Annals of hepato-biliary-pancreatic surgery最新文献

Backgrounds/aims: We compared the postoperative outcomes of single-incision laparoscopic cholecystectomy (SILC) with those of single-incision robotic cholecystectomy (SIRC) using the da Vinci Xi and SP systems.

Methods: We retrospectively analyzed data from 206 patients who underwent these procedures by a single surgeon between August 2020 and April 2022. Propensity score matching was used to adjust for confounders and evaluate outcomes.

Results: SILC exhibited shorter operation times compared to SIRC with Xi and SP (44.9 ± 14.5 min vs. 55.3 ± 12.2 min vs. 55.2 ± 16.2 min, p < 0.001). SIRC with Xi had shorter docking times (6.2 ± 2.8 min vs. 10.3 ± 2.3 min, p < 0.001), while SIRC with SP demonstrated reduced console times (11.2 ± 2.4 min vs. 18.6 ± 8.0 min, p < 0.001). Pain scores and complications did not significantly differ between the groups.

Conclusions: Both SILC and SIRC showed comparable outcomes, with the SP system providing advantages such as reduced console time and fully articulated arms, likely reducing surgeon stress.

The liver hanging maneuver (LHM), introduced by Belghiti et al. in 2001, has been widely adapted to various hepatectomy techniques to reduce blood loss and facilitate parenchymal transection. However, its primary limitation is the risk of vascular injury, particularly near the inferior vena cava (IVC). In this report, we describe a modified "Loop-Hanging" maneuver designed as an alternative to enhance exposure during parenchymal transection and improve the control of Glissonean pedicles. In this case, we employed the technique during an open right hemihepatectomy on a 47-year-old male patient with a complex bile duct injury following two unsuccessful Roux-en-Y hepaticojejunostomies (RYHJ). The patient was referred to our institution due to an RYHJ stricture. Imaging identified a right hepatic artery pseudoaneurysm and a fistula to the biliary limb. After two failed attempts at endovascular embolization, a surgical approach was determined through multidisciplinary discussions. During the surgery, the liver was looped with a nasogastric tube positioned anterior to the IVC, allowing gentle upward traction that facilitated the transection, minimized bleeding, and enhanced pedicle control. The LHM is known to reduce blood loss but carries risks for patients with anatomical variations, scarring, or cirrhosis. Our "Loop-Hanging" technique retains the core advantages of LHM, simplifies the process, and diminishes the risk of vascular injury. Further research is required to assess its safety and broader applicability.

Backgrounds/aims: Although anatomical liver resection is considered more effective in preventing complications and recurrence in hepatocellular carcinoma, its efficacy has yet to be clearly defined in colorectal cancer liver metastasis (CLM).

Methods: From January 2000 to December 2023, 145 patients underwent liver resections for CLM, divided into anatomic and non-anatomic resection cohorts. The dataset included demographic details, tumor size, number and distribution of metastases, neoadjuvant chemotherapy, primary tumor location and stage, type of liver surgery, transfusion rates, duration of hospital stay, postoperative complications, and completeness of resection.

Results: Of the 145 patients who underwent liver resections for metastases from colorectal cancer, 62 were in the anatomic group and 83 were in the non-anatomic group. The anatomic group had larger tumors (6.71 cm vs. 3.18 cm). Intraoperative transfusion rates were higher in the anatomic group (56.5% vs. 12.0%). Hospital stays, positive resection margin rates, and postoperative complication rates showed no significant differences. One surgery-related death occurred in the anatomic group. Disease-free and overall survival rates were comparable between groups.

Conclusions: Anatomic liver resection did not demonstrate a reduction in recurrence or an improvement in survival rates compared to non-anatomic resection. As such, anatomical resection does not offer a survival advantage over non-anatomical resection. Consequently, surgical method selection should prioritize patient safety, preservation of residual liver parenchyma, and tumor-specific factors.

Backgrounds/aims: Distal pancreatectomy with splenectomy (DPS) is a common surgical procedure for pancreatic body cancer. However, spleen-preserving distal pancreatectomy (SPDP) utilizing the Warshaw technique (WT) in malignancies is generally not favored due to concerns about inadequate resection. This study aims to assess the feasibility and oncologic outcomes of employing SPDP with WT in pancreatic body cancer.

Methods: We conducted a retrospective analysis comparing 21 SPDP patients with 63 DPS patients matched by propensity score from January 2018 to November 2022. Clinical outcomes and follow-up data were analyzed using R.

Results: Both groups exhibited similar demographic, intraoperative, and pathological characteristics, with the exception of a reduced number of total lymph nodes (p = 0.006) in the SPDP group. There were no significant differences in the rates of postoperative complications, recurrence, or metastasis. Local recurrence predominantly occurred in the central region as opposed to the spleen region. There were no cases of isolated recurrences in the splenic region. Median overall survival and recurrence-free survival times were 51.5 months for SPDP vs 30.5 months for DPS and 18.7 months vs 16.8 months, respectively (p > 0.05). The incidence of partial splenic infarction and left-side portal hypertension in the SPDP group was 28.6% (6/21) and 9.5% (2/21), respectively, without necessitating splenic abscess puncture, splenectomy, or causing bleeding from perigastric varices.

