HPB Surgeons Research Articles

Meta-analysis of routine abdominal drainage versus no drainage following distal pancreatectomy: Does the best available evidence overcome "HPB surgeon's paranoia"?

To evaluate comparative outcomes of routine abdominal drainage versus no drainage after distal pancreatectomy (DP). A systematic search of MEDLINE, CENTRAL and Web of Science and bibliographic reference lists were conducted (last search: 20th April 2024). All comparative studies reporting outcomes of DP with routine abdominal drainage and no drainage were included and their risk of bias were assessed. Overall perioperative complications, clinically-relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), postoperative haemorrhage, surgical site infections (SSIs), need for radiological intervention, reoperation, re-admission, and postoperative mortality were the evaluated outcome parameters. Eight comparative studies (2 randomised and 6 observational) reporting 8164 patients who underwent DP with (n=6394) or without (n=1770) routine abdominal drainage were included. Routine abdominal drainage was associated with significantly higher rates of CR-POPF (OR 2.87; 95% CI 2.34-3.52, p<0.00001), radiological intervention (OR 1.33; 95% CI 1.10-1.61, p=0.0003), SSIs (OR 2.47; 95% CI 1.29-4.72, p=0.006) or re-admission (OR 1.54; 95% CI 1.30-1.82, P<0.00001) compared to no use of drain. However, there was no significant difference in C-D III or higher postoperative morbidities (OR 1.25; 95% CI 0.98-1.60, p=0.08), DGE (OR 1.17; 95% CI 0.81-1.67, p=0.41), reoperation (OR 1.11; 95% CI 0.80-1.54, P=0.53), postoperative haemorrhage (OR 0.59; 95% CI 0.18-2.00, P=0.40), or mortality (RD 0.0; 95% CI -0.01-0.01, p=0.76) between two groups. The meta-analysis of best available evidence indicates safety of "no drain policy" in distal pancreatectomy considering its lower risk of CR-POPF, re-intervention and hospital re-admission. More randomised evidence is required to overcome the "HPB surgeon's paranoia".

Advancing excellence: a national peer-coaching program for advanced laparoscopic HPB techniques

BackgroundSurgical coaching is valuable for disseminating knowledge, refining skills, and fostering continuous professional development for surgeons in practice. This work aims to implement a national coaching program for Canadian HPB surgeons, emphasizing advanced laparoscopic techniques, and to assess subsequent adoption. Secondary objectives include evaluating surgeon perceptions, barriers, and experiences. MethodsMid-to-late career HPB surgeons across Canada joined a peer surgical coaching program for advanced laparoscopic skills. The program included didactic sessions followed by practical coaching with case observation, simulation labs, and real-time coaching in the operating room. One lead surgeon from each center was invited to participate in the exit interview. ResultsEight centers across four provinces completed the program, and one lead surgeon from each site was interviewed. Surgeons reported a 34.9 % increase in self-perceived comfort levels in laparoscopic HPB surgeries, with a 24.2 % and 56.7 % increase in laparoscopic liver and pancreas resections, respectively. Participants acknowledged challenges in implementing surgical coaching, citing barriers related to surgeon and societal factors. Overcoming these challenges required mutual respect, openness to learning, and building sustained change through team collaboration and long-term coach relationships. DiscussionThis work demonstrated the practicality of a nationwide coaching program and its capacity to effect substantial, long-term change in clinical practice.

Ultrasound principles and instrumentation

Ultrasound (US) is a fundamental and inexpensive tool both for the prompt diagnosis and for the study of diverse medical conditions. Its widespread use is partly due to the availability of US devices in the daily practice of physicians. US can be performed in real-time and is instrumental in the generation of clinical algorithms for the management of situations like trauma. It also constitutes a primary approach for the study of oncological diseases, and a guidance tool for interventions such as percutaneous drainages. In addition, and specifically for HPB surgeons, US is an essential tool in the operating room: intraoperative (either open or laparoscopic) US is necessary for the accurate determination of the stage, location, number, and margins of tumors within the liver, pancreas, or biliary tree. On another note, reading and understanding US images are skills that require time and training, which should be taught during surgical residencies. However, this is not customary in most residencies globally. This chapter offers a concise yet comprehensive elucidation of the basic principles of ultrasonography, the instruments required to perform an ultrasonic assessment of a patient, and the basic ultrasound controls.

