Does the Artery-first Approach Improve the Rate of R0 Resection in Pancreatoduodenectomy?: A Multicenter, Randomized, Controlled Trial.

OBJECTIVE: To compare the rates of R0 resection in pancreatoduodenectomy (PD) for pancreatic and periampullary malignant tumors by means of standard (ST-PD) versus artery-first approach (AFA-PD). BACKGROUND: Standardized histological examination of PD specimens has shown that most pancreatic resections thought to be R0 resections are R1. "Artery-first approach" is a surgical technique characterized by meticulous dissection of arterial planes and clearing of retropancreatic tissue in an attempt to achieve a higher rate of R0. To date, studies comparing AFA-PD versus ST-PD are retrospective cohort or case-control studies. METHODS: A multicenter, randomized, controlled trial was conducted in 10 University Hospitals (NCT02803814, ClinicalTrials.gov). Eligible patients were those who presented with pancreatic head adenocarcinoma and periampullary tumors (ampulloma, distal cholangiocarcinoma, duodenal adenocarcinoma). Assignment to each group (ST-PD or AFA-PD) was randomized by blocks and stratified by centers. The primary end-point was the rate of tumor-free resection margins (R0); secondary end-points were postoperative complications and mortality. RESULTS: One hundred seventy-nine patients were assessed for eligibility and 176 randomized. After exclusions, the final analysis included 75 ST-PD and 78 AFA-PD. R0 resection rates were 77.3% (95% CI: 68.4-87.4) with ST-PD and 67.9% (95% CI: 58.3-79.1) with AFA-PD, P=0.194. There were no significant differences in postoperative complication rates, overall 73.3% versus 67.9%, and perioperative mortality 4% versus 6.4%. CONCLUSIONS: Despite theoretical oncological advantages associated with AFA-PD and evidence coming from low-level studies, this multicenter, randomized, controlled trial has found no difference neither in R0 resection rates nor in postoperative complications in patients undergoing ST-PD versus AFA-PD for pancreatic head adenocarcinoma and other periampullary tumors.

Textbook outcomes in the liver-first approach for colorectal liver metastases: prospective multicentre analysis.

BACKGROUND: Textbook outcome is a valuable tool for assessing surgical outcomes. The aim of this study was to analyse textbook-outcome rates in the prospective Spanish National Registry of the Liver-First Approach (RENACI Project) and the factors influencing textbook-outcome achievement. Additionally, a model for assessing a procedure-specific textbook outcome for the liver-first approach was proposed. METHODS: A retrospective analysis of a prospective and multicentre database that included consecutive patients with colorectal cancers and synchronous liver metastases who underwent a liver-first approach between June 2019 and August 2020 was performed. Two types of textbook outcome were measured: classic textbook outcome and liver-first-approach-specific textbook outcome (which included negative margins, no perioperative transfusion, no postoperative major surgical complications, no prolonged length of hospital stay, no readmissions, no mortality, and full treatment completion). The primary endpoint was textbook-outcome rate for a liver-first approach at 90 days. RESULTS: A total of 149 patients were included in the analysis. Classic and liver-first-approach-specific textbook-outcome rates were 71.8 per cent (107 patients) and 46 per cent (69 patients) respectively. Factors significantly associated with liver-first-approach-specific textbook-outcome achievement in the multivariable analysis were the number of metastases (OR 0.82 (95 per cent c.i. 0.73 to 0.92); P = 0.001) and intraoperative blood loss (OR 0.99 (95 per cent c.i. 0.99 to 1.00); P = 0.007). Prolonged length of hospital stay (33 patients, 41 per cent), positive margins (31 patients, 39 per cent), perioperative transfusion (27 patients, 34 per cent), and no full treatment completion (18 patients, 23 per cent) were the items that most frequently prevented liver-first-approach-specific textbook-outcome achievement. CONCLUSION: Liver-first-approach-specific textbook outcome is a promising tool for measuring the quality of care when using the liver-first approach for synchronous colorectal liver metastases.

Feasibility and Short-Term Outcomes in Liver-First Approach: A Spanish Snapshot Study (the RENACI Project).

