Short-Term Outcomes After Robotic Versus Open Liver Resection: A Systematic Review and Meta-analysis.

BACKGROUND: Robotic liver surgery is a novel technique expanding the field of minimally invasive approaches. An increasing number of studies assess the outcomes of robotic liver resections (RLR). The aim of our meta-analysis is to provide an up-to-date comparison of RLR versus open liver resections (OLR), evaluating its safety and efficacy. MATERIALS AND METHODS: A systematic search of MEDLINE, Scopus, Google Scholar, Cochrane, and Clinicaltrials.gov for articles published from January 2000 until January 2022 was undertaken. RESULTS: Thirteen non-randomized retrospective and one prospective clinical study enlisting 1801 patients met our inclusion criteria, with 640 patients undergoing RLR and 1161 undergoing OLR. RLR resulted in significantly lower overall morbidity (p < 0.001), shorter length of hospital stay (p = 0.002), and less intraoperative blood loss (p < 0.001). Operative time was found to be significantly higher in the RLR group (p < 0.001). Blood transfusion requirements, R0 resection, and mortality rates presented no difference among the two groups. The cumulative rate of conversion was 5% in the RLR group. CONCLUSION: The increasing experience in the implementation of the robot will undoubtedly generate more prospective randomized studies, necessary to assess its potential superiority over the traditional open approach, in a variety of hepatic lesions.

Safety and Efficacy of Laparoscopic Caudate Lobectomy: A Systematic Review.

Resection of the caudate lobe of the liver is considered a highly challenging type of liver resection due to the region's intimacy with critical vascular structures and deep anatomic location inside the abdominal cavity. Laparoscopic resection of the caudate lobe is considered one of the most challenging laparoscopic liver procedures. The objective of our systematic review was to evaluate the safety, technical feasibility and main outcomes of laparoscopic caudate lobectomy LCL. A systematic review of the literature was undertaken for studies published until September 2021. A total of 20 studies comprising 221 patients were included. Of these subjects, 36% were women, whereas the vast majority of resections (66%) were performed for malignant tumors. Tumor size varied significantly between 2 and 160 mm in the largest diameter. The mean operative time was 210 min (range 60-740 min), and estimated blood loss was 173.6 mL (range 50-3600 mL). The median hospital length of stay LOS was 6.5 days (range 2-15 days). Seven cases of conversion to open were reported. The vast majority of patients (93.7%) underwent complete resection (R0) of their tumors. Thirty-six out of 221 patients developed postoperative complications, with 5.8% of all patients developing a major complication (Clavien-Dindo classification ≥ III).No perioperative deaths were reported by the included studies. LCL seems to be a safe and feasible alternative to open caudate lobectomy OCL in selected patients when undertaken in high-volume centers by experienced surgeons.

Simultaneous robotic-assisted resection of colorectal cancer and synchronous liver metastases: a systematic review.

Simultaneous resections of primary colorectal cancer (CRC) and synchronous colorectal liver metastases (CRLM) have emerged as safe and efficient procedures for selected patients. Besides the traditional open approach for simultaneous resections, similar outcomes have been reported for minimally invasive approaches. Over the past years, a number of studies have sought to evaluate the safety and efficacy of simultaneous robotic-assisted resections (SRAR) for patients with synchronous CRC and CRLM. The objective of this systematic review is to evaluate the safety, technical feasibility and outcomes of SRAR of the primary CRC and CRLM. A comprehensive review of the literature was undertaken. Nine studies comprising a total of 29 patients (16 males) who underwent SRAR were considered eligible for inclusion. The primary tumor site was the rectum in 22 (76%) patients and the colon in 7 (24%) patients. A minor liver resection was performed in the majority of the cases (n = 24; 82%). The median operative time and estimated blood loss were 399.5 min (range 300-682) and 274 ml (range 10-780 ml), respectively. No cases of conversion to open were reported. The median LOS was 7 days (range 2-28 days). All patients reportedly underwent R0 resection. Overall and major morbidity rates were 38% and 7%, respectively, while no perioperative deaths were reported. Despite the limited number of studies, SRAR seems to be a safe and efficient minimally invasive approach for highly selected patients always implemented in the context of multidisciplinary patient management.

Is Single-Incision Laparoscopic Liver Surgery Safe and Efficient for the Treatment of Malignant Hepatic Tumors? A Systematic Review.

