Safety of robotic cholecystectomy as index training procedure: the UK experience.

AIMS: To evaluate the safety profile of robotic cholecystectomy performed within the United Kingdom (UK) Robotic Hepatopancreatobiliary (HPB) training programme. METHODS: A retrospective evaluation of prospectively collected data from eleven centres participating in the UK Robotic HPB training programme was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. RESULTS: A total of 600 patients were included. The median age was 53 (IQR 65-41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600), and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). CONCLUSION: The current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low bile leak rate, low conversion to open surgery, and low need for subtotal cholecystectomy.

What are the true benefits of robotic pancreaticoduodenectomy for patients with pancreatic cancer?

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, and multimodal treatment including high-quality surgery can improve survival outcomes. Pancreaticoduodenectomy (PD) has evolved with minimally invasive approaches including the implementation of robotic PD (RPD). In this special report, we review the literature whilst evaluating the 'true benefits' of RPD compared to open approach for the treatment of PDAC. AREAS COVERED: We have performed a mini-review of studies assessing PD approaches and compared intraoperative characteristics, perioperative outcomes, post-operative complications and oncological outcomes. EXPERT OPINION: RPD was associated with similar or longer operative times, and reduced intra-operative blood loss. Perioperative pain scores were significantly lower with shorter lengths of stay with the robotic approach. With regards to post-operative complications, post-operative pancreatic fistula rates were similar, with lower rates of clinically relevant fistulas after RPD. Oncological outcomes were comparable or superior in terms of margin status, lymph node harvest, time to chemotherapy and survival between RPD and OPD. In conclusion, RPD allows safe implementation of minimally invasive PD. The current literature shows that RPD is either equivalent, or superior in certain aspects to OPD. Once more centers gain sufficient experience, RPD is likely to demonstrate clear superiority over alternative approaches.

Tonsillar Extraintestinal Enteropathy-Associated T-Cell Lymphoma in a Patient With Celiac Disease.

Enteropathy-associated T-cell lymphoma (EATL) is a rare but serious complication of celiac disease. Diagnosis is challenging. Patients can present with weight loss, abdominal pain, and diarrhea or acutely with bowel perforation or obstruction. Patients often present with advanced disease. Malnutrition further limits treatment options. Early diagnosis is important to start aggressive treatment strategies. However, even with prompt diagnosis, prognosis remains poor with a high mortality rate. We report the first documented case of sole tonsillar involvement, a rare extraintestinal and extranodal site of disease, leading to EATL diagnosis. We also highlight some of the challenges in diagnosing EATL.

Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 µmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.

Left hepatic trisectionectomy for hepatobiliary malignancies: Its' role and outcomes. A retrospective cohort study.

BACKGROUND: Left hepatic trisectionectomy (LHT) is a complex hepatic resection; its' role and outcomes in hepatobiliary malignancies remains unclear. MATERIALS AND METHODS: All patients undergoing LHT at the tertiary HPB referral unit at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database. RESULTS: Twenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43-76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210-585 min). Median blood loss was 750 ml (300-2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively. CONCLUSION: This study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections.

A novel technique of needle-guided laparoscopic enucleation of insulinomas.

Insulinomas are rare, usually benign and solitary neuroendocrine tumors that cause oversecretion of insulin. Surgical excision remains the only treatment modality with the potential for cure. Compared to open extensive pancreatic resections, laparoscopic enucleation of these tumors offers effective treatment, and significantly reduced risks of complications. However, accurate tumor localization is extremely important, especially in cases of lesions deep seated into the head of the pancreas. We present here a novel technique of intraoperative localization of lesions that are not visible on the surface of pancreas. Using laparoscopic intraoperative ultrasound, tumors were located in the parenchyma of the pancreatic head and then an 18-G needle was inserted into the pancreatic lesion intraoperatively under laparoscopic sonographic guidance. The pancreatic parenchyma was then divided until the dome of tumor was visible, minimizing tissue trauma, and enucleation was performed. This technique is a useful tool that substantially improves the chances of successful laparoscopic enucleation of deep-seated small pancreatic insulinomas.

