What are the true benefits of robotic pancreaticoduodenectomy for patients with pancreatic cancer?

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, and multimodal treatment including high-quality surgery can improve survival outcomes. Pancreaticoduodenectomy (PD) has evolved with minimally invasive approaches including the implementation of robotic PD (RPD). In this special report, we review the literature whilst evaluating the 'true benefits' of RPD compared to open approach for the treatment of PDAC. AREAS COVERED: We have performed a mini-review of studies assessing PD approaches and compared intraoperative characteristics, perioperative outcomes, post-operative complications and oncological outcomes. EXPERT OPINION: RPD was associated with similar or longer operative times, and reduced intra-operative blood loss. Perioperative pain scores were significantly lower with shorter lengths of stay with the robotic approach. With regards to post-operative complications, post-operative pancreatic fistula rates were similar, with lower rates of clinically relevant fistulas after RPD. Oncological outcomes were comparable or superior in terms of margin status, lymph node harvest, time to chemotherapy and survival between RPD and OPD. In conclusion, RPD allows safe implementation of minimally invasive PD. The current literature shows that RPD is either equivalent, or superior in certain aspects to OPD. Once more centers gain sufficient experience, RPD is likely to demonstrate clear superiority over alternative approaches.

Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 µmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.

Acute necrotising pancreatitis - early management in the district general hospital and tertiary hepato-pancreatico-biliary unit.

Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.

A randomised, single blinded trial, assessing the effect of a two week preoperative very low calorie diet on laparoscopic cholecystectomy in obese patients.

BACKGROUND: Laparoscopic cholecystectomy (LC) can be technically challenging in the obese. The primary aim of the trial was to establish whether following a Very Low Calorie Diet (VLCD) for two weeks pre-operatively reduces operation time. Secondary outcomes included perceived operative difficulty and length of hospital stay. METHODS: A single-blinded, randomized controlled trial of consecutive patients with symptomatic gallstones and BMI >30 kg/m(2) 46 patients were randomized to a VLCD or normal diet for two weeks prior to LC. Food diaries were used to document dietary intake. The primary outcome measure was operation time. Secondary outcomes were length of stay, weight change operative complications, day case rates and perceived difficulty of operation. RESULTS: The VLCD was well tolerated and had significantly greater preoperative weight loss (3.48 kg vs. 0.98 kg; p < 0.0001). Median operative time was significantly reduced by 6 min in the VLCD group (25 vs. 31 min; p = 0.0096). There were no differences in post-operative complications, length of stay, or day case rates between the groups. Dissection of Calot's triangle was deemed significantly easier in the VLCD group. CONCLUSION: A two week VLCD prior to elective laparoscopic cholecystectomy in obese patients is safe, well tolerated and was shown to significantly reduce pre-operative weight and operative time. ISRCTN: 61630192. http://www.isrctn.com/ISRCTN61630192 Trial registration.

The value of contrast studies in the evaluation of bowel strictures after necrotising enterocolitis.

PURPOSE: Strictures of the bowel are a frequent complication post-necrotising enterocolitis (NEC). Contrast studies are routinely performed prior to stoma closure following NEC. The aim of this study was to evaluate the ability of these studies to detect strictures and also directly compare them to operative and histological findings. METHODS: Two hundred and fourteen neonates who had a diagnosis of NEC (Bell stage 2 or greater) in a single unit (2007-2011) were analysed. Their case notes, radiology, and histology were reviewed. RESULTS: One hundred and sixteen neonates underwent an emergency laparotomy and 77 had stomas fashioned. Sixty-six patients had a contrast study prior to stoma closure (distal loopogram 18, contrast enema 37, both studies 11). Colonic strictures were reported in 18 patients and small bowel strictures were reported in two patients. Fourteen of these colonic strictures were confirmed at operation and on histology but three colonic strictures were missed on contrast studies; one patient had had both contrast studies and the other two only a distal loopogram. Two small bowel strictures reported were confirmed and an additional small bowel stricture missed on distal loopogram was also detected at the time of operation. The incidence of post-op strictures was 19 out of 68 patients (27.9 %) and 16 (84.2 %) of these strictures were found in the colon. Contrast enemas had a much higher sensitivity for detecting post-NEC colonic strictures than distal loopograms; 93 versus 50 %, respectively; however, they are more likely to give a false positive result and therefore their specificity is lower; 88 versus 95 %, respectively. CONCLUSION: Colon is the commonest site for post-NEC stricture and contrast enema is the study of choice for detecting these strictures prior to stoma closure.

A cross sectional study of colonic diverticulosis in the London Bangladeshi population.

BACKGROUND: Diverticular disease is the most common morphological abnormality of the colon and the fifth most important gastrointestinal disease in terms of cost in the Western world. Tower Hamlets is the poorest borough in London containing a large Bangladeshi community. We observed that emergency admissions with complications of colonic diverticulosis were minimal in the Bangladeshi community. The objective was to compare the background prevalence of colonic diverticulosis in Bangladeshis with other ethnicities in patients undergoing colonoscopy at a single centre in Tower Hamlets. METHODS: Four thousand four hundred and fifty-four consecutive colonoscopy reports over a 2-year period were retrospectively analysed. Patients under 40 years of age and repeat colonoscopies were excluded, leaving 3151 patients (mean age: 63 years; 48% male). Demographics including ethnicity and medical background were retrieved from the electronic patient record system and findings correlated with the prevalence of other 'Western' diseases in the cohort. RESULTS: Six hundred and thirty out of 3151 (20%) colonoscopies were performed on Bangladeshis. The prevalence of colonic diverticulosis was significantly lower in Bangladeshis (17/630: 2.7%) than Caucasians (673/1869: 36%), Indians/Pakistanis (16/161: 9.9%), Oriental (15/44: 34%) and Black (90/369: 24.4%) patient groups (χ(2) p < 0.0001 for all comparisons). The prevalence of classical sigmoid diverticulosis in the Bangladeshi cohort was only 1.0%, despite significantly more Bangladeshi patients undergoing colonoscopy for abdominal pain (p < 0.0001, χ(2)) and diarrhoea (p < 0.0034, χ(2)). There was also a significantly greater incidence of type 2 diabetes mellitus and ischaemic heart disease (p < 0.0001, χ(2)) in Bangladeshi patients. CONCLUSIONS: There is a negligible prevalence of colonic diverticulosis in the Bangladeshi population of London who undergo colonoscopy. This is in spite of a high incidence of type 2 diabetes and ischaemic heart disease. The effect of diet and genetics on the prevalence of colonic diverticulosis in Bangladeshis is not known and merits further investigation.