Robotic Left Hepatectomy with En Bloc Biliary Resection and Roux-en-Y Hepaticojejunostomy: A Technique of Portal Venous Tangential Vascular Reconstruction.

BACKGROUND: Robotic technology is increasingly utilized in perihilar cholangiocarcinoma treatments, requiring expertise in minimally invasive liver surgeries and biliary reconstructions. These resections often involve vascular and multiple sectoral bile duct reconstructions. Minimally invasive vascular repairs are now emerging with promising outcomes, potentially altering criteria for selecting minimally invasive hepatobiliary tumor resections. In this multimedia article, we describe our technique of robotic portal venous tangential primary reconstruction with right sectoral bile duct unification ductoplasty for the treatment of perihilar cholangiocarcinoma using the robotic approach. METHODS: The robotic technique was chosen in this operation with preoperative anticipation of needing vascular resection and reconstruction due to left portal vein tumor involvement. Additionally, a Roux-en-Y hepaticojejunostomy to the right anterior and posterior sectoral duct was planned for biliary reconstruction. Proximal and distal vascular control of the portal vein bifurcation was obtained by placing vascular bulldog clamps across the main and right portal veins. Once an R0 vascular margin was obtained on the left portal vein, portal bifurcation was tangentially repaired. Perfusion to the liver was then restored, and left hemihepatectomy with en bloc extrahepatic biliary resection was carried out, followed by Roux-en-Y hepaticojejunostomy reconstruction to the right anterior and posterior sectoral bile ducts, as a single anastomosis. RESULTS: The operation was uneventful without vascular or biliary complications. Robotic unification ductoplasty circumvented the need for multiple anastomoses. CONCLUSION: The robotic approach for left-sided perihilar cholangiocarcinoma resections, requiring precise biliovascular management, is safe, feasible, and efficient. This method demonstrates the potential of robotic techniques as an alternative to traditional open surgery.

Clinical Outcomes of Robotic Resection for Perihilar Cholangiocarcinoma: A First, Multicenter, Trans-Atlantic, Expert-Center, Collaborative Study.

INTRODUCTION: Perihilar cholangiocarcinoma is a difficult cancer to treat with frequent vascular invasion, local recurrence, and poor survival. Due to the need for biliary anastomosis and potential vascular resection, the standard approach is an open operation. Suboptimal outcomes after laparoscopic resection had been sporadically reported by high-volume centers. In this first, Trans-Atlantic, multicenter study, we report our outcomes of robotic resection for perihilar cholangiocarcinoma. This is the largest study of its kind in the Western hemisphere. METHODS: Between 2016 and 2023, we prospectively followed patients undergoing robotic resection for perihilar cholangiocarcinoma at three, high-volume, robotic, liver-surgery centers. RESULTS: Thirty-eight patients underwent perihilar cholangiocarcinoma utilizing the robotic technique; Klatskin type-3 was the most common. The median age was 72 years, and 82% of the patients underwent preoperative biliary drainage. Median operative time was 481 minutes with a median estimated blood loss of 200 mL. The number of harvested lymph nodes was seven, and 11 (28%) patients yielded positive lymph nodes. Three patients required vascular reconstruction; 18% of patients had >1 biliary anastomosis. R0 resection margins were achieved in 82% of patients. Clavien-Dindo Grade ≥3 complications were seen in 16% of patients. The length of stay was 6 days. Five patients had an unplanned readmission within 30 days. One patient died within 30 days. With a median follow-up of 15 months, 68% of patients are alive without disease, 13% recurred, and 19% died. CONCLUSIONS: Application of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with acceptable short-term clinical and oncological outcomes.

A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS.