Gall bladder malignancy: an unusual association.

Gall bladder malignancy predominantly comprises adenocarcinoma and is found mostly in a late stage whereas primary lymphoma of mucosa associated lymphoid tissue (MALT) within the gall bladder is exceedingly rare and has an incidental presentation. We report a case of well differentiated adenocarcinoma with MALT lymphoma of the gall bladder in an 83 year old woman. To our knowledge, this is the first case of a carcinoma and lymphoma occurring simultaneously in the gall bladder.

The usefulness of P-POSSUM score in patients undergoing elective liver resection for benign disease, metastatic colorectal cancer and non-colorectal cancer.

BACKGROUND/AIMS: P-POSSUM predicts operative risk and mortality, although few reports describe its use in elective liver resection. We analysed P-POSSUM scores in patients undergoing resection for colorectal liver metastases, non-colorectal cancer and benign liver dis-ease. METHODOLOGY: Data for 664 elective liver resections were included between 1998 and 2009; 480 for colorectal metastases; 96 for benign and 88 for non-colorectal disease. Peri-operative management was standardised according to unit protocol. RESULTS: P-POSSUM predicted mortality was 3.73%, 6.27% and 9.99% for benign, colorectal and non-colorectal can-cer patients. 60-day mortality was 1.04%, 1.88% and 6.81%, p<0.001. There was correlation between predicted and actual mortality in non-colorectal patients, p=0.029 and weak correlation between physiological score and mortality in each group. There were high-er physiological scores in patients with morbidity and higher predicted mortality in colorectal patients experiencing morbidity, p=0.014. There was correlation be-tween observed and expected operative mortality in benign and non-colorectal patients. Long-term survival was unaffected by various aspects of the P-POSSUM system. CONCLUSIONS: Predicted mortality is over estimated in patients undergoing liver resection. Pre-operative,physiological score and predicted mortality may have a role predicting morbidity. P-POSSUM is ineffective in predicting prognosis following colorectal cancer metastases resection, although may be used to stratify risk in high risk cancer patients.

Analysis of residual pancreatic bed necrosis using computed tomography following minimally invasive necrosectomy.

PURPOSE: In a unit practicing minimally invasive pancreatic necrosectomy (MIPN), our aim was to assess whether tomographic residual necrotic volume was an objective indicator for repeat necrosectomy. METHODS: Prospective study of acute pancreatitis admissions. Patients with infected pancreatic necrosis or deteriorating sepsis had MIPN. Outcome parameters included necrotic volumes, conversion rate, morbidity, and mortality. RESULTS: Thirty patients were admitted with acute pancreatitis of which 15 required organ support. Twenty-nine necrosectomy sessions were performed. Average time from admission to necrosectomy was 39.7 days with an internecrosectomy interval of 6 to 14 days. Mean reduction of necrosis volume was 89.5% and postnecrosectomy volumes were variable. Mean length of hospital and intensive care unit stay was 124.3 and 40.2 days, respectively. Complications included bleeding, pancreatic fistula, and gastric outlet obstruction. No in-hospital deaths or conversions occurred. CONCLUSION: Frequent MIPN achieves substantial pancreatic bed volume reduction with no conversions. Repetitive tomographic scanning is of limited use as an indicator for renecrosectomy.

Early postoperative outcomes following hepatic resection for benign liver disease in 79 consecutive patients.

