Laparoscopic versus open pancreatic resection for ductal adenocarcinoma: separate propensity score matching analyses of distal pancreatectomy and pancreaticoduodenectomy.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is a leading causes of cancer mortality worldwide. Currently, laparoscopic pancreatic resection (LPR) is extensively applied to treat benign and low-grade diseases related to the pancreas. The viability and safety of LPR for PDAC needs to be understood better. Laparoscopic distal pancreatectomy (LDP) and pancreaticoduodenectomy (LPD) are the two main surgical approaches for PDAC. We performed separate propensity score matching (PSM) analyses to assess the surgical and oncological outcomes of LPR for PDAC by comparing LDP with open distal pancreatectomy (ODP) as well as LPD with open pancreaticoduodenectomy (OPD). METHODS: We assessed the data of patients who underwent distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) for PDAC between January 2004 and February 2020 at our hospital. A one-to-one PSM was applied to prevent selection bias by accounting for factors such as age, sex, body mass index, and tumour size. The DP group included 86 LDP patients and 86 ODP patients, whereas the PD group included 101 LPD patients and 101 OPD patients. Baseline characteristics, intraoperative effects, postoperative recovery, and survival outcomes were compared. RESULTS: Compared to ODP, LDP was associated with shorter operative time, lesser blood loss, and similar overall morbidity. Of the 101 patients who underwent LPD, 10 patients (9.9%) required conversion to laparotomy. The short-term surgical advantage of LPD is not as apparent as that of LDP due to conversions. Compared with OPD, LPD was associated with longer operative time, lesser blood loss, and similar overall morbidity. For oncological and survival outcomes, there were no significant differences in tumour size, R0 resection rate, and tumour stage in both the DP and PD subgroups. However, laparoscopic procedures appear to have an advantage over open surgery in terms of retrieved lymph nodes (DP subgroup: 14.4 ± 5.2 vs. 11.7 ± 5.1, p = 0.03; PD subgroup 21.9 ± 6.6 vs. 18.9 ± 5.4, p = 0.07). These two groups did not show a significant difference in the pattern of recurrence and overall survival rate. CONCLUSIONS: Laparoscopic DP and PD are feasible and oncologically safe procedures for PDAC, with similar postoperative outcomes and long-term survival among patients who underwent open surgery.

Comparison of clinical outcomes and quality of life between laparoscopic distal pancreatectomy with or without spleen preservation.

BACKGROUND: The studies comparing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic distal pancreatosplenectomy (LDPS) are limited. This study aimed to compare clinical outcomes and quality of life of patients undergoing LSPDP and LDPS. METHODS: Between March 2004 and December 2014, patients who underwent laparoscopic distal pancreatectomy were reviewed. Patients were divided into 2 groups as LSPDP and LDPS. Data considered for comparison analysis were patient demographics, intraoperative variables, morbidity, postoperative hospital stay, mortality, pathologic findings, and quality of life (SF-36 questionnaire). RESULTS: A total of 110 patients (50 LSPDP and 60 LDPS) were included in the final analysis. Baseline characteristics were similar in the 2 groups. The LSPDP group had a significantly shorter operative time(153.3 ± 46.2 vs. 179.9 ± 54.1 min, p = 0.015) than the LDPS group. Also in analysis of propensity-matched population(LSPDP:LDPS = 35:35, 1:1 matching), LSPDP group still had a significantly shorter operative time (159.3 ± 36.2 vs. 172.9 ± 44.1 min, p = 0.045) than the LDPS group.There were no significant differences with respect to estimated blood loss, first flatus time, diet start time, and postoperative hospital stay. Postoperative outcomes, including morbidity, pancreatic fistula rates, and mortality, were similar in the LSPDP and LDPS group. On the follow-up survey, the total quality of life score (635.8 ± 50.7 vs. 596.1 ± 92.1)was higher in the LSPDP group compared with the LDPS group. However, the differences were not statistically significant(p > 0.05). The score in vitality (82.5 ± 14.4 vs. 68.9 ± 11.4, p = 0.046) was significantly higher in LSPDP group and not statistically significant in other areas (p > 0.05).Similar results of quality of life assessment were found in analysis of propensity-matched population. CONCLUSIONS: Compared to LDPS, LSPDP had shorter operating time and better quality of life with similar morbidity and recovery period.

