Hepatopancreaticobiliary Surgery Research Articles

Upper gastrointestinal and hepatopancreaticobiliary surgery in New Zealand: Balancing the volume-outcome relationship with accessibility in a surgically low volume country.

New Zealand has a population of only 5.5 million meaning that for many surgical procedures the country qualifies as a "low-volume center." However, the health system is well developed and required to provide complex surgical procedures that benchmark internationally against comparable countries. This investigation was undertaken to review regional variation and volumes of complex resection and palliative upper gastrointestinal (UGI) surgical procedures within New Zealand. Data pertaining to patients undergoing complex resectional UGI procedures (esophagectomy, gastrectomy, pancreatectomy, and hepatectomies) and palliative UGI procedures (esophageal stenting, enteroenterostomy, biliary enteric anastomosis, and liver ablation) in a New Zealand hospital between January 1, 2000 and December 31, 2019 were obtained from the National Minimum Dataset. New Zealand is a low-volume center for UGI surgery (229 hepatectomies, 250 gastrectomies, 126 pancreatectomies, and 74 esophagectomies annually). Over 80% of patients undergoing hepatic resection/ablation, gastrectomy, esophagectomy, and pancreatectomy are treated in one of the six national cancer centers (Auckland, Waikato, Mid-Central, Capital Coast, Canterbury, or Southern). There is evidence of the decreasing frequency of these procedures in small centers with increasing frequency in large centers suggesting that some regionalization is occurring. Palliative procedures were more widely performed. Indigenous Māori were less likely to be treated in a nationally designated cancer center than non-Māori. The challenge for New Zealand and similarly sized countries is to develop and implement a system that optimizes the skills and pathways that come from a frequent performance of complex surgery while maintaining system resilience and ensuring equitable access for all patients.

Ultrasound guided erector spinae plane block versus intrathecal morphine for analgesia following major hepatopancreaticobiliary surgery

ABSTRACT Background Intrathecal morphine (ITM) has been evidenced to provide efficient analgesia for hepatopancreaticobiliary surgery (HPB) in the postoperative period. Despite its benefits, ITM carries certain risks, such as pruritus, postoperative nausea and vomiting, and of utmost importance, the possibility of delayed respiratory depression. We conducted this study to compare the effectiveness of bilateral erector spinae plane block (ESPB) and ITM for analgesia following major HPB surgery. Our hypothesis was that bilateral ESPB would lead to a significant reduction in opioid consumption within the first 24 hours following surgery, with a lower incidence of side effects. Methods Forty patients with scheduled major HPB surgery were randomly allocated to receive either bilateral ESPB (n = 20) or ITM (n = 20) before general anesthesia induction. The primary outcome was cumulative postoperative nalbuphine consumption in the first 24 hours. Results Cumulative nalbuphine consumption at 24 hours after surgery was significantly lower in the ITM group compared to ESPB (3.05 ± 0.38 versus 6.56 ± 0.88 respectively). However, the ESPB group demonstrated effective pain control as indicated by pain scores of ≤2 at rest and ≤3 when coughing throughout all measured time points. Moreover, ESPB significantly reduced the incidence of postoperative nausea, vomiting (p = 0.03), and pruritus (p = 0.003) within the first 24 hours postoperatively compared to ITM. Conclusions Although bilateral ESPB resulted in higher opioid consumption than ITM in the first 24 hours after major HPB surgery, the adverse effects were less with minimal or no risk of hemodynamic instability.

Duct-to-mucosa versus invagination pancreaticogastrostomy reconstruction after pancreaticodudenectomy: a comparative study