Surgery for oligometastatic pancreatic cancer to the liver: an international survey of HPB surgeons

Surgery for oligometastatic pancreatic cancer to the liver: an international survey of HPB surgeons

What would you do? a survey of HPB surgeons practice patterns

What would you do? a survey of HPB surgeons practice patterns

What would you do? a survey of HPB surgeons practice patterns

What would you do? a survey of HPB surgeons practice patterns

What would you do? A survey of HPB surgeons practice patterns

BackgroundThe surgical decision making for pancreatic adenocarcinoma is complex. Although practice guidelines exist for many scenarios, these do not cover many common eventualities that may be encountered during these cases. We sought to identify the practice pattern variations amongst pancreatic surgeons in response to commonly experienced clinical scenarios. MethodsA multiple-choice questionnaire was distributed to all full members of the IHPBA. Participant demographics, training history, and clinical practice information were obtained. The survey provided various operative scenarios and participants were asked how they would likely proceed. Responses were collected and stored anonymously in a secure database. Statistical analysis was performed using Stata 16.0. Results164 responses were submitted. Most of the respondents were male and had been in practice for over 10 years. The median age range was 40–50 years old. When asked about staging laparoscopy, the majority performed it selectively.For most respondents a pathological aorto-caval nodes was a reason to abort the procedure but most would have continued in the setting of a positive hepatic artery node.When encountering a single Segment 2 liver metastasis, participants who practiced in Europe were significantly more likely to resect and proceed compared to those in Asia and North America. Participants who had undergone only a Surgical Oncology fellowship were most likely to abort.With respect to direct colonic invasion, most participants would resect the specimen en bloc. Respondents who participated in fewer that 20 PDAC operations/year were most likely to abort. ConclusionsSurgical decision making in PDAC surgery is complex and there is significant disagreement on the correct management. While formal guidelines cannot exist for all situations, this survey highlights the need for consensus on commonly encountered operative scenarios.

EGS P07 Upper GI Injury trends, rates, and mortality in major trauma centre

Abstract Background Trauma is one of the leading causes of death in UK. Moderate and severe trauma presents with multi-organ / multi cavity involvement. Robust resuscitation, methodical approach, prompt diagnosis and early surgical intervention have an impact on mortality. Injury severity score (ISS) is widely used across trauma centres to estimate severity. It is found to be linked with mortality and outcome. An ISS of 9-15 classes as moderate and an ISS of &amp;gt; 15 is considered severe trauma. In this study we aimed to evaluate the mortality associated with upper GI injuries I.e., oesophagus, stomach, duodenum, liver, pancreas, spleen and diaphragm. Methods Retrospective analysis was carried out on prospectively maintained trauma data base in an urban major trauma centre (MTC) with tertiary upper GI surgical cover. All patients presenting with moderate or severe trauma based on ISS between 1st of January 2012 to 31st of Dec 2022 were included in this study. Proportion of upper GI injuries in reference to overall major trauma cases were analysed. All cause index-admission mortality associated with upper GI injuries was calculated. Results A total of 8984 patients presented in this centre with moderate - severe trauma (ISS&amp;gt;9) during study period. Overall mortality was found to be 8.6% (n=780). Liver injuries were seen in 228 (2.5%), splenic injuries in 226 (2.5%), diaphragmatic rupture in 26 (0.29%), oesophago-gastric (OG) trauma in 16 (0.2%) and duodenum and pancreatic injuries in 15 (0.17%) patients. Highest mortality was found in OG trauma with 31.2%, followed by diaphragmatic injures with 19%, liver injuries with 12.7%, splenic injuries with 9.3%. Upper GI injuries are associated with high median ISS of 28.5 and present as polytrauma spectrum. Conclusions Although oesophago-gastric injuries are rare but, have relatively high mortality. Early aggressive resuscitation, involvement of oesophago-gastric or HPB surgeons, and multidisciplinary approach is required to deal with such complex injuries to get the best outcome. Robust national collaborative mechanisms across MTCs should be encouraged to share experiences, learn lessons and promote research.

