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.

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.

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.

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.

The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma.

Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.

The Implications of Readmission on Cost and Patient Outcomes Following Distal Pancreatectomy and Splenectomy.

BACKGROUND: Robotic platform usage for distal pancreatectomy and splenectomy has grown exponentially in recent years. This study aims to identify the impact of readmission following robotic distal pancreatectomy and splenectomy and to analyze the financial implications of these readmissions. METHODS: We prospectively followed 137 patients after robotic distal pancreatectomy and splenectomy. Readmission was defined as rehospitalization within 30 days post-discharge. Total cost incorporated initial and readmission hospital costs, when applicable. Outcomes were analyzed using chi-square/Fisher's exact test and Student's t test. Data are presented as median (mean ± SD). RESULTS: Of 137 patients, 20 (14%) were readmitted. Readmitted patients were 67 (66 ± 10.3) years old and had a BMI of 30 (30 ± 7.0) kg/m2; 9 (45%) had previous abdominal operations. Non-readmitted patients were 67 (62 ± 14.7) years old and had a BMI of 28 (28 ± 5.7) kg/m2; 37 (32%) had previous abdominal operations (P = NS, for all). Readmitted patients vs non-readmitted patients had operative durations of 327 (363 ± 179.1) vs 251 (293 ± 176.4) minutes (P = .10), estimated blood loss (EBL) of 90 (159 ± 214.6) vs 100 (244 ± 559.4) mL (P = .50), and tumor diameter of 3 (4 ± 2.0) vs 3 (4 ± 2.9) cm (P = 1.00). Initial length of stay (LOS) for readmitted patients vs patients who were not readmitted was 5 (5 ± 2.7) vs 4 (5 ± 3.0) days (P = 1.00); total hospital cost of those readmitted, including both admissions, was $29,095 (32,324 ± 20,227.38) vs $24,663 (25,075 ± 10,786.45) (P = .018) for those not readmitted. DISCUSSION: Despite a similar perioperative course, readmissions were associated with increased costs. We propose thorough consideration before readmission and increased patient education initiatives will reduce readmissions after robotic distal pancreatectomy and splenectomy.

Causes of dissatisfaction after laparoscopic fundoplication: the impact of new symptoms, recurrent symptoms, and the patient experience.

BACKGROUND: Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication. METHODS: All patients undergoing laparoscopic fundoplication in the authors' series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from "very satisfying" to "very unsatisfying." Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported. RESULTS: Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication. CONCLUSIONS: Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time.

Laparo-endoscopic single-site (LESS) cholecystectomy with epidural vs. general anesthesia.

BACKGROUND: Laparo-endoscopic single-site (LESS) surgery involves a single umbilical incision, lending itself to epidural anesthesia. This prospective, randomized study was undertaken to evaluate epidural anesthesia for patients undergoing LESS cholecystectomy, to assess the feasibility, and to analyze all intraoperative and postoperative complications. The secondary objectives were to determine differences in postoperative pain and time until PACU discharge-to-home readiness between patients. METHODS: With institutional review board approval, 20 patients with chronic cholecystitis, cholelithiasis, and/or biliary dyskinesia were randomized to receive spinal epidural anesthesia (n = 10) or general anesthesia (n = 10). Postoperative pain at rest was recorded in the PACU every 10 min, and at rest and walking at discharge using the visual analog scale (VAS). Operative time and time until PACU discharge-to-home readiness were recorded. Results are expressed as mean ± SD. RESULTS: Patient age, American Society of Anesthesiologists class, and body mass index were similar. There were no additional ports/incisions, conversions to "open" operations, or conversions to general anesthesia. There were no differences in operative duration. Time until postanesthesia care unit discharge-to-home ready was not significantly different. The most common postoperative adverse event was urinary retention (1 epidural and 3 general anesthesia patients). Resting postoperative VAS pain score at discharge was 4.7 ± 2.5 vs. 2.2 ± 1.6 (p = 0.02, general versus epidural anesthesia respectively); the stressed VAS pain score at discharge was 6.1 ± 2.3 vs. 3.1 ± 2.8 (p = 0.02, general versus epidural anesthesia respectively). CONCLUSIONS: LESS cholecystectomy with epidural anesthesia was completed with no operative or anesthetic conversions, and less postoperative pain at discharge. Epidural anesthesia appears to be a preferable alternative to general anesthesia for patients undergoing LESS cholecystectomy.

Obesity portends increased morbidity and earlier recurrence following liver transplantation for hepatocellular carcinoma.