Background Pancreaticoduodenectomy (PD) is the most used standard operation for both benign and malignant diseases in the pancreatic head. Panc. Fistula following pancreaticoduodenectomy is relatively common and remains a major cause of mortality and morbidity. Aim To evaluate the early outcome of the main two techniques of pancreatic duct anastomosis with the stomach (duct-to mucosa vs. invagination) in patients who undergo pancreaticodudenectomy. Patients and methods This is a prospective randomized study was conducted on 50 patients with elective PD with two schedule techniques of pancreatic anastomoses with the stomach divided in two groups: group A (duct-to mucosa technique) and group B (invagination technique) performed in the department of the Hepato-pancreaticobiliary surgery, National Liver Institute, Menoufia University form October 2019 to October 2021. Results This study showed that, postoperative pancreatic fistula (POPF) developed in 1 (4%) case in group A and 5 (20%) cases in group B. regarding Delayed Gastric Empting (DGE), 15 (60.00%) patients had no DGE, 5 (20.00%) patients had grade A, 4 (16.00%) had grade B,1 (4.00%) had grade C among group A while, among group B, 20 (80.00%) patients had no DGE, 5 (20.00%) patients had grade A, with no significant difference (P = 0.126). Also, there was no statistically significant difference between the two groups regarding diagnostic tools, preoperative drainage as well tumor size, type of tumor regarding histopathological examination as the majority of examined specimens were adenocarcinoma. Conclusion Our study concluded that were Duct-to-mucosa pancreaticogastrostry is safer anastomosis. Following pancreatico duodenectomy other than invagination technique.

A core set of quality performance indicators for HPB procedures: a global consensus for hepatectomy, pancreatectomy, and complex biliary surgery

BackgroundSurgery for hepatopancreaticobiliary (HPB) conditions is performed worldwide. This investigation aimed to develop a set of globally accepted procedural quality performance indicators (QPI) for HPB surgical procedures. MethodsA systematic literature review generated a dataset of published QPI for hepatectomy, pancreatectomy, complex biliary surgery and cholecystectomy. Using a modified Delphi process, three rounds were conducted with working groups composed of self-nominating members of the International Hepatopancreaticobiliary Association (IHPBA). The final set of QPI was circulated to the full membership of the IHPBA for review. ResultsSeven “core” indicators were agreed for hepatectomy, pancreatectomy, and complex biliary surgery (availability of specific services on site, a specialised surgical team with at least two certified HPB surgeons, a satisfactory institutional case volume, synoptic pathology reporting, undertaking of unplanned reintervention procedures within 90 days, the incidence of post-procedure bile leak and Clavien-Dindo grade ≥III complications and 90-day post-procedural mortality). Three further procedure specific QPI were proposed for pancreatectomy, six for hepatectomy and complex biliary surgery. Nine procedure-specific QPIs were proposed for cholecystectomy. The final set of proposed indicators were reviewed and approved by 102 IHPBA members from 34 countries. ConclusionsThis work presents a core set of internationally agreed QPI for HPB surgery.

Contemporary practice and perception of autologous blood salvage in hepato-pancreatico-biliary operations: an international survey

BackgroundThis study aimed to assess contemporary knowledge, attitudes and behaviors around transfusion of intraoperative salvaged blood (sRBCt) during hepato-pancreatico-biliary (HPB) operations. Findings are meant to inform the design of future studies that address provider concerns to change behaviors and improve patient outcomes. MethodsA survey was designed and assessed for relevance, readability and content, and distributed to an international audience of surgeons performing HPB operations. ResultsThe 237 respondents were predominantly distributed across North America (37.55%), Europe (27.43%) and Asia (19.83%). Roughly one-half (52.74%) of respondents had used sRBCt in HPB surgery before. Transplantation surgeons were more likely than HPB surgeons to have previously used sRBCt [odds ratio = 5.18 (95% CI 1.89–14.20)]. More respondents believed sRBCt was safe for non-cancer versus cancer operations (68.57% vs. 24.17%, p < 0.0001). Less than half (45.71%) of respondents believed that sRBCt was safe in clean-contaminated fields. Most did not utilize preoperative strategies to avoid donor transfusion. ConclusionPractices related to sRBCt in HPB operations vary widely and there is no consensus on its use. Concerns seem primarily related to cancer-specific and infectious outcomes. While further studies are pursued, surgeons may increase their utilization of preoperative strategies to boost hemoglobin levels for at risk patients.

Dr. Leslie H. Blumgart - A 'Living Legend' and 'The Professor'.