HPB P52 Castleman Disease in Hepato-pancreaticobiliary Surgery: Friend or Foe?

Abstract Background Castleman disease is a rare lymphoproliferative disorder with low malignant potential. It is associated with risk of lymphoma &amp; follicular dendritic cell tumours. The disease is poorly understood and is well noted in literature, the difficulty in reaching to a diagnosis. While the systemic form of the disease is a subject of Hematological work up, the unifocal disease usually consists of radiologically detected retro-peritoneal or mesenteric masses posing diagnostic challenge to hepato-pancreatico-biliary surgeons. Methods Over a period of 12 years, from 2011 till 2023, in our institution we have identified 4 cases of Castleman disease. Median age of is 60 yo with equal incidence in both sexes. In our series, in all four cases, the diagnosis was incidental while they were being worked up for other conditions. In fact, in 1 case the diagnosis was unexpected after surgery for other reason. Extensive work up including cross-sectional imaging studies failed to reach a diagnosis, therefore, the latter was established by excision. Results All four patients underwent resection that accomplished diagnosis.Three patients underwent surgery for primary excision of the tumour located in various sites of upper abdomen; one para-duodenal, one retro-hepatic and one aorto-caval. In one case, the nodule was a FDG-PET avid mesenteric mass resected in the context of planned Whipple’s procedure for cancer. The Histopathological examination confirmed diagnosis in all cases. Haematology follow-up was recommended in two cases one of which progressed to follicular dendritic cell tumor. All patients were HIV negative and HHV-8 negative. The longest follow-up is 12 years with no evidence of recurrence. Conclusions Castleman’s disease is a rare entity with very low malignant potential. Cases with unifocal disease in upper abdomen are referred to Hepato-pancreato-biliary surgeons and resection is the treatment of choice. The latter allows histopathological analysis establishing the diagnosis. This case series is useful to all HPB surgeons who may come across this diagnostic challenge for this poorly understood pathology.

Supply and demand of hepatopancreatobiliary surgeons in the United States

BackgroundHepatopancreatobiliary (HPB) surgery requires specialized training and adequate case volumes to maintain procedural proficiency and optimal outcomes. Studies of individual HPB surgeon supply related to annual HPB case demand are sparse. This study assesses the supply and demand of the HPB surgical workforce in the United States (US). MethodsThe National Inpatient Sample (NIS) was queried from 1998–2019 to estimate the number of HPB procedures performed. To approximate the number of HPB surgeons, models based on previous HPB workforce publications were employed. We then calculated the number of HPB surgeons needed to maintain volume-outcome thresholds at current reported levels of centralization. ResultsIn 2019, approximately 37,335 patients underwent inpatient HPB procedures in the US, while an estimated 905–1191 HPB surgeons were practicing. Assuming 50% centralization and an optimal volume-outcome threshold of 24 HPB cases-per-year, only 778 HPB surgeons were needed. Without adjustment in centralization, by 2030 there will be a demand of fewer than 12 annual cases per HPB surgeon. ConclusionThe current supply of HPB surgeons may exceed demand in the United States. Without alteration in training pathways or improved care centralization, by 2030, there will be insufficient HPB case volume per surgeon to maintain published volume-outcome standards.