Surgical outcomes of laparoscopic distal pancreatectomy in elderly and octogenarian patients: a single-center, comparative study.

BACKGROUND: Although recent reports have suggested the advantages of laparoscopic distal pancreatectomy (LDP), the potential benefits of this approach in elderly patients remain unclear. The aim of this study was to clarify the value of LDP in the elderly, in whom co-morbid diseases were generally more common. METHODS: Seventy elderly patients (≥ 70 years) and 264 non-elderly patients (40-69 years) who underwent LDP, and 48 elderly patients (≥ 70 years) who underwent open distal pancreatectomy (ODP) between May 2005 and May 2018 were studied. Demographics, intraoperative, and postoperative outcomes were compared. RESULTS: Comorbidity was more common in elderly patients than in non-elderly patients who underwent LDP (57.1 vs. 38.3%, p < 0.01). The intraoperative factors, postoperative complication rate, and length of hospital stay were comparable in these two groups. Elderly patients who underwent LDP had a significantly shorter operative time (185.5 vs. 208.0 min, p = 0.02), less blood loss (191.0 vs. 291.8 mL, p < 0.01), and reduced length of postoperative hospital stay (11.4 vs. 15.1 days, p < 0.01) than elderly patients who had ODP. The overall complication rate tended to be lower in LDP group than that in ODP group (20.0 vs. 33.3%, p = 0.07). CONCLUSION: LDP performed on the elderly is safe and feasible, leading to short-term outcomes similar to those of non-elderly patients. LDP could be an alternative to ODP in elderly patients, providing a lower rate of morbidity and favorable postoperative recovery and outcomes.

Short-term outcomes of laparoscopic total gastrectomy for gastric cancer: a comparative study with laparoscopic distal gastrectomy at a high-volume center.

BACKGROUND: Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, laparoscopic total gastrectomy (LTG) has been reported rarely when compared with LDG. This study was designed to evaluate the surgical outcomes as well as the morbidity and mortality of LTG compared with LDG to confirm the feasibility and safety of LTG. MATERIAL AND METHODS: We reviewed the data of patients at our institution undergoing LTG (n = 448) or LDG (n = 956) for gastric cancer between January 2008 and July 2016. Then the clinical characteristics and perioperative clinical outcomes of the two groups were compared. RESULTS: Except for tumor size and stage, there were no statistically significant differences in the clinicopathological parameters between the groups. LTG was associated with significantly longer operation time, late time to postoperative diet, and longer hospital stay compared with the LDG group. Overall complications developed in 60 patients (13.4%) and surgical complications in 48 patients (10.7%) after LTG. Postoperative complications were less frequent in the LDG group than in the LTG group (8.4% versus 13.4%, p < .01), and fewer surgical complications were observed with LDG than with LTG (7.5% versus 10.7%, p = .05). CONCLUSIONS: The results of LTG were favorable even though are not inferior to those of LDG. LTG for gastric cancer is technically feasible and safe. However, because of the limits of this study, other high-quality studies are needed for further evaluation.

Short-term outcomes of laparoscopic local resection for gastric submucosal tumors: a single-center experience of 266 patients.

BACKGROUND: Laparoscopic resections for submucosal tumors (SMTs) of the stomach have been developed rapidly over the past decade. Several types of laparoscopic methods for gastric SMTs have been created. We assessed the short-term outcomes of two commonly used types of laparoscopic local resection (LLR) for gastric SMTs and reported our findings. METHODS: We retrospectively analyzed the clinicopathological results of 266 patients with gastric SMTs whom underwent LLR between January 2006 and September 2016. 228 of these underwent laparoscopic exogastric wedge resection (LEWR), the remaining 38 patients with the tumors near the esophagogastric junction (EGJ) or antrum underwent laparoscopic transgastric resection (LTR). RESULTS: All the patients underwent laparoscopic resections successfully. The mean operation times of LEWR and LTR were 90.2 ± 37.2 min and 101.7 ± 38.5 min respectively. The postoperative length of hospital stays for LEWR and LTR were 5.1 ± 2.1 days and 5.3 ± 1.7 days respectively. There was a low complication rate (4.4%) and zero mortality in our series. CONCLUSION: ELWR is technically feasible therapy of gastric SMTs. LTR is secure and effective for gastric intraluminal SMTs located near the EGJ or antrum.