BACKGROUND: Obesity has been associated with poor oncologic outcomes following pancreatoduodenectomy for pancreatic cancer. However, there is a paucity of evidence on the impact of obesity on postoperative complications, oncologic outcome and survival in patients with hepatocellular carcinoma (HCC) undergoing orthotopic liver transplantation (OLT). METHODS: From a database of over 1000 patients who underwent OLT during 1996-2008, 159 patients with a diagnosis of HCC were identified. Demographic data, body mass index (BMI), perioperative parameters, recurrence and survival were obtained. Complications were grouped according to Clavien-Dindo grading (Grades I-V). RESULTS: There were increased incidences of life-threatening complications in overweight (58%) and obese (70%) patients compared with the non-obese patient group (41%) (P < 0.05). Furthermore, the incidence of recurrence of HCC was doubled in the presence of overweight (15%) and obesity (15%) compared with non-obesity (7%) (P < 0.05). Time to recurrence also decreased significantly. Differences in mean ± standard deviation survival in the overweight (45 ± 3 months) and obese (41 ± 4 months) groups compared with the non-obese group (58 ± 6 months) did not reach statistical significance. CONCLUSIONS: These findings indicate that BMI is an important surrogate marker for obesity and portends an increased risk for complications and a poorer oncologic outcome following OLT for HCC.

Simultaneous Resection of Colorectal Carcinoma and Hepatic Metastases is Safe and Effective: Examining the Role of the Robotic Approach.

BACKGROUNDS AND OBJECTIVES: Up to 50% of patients with colorectal carcinoma (CRC) present with liver metastases (CLM) throughout their course. Complete resection of both sites provides the only chance for cure. Either a staged or simultaneous resection is feasible. The latter avoids delays in adjuvant systemic chemotherapy but may increase technical complexity and perioperative complications. We aim to evaluate our initial outcomes of simultaneous CRC and CLM resections with a focus on the robotic technique. METHOD: With institutional review board approval, we followed 26 consecutive patients who underwent simultaneous/concomitant liver and colorectal resection. Major liver resection is defined as resection of ≥3 contiguous Couinaud segments. Data are presented as median (mean ± SD). RESULTS: Patients were 64 (63 ± 14.0) years old. Body mass index was 29 (29 ± 5.7) kg/m2. 54% of patients had prior abdominal operation(s). A majority of patients were >ASA class III (73%), underwent major liver resection (62%) with robotic approach (77%). In the robotic cohort, there were no unplanned conversions to open. Estimated blood loss was 150 (210 ± 181.8) ml. Total operative duration was 446 (463 ± 93.6) minutes. Negative margins (R0) were obtained in all patients. Postoperative complication of Clavien-Dindo≥3 occurred in three patients, including one requiring reoperation with end ileostomy for anastomotic leak. Length of stay was 5 (6 ± 3.5) days. Three patients were readmitted within 30 days after discharge, none for reoperation. There was no 90-day mortality. CONCLUSION: Our cohort of concomitant CRC and CLM resection demonstrates safety and efficacy via both the open and robotic approach.

Comparative Analysis of NSQIP National Outcomes and Projected Outcomes versus Our Institutional Outcomes for Robotic Gastrectomy: The Future of Gastric Resection.

BACKGROUND: The robotic approach has vast applications in surgery; however, the utility of robotic gastrectomy has yet to be clearly defined. This study aimed to compare outcomes following robotic gastrectomy at our institution to the national patient-specific predicted outcomes data provided by the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). METHODS: We prospectively studied 73 patients who underwent robotic gastrectomy under our care. ACS NSQIP outcomes after gastrectomy and predicted outcomes for our patients were compared with our actual outcomes utilizing students t test and chi-square analysis, where applicable. Data are presented as median (mean ± SD). RESULTS: Patients were 65 (66 ± 10.7) years old with a BMI of 26 (28 ± 6.5) kg/m2. 35 patients had gastric adenocarcinomas and 22 had gastrointestinal stromal tumors Operative duration was 245 (250 ± 114.7) minutes, estimated blood loss was 50 (83 ± 91.6) mL, and there were no conversions to 'open'. 1% of patients experienced superficial surgical site infections compared to the NSQIP predicted rate of 10% (P < .05). Length of stay (LOS) was 5 (6 ± 4.2) days vs NSQIP's predicted LOS of 8 (8 ± 3.2) days (P < .05). Three patients died during their postoperative hospital course (4%), due to multi-system organ failure and cardiac arrest. 1-year, 3-year, and 5-year estimated survival for patients with gastric adenocarcinoma was 76%, 63%, and 63%, respectively. DISCUSSION: Robotic gastrectomy yields salutary patient outcomes and optimal survival for varying gastric diseases, particularly gastric adenocarcinoma. Our patients experienced shorter hospital stays and reduced complications relative to patients in NSQIP and predicted outcome for our patients. Gastrectomy undertaken robotically is the future of gastric resection.