BACKGROUND: The increasing use of robotic systems for anti-reflux operations prompted this study to evaluate and compare the efficacy of robotic and Laparo-Endoscopic Single-Site (LESS) approaches. METHODS: From 2012, 228 robotic fundoplication and 518 LESS fundoplication patients were prospectively followed, analyzing perioperative metrics. Data are presented as median (mean ± SD); significance at p ≤ 0.05. RESULTS: Patients undergoing a robotic vs. LESS fundoplication were 67 (64 ± 13.7) vs. 61 (59 ± 15.1) years-old with BMIs of 25 (25 ± 3.2) vs. 26 (25 ± 3.9) kg/m2 (p = 0.001 and 1.00, respectively). 72% of patients who underwent the robotic approach had a previous abdominal operation(s) vs 44% who underwent the LESS approach (p = 0.0001). 38% vs. 8% had a re-operative fundoplication (p = 0.0001), 59% vs. 45% had a type IV hiatal hernia (p = 0.0004). Operative duration was 160 (176 ± 76.7) vs. 130 (135 ± 50.5) min (p = 0.0001). There were 0 (robotic) vs. 5 (LESS) conversions to a different approach (p = 0.33). 5 Patients vs. 3 patients experienced postoperative complications (p = 0.06), and length of stay (LOS) was 1 (2 ± 2.6) vs. 1 (1 ± 3.2) days (p = 0.0001). Patient symptomatic dysphagia preoperatively for the robotic vs. LESS approach was scored as 2 (2.4 ± 1.9) vs. 1 (1.9 ± 1.6). Postoperatively, symptomatic dysphagia was scored as 1 (1.5 ± 1.6) vs. 1 (1.7 ± 1.7). The change in these scores was - 1 (- 1 ± 2.2) vs. 0 (- 0.5 ± 2.2) (p = 0.004). CONCLUSION: Despite longer operative times and LOS in older patients, the robotic approach is efficient in undertaking very difficult operations, including patients with type IV or recurrent hiatal hernias. Furthermore, preoperative anti-reflux operations were more likely to be undertaken with the robotic approach than the LESS approach. The patient's postoperative symptomatic dysphagia improved relatively more than after the LESS approach. The vast majority of patients who underwent the LESS approach enjoyed improved cosmesis, thus, making LESS a stronger candidate for more routine operations. Despite patient selection bias, the robotic and LESS approaches to anti-reflux operations are safe, efficacious, and should be situationally utilized.

Epidural versus general anesthesia for laparo-endoscopic single-site cholecystectomy: a randomized controlled trial.

INTRODUCTION: This study compares outcomes after LESS cholecystectomy utilizing epidural versus general anesthesia. METHODS: Patients undergoing LESS Cholecystectomy were randomized into receiving epidural or general anesthesia by protocol. Patients used a Visual Analog Scale to rate pain from 0 (no pain) to 10 (severe pain). Data presented as median (mean ± standard deviation). RESULTS: 75 patients underwent LESS cholecystectomy with general anesthesia [32 patients (22% men) after five patients withdrew consent] or epidural anesthesia [23 patients (22% men) after 15 patients withdrew consent]. Respectively, they were of age 38 years (41 ± 15.1) and 47 years (48 ± 13.9), BMI 29 (28 ± 4.9) kg/m2 and 28 (28 ± 3.8) kg/m2, and ASA 2 (2 ± 0.5) and 2 (2 ± 0.3) (p > 0.05 for all). LOS for patients receiving general vs. epidural anesthesia was 72 min (122 ± 104.4) vs. 95 min (113 ± 77.5) (p = 0.25). On POD 0, patients receiving general anesthesia rated pain as 4 (4 ± 2.9) vs. 0 (1 ± 2.2) for epidural anesthesia (p = 0.02). On POD 1, they rated pain as 6 (5 ± 2.3) vs. 6 (6 ± 2.9) (p = 0.68). On POD 6, patients rated pain as 3 (3 ± 2.7) vs. 4 (3 ± 2.2) (p = 1.00). For patient satisfaction with incisional scars for those receiving general vs. epidural anesthesia, patients rated their scars to be 10 (8 ± 3.6) vs. 10 (9 ± 1.2) (p = 0.21). Total costs for the hospital using general vs. epidural anesthesia were found $6,909 (7,167 ± 2,083.8) vs. $6,225 (5,848 ± 1530.1) (p = 0.014), respectively. Patients self-assessed satisfaction on a scale of 1 (worst) to 5 (best) as a 5 (5 ± 0). CONCLUSIONS: Patients undergoing LESS cholecystectomy with general vs. epidural anesthesia had similar demographics, LOS, and pain scores. Patients that received epidural anesthesia reported less pain and incurred less cost. Utilization of epidural anesthesia in lieu of general anesthesia for LESS cholecystectomy is safe, reduces pain, and offers potential cost savings.

Unplanned conversions of robotic pancreaticoduodenectomy: short-term outcomes and suggested stepwise approach for a safe conversion.