Dr Leslie Blumgart, a name that requires no introduction, was a pioneer and one of the most influential figures in hepatobiliary and pancreatic surgery. His methods and innovations have revolutionized the way these pathologies are being approached. He was one of the pioneering surgeons in the world who sought to make hepatopancreaticobiliary surgery a recognized specialty. His work took this field from a place with frequent and drastic complications to a safer and more effective zone. He was born to Harold Herman Blumgart and Hilda Blumgart on December 7, 1931, in South Africa. He did his schooling at Jepp High School in Johanessburg and was initially trained as a dentist at Witwatersrand University in Johanessburg in 1954, where he completed his graduation. He later moved to England, where he received his medical degree and surgical training at the University of Sheffield and graduated with an MBChB and MD. He accepted his first academic position as Lecturer and Deputy Director, Department of Surgery, Welsh National School of Medicine, Cardiff, from 1970 to 1972. He subsequently moved to the Glasgow Royal Infirmary as the St. Mungo Professor of Surgery from 1972 to 1979. He then served as Professor Director and Honorary Consultant Surgeon for the Department of Surgery at the Royal Postgraduate Medical School, University of London and Honorary Consultant, Hammersmith Hospital, London, 1979–1986. He was later recruited as Professor and Director of the Department of Visceral and Transplantation Surgery, University of Bern in Switzerland from 1986 to1991. In 1991, he accepted the position of Chief of the Hepatopancreaticobiliary Service in the Department of Surgery at Memorial Sloan Kettering Cancer Centre, New York, and was the holder of the Enid Haupt Chair. He was promoted to director of the program on hepatobiliary diseases in 1995. Dr Blumgart has authored over 600 peer-reviewed papers, edited 15 books, and written over 150 book chapters1. He has authored a number of books, including Blumgart’s Surgery of the Liver, Biliary Tract, and Pancreas2, currently in its 7th edition, and the Video Atlas: Liver, Biliary & Pancreatic Surgery. He has served on the editorial boards of 14 major journals in surgery, gastroenterology, and oncology. He has lectured widely as a visiting professor in the United States and abroad, delivering over 200 lectures and orations.He was a founding member of the International Biliary Association (now the International Hepato-Pancreatico-Biliary Association) and later rose to become its president. In more recent years, he was honored by the International Hepato-Pancreatico-Biliary Association as a ‘living legend.’ He was also a member of the Society for Surgery of the Alimentary Tract, the United States of America, the Hong Kong Surgical Society, the Hellenic Surgical Society, the Los Angeles Surgical Society, and the Yugoslav Society of Surgery. Following his significant contributions to surgical oncology, and in particular to Hepatopancreaticobiliary surgery, Dr Blumgart was awarded the Lifetime Achievement Award during the opening session of 34th Congress of the European Society of Surgical Oncology in partnership with British Association of Surgical Oncologists, 2014. Some of the many laurels he received during his career are honorary fellowships from multiple surgical colleges around the world, including the Royal Colleges of Surgeons in Edinburgh (Glasgow), the French Surgical Association, the Austrian Society of Surgery and the Italian Society of Surgery. He was also awarded the Acral Medal of the Swedish Society of Surgery. ‘The Professor,’ as he was called by his trainees, was a dominant figure in the evolution of hepatopancreaticobiliary surgery around the world for almost 50 years. He had built a great hepatopancreaticobiliary surgery academic and clinical program at Memorial Sloan Kettering Cancer Centre since 1991 and had trained a generation of surgical oncologists and hepatopancreaticobiliary surgeons who now carry forward his legacy. Dr Blumgart also generated a video library of complex hepatopancreaticobiliary procedures which he used in simplifying the training of many surgeons for many years. Watercolor painting and wood carving were his lesser-well known talents, which he pursued after he retired from clinical practice. Dr Blumgart recently passed away on September 27, 2022, and is survived by his wife Sarah Blumgart, and his children and grandchildren. Ethical approval None. Sources of funding None. Authors’ contribution H.A.: resources, writing – original draft, visualization. N.G.: conceptualization, validation, supervision. Conflict of interest disclosure The author declare that they have no conflict of interest. Research registration unique identifying number (UIN) None. Guarantor Nikhil Gupta and Himanshu Agrawal.

Safety of post discharge extended VTE prophylaxis after hepatopancreatobiliary surgery

Background: Patients undergoing hepatopancreaticobiliary (HPB) operations for malignancy are at high risk for venous thromboembolism (VTE) following surgery. Due to potential risk of bleeding, differing recommendations have been proposed for the use of extended VTE prophylaxis after hospital discharge in this patient population. This study aims to examine the safety of routine post-discharge extended VTE prophylaxis in patients at high risk for VTE events following HPB surgery.

