Invasive Resection Research Articles

The efficacy and safety analysis of cervical and abdominal double single-port minimally invasive esophagectomy

Objective: To summarize the efficacy and safety of minimally invasive esophagectomy through cervical and abdominal double single-port. Methods: A total of 28 patients who underwent cervical and abdominal double single-port minimally invasive radical resection of esophageal cancer from January 2021 to October 2022 in the First Affiliated Hospital of Fujian Medical University were retrospectively collected, including 18 males and 10 females, aged 58-80 (72±4) years. All patients were placed in the supine position, the single port was operated through the cervical mediastinum first, then the single port was operated through the abdominal cavity, and finally the neck was anastomosed. The operative time, intraoperative blood loss, postoperative ambulation time, postoperative drainage tube removal time, postoperative complications, postoperative pathological examination results, postoperative discharge time of patients were recorded and followed. Results: In the included 28 patients, there were twenty-six patients successfully completed the cervical and abdominal double single-port minimally invasive radical resection of esophageal cancer, and two patients were transferred to the right thoracoscopic surgery due to oozing of blood and unclear visual field, without conversion to laparotomy or enlargement of the incision occurred. The operation time was 125 to 215 (152±32) minutes, including 43 to 100 (56±15) minutes in the mediastinum and 35 to 63 (40±5) minutes in the abdominal cavity. Intra-operative blood loss was 55-100 (45±20) ml. There were 8 to 14 (11±3) lymph nodes dissected in the mediastinum and 7 to 15 (9±3) lymph nodes dissected in the abdominal cavity. Twenty-eight patients were active in bed 1 to 2 days after surgery. The left cervical drainage tube was removed 2 days after surgery. There was no anastomotic fistula, anastomotic stenosis, pulmonary infection, chylothorax and stomach emptying disorder in the whole group. Pleural effusion occurred in 4 cases, all of them had pleural damage during the operation, and were cured after postoperative puncture and drainage; two cases had hoarseness and one case had cough after eating, all patients were discharged from hospital after eating liquid. Postoperative hospital median stay was [ M(Q1, Q3)] 7(6, 9) d. The postoperative pathological examination results of all patients were squamous cell carcinoma, and the postoperative pathological stage was pT1-3N0-1M0. The median postoperative follow-up was 25 (5, 35) months, and no patients had complications, recurrence, metastasis or death during the follow-up period. Conclusion: The cervical and abdominal double single-hole minimally invasive radical resection of esophageal cancer is safe and feasible, with good short-term efficacy, which provide an opportunity for radical surgery for patients with advanced age, poor cardiopulmonary function or insufficient thoracic conditions.

Minimally invasive liver resection in Korea: A national survey based on 20 years’ experience

Minimally invasive liver resection in Korea: A national survey based on 20 years’ experience

Role of preoperative 3D rendering for minimally invasive parenchyma sparing liver resections

Roberto MONTALTI*, Gianluca ROMPIANESI, Francesca PEGORARO, Mariano GIGLIO, Giuseppe DE SIMONE, Pietro VENETUCCI, Roberto TROISI. Ann Hepatobiliary Pancreat Surg 2023;27:S100. https://doi.org/10.14701/ahbps.2023S1.OP-6-6

Retroperitoneoscopic or Transperitoneal Approach for Neurogenic and Adrenal Tumors in Children? A Comparison on the Way to Enhanced Recovery in Pediatric Surgical Oncology