PURPOSE: The objective of this review was to evaluate the safety and efficiency of single-incision laparoscopic liver surgery (SILLS) for malignant liver lesions. METHODS: A retrospective review of the Medline database was performed, including studies published up to February 2019. RESULTS: Overall, 69 patients (50 males) with a median age of 61 years (range, 31-90) from 16 studies underwent SILLS for malignant liver disease and were included in this review. The majority of patients underwent resection for hepatocellular carcinoma (n = 52, 75 %), followed by metastatic disease (n = 15, 22 %). The hepatic lesions were located in anterolateral liver segments in 62 patients (90 %) and in posterosuperior liver segments in 7 patients (10 %). Sixty-five patients (94 %) underwent minor liver resection. The median blood loss was 200 mL (range 0-2500), while 4 patients that underwent single-port resection were converted to either conventional laparoscopy or open resections. Two cases were reported to be associated with postoperative complications in the single-port group (1 [1.7 %] grade Dindo-Clavien I-II, 1 [1.7 %] grade Dindo-Clavien III-IV), while no complications were noted in the multiport group. All patients successfully underwent R0 resection. CONCLUSIONS: SILLS seems to be a safe and efficient treatment modality for malignant liver disease when performed by experienced surgeons in carefully selected patients. More studies are needed to better identify which patients may benefit from such an operative approach.

Duodenocolostomy as Treatment of Ileus in Short Bowel Syndrome: A Case Report.

BACKGROUND Short bowel syndrome (SBS) is a malabsorption syndrome that results from an extensive intestinal resection or repeated small bowel resections. Postoperative small bowel obstruction is a well-known complication of abdominal surgeries requiring readmission and reoperation after failed conservative management. A combination of the above factors poses a clinical challenge for surgeons due to lack of applicable treatment options. CASE REPORT A 68-year-old man underwent repetitive laparotomies and multiple small bowel resections for an incarcerated inguinal hernia, resulting in SBS. Postoperative small bowel obstruction resulting from an anastomotic stricture near the ligament of Treitz made the patient unable to sustain oral nutrition. During reoperation, insufficient jejunum length and extensive intraabdominal adhesions led us to perform a primary side-to-side duodenocolonic anastomosis, which is an unusual treatment option. After a long but uncomplicated postoperative course, the patient was able to ingest solid foods and was discharged in healthy condition with parental nutritional support. CONCLUSIONS Duodenocolostomy can be a treatment of last resort in patients with limited surgical treatment options and can lead to a significant improvement of their quality of life.

The Emerging Role of Laparoscopic Liver Resection in the Treatment of Recurrent Hepatocellular Carcinoma: A Systematic Review.

BACKGROUND/AIM: Tumor recurrence complicates more than half of patients at 5 years after primary hepatocellular carcinoma (HCC) resection. Repeat open liver resection (ROLR) is the standard procedure for patients eligible for repeat resection, whereas laparoscopic repeat liver resection (RLLR) has been proposed as an alternative approach. The aim of this systematic review is to evaluate studies reporting on outcomes of RLLR for recurrent HCC (rHCC). MATERIALS AND METHODS: A comprehensive search of the literature was undertaken. RESULTS: A total of 11 studies, 6 non-comparative and 5 comparative (RLLR versus ROLR), which reported outcomes for 165 patients who underwent RLLR, were included in our review. RLLRs were associated with reduced blood loss, shorter hospital stay, lower conversion to ROLR and lower morbidity rates. CONCLUSION: Selected patients with rHCC who undergo RLLR, benefit in terms of short-term outcomes. Larger prospective trials will elucidate the impact of RLLR on long-term outcomes and establish treatment guidelines.

Intraluminal rectal cancer metastasis to the small bowel: An extremely rare case report.

