Objective
To evaluate the effect of three-dimensional (3D) visualization on operative performance during elective laparoscopic liver resection (LLR).
Background
Major limitations of conventional ...laparoscopy are lack of depth perception and tactile feedback. Introduction of robotic technology, which employs 3D imaging, has removed only one of these technical obstacles. Despite the significant advantages claimed, 3D systems have not been widely accepted.
Methods
In this single institutional study, 20 patients undergoing LLR by high-definition 3D laparoscope between April 2014 and August 2014 were matched to a retrospective control group of patients who underwent LLR by two-dimensional (2D) laparoscope.
Results
The number of patients who underwent major liver resection was 5 (25 %) in the 3D group and 10 (25 %) in the 2D group. There was no significant difference in contralateral wedge resection or combined resections between the 3D and 2D groups. There was no difference in the proportion of patients undergoing previous abdominal surgery (70 vs. 77 %,
p
= 0.523) or previous hepatectomy (20 vs. 27.5 %,
p
= 0.75). The operative time was significantly shorter in the 3D group when compared to 2D (225 ± 109 vs. 284 ± 71 min,
p
= 0.03). There was no significant difference in blood loss in the 3D group when compared to 2D group (204 ± 226 in 3D vs. 252 ± 349 ml in 2D group,
p
= 0.291). The major complication rates were similar, 5 % (1/20) and 7.5 % (3/40), respectively, (
p
≥ 0.99).
Conclusion
3D visualization may reduce the operating time compared to high-definition 2D. Further large studies, preferably prospective randomized control trials are required to confirm this.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The safety and feasibility of laparoscopic, two-stage hepatectomy for bilobar colorectal liver metastases is poorly evaluated.
We reviewed retrospectively 86 consecutive patients who underwent ...complete two-stage hepatectomy (left lobe clearance as the first stage and standard/extended right hepatectomy as the second stage) for bilobar colorectal liver metastases between 2007 and 2017 in 2 tertiary centers. Short- and long-term outcomes were compared between laparoscopic and open two-stage hepatectomy before and after propensity score matching.
Laparoscopic two-stage hepatectomy was performed in 38 patients and open two-stage hepatectomy in 48. After propensity score matching, 25 laparoscopic and 25 open patients showed similar preoperative characteristics. For the first stage, a laparoscopic approach was associated with lesser hospital stays (4 vs 7.5 days; P < .001). For the second stage, a laparoscopic approach was associated with less blood loss (250 vs 500 mL; P = .040), less postoperative complications (32% vs 60%; P = .047), lesser hospital stays (9 vs 16 days; P = .013), and earlier administration of chemotherapy (1.6 vs 2 months; P = .039). Overall survival, recurrence-free survival, and liver-recurrence-free survival were comparable between the groups (3-year overall survival: 80% vs 54%; P = .154; 2-year recurrence-free survival: 20% vs 18%; P = .200; 2-year liver-recurrence-free survival: 39% vs 33%; P = .269). Although both groups had comparable recurrence patterns, repeat hepatectomies for recurrence were performed more frequently in the laparoscopic two-stage hepatectomy group (56% vs 0%; P = .006).
Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases is safe and feasible with favorable surgical and oncologic outcomes compared to open two-stage hepatectomy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
<p data-select-like-a-boss="1">Objective: The aim of this study was to compare oncological outcomes after minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) in ...patients with pancreatic ductal adenocarcinoma (PDAC).
Background: Cohort studies have suggested superior short-term outcomes of MIDP vs. ODP. Recent international surveys, however, revealed that surgeons have concerns about the oncological outcomes of MIDP for PDAC.
Methods: This is a pan-European propensity score matched study including patients who underwent MIDP (laparoscopic or robot-assisted) or ODP for PDAC between January 1, 2007 and July 1, 2015. MIDP patients were matched to ODP patients in a 1:1 ratio. Main outcomes were radical (R0) resection, lymph node retrieval, and survival.
Results: In total, 1212 patients were included from 34 centers in 11 countries. Of 356 (29%) MIDP patients, 340 could be matched. After matching, the MIDP conversion rate was 19% (n = 62). Median blood loss 200 mL (60–400) vs 300 mL (150–500), P = 0.001 and hospital stay 8 (6–12) vs 9 (7–14) days, P < 0.001 were lower after MIDP. Clavien-Dindo grade ≥3 complications (18% vs 21%, P = 0.431) and 90-day mortality (2% vs 3%, P > 0.99) were comparable for MIDP and ODP, respectively. R0 resection rate was higher (67% vs 58%, P = 0.019), whereas Gerota's fascia resection (31% vs 60%, P < 0.001) and lymph node retrieval 14 (8–22) vs 22 (14–31), P < 0.001 were lower after MIDP. Median overall survival was 28 95% confidence interval (CI), 22–34 versus 31 (95% CI, 26–36) months ( P = 0.929).
Conclusions: Comparable survival was seen after MIDP and ODP for PDAC, but the opposing differences in R0 resection rate, resection of Gerota's fascia, and lymph node retrieval strengthen the need for a randomized trial to confirm the oncological safety of MIDP.