BackgroundMinimally invasive surgery is increasingly utilized for resection of neurogenic tumors in children. The minimally invasive retroperitoneoscopic approach was recently reported in children, but transperitoneal laparoscopy still remains the most common technique. The aim of this study is to compare a novel single-port retroperitoneoscopy (SPR) approach for pediatric neurogenic tumor resection with transperitoneal laparoscopic (TPL). MethodsPatients undergoing minimally invasive resection of abdominal neurogenic tumors over 5 years at a single institution (from 2018 to 2022) were retrospectively reviewed. Tumor volume, stage, presence of image-defined risk factors (IDRFs), neoadjuvant chemotherapy, operative time, estimated blood loss (EBL), length of stay (LOS), complications, oral morphine equivalents per kilogram (OME/Kg), and time to chemotherapy were assessed and compared with SPR and TPL approaches. ResultsEighteen and fifteen patients underwent TPL and SPR, respectively. No significant differences were found between the TPL and SPR approaches in terms of tumor characteristics and IDRFs. Patients who underwent SPR had a significantly faster recovery (p = 0.008) and less postoperative opioid use compared to those in TPL (p = 0.02), thus allowing an enhanced recovery after surgery (ERAS) protocol application. TPL and SPR approaches were performed in presence of IDRFs, respectively in 2 (11%) and 4 patients (27%), with a IDRFs-related conversion in one TPL procedure. Both approaches had one < Grade 3 Clavien Dindo complication, but not requiring further surgery. DiscussionSPR approach can be considered as a safe and feasible minimally invasive approach for the resection of pediatric primary adrenal and neurogenic tumors. The retroperitoneoscopic approach performed using a single port technique represents a promising new frontier of ERAS application in pediatric surgical oncology. ConclusionSPR is a viable surgical alternative in selected neurogenic abdominal tumors with limited IDRFs, thus allowing for the application of ERAS protocols in these patients. Level of EvidenceLevel III.

P.141 The value of using flash visual evoked potentials monitoring during minimally invasive endoscopic meningioma resection: a retrospective chart review

Background: Endoscopic endonasal surgeries performed in areas involving the visual pathway are associated with postoperative visual dysfunction. We previously demonstrated that continued eye monitoring during surgery by flash visual evoked potential (FVEP) represents a good method to prevent/reduce visual deficit post-surgery. We wondered whether FVEP monitoring may be more beneficial in patients with meningioma, strongly associated with postoperative visual loss.The aim was to explore the visual capacity in patients subjected to meningioma resection at The Ottawa Hospital. Methods: A retrospective chart review of patients who underwent minimally invasive endoscopic skull base surgery and FVEP monitoring for meningioma resection (July 2018 to present) was conducted. Only patients with available pre- (up to 3 months) and post-surgery (1-9 months) visual evaluation were analyzed. Results: 40 eyes were included (20 patients). The median age was 61 years (range:43-84) and 90% of patients were female. The LogMAR visual acuity was not significantly modified post-surgery (from +0.25 to +0.21; p=0.7). Color vision (# errors reading Ishihara/16-plates) was not modified post-surgery (from 2.6 to 3.2; p=0.6). Visual field (Humphrey, 32-2) was not significantly modified post-surgery (from 78.1% to 81.9%; p=0.7). Conclusions: The prevention of visual pathway injury during surgery by FVEP monitoring prevents visual deficits after endoscopic meningioma resection.

Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis.

Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79min vs. LECA: 143 ± 52min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.

Fluorescence-Guided Robotic Segment 8 Superior Liver Resection. Technical Approach to Sectoral Inflow Occlusion.

In the past decade, precision hepatectomy which requires the understanding of segmental and subsegmental liver anatomy has gained popularity due to its parenchymal-sparing benefits. The importance of this concept has led liver surgeons to a consensus conference and its guideline in regards to precision anatomy in minimally invasive liver resection, held in Tokyo in 2020. A precise control of the sectoral hepatic artery and portal vein allows for a bloodless liver resection, without the use of Pringle maneuver. In the literature, technical description of the right anterior portal pedicle dissection during minimally invasive robotic liver surgery is limited. In this study, we therefore demonstrate such a technique using fluorescence guidance during robotic segment 8 superior liver resection.

Robotic emergency liver resection of ruptured hepatocellular carcinoma.

The spontaneous rupture of hepatocellular carcinoma (HCC) is a rare complication. The management of this complication needs a stepwise, multidisciplinary approach which considers first of all clinical conditions of the patient and also the possibility of the best curative treatment. We report our experience of an emergency robotic liver resection for a ruptured HCC in an elderly patient. Minimally invasive liver resection is currently recognised as a safe and feasible approach to the treatment of HCC in elderly patients. Our patient presented haemodynamic stability, which allows us to perform a robotic resection of segment 3. To our knowledge, this is the first report of the application of a robotic platform in an emergency setting for liver resection. Rupture of HCC is an uncommon complication, burdened by a high rate of mortality. Its management still remains controversial. Treatment should be individualised taking into consideration the clinical status of the patient, tumour features and possibility of centre therapeutic strategy.

