Robotic, laparoscopic and open surgery for gallbladder cancer: a systematic review and network meta-analysis.

INTRODUCTION: Minimally invasive oncological resections have become increasingly widespread in the surgical management of cancers. However, the role of minimally invasive surgery (MIS) for gallbladder cancer (GBC) remains unclear. We aim to perform a systematic review and network meta-analysis of existing literature to evaluate the safety and feasibility of laparoscopic and robotic surgery in the management of GBC compared to open surgery (OS) by comparing outcomes. METHODS: A literature search of the PubMed/MEDLINE (2000 to December 2021) and EMBASE (2000 to December 2021) databases was conducted. The primary outcome studied was overall survival, and secondary outcomes studied were postoperative morbidity, severe complications, incidence of bile leak, length of hospital stay, operation time, R0 resection rate, local recurrence and lymph node yield. RESULTS: Thirty-two full-text articles met the eligibility criteria and were included in the final analysis with a total of 5883 patients undergoing either OS or MIS (laparoscopic or robotic) for GBC. 1- and 2-stage meta-analyses did not reveal any significant differences between OS, laparoscopic and robotic surgery in terms of overall survival, R0 resection, lymph node harvest, local recurrence and post-operative complications. Patients who underwent OS had significantly longer hospitalization stay and intra-operative blood loss compared to those who underwent laparoscopic or robotic surgery. Network meta-analysis did not reveal any significant differences between post-operative and survival outcomes of laparoscopic vs robotic surgery groups. CONCLUSION: This network meta-analysis suggests that both laparoscopic and robotic surgery are safe and effective approaches in the surgical management of GBC, with post-operative and survival outcomes comparable to OS. An MIS approach may also lead to shorter hospitalization stay, less intraoperative blood loss and post-operative complications compared to OS. There was no obvious benefit of either MIS approach (laparoscopic versus robotic) over the other.

Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis.

BACKGROUND: Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing post-operative drain management is a potential strategy in reducing this major complication. METHODS: Studies involving pancreatic resections, including both pancreaticoduodenectomy (PD) and distal pancreatic resections (DP), with intra-operative drain placement were screened. Early drain removal was defined as removal before or on the 3rd post-operative day (POD) while late drain removal was defined as after the 3rd POD. The primary outcome was CR-POPF, International Study Group of Pancreatic Surgery (ISGPS) Grade B and above. Secondary outcomes were all complications, severe complications, post-operative haemorrhage, intra-abdominal infections, delayed gastric emptying, reoperation, length of stay, readmission, and mortality. RESULTS: Nine studies met the inclusion criteria and were included for analysis. The studies had a total of 8574 patients, comprising 1946 in the early removal group and 6628 in the late removal group. Early drain removal was associated with a significantly lower risk of CR-POPF (OR: 0.24, p < 0.01). Significant reduction in risk of post-operative haemorrhage (OR: 0.55, p < 0.01), intra-abdominal infection (OR: 0.35, p < 0.01), re-admission (OR: 0.63, p < 0.01), re-operation (OR: 0.70, p = 0.03), presence of any complications (OR: 0.46, p < 0.01), and reduced length of stay (SMD: -0.75, p < 0.01) in the early removal group was also observed. CONCLUSION: Early drain removal is associated with significant reductions in incidence of CR-POPF and other post-operative complications. Further prospective randomised trials in this area are recommended to validate these findings.

Analysis of perioperative outcomes following laparoscopic repeat liver resection compared to laparoscopic primary liver resection based on a single surgeon's experience: A 1:2 propensity score-matched study.

BACKGROUND: We report a single surgeon experience with laparoscopic repeat liver resection (LRLR), and analyse short-term outcomes relative to laparoscopic primary liver resection (LPLR). METHODS: Two-hundred and twenty-two laparoscopic liver resections were performed from 2012 to 2019 of which 33 were LRLR. 1:2 propensity-score matching was done to compare 32 LRLR with 64 LPLR cohort. We further analyzed the first 16 LRLR cases compared to the subsequent 17 cases. RESULTS: 32 LRLR cases were matched to 64 LPLR cases. Apart from a higher frequency of Pringle maneuver in the LPLR cohort (p = 0.006), there were no differences in other perioperative outcomes. There were more posterosuperior located tumours (75.0% vs 17.6%, p = 0.003) and higher median difficulty score (8.50 vs 5.00, p = 0.025) in the initial 16 LRLR cases compared to the next 17. The earlier group had higher median blood loss (250.00 ml vs 50.00 ml, p = 0.012), but other outcomes were similar. CONCLUSION: LRLR may be safely performed in selected patients with no difference in key perioperative outcomes compared to LPLR.