Postoperative Bile Leakage Research Articles

Intraoperative real-time imaging-guided laparoscopic liver resection

In recent years, laparoscopic hepatectomy has developed rapidly, but new challenges are posed to surgeons because of this surgical approach. The disadvantages of laparoscopic surgery can be effectively solved by using intraoperative real-time imaging guidance technology. Laparoscopic ultrasound can be used to discover and diagnose the nature of lesions, mark the important pipeline structure, determine the cutting edge, and guide puncture. ICG fluorescence imaging can be applied to the identification, localization, characterization of intraoperative lesions, the marking of specific liver segments and the prevention of postoperative bile leakage. These two technologies are the only two real-time imaging guidance technologies in laparoscopic hepatectomy at present, which truly make up for the shortcomings of laparoscopic liver surgery such as the inability to palpate and limited exploration exposure. Key words: Laparoscopy; Hepatectomy; Surgery, image-guided

Indocyanine green fluorescence imaging via endoscopic nasal biliary drainage during laparoscopic deroofing of liver cysts.

Laparoscopic deroofing of liver cysts is widely accepted as the treatment of symptomatic huge liver cysts. As bile leakage is a common complication of this procedure, indocyanine green (ICG) imaging has played an active role in detecting intrahepatic biliary tract. However, infusion ICG imaging needs time rag after injection due to moving from bloodstream to bile, and also, additional injection is needed when the fluorescent imaging is not clear. To cover this weakness of ICG imaging, we first applied ICG imaging via 5-Fr endoscopic nasal biliary drainage (ENBD) during laparoscopic deroofing of liver cysts. This technique promptly gives us ICG imaging after ICG injection from ENBD; in addition, direct ICG imaging sometimes reveals minor leakage from sealing line and staple lines; therefore, we believe that direct ICG imaging via ENBD helps us to prevent post-operative bile leakage.

Laparoscopic versus open surgery for the management of post-cholecystectomy benign biliary strictures.

Surgical management by a bilioenteric anastomosis is the standard for the repair of post-cholecystectomy benign biliary strictures (BBS). This is traditionally done as an open operation. There are a few reports describing the procedure by a laparoscopic technique. The aim of the present study was to describe our experience of laparoscopic bilio-enteric anastomosis [Roux-en-Y hepaticojejunostomy (LRYHJ)/laparoscopic hepaticoduodenostomy (LHD)] in the management of post-cholecystectomy BBS and compare the outcomes with our patients operated by the open approach. Retrospective analysis of prospective data of post-cholecystectomy BBS patients treated by laparoscopic bilio-enteric anastomosis. The outcomes were compared with patients who underwent an open repair. Between January 2016 and February 2019, 63 patients underwent surgery for post-cholecystectomy BBS. Twenty-nine patients who underwent laparoscopic bilio-enteric anastomosis (LRYHJ-13, LHD-16) were compared with 34 patients who underwent an open repair. The median age (40 vs 39) years, type of index surgery [laparoscopic cholecystectomy (13 vs 15), laparoscopic converted to open cholecystectomy (10 vs 16), and open cholecystectomy (6 vs 3)], type of injury low stricture (7 vs 5) and high stricture (22 vs 29), preoperative biliary fistula (23 vs 30), and time from injury to repair (6 vs 7months) were similar in the 2 groups. The median duration of surgery was also similar (210 vs 200min, p = 0.937); however, the median intraoperative blood loss (50mL vs 200mL, p = 0.001), time to resume oral diet (2 vs 4days p = 0.023),** and median duration of postoperative hospital stay (6 vs 8days, p = 0.001) were significantly less in the laparoscopy group. Overall morbidity rate (within 30days post-surgery) was significantly higher in the open repair group (38% vs 20%). In a subgroup analysis of the laparoscopic repair group, the operative time in patients who underwent an LHD was significantly less than LRYHJ (190 vs 230min, p = 0.034). The other parameters like the mean intraoperative blood loss, time to initiate oral diet, duration of postoperative hospital stay, and incidence of postoperative bile leak were similar. Patients undergoing open repair had a median follow-up of 26months with two developing anastomotic stenosis and those undergoing laparoscopic repair had a median follow-up for 9months with one developing anastomotic stenosis. Laparoscopic surgery for post-cholecystectomy BBS with an LRYHJ or LHD is feasible and safe and compares favourably with the open approach.