Laparoscopic versus open enucleation for pancreatic neoplasms: clinical outcomes and pancreatic function analysis.

BACKGROUND: The studies comparing laparoscopic enucleation (LE) with open enucleation (OE) are limited. This study aimed to compare perioperative outcomes of patients undergoing LE and OE and to assess the pancreatic function after LE. METHODS: Between February 2001 and July 2014, patients who underwent enucleation were reviewed. Patients were divided into two groups as LE and OE. Data considered for comparison analysis were patient demographics, intraoperative variables, morbidity, postoperative hospital stay, mortality, pathologic findings, and long-term follow-up (including pancreatic function). RESULTS: Thirty-seven patients (15 LE and 22 OE) were included in the final analysis. Baseline characteristics were similar in the two groups. LE group showed significantly shorter operating time (118.2 ± 33.1 vs. 155.2 ± 44.3 min, p = 0.009), lower estimated blood loss (80.0 ± 71.2 vs. 195.5 ± 103.4 ml, p = 0.001), shorter first flatus time (1.8 ± 1.0 vs. 3.4 ± 1.8 days, p = 0.004), shorter diet start time (2.4 ± 1.0 vs. 4.4 ± 2.0 days, p = 0.001), shorter postoperative hospital stay (7.9 ± 3.4 vs. 11.2 ± 5.7 days, p = 0.046). Postoperative outcomes, including morbidity (40.0 vs. 45.5 %, p = 1.000), grade B/C pancreatic fistula rates (20.0 vs. 13.6 %, p = 0.874), and mortality, were similar in the two groups. The median follow-up period was 47 months (range 7-163 months). No local recurrence or distant metastasis was detected in either group. Only one patient (4.8 %) underwent OE developed new-onset diabetes, in comparison with none in the LE group. One patient (7.1 %) had weight loss and received pancreatic enzyme supplementation in the LE group, in comparison with two patients (9.5 %) in the OE group. CONCLUSIONS: LE is a safe and feasible technique for the benign or low malignant-potential pancreatic neoplasms. Compared to OE, LE had shorter operating time, lower estimated blood loss, and faster recovery. LE could preserve the pancreatic function as the OE.

Totally laparoscopic versus laparoscopic-assisted total gastrectomy for upper and middle gastric cancer: a single-unit experience of 253 cases with meta-analysis.

BACKGROUND: Laparoscopic-assisted total gastrectomy (LATG) is the most commonly used methods of laparoscopic gastrectomy for upper and middle gastric cancer. However, totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult, especially for the intracorporeal esophagojejunostomy. We adopted TLTG with various types of intracorporeal esophagojejunostomy. In this study, we compared LATG and TLTG to evaluate their outcomes. METHODS: From March 2006 to September 2015, 253 patients with upper and middle gastric cancer underwent laparoscopic total gastrectomy (LTG), 145 patients underwent LATG, and 108 patients underwent TLTG. The clinicopathological characteristics and postoperative outcomes were retrospectively compared between the two groups. Furthermore, a systematic review and meta-analysis were conducted. RESULTS: The operation time and estimated blood loss were similar between the groups. There were no significant differences in first flatus, diet initiation, and postoperative hospital stay. The surgical complication rates were 17.2% (25/145) and 13.9% (15/108) in the LATG and TLTG groups, respectively. The meta-analysis also revealed no significant differences in the operation time, estimated blood loss, time to first flatus, length of hospital stay, overall, and anastomosis-related complications among the groups. CONCLUSIONS: TLTG is a feasible choice for gastric cancer patients, with comparable results to the LATG approach.

Totally laparoscopic gastrectomy using intracorporeally stapler or hand-sewn anastomosis for gastric cancer: a single-center experience of 478 consecutive cases and outcomes.