OBJECTIVE: With the increased adoption of robotic pancreaticoduodenectomy, the effects of unplanned conversions to an 'open' operation are ill-defined. This study aims to describe the impact of unplanned conversions of robotic pancreaticoduodenectomy on short-term outcomes and suggest a stepwise approach for safe unplanned conversions during robotic pancreaticoduodenectomy. METHODS: This is an analysis of 400 consecutive patients undergoing robotic pancreaticoduodenectomy in a single high-volume institution. Data are presented as median (mean ± SD), and significance is accepted with 95% probability. RESULTS: Between November 2012 and February 2023, 184 (46%) women and 216 (54%) men, aged 70 (68 ± 11.0) years, underwent a robotic pancreaticoduodenectomy. Unplanned conversions occurred in 42 (10.5%) patients; 18 (5%) were converted due to unanticipated vascular involvement, 13 (3%) due to failure to obtain definitive control of bleeding, and 11 (3%) due to visceral obesity. Men were more likely to require a conversion than women (29 vs. 13, p = 0.05). Conversions were associated with shorter operative time (376 (323 ± 182.2) vs. 434 (441 ± 98.7) min, p < 0.0001) but higher estimated blood loss (675 (1010 ± 1168.1) vs. 150 (196 ± 176.8) mL, p < 0.0001). Patients that required an unplanned conversion had higher rates of complications with Clavien-Dindo scores of III-V (31% vs. 12%, p = 0.003), longer length of stay (8 (11 ± 11.6) vs. 5 (7 ± 6.2), p = 0.0005), longer ICU length of stay (1 (2 ± 5.1) vs. 0 (0 ± 1.3), p < 0.0001) and higher mortality rates (21% vs. 4%, p = 0.0001). The conversion rate significantly decreased over time (p < 0.0001). CONCLUSIONS: Unplanned conversions of robotic pancreaticoduodenectomy significantly and negatively affect short-term outcomes, including postoperative mortality. Men were more likely to require a conversion than women. The unplanned conversions rates significantly decreased over time, implying that increased proficiency and patient selection may prevent unplanned conversions. An unplanned conversion should be undertaken in an organized stepwise approach to maximize patient safety.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience.

BACKGROUND: Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes. METHODS: This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD). RESULTS: From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3 ± 0.5; the MELD score was 9 ± 4.1; the Child-Pugh score was 6 ± 1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272 min, and the average blood loss amounted to 79 mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4 days, with a readmission rate of 15% within 30 days. During an average follow-up period of 33 months, one patient had to undergo a revision at 18 months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities. CONCLUSIONS: Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Outcomes after pancreaticoduodenectomy with or without preoperative hyperbaric oxygen therapy.

Background: Hyperbaric oxygen (HBO2) therapy is an alternative method against the deleterious effects of ischemic/reperfusion (I/R) injury and its inflammatory response. This study assessed the effect of preoperative HBO2 on patients undergoing pancreaticoduodenectomy. Study Design: Patients were randomized via a computer-generated algorithm. Patients in the HBO2 cohort received two sessions of HBO2 the evening before and the morning of surgery. Measurements of inflammatory mediators and self-assessed pain scales were determined pre-and postoperatively. In addition, perioperative variables and long-term survival were collected and analyzed. Data are presented as median (mean ± SD). Results: 33 patients were included; 17 received preoperative HBO2, and 16 did not. There were no intraoperative or postoperative statistical differences between patients with or without preoperative HBO2. Erythrocyte sedimentation rate (ESR), IL-6, and IL-10 increased slightly before returning to normal, while TGF-alpha decreased before increasing. However, there were no differences with or without HBO2. At postoperative day 30, the pain level measured with VAS score (Visual Analog Score) was lower after HBO2 (1 ± 1.3 vs. 3 ± 3.0, p=0.05). Eleven (76%) patients in the HBO2 cohort and 12 (75%) patients in the non- HBO2 had malignant pathology. The percentage of positive lymph nodes in the HBO2 was 7% compared to 14% in the non-HBO2 (p<0.001). Overall survival was inferior after HBO2 compared to the non- HBO2 (p=0.03). Conclusions: Preoperative HBO2 did not affect perioperative outcomes or significantly change the inflammatory mediators for patients undergoing robotic pancreaticoduodenectomy. Long-term survival was inferior after preoperative HBO2. Further randomized controlled studies are required to assess the full impact of this treatment on patients' prognosis.

New generation evaluations: video-based surgical assessments : A technology update.