Survival and Robotic Approach for Pancreaticoduodenectomy: A Propensity Score-Match Study.

BACKGROUND: Robotic surgery is a burgeoning minimally invasive approach to pancreaticoduodenectomy. This study was undertaken to compare survival after robotic vs "open" pancreaticoduodenectomy for ductal adenocarcinoma using propensity score-matched patients. STUDY DESIGN: With institutional review board approval, we prospectively followed 521 patients who underwent robotic (n = 311) or open (n = 210) pancreaticoduodenectomy. Patients who underwent robotic (n = 75) or open (n = 75) pancreaticoduodenectomy were propensity score-matched by age, sex, and American Joint Committee on Cancer stage. Neoadjuvant therapy was rarely administered, and adjuvant therapy was stressed (FOLFIRINOX for patients <70 years of age and gemcitabine + nab-paclitaxel for patients >70 years of age). Data are presented as median (mean ± SD). RESULTS: Operative duration was longer and estimated blood loss and length of stay were less with robotic pancreaticoduodenectomy (421 [409 ± 94.0] vs 267 [254 ± 81.2] minutes; 307 [(150 ± 605.3] vs 444 [255 ± 353.1] mL; 7 [5 ± 5.1] vs 11 [8 ± 9.5] days; p < 0.00001 for all). There were no differences in complications (Clavien-Dindo class ≥III, p = 0.30), in-hospital mortality (p = 0.61), or 30-day readmission rates (p = 0.19). Median survival after robotic vs open pancreaticoduodenectomy was 37 vs 24 months (p = 0.08). For propensity score-matched patients, operative duration for robotic pancreaticoduodenectomy was longer (442 [438 ± 117.7] vs 261 [249 ± 67.1] minutes) and estimated blood loss was less (269 [200 ± 296.1] vs 468 [300 ± 394.9] mL), as was length of stay (7 [5 ± 5.1] vs 10 [7 ± 8.6] days; p < 0.00001 for all). There were no differences in complication rates (Clavien-Dindo class ≥ III, p = 0.31) or in-hospital mortality (p = 0.40); 30-day readmissions were fewer after robotic pancreaticoduodenectomy (7% vs 20%, p = 0.03). Median survival for the robotic vs the open approach was 41 vs 17 months (p = 0.02). CONCLUSION: Patients that underwent robotic pancreaticoduodenectomy had longer operations, less estimated blood loss, shorter length of stay, and fewer 30-day readmissions; they lived much longer than patients who underwent open pancreaticoduodenectomy. We believe that robotic pancreaticoduodenectomy provides salutary and survival benefits for reasons yet unknown.

Laparoendoscopic single-site Heller myotomy with anterior fundoplication for achalasia.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery is beginning to include advanced laparoscopic operations such as Heller myotomy with anterior fundoplication. However, the efficacy of LESS Heller myotomy has not been established. This study aimed to evaluate the authors' initial experience with LESS Heller myotomy for achalasia. METHODS: Transumbilical LESS Heller myotomy with concomitant anterior fundoplication for achalasia was undertaken for 66 patients after October 2007. Outcomes including operative time, complications, and length of hospital stay were recorded and compared with those for an earlier contiguous group of 66 consecutive patients undergoing conventional multi-incision laparoscopic Heller myotomy with anterior fundoplication. Symptoms before and after myotomy were scored by the patients using a Likert scale ranging from 0 (never/not severe) to 10 (always/very severe). Data were analyzed using the Mann-Whitney U test, the Wilcoxon matched-pairs test, and Fisher's exact test where appropriate. RESULTS: Patients undergoing LESS Heller myotomy were similar to those undergoing conventional laparoscopic Heller myotomy in gender, age, body mass index (BMI), blood loss, and length of hospital stay. However, the patients undergoing LESS Heller myotomies had operations of significantly longer duration (median, 117 vs. 93 min with the conventional laparoscopic approach) (p<0.003). For 11 patients (16%) undergoing LESS Heller myotomy, additional ports/incisions were required. No patients were converted to "open" operations, and no patients had procedure-specific complications. Symptom reduction was dramatic and satisfying after both LESS and conventional laparoscopic myotomy with fundoplication. The symptom reduction was similar with the two procedures. The LESS approach left no apparent umbilical scar. CONCLUSION: Heller myotomy with anterior fundoplication effectively treats achalasia. The findings showed LESS Heller myotomy with anterior fundoplication to be feasible, safe, and efficacious. Although the LESS approach increases operative time, it does not increase procedure-related morbidity or hospital length of stay and avoids apparent umbilical scarring. Laparoendoscopic single-site surgery represents a paradigm shift to more minimally invasive surgery and is applicable to advanced laparoscopic operations such as Heller myotomy and anterior fundoplication.