HPB P18 The introduction of antimicrobial-coated sutures to reduce the rate of surgical site infections in the hepatopancreaticobiliary (HPB) department: a quality improvement project

Abstract Background Surgical site infections (SSIs) are the most common postoperative complication in developed countries. In the United Kingdom (UK), the most recent data from Public Health England showed that ten-year trends in SSI risk varied by surgical group, with the highest risk observed in hepatopancreaticobiliary (HPB) surgery. Several methods for SSI prevention have been researched and implemented in surgical practice such as appropriate antibiotic prophylaxis, hair removal and careful sterilisation of equipment. Due to their chemical composition, sutures utilised in abdominal surgery can promote bacterial colonisation. Antimicrobial-coated sutures have been manufactured to investigate if the addition of a synthetic, non-ionizing, broad-spectrum antimicrobial can prevents colonisation, reduce the rate of bacterial adherence and therefore decrease the rate of SSIs. In 2021, NICE released a statement advising the use of antimicrobial-coated sutures as part of a bundle of care in wound closure to prevent site infection after surgical procedures. Little research is available on the use of antimicrobial-coated sutures for anastomosis closure. We carried out a quality improvement project, assessing the rate of SSI with standard sutures, followed by the use of antimicrobial-coated sutures to investigate reduction on SSI rates for both anastomosis and skin closure. Methods A quality improvement project, following the PDSA cycle, was carried out investigating rates of SSIs on all HPB patients undergoing an open procedure at Churchill Hospital, Oxford between November 2020 and June 2021. Data on SSI rates was collected electronically based on ward round entries, radiology and microbiology results. SSI were classified as ‘superficial’, ‘deep’ and ‘organ’ site infections based on the UK Health Security Agency (UKHSA) classification criteria. Antimicrobial-coated sutures were introduced in June 2021 and data was collected until November 2021. Chi-squared tests (X2) were carried to compare SSI results between the two groups. Secondary analysis was carried out examining culture results for organ SSIs. Results 167 patients had open operations between November 2020 and November 2021. 88 patients had standard sutures, 28/88 (32%) developed SSIs, of which 20/28 (71%) were organ SSIs. 79 patients had antimicrobial-coated sutures. 17/79 (22%) developed SSIs, of which 12/17 (72%) were organ SSIs. There was an overall 10% reduction in SSI rates [X2 (1, N= 212) = 0.04, p-value &amp;gt; 0.05)]. Crucially, there was a reduction in positive cultures with antimicrobial-coated sutures, where 42% of samples sent for microbiology analysis, compared to 25% in standard sutures, were negative cultures [X2 (1, N= 34) = 1.29, p-value &amp;gt; 0.05)]. Conclusions There is reduction in superficial and organ SSIs when antimicrobial-coated sutures are utilised. Crucially, there is a marked reduction in positive cultures when these are used for anastomosis closure. As hepatopancreaticobiliary surgery has a high leak rate of 10–30% after resection, a proportion of patients will develop abdominal collections due to leaks and not due to infection. Further multi-centre studies with larger sample sizes need to be carried out within the HPB population to further investigate reduction in SSI caused by antimicrobial-coated sutures and the impact it has on microbiology cultures. Almost half of culture samples sent for microbiology analysis from radiologically confirmed organ SSIs grew negative cultures. Further research is needed to determine if the definition of what is considered an organ SSI in the HPB population needs changing and if the UKHSA criteria needs re-classification in this surgical group in light of both the percentage of negative cultures reported and the standard leak rate in these operations.

Professor Leslie H. Blumgart-Pioneering Hepatopancreaticobiliary Surgeon: a Tribute.

Leslie Harold Blumgart was the surgeon behind making Hepatopancreaticobiliary surgery a speciality and his recent demise will always leave a void in that field. He was the person who classified anatomical variations in the biliary tract and devised a special anastomotic technique to decrease the rate of postoperative pancreatic duct fistula after Whipple’s pancreaticoduodenectomy. His contribution in managing hepatobiliary oncology cases with chemotherapy and radiotherapy was also significant. No wonder, he was designated as the “living legend” by the International Hepatopancreaticobiliary Association.