BACKGROUND: Surgical skill training, assessment, and feedback are the backbone of surgical training. High-quality skills require expert supervision and evaluation throughout a resource-intensive multi-year training process. As technological barriers to internet access and the ability to save and upload surgical videos continue to improve, video-based assessment technology is emerging as a tool that could reshape surgical training for the next generation of surgeons. Video-based assessment platforms have the potential to allow surgeons from across the globe to upload their surgical videos online and receive high-quality, standardized, and unbiased feedback. They combine visual recordings of a surgeon's operative technique, with standardized grading tools that have the potential to significantly impact surgical training and technical skill acquisition across the world. METHOD: The platforms included in this review are in various stages of development after a thorough discussion with national experts on the SAGES TAVAC (Technology and Value Assessments) Committee. For each VBA program, a description of its platform was given and a literature review was obtained using a PubMed search performed from inception until December 2021. RESULTS: The study reviewed all video-based assessment programs currently available in the market, identified their strengths and weaknesses, and how they can be optimized in future. CONCLUSION: The technological platforms will play a key role in the training and technical skill acquisition of the next generation of surgeons and can have an immense impact on patient care across the world. There is immense potential for all these platforms to grow and become incorporated within the framework of an effective surgical training program.

Robotic Extrahepatic Biliary Resection with Roux-en-Y Hepaticojejunostomy for Type 2 Klatskin Tumor.

BACKGROUND: Despite the widespread of laparoscopic technique in hepatobiliary tumor resection, nearly all Klatskin tumor resection is undertaken using an open approach (Marino et al. in Updates Surg 72(3):911-912. https://doi.org/10.1007/s13304-020-00777-8 ; Sucandy et al. in Am Surg, 2020. https://doi.org/10.1177/0003134820956336 , Am Surg, 2020;86(3):200-207; Luberice et al. in HPB (Oxford), 2020. https://doi.org/10.1016/j.hpb.2020.10.008 ; Ciria et al. in J Hepatobiliary Pancreat Sci, 2020. https://doi.org/10.1002/jhbp.869 ; Chong and Choi in J Gastrointest Surg 23(9):1947-19488, 2019. https://doi.org/10.1007/s11605-019-04242-9 ). A minimally invasive approach for malignant extrahepatic biliary resection is rarely used due to technical complexity and concerns of oncological inferiority. In the United States, robotic technique for Klatskin tumor resection has not been adequately described. This video described our technique of robotic extrahepatic biliary resection with Roux-en-Y hepaticojejunostomy (HJ) for type 2 Klatskin tumor. METHODS: A 77-year-old man presented with obstructive jaundice. Endobiliary brushing confirmed adenocarcinoma. MRI/MRCP showed a focal lesion at the cystic duct entrance into the common hepatic duct, extending cephalad toward the biliary bifurcation. No obvious vascular invasion was identified on the CT scan. RESULTS: The operation was undertaken using a six-port technique. Systematic portal dissection was undertaken to identify the bile duct at the level of the pancreas up toward the hepatic hilum. A partial Kocher maneuver was performed to expose the area dorsal to the distal common bile duct, which allows for a more thorough lymphadenectomy and facilitates creation of a later tension-free hepaticojejunostomy. The distal common bile duct was transected, and the distal margin was sent for frozen section. The right hepatic artery coursing posterior to the common hepatic duct was skeletonized and preserved. Biliary duct bifurcation was transected at the level of the right and left duct, removing the cancer completely. Portal lymphadenectomy was completed as part of oncological staging and treatment. A total of eight lymph nodes were removed and all confirmed to be nonneoplastic on the final pathology report. For the purpose of the biliary reconstruction, a standard side-to-side stapled jejunojejunostomy was created. A jejunal mesenteric defect was closed to prevent a future internal herniation. A 60-cm Roux limb was transposed antecolically for the Roux-en-Y hepaticojejunostomy. A running technique was used to create a watertight end-to-side bilioenteric anastomosis, using 3-0 barbed sutures, 6 inches in length. A closed suction drain was placed before closing. Pathology report confirmed intraductal papillary adenocarcinoma with R-0 resection margins (proximal, distal, and radial margin). Perineural invasion was present; however, lymphovascular invasion was not identified. Total operative time was 240 minutes with 75 ml of estimated blood loss. The postoperative recovery was uneventful. One-year follow-up showed no evidence of disease recurrence or HJ anastomotic stricture. CONCLUSIONS: This video demonstrates a safe and feasible application of the robotic platform in extrahepatic bile duct cancer resection requiring fine biliary reconstruction.