Laparoscopic subtotal cholecystectomy a salvageable procedure in patients with comorbidities

Aim: Our aim of study to show the feasibility and outcomes of laparoscopicsubtotal cholecystectomy in presence of difficult calot’s triangle anatomy, even inpresence of cormobidities.Materials & Methods: This study involved a retrospective analysis of patientsmanaged by laparoscopic subtotal cholecystectomy from January 2014 toDecember 2019. Here we analyzed the demography, indications, associated comorbidity,complications, management and their outcomes.Results: During this study period 53 cases underwent LSTC (laparoscopicsubtotal cholecystectomy), Median age of patients was 52 years (range 31-76years). 33 (62.26%) frozen calot’s triangle was the main peroperative findings inthese cases. The infundibulum of gall bladder was mainly managed byendosuturing of the stump (n=21) rest of cases managed by an Endo GIA (n=7),serial metallic clipping (n=2) and in 4 cases stump was left unsutured with onesubhepatic drain placement, 1 case omentum sutured over the cystic duct stumpanother 1 case of cholecystoduodenal fistula was repair with vicryl 3-0. Therewere (n=18) type I, (n=24) type II, (n=11) type III laparoscopic subtotalcholecystectomy done in our study. Two (3.77%) patients had postoperativemorbidity. 1 (1.88%) case had a postoperative bile leak which was successfullymanaged by ERC and stenting. None of the case had a wound infection or intraabdominal collection; there was no mortality and no bile duct injury. The medianpostoperative stay was 4 days (range 2-16 days). The mean follow up durationwas 60 months and the outcome was excellent in all the patients.Abbreviation: ERC (Endoscopic Retrograde Cholangiography), LSC(Laparoscopic Subtotal Cholecystectomy), GB (Gall Bladder),Conclusions: In scenario of difficult calot’s triangle, laparoscopic subtotalcholecystectomy is an effective and safe option, which shows excellentpostoperative recovery and ensures a satisfactory functional outcome for thepatient gall stone disease even in presence of comorbidities.Clinical Significance:KEYWORDSLaparoscopic cholecystectomy, Laparoscopic Subtotal cholecystectomy, difficult cholecystectomy.

Family Function in Pediatric Liver Transplant Recipients Residing In a Developing Country

BackgroundPediatric liver transplantation (LT) can affect recipients’ family function; however, inconsistent results between studies exist, and data from developing nations are sparse. We aimed to evaluate family function and identify factors associated with suboptimal function in pediatric LT recipients. MethodsA cross-sectional study was performed at a teaching hospital in Bangkok, Thailand between May 2018 and December 2018. We included the families of children aged 2 to 18 years who underwent LT for at least 1 year. Chulalongkorn Family Inventory (CFI) was used to evaluate the family function in these children comparing with families of healthy children. Family function was interpreted from the total CFI score and characterized as dysfunctional, normal-functioned, and well-functioned. ResultsWe enrolled families of 82 LT recipients and 72 healthy children. LT recipients had median age of 7.4 (interquartile range: 4.5-10.3) years. Eighteen children (22%) had a single parent, and at least one unemployed parent was reported in 25%. Most (96%) had well-functioned families, and none had a dysfunctional family. Furthermore, the total score was not significantly different between families of LT and healthy children (P = .95). LT families had a higher score in problem-solving (P < .01) and lower score in the affective involvement and general functioning dimension (P < .01 and .02, respectively). Among the LT children, postoperative bile leakage was associated with lower overall family function score. ConclusionsEven though most recipients had good family function, physicians should pay close attention to specific aspects of family function, especially in children with certain postoperative complications.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2years.

Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series. A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population. Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23). This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

Minimally invasive strategy for type I choledochal cyst in adult: combination of laparoscopy and choledochoscopy.

Choledochal cyst (CC)is a rare disease entity, more commonly occurring in Asian populations. In case of no contraindication, CC is resected to avoid future malignancies and future complications. To determine the optimal technique for treatment of patients with type I choledochal cyst by comparisons of indicators, including the duration of surgery, loss of blood, rates of complication, duration of hospitalization, and outcomes of long-term follow-up. From January 2009 to September 2017, a combination of laparoscopy and choledochoscopy surgery was implemented for type I choledochal cyst in adult. Patients' demographics data and treatment outcomes were collected prospectively during the follow-up. Fifty-eight patients with type I choledochal cyst were managed using this strategy. The combination of laparoscopic and intraoperative choledochoscopy was successfully performed in all patients without conversion or morbidity. When compared with a historical cohort of 71 patients who underwent a surgery for CC, this group of patients had significantly shorter duration of hospitalization (9.0 ± 6.5days vs. 13.0 ± 8.0days, P < 0.05). We also observed a lower blood loss (128.8 ± 60.2mL vs. 178.1 ± 58.2mL, P < 0.05), although the duration of the surgery (320.0 ± 50.0min vs. 190.0 ± 24.5min, P < 0.05) was longer. However, no significant difference was found in the rate of postoperative bleeding complication (3.45% vs. 4.23%, P = 0.82) and bile leakage complication (6.90% vs. 4.23%, P = 0.51). The two groups had similar rates of anastomotic stenosis (0.96% vs. 0.61%%, P = 0.47), jaundice (0.58% vs. 0.61%, P = 0.95), cholangitis (0.38% vs. 0.30%, P = 0.81), and reoperation (0.38% vs. 0.15%, P = 0.43). The type I choledochal cyst in adult can be effectively managed by laparoscopic surgery combined with inoperative choledochoscopy, which is feasible and minimally invasive. With the development of laparoscopic techniques and instruments, laparoscopic surgery may become the first-choice treatment for type I choledochal cyst treatment.

A case with combined postoperative bile leakage and anastomotic stricture after liver transplantation treated with magnet compression anastomosis

A case with combined postoperative bile leakage and anastomotic stricture after liver transplantation treated with magnet compression anastomosis

A clinical study for preoperative prediction of cyst-biliary communications in hepatic hydatid cyst disease

Background: Cyst-biliary communication with hepatic hydatid cyst disease is responsible for postoperative bile leakage after surgical management. This study aims to detect various predictors of cyst-biliary communication and their predictive accuracy.Methods: This study was done in the patients of hydatid cysts who underwent surgical management for hydatid disease of the liver. Various factors were studied and their accuracy for preoperative prediction of cyst-biliary communication analyzed.Results: There were 38 (22 males, 16 females) patients with hepatic hydatid cysts with a mean age of 38.7±15.4 years. Cyst-biliary communications were detected in 12 patients (31.6%). Independent strong predictors were tenderness in right hypochondrium (p=0.035), total leucocyte count (TLC)&gt;12,000/mm3 (p=0.0017), eosinophil count &gt;5 × 108/l (p=0.0086), red blood cell distribution width (RDW) &gt;15% (p=0.014), segment IV,V,VII involvement and cyst size &gt;10 cms (p=0.01) on multivariate analysis.Conclusions: Cyst-biliary communication is more common in patients presenting with tenderness in right hypochondrium, large cyst size, location in the central segments of liver close to biliary confluence, and with high values of TLC, Eosinophil count and RDW. The predictors demonstrated in this study should allow the likelihood of cyst-biliary communication to be determined preoperatively and, thus, indicate the need for additional procedures during operations to prevent the complications of biliary leakage.