BACKGROUND: Totally laparoscopic gastrectomy (TLG) using intracorporeal anastomosis has gradually become mature thanks to the advancements of laparoscopic surgical instruments and the accumulation of operative experience. The goal of this study is to review our institution's experience with TLG for the treatment of gastric cancer. METHODS: A retrospective study was conducted to examine the short-term outcomes of TLG using intracorporeally stapler or hand-sewn anastomosis performed at Sir Run Run Shaw Hospital between March 2007 and June 2015. The details of intracorporeal anastomosis were described, and the clinicopathological data, surgical outcomes, and postoperative complications were evaluated. RESULTS: Four hundred seventy-eight patients were included in the study. Generally speaking, the patients could be divided into stapler or hand-sewn groups according to whether intracorporeal anastomosis was performed by only hand-sewn technique (n = 97) or only stapling devices (n = 381). For overall patients, the mean operation time and anastomotic time were 225.7 and 30.0 min, respectively. Postoperative complications were observed in 65 patients. All of the patients recovered well without perioperative death by conservative or surgical management. CONCLUSIONS: TLG using intracorporeally stapler or hand-sewn anastomosis is a reasonable option for the treatment of gastric cancer, with early data showing acceptable perioperative outcomes.

Comparing the short-term outcomes of intracorporeal esophagojejunostomy with extracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer.

BACKGROUND: Totally laparoscopic distal gastrectomy (TLDG) using intracorporeal anastomosis has gradually developed due to advancements in laparoscopic surgical instruments. However, totally laparoscopic total gastrectomy (TLTG) with intracorporeal esophagojejunostomy (IE) is still uncommon because of technical difficulties. Herein, we evaluated various types of IE after TLTG in terms of the technical aspects. We compared the short-term operative outcomes between TLTG with IE and laparoscopy-assisted total gastrectomy (LATG) with extracorporeal esophagojejunostomy (EE). METHODS: Between March 2006 and December 2014, a total of 213 patients with gastric cancer underwent TLTG and LATG. Overall, 92 patients underwent TLTG with IE, and 121 patients underwent LATG with EE. Generally, there are two methods of IE: mechanical staplers (circular or linear staplers) and hand-sewn sutures. Surgical efficiencies and outcomes were compared between two groups. We also described various types of IE using a subgroup analysis. RESULTS: The mean operation times were similar in the two groups, as was the number of retrieved lymph nodes. However, the mean estimated blood loss of TLTG was statistically lower than LATG. There were no significant differences in time to first flatus, the time to restart oral intake, the length of the hospital stay after operation, and postoperative complications. Four types of IE have been applied after TLTG, including 42 cases of hand-sewn IE. The overall mean operation time and the mean anastomotic time in TLTG were 279.5 ± 38.4 min and 52.6 ± 18.9 min respectively. There was no case of conversion to open procedure. Postoperative complication occurred in 16 patients (17.4%) and no postoperative mortality occurred. CONCLUSIONS: IE is a feasible procedure and can be safely performed for TLTG with the proper laparoscopic expertise. It is technically feasible to perform hand-sewn IE after TLTG, which can reduce the cost of the laparoscopic procedure.

[Single-incision laparoscopic surgery with self-made port for totally extraperitoneal hernioplasty: a report of 7 cases].

OBJECTIVE: To explore the feasibility of single-incision laparoscopic totally extraperitoneal hernioplasty (SILS-TEP) with self-made port for repairing of inguinal hernia. METHODS: SILS-TEP was performed in 7 inguinal hernia patients (9 sides) with conventional laparoscopic instruments and self-made port, which composed of a wound retractor, surgical gloves and 3 ordinary trocars. The clinical data and follow-up results of 7 cases were retrospectively collected and analyzed. RESULTS: The self-made port was applied for SILS-TEP uneventfully without the need of additional ports in all 7 patients (9 inguinal hernias). The median operating time was 90. 0 (70-125) min, intraoperative blood loss was 10. 0 (5. 0-20. 0) mL and postoperative hospital stay was 2.0 (2. 0-4. 0) d. The median pain scores of visual analog scale (VAS) at 6 h,12 h, 24 h and 14 d were 3(2~4), 2(1~2), 1(0~2) and 0(0~1), respectively. There were no intraoperative complications reported, and all patients were satisfied with wound healing. No hernia recurrence was observed during the 3-months of follow-up. CONCLUSION: Our initial experiences show that SILS-TEP with self-made port is a safe and feasible surgery, which can simplify the procedure with available equipments and reduce the cost, therefore can be applied in grass-root hospitals.

