Laparoscopic hepaticojejunostomy and gastrojejunostomy for palliative treatment of pancreatic head cancer in 48 patients

Preliminary comparison of total laparoscopic and open radical resection for hepatic hilar cholangiocarcinoma a single-center cohort study

BACKGROUD

The aim was to compare perioperative outcomes of hilar cholangiocarcinoma (HCCA) radical resection performed through the laparoscopic route or by open surgery in single-center cohort study.

METHODS

A retrospective study included all patients undergoing HCCA radical resection in our center from January 2018 to November 2019. Short-term outcomes of patients with laparoscopic and open surgery were compared demographic characteristics, intraoperative and postoperative parameters and extent of resection.

RESULTS

Among 64 patients included, 34 were performed with laparoscopic route and 30 were with open surgery. Laparoscopic versus open group was associated with a longer operation duration [475.50(219.00-630.00) vs. 375.00(220.00-557.00) min, P = 0.031], similar intraoperative bleeding volume [300.00(50.00-3500.00) vs. 350.00(100.00-1500.00) ml, P = 0.426]. No significant differences in tumor diameter [2.00(1.50-3.00) vs. 2.00(1.50-3.00) cm, P = 0.965], the number of lymph nodes retrieved [9.50(6.00-15.00) vs. 8.50(5.00-12.00), P = 0.706], and resection margins (94.1% vs. 86.7%, P = 0.407) between the two approaches were found. The LOS [20.00(10.00-44.00) vs. 21.00(6.00-27.00) d, P = 0.622], bile leakage (23.5% vs. 26.7%, P = 0.781), and liver failure (8.80% vs. 6.70%, P>0.99) were similar in the two groups. There was one patient in open surgery group developing liver failure and finally expired.

CONCLUSION

The safety and radicality of laparoscopic resection for HCCA are similar to open surgery and can be technically improved by rational trocar distribution, total caudate lobectomy and appropriate cholangioenteric anastomosis strategy.

Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction

Periampullary cancers are often diagnosed at advanced stages and can cause both biliary and duodenal obstruction. As these two obstructions reduce patients’ performance status and quality of life, appropriate management of the disease is important. Combined malignant biliary and duodenal obstruction is classified according to the location and timing of the duodenal obstruction, which also affect treatment options. Traditionally, surgical bypass (gastrojejunostomy and hepaticojejunostomy) has been performed for the treatment of unresectable periampullary cancer. However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. Thus, endoscopic double stenting (transpapillary stenting and enteral stenting) has become the current standard of care. Limitations of transpapillary stenting include its technical difficulty and the risk of duodenal-biliary reflux. Recently, endoscopic ultrasound-guided procedures have emerged as a novel platform and have been increasingly utilized in the management of biliary and duodenal obstruction. As the prognosis of periampullary cancer has improved due to recent advances in chemotherapy, treatment strategies for biliary and duodenal obstruction are becoming more important. In this article, we review the treatment strategies for combined malignant biliary and duodenal obstruction based on the latest evidence.

Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study

Background

Palliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome.

Methods

Consecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined.

Results

A total of 93 patients (age 69 [28–92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality.

Conclusions

Palliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.

Double Stenting for Malignant Biliary and Duodenal Obstruction: A Systematic Review and Meta-Analysis

Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited.

Robotic hepaticojejunostomy: surgical technique and risk factor analysis for anastomotic leak and stenosis

BACKGROUND

A variety of techniques have been described for the construction of the HJ (hepaticojejunostomy). Due to its technical challenges, HJ is rarely performed in a pure laparoscopic setting. In stark contrast, the increasing availability of the robotic platform has sparked new interest in pursuing this procedure in a minimally invasive fashion. The aim of our study was to describe our surgical technique and to identify risk factors for anastomotic leak and stenosis following robotic surgery.

METHODS

We performed a retrospective analysis of a prospectively collected database, including all consecutive HJ carried out for different indications over a 10 year period.

RESULTS

One hundred fifty-two patients undergoing robotic HJ performed by the same surgeon were analyzed. Bile leak occurred in 2.6% of the patients. Stricture rate was 3.3%. The median follow up was 25.5 months. There was no mortality related to anastomotic complications. On univariate analysis, patient's age less than 65 years was the only risk factor for anastomotic stricture. On multivariate analysis, no predictor factors for leak or stenosis were identified.

CONCLUSION

HJs carried out in a robotic fashion allow highly satisfactory results. No independent risk factors for bile leak of stenosis were identified on multivariate analysis.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Prognosis following surgical bypass compared with laparotomy alone in unresectable pancreatic adenocarcinoma

BACKGROUND

Resection with curative intent has been shown to prolong survival of patients with locoregional pancreatic ductal adenocarcinoma (PDAC). However, up to 33 per cent of patients are deemed unresectable at exploratory laparotomy owing to unanticipated locally advanced or metastatic disease. In these patients, prophylactic double bypass (PDB) procedures have been considered the standard of care. The aim of this study was to compare PDB with exploratory laparotomy alone in terms of impact on postoperative course, chemotherapy and overall survival.

METHODS

This retrospective observational cohort study (2004-2013) was conducted using a prospective institutional database. Patients with histologically confirmed, unresectable PDAC were included. Relationships between PDB procedures, exploratory laparotomy alone, postoperative chemotherapy and best supportive care were investigated by means of Cox regression. Overall survival was compared using Kaplan-Meier estimations and log rank test.

RESULTS

Of 503 patients with PDAC scheduled for resection with curative intent, 104 were deemed unresectable at laparotomy (resection rate 79·3 per cent). Seventy-four patients underwent PDB procedures and 30 had exploratory laparotomy alone. PDB and exploratory laparotomy were similar in terms of perioperative mortality, initiation of chemotherapy and overall survival. Compared with best supportive care, postoperative chemotherapy prolonged survival (8·0 versus 14·4 months in locally advanced PDAC, P = 0·007; 2·3 versus 8·0 months in metastatic PDAC, P < 0·001). Patients undergoing chemotherapy following exploratory laparotomy alone had longer median overall survival than patients undergoing chemotherapy following PDB procedures (16·3 versus 10·3 months; P = 0·040).

CONCLUSION

Patients with pancreatic cancer deemed unresectable at laparotomy may derive survival benefit from subsequent chemotherapy as opposed to supportive care alone. At laparotomy, proceeding with a bypass procedure for prophylactic symptom control may be prognostically unfavourable.

The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis

Roux-en-Y hepaticojejunostomy (RYHJ) is currently considered as the definitive treatment for iatrogenic bile duct injuries and the principal representative of biliary diversion procedures. This technique has met many milestones of extensive evolution, particularly the last years of concomitant technological evolution (laparoscopic/robotic approach). Anastomotic strictures and leaks, which may have deleterious effects on the survival and quality of life of a patient with biliary obstruction of any cause, made the need of the development of a safe and efficient RYHJ compulsory. The aim of this technical analysis and the juxtaposed discussions is to elucidate with the most important milestones and technical tips and tricks all aspects of a feasible and reliable RYHJ technique that is performed in our center for the last 25 years in around 400 patients.

Surgical Management of Chronic Pancreatitis

Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.