Cancerous and healthy human colon samples have been analyzed ex-vivo using a multispectral imaging Mueller polarimeter operated in the visible (from 500 to 700 nm) in a backscattering configuration ...with diffuse light illumination. Three samples of Liberkühn colon adenocarcinomas have been studied: common, mucinous and treated by radiochemotherapy. For each sample, several specific zones have been chosen, based on their visual staging and polarimetric responses, which have been correlated to the histology of the corresponding cuts. The most relevant polarimetric images are those quantifying the depolarization for incident linearly polarized light. The measured depolarization depends on several factors, namely the presence or absence of tumor, its exophytic (budding) or endophytic (penetrating) nature, its thickness (its degree of ulceration) and its level of penetration in deeper layers (submucosa, muscularis externa and serosa). The cellular density, the concentration of stroma, the presence or absence of mucus and the light penetration depth, which increases with wavelength, are also relevant parameters. Our data indicate that the tissues with the lowest and highest depolarizing powers are respectively mucus-free tumoral tissue with high cellular density and healthy serosa, while healthy submucosa, muscularis externa as well as mucinous tumor probably feature intermediate values. Moreover, the specimen coming from a patient treated successfully with radiochemotherapy exhibited a uniform polarimetric response typical of healthy tissue even in the initially pathological zone. These results demonstrate that multi-spectral Mueller imaging can provide useful contrasts to quickly stage human colon cancer ex-vivo and to distinguish between different histological variants of tumor.
Pre‐operative simulation using three‐dimensional (3D) reconstructions have been suggested to enhance surgical planning of hepatectomy. Evidence on its benefits for hepatectomy patients remains ...limited. This systematic review examined the use and impact of pre‐operative simulation and intraoperative navigation on hepatectomy outcomes. A systematical searched electronic databases for studies reporting on the use and results of simulation and navigation for hepatectomy was performed. The primary outcome was change in operative plan based on simulation. Secondary outcomes included operating time (min), estimated blood loss, surgical margins, 30‐day postoperative morbidity and mortality, and study‐specific outcomes. From 222 citations, we included 11 studies including 497 patients. All were observational cohort studies. No study compared hepatectomy with and without simulation. All studies performed 3D reconstruction and segmentation, most commonly with volumetrics measurements. In six studies reporting intraoperative navigation, five relied on ultrasound, and one on a resection map. Of two studies reporting on it, the resection line was changed intraoperatively in one third of patients, based on simulation. Virtually predicted liver volumes (Pearson correlation r = 0.917 to 0.995) and surgical margins (r = 0.84 to 0.967) correlated highly with actual ones in eight studies. Heterogeneity of the included studies precluded meta‐analysis.Pre‐operative simulation seems accurate in measuring volumetrics and surgical margins. Current studies lack intraoperative transposition of simulation for direct navigation. Simulation appears useful planning of hepatectomies, but further work is warranted focusing on the development of improved tools and appraisal of their clinical impact compared to traditional resection.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Compare oncologic results of laparoscopic versus open hepatectomy for resection of colorectal metastases to the liver.
Open hepatectomy (OH) is the current standard of care for the management of ...colorectal liver metastases. Although the feasibility of laparoscopic hepatectomy (LH) has been established, only select centers have used this technique as their primary modality. At present there is no study comparing the oncologic outcomes for colorectal liver metastases patients undergoing LH versus OH.
Two groups composed of 60 patients each were obtained from 2 specialized liver units performing either OH or LH as their primary modality. Cohorts of 215 LH cases and 1783 OH were used to establish the study population. Patients were compared on an intention to treat basis using 9 preoperative prognostic criteria obtained from LiverMetSurvey. These included sex, age, primary tumor localization, number of tumors, diameter of tumor, distribution of metastases, presence of extrahepatic disease, initial respectability, and the use of prehepatectomy chemotherapy. Overall survival and disease-free survival were compared between OH and LH for a follow-up of 36 months.
The median follow-up for the LH group is 30 months and 33 months for the OH group (P = 0.75). One-, 3-, and 5-year patient survival for LH was 97%, 82%, and 64% and 97%, 70%, and 56% in the OH group, respectively (P = 0.32). One-, 3-, and 5-year disease-free survival was 70%, 47%, and 35% and 70%, 40%, and 27% (P = 0.32), respectively for the 2 groups.
In a highly specialized center, first line application of laparoscopic liver resection in selected patients can provide comparable oncologic results to treatment with open liver resection for patients with colorectal liver metastases.
The original difficulty scoring system was revised after discussion at the 2nd International Consensus Conference on Laparoscopic Liver Resection held in Morioka (Iwate Prefecture) in Japan and ...renamed the IWATE criteria (a 4-level classification system involving 6 preoperative factors). We used Japanese and French cohorts to validate the IWATE criteria by evaluating their association with the procedure-based difficulty classification proposed by the Institut Mutualiste Montsouris.