Hybrid Laparoendoscopic-Radiologic Procedure for Laparoscopic Cholecystectomy Complicated With Choledocolithiasis.

The removal of common bile duct stones (CBDS) is routinely performed as either a 1-stage or 2-stage procedure. Despite many developments in both methods, the optimal approach has not been established to date. This study aimed to investigate the value and short-term outcomes of hybrid laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) combined with intraoperative endoscopic nasobiliary drainage (IO-ENBD) after primary duct closure (PDC) and intraoperative cholangiography (IOC) in patients with concomitant gallbladder stones (GBS) and CBDS. Forty-seven patients with GBS and CBDS who underwent LC and LCBDE, PDC with IO-ENBD, and IOC were retrospectively enrolled. Stone characteristics and removal, operative data, and postoperative outcomes were recorded and analyzed. A total of 46 (97.87%) procedures were completed without conversion to open surgery. The mean operating time was 127.15±8.36 minutes (range, 97 to 158 min). Three patients (6.38%) had residual stones during IOC but achieved 100% stone clearance eventually. Postoperative pancreatitis and bile leakage rates were 4.26% and 2.13%, respectively. A hybrid procedure combining LC and LCBDE, PDC with IO-ENBD, and IOC is safe and feasible for concomitant GBS and CBDS.

OMENTUM PIECE FOR PREVENTION OF BILE LEAKAGE AFTER SUBTOTAL CHOLECYSTECTOMY

Introduction: Acute cholecystitis is an acute inflammatory condition of the gallbladder of which 95% of cases of acute cholecystitis are due to an obstructing calculus in the gallbladder neck or cystic duct. Acute cholecystitis and difficult gall bladder have severe inflammation and anatomical deformities i.e. empyema, Mirizzi syndrome and sometimes gangrene. In recent years, there is an increasing trend towards subtotal cholecystectomy and general acceptance is higher due to higher incidence of complications in difficult gall bladder. Although, the results of subtotal cholecystectomy are satisfactory but the post-operative bile leak is a problem of great concern. There are many techniques that have been adopted, but bile leakage compared to closing of cystic duct directly is very high in subtotal cholecystectomy. &#x0D; Material and Methods: The Omentum Plugging Technique (OPT) and Primary Closure Technique (PCT) was done to prevent bile leak in cases were total cholecystectomy could not be performed. Patients were included in the study with the diagnosis of cholelithiasis and patients who had undergone subtotal cholecystectomy for gallstone diseases with both OPT and PCT Technique. Under general anaesthesia patients were operated. Patients were first decompressed at the fundus with the suction and harmonic scalpel or l-hook was used for transection of gall bladder and wash was given and both the anterior and posterior walls were excised leaving an anterior and posterior wall intact and OPT, a piece of omentum that matches the size of the opening of the gallbladder stump is resected from the greater omentum and plugged into the gallbladder stump.&#x0D; Results: A total of 486 patients were operated, of which 36 patients (7.4%) underwent subtotal cholecystectomy because it was not possible to close their cystic ducts because they had difficult gallbladders, of which 18 patients in taken in OPT and 18 patients taken in PCT group. Average age in OPT group was 49.48 ± 9.59 years while in PCT group was 54.47 ± 16.21. In OPT group there were 10 (62.5%) male and 6 (37.5%) female, in PCT group 11 (68.75%) male and 5 (31.25%) female were observed. History of CBD Stone was recorded in 3 (18.75%) and 2 (12.50%) patients in OPT and PCT group respectively. No History of Abdominal Surgery was noted in both the group. Intra-operative Haemorrhage in OPT Group was 118 (16-359) ml while in PCT group was 164 (10-578) ml. Duration of Operation Time OPT Group was 156 ± 15.77 ml while in PCT group it was 105 ± 17.35 minutes. Total post-operative complications and post-operative bile leakage were seen in 2 patients in OPT group while in PCT group it was seen in 10 patients. (P= 0.0040). Post-operative intervention was done on one patient in OPT group and on 9 patients in PCT group. Mean Duration of drain was 3.5 ± 1.24 days in OPT group and 8.59 ± 2.46 days in PCT group (P&lt; 0.0001). Post-operative hospital stay was 8.84 ± 2.14days in OPT group and 13.45 ± 2.11days (P&lt; 0.0001). Conclusion: In a difficult gall bladder SC is required during cholecystectomy and for prevention of postoperative bile leakage OPT technique can be safe and more feasible alternative than conventional procedures.&#x0D; Keywords: Subtotal cholecystectomy (SC), Omentum Plugging Technique (OPT), Primary Closure Technique (PCT), gall bladder.