AHPBA senior leaders’ assessments of strengths, weaknesses, opportunities, and threats facing fellowship training in HPB surgery: “We need to standardize our training experiences”

BackgroundMultiple fellowship programs in North America prepare surgeons for a career in Hepato-Pancreatico-Biliary (HPB) surgery. Inconsistent operative experiences and disease process exposures across programs and pathways produces variability in training product and therefore, lack of clarity around what trained HPB surgeons are prepared to do in early practice. Thus, a strengths, weaknesses, opportunities, and threats (SWOT) analysis of AHPBA fellowship training was conducted. MethodsThis was a mixed-methods, cross-sectional study. Eleven AHPBA-Founding Members (FM) and 24 current or former Program Directors (PD) of programs eligible for AHPBA certificates were surveyed and interviewed. Grounded theory principles and thematic network analysis were used to analyze interview transcripts. Descriptive statistics were used to analyze survey data. ResultsThree main themes were identified: (i) Concern for training rigor and consistency (ii) Desire to standardize curricula and broaden training requirements and, (iii) Need to validate both the value of training and job marketability via certification. DiscussionBased on the themes identified, the strengths of AHPBA-certified HPB programs include superior technical training and case volumes. Areas of improvement included elevating baseline competencies by increasing required case volume and breadth to ensure minimally invasive experience, operative autonomy, and multidisciplinary care coordination.

Pancreaticoduodenectomy with right hemicolectomy for advanced malignancy: a single UK hepatopancreaticobiliary centre experience.

Locally advanced intestinal neoplasms including colon cancer may require radical en bloc pancreaticoduodenectomy and right hemicolectomy (PD-RC) to achieve curative, margin-negative resection, but the safety and benefit of this uncommon procedure has not been established. The Association of Coloproctology of Great Britain and Ireland IMPACT initiative has also highlighted a lack of awareness about current services available within the UK for patients with advanced colorectal cancer and concerns about low-volume centres managing complex cases. Thus, we aimed to review the feasibility, safety and long-term outcomes of this procedure at a single high-volume hepatopancreaticobiliary surgery unit in the UK. A retrospective cohort study was performed using a database of all consecutive patients with intestinal cancer who had been referred to our regional advanced multidisciplinary team and undergone PD-RC in a 7-year period (2013-2020). Clinico-pathological and outcome data were reviewed. Ten patients (mean age 54 ± 13,8/10 men) were identified. Final histology revealed the primary tumour sites were colon (n=7) and duodenum (n=3). R0 resection was achieved in all cases. The major complication rate (Clavien-Dindo ≥ 3) was 10% (1/10) with no deaths within 90 days of surgery. The Kaplan-Meier estimated 5-year overall survival was 83.3% (95% CI 58.3%-100%). Univariate survival analysis identified perineural invasion and extra-colonic origin as predictors of poor survival (log-rank P < 0.05). En bloc PD-RC for locally advanced intestinal cancer can be performed safely with a high proportion of margin-negative resections and resultant long-term survival in carefully selected patients.

Treatment of unresectable locally advanced pancreatic cancer with percutaneous irreversible electroporation (IRE) following initial systemic chemotherapy (LAP-PIE) trial: study protocol for a feasibility randomised controlled trial

BackgroundApproximately 30% of patients with pancreas cancer have unresectable locally advanced disease, which is currently treated with systemic chemotherapy. A new treatment option of irreversible electroporation (IRE) has been investigated...

Evaluation of treatment delays in hepatopancreatico-biliary surgery during the first COVID-19 wave.

The COVID-19 pandemic has caused oncological services worldwide to face unprecedented challenges resulting in treatment disruption for surgical patients. Hepatopancreatico-biliary (HPB) cancers are characterised by rapid disease progression. This study aims to assess delays in receiving surgery for this patient cohort during the first COVID-19 wave. Patients undergoing surgery between April and July 2020 (COVID-19 period) were compared with a control group from the preceding year. Delay in receiving surgery was defined as more than 50 days between referral and surgery date. Statistical analysis was carried out to evaluate predictors of delay and short-term outcomes. During the COVID-19 and pre-COVID-19 periods, 94 and 115 patients underwent surgery, respectively. No patients contracted COVID-19 postoperatively. Some 118 patients waited more than 50 days for surgery versus 91 who received surgery within 50 days from referral. Independent predictors for surgical delay were undergoing surgery in the COVID-19 era (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1; p=0.015), referral pathway (OR 35.1, 95% CI 4.2-296; p=0.001) and presenting pathology (OR 8.3, 95% CI 1.2-56.1; p=0.03). Short-term outcomes were comparable between groups. Patient referral pathway and presenting pathology may contribute to delays in undergoing HPB cancer surgery during COVID-19 outbreaks. It is hoped that a better understanding of these factors will aid in designing shifts in healthcare policy during future pandemic outbreaks.