Conclusions: SPDP did not negatively impact local recurrence or survival rates in selected pancreatic body cancer patients. Further studies are necessary for validation.

Backgrounds/aims: Robotic surgery for perihilar cholangiocarcinoma is in the developmental and exploratory phase. The objective of this study was to compare the short-term outcomes and survival rates of robotic versus open resection for perihilar cholangiocarcinoma in a single center, and to determine the reliable scope of robotic interventions.

Methods: A comparative analysis of outcomes from open and robotic resections at a single center was conducted using propensity score matching (PSM). The balance of covariates was assessed using standardized mean differences, and the robotic resection procedures adhered to the standards of open surgery.

Results: PSM was effectively applied between 41 robotic and 82 open resections. No differences were observed in blood loss, overall and severe morbidity, 90-day mortality, or length of hospital stay. Robotic resections were longer but resulted in better immediate oncological outcomes. Median overall survival for the robotic and open groups was 44 and 30 months (p = 0.259) before PSM and 44 and 29 months (p = 0.164) after PSM respectively. Conversion was required in 8 cases. A subgroup analysis excluding conversions revealed no differences in immediate and long-term outcomes. All patients undergoing robotic resection for Bismuth types I and II were alive at a mean follow-up of 37 months.

Conclusions: The robotic approach is comparable to open resection regarding immediate outcomes and survival in select patients with perihilar cholangiocarcinoma. For patients with Bismuth type I and II tumors and early (stages I and II) TNM stages, robotic resection is a reliable treatment option when aligned with the principles of open surgery.

Heterotopic pancreas (HP) refers to the presence of ectopic pancreatic tissue located outside of the normal pancreatic location without anatomical or vascular continuity with the pancreas. HP within the gallbladder (HPGB) was first described by Otschkin in 1916. It remains an exceedingly rare pathology with few reported cases. Here we describe a case of HPGB in a 42-year-old female following laparoscopic cholecystectomy for symptoms of biliary colic. She presented with epigastric pain, elevated levels in liver function tests, and gallbladder sludge on ultrasound. Her lipase and bilirubin levels were within normal limits. Histopathological assessment of the gallbladder identified mild chronic cholecystitis and pancreatic heterotopia adjacent to the cystic duct of the gallbladder with all three elements (ducts, acini, and endocrine islets) of the pancreas, consistent with type 1 based on the classification of Gaspar Fuentes et al. HPGB is often diagnosed incidentally during histopathological examination after cholecystectomy. Preoperative diagnosis is challenging due to its rarity. It is thought to be asymptomatic. Although the clinical significance of HPGB remains uncertain, it has been hypothesized that HPGB can cause acalculous cholecystitis and also have the potential for malignant transformation. Our case supports the theory that the exocrine function of an ectopic pancreatic tissue may contribute to chronic inflammation in the gallbladder. In conclusion, although HPGB is a rare finding with unclear clinical relevance, its potential for malignancy and association with cholecystitis warrant further investigation. Given its scarcity, most knowledge about HPGB comes from case reports and case series. This report adds to the existing literature.

To examine the feasibility and safety of robotic radical resection (RRR) for hilar cholangiocarcinoma (HCCA). A PRISMA-compliant meta-analysis with meta-regression was conducted, including studies reporting outcomes of RRR in patients with HCCA. Six studies comprising 295 patients were included. In highly selected patients (body mass index [BMI] < 25 kg/m" ; tumor size < 3 cm), RRR of HCCA proved safe and feasible (Clavien-Dindo ≥ III complications: 14.8% [95% confidence interval 8.7%-20.8%]; 30-day mortality: 1.9% [0%-4.2%]; conversion to open surgery: 1.9% [0%-4.2%]; intraoperative blood loss: 210 mL [119-301 mL]; operative time: 481 minutes [339-623 minutes]; R0 resection rate: 82.2% [75.0%-89.4%]; retrieved lymph nodes: 12 [9-16]). Younger age (p = 0.008), higher BMI (p = 0.009), larger tumors (p = 0.048), and performing liver resections (p = 0.017) increased blood loss. American Society of Anesthesiologists status ≥ III (p < 0.001) and Bismuth IV disease (p < 0.001) increased operative times. Preoperative biliary drainage (p = 0.027) enhanced R0 resection rates. RRR led to less bleeding (mean difference [MD]: -184 mL, p = 0.0005), longer operative times (MD: 162 minutes, p = 0.001), and improved R0 resection rates (odds ratio: 3.29, p = 0.006) compared with the open approach. Subject to selection bias and type 2 error, RRR for HCCA might be safe and feasible in highly selected patients (favorable BMI and tumor size). The findings should not be taken as definitive conclusions but may be used for hypothesis generation in subsequent trials.