Albumin-Indocyanine Green Evaluation (ALICE) grade predicts bile leakage after hepatic resection.

We investigated the predictors of bile leakage after hepatic resection. The data of 270 consecutive patients who underwent curative hepatic resection in our institute between January, 2016 and April, 2019 were reviewed retrospectively. The patients were assigned to one of two groups according to the presence of bile leakage and the clinicopathological and surgical outcomes were analyzed. Bile leakage was defined by the International Study Group of Liver Surgery (ISGLS) grade. There were no hospital deaths. The median intraoperative blood loss volume was 167ml. Bile leakage occurred in 12 patients (4.4%), as ISGLS grade A leakage in 1 and as ISGLS grade B leakage in 11. The mean hospital stay was significantly longer for patients with bile leakage. High-risk procedures, hepatocellular carcinoma, and Albumin-Indocyanine Green Evaluation (ALICE) grade 3 were independent predictors of ISGLS grade B or C postoperative bile leakage. In patients with three high-risk factors, the incidence of bile leakage was 53.9%. Based on this retrospective analysis, high-risk procedures, hepatocellular carcinoma, and ALICE grade 3 were independent predictors of bile leakage in patients undergoing hepatic resection. Thus, special care must be taken during surgery to prevent bile leakage in patients with these risk factors.

Management of congenital giant liver cyst with postoperative bile leak: A case report and literature review

Congenital liver cyst is an uncommon disease in infancy and is usually asymptomatic. However, even rarer are congenital giant liver cysts which by virtue of their size are problematic. We discuss a case of a newborn with a giant hepatic cyst who was successfully treated surgically but experienced a postoperative bile leak as a complication. We review the management of this entity and propose an algorithm of care.

Imaging findings and available percutaneous techniques for the treatment of bile leaks after hepatobiliary surgery.

BackgroundThe aim of this study was to evaluate the diagnosis and management of postoperative bile leaks, reporting typical diagnostic findings and available percutaneous techniques in association with other diagnostic and management methods.MethodsThirty-six patients (28 male) were treated for postoperative bile leaks. A biliary leak was clinically suspected in case of persistent leakage of bilious material from a surgical drain, or in the presence of non-specific symptoms such as abdominal pain, fever and anorexia, with or without laboratory alteration of liver enzymes. Radiological confirmation was mainly based on noninvasive methods such as ultrasound, computed tomography, and magnetic resonance cholangiopancreatography. We assessed each treatment by evaluating multiple factors, including technical success (TS) and clinical effectiveness (CE), defined as primary or secondary. We also evaluated overall CE (OCE), defined as leak control with either single or multiple procedures.ResultsTS and OCE were achieved in all patients (36/36; 100%) with a grade A or B biliary leak. No grade C was observed. There were no major complications. Minor complications were observed in 7/36 (19.4%) patients. No procedure-related deaths occurred.ConclusionsIn our study, considering all percutaneous techniques, leak healing was achieved in all the patients with a grade A or B biliary leak. These procedures provide a less invasive approach and are increasingly recognized as having a significant role in the management of complications and should be considered as an integral component in the postoperative management of these patients.

SURGICAL MANAGEMENT OF LARGE HEPATOCELLULAR CARCINOMA: THE FIRST SINGLE-CENTER STUDY FROM WESTERN INDIA.