A large series of true pancreaticoduodenal artery aneurysms

IntroductionTrue pancreaticoduodenal artery aneurysms (PDAAs) are rare, and prior reports often fail to distinguish true aneurysms from pseudoaneuryms. We sought to characterize all patients who presented to our health system from 2004 to 2019 with true PDAAs, with a focus on risk factors, interventions, and patient outcomes. MethodsPatients were identified by querying a single health system picture archiving and communication system database for radiographic reports noting a PDAA. A retrospective chart review was performed on all identified patients. Patients with pseudoaneurysm, identified as those with a history of pancreatitis, abdominal malignancy, hepatopancreaticobiliary surgery, or abdominal trauma, were excluded. Continuous variables were compared using t-tests, and categorical variables were compared using Fisher's exact tests. ResultsA total of 59 true PDAAs were identified. Forty aneurysms (68%) were intact (iPDAAs) and 19 (32%) were ruptured (rPDAAs) at presentation. The mean size of rPDAAs was 16.4 mm (median size, 14.0 mm; range, 10-42 mm), and the mean size of iPDAAs was 19.4 mm (median size, 17.5 mm; range, 8-88 mm); this difference was not statistically significant (P = .95). Significant celiac disease (occlusion or >70% stenosis) was noted in 39 aneurysms (66%). Those with rupture were less likely to have significant celiac disease (42% vs 78%; P = .017) and less likely to have aneurysmal wall calcifications (6% vs 53%; P = .002). Thirty-seven patients underwent intervention (63%), with eight (22%) undergoing concomitant hepatic revascularization (two stents and six bypasses) due to the presence of celiac disease. Eighteen patients with occluded celiac arteries underwent aneurysm intervention; of those, 11 were performed without hepatic revascularization (61.1%). Those with rPDAAs experienced an aneurysm-related mortality of 10.5%, whereas those with iPDAAs experienced a rate of 5.6%. One patient with celiac occlusion and PDA rupture who did not undergo hepatic artery bypass expired postoperatively from hepatic ischemia. rPDAAs showed a trend toward the increased need for aneurysm-related endovascular or open reintervention, but this was not statistically significant (47% vs 28%; P = .13). ConclusionsThese findings support previous reports that the rupture risk of PDAAs is independent of size, their development is often associated with significant celiac stenosis or occlusion, and rupture risk appears decreased in patients with concomitant celiac disease or aneurysm wall calcifications. Endovascular intervention is the preferred initial treatment for both iPDAAs and rPDAAs, but reintervention rates are high in both groups. The role for hepatic revascularization remains uncertain, but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo PDAA interventions.

Artificial intelligence in hepatopancreaticobiliary surgery - promises and perils

Research and development in artificial intelligence (AI) has been experiencing a resurgence over the past decade. The rapid growth and evolution of AI approaches can leave one feeling overwhelmed and confused about how these technologies will impact hepatopancreaticobiliary (HPB) surgery, the obstacles to its clinical translation, and the role that HPB surgeons can play in accelerating AI’s development and ultimate clinical impact. This review outlines some of the basic terminology and current approaches in surgical AI, obstacles to further development and translation of AI, and how HPB surgeons can influence its future in surgery.

Bile Leak Detection after HPB Surgery Using Eovist Enhanced MRI Protocols: Is There Still a Diagnostic Role for HIDA Scans?

Introduction: Post-surgical bile leaks (PBL) are a dreaded complication following hepatopancreaticobiliary (HPB) surgery, associated with systemic inflammation and consequential morbidity. Traditionally, HIDA (hepatobiliary iminodiacetic-acid) imaging was the preferred modality. This study aims to compare HIDA imaging with eovist-enhanced MRI (magnetic resonance-imaging) for PBL detection and localisation following HPB surgery.