Prolonged survival in patients suffering from colorectal cancer (CRC) may lead to the emergence of rare metastatic sites that are not well-documented in the literature. We herein describe a very rare case of an intraluminal small intestinal metastasis in a patient with previously resected CRC. A 71-year-old Caucasian male patient with a history of rectosigmoid junction cancer was initially treated with anterior resection. The tumor was classified as pT3pN0 (0/26) M0, stage II. Eighteen months after the primary surgery, local recurrence was detected in the presacral region, and the patient received combined image-guided radiotherapy and chemotherapy. Two months later, due to residual disease at the level of the anastomosis, the patient underwent additional low anterior resection with a diverting stoma. During extensive adhesiolysis, a small palpable intraluminal mass was identified in the jejunum, and segmental small bowel resection was performed. Pathological examination of the resected specimen confirmed that the lesion was a metastasis from the CRC primary. The precise mechanism and clinical significance of CRC metastasis to the small bowel remain unclear. There is limited clinical experience with this condition, as <20 cases have been reported in the literature to date. The main symptoms leading to evaluation, diagnosis and surgical resection are bowel obstruction and bleeding. The present case highlights the possibility of uncomplicated presence of metastatic CRC in the small bowel. Therefore, dilligent inspection of the peritoneal cavity, including the entire length of the gastrointestinal canal, is of paramount importance, particularly in cases of recurrent CRC.

Early Experience in Starting a Laparoscopic Liver Resection Program in Greece.

BACKGROUND AND OBJECTIVES: Laparoscopic liver resections (LLRs) have gained wider acceptance during the decade as safe and efficient procedures in the management of several benign and malignant diseases when performed by experienced surgeons. We report our initial institutional experience with LLRs performed by 1 certified hepatobiliary surgeon. METHODS: Patients undergoing LLRs by 1 senior hepatobiliary surgeon in our Institution during the period from January 2012 through January 2017 were prospectively sampled and retrospectively analyzed for the purposes of this study. RESULTS: Forty-two of 175 patients (24%) who had surgery for liver tumors underwent LLR. Median age was 64 years; median body mass index and Charlson comorbidity index were 27.3 kg/m2 and 6.5, respectively. Patients underwent resections for benign (n = 22) or malignant (n = 20) lesions. Median total operating time was 115 minutes and liver resections included: 1 left hepatectomy, 11 bisegmentectomies, 7 segmentectomies, 5 wide wedge resections, 1 left lateral sectionectomy combined with segmentectomy and radiofrequency ablation, 15 liver cyst unroofing, 1 laparoscopic drainage of a pyogenic liver abscess, and 1 laparoscopic drainage of a hepatic hydatid cyst. Blood transfusion was needed in 10 patients. Six patients (14%) had postoperative complications, none of which necessitated reoperation. None of the patients was admitted to the intensive care unit after surgery, and the median hospital stay was 4 days. The tumor-free resection margin was documented in all primary or secondary oncologic cases. CONCLUSIONS: Careful patient selection and compliance with the international recommendations are the keys for the successful introduction and evolution of an LLR program with a certified hepatobiliary surgeon with laparoscopic experience.

A rare anatomical variation of the biliary tree.

A 31-year-old woman was admitted to our department in order to undergo a laparoscopic cholecystectomy. The operation was converted to open due to cholorrhea during the dissection in the hepatocystic triangle. The cholorrhea came from a transected bile duct, which was 2 mm in diameter, came out of the hepatoduodenal ligament, ran along the common hepatic duct and drained into the cystic duct, in proximity to the neck of the gallbladder. The gallbladder was removed and an intraoperative cholangiography revealed that the aberrant bile duct was originated from the right posterior sectoral duct (RPSD). The RPSD continued its typical course up to its confluence with the right anterior sectoral duct and the formation of the right hepatic duct. This is a rare type of aberrant bile duct, which is added to the long catalogue of the anatomical variations of the biliary tree.

The value of staging laparoscopy in gastric cancer.

Treatment options for patients with gastric cancer (GC) are based on tumor staging and resectability. Although only surgery provides improved survival, resection is contraindicated and should be avoided in the presence of intra-abdominal disease stage M1 (liver, peritoneal, or non-local lymph node metastases). Thus, a detailed and precise evaluation is imperative for optimal treatment. Staging laparoscopy (SL) constitutes a major tool in the accurate diagnosis of several types of cancers, including GC. SL presents several critical advantages: it can diagnose intra-abdominal disease; serve as a complement to other imaging studies; allow for biopsies; facilitate intraoperative ultrasound evaluations; allow for sampling of peritoneal fluid for cytological examination; and serve as an option for the administration of intraperitoneal chemotherapy. Although considered and advocated as a very useful asset in the pre-treatment cancer-staging arsenal, the wider application of SL has been long debated. The purpose of our study was to evaluate the contribution of laparoscopy to GC staging.

Meta-meta-analysis: A paradigm in the case of surgical publications.

