The impact of indocyanine green fluorescence angiography (ICG-FA) on anastomotic leak rates and postoperative outcomes in colorectal anastomoses: a systematic review

BACKGROUND

Anastomotic leak (AL) is a major complication in colorectal surgery, significantly contributing to perioperative morbidity and mortality. Among strategies to prevent AL, Indocyanine Green Fluorescence Angiography (ICG-FA) has emerged as a promising method for assessing bowel perfusion intraoperatively. This systematic review evaluates the impact of ICG-FA on AL rates and other postoperative outcomes following colorectal anastomoses.

METHODS

A systematic search was conducted in PubMed, PubMed Central, MEDLINE, and Google Scholar, following PRISMA guidelines. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and retrospective cohort studies comparing ICG-FA to controls in adult patients undergoing colorectal resections and anastomoses. Data on AL rates, intraoperative characteristics, and postoperative outcomes were extracted. Quality assessment was performed using the Newcastle-Ottawa Scale and the Revised Cochrane Risk-of-Bias Tool.

RESULTS

Sixteen studies (12 retrospective, 1 prospective, and 3 RCTs) involving 3231 patients (1562 ICG-FA and 1669 controls) were included. AL rates were significantly lower in the ICG-FA group (5.18%) compared to controls (11.50%) (p < 0.01). ICG-FA influenced surgical plans in 16.31% of cases. Operative time and ileostomy formation rates were comparable between groups. Reoperation, ileus, and wound infection rates showed minimal differences. Mortality rates were low in both groups (ICG-FA: 0.55%, control: 0.51%).

CONCLUSION

ICG-FA significantly reduces AL rates without increasing operative time or postoperative complications. This technique provides a reliable and safe assessment of bowel perfusion, supporting its integration into colorectal surgery protocols. Further high-quality RCTs are needed to confirm these findings and optimise its application.

Laparoscopic-assisted pancreaticoduodenectomy for periampullary carcinoma: An experience of 50 cases from a single tertiary care center

OBJECTIVES

Laparoscopic-assisted pancreaticoduodenectomy (LAPD) is being performed in several centers worldwide. The proportion of minimally invasive pancreaticoduodenectomy for periampullary carcinoma (PAC) has recently increased, owing to its potential benefits. However, the safety and feasibility of LAPD have not yet been standardized. In this study, it was aimed to report our experience with LAPD in 50 patients.

MATERIAL AND METHODS

Fifty patients with resectable PAC who underwent LAPD between June 2021 and August 2023 were retrospectively analyzed.

RESULTS

Mean age of the study group was 49.9 ± 12 years, and most were females (54%). Ampullary carcinoma was the most common type (58%). Mean operative time and estimated blood loss were 460 ± 40 minutes and 426 ± 156 mL, respectively. Four patients had suspected portal vein involvement, and two patients had hemorrhage during uncinate process dissection, resulting in conversion to open surgery. Severe post-operative morbidity was noted in 13 (26%) patients. Following surgery, Grade B post-operative pancreatic fistula was present in 26% of patients, whereas Grade B and C delayed gastric emptying was present in 18% and 2% of patients, respectively. Mean hospital stay was 9.4 ± 2.8 days. Mean number of lymph nodes harvested was 13.4 ± 4. All patients underwent R0 resection, and no mortality was noted during the 30-day follow-up period.

CONCLUSION

LAPD is a feasible procedure for resectable PAC offering good oncological outcomes and minimal complications. It can be performed effectively by experienced surgeons in specialized centers.

Comparison of short-term outcomes of open and laparoscopic assisted pancreaticoduodenectomy for periampullary carcinoma: A propensity score-matched analysis

BACKGROUNDS/AIMS

Postoperative pancreatic fistula is the key worry in the ongoing debate about the safety and effectiveness of total laparoscopic pancreaticoduodenectomy (TLPD). Laparoscopic-assisted pancreaticoduodenectomy (LAPD), a hybrid approach combining laparoscopic resection and anastomosis with a small incision, is an alternative to TLPD. This study compares the short-term outcomes and oncological efficacy of LAPD vs. open pancreaticoduodenectomy (OPD).

METHODS

A retrospective analysis of data of all patients who underwent LAPD or OPD for periampullary carcinoma at a tertiary care center in Northeast India from July 2019 to August 2023 was done. A total of 30 LAPDs and 30 OPDs were compared after 1:1 propensity score matching. Demographic data, intraoperative and postoperative data (30 days), and pathological data were compared.