(1) Background: The liver-first approach may be indicated for colorectal cancer patients with synchronous liver metastases to whom preoperative chemotherapy opens a potential window in which liver resection may be undertaken. This study aims to present the data of feasibility and short-term outcomes in the liver-first approach. (2) Methods: A prospective observational study was performed in Spanish hospitals that had a medium/high-volume of HPB surgeries from 1 June 2019 to 31 August 2020. (3) Results: In total, 40 hospitals participated, including a total of 2288 hepatectomies, 1350 for colorectal liver metastases, 150 of them (11.1%) using the liver-first approach, 63 (42.0%) in hospitals performing <50 hepatectomies/year. The proportion of patients as ASA III was significantly higher in centers performing ≥50 hepatectomies/year (difference: 18.9%; p = 0.0213). In 81.1% of the cases, the primary tumor was in the rectum or sigmoid colon. In total, 40% of the patients underwent major hepatectomies. The surgical approach was open surgery in 87 (58.0%) patients. Resection margins were R0 in 78.5% of the patients. In total, 40 (26.7%) patients had complications after the liver resection and 36 (27.3%) had complications after the primary resection. One-hundred and thirty-two (89.3%) patients completed the therapeutic regime. (4) Conclusions: There were no differences in the surgical outcomes between the centers performing <50 and ≥50 hepatectomies/year. Further analysis evaluating factors associated with clinical outcomes and determining the best candidates for this approach will be subsequently conducted.

Open versus laparoscopic hepatectomies within an ERAS (Enhanced Recovery After Surgery) program. Are there differences?

BACKGROUND: Laparoscopic procedures have gained popularity because they favor a faster recovery. In the same way, the establishment of an enhanced recovery after surgery (ERAS) program in major abdominal surgery has shortened the hospital stay. There are several studies that report the results on ERAS programs applied to open or laparoscopic hepatectomies or comparing one of them with the classic approach but few have compared the results between both within an ERAS program. OBJECTIVE: To compare the results between open and laparoscopic hepatectomies in the same ERAS program. METHOD: Thirty-six patients undergoing hepatectomies were enrolled in this study and were either laparoscopically or open in an identical ERAS program. Hospital stay and the number of complications were taken as primary end points. RESULTS: There were no significant differences between both groups in terms of hospital stay or number of complications. The differences were in a shorter time of surgery and an earlier ambulation in favor of open surgery and a better full recovery in favor of the laparoscopic approach. CONCLUSIONS: Initial data suggest that there would be no benefits in terms of hospital stay and complication rate of laparoscopic hepatectomies over open ones within an ERAS program.

ANTECEDENTES: Los procedimientos laparoscópicos ganaron popularidad porque favorecen una recuperación rápida. El establecimiento de programas ERAS (Enhanced Recovery After Surgery) en cirugía mayor abdominal ha acortado la estancia hospitalaria independientemente de la vía de abordaje. Varios trabajos informan los resultados sobre programas ERAS aplicados a hepatectomías abiertas o laparoscópicas, o comparando una de ellas con el abordaje clásico, pero pocos han comparado los resultados entre ambas dentro de un programa ERAS. OBJETIVO: Comparar, dentro un mismo programa ERAS, los resultados entre hepatectomías abiertas y laparoscópicas. MÉTODO: Se incorporaron a este estudio 36 pacientes sometidos a hepatectomías que fueron abordados por vía laparoscópica o abierta dentro de un programa ERAS. Los objetivos primarios fueron la estancia hospitalaria y el número de complicaciones. RESULTADOS: No hubo diferencias significativas entre ambos grupos en cuanto a estancia hospitalaria ni número de complicaciones. Las diferencias radicaron en un menor tiempo de cirugía y una deambulación más precoz a favor de la cirugía abierta, y una recuperación total mejor a favor del abordaje laparoscópico. CONCLUSIONES: Los datos iniciales sugieren que no habría beneficios en cuanto a estancia hospitalaria e índice de complicaciones de las hepatectomías laparoscópicas sobre las abiertas dentro de un programa ERAS.

Perforación rectal espontánea con evisceración transanal del intestino delgado. A propósito de un caso y revisión de la literatura / Spontaneous perforation of the rectum with transanal evisceration of the small bowel: A case report and review of the literature

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Comment on subvesical bile duct injury resolved by percutaneous drainage / Comentario sobre lesión del conducto subvesical resuelta por drenaje percutáneo

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