Comparison of endoscopic ultrasound-guided drainage and percutaneous catheter drainage of postoperative fluid collection after pancreaticoduodenectomy.

Backgrounds/Aims: Postoperative fluid collection is a common complication of pancreatic resection without clear management guidelines. This study aimed to compare outcomes of endoscopic ultrasound (EUS)-guided trans-gastric drainage and percutaneous catheter drainage (PCD) in patients who experienced this adverse event after pancreaticoduodenectomy (PD). Methods: Demographic and clinical data and intervention outcomes of 53 patients who underwent drainage procedure (EUS-guided, n = 32; PCD, n = 21) for fluid collection after PD between January 2015 and June 2019 in our tertiary referral center were retrospectively analyzed. Results: Prior to drainage, 83.0% had leukocytosis and 92.5% presented with one or more of the following signs or symptoms: fever (69.8%), abdominal pain (69.8%), and nausea/vomiting (17.0%). Within 8 weeks of drainage, 77.4% showed a diameter decrease of more than 50% (87.5% in EUS vs. 66.7% in PCD, p = 0.09). Post-procedural intravenous antibiotics were used for an average of 8.1 ± 4.3 days and 12.4 ± 7.4 days for EUS group and PCD group, respectively (p = 0.01). The EUS group had a shorter post-procedural hospital stay than the PCD group (9.8 ± 1.1 vs. 15.8 ± 2.2 days, p < 0.01). However, the two groups showed no statistically significant difference in technical or clinical success rate, reintervention rate, or adverse event rate. Conclusions: EUS-guided drainage and PCD are both safe and effective methods for managing fluid collection after PD. However, EUS-guided drainage can shorten hospital stay and duration of intravenous antibiotics use.

The feasibility of robotic left-side hepatectomy with comparison of laparoscopic and open approach: Consecutive series of single surgeon.

BACKGROUND: Recent studies report safety and effectiveness of robotic hepatectomy. In present study, we describe our initial experiences with robotic hepatectomy, focusing on left-side procedures. METHODS: A retrospective review was conducted of 13, 10, and 11 consecutive patients who underwent robotic, laparoscopic, and open left-side hepatectomy by the single surgeon. RESULTS: There were no significant differences in the estimated blood loss, application of Pringle maneuver, postoperative hospital stays, number of IV analgesic injections, or postoperative complications between the robotic and laparoscopic groups. The robotic group had a smaller number of patients applied a Pringle maneuver (8.3 vs 90.9%, P < 0.001), a shorter postoperative hospital stays (7.0 vs 9.0 days, P = 0.044), and a less use of IV analgesics (2.8 vs 8.2, P = 0.005) than the open group. CONCLUSIONS: From our initial experiences, a robotic left-side hepatectomy seems to be a feasible and safe procedure when compared with the laparoscopic and open left-side hepatectomies.

Clinicopathologic Characteristics and Optimal Surgical Treatment of Duodenal Gastrointestinal Stromal Tumor.

BACKGROUND: The clinicopathologic characteristics of duodenal gastrointestinal stromal tumor (GIST) were unclear and the optimal surgical procedure for duodenal GIST remains poorly defined. We aimed to analyze clinicopathological characteristics, survival outcomes based on the surgical procedure, and recommend optimal surgical treatment for duodenal GIST. METHODS: From July 2000 to April 2017, 118 patients with localized duodenal GIST underwent curative surgical resection at a single institution. We retrospectively reviewed the clinicopathological characteristics and survival outcomes. RESULTS: The 5-year overall survival (OS) and disease-free survival (DFS) rates were 94.9 and 79.2%, respectively. On multivariate analysis, the mitotic count was a statistically significant prognostic factor for DFS. Limited resection (LR) was performed in 20 patients with GIST in the first or fourth portion of the duodenum. Both LR and pancreaticoduodenectomy (PD) were performed in 98 patients with GIST in second or third portion of the duodenum. The patients in the LR group had less late complications than in the PD group and no postoperative newly developed diabetes mellitus. The minimally invasive LR (MI-LR) group had a shorter duration of surgery and shorter length of postoperative hospital stay. CONCLUSION: LR is a feasible and effective surgical treatment for patients with small-sized and antimesenteric-sided duodenal GIST in terms of late complications and postoperative diabetic complications. MI-LR has better perioperative outcomes than open LR. Therefore, we should consider MI-LR as an optimal surgical treatment for selected patients with duodenal GIST.