ABSTRACT Background: Majority of patients with large size HCC (>10 cm) are not offered surgery as per Barcelona Clinic Liver Cancer (BCLC) criteria and hence, their outcomes are not well studied, especially from India, owing to a lower incidence. Aim: To analyze outcomes of surgery for large HCCs. Methods: This retrospective observational study included all patients who underwent surgery for large HCC from January 2007 to December 2017. The entire perioperative and follow up data was collected and analyzed. Results: Nineteen patients were included. Ten were non-cirrhotic; 16 were BCLC grade A; one BCLC grade B; and two were BCLC C. Two cirrhotic and three non-cirrhotic underwent preoperative sequential trans-arterial chemoembolization and portal vein embolization. Right hepatectomy was the most commonly done procedure. The postoperative 30-day mortality rate was 5% (1/19). Wound infection and postoperative ascites was seen in seven patients each. Postoperative liver failure was seen in five. Two cirrhotic and two non-cirrhotic patients had postoperative bile leak. The hospital stay was 11.9±5.4 days (median 12 days). Vascular invasion was present in four cirrhotic and five non-cirrhotic patients. The median follow-up was 32 months. Five patients died in the follow-up period. Seven had recurrence and median recurrence free survival was 18 months. The cumulative recurrence free survival was 88% and 54%, whereas the cumulative overall survival was 94% and 73% at one and three years respectively. Both were better in non-cirrhotic; however, the difference was not statistically significant. The recurrence free survival was better in patients without vascular invasion and the difference was statistically significant (p=0.011). Conclusion: Large HCC is not a contraindication for surgery. Vascular invasion if present, adversely affects survival. Proper case selection can provide the most favorable survival with minimal morbidity.

Prevention of postoperative pancreatic fistulas by a newly designed tissue sealant patch

Background and aims: Sealing devices used in surgical routine are usually designed to provide hemostasis. Other indications like postoperative pancreatic fistula (POPF) or bile leakage are not affected. Therefore we developed a biodegradable tissue sealant patch to achieve hemostasis and to prevent POPF. Study Design: The tissue sealant patch was developed in a multi angle approach including in-vitro tensile and burst pressure testing. For benchmarking, the sealant was compared to routinely used competitors like Tachosil, Hemopatch and Veriset. The hemostatic capability was tested in-vivo in a porcine randomized trial with in total 15 animals (group A: new sealant, group B: Tachosil, group C: Veriset). The prevention of POPF was tested in a randomized porcine spleen-preserving left pancreatectomy model with in total 14 animals (Group A: new sealant, Group B: suturing). Results: More than 30 different prototypes were screened in-vitro and the finally used sealant showed significantly stronger tissue adhesion in burst pressure and tensile testing (p<0.05 each) and withstood pancreatic fluid with sustained structural stability (p<0.05 each). Additionally the patch showed also superior hemostatic features in-vivo. Finally, the patch was challenged in a porcine pancreatic fistula model. 14 animals underwent spleen-preserving left pancreatcetomy and were randomized in two groups (sealant vs. suturing; n=7 each). After 14 days, the incidence POPF was 1/7 in the sealant group compared 6/7 in the suturing group (p<0.05). Conclusions: The actual used devices mainly focus on bleeding control and are not able to prevent POPF. The new sealant outperformed all available devices in extensive in-vitro as well as in-vivo animal testing. To our knowledge, this is the first report of a randomized trial showing the efficacy of a tissue sealant device for preventing postoperative pancreatic fistulas

No difference in complication rate after neoadjuvant chemotherapy versus upfront pancreatic surgery - a review of the Swedish National Pancreatic and Periampullary cancer Registry