Risk Factors for Postoperative Complications Following Resection of Colorectal Liver Metastases and the Impact on Long-Term Survival: A Population-Based National Cohort Study

BackgroundPostoperative complications (POCs) following resection of colorectal liver metastases (CRLM) are common. The objective of this study was to evaluate risk factors for developing complications and their impact on survival considering prognostic factors of the primary tumor, metastatic pattern and treatment in a well-defined national cohort.MethodsPatients treated with resection for CRLM that was also radically resected for their primary colorectal cancer (diagnosed in 2009–2013) were identified in Swedish national registers. Liver resections were categorized according to extent of surgery (Category I–IV). Risk factors for developing POCs as well as prognostic impact of POCs were evaluated in multivariable analyses. A subgroup analysis of minor resections was performed to evaluate POCs after laparoscopic surgery.ResultsPOCs were registered for 24% (276/1144) of all patients after CRLM resection. Major resection was a risk factor for POCs in multivariable analysis (IRR 1.76; P = 0.001). Comparing laparoscopic and open resections in the subgroup analysis of small resections, 6% (4/68) in the laparoscopic group developed POCs compared to 18% (51/289) after open resection (IRR 0.32; P = 0.024). POCs were associated with a 27% increased excess mortality rate (EMRR 1.27; P = 0.044). However, primary tumor characteristics, tumor burden in the liver, extrahepatic spread, extent of liver resection and radicality had higher impact on survival.ConclusionMinimal invasive resections were associated with a decreased risk of POCs following resection of CRLM which should be considered in surgical strategy. Postoperative complications were associated with a moderate risk for inferior survival.

Current update on multimodal analgesia and nonopiate surgical pain management

Based on the Competency Assessment Tool, herein we developed an assessment instrument suitable to evaluate the implantation of central intravenous devices.Surgical assessment is based mainly on the subjective impressions of the teacher. Based on the “Competency Assessment Tool” (CAT) developed for the evaluation of technical surgical skills in minimally invasive colorectal resection, we designed an assessment tool suitable to evaluate the implantation of central venous access devices performed by junior surgical trainees.Four major assessments during the different steps of the intervention were used in this evaluation. Each of these tasks was divided into four sub-domains according to surgical skill. In addition to the CAT score, the apprentices’ skills were evaluated using a visual assessment that was quantified using an analogue scale (value from 1 to 10). The candidates were classified into junior and senior trainees depending on the number of procedures they had already performed and on their surgical experience.71 procedures were evaluated during the study period. Seven senior trainees conducted 43 procedures and five junior trainees performed 28 interventions. The senior trainees had significantly higher CAT scores than junior candidates, and the scores fluctuated according to surgical experience, usually reaching their peak after 10 procedures.The CAT model is well suited for the assessment of surgical trainees during central venous access device implantation. It enables a close assessment of the learning process and the technical skills of trainees, which helps them improving in a safe, standardized manner.

Laparoscopic and Open Liver Resections for Colorectal Cancer Liver Metastasis in the Ukrainian State Center.

Background Minimally invasive liver resections for metastatic colorectal cancer have been increasingly performed all over the world with promising results. We planned the current studyto review our experience on this matter and compare short- and long-term outcomes of laparoscopicliver resection (LLR) and open liver resection(OLR) in patients with colorectal cancer liver metastasis (CRLM). Materials and methods This is a single-center retrospective analysis of patients with CRLM who underwent laparoscopic (n=86) and open (n=96) surgical treatment for metastatic liver lesions between March 2016 and November 2022. Tumor characteristics, intra- and postoperative results, overall survival (OS), and disease-free survival (DFS)were analyzed and compared. Results LLR was associated with significantly shorter surgery duration (180 minutes versus 295 minutes, p=0.03). There was no significant difference in blood loss between the two groups (100 mL versus 350 mL, p=0.061). Additionally, the laparoscopic approach was associated with significantly shorter hospital stays (6 days versus 9 days, p=0.004). The rate of major complications (Clavien-Dindo classification ≥ 3) was lower in the LLR group (5.8% versus 16.6%, p=0.037). There was no mortality in the LLR group, and in the OLR group, one lethal case was induced by mesenteric thrombosis on the fifth postoperative day. We did not find a statistically significant difference in the OS rate between the two groups at one, three, and five years: 97.3%, 74.7%, and 43.4%, respectively,in the OLR group and 95.1%, 70.3%, and 49.5%,respectively,in the LLR group (p=0.53). DFS at one, three, and five years were 88.7%, 52.3%, and 25.5%,respectively, in the LLR group and 71.9%, 53.1%, and 19.3%, respectively, in the OLR group(p=0.66). Conclusions This study showed that laparoscopic liver surgery is a safe and effective method of CRLM treatment in our center. LLR was associated with a decrease in major morbidity, shorter surgery duration, and reduced postoperative hospital stay. Minimally invasive liver resections showed similar oncological outcomes to the open approach in terms of overall and disease-free survival.