Effect of reoperation on long-term outcome of pT1b/T2 gallbladder carcinoma after initial laparoscopic cholecystectomy.

BACKGROUND: A small proportion of gallbladder carcinomas (GBC) are incidentally detected after laparoscopic cholecystectomy (LC). This study intended to analyze the effect of extended reoperation on the long-term outcome of patients with pT1b/T2 GBC who had initially undergone LC. METHODS: A cohort of 203 patients who underwent R0 resection and whose pathology was pT1b or pT2 GBC was divided into 3 groups: open surgery (group I, n = 150), LC only (group II, n = 25), and initial LC and subsequent reoperation (group III, n = 28). RESULTS: Mean ages were 62.3 ± 9.6 years, 65.9 ± 11.8 years, and 57.1 ± 7.7 years in groups I, II, and III, respectively (p = 0.001). The numbers of pT1b and pT2 patients were 75 and 75 in group I, 15 and 10 in group II, and 6 and 22 in group III, respectively. Residual tumors after LC were found in none of 6 pT1b patients and 5 of 22 pT2 patients. Overall 5-year patient survival rate was 70.1 % for all-cause death and 73.5 % for tumor recurrence-associated death (76.0 % in group I, 64.0 % in group II, and 63.0 % in group III [p = 0.607]; 84.4 % in pT1b group I, 68.8 % in pT1b group II, and 83.3 % in pT1b group III [p = 0.649]; 67.6 % in pT2 group I, 50 % in pT2 group II, and 61.9 % in pT2 group III [p = 0.895]). Concurrent bile duct resection in pT2 patients did not affect survival outcomes (p = 0.601). CONCLUSIONS: No definite survival benefit from reoperation was observed in patients with pT1b lesions. Residual tumor was found in 23 % of pT2 patients after reoperation, and the survival outcomes of these patients were comparable to those of the open surgery group. Therefore, reoperation for pT1b GBC following LC can be individually indicated because its indication remains unclear, but it should be highly recommended for pT2 GBC.

Prognosis of patients with pT1b/T2 gallbladder carcinoma who have undergone laparoscopic cholecystectomy as an initial operation.

BACKGROUNDS/AIMS: Laparoscopic cholecystectomy (LC) has become a standard procedure for treatment of benign gallbladder diseases. There has been a small proportion of gallbladder cancer (GBC) which was incidentally found in the gallbladder specimen, and LC has been tried in some patients with faintly suspected GBC. This study intended to analyze the prognosis of patients with pT1b/T2 GBC who have undergone LC and the outcome of extended re-operation. METHODS: After analyzing the institutional profiles of 500 GBC patients who have undergone surgical resection, we selected 64 patients who underwent LC initially from January 1996 to December 2008 and whose gallbladder pathology was confined to pT1b or pT2 lesions. Of them, 34 patients (53.1%) underwent extended reoperation. Their medical records were reviewed retrospectively. RESULTS: In the LC only group (n=30), mean age of the 16 pT1 patients was 65.7±12.5 years and mean age of the 14 pT2 patients was 66.7±10.1 years. In the reoperation group (n=34), mean age of the 8 pT1b patients was 52.6±9.9 years and in 26 pT2 patients, mean age was 59.2±7.9 years. The reoperation group showed a younger patient age pattern than the LC only group (p=0.001). The types of reoperation were liver resection with lymph node (LN) dissection in 17, bile duct resection with LN dissection in 2, and hepatectomy and bile duct resection with LN dissection in 15. In the LC only group, the 5-year survival rate (5-YSR) was 70.3% in pT1b and 43.2% in pT2. In the reoperation group, 5-YSR was 62.5% in pT1b (n=8) and 59.5% in pT2 (n=26). A survival comparison between the two groups showed no significant survival gain in pT1 patients (p=0.69) and in pT2 patients (p=0.14). In our whole database analysis, 5-YSR of pT1bNx lesions was 70% after cholecystectomy and 78% after extended cholecystectomy. Lymph node metastasis was identified in 11% of pT1b lesions. For pT2N0 lesions, overall 5-YSR was 62% after R0 resection, showing no survival difference between primary extended surgery and LC-redo operation (p=0.45). CONCLUSIONS: The survival gain of reoperation was not evident in pT1b lesions. In contrast, some noticeable but not statistically significant survival difference was observed in pT2 lesions. Thus, reoperation for pT1b/T2 GBC following LC is indicated for individualized reasons, especially in patients with pT1b lesions. Old age was one of the important factors in deciding not to reoperate.