RESULTS

The study included a total of 93 patients, 30 underwent LAPD and 62 underwent OPD. After propensity score matching, the matched cohort included 30 patients in both groups. The LAPD presented several advantages over the OPD group, including a shorter incision length, reduced postoperative pain, earlier initiation of oral feeding, and shorter hospital stays. LAPD was not found to be inferior to OPD in terms of pancreatic fistula incidence (Grade B, 30.0% vs. 33.3%), achieving R0 resection (100% vs. 93.3%), and the number of lymph nodes harvested (12 vs. 14, p = 0.620). No significant differences in blood loss, short-term complications, pathological outcomes, readmissions, and early (30-day) mortality were observed between the two groups.

CONCLUSIONS

LAPD has comparable safety, technical feasibility, and short-term oncological efficacy.

Comparison of surgical outcomes between shunt surgery and devascularization in non-cirrhotic portal hypertension

Objectives

Non-cirrhotic portal hypertension (NCPH) is the most common cause of portal hypertension and upper gastro-intestinal bleeding in children and adolescents in developing nations. It is characterized by features of portal hypertension with preserved liver function. Proximal splenorenal shunt (PSRS) and esophagogastric devascularization are the two most commonly performed surgeries for its management. The present study is aimed at comparison of surgical outcomes between these two procedures.

Material and Methods

Between April 2018 and March 2022, prospectively maintained data of consecutive NCPH cases who underwent surgical intervention was reviewed retrospectively. Cases were categorized into two groups- shunt surgery and devascularization. The pre-operative characteristics, peri-operative morbidity and long-term outcomes were compared between the groups.

Results

Of 112 cases who were treated during the study period, 54 cases which underwent surgery were included in the study. Of these, 20 cases underwent PSRS, and splenectomy and devascularization was performed in 34 cases. There was no difference in pre-operative variables between the two groups. Patients undergoing PSRS experienced longer duration of surgery (260 vs. 200 minutes, p <0.001), and those in the devascularization group had significantly greater operative blood loss (350 vs. 455 ml, p <0.001). Post-operative morbidity was comparable between the two groups. Hypersplenism was corrected in all cases and no cases reported rebleeding after median follow-up of 30 months. Three cases in each group developed features of portal biliopathy in follow up period.

Conclusion

Both PSRS and devascularization procedures have comparable efficacy and safety in the management of NCPH.

The impact of vascular injuries on the management of bile duct injury following laparoscopic cholecystectomy- insights from a prospective study

BACKGROUND

Our study aimed to compare the clinical presentation and outcomes of post-cholecystectomy bile duct injuries (BDI) with and without arterial injuries.

METHODS

A prospective analysis of 123 patients with post-cholecystectomy BDI between July 2018 and January 2022 was performed. Multivariate logistic regression analysis was used to assess the impact of vascular injuries on perioperative complications and long-term outcomes after delayed repair.

RESULTS

Of 123 patients, 42 (34%) had associated vascular injuries, predominantly right hepatic artery disruptions. These patients experienced significantly higher perioperative complications after the index surgery (Cholangiolar abscess- 83.3% vs 32.1% ( p<0.001), recurrent cholangitis- 66.67 % vs 14.81 % ( p<0.001), blood transfusions ³2 - 89.74 % vs 28.57 % ( p<0.001), hospital admissions ³3 - 3.88 ± 1.99 vs 2.49 ± 0.74 ( p<0.001). Delayed Hepp-Couinaud biliary repair was performed in 112 patients. After a median follow-up, of 2 years, 85 (51.43 % vs. 88.16 % ), 12 (25.71 % vs. 3.89 %), 6 (11.43 % vs. 2.59 %), and 9 (11.43 % vs. 6.49 %) patients had excellent, good, fair, and poor outcomes.

CONCLUSION

Concomitant vasculobiliary injuries were associated with increased morbidity after index surgery; however, the long-term outcomes following definitive biliary repair remained comparable.

Enteral nutrition versus parenteral nutrition in the management of postoperative pancreatic fistula following pancreaticoduodenectomy: a prospective observational study

BACKGROUND

Postoperative pancreatic fistula (POPF) presents a significant challenge to oral intake after pancreaticoduodenectomy (PD). Strategies such as enteral feeding via nasojejunal tube, feeding jejunostomy (FJ), and total parenteral nutrition (TPN) are commonly used to optimize postoperative nutrition. However, the routine use of FJ in PD remains controversial. This study assesses the effectiveness of enteral feeding versus TPN in the management of POPF.