Optimizing opioid prescribing practices after minimally invasive lung resection through a quality-improvement intervention.

In their 2019 guideline on the prescribing and management of opioids after elective ambulatory thoracic surgery, the Canadian Association of Thoracic Surgeons (CATS) recommended 120 morphine milligram equivalents (MME) after minimally invasive (video-assisted thoracoscopic surgery [VATS]) lung resection. We conducted a quality-improvement project to optimize opioid prescribing after VATS lung resection. We assessed baseline prescribing practices for opioid-naive patients. Using a mixed-methods approach, we selected 2 quality-improvement interventions: formal incorporation of the CATS guideline into our postoperative care pathway, and development of a patient information handout regarding opioids. The intervention was initiated on Oct. 1, 2020, and was formally implemented on Dec. 1, 2020. The outcome measure was average MME of discharge opioid prescriptions, the process measure was proportion of discharge prescriptions exceeding the recommended dosage, and the balancing measure was opioid prescription refills. We analyzed the data using control charts, and compared all measures between the pre-intervention (12 mo before) and postintervention (12 mo after) groups. A total of 348 patients who underwent VATS lung resection were identified, 173 before the intervention and 175 after the intervention. Significantly less MME was prescribed after the intervention (100 v. 158, p < 0.001), and a lower proportion of prescriptions were nonadherent to the guideline (18.9% v. 50.9%, p < 0.001). Control charts showed special cause variation corresponding with the intervention, and system stability existed after the intervention. There was no statistically significant difference in the proportion or dosage of opioid prescription refills after the intervention. After implementation of the CATS opioid guideline, there was a significant reduction in opioids prescribed at discharge and no increase in opioid prescription refills. Control charts are a valuable resource for monitoring outcomes on an ongoing basis and for assessing the effects of an intervention.

Use of Barbed Suture During Minimally Invasive Resection of the Choledochal Cyst

Introduction: Choledochal cysts are rare congenital anomalies of the bile ducts, characterized by dilations of the intrahepatic and extrahepatic biliary ducts. Approximately 80% are diagnosed in childhood, with a higher incidence in Asian countries.1 Imaging studies are essential for the diagnosis, including magnetic resonance cholangiopancreatography as the method of choice.2 Patients with types I, II, or IV cysts usually undergo surgical resection of the cysts because of the significant risk of malignancy. The treatment of choice of type I bile duct cysts in adults is total cystectomy and hepaticojejunostomy in a Roux-en-Y manner.2 The advantages of this procedure include a reduced incidence of anastomotic strictures, stone formation, cholangitis, and intracystic malignancy.2 This video shows the surgical steps, tips, and tricks of minimally invasive resection of the choledochal cyst and continuity with a bilioenteric anastomosis. Materials and Methods: A 48-year-old woman with previous laparoscopic cholecystectomy presented with a history of right subcostal pain and jaundice. After magnetic resonance cholangiopancreatography, a type I Todani choledochal cyst was diagnosed with a width of the proximal bile duct of 12 mm. She underwent minimally invasive resection of the bile duct and a terminolateral hepaticojejunostomy in a Roux-en-Y manner. Operatively, an 11 mm trocar was placed at the umbilicus. Three 5 mm trocars were placed in the epigastrium, right hypochondrium, and right flank. An 11 mm trocar was placed in the left flank. A type I choledochal cyst was confirmed with cystic duct dilation. The right hepatic artery, proximal bile duct, and portal vein were identified. The main bile duct was completely dissected, and two clips were placed in the intrapancreatic portion. The distal part of the bile duct was sectioned above the clips. The proximal bile duct was divided 1 cm from the hilar plate and the specimen was completely removed. The jejunal loop was identified and a terminolateral hepaticojejunal anastomosis was performed using barbed suture (V-locTM 4/0, Covidien). Then, a laterolateral jejunojejunal anastomosis was performed using a stapler. The common loop between the two anastomosis was sectioned with another stapler that completed the Roux-en-Y. Finally, a subhepatic suction drain was left. Results: The drain was removed 72 hours after the procedure and the patient was discharged on postoperative day 6 without complications. The pathology report confirmed a choledochal cyst without malignancy. A follow-up was done at 1 and 6 months. The patient was asymptomatic and blood workup and cholangiography were normal. Conclusions: Different publications with high level of evidence document that minimally invasive surgical treatment on Todani I choledochal cysts reduces hospital stay and postoperative pain compared with an open approach.3 It is a demanding technique with a long learning curve that decreases with the use of barbed sutures without increasing complications. No competing financial interests exist. Runtime of video: 10 mins 0 secs

