Impact of Helicobacter pylori Status on Postoperative Morbidities After Laparoscopic Sleeve Gastrectomy in an Endemic Region (a Retrospective Multicentric Study).

PURPOSE: Studies are still ongoing to determine whether Helicobacter pylori (HP) may affect the results of laparoscopic sleeve gastrectomy (LSG). The main research objectives were HP prevalence in patients with severe obesity and the effects of HP status on outcomes. PATIENTS AND METHODS: This multicenter retrospective study included patients with severe obesity who had LSG. The patients were grouped into three groups based on the HP status of preoperative endoscopic biopsies and postoperative specimen results: group I (negative HP), group II (eradicated HP), and group III (positive HP). The primary outcome was the overall postoperative morbidities. RESULTS: One thousand six hundred fifteen patients who underwent LSG for severe obesity were included in this study. Seven hundred fifty (46.4%) patients had negative HP, and 637 (39.4%) patients had eradicated HP, whereas 228 (14.1%) patients had positive HP. The antral and gastric body wall thickness was significantly noticed with positive HP. The groups had no significant differences regarding postoperative complication frequency, severity, and hospital mortality. The rates of gastric leakage in the three groups do not differ significantly. BMI > 50, gastropexy, gastric thickness, and antral resection were found to be independent risk factors for the occurrence of postoperative complications after LSG. There was no statistical significance as regards postoperative %TWL and %EWL among the three groups. CONCLUSION: The early results of LSG do not appear to be impacted by HP's status. The early postoperative course is unaffected by HP eradication anymore. Therefore, routine preoperative HP testing may not be as necessary, and management can be finished after LSG.

Prevalence, Risk Factors, and Management of Postoperative Nausea and Vomiting After Laparoscopic Sleeve Gastrectomy (a Retrospective Multicentric Study).

PURPOSE: Postoperative nausea and vomiting (PONV) is a frequent unappealing laparoscopic sleeve gastrectomy (LSG) sequel. The study's purpose was to determine the prevalence, risk factors of PONV, and management of PONV after LSG. PATIENTS AND METHODS: This multicenter retrospective study included patients with morbid obesity who had LSG between January 2022 and April 2023. The age range for LSG was 16 to 65 years, and the eligibility requirements included morbid obesity according to international guidelines. RESULTS: PONV was experienced by 74.6% of patients who underwent LSG at 6 h postoperative. Multivariate analysis revealed that female gender, smokers, preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were found to be independent protective variables against the development of PONV. Combined intravenous ondansetron and metoclopramide improved 92.6% of patients who developed PONV. Dexamethasone and antihistamines drugs are given for 42 cases with persistent PONV after using intravenous ondansetron and metoclopramide. Pain management postoperatively by opioid-free analgesia managed PONV. Helicobacter pylori status has no role in the development of PONV after LSG. CONCLUSION: Female gender, smoking, presence of preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were observed to be independent protective factors against the occurrence of PONV. Combined intravenous ondansetron and metoclopramide improved PONV. Dexamethasone and antihistamines drugs are given for persistent PONV.

Prevalence, Predictors, and Management of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy: a Multicenter Cohort Study.

BACKGROUND: One of the most popular bariatric procedures is laparoscopic sleeve gastrectomy (LSG), which can either cause or worsen gastroesophageal reflux disease (GERD). Therefore, the goal of this study was to examine the prevalence, predictors, and management of GERD symptoms after LSG. MATERIALS AND METHODS: From January 2017 to January 2022, we looked at patients who had a primary LSG and developed GERD. Before LSG, all patients underwent a barium meal and upper endoscopy. After LSG, barium meal, endoscopy, esophageal manometry, and 24-h pH measurements were performed for selected patients. The diagnosis of GERD is based on the GERD-HRQL questionnaire and upper endoscopy. RESULTS: The study included 1537 patients (62.5% women and 37.5% men) with a mean age of 34.4 years. The mean % TWL was 40.7% during a mean follow-up period of 15.9 months. A total of 379 patients (24.7%) experienced postoperative GERD, of whom 328 (21.3%) had postoperative de novo GERD symptoms, 25 (1.6%) had worsened preoperative GERD, and 26 (1.7%) had the same preoperative GERD symptoms. Antral preservation and gastropexy were protective factors against the development of GERD after LSG. LSG was converted to LRYGB in 15.8% of the patients with GERD. The response to medical treatment was observed in 300 (79.2%) patients with GERD. CONCLUSION: Post-LSG GERD presented in 379 patients (24.7%). Antral preservation and gastropexy were protective factors for the development of postoperative GERD after LSG. Medical treatment was the main line of treatment for GERD. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT05416645.