[The diagnosis and treatment of pancreatic neuroendocrine neoplasms].

OBJECTIVE: To analyze the prognostic factors of pancreatic neuroendocrine neoplasms (PNEN). METHODS: Clinical data of 61 patients with PNEN from March 1992 to December 2012 was retrospectively analyzed. There were 23 male and 38 female patients, with a median age of 52 years (ranged from 22 to 68 years). Forty-one patients were non-functional tumors, and 20 patients were functional tumors. Fifty-nine patients received operation, 13 (22.0%) patients underwent laparoscopic operation, 2 patients underwent puncture biopsy under CT guidance. Survival was analyzed with the Kaplan-Meier method. RESULTS: Among these patients, 53 (86.9%) patients underwent curative resection. The cases of grade G1, G2, G3 were 41 (67.2%), 9 (14.8%), 11 (18.0%), respectively. The cases of stageI, II, III, IV were 47 (77.0%), 7 (11.5%), 2 (3.3%), 5 (8.2%), respectively. Liver metastasis, neural invasion were found in 5 cases (8.2%), 5 cases (8.2%), respectively. The median follow-up period was 40 months (ranged from 3 to 209 months). The overall 1-, 3-, 5-year survival rates were 92.0%, 89.7%, 86.3%, respectively. Univariate analysis showed WHO classification (χ(2) = 18.503), TNM staging system (χ(2) = 23.401), liver metastasis (χ(2) = 18.606), neural invasion (χ(2) = 10.091), resection status (χ(2) = 25.514) were prognostic factors of PNEN (all P = 0.000). CONCLUSIONS: Surgical resection in PNEN results in long-term survival. WHO classification, TNM staging, resection status are effective in predicting the prognosis of PNEN. Liver metastasis, neural invasion predicted poor prognosis.

[The clinical comparison of totally laparoscopic versus open total gastrectomy for gastric cancer].

OBJECTIVE: To investigate the feasibility, safety and oncological effect of totally laparoscopic total gastrectomy (TLTG). METHODS: The clinical data of TLTG cases and open total gastrectomy (OTG) patients between November 2007 and October 2011 were analyzed. Also compared the feasibility, safety and short-term outcomes of TLTG with OTG. RESULTS: Ninty cases were analyzed. There were 18 cases in the TLTG group and 72 cases in the OTG group. Operation time was significantly longer in the TLTG group ((310 ± 86) minutes) than in the OTG group ((256 ± 57) min, t = 4.963, P = 0.002), However, the blood loss were significantly lower in the TLTG group ((136 ± 84) ml vs. (359 ± 141) ml, t = -11.734, P = 0.000). The post operative morbidity was similar between the TLTG and OTG group. First flatus time (t = -7.020), first diet time (t = -6.166 and -5.698), and post operative hospital stay (t = -4.610) were significantly shorter in the TLTG group than in the OTG group (P < 0.05). CONCLUSIONS: LTG is a safe and feasible procedure with quick post-operation recovery. The laparoscopic side-to-side esophagojejunal anastomosis is a safe and feasible method of alimentary reconstruction after laparoscopic total gastrectomy.

Rab31 promotes metastasis and cisplatin resistance in stomach adenocarcinoma through Twist1-mediated EMT.

Stomach adenocarcinoma (STAD) is one of the leading causes of cancer-related death globally. Metastasis and drug resistance are two major causes of failures in current chemotherapy. Here, we found that the expression of Ras-related protein 31 (Rab31) is upregulated in human STAD tissues and high expression of Rab31 is closely associated with poor survival time. Furthermore, we revealed that Rab31 promotes cisplatin resistance and metastasis in human STAD cells. Reduced Rab31 expression induces tumor cell apoptosis and increases cisplatin sensitivity in STAD cells; Rab31 overexpression yielded the opposite result. Rab31 silencing prevented STAD cell migration, whereas the overexpression of Rab31 increased the metastatic potential. Further work showed that Rab31 mediates cisplatin resistance and metastasis via epithelial-mesenchymal transition (EMT) pathway. In addition, we found that both Rab31 overexpression and cisplatin treatment results in increased Twist1 expression. Depletion of Twist1 enhances sensitivity to cisplatin in STAD cells, which cannot be fully reversed by Rab31 overexpression. Rab31 could activate Twist1 by activating Stat3 and inhibiting Mucin 1 (MUC-1). The present study also demonstrates that Rab31 knockdown inhibited tumor growth in mice STAD models. These findings indicate that Rab31 is a novel and promising biomarker and potential therapeutic target for diagnosis, treatment and prognosis prediction in STAD patients. Our data not only identifies a novel Rab31/Stat3/MUC-1/Twist1/EMT pathway in STAD metastasis and drug resistance, but it also provides direction for the exploration of novel strategies to predict and treat STAD in the future.