Backgrounds/aims: Assessing surgical difficulty in laparoscopic cholecystectomy (LC) is challenging due to variations in surgeon proficiency and institutional protocols. This study evaluates surgeons' perspectives on procedural difficulty and examines how intraoperative findings and preoperative imaging contribute to refining difficulty assessment criteria.

Methods: A cross-sectional survey was conducted among 50 laparoscopic surgeons in India, providing insights into tolerances for surgical duration and blood loss, reasons for conversion, and predictors of complexity. Responses were analyzed using SPSS, with statistical significance set at p < 0.05.

Results: Among surveyed surgeons, 82.0% were male, and 78.0% worked in private institutions and 52.0% had performed over 1,000 LCs. Conversion to open surgery was primarily influenced by significant blood loss (68.0%) and biliary injury (94.0%). While 38.0% preferred surgeries under 60 minutes, 26.0% imposed no time constraints. Key intraoperative challenges included dense adhesions, cholecysto-enteric fistulas, and fibrosis. Less experienced surgeons reported greater challenges with scarring adhesions and anatomical variations, but no significant differences were found for other factors like edematous or necrotic changes. Preoperative imaging was considered essential by most surgeons.

Conclusions: This study underscores the limited reliability of traditional parameters for assessing difficulty in LC. Surgeons highlighted the importance of objective intraoperative findings and preoperative imaging in predicting surgical challenges. Factors such as adhesions, fibrosis, and anatomical variations significantly impact LC difficulty, with decisions regarding conversion to open surgery largely driven by individual judgment rather than experience. Standardized grading systems incorporating these factors could improve surgical planning, reduce complications, and enhance patient outcomes.

Laparoscopic subtotal cholecystectomy (LSC) has been a safe and viable alternative to conversion to laparotomy in cases of severe cholecystitis. The objective of this study is to determine the utility of intraoperative choledochoscopy in LSC for the exploration of the gallbladder, cyst duct, and subsequent stone clearance of the cystic duct in cases of severe cholecystitis. A total of 72 patients diagnosed with severe cholecystitis received choledochoscopy-assisted laparoscopic subtotal cholecystectomy (CALSC). A choledochoscopy was performed to explore the gallbladder cavity and/or cystic duct, and to extract stones using a range of techniques. The clinical records, including the operative records and outcomes, were subjected to analysis. No LSC was converted to open surgery, and no bile duct or vascular injuries were sustained. All stones within the cystic duct were removed by a combination of techniques, including high-frequency needle knife electrotomy, basket, and electrohydraulic lithotripsy. A follow-up examination revealed the absence of residual bile duct stones, with the exception of one common bile duct stone, which was extracted via endoscopic retrograde cholangiopancreatography. In certain special cases, CALSC may prove to be an efficacious treatment for the management of severe cholecystitis. This technique allows for optimal comprehension of the situation within the gallbladder cavity and cystic duct, facilitating the removal of stones from the cystic duct and reducing the residue of the non-functional gallbladder remnant.

Backgrounds/aims: To determine short-term and long-term outcomes after pancreas preserving total duodenectomy (PPTD).

Methods: A case series and a complementary meta-analysis were conducted. All patients with (pre)neoplastic lesions of duodenum who underwent PPTD in a tertiary center for pancreatic surgery between May 2009 and October 2022 were included for the case series. All studies in the literature with a sample size of 10 or more patients reporting outcomes of PPTD were included for the meta-analysis.

Results: A total of 439 patients (18 from case series and 421 from literature) were analyzed. Clavien-Dindo (CD) I complications in 2.9% (95% confidence interval [CI] 0.6%-5.2%), CD II complications in 21.1% (14.6%-27.6%), CD III complications in 18.1% (9.3%-26.9%), CD IV complications in 2.7% (0.5%-4.9%), and CD V complications in 2.2% (0.2%-4.2%) of patients were found. Probabilities of overall survival and recurrence-free survival at 15 years were 87% and 86%, respectively. There was no significant difference in the risk of mortality (odds ratio [OR]: 0.82, p = 0.830), total complications (OR: 0.77, p = 0.440), postoperative pancreatic fistula (OR: 0.43, p = 0.140), delayed gastric emptying (OR: 0.70, p = 0.450), or postoperative bleeding (OR: 0.97, p = 0.960) between PPTD and pancreaticoduodenectomy.

Conclusions: PPTD is safe and feasible for (pre)neoplastic lesions of duodenum not involving the pancreatic head. The risk of severe complications (CD > III) is low and long-term outcomes are favorable. Whether PPTD provides advantages over more radical techniques in terms of long-term outcomes remains controversial and requires further research.