BACKGROUND: Liver resection is an accepted treatment modality for malignant disease of the liver. However, because of its potential morbidity and mortality, the practice of liver resection in benign disease is more controversial. This study was designed to assess the early outcomes of 79 consecutive liver resections for benign disease over a 12-year period and compare these with early outcomes of 390 consecutive liver resections for metastatic colorectal cancer (MCRC) during the same period. METHODS: Consecutive liver resections were carried out in a single hepatopancreatobiliary (HPB) centre between 1996 and 2008. Patient demographics and early outcomes were recorded. Statistical analyses were performed using spss (Version 15). P < 0.05 was considered to be significant. RESULTS: There was no difference in median age between the benign group vs. the MCRC group (P = 0.181). However, there was a significant trend towards a lower ASA grade in the benign group (P < 0.001). There was no difference in median blood loss (P = 0.139) or hospital stay (P = 0.262). Morbidity rates were 8.9% in the benign group and 20.5% in the MCRC group (P = 0.002). The rate of serious complications was 1.3% in the benign group compared with 4.4% in the MCRC group (P = 0.041). There were no postoperative deaths in the benign group and eight (2%) in the MCRC group (P = 0.004). CONCLUSIONS: Liver resection for benign liver tumours can be undertaken with a mortality rate approaching zero and minimal morbidity in specialist HPB units.

Operative mortality, blood loss and the use of Pringle manoeuvres in 526 consecutive liver resections.

INTRODUCTION: Centres with high volumes of high-risk surgery have significantly better outcomes than low-volume centres for pancreatic resection, oesophagectomy and pelvic exenteration. However, this has not to date been conclusively demonstrated for hepatic resection. With increased experience, operative practice can change. The use of the Pringle manoeuvre reduced substantially over a 12-year period in a single centre as it was felt anecdotally that its use increased the incidence of hepatic insufficiency and operative mortality. This study was designed to review 12 years of experience in a single hepatobiliary centre. PATIENTS AND METHODS: Data regarding 526 consecutive liver resections were prospectively recorded and retrospectively analysed in a high-volume referral unit over a 12-year period. Patients' demographics, operative mortality and morbidity were analysed on an annual basis. RESULTS: Overall peri-operative mortality was 1.9%. Operative mortality in the first 6 years compared to the latter 6 years was 4.1% and 1.2%, respectively (P = 0.13). The morbidity rate was 26.8% and 20.3% in the first and second halves of the study, respectively (P = 0.15). With increased experience, intra-operative blood loss and patients receiving blood transfusions decreased (P = 0.047 and 0.03, respectively) while the number of intra-operative Pringle manoeuvres also decreased (P < 0.0001). Hospital stay decreased significantly over the 12 years (P = 0.049). CONCLUSIONS: High-volume centres are the safest environment for hepatic resection. With increased experience, it may be possible to reduce the intra-operative use of the Pringle manoeuvre without increasing the intra-operative blood loss. This may be associated with a decrease in hepatic insufficiency and peri-operative mortality.

Early and long-term outcomes of patients undergoing liver resection and diaphragm excision for advanced colorectal liver metastases.

INTRODUCTION: At present, liver resection offers the best long-term outcome and only chance for cure in patients with colorectal liver metastases. However, there are no large series that report the early and long-term outcomes of patients who require simultaneous diaphragm excision. This study was designed to investigate these patients. PATIENTS AND METHODS: A total of 285 consecutive liver resections were performed over a 10-year period. Of these, 258 had liver resections alone and 27 underwent liver resection and simultaneous diaphragm excision. Data were collected prospectively and analysed retrospectively. Pre-operative assessment was standardised. The outcomes between the two groups were compared. RESULTS: There was no difference in age, hospital stay or intra-operative blood loss. The diaphragm was histologically involved in four out of 27 resections. As a result, the cancer involved resection margin incidence was greater in the liver resection and diaphragm excision group (14.8% versus 3.9%; P = 0.12). The median tumour size was also different between the two groups (60 mm versus 30 mm; P = 0.001). The liver and diaphragm resection group had a greater peri-operative complication rate (44.4% versus 21.3%; P = 0.02) and mortality (7.4% versus 1.6%; P = 0.25). Overall and disease-free survival was significantly worse in the group who underwent simultaneous diaphragm excision and liver resection (P = 0.04 and P = 0.005, respectively). Diaphragm invasion was found to be an independent predictor of poor overall outcome (P = 0.02). CONCLUSIONS: Liver resection and simultaneous diaphragm excision have a greater incidence of peri-operative morbidity and mortality and a significantly worse long-term outcome compared with liver resection alone. However, these data suggest that liver resection in the presence of diaphragm invasion may still offer a favourable outcome compared with chemotherapy treatment alone. Therefore, we believe that diaphragm involvement by tumour should not be a contra-indication to hepatectomy.