Background: During the last decade, the practice of neoadjuvant chemotherapy in pancreatic cancer has become more frequent. Pathological response and over-all survival are promising, however the knowledge of potential perioperative chemotherapy related complications is deficient. The aim of this study was to compare the complication scenario of patients receiving neoadjuvant therapy in borderline resectable and locally advanced disease with those who had upfront pancreatic surgery. Methods: From the Swedish National Pancreatic and Periampullary cancer Registry, all patients who were resected for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified. Data on basic patient characteristics, neoadjuvant therapy and post-operative complications were additionally obtained from the registry. Comparisons between groups were performed using non-parametric tests. Results: Within the total cohort of 12006 patients, 3772 underwent surgery and 1619 patients (51% men, median age 69 years) were resected for pancreatic ductal adenocarcinoma. Among these, 75 patients received neoadjuvant treatment followed by surgery. The patients who received chemotherapy were younger (median 64 years versus 69 years, p<0.001), otherwise no evident variation was found in baseline characteristics. When comparing major post-operative complications bile leakage was more common among the neoadjuvant patients (p=0.046), however this subgroup contained only 5 patients. No other significant difference was found between the two groups (see attached table). Conclusions: When analyzing a large national database scarcely no difference in post-operative complications was found between patients receiving neoadjuvant therapy due to borderline resectable or locally advanced pancreatic cancer and those who underwent upfront surgery for the disease. Complications UFS and NAT

Textbook Outcome: Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery.

Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome. Post-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates. Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment. TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.

Short-term outcomes of surgical resection and radiofrequency in treatment of hepatocellular carcinoma

Backgroundand aim To evaluate surgical liver resection in comparison with radiofrequency in the treatment of early hepatocellular carcinoma (HCC) regarding intraoperative blood loss and transfusion, time of respectability, time of operation, ICU stay, hospital stay, postoperative morbidity, mortality, and overall survival.Introduction Surgical resection and radiofrequency ablation (RFA) in the treatment of HCC are different modalities for the treatment of HCC.Patients and methods This is a prospective study that included 60 patients with HCC randomized into hepatic resection and RFA groups at Al-Zahraa University Hospital from 2016 to 2019. Demographic and biochemical characteristics, intraoperative data, postsurgical complications, and overall survival rate were compared between groups.Results Surgical resection group had longer operative time, resection time, blood loss and blood transfusion, hospital stay, and ICU stay than RFA group. Postoperative hemorrhage, bile leak, and chest infection were markedly decreased in RFA group than surgical resection group. Wound infection and ascites are similar in the two patient groups. Regarding the median follow-up during the 3 years, there were no significant differences between the treatment groups in 1- and 3-year overall survival.Conclusion Surgical resection is considered the primary solution if the patient’s liver function and general conditions are good enough to undergo surgical intervention. RFA is considered superior to hepatic resection in the treatment of HCC in terms of operation duration and other complications like hemorrhage and bile leak. RFA revealed similar overall survival to surgical resection. RFA is accessible and a promising liver resection method with very good results.

Laparoscopic caudate lobe resection for the treatment of hepatolithiasis.

Background:To explore the safety and feasibility of laparoscopic caudate lobe (CL) resection for the treatment of hepatolithiasis.Methods:A retrospective study of nine patients who received laparoscopic CL resection for treatment of hepatolithiasis in our hospital from January 2013 to April 2017. Of these cases, we studied the patients’ demographic data, the operation time, blood loss, post-operative hospital stay, post-operative complications and prognosis.Results:All the nine cases are performed successfully; the post-operative recovery was symptom free except for one case of post-operative bile leakage. Among them, there were six cases of CL resection in combination with other lobe, three cases of separate CL resection, and three cases of whole CL resection. The average operative time was 310 min (Range: 180–450 min), the average intraoperative blood loss was 530 ml (Range: 100–1000 ml), average post-operative hospital stay was 9 days (Range: 6–13 days), average total hospital stay was 10 days (Range: 9–19 days). Intraoperative calculi exhaustion rate was 66.7% (6/9), which at the end of treatment was 88.9% (8/9). No cases had calculi recurrence.Conclusion:The application of laparoscopic CL resection is feasible and safe.