[Laparoscopic distal pancreatectomy: the experience of 68 cases in a single centre].

OBJECTIVE: To evaluate the feasibility and efficacy of laparoscopic distal pancreatectomy. METHODS: Totally 68 patients (male 23, female 45) aged 17 to 77 years, with distal pancreatic lesions, underwent laparoscopic distal pancreatectomy from November 2003 to December 2010. The clinical data were collected. Safety, feasibility and crucial technique manipulation were analyzed retrospectively. RESULTS: All 68 operations were successful with two cases conversion to open, including 48 cases combined with splenectomy, and 18 cases with preservation of spleen. Fourteen cases received with combination resection of multi-organs, including 4 cases with cholecystectomy, 1 case resection of right adrenal adenoma and cholecystectomy, 1 case with myomectomy and left ovarian teratomectomy; 1 case with right ovarian teratomectomy, 1 case with resection of left adrenal adenoma, 1 case with resection of both adrenal adenoma, 1 case with resection of liver metastasis, 1 case with cholecystectomy and resection of liver metastasis, 1 case with resection of left adrenal adenoma and liver metastasis, 1 case with resection of left adrenal adenoma and colon and spleen, 1 case with biopsy of liver nodule. The mean operative time was (209 ± 58) minutes, the mean intraoperative blood loss was (191 ± 123) ml, and the mean postoperative hospital stay was (8 ± 4) days. The rate of overall postoperative complications was 18.1%, including an 12.1% rate of clinical pancreatic fistula. Only one case needed a reoperation, and there was no postoperative mortality. CONCLUSION: Laparoscopic distal pancreatectomy with or without splenectomy is safe and feasible in the treatment of most distal pancreatic tumors.

[Totally laparoscopic gastrectomy for gastric cancer].

OBJECTIVE: To evaluate the feasibility and clinical efficacy of totally laparoscopic gastrectomy (TLG) for gastric cancer. METHODS: The investigators retrospectively analyzed 37 cases undergoing TLG for gastric cancer from March 2007 to April 2009 at Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University. RESULTS: All 37 cases underwent successful TLG. There was neither transfer to open nor laparoscopic assisted surgery. Twenty-nine cases underwent distal gastrectomy with Billroth II reconstruction, 8 cases total gastrectomy with Roux-en-Y reconstruction, including 5 cases with end-to-side esophageal jejunostomy and 3 cases with side-to-side esophageal jejunostomy. Nineteen cases assisted by intraoperative gastroscopy for tumor locating. The operation duration was 210 - 355 min [mean (284 +/- 43) min]. The blood loss was 80 - 450 ml [mean (175 +/- 62) ml]. The number of dissected lymph nodes was 18 - 55 [mean (31 +/- 9)]. Two cases had post-operative complications, with 1 case of pulmonary infection recovering well after symptomatic treatment and 1 case of temporary delayed gastric emptying recovering well after gastrointestinal decompression for 6 days. No mortality was reported. The hospital stay was 6 - 14 d [mean (9 +/- 2) d]. There was no recurrence during the follow-up period of 2 - 25 months. CONCLUSIONS: For surgeons with rich experiences of laparoscopic surgery, TLG for gastric cancer is both safe and feasible. The short-term efficacy of TLG is satisfactory. Furthermore, TLG conforms more to the concept of minimally invasive surgery and the principle of tumor-free technique.

Trans-umbilical single-incision laparoscopic trans-abdominal pre-peritoneal hernioplasty of inguinal hernia by self-made glove port.