Arterial sleeve lobectomy for lung cancer invading chest wall.

Lung cancer is a leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) is a predominant subtype and treatment may include immunotherapy, radiotherapy, chemotherapy, and surgery. Tumors of bigger size infiltrating large bronchi and vessels require more invasive resection such as pneumonectomy. To save lung parenchyma, sleeve lobectomy can be performed in certain patients.We report the case of a patient with NSCLC infiltrating the chest wall who underwent arterial sleeve lobectomy with rib resection. Furthermore, we discuss other surgical treatment strategies.A 58-year-old female patient was admitted to the hospital in 2020 with pain in her left posterolateral chest. Radiological imaging revealed a tumor (5.0×3.5×4.8cm) in the top of the left lung, infiltrating pulmonary artery and ribs. Therefore, left upper sleeve lobectomy together with resection of rib blocks II to V was performed. The surgery was uncomplicated, but a few weeks postoperatively, the patient experienced repeated episodes of consciousness disturbances. Contrast CT revealed a cerebral malformation in the patient who died 3.5 months after surgery.Sleeve lobectomy can be safely performed in patients with lung tumors infiltrating larger bronchi and vessels who would not tolerate pneumonectomy.

Histological and molecular characteristics of tumours of the peripheral nervous system

Tumours of the peripheral nervous system occur sporadically in adults and except for aminority of entities, these tumours are usually benign. The most common are nerve sheath tumours. Because these tumours grow in direct proximity or even invade peripheral nerve bundles, they can lead to severe pain and motion deficits. From the neurosurgical perspective these tumours are technically challenging, and especially for tumours with an invasive growth pattern complete resection may not be possible. Peripheral nervous system tumours that are associated with tumour syndromes such as neurofibromatosis type1 and2 or schwannomatosis are a particular clinical challenge. The goal of the current article is to present histological and molecular characteristics of peripheral nervous system tumours. Furthermore, future targeted therapy strategies are presented.

Neurogenic Thoracic Outlet Syndrome Induced by Subclavius Muscle Hypertrophy: A Case Report

Neurogenic thoracic outlet syndrome (NTOS) is a complex disorder characterized by compression of the brachial plexus, resulting in pain, weakness, and sensory changes in the upper extremity. Traditional surgical treatments, such as first rib resection or anterior scalene muscle resection, can be invasive and associated with significant morbidity. We present a unique case of a patient diagnosed with NTOS who underwent a preoperative magnetic resonance imaging with the shoulder in an abduction position to identify the cause of NTOS. A minimally invasive subclavius muscle resection was subsequently performed, resulting in a dramatic reduction in pain and significant improvement in motor symptoms. This less invasive approach led to a quicker recovery time and reduced morbidity compared to traditional surgical methods. This case report suggests that before surgery, thoroughly investigating the causes of NTOS and selectively performing decompression only on the structures requiring intervention could also be considered a viable treatment option.