Robotic resection of extrahepatic cholangiocarcinoma: Institutional outcomes of bile duct cancer surgery using a minimally invasive technique.

BACKGROUND AND OBJECTIVES: The purpose of this study is to report our early experience and outcomes, the first in North America, of Extrahepatic Cholangiocarcinoma (EHC) resection with Roux-en Y Hepaticojejunostomy reconstruction via the robotic approach. METHODS: With Institutional Review Board approval, 15 patients who underwent robotic resection of EHC were studied. RESULTS: Patients were 74 (73 ± 8.9) years of age. There were 9 men and 6 women. Average body mass index was 24 (27 ± 6.3) kg·m-2 . Mean & Median ASA class was 3. Median Tumor size was 2 (2 ± 1.3) cm. There were no intraoperative complications. Operative duration was 453 (443 ± 85.0) minutes and the estimated blood loss was 150 (182 ± 138.4) ml. No patient required admission to the intensive care unit. Hospital length of stay was 4 (6 ± 3.2) days. There was one patient with Clavien-Dindo Class 3 or greater complication. No mortality was seen in this series. DISCUSSION: Robotic resection of EHC is safe, feasible, and reproducible with excellent clinical outcomes. Consequently, the robotic technique should be considered in some patients requiring EHC resection.

Propensity score matched comparison of robotic and open major hepatectomy for malignant liver tumors.

BACKGROUND: Outcome data on robotic major hepatectomy are lacking. This study was undertaken to compare robotic vs. 'open' major hepatectomy utilizing patient propensity score matching (PSM). METHODS: With institutional review board approval, we prospectively followed 183 consecutive patients who underwent robotic or 'open' major hepatectomy, defined as removal of three or more Couinaud segments. 42 patients who underwent 'open' approach were matched with 42 patients who underwent robotic approach. The criteria for PSM were age, resection type, tumor size, tumor type, and BMI. Survival was individually stratified for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (IHCC), and colorectal liver metastases (CLM). The data are presented as: median (mean ± SD). RESULTS: Operative duration for the robotic approach was 293 (302 ± 131.5) vs. 280 (300 ± 115.6) minutes for the 'open' approach (p = NS). Estimated Blood Loss (EBL) was 200 (239 ± 183.6) vs. 300 (491 ± 577.1) ml (p = 0.01). There were zero postoperative complications with a Clavien-Dindo classification ≥ III for the robotic approach and three for the 'open' approach (p = NS). ICU length of stay (LOS) was 1 (1 ± 0) vs. 2 (3 ± 2.0) days (p = 0.0001) and overall LOS was 4 (4 ± 3.3) vs. 6 (6 ± 2.7) days (p = 0.003). In terms of long-term oncological outcomes, overall survival was similar for patients with IHCC and CLM regardless of the approach. However, patients with HCC who underwent robotic resection lived significantly longer (p = 0.05). CONCLUSION: Utilizing propensity score matched analysis, the robotic approach was associated with a lower EBL, shorter ICU LOS, and shorter overall LOS while maintaining similar operative duration and promoting survival in patients with HCC. We believe that the robotic approach is safe and efficacious and should be considered a preferred alternative approach for major hepatectomy.

Men surgeons' perceptions of women surgeons: is there a bias against women in surgery?

BACKGROUND: Surgery has long been a man-dominated discipline with gender roles traditionally defined along societal norms. Presumably, as society has evolved, so have men surgeons' perceptions of women surgeons, though data are lacking. This study was undertaken to determine if men surgeons' perceptions of women surgeons represent a bias against women in Surgery. METHODS: 190 men surgeons were queried about attitudes toward women surgeons utilizing a validated questionnaire. The survey included binary, multiple choice, and Likert scale questions (1 = definitely disagree to 5 = definitely agree). RESULTS: 84% of the men surgeons have been attending surgeons for more than 5 years; 80% deem women surgeons as capable as their man colleagues. 80% of respondents consider it possible for a woman to be a good surgeon, mother, and spouse; however, 76% believe women surgeons experience more pressure to balance work and family. 75% of the men surgeons think women surgeons have the same advancement opportunities as men, though 30% believe gender discrimination exists in Surgery. 45% of the respondents consider the "surgical discipline" accountable for fewer women finishing training, yet 57% think the rate of women entering Surgery is not a problem to address. CONCLUSION: While most men surgeons have favorable opinions of the personal and professional abilities of women surgeons, favorable opinions are not universal; a bias against women persists in Surgery. Considering most medical students today are women, the discipline of Surgery dismisses this talent pool only to its detriment. Surgery, and men in Surgery specifically, must evolve to eliminate bias against women in Surgery, promoting an equitable and inclusive work environment for the betterment of Surgery and all its stakeholders, including patients.