Laparoscopic Roux-en-Y hepaticojejunostomy as an acute treatment of a right posterior hepatic duct injury: a case report

BackgroundLaparoscopic cholecystectomy (LC) remains as the gold standard of surgical treatment for gallstone disease. Biliary duct injury (BDI) is an infrequent but serious complication of LC. Strasberg's critical view is a useful strategy to minimize the risk of a BDI. However, BDIs could still happen. Variations of the right posterior hepatic duct (RPHD) are common. The surgical treatment of RPHD injury is challenging and literature on this matter is scarce.Case summaryAberrant drainage of the right posterior hepatic duct (RPHD) into the gallbladder neck was unexpectedly identified in a 43-year-old man during laparoscopic cholecystectomy. Intraoperative consultation with a specialized Hepatobiliary surgeon was accomplished and a laparoscopic anastomosis between the RPHD and the jejunum with a Roux-en-Y reconstruction was carried out. The operation was uneventful with no long-term complication reported over a 12-month follow-up period.ConclusionAberrant implantation of the RPHD into the gallbladder neck must be borne in mind despite its low incidence. Previous studies reporting the management of this injury are scarce. In our case, a laparoscopic Roux-en-Y hepaticojejunostomy with the RPHD by an experienced HPB surgeon was a successful strategy to solve this difficult case.

Photographic documentation during safe laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the most frequent procedure for the general surgeon. Biliary injury is a concern that must be addressed with the purpose of lowering the rate. The critical view of safety (CVS) is a target of dissection that impulses safety during the procedure. Determine by an ambispective analysis the safety during dissection of laparoscopic cholecystectomy in Hospital Civil de Culiacán (México). Descriptive, ambispective, observational, cross-sectional. Patients admitted to the operating room for a laparoscopic cholecystectomy were scored with Doublet photography rating criteria from January 1st 2015 to January 31, 2017. 321 patients were evaluated, 77.9% were female and 22.1% male. The mean age was 45.57 ± 16.17 years. 65.4% had admission diagnosis of cholelithiasis, 24.3% acute cholecystitis, 5.9% chronic cholecystitis, 3.7% hydrocolecist and 0.6% pyocolecist. Surgeries were scored with Doublet photography. The CVS was obtained in 41.4% of the procedures with a statistical significance between a HPB surgeon and a general surgery resident (p ≤ 0.05). Recording Doublet photography provides a reliable CVS dissection criterion. It can be easily reproduced during laparoscopic cholecystectomy. The identification of cystic structures adds to the culture of safety during laparoscopic cholecystectomy.

Completion Pancreatectomy as a Treatment Option for Complications Following Pancreatoduodenectomy.

Pancreatoduodenectomy remains a complex abdominal operation for hpb surgeons. Significant complications keep on occurring to many patients undergoing Whipple procedure. We present ten patients, who required completion pancreatectomy in the early postoperative period after Whipples procedure, due to postoperative complications. Indications for completion pancreatectomy included: Sepsis secondary to uncontrolled GRADE C postoperative pancreatic fistula, pancreatic leak and bleeding, postoperative hemorrhage, pancreatic leak with gastrointestinal anastomosis dehiscence, and hepaticojejunal anastomosis dehiscence combined with hemorrhage. Completion pancreatectomy was carried out at a mean interval of 9 days following Whipple procedure. Six patients (60%) survived the operation and discharged from the hospital, with a median survival of 21.3 months. Four patients (40%) died in the early post-operative period due to sepsis (10%) and multiple organ failure (30%). Completion pancreatectomy after pancreatoduodenectomy is rarely indicated and it can be considered as a salvage procedure in the management of severe life-threatening post pancreatic surgery complications.

Laparoscopic surgery for MIRIZZI syndrome tipo IV

Background: The Mirizzi syndrome is a challenge for HPB surgeons. The minimally invasive resolution is possible in the reference centers with experience in biliary patology and laparoscopic surgery. We present a case resolved in our center with reconstruction with an Roux-en-Y hepaticojejunostomy anastomosis.