Role of preoperative 3D rendering for minimally invasive parenchyma sparing liver resections

Background3D rendering (3DR) represents a promising approach to plan surgical strategies. The study aimed to compare the results of minimally invasive liver resections (MILS) in patients with 3DR versus conventional 2D CT-scan. MethodsWe performed 118 3DR for various indications; the patients underwent a preoperative tri-phasic CT-scan and rendered with Synapse3D® Software. Fifty-six patients undergoing MILS with pre-operative 3DR were compared to a similar cohort of 127 patients undergoing conventional pre-operative 2D CT-scan using the propensity score matching (PSM) analysis. ResultsThe 3DR mandated pre-operative surgical plan variations in 33.9% cases, contraindicated surgery in 12.7%, providing a new surgical indication in 5.9% previously excluded cases. PSM identified 39 patients in both groups with comparable results in terms of conversion rates, blood loss, blood transfusions, parenchymal R1-margins, grade ≥3 Clavien-Dindo complications, 90-days mortality, and hospital stay respectively in 3DR and conventional 2D. Operative time was significantly increased in the 3DR group (402 vs. 347 min, p = 0.020). Vascular R1 resections were 25.6% vs 7.7% (p = 0.068), while the conversion rate was 0% vs 10.2% (p = 0.058), respectively, for 3DR group vs conventional 2D. Conclusion3DR may help in surgical planning increasing resectability rate while reducing conversion rates, allowing the precise identification of anatomical landmarks in minimally invasive parenchyma-preserving liver resections.

Practice variation and outcomes of minimally invasive minor liver resections in patients with colorectal liver metastases: a population-based study

IntroductionIn 2017, the Southampton guideline stated that minimally invasive liver resections (MILR) should considered standard practice for minor liver resections. This study aimed to assess recent implementation rates of minor MILR, factors associated with performing MILR, hospital variation, and outcomes in patients with colorectal liver metastases (CRLM).MethodsThis population-based study included all patients who underwent minor liver resection for CRLM in the Netherlands between 2014 and 2021. Factors associated with MILR and nationwide hospital variation were assessed using multilevel multivariable logistic regression. Propensity-score matching (PSM) was applied to compare outcomes between minor MILR and minor open liver resections. Overall survival (OS) was assessed with Kaplan–Meier analysis on patients operated until 2018.ResultsOf 4,488 patients included, 1,695 (37.8%) underwent MILR. PSM resulted in 1,338 patients in each group. Implementation of MILR increased to 51.2% in 2021. Factors associated with not performing MILR included treatment with preoperative chemotherapy (aOR 0.61 CI:0.50–0.75, p < 0.001), treatment in a tertiary referral hospital (aOR 0.57 CI:0.50–0.67, p < 0.001), and larger diameter and number of CRLM. Significant hospital variation was observed in use of MILR (7.5% to 93.0%). After case-mix correction, six hospitals performed fewer, and six hospitals performed more MILRs than expected. In the PSM cohort, MILR was associated with a decrease in blood loss (aOR 0.99 CI:0.99–0.99, p < 0.01), cardiac complications (aOR 0.29, CI:0.10–0.70, p = 0.009), IC admissions (aOR 0.66, CI:0.50–0.89, p = 0.005), and shorter hospital stay (aOR CI:0.94–0.99, p < 0.01). Five-year OS rates for MILR and OLR were 53.7% versus 48.6%, p = 0.21.ConclusionAlthough uptake of MILR is increasing in the Netherlands, significant hospital variation remains. MILR benefits short-term outcomes, while overall survival is comparable to open liver surgery.Graphical abstract

Propensity Matched Comparison of 30-Day Outcomes Between Minimally Invasive and Open Simultaneous Resection of Colorectal Primary Tumor and Liver Metastases

Carpenter, Elizabeth Lee MD; Valdera, Franklin Antonio MD; Smolinsky, Todd L MD; Thomas, Katryna K MD; Spitzer, Holly DO; Wagler, Amy E PhD; Liang, Panfeng MS; Clifton, Guy Travis MD, FACS; Nelson, Daniel W DO, FACS; Vreeland, Timothy J MD, FACS Author Information

Changing trends in the minimally invasive surgery for chronic pancreatitis.

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.