Laparoscopic inguinal herniorrhaphy has been well established for the management of primary and recurrent inguinal hernias. Single-incision laparoscopic surgery (SILS) has now been accepted as a less invasive alternative to conventional laparoscopic surgery. However, commercially available access devices for SILS had disadvantages such as rigidness and crowding. This series aimed to analyze the feasibility and safety of single-incision laparoscopic trans-abdominal pre-peritoneal hernioplasty (SILS-TAPP) by applying our self-made device for managing inguinal hernia.We collected and reviewed the medical records of patients who received SILS-TAPP using a self-made glove-port device between January 2014 and January 2016. All operations were performed by the same surgical team. The demographics and intra- and perioperative outcomes were evaluated.SILS-TAPP was successfully performed in 105 patients (131 inguinal hernia repairs). No major intra- and postoperative morbidities were encountered, and no conversion to a conventional 3-port approach or open surgery was required. The mean operative time was 73.5 min and the mean postoperative hospital stay was 2.1 days. Three minor short-term complications were noted, which were resolved without surgical intervention. One recurrence was diagnosed during follow-up and treated using a second TAPP procedure.SILS-TAPP was shown to be a feasible, safe procedure in patients with an inguinal hernia. A simple self-made glove-port device was proven as a practical method of SILS-TAPP.

Laparoscopic gastrectomy using intracorporeally hand-sewn anastomosis of esophagojejunostomy, gastroduodenostomy, or gastrojejunostomy for gastric cancer.

Laparoscopic gastrectomy (LG) using intracorporeal anastomosis has recently become more prevalent due to the advancements of laparoscopic surgical instruments. However, intracorporeally hand-sewn anastomosis (IHSA) is still uncommon because of technical difficulties. In this study, we evaluated various types of IHSA following LG with respect to the technical aspects and postoperative outcomes.Seventy-six patients who underwent LG using IHSA for treatment of gastric cancer between September 2014 and June 2018 were enrolled in this study. We described the details of IHSA in step-by-step manner, evaluated the clinicopathological data and surgical outcomes, and summarized the clinical experiences.Four types of IHSA have been described: one for total gastrectomy (Roux-en-Y) and 3 for distal gastrectomy (Roux-en-Y, Billroth I, and Billroth II). The mean operation time and anastomotic time was 288.7 minutes and 54.3 minutes, respectively. Postoperative complications were observed in 13 patients. All of the patients recovered well with conservative surgical management. There was no case of conversion to open surgery, anastomotic leakage, or mortality.LG using IHSA was safe and feasible and had several advantages compared to mechanical anastomosis. The technique lengthened operating time, but this could be mitigated by increased surgical training and experience.

Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center propensity score matching study.

Laparoscopic distal pancreatectomy (LDP) for benign and low-grade malignant pancreatic diseases has been increasingly utilized. However, the use of LDP for pancreatic ductal adenocarcinoma (PDAC) remains controversial and has not been widely accepted. In this study, the outcomes of LDP versus conventional open distal pancreatectomy (ODP) for left-sided PDAC were examined. A retrospective review of patients who underwent LDP or ODP for left-sided PDAC between January 2010 and January 2019 was conducted. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors including age, sex, ASA grade, tumor size, and combined resection. Demographic data, their pathological and short-term clinical parameters, and long-term oncological outcomes were compared between the LDP and ODP groups. A total of 197 patients with PDAC were enrolled. There were 115 (58.4%) patients in the LDP group and 82 (41.6%) patients in the ODP group. After 1:1 PSM, 66 well-matched patients in each group were evaluated. The LDP group had lesser blood loss (195 vs. 210 mL, p < 0.01), shorter operative time (193.6 vs. 217.5 min; p = 0.02), and shorter hospital stay (12 vs. 15 days, p < 0.01), whereas the overall complication rates were comparable between groups (10.6% vs.16.7%, p = 0.31). There were no significant differences between the LDP and ODP groups regarding 3-year recurrence-free or overall survival rate (p = 0.89 and p = 0.33, respectively). LDP in the treatment of left-sided PDAC is a technically safe, feasible and favorable approach in short-term surgical outcomes. Moreover, patients undergoing LDP than ODP for PDAC had comparable oncological metrics and similar middle-term survival rate.

Minimally invasive pancreatoduodenectomy is associated with lower morbidity compared to open pancreatoduodenectomy: An updated meta-analysis of randomized controlled trials and high-quality nonrandomized studies.