HPB P48 Minimally invasive HPB surgery in the UK from consultant and trainee perspectives

Abstract Background This survey took a ‘'snapshot’’ of prevailing attitudes towards minimally invasive HPB surgery from a consultant and trainee perspective. Methods Between November 2020 and January 2021, two google surveys were emailed to all HPB tertiary centres in the UK. The questionnaire contained 33 and 31 questions respectively regarding minimally invasive practice and training. Results Thirty-five HPB consultants completed the survey. The most common indications for conversion were failure to progress (91.4%), excessive blood loss (85.7%), access issues (85.7%). The majority (78.8%) of HPB surgeons undertook minimally invasive distal pancreatectomy (MIDP). One consultant undertook minimally invasive pancreaticoduodenectomy (MIPD), 48.4% declared not performing MIPDs due to uncertainty of its superiority. Eighty-five-point seven percent performed minimally invasive minor liver resection and segementectomy (MImLRS), 70.6% reported better outcomes with this approach; 28.6% of consultants performed minimally invasive major liver resection (MIMLR), 23.3% reported better outcomes with MIMLR. Half of HPB trainees did not have access to complex laparoscopic HPB procedures; 72.2% desired fellowship training. Conclusions MImLRS and MIDP are accepted approaches by most HPB consultants correlating with a perception that outcomes are better/comparable to open approaches, in contrast to MIPD and MIMLR. HPB trainees lack laparoscopic HPB exposure leading them to seek further experience with fellowships.

Hepato-pancreato-biliary surgery in Mexico and Latin America during the COVID-19 pandemic (2020): Results from AMHPB survey.

The Mexican Hepato-Pancreato-Biliary Association (AMHPB) conducted a survey, aiming to gather experience and opinions of HPB surgeons about HPB surgery in the 2020 COVID-19 pandemic year. An online survey was conducted (33 items: demographics, patient referral, COVID-19 screening and limitations, hospital occupancy and surgical practice) to AMHPB members and attendees of the previous meetings of the Society through a self-administered questionnaire. Answers were excluded if respondents were not from Latin America. 88 participants answered (47.5 ± 10 years, 94% male and 65.9% Mexicans). About 8% worked in COVID-19 converted hospitals. About 1.1% did not perform pre-operative COVID-19 testing. Polymerase chain reaction (33%) was the most common COVID-19 pre-operative test. The number of patient referrals decreased 62.5%. About 29.5% had one patient who died from COVID-19 during preoperative surgical evaluation. About 64.7% answered that surgical case volume decreased. About 17% and 23% respondents considered that surgical morbidity and mortality increased, respectively. Hospital resources and COVID-19 infection were responsible for change in surgical outcomes. Lack of ICU beds (54%) was the most common cause of surgical cancellation. COVID-19 had a strong negative impact on HPB surgery in Mexico and Latin America in terms of patient reference, case volume and surgical outcomes.

Indications and Outcomes of Completion Cholecystectomy: A 5-year Experience From a Rural Tertiary Center.

Completion cholecystectomy (CC) is performed for recurrent or persistent biliary symptoms following subtotal cholecystectomy (STC) or incomplete cholecystectomy (IC). Due to its complexity, cases are often referred to hepato-pancreato-biliary (HBP) surgeons. There is little published literature on indications or outcomes of CC. Completion cholecystectomy cases performed between 2016 and 2021 by the sole HPB surgeon covering a rural referral base of >250-mile radius in West Texas were included. Primary variables of interest include indications and outcomes of CC. Of the eleven patients included, 5 (45.5%) had laparoscopic STC, 3 patients (27.3%) had laparoscopic converted to open STC, and 2 (18.2%) had laparoscopic IC. Most STC cases (6/9, 66.6%) were reconstituting, while 3 STC cases were fenestrating (all had persistent bile leak). For reconstituting STC, indications were symptomatic cholelithiasis in 5 patients (45.5%), and choledocholithiasis in 3 patients (27.3%). The median (IQR) duration between index procedure and subsequent CC was 15 (1.4-92) months. The median (IQR) remnant gallbladder length was 4 (3-4.5) cm. Completion cholecystectomy was performed robotically in 8 cases (72.7%). Post-CC complications occurred in 3 patients (27.3%); these were 1 superficial surgical site infection, 1 hepatic abscess requiring percutaneous drainage, and lastly atrial fibrillation. All patients requiring CC had residual gallbladder remnant >2.5cm; this is longer than recommended for STC. Completion cholecystectomy is a complex operation that carries significant morbidity, even when performed using minimally invasive techniques. As bailout procedures become more common in severely inflamed cholecystitis, it is important to collate more data on the outcomes of requiring CC.