Heller myotomy with esophageal diverticulectomy: an operation in need of improvement.

BACKGROUND: This study was undertaken to evaluate the outcomes after laparoscopic Heller myotomy with anterior fundoplication and diverticulectomy for patients with achalasia and esophageal diverticula. METHODS: 634 patients undergoing laparoscopic Heller myotomy and anterior fundoplication from 1992 to 2015 are prospectively followed up; patients were stratified for those undergoing concomitant diverticulectomy. Patients graded symptom frequency and severity before and after myotomy, using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Median data are presented (mean ± SD). RESULTS: Forty-four patients, age 70 years (65 ± 14.2), underwent laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 182 min (183 ± 54.6). Fifty percentage of patients had a postoperative complication: Most notable were leaks at the diverticulectomy site (n = 8) and pulmonary complications (n = 11; 10 effusion, 1 empyema). Length of stay (LOS) was 3 days (5 ± 8.3). All leaks occurred after discharge and resolved without sequelae using transthoracic catheter drainage and parenteral nutrition; two patients received endoscopic esophageal stents. Median follow-up is 39 months. Symptoms amelioration was significant postoperatively, including severity of dysphagia [6 (6 ± 3.9) to 2(4 ± 3.6)]. Seventy-six percentage of patients rated their symptoms at last follow-up as satisfying/very satisfying. Seventy-seven percentage of patients had symptoms once per week or less. Eighty-one percentage would have the operation again knowing what they know now. CONCLUSIONS: Laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy well palliate the symptoms of achalasia with accompanying esophageal diverticulum. The operations are generally longer than those without diverticulectomy and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). In particular, leaks at the diverticulectomy site are unpredictable, occur after discharge, and remain vexing. Nevertheless, for this advanced form of achalasia, long-term symptom relief and patient satisfaction are high after anterior fundoplication with concomitant diverticulectomy. New and innovative techniques are needed to decrease the frequency of leaks at the diverticulectomy site.

A comprehensive process for disclosing and managing conflicts of interest on perceived bias at the SAGES annual meeting.

INTRODUCTION: The relationship between the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and its industry partners has been longstanding, productive technologically, and beneficial to patient care and education. In order to both maintain this important relationship to honor its responsibility to society for increasing transparency, SAGES established a Conflict of Interest Task Force (CITF) and charged it with identifying and managing potential conflicts of interest (COI) and limiting bias at the SAGES Annual Scientific Meetings. The CITF developed and implemented a comprehensive process for reporting, evaluating, and managing COI in accordance with (and exceeding) Accreditation Council for Continuing Medical Education guidelines. METHODS: From 2011 to 2013, all presenters, moderators, and session chairs received proactive and progressively increasing levels of education regarding the CITF rationale and processes and were required to disclose all relationships with commercial interests. Disclosures were reviewed and discussed by multiple layers of reviewers, including moderators, chairs, and CITF committee members with tiered, prescribed actions in a standardized, uniform fashion. Meeting attendees were surveyed anonymously after the annual meeting regarding perceived bias. The CITF database was then analyzed and compared to the reports of perceived bias to determine whether the implementation of this comprehensive process had been effective. RESULTS: In 2011, 68 of 484 presenters (14 %) disclosed relationships with commercial interests. In 2012, 173 of 523 presenters (33.5 %) disclosed relationships, with 49 having prior review (9.4 %), and eight required alteration. In 2013, 190 of 454 presenters disclosed relationships (41.9 %), with 93 presentations receiving prior review (20.4 %), and 20 presentations were altered. From 2008 to 2010, the perceived bias among attendees surveyed was 4.7, 6.2, and 4.4 %; and in 2011-2013, was 2.2, 1.2, and 1.5 %. CONCLUSION: It is possible to have a surgical meeting that includes participation of speakers that have industry relationships, and minimize perceived bias.

Pancreaticoduodenectomy in Florida: do 20-year trends document the salutary benefits of centralization of care?