BACKGROUND: Minimally invasive pancreatoduodenectomy (MIPD) is being increasingly performed as an alternative to open pancreatoduodenectomy (OPD) in selected patients. Our study aimed to present a meta-analysis of the high-quality studies conducted that compared MIPD to OPD performed for pancreatic head and periampullary diseases. METHODS: A systematic review of the available literature was performed to identify those studies conducted that compared MIPD to OPD. Here, all randomized controlled trials identified were included, while the selection of high-quality, nonrandomized comparative studies were based on a validated tool (i.e., Methodological Index for Nonrandomized Studies). Intraoperative outcomes, postoperative recovery, oncologic clearance, and postoperative complications were also evaluated. RESULTS: Sixteen studies matched the selection criteria, including a total of 3168 patients (32.1% MIPD, 67.9% OPD). The pooled data showed that MIPD was associated with a longer operative time (weighted mean difference [WMD] = 80.89 minutes, 95% confidence interval [CI]: 39.74-122.05, P < .01), less blood loss (WMD = -227.62 mL, 95% CI: -305.48 to -149.75, P < .01), shorter hospital stay (WMD = -4.68 days, 95% CI: -5.52 to -3.84, P < .01), and an increase in retrieved lymph nodes (WMD = 1.85, 95% CI: 1.33-2.37, P < .01). Furthermore, the overall morbidity was significantly lower in the MIPD group (OR = 0.67, 95% CI: 0.54-0.82, P < .01), as were total postoperative pancreatic fistula (POPF) (OR = 0.79, 95% CI: 0.63-0.99, P = .04), delayed gastric emptying (DGE) (OR = 0.71, 95% CI: 0.52-0.96, P = .02), and wound infection (OR = 0.56, 95% CI: 0.39-0.79, P < .01). However, there were no statistically significant differences observed in major complications, clinically significant POPFs, reoperation rate, and mortality. CONCLUSION: Our study suggests that MIPD is a safe alternative to OPD, as it is associated with less blood loss and better postoperative recovery in terms of the overall postoperative complications as well as POPF, DGE, and wound infection. Methodologic high-quality comparative studies are required for further evaluation.

Evolution of Laparoscopic Pancreatic Resections for Pancreatic and Periampullary Diseases: Perioperative Outcomes of 605 Patients at a High-Volume Center.

Background: Laparoscopic pancreatectomy (LP) is increasingly performed with several institutional series and comparative studies reported. We have applied LP to a variety of pancreatic resections since 2004. This article is to report results of 15-year practice of 605 LPs for pancreatic and periampullary diseases. Methods: Patients with benign or malignant diseases in the pancreas and periampullary region, who underwent LP from June 2004 to June 2018, were retrospectively reviewed. The demographics and indications, and intraoperative and perioperative outcomes were evaluated. Results: A total of 605 consecutive LPs were analyzed, including 237 (39.2%) distal pancreatectomy with splenectomy (DPS), 116 (19.2%) spleen-preserving distal pancreatectomy (SPDP), 30 (5.0%) enucleation (EN), 30 (5.0%) central pancreatectomy (CP), 186 (30.7%) pancreatoduodenectomy (PD), and 6 (1.0%) pancreatoduodenectomy with total pancreatectomy (PDTP). The most common pathologic finding was pancreatic ductal adenocarcinomas (146, 24.1%). Conversion to open procedure was required in 22 patients (3.6%) (12 with PD, 8 with DPS, 1 with CP, and 1 with PDTP). The mean operative time was 241.5 ± 105.5 minutes (range 50-550 minutes) for the entire population and 367.1 ± 61.8 minutes (range 230-550 minutes) for PD. Clinically significant pancreatic fistula (ISGPF grade B and C) rate was 12.4% for the entire cohort and 16.1% for PD. Rate of Clavien-Dindo III-V complications was 17.4% for the entire cohort and 23.7% for PD. Ninety-day mortality was observed only in the cohort of patients undergoing PD (n = 4). Conclusions: The LP procedure appears to be technically safe and feasible, with an acceptable rate of morbidity when performed at our experienced, high-volume center. However, PD has less favorable outcomes and needs further evaluation.