Liver drains after surgery: what is the real practice? An international snapshot from the Li.DR.A.S. survey.

Despite current evidence, the use of drains in liver surgery is still controversial. We conducted an international survey to investigate the clinical use of drains in the E-AHPBA, A-HPBA and A-PHPBA communities. An open survey of 30 questions was prepared on Google-Form and distributed by email to all members. One hundred and ninety-one HPB surgeons responded to the survey. One hundred and twelve surgeons (58.6%) reported routine use of abdominal drains after liver resections. Eighty-eight (46.1%) responded that removal was driven by low volume and low bilirubin levels in the drains. For minor liver resection, 97 (50.8%) surgeons reported using drains selectively; in contrast, 134 (70.2%) surgeons prefer to use a drain always after major procedures. Among patients with cirrhosis, 87 (45.5%) surgeons reported routine drains placement, while 84 (44.0%) considered drains selectively. A no-drain policy was most prevalent among surgeons from North America (80%) versus Asian-Pacific (70.0%), European and African (60.8%), and South American (61.5%) surgeons. Among minimally invasive surgeons, 74.2% reported drain use only in selected cases versus 35.0% among surgeons who performed open surgery. The practice of draining after liver surgery is still highly variable among centers and surgeons around the world, with a high variability according to the underlying liver condition and planned surgical approach.

Visiting scholars from around the world: The impact of Korea training on my career as an HPB surgeon in Saudi Arabia

Visiting scholars from around the world: The impact of Korea training on my career as an HPB surgeon in Saudi Arabia

Intraoperative complexity and risk factors associated with conversion to open surgery during laparoscopic cholecystectomy in eight hospitals in Mexico City.

The conversion to open surgery (COS) during the Laparoscopic Cholecystectomy (LC) is reported to occur at a rate of 10-15%. Some preoperative risk factors (RF) have been postulated; however, few studies have evaluated these factors and the intraoperative complexity with the COS rate. The aim of the study was to evaluate the preoperative RF and intraoperative complexity using the Parkland grading scale (PGS) with the COS rate in LC. A retrospective study was done evaluating the demographic and surgical variables from the patients and LC videos from 8 different hospitals of Mexico City from December 2018 to January 2020. The evaluation of the PGS was done by 2 surgeons (one MI and one HPB surgeon); the PGS was also categorized as Non-Complex LC (nCLC, PGS1-2) and Complex LC (CLC, PGS 3-5). Logistic regression was used to evaluate the association of this factors with the COS rate. 430 LC were analyzed; 358 (78.61%) were women, 261 (60.7%) were elective and 169(39.3%) urgent LC, the mean age was 44.06 (SD ± 13.16) years. 21 (4.8%) LC were COS; the mean age of this group was 55 (SD ± 12.95), 3 (0.7%) were nCLC and 18 (4.19%) CLC, mean PGS of 3.76 (SD ± 1.09), the mean time to COS was 48.67 (SD ± 41.9), the estimated blood loss (EBL) was 258 (SD ± 260.22) and 6 (1.4%) intraoperative BDI were recognized on this group. Univariate analysis showed a significant association with the COS with male sex, older age, age > 45years, presence of comorbidities, a higher PGS, a CLC, higher EBL and possible BDI; multivariate analysis produced a model using male sex, age, presence of comorbidities and a CLC with a 0.809 area under the ROC curve. The recognition of the associated RF and a CLC can guide the surgeon to establish preoperative and bailout strategies during the procedure, recognizing a higher risk of COS and its higher morbidity.