METHODS

A prospective observational study was conducted on 100 patients undergoing classical PD at a tertiary care centre in eastern India between July 2019 and July 2024. Patients were randomly allocated to FJ and non-FJ groups in a 1:1 ratio. The primary endpoints were procedure-related complications (POPF, delayed gastric emptying (DGE), post-pancreatectomy haemorrhage, bile leak, Clavien-Dindo grade ≥ 3), hospital stay, additional costs and 30-day mortality in patients with clinically relevant POPF.

RESULTS

Of the 100 patients, 50 underwent routine FJ placement, and 50 did not. Most POPF cases were Grade B (34% versus 24%). Subgroup analysis of patients with clinically relevant POPF revealed that FJ placement significantly reduced fistula duration (3.8 versus 5.2 weeks, P < 0.001), intra-abdominal drain duration (26.4 versus 34.9 days, P < 0.001), hospital stay (7.9 versus 9.9 days, P < 0.001) and cost expenses (1301 ± 524 versus 1982 ± 441, P < 0.001). There were no differences in complication rates, reoperations, readmissions or 30-day mortality. FJ placement was not associated with adverse events.

CONCLUSION

Routine FJ is a safe and cost-effective strategy for PD patients requiring prolonged nutritional support.

Liver biopsy in patients with gall stone disease and concomitant non-alcoholic fatty liver disease undergoing cholecystectomy: A prospective observational study

Objectives

Gallstone disease (GSD) and non-alcoholic fatty liver disease (NAFLD) share common risk factors. NAFLD can progress to non-alcoholic steatohepatitis (NASH), which may lead to severe liver conditions. This study aimed to assess the prevalence of NASH and associated factors in patients with GSD and fatty liver undergoing cholecystectomy.

Material and Methods

This prospective observational study was conducted from March 2021 to June 2023 and included 134 patients diagnosed with GSD and fatty liver based on preoperative ultrasound. Core liver biopsies were obtained during cholecystectomy. Preoperatively, clinical, anthropometric, demographic, biochemical variables, and FibroScan parameters were recorded.

Results

NASH was found in 21 (15.67%) patients, while 50 (37.31%) patients had probable NASH, and 63 (47.01%) had non-NASH scores. Metabolic syndrome was present in 63.6% of the patients. Univariate analysis revealed significant differences in AST and ALT values between the NASH and nonNASH groups. In multivariate analysis, AST was statistically significant (p= 0.041). Mean controlled attenuation parameter in patients with non-NASH was 219.40 ± 60.44 dB/m, and in patients with NASH, it was 265.48 ± 63.47 dB/m (p= 0.006). Fibrosis was present in 33 of the 82 slides examined, with 17 patients having grade 2 and two patients with grade 3 fibrosis.

Conclusion

The high prevalence of NASH among GSD patients highlights a significant public health issue, prompting consideration for liver biopsy in individuals with NAFLD and GSD undergoing laparoscopic cholecystectomy.

Evidence-based approach for intraabdominal drainage in pancreatic surgery: A systematic review and meta-analysis

BACKGROUND

Historically intraoperative drains were employed after pancreatic surgery but over the last decade, there has been debate over the routine usage of drains.

AIM

To assess the necessity of intra-abdominal drain placement, identify the most effective drain type, and determine the optimal timing for drain removal.

METHODS

A systematic review of electronic databases, including PubMed, MEDLINE, PubMed Central, and Google Scholar, was conducted using Medical Subject Headings and keywords until December 2023. From an initial pool of 1910 articles, 48 were included after exclusion and screening. The primary outcomes analyzed were clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), overall morbidity, and mortality. Subgroup analyses were performed for pancreaticoduodenectomy and distal pancreatectomy.

RESULTS

Routine use of drains is associated with a statistically significant increase in the risk of CR-POPF and DGE. Conversely, patients who did not have drains placed experienced a significant reduction in morbidity, readmission rates, and reoperations. No significant differences were observed between active and passive drain types. Early drain removal (< 3 days) yielded favorable outcomes compared to delayed removal.

CONCLUSION

Analysis of randomized controlled trials and cohort studies did not demonstrate an advantage of routine drain placement following pancreatic resection, potentially contributing to increased morbidity and mortality. The decision to use drains should be left to the discretion of the operating surgeon. However, early drain removal can substantially reduce morbidity.