Hepatobiliary surgery and nutrition最新文献

Background: Gallbladder cancer (GBCa) is a rare disease in western countries and surgery remains the state of art, given the tumor is technically resectable. However, data for major liver resection in patients with advanced GBCa is scarce. Objective of this study was to analyze survival outcome measures of patients undergoing major liver resection for GBCa.

Methods: We conducted a single center retrospective cohort study in a high volume hepato-pancreato-biliary (HPB) center screening all patients with gallbladder cancer (GBCa) being treated between 2008-2023. Inclusion criteria were met when resection [major hepatectomy (MaH); minor hepatectomy (MiH)] or palliative chemotherapy (either after surgical exploration +EL/sPC or primarily -EL/pPC) was performed at the University Medical Center Mainz and diagnosis of GBCa was histologically confirmed. Survival analysis was conducted using Kaplan-Meier method. Univariate and multivariate analysis was performed to identify independent predictors of survival.

Results: In total, 167 patients met the inclusion criteria, with 80 patients undergoing resection (MaH, n=20; MiH, n=60) and 87 patients undergoing palliative chemotherapy (n=68 after surgical exploration, n=19 primary palliative chemotherapy). The median survival for patients receiving a MaH or MiH were 11.96 months [95% confidence interval (CI): 1.11-22.81] and 25.1 months (95% CI: 19.37-30.85), respectively. MiH was associated with statistically significant improved survival compared to every other group (MiH vs. +EL/sPC, P<0.001; MiH vs. MaH, P=0.004; MiH vs. -EL/pPC, P<0.001). Two patients survived longer than 36 months after MaH. Conversely, median survival in the +EL/sPC group was 10.32 months (95% CI: 7.74-12.9), and statistically non-inferior to MaH (P=0.052). Patients receiving primary palliative treatment (-EL/pPC) survived median 7.26 months (95% CI: 0.0-15.4), showing no statistically significant discrepancy to MaH either (P=0.25). In a multivariate analysis of patients who underwent resection, MaH (P=0.04) and R-stage (P=0.02) were identified as independent predictors of worse overall survival.

Conclusions: MiH, if applicable, is associated with improved survival in GBCa, whereas only few patients benefited from major hepatectomies. This is, however, not attributable to the surgical technique, but rather to the advanced tumor necessitating major and/or extended resections. New neoadjuvant chemotherapy concepts are urgently needed to reduce preoperative tumor burden and improve survival outcomes.

Background: Pancreatoduodenectomy (PD) is a major surgical procedure that is still mostly performed via open approach [open PD (OPD)] since the laparoscopic approach (LA) is limited outside specialised centers. Robot-assisted PD (RPD) appears to decrease the difficulties associated with LA. However, previously published studies are partly biased because they stem from institutions with extensive access to robotic platforms (ARPs). The present study aims to analyse the safety of RPD compared with OPD and the specific learning curve when performed with limited ARP.

Methods: This prospective single-center study was conducted in a high-volume pancreatic surgery center but with limited ARP between May 2018 and October 2023. Safety (primary endpoint: 90-day mortality) was assessed using propensity score matching (2:1) to compare RPD and OPD. The learning curve was evaluated using cumulative sum (CUSUM) control chart analysis (split into three consecutive periods of 20 patients), focusing on operative time and complications.

Results: A total of 354 PD were analysed, of which 60 (17%) were RPD. A matched cohort of 120 OPD was used for comparison. The conversion rate was 15% in the RPD group. The 90-day mortality rate was 5% and 8.3% for RPD and OPD, respectively (P=0.55). The RPD learning curve showed a reduction in hospital stay (19.9 vs. 25.3 vs. 14.5 days, P=0.17) and a decrease in post-operative complications with increasing experience.

Conclusions: Even with limited ARP, setting up a robotic program for PD is feasible and safe but it requires a learning curve of 40 patients. During this initial phase, careful patient selection is mandatory.