Robotic Complex Fundoplication in Patients at High-Risk to Fail.

BACKGROUND: This study was undertaken to analyze our outcomes after robotic fundoplication for GERD in patients with failed antireflux procedures, with type IV (i.e., giant) hiatal hernias, or after extensive intra-abdominal surgery with mesh, and to compare our results to outcomes predicted by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and to national outcomes reported by NSQIP. METHODS: 100 patients undergoing robotic fundoplication for the aforementioned factors were prospectively followed. RESULTS: 100 patients, aged 67 (67 ± 10.3) years with body mass index (BMI) of 26 (25 ± 2.9) kg/m2 underwent robotic fundoplication for failed antireflux fundoplications (43%), type IV hiatal hernias (31%), or after extensive intra-abdominal surgery with mesh (26%). Operative duration was 184 (196 ± 74.3) min with an estimated blood loss of 24 (51 ± 82.9) mL. Length of stay was 1 (2 ± 3.6) day. Two patients developed postoperative ileus. Two patients were readmitted within 30 days for nausea.Nationally reported outcomes and those predicted by NSQIP were similar. When comparing our actual outcomes to predicted and national NSQIP outcomes, actual outcomes were superior for serious complications, any complications, pneumonia, surgical site infection, deep vein thrombosis, readmission, return to OR, and sepsis (P < 0.05); our actual outcomes were not worse for renal failure, deaths, cardiac complications, and discharge to a nursing facility. CONCLUSIONS: Our patients were not a selective group; rather they were more complex than reported in NSQIP. Most of our results after robotic fundoplication were superior to predicted and national outcomes. The utilization of the robotic platform for complex operations and fundoplications to treat patients with GERD is safe and efficacious.

Impact of hospital and surgeon volumes in the management of complicated portal hypertension: review of a statewide database in Florida.

Mortality after complex surgical procedures has been shown to be inversely related to hospital volume. The purpose of this study was to determine whether these findings are applicable to radiologic and surgical procedures for complicated portal hypertension. The Agency for Healthcare Administration for the State of Florida database was queried to determine outcomes after transjugular intrahepatic stent shunts (TIPS) or surgical shunts from 2000 to 2003. A total of 1486 patients underwent either TIPS (1321) or surgical shunts (165). Natural breakpoints occurred at two and six procedures per year were correlated with survival for surgical shunts but not TIPS. Overall mortality was not different between TIPS and surgical shunts (11.0 vs. 12.7%, P = 0.51); however, the cost of TIPS was significantly lower (62,000 +/- 58.5 vs. 107,000 +/- 97.8, P < 0.001) as well as the length of hospitalization (9 +/- 9.0 days vs. 15 days +/- 12.6 days, P < 0.001). Surgical procedures for complicated portal hypertension are rapidly being replaced by TIPS. Like with other complex procedures, outcomes are related to hospital volume.

Surgical shunting versus transjugular intrahepatic portasystemic shunting for bleeding varices resulting from portal hypertension and cirrhosis: a meta-analysis.

Surgical shunting was the mainstay in treating portal hypertension for years. Recently, transjugular intrahepatic portasystemic shunting (TIPS) has replaced surgical shunting, first as a "bridge" to transplantation and ultimately as first-line therapy for bleeding varices. This study was undertaken to examine evidence from trials comparing TIPS with surgical shunting to reassess the role of surgery in treating portal hypertension. The National Library of Medicine and the National Institutes of Health were searched for clinical trials comparing surgical shunting with TIPS. Meta-analysis using the fixed effects model was undertaken with end points of 30-day and 1- and 2-year survival and shunt failure (inability to complete shunt, irreversible shunt occlusion, major rehemorrhage, unanticipated liver transplantation, death). Three prospective randomized trials and one retrospective case-controlled study were identified. Analysis was limited to patients of Child Classes A or B. Significantly better 2-year survival (OR 2.5 [1.2-5.2]) and significantly less frequent shunt failure (OR 0.3 [0.1-0.9]) were seen in patients undergoing surgical shunting compared with TIPS. Meta-analysis promotes surgical shunting relative to TIPS because of improved survival and less frequent shunt failure. Surgical shunting should be accepted as first-line therapy for bleeding varices resulting from portal hypertension.