with a high first pass clearance. In this study we evaluated a cohort of patients with unresectable HCC treated with gemcitabine-TACE alone. METHODOLOGY: A review of all patients that underwent gemcitabine-TACE for unresectable HCC from 2002 to 2006 was performed. No patients were eligible for resection, liver transplantation or ablation. All patients received gemcitabine-TACE alone. The primary outcome measure was survival from first treatment. Secondary outcome measures included radiological response and toxicity. RESULTS: 55 patients underwent a total of 172 gemcitabine-TACE treatments for unresectable HCC. Median age was 64.7 years. All patients had Barcelona-Clinic Liver Cancer (BCLC) stage B (44%) or C (56%) disease. Median survival following gemcitabine-TACE was 8.8 months. 22% demonstrated a partial response and 61% had stable disease. 6% experienced grade 3/4 adverse events. There was 1 treatment related death. CONCLUSIONS: Gemcitabine-TACE is well tolerated and appears to provide an alternative agent for patients with unresectable HCC undergoing chemoembolization.

Laparoscopic resection of benign hepatic cysts: a new standard.

BACKGROUND: We sought to evaluate the feasibility and outcomes of laparoscopic resection of symptomatic hepatic cysts. STUDY DESIGN: Fifty-one patients underwent laparoscopic resections for symptomatic hepatic cysts. Resection was accomplished laparoscopically with an Endo-GIA vascular stapler. Data were collected in a prospective database. RESULTS: Median patient age was 60 years, with a median lesion diameter of 13 cm. Indication for surgical treatment was pain in 92% of patients. Laparoscopic resection was successful in 100% of patients. A pure laparoscopic approach was used in 58% of patients, the remaining used a hand port. Median operating time was 178 minutes. Preoperative diagnosis was polycystic liver in 88% and simple cyst in 12% diagnosed by preoperative imaging. Histologic examination showed 90% to be simple cysts and 10% cystadenomas. There were nine minor perioperative complications. Median hospital stay was 2 days. Relief of symptoms was achieved in all patients operated on for pain, with a median followup of 13 months. Two patients required reoperation for recurrence of the same cyst. CT or MRI was used for yearly followup. CONCLUSIONS: Laparoscopic resection of symptomatic liver cysts is a feasible and effective method to relieve symptoms with minimal surgical trauma. This series represents the largest report of laparoscopic management for benign hepatic cysts and provides evidence for a routine laparoscopic approach to benign symptomatic cysts. Traditional surgical methods should be reserved for when a malignancy is expected, laparoscopy is contraindicated, or for recurrence after an initial laparoscopic approach.

Surgical management of hepatocellular adenoma: take it or leave it?

BACKGROUND: Hepatocellular adenoma (HA) is a rare benign tumor of the liver. Surgical resection is generally indicated to reduce risks of hemorrhage and malignant transformation. We sought to evaluate clinical presentation, surgical management, and outcomes of patients with HA at our institution. METHODS: We performed a retrospective review of 41 patients who underwent surgical resection for HA between 1988 and 2007. RESULTS: Thirty-eight patients were women, and the median age at presentation was 36 years (range, 19-65 years). The most common clinical presentation was abdominal pain (70%) followed by incidental radiological finding (17%). Twenty-two patients had a history of oral contraceptive use. Median number of HA was one (range, 1-3). There were 32 open cases (3 trisectionectomy, 15 hemihepatectomy, 7 sectionectomy, 4 segmentectomy, and 3 wedge resection), and 9 laparoscopic cases (1 hemihepatectomy, 5 sectionectomy, 1 segmentectomy, and 2 wedge resection). The median estimated blood loss was 225 mL (range, 0-3400 mL). The median length of stay was 6 days (range, 1-15 days). Surgical morbidities included pleural effusion requiring percutaneous drainage (n = 2), pneumonia (n = 1), and wound infection (n = 1). There was no perioperative mortality. Twelve patients had hemorrhage from HA. Hepatocellular carcinoma was observed in two patients with HA. Median follow-up was 23 months (range, 1-194 months), at which time all patients were alive. CONCLUSION: In view of 29% hemorrhagic and 5% malignant complication rates, we recommend surgical resection over observation if patient comorbidities and anatomic location of HA are favorable. A laparoscopic approach can be safely used in selected cases.

Bridging locoregional therapy for hepatocellular carcinoma prior to liver transplantation.

INTRODUCTION: The impact of locoregional therapy prior to liver transplantation for hepatocellular carcinoma utilizing either transcatheter arterial chemoembolization (TACE), yttrium-90 ((90)Y), radiofrequency ablation (RFA), or resection prior to orthotopic liver transplantation (OLT) is largely unknown. We sought to examine locoregional therapies and their effect on survival compared with transplantation alone. METHODS: A retrospective review of a prospectively collected database. RESULTS: 123 patients were included. Patients were analyzed in two groups. Group I consisted of 50 patients that received therapy (20 TACE; 16 (90)Y; 13 RFA, 3 resections). Group II consisted of 73 patients transplanted without therapy. Median list time was 28 days (range 2-260 days ) in group I, and 24 days (range 1-380 days) in group II. Median time from therapy to OLT was 3.8 months (range 9 days to 68 months). Twelve patients (24%) were successfully downstaged (8 TACE, 2 (90)Y, 2 RFA/resection). Overall 1-, 3-, and 5-year survival were 81%, 74%, and 74%, respectively. Survival was not statistically significantly different between the two groups (P = 0.53). The 12 patients downstaged did not have a significant difference in survival as compared with the patients who received therapy but did not respond or the patients who were transplanted without therapy (P = 0.76). CONCLUSION: Our report addresses locoregional therapy for hepatocellular carcinoma as a bridge to transplant. There was no statistical difference in overall survival between patients treated and those not treated prior to transplant. We provide further evidence that locoregional therapy is a safe tool for patients on the transplant list, does not impact survival, and can downstage selected patients to allow life-saving liver transplantation.

Lymphatic mapping and sentinel node biopsy: a surgical perspective.

Lymphatic mapping and sentinel node biopsy has been rapidly and widely adopted by the surgical community as an oncologic equivalent elective lymphadenectomy for regional node staging in both melanoma and breast cancer. Despite being the de facto standard of care, it remains a highly unstandardized procedure surrounded by many unresolved controversies for surgeons who perform the procedure. The controversies are as basic as the definition of the real sentinel node and as specific as the appropriate localization pharmaceutical(s), site of injection, timing of the injection, and utility of external scintigraphy (dynamic versus. static). Furthermore, questions regarding surgical training, indications, and contraindications remain unanswered. Because there are few long-term studies stratified by technique and indication, the resolution of these surgical controversies are unlikely in the near future.