A safe, effective, and cheap method of achieving pancreatic rest in patients with chronic pancreatitis with refractory symptoms and malnutrition.

OBJECTIVES: Chronic pancreatitis (CP) is common. It is associated with a substantial morbidity, including malnutrition, malabsorption, pseudocysts, metabolic disturbances, and intractable abdominal pain. Approximately 5% of patients with CP are refractory to nutritional support and opiate analgesia, making management challenging.Pancreatic rest can provide symptomatic relief. However, achieving simultaneous pancreatic rest and adequate nutritional support in these patients is difficult. We describe a technique for providing nutritional support and pancreatic rest in patients with intractable symptomatic CP. METHODS: Three patients with symptomatic CP refractory to standard treatment were included in the study. All 3 patients had masses associated with the pancreas. Symptom relief and adequate nutritional support were achieved by inserting a long-term nasojejunal (NJ) tube (Flocare Bengmark, Nutricia Clinical Care, United Kingdom) under ambulatory endoscopic guidance. Data were recorded prospectively. RESULTS: Long-term NJ tube feeding achieved pancreatic rest and significant symptomatic relief while delivering adequate nutritional support. Pseudocyst size decreased substantially in 2 patients. The third patient was found to have pancreatic carcinoma after pancreaticoduodenectomy. CONCLUSIONS: In patients with symptomatic CP refractory to standard nutritional support and opiate analgesia, long-term NJ tube feeding can be a cheap, well-tolerated, safe, and effective method of providing adequate nutritional support and substantially relieving intractable symptoms.

Total gastric necrosis due to aberrant arterial anatomy and retrograde blood flow in the gastroduodenal artery: a complication following pancreaticoduodenectomy.

Patients with coeliac artery occlusion often remain asymptomatic due to the rich collateral blood supply (pancreaticoduodenal arcades) from the superior mesenteric artery. However, division of the gastroduodenal artery (GDA) during pancreaticoduodenectomy may result in compromised blood supply to the liver, stomach and spleen. Postoperative complications associated with this condition are rarely reported in the literature. We report two cases of coeliac artery occlusion encountered during pancreaticoduodenectomy, one of which was complicated by hepatic ischaemia and total gastric infarction postoperatively. Based on our experience and review of the literature, a management algorithm for coeliac artery stenosis encountered during pancreaticoduodenectomy is proposed.

Case for postoperative surveillance following colorectal cancer resection.

Over 4 years have elapsed since the first National Health and Medical Research Council (NHMRC) guidelines were published for the management of patients after potentially curative resection of colorectal cancer. New information has now been published indicating that more intensive follow up than was originally recommended might provide a survival benefit for patients. This new information should be considered when formulating new NHMRC guidelines. In particular, meta-analyses of published individual trials have suggested a survival advantage that was not evident in the individual studies. There have been significant developments in chemotherapy with new individual agents and use of agents in combination that have proved far more effective than previous protocols. The therapeutic effect of these developments is the downstaging of some patients with metastatic disease, which was previously unresectable, to undergo resection. Furthermore, there is now some evidence that palliation of patients with advanced disease is more effective if commenced before the development of symptoms and this needs to be considered in the assessment of the benefits of follow up. There have been limited studies of cost-effectiveness, but international analyses suggest that the costs associated with more intensive follow-up regimes are within the accepted cost parameters associated with the management of many other conditions.