Presentation and outcomes of acute appendicitis during COVID-19 pandemic: lessons learned from the Middle East-a multicentre prospective cohort study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic had a striking impact on healthcare services in the world. The present study aimed to investigate the impact of the COVID-19 pandemic on the presentation management and outcomes of acute appendicitis (AA) in different centers in the Middle East. METHODS: This multicenter cohort study compared the presentation and outcomes of patients with AA who presented during the COVID-19 pandemic in comparison to patients who presented before the onset of the pandemic. Demographic data, clinical presentation, management strategy, and outcomes were prospectively collected and compared. RESULTS: Seven hundred seventy-one patients presented with AA during the COVID pandemic versus 1174 in the pre-COVID period. Delayed and complex presentation of AA was significantly more observed during the pandemic period. Seventy-six percent of patients underwent CT scanning to confirm the diagnosis of AA during the pandemic period, compared to 62.7% in the pre-COVID period. Non-operative management (NOM) was more frequently employed in the pandemic period. Postoperative complications were higher amid the pandemic as compared to before its onset. Reoperation and readmission rates were significantly higher in the COVID period, whereas the negative appendicectomy rate was significantly lower in the pandemic period (p = 0.0001). CONCLUSION: During the COVID-19 pandemic, a remarkable decrease in the number of patients with AA was seen along with a higher incidence of complex AA, greater use of CT scanning, and more application of NOM. The rates of postoperative complications, reoperation, and readmission were significantly higher during the COVID period.

Effect of Altitude Level on Surgical Outcomes of Laparoscopic Sleeve Gastrectomy for Patients With Morbid Obesity: A Multicentre Prospective Study.

BACKGROUND: This study aimed to evaluate the impact of altitude level on surgical outcomes of laparoscopic sleeve gastrectomy (LSG) for patients with morbid obesity. METHODS: At the normal altitude level, 808 patients underwent LSG, and 467 patients underwent LSG in high-altitude regions. The primary outcome was evaluated based on the postoperative morbidity rate. Secondary outcomes were evaluated based on operating time, mortality, hospital stay, percentage of total weight loss (TWL), and comorbidities improvement. RESULTS: No significant differences were noted in-hospital stay, time to start oral intake, gastric leakage, overall complications, and hospital mortality between the 2 groups. Deep vein thrombosis, pulmonary embolism, and mesenteric vascular occlusion were significantly higher in high altitude [11 (1.3%) vs. 14 (3%), P=0.04; 8 (0.7%) vs. 11 (2.4%), P=0.01; 4 (0.5%) vs. 8 (1.7%), P=0.03, respectively]. Patients with normal altitude recorded a better %TWL than those at high altitude after 12 months (41±9 vs. 39±9.6, P=0.002) and after 24 months (41±8 vs. 40±9, P=0.009). In both groups, a significant improvement was noted in comorbidity after LSG. CONCLUSION: The %TWL significantly achieved with LSG in normal and high altitudes. After 12 and 24 months, the %TWL is significantly higher with LSG at normal altitudes. High altitude is associated with a high incidence of deep vein thrombosis, pulmonary embolism, and superior mesenteric vascular occlusion with LSG.

The effect of stoma size on the mid-term weight loss outcome of one anastomosis gastric bypass (OAGB): a single-blinded prospective randomized trial.

BACKGROUND: One anastomosis gastric bypass (OAGB) is gaining wide spread acceptance among bariatric surgeons all over the world because of its technical simplicity and documented efficacy. However, the relation between stoma size in OAGB and magnitude of weight loss has not been addressed. OBJECTIVES: To evaluate the effect of stoma size on the mid-term weight loss outcome for patients with obesity after OAGB. SETTING: University Hospital. MATERIALS AND METHODS: This is a single-blinded prospectively randomized trial. From March 2014 to September 2016, 83 patients, eligible for bariatric surgery, were included in the study. OAGB was carried out with the same technical steps, except for the size of the gastrojejunostomy (GJ). Patients were randomly allocated into two equal groups; narrow GJ group (30 mm) and wide GJ group (45 mm). The percentage of total weight loss (%TWL) and the percentage of excess weight loss (%EWL) were recorded at 6, 12 and