Patients who had undergone laparoscopic liver resection at multiple Japanese multi-institutions or the Institut Mutualiste Montsouris were assigned to the multiple Japanese multi-institution (n = 1,867) or Institut Mutualiste Montsouris cohort (n = 433). We analyzed clinical characteristics and outcomes according to the 4-level IWATE criteria difficulties (low, intermediate, advanced, and expert) and evaluated their association with 11 laparoscopic liver resection procedures in the Institut Mutualiste Montsouris classification (low, intermediate, and high levels).
We found significant differences in age, surgical indications, and the 4-level IWATE criteria difficulties between the cohorts (all, P < .001). Operation time and blood loss were significantly different among the 4-level difficulties in both cohorts (all, P < .001). The rates of conversion, postoperative complications, liver failure, and in-hospital deaths also increased significantly with increasing difficulty (all, P < .001). The IWATE criteria classified the three low-level Institut Mutualiste Montsouris procedures in the low-to-intermediate levels, the two intermediate-level procedures in the intermediate-to-advanced levels, and the six high-level procedures in the advanced-to-expert levels.
We observed associations between the IWATE criteria and intraoperative and postoperative outcomes in the Japanese multi-institution and Institut Mutualiste Montsouris cohorts and thus validated the IWATE system.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
Using the Ideal Development Exploration Assessment and Long-term study (IDEAL) paradigm, Halls et al. created risk-adjusted cumulative sum (RA-CUSUM) curves concluding that Pioneers (P) ...and Early Adopters (EA) of minimally invasive (MI) liver resection obtained similar results after fewer cases. In this study, we applied this framework to a MI Hepatic-Pancreatic and Biliary fellowship-trained surgeon (FT) in order to assess where along the curves this generation fell.
Methods
The term FT was used to designate surgeons without previous independent operative experience who went from surgical residency directly into fellowship. Three phases of the learning curve were defined using published data on EAs and Ps of MI Hepatectomy, including phase 1 (initiation) (i.e., the first 17 or 50), phase 2 (standardization) (i.e., cases 18–46 or 1–50) and phase 3 (proficiency) (i.e., cases after 46, 50 or 135). Data analysis was performed using the Social Science Statistics software (
www.socscistatistics.com
). Statistical significance was defined as
p
< .05.
Results
From November 2007 until April 2018, 95 MI hepatectomies were performed by a FT. During phase 1, the FT approached larger tumors than the EA group (
p
= 0.002), that were more often malignant (94.1%) when compared to the P group (52.5%) (
p
< 0.001). During phase 2, the FT operated on larger tumors and more malignancies (93.1%) when compared to the Ps (
p
= 0.004 and
p
= 0.017, respectively). However, there was no difference when compared to the EA. In the phase 3, the EAs tended to perform more major hepatectomies (58.7) when compared to either the FT (30.6%) (
p
= 0.002) or the P’s cases 51–135 and after 135 (35.3% and 44.3%, respectively) (both
p
values < 0.001). When compared to the Ps cases from 51–135, the FT operated on more malignancies (
p
= 0.012), but this was no longer the case after 135 cases by the Ps (
p
= 0.164). There were no statistically significant differences when conversions; major complications or 30- and 90-day mortality were compared among these 3 groups.
Discussion
Using the IDEAL framework and RA-CUSUM curves, a FT surgeon was found to have curves similar to EAs despite having no previous independent experience operating on the liver. As in our study, FTs may tend to approach larger and more malignant tumors and do more concomitant procedures in patients with higher ASA classifications than either of their predecessors, without statistically significant increases in major morbidity or mortality.
Conclusion
It is possible that the ISP (i.e., initiation, standardization, proficiency) model could apply to other innovative surgical procedures, creating different learning curves depending on where along the IDEAL paradigm surgeons fall.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Although minor laparoscopic liver resections (LLRs) appear as standardized procedures, major LLRs are still limited to few expert teams. The aim of this study was to report the combined data of 18 ...international centers performing major LLR. Variables evaluated were number and type of LLR, surgical indications, number of synchronous colorectal resections, details on technical points, conversion rates, operative time, blood loss and surgical margins. From 1996 to 2014, a total of 5388 LLR were carried out including 1184 major LLRs. The most frequent indication for laparoscopic right hepatectomy (LRH) was colorectal liver metastases (37.0%). Seven centers used hand assistance or hybrid approach selectively for LRH mostly at the beginning of their experience. Seven centers apply Pringle's maneuver routinely. The conversion rate for all major LLRs was 10% and mean operative time was 291 min. Mean estimated blood loss for all major LLR was 327 ml and negative surgical margin rate was 96.5%. Major LLRs still remain challenging procedures requiring important experience in both laparoscopy and liver surgery. Stimulating the younger generation to learn and accomplish these techniques is the better way to guarantee further development of this surgical field.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained ...(FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques.
Method
We retrospectively reviewed a MI-HPB-FT surgeon’s 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery.
Results
From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (
p
= 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days),
p
< 0.001 and
p
= 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min),
p
< 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively,
p
= 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively,
p
= 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (
p
= 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (
p
= 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (
p
= 0.03).
Conclusion
FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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