BACKGROUND: Concentration of care has been promoted as fostering superior outcomes. This study was undertaken to determine if the concentration of care is occurring in Florida for a pancreaticoduodenectomy, and if so, is it having a salutary effect. METHODS: The data for a pancreaticoduodenectomy were obtained from the Florida Agency for Health Care Administration for three 3-year periods:1992-1994, 2001-2003, 2010-2012; data were sorted by surgeon volume of pancreaticoduodenectomy during these periods and correlated with post-operative length of stay (LOS), in-hospital mortality and hospital charges (adjusted to 2012 dollars). RESULTS: Relative to 1992-1994, in 2010-2012 46% fewer surgeons performed 115% more pancreaticoduodenectomies with significant reductions in LOS and in-hospital mortality, and higher charges (P < 0.001 for each). From 1992-1994 to 2010-2012 there was an 18-fold increase in the number of pancreaticoduodenectomies by surgeons completing ≥ 12 per year (n = 45 to n = 806, respectively). During 2010-2012, the more frequently surgeons performed a pancreaticoduodenectomy, the shorter LOS, the lower in-hospital mortality, the greater the likelihood of discharge home and the lower the hospital charges (P < 0.03 for each). CONCLUSIONS: Over the last 20 years, the concentration of care has occurred in Florida with substantially fewer surgeons undertaking many more pancreaticoduodenectomies with dramatic improvements in LOS and in-hospital mortality, albeit with increased hospital charges.

A single institution's experience with robotic resections of biliary tract cancers: an analysis of the short-term outcomes and long-term survival.

INTRODUCTION: Perihilar cholangiocarcinoma, intrahepatic cholangiocarcinoma (IHCC), and gall bladder cancer are difficult malignancies to treat and are characterized by a tendency for local recurrence and a generally unfavorable prognosis. Surgical resection offers the only potential cure, conventionally performed via the open approach. Although minimally invasive approaches show promise, data remain limited. METHODS: With the institutional review board's approval, we prospectively followed 100 patients between 2013 and 2023 who underwent robotic surgical resection for perihilar, IHCC, and gallbladder cholangiocarcinoma. Data are presented as median (mean ± SD). Significance was accepted at P ≤ .05. RESULTS: The median patient age was 70 years, and the median operative duration was 333 min, with an estimated blood loss of 200 mL. Importantly, no unplanned conversions occurred, and only 1 intraoperative complication occurred within the IHCC cohort. The median length of stay was 4 days. There were a total of 19 postoperative complications and 19 readmissions within 30 days. Additionally, there were 3 in-hospital mortalities and 5 90-day mortalities. R0 resection was achieved in 87% of patients and R1 resection in 13%. At a median follow-up of 36 months, 62% of patients demonstrated disease-free survival, whereas 6% continued to live with the disease, and 32% did not survive. CONCLUSION: Our experience demonstrates the feasibility and safety of robotic resection for these complex malignancies, yielding promising short-term outcomes. Further investigation is required to ascertain the long-term oncologic outcomes.

A decade of experience with 530 minimally invasive robotic hepatectomies from a single tertiary hepatobiliary center: analysis of short-term outcomes and oncologic survival.

BACKGROUND: This research is the first study in the United States to document more than a decade of experience with 530 patients who underwent robotic hepatectomy at a single high-volume institution. METHODS: With institutional review board approval, a prospectively collected database of consecutive patients who underwent robotic hepatectomy from 2012 to January 2024 was reviewed. Data are presented as median (mean ± SD). RESULTS: Of the 530 robotic hepatectomies, 231 (44.0%) were minor resections, 133 (25.0%) were technically major resections, and 166 (31.0%) were major resections. The patients were aged 63.0 (61.0 ± 14.7) years with a body mass index of 28.0 (29.0 ± 7.9) kg/m2. Cirrhosis was present in 80 patients (19.0%), with an American Society of Anesthesiologists score of 3.0 (3.0 ± 0.5) and a Model for End-Stage Liver Disease score of 7.0 (8.0 ± 3.0). Of note, 280 patients (53.0%) had previous abdominal operations, and 44 patients (8%) had previous liver resections. The operative time was 233.0 (260.0 ± 130.7) minutes, and the estimated blood loss was 100.0 (165.0 ± 205.0) mL. Moreover, 353 patients (66%) had hepatectomies for neoplastic disease, and 500 patients (95%) had an R0 resection margin. The tumor size was 4.0 (5.0 ± 3.6) cm. The total 90-day postoperative complications were 45 (8%), of which 21 (4%) were classified as major complications (Clavien-Dindo score of >III). The length of stay was 3.0 (4.0 ± 3.7) days, and the 30-day readmission rate was 86 (16%). The overall survival rates at 1, 3, and 5 years were 82%, 65%, and 59% for colorectal liver metastases, 84%, 68%, and 60% for hepatocellular carcinoma, and 79%, 61%, and 50% for intrahepatic cholangiocarcinoma, respectively. CONCLUSION: After a decade of application and optimization at a high-volume institution, the robotic approach has been demonstrated to be a safe and effective approach to liver resection.