PURPOSE: Meta-analyses are considered to provide level I-II evidence. Based on this premise, several statements have been developed to standardize guidelines and optimize results. The purpose of this study was to investigate the quality of the information delivered by meta-analyses. METHODS: Meta-analyses published in Annals of Surgery during an 11-year period were reviewed whereas individual publications of each meta-analysis were assessed. An Excel database encompassing 29 parameters was constructed based on the Quality of Reporting of Meta-analyses (QUOROM) statement. RESULTS: The present study included 31 consecutive meta- analyses. The number of meta-analyses conforming with each of the parameters considered was as follows: information obtained from more than 2 databases 23/31; language of publication exclusively English 25/31; defined population, intervention, and principal outcomes 31/31; study design encompassing review of randomised controlled trials (RCTs) 10/31; quality assessment of contributing publications 10/31; handling of missing data 10/31; assessment of statistical heterogeneity 30/31; subgroup analysis 23/31; assessment of publication bias 26/31; agreement on selection and validity assessment 22/31; simple summary results 28/31; data available to calculate effect size and confidence interval 27/31; key findings summarized 30/31; clinical inferences based on internal and external validity 24/31; description of potential biases in the review process 23/31; future research agenda suggested 18/31. CONCLUSIONS: Evidence derived from meta-analyses must be interpreted with caution. Although QUOROM guidelines were observed, quality assessments showed considerable variability.

Trends in white blood cell and platelet indices in a comparison of patients with papillary thyroid carcinoma and multinodular goiter do not permit differentiation between the conditions.

AIM: Carcinogenesis has been related to systematic inflammatory response. Our aim was to study white blood cell and platelet indices as markers of this inflammatory response in thyroid cancer and to associate them with various clinicopathological parameters. METHODS: We included 228 patients who underwent thyroidectomy within a period of 54 months, 89 with papillary thyroid carcinoma and 139 with multinodular hyperplasia. We examined potential links between white blood cell and platelet indices on the one hand and the type thyroid pathology and various clinicopathological parameters on the other. RESULTS: No significant differences were detected between thyroid cancer and multinodular hyperplasia and no significant associations were detected with regard to lymphovascular invasion and tumor size. However, the mean platelet volume was higher in multifocal tumors, while the platelet count, plateletcrit, and platelet-to-lymphocyte ratio were increased in cases with extrathyroidal extension and in T3 tumors. Additionally, T3 tumors had lower platelet distribution width. These associations demonstrated low accuracy in predicting these pathological features, but they were found to provide a satisfying negative predictive value, with the exception of the mean platelet volume. CONCLUSIONS: White blood cell and platelet indices cannot assist in distinguishing benign goiter from thyroid cancer. However, they can provide information about tumor multifocality, extrathyroidal extension, and presence of a T3 tumor, and they may be used as a means to exclude these pathological characteristics, especially the last two, in papillary thyroid carcinoma.

Conventional transanal excision for a very low gastrointestinal stromal tumour.

Gastrointestinal stromal tumour (GIST) represents a rare tumour entity, which has been more intensively investigated during the last decade. The rectum as the primary site of GIST is even uncommon. The space constraints in the pelvis renders optimal oncological surgery demanding and proximity of these lesions to the anal sphincter enhances the potential morbidity of any radical surgery. We herein report on a young patient with a >5 cm rectal GIST localised at 1 cm from the anorectal junction.

Laparoscopic versus open liver resection for hepatocellular carcinoma: initial experience in Greece.

BACKGROUND: Liver resection represents the treatment of choice for a small proportion of patients with hepatocellular carcinoma (HCC), amenable to surgery. The remarkable evolution in surgical techniques during the last decades introduced laparoscopic hepatectomy in the operative management of HCC, even in the presence of liver cirrhosis. No comparative study on laparoscopic or open liver resection for HCC has been conducted in Greece yet. METHODS: Patients undergoing liver resection for HCC by one senior hepatobiliary surgeon in our Institution during the period 11/2011-02/2016 were prospectively sampled and retrospectively analyzed for the purposes of this study. Statistical analysis encompassed Student's t-test, Fisher's exact test, the Kaplan-Meier method/log rank test and Cox proportional hazard regression analyses. RESULTS: Eleven patients underwent laparoscopic and 21 open liver resection, respectively. Statistical differences between the 2 groups were observed for tumor size (P=0.04), major resections (P=0.01), Pringle maneuver (P=0.008), intraoperative blood transfusion (P=0.03), and duration of operation (P=0.004). Resection margins, and tumor recurrence showed no statistical differences. Three-year postoperative survival after laparoscopic and open hepatectomy was 100%, and 67%, respectively (P=0.06). Regression analysis for patient survival revealed prognostic value for BCLC staging, γ-glutamyl transferase levels, laparoscopic hepatectomy, UICC stage, Dindo-Clavien classification, and hospital stay. Laparoscopic hepatectomy remained as independent predictor of survival by multivariate analysis (P=0.0142). CONCLUSION: Laparoscopic hepatectomy for HCC in chronic liver disease represents a safe and innovative treatment tool in the management of these patients under the presupposition of careful patient selection.