Artificial intelligence in hepatFIGopancreaticobiliary surgery: a systematic review

Aim: The aim of this systematic review was to provide an overview of Machine Learning applications within hepatopancreaticobiliary surgery. The secondary aim was to evaluate the predictive performances of applied Machine Learning models. Methods: A systematic search was conducted in PubMed, EMBASE, Cochrane, and Web of Science. Studies were only eligible for inclusion when they described Machine Learning in hepatopancreaticobiliary surgery. The Cochrane and PROBAST risk of bias tools were used to evaluate the quality of studies and included Machine Learning models. Results: Out of 1821 articles, 52 studies have met the inclusion criteria. The majority of Machine Learning models were developed to predict the course of disease, and postoperative complications. The course of disease has been predicted with accuracies up to 99%, and postoperative complications with accuracies up to 89%. Most studies had a retrospective study design, in which external validation was absent for Machine Learning models. Conclusion: Machine learning models have shown promising accuracies in the prediction of short-term and long-term surgical outcomes after hepatopancreaticobiliary surgery. External validation of Machine Learning models is required to facilitate the clinical introduction of Machine Learning.

The Local Arterial Anatomy and its Implications on the Performance of Pancreaticoduodenectomy

Introduction: During hepato-pancreaticobiliary surgery, the variations in the local arterial anatomy encountered have important operative implications. Meticulous preoperative evaluation using various imaging techniques can aid the surgeon and prevent major catastrophes. We examined which variations affected the operative procedure.

Impact of surgical drain output monitoring on patient outcomes in hepatopancreaticobiliary surgery: A systematic review.

Surgical drains are widely utilized in hepatopancreaticobiliary surgery to prevent intra-abdominal collections and identify postoperative complications. Surgical drain monitoring ranges from simple-output measurements to specific analysis for constituents such as amylase. This systematic review aimed to determine whether surgical drain monitoring can detect postoperative complications and impact on patient outcomes. A systematic review was performed, and the following databases searched between 02/03/20 and 26/04/20: MEDLINE, EMBASE, The Cochrane Library, and Clinicaltrials.gov. All studies describing surgical drain monitoring of output and content in adult patients undergoing hepatopancreaticobiliary surgery were considered. Other invasive methods of intra-abdominal sampling were excluded. The search returned 403 articles. Following abstract review, 390 were excluded and 13 articles were included for full review. The studies were classified according to speciality and featured 11 pancreatic surgery and 2 hepatobiliary surgery studies with a total sample of 3262 patients. Postoperative monitoring of drain amylase detected pancreatic fistula formation and drain bilirubin testing facilitated bile leak detection. Both methods enabled early drain removal. Improved patient outcomes were observed through decreased incidence of postoperative complications (pancreatic fistulas, intra-abdominal infections, and surgical-site infections), length of stay, and mortality rate. Isolated monitoring of drain output did not confer any clinical benefits. Surgical drain monitoring has advantages in the postoperative care for selected patients undergoing hepatopancreaticobiliary surgery. Enhanced surgical drain monitoring involving the testing of drain amylase and bilirubin improves the detection of complications in the immediate postoperative period.

Duodenal perforation secondary to stent migration after ERCP for hepatobiliary tuberculosis: Case report of a lethal complication in a young patient.

IntroductionInterventional internal drainage of the biliary tract has become an established procedure for the temporary and definitive treatment of biliary obstruction due to malignant or benign disease. The complication rate is reported to be so low that when feasible, this technique is preferred over a surgical drainage procedure.Presentation of a caseA 26-year old woman was referred to the hepatopancreaticobiliary surgery service due to severe abdominal pain for 3 days after undergoing endoscopic retrograde cholangiopancreatography (ERCP). She underwent biliary dilatation and stent insertion for obstructive jaundice secondary to biliary stricture from hepatobiliary tuberculosis. The patient underwent exploratory laparotomy, peritoneal lavage, duodenorrhaphy and tube jejunostomy for bilious peritonitis and duodenal perforation from biliary stent migration. The patient died one day post-operation due to septic shock from secondary bacterial peritonitis.DiscussionERCP and other interventional endoscopic biliary interventions are increasingly being used for biliary obstruction. Despite the various complications which arise from these diagnostic and therapeutic modalities, complications are relatively uncommon. Duodenal perforation from biliary stent migration is a rare complication after undergoing ERCP and stenting. However, in patients presenting with severe pain and physical signs of acute abdomen after the procedure, it should always be a consideration.ConclusionsDespite the relative safety of interventional techniques for biliary obstruction, complications like pancreatitis, hemorrhage and perforation may occur. Early recognition and high index of suspicion allows for early intervention with good outcomes. Duodenal perforation from stent migration can occur and when intervention is delayed may lead to morbidity and mortality.