Analysis of survival outcomes following robotic hepatectomy for malignant liver diseases.

BACKGROUND: Despite increased adoption of the robotic platform for complex hepatobiliary resections for malignant disease, little is known about long-term survival outcomes. This is the first study to evaluate the postoperative outcomes, and short- and long-term survival rates after a robotic hepatectomy for five major malignant disease processes. METHODS: A prospectively collected database of patients who underwent a robotic hepatectomy for malignant disease was reviewed. Pathologies included colorectal liver metastases (CLM), hepatocellular carcinoma (HCC), Klatskin tumor, intrahepatic cholangiocarcinoma (IHCC), and gallbladder cancer (GC). Data are presented as median (mean â€‹± â€‹standard deviation) for illustrative purposes. RESULTS: Of the 210 consecutive patients who underwent robotic hepatectomy for malignant disease, 75 (35 â€‹%) had CLM, 69 (33 â€‹%) had HCC, 27 (13 â€‹%) had Klatskin tumor, 20 (10 â€‹%) had IHCC, and 19 (9 â€‹%) had GC. Patients were 66 (65 â€‹± â€‹12.4) years old with a BMI of 29 (29 â€‹± â€‹6.5) kg/m2. R0 resection was achieved in 91 â€‹%, and 65 â€‹% underwent a major hepatectomy. Postoperative major complication rate was 6 â€‹%, length of stay was four (5 â€‹± â€‹4.3) days, and 30-day readmission rate was 17 â€‹%. Survival at 1, 3, and 5-years were 93 â€‹%/75 â€‹%/72 â€‹% for CLM, 84 â€‹%/71 â€‹%/64 â€‹% for HCC, 73 â€‹%/55 â€‹%/55 â€‹% for Klatskin tumor, 80 â€‹%/69 â€‹%/69 â€‹% for IHCC, 79 â€‹%/65 â€‹%/65 â€‹% for GC. CONCLUSION: This study suggests a favorable 5-year overall survival benefit with use of the robotic platform in hepatic resection for colorectal metastases, hepatocellular carcinoma, intrahepatic cholangiocarcinoma, Klatskin tumor, and gallbladder cancer. The robotic platform facilitates fine dissection in complex hepatobiliary operations, with a high rate of R0 resections and excellent perioperative clinical outcomes.

Do pre-operative endoscopic procedures, impact the surgical outcomes of robotic pancreaticoduodenectomy?

The role and risks of pre-operative endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound with fine needle aspiration (EUS/FNA), in patients undergoing robotic pancreaticoduodenectomy are not well-defined despite a broad consensus on the utility of these interventions for diagnostic and therapeutic purposes prior to major pancreatic operations. This study investigates the impact of such preoperative endoscopic interventions on perioperative outcomes in robotic pancreaticoduodenectomy. With Institutional Review Board (IRB) approval we retrospectively analyzed 772 patients who underwent robotic pancreatectomies between 2012 and 2023. Specifically, 430 of these patients underwent a robotic pancreaticoduodenectomy were prospectively evaluated: 93 (22%) patients underwent ERCP with EUS and FNA, 45 (10%) ERCP only, and 31 (7%) EUS and FNA, while 261 (61%) did not. Statistical analyses were performed using chi-square tests and Student's t-tests to compare perioperative outcomes between the two cohorts. Statistically significant differences were observed in patients who underwent a pre-operative endoscopic intervention and were more likely to have converted to an open operation (p = 0.04). The average number of harvested lymph nodes for patients who underwent preoperative endoscopic intervention was statistically significant compared to those who did not (p = 0.0001). All other perioperative variables were consistent across all cohorts. Patients who underwent endoscopic intervention before robotic pancreaticoduodenectomy were more likely to have an unplanned open operation. This study demonstrates the increased operative difficulties introduced by preoperative endoscopic interventions. Although there was no impact on overall patient outcomes, surgeons' experience can minimize the associated risks.