Synchronous trifocal colorectal cancer.

Synchronous colorectal cancers (SCRCs) have been increasingly diagnosed due to emerging diagnostic modalities. The presence of three or more synchronous colorectal cancers has, however, only rarely been reported. A 76-year-old white man presented for management of two concurrent colorectal adenocarcinomas in the left colon evidenced on total colonoscopy. Preoperative abdominal ultrasonography and thoracoabdominal computed tomography were negative for metastatic disease. The patient underwent an elective left hemicolectomy. The pathology report ultimately showed the presence of three moderately differentiated, distinct colorectal cancers. The patient experienced an uneventful recovery.

Panniculitis: an unusual presenting manifestation of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a systemic inflammatory disease affecting primarily the joints but also other organs including skin. Panniculitis is an extremely rare manifestation of the disease manifesting mainly as reddish, ulcerative painful nodules and papules, usually in the legs. Histopathologically, it is characterised by liponecrobiosis, granulocytic and histiocytic infiltrates and vasculopathy. Herein, we describe a middle-aged woman with past medical history of hypertension and diabetes mellitus, and unremarkable family history, who presented with symmetrical polyarthritis, low grade fever and painful subcutaneous nodules in the abdomen. Her laboratory tests showed high acute phase reactants, positive rheumatoid factor and anti-Ro autoantibodies and negative anti-CCP. Surgical resection and histological examination of the nodules revealed neutrophilic lobular panniculitis associated with RA. She was treated with low doses of glucocorticosteroids and methotrexate. The latter was substituted with leflunomide due to toxicity. The patient had significant clinical and laboratory improvement.

A case report of successful treatment of pyoderma gangrenosum in a patient with autoimmune hepatitis, and review of the literature.

BACKGROUND: Pyoderma Gangrenosum (PG) is a cutaneous condition, its diagnosis suggested by the presence of a painful cutaneous ulcer showing rapid progression. Pyoderma gangrenosum is associated with a concomitant systemic disease in 50 to 70 % of cases, including inflammatory bowel disease (IBD), rheumatoid arthritis, and lymphoproliferative disorders. Although PG has also been reported with viral hepatitis, it is rarely associated with autoimmune hepatitis. CASE PRESENTATION: A 19-year-old Caucasian female, with a prior diagnosis of autoimmune hepatitis (AIH) in remission, presented with bilateral lower limb ulcers 4 years after the diagnosis of AIH. She was diagnosed with PG and treated with high-dose prednisolone, methotrexate and cyclosporine. One year later she was well, the ulcers completely healed, and with the autoimmune hepatitis still in remission. CONCLUSION: We report a case of autoimmune hepatitis and the subsequent, rarely occurring, extra-hepatic onset of pyoderma gangrenosum, with the AIH in remission, strengthening the association between the two conditions. Since both the AIH and the PG can present serious diagnostic challenges, thus delaying vital therapy, it is important that the development of either prompts us to consider the possibility of the other developing in the future or if already present facilitate its diagnosis, such considerations making the case for a systematic follow up.

Surgery for giant primary neuroendocrine carcinoma of the liver.

Liver resection for primary hepatic neuroendocrine carcinoma (phNEC) has only scarcely been reported in the literature. We herein report on a 19-year-old female with a solitary 27 × 13-cm-big phNEC, which was initially considered as hemangioma. An extended right hepatectomy (segments V-VIII, partially IVa) was performed. Resection margins were free of tumor (R0 resection). Ki67 expression was 35%. Postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. Two years after surgery, the patient remains disease-free and in good general condition. Large series and longer follow-up studies are required for the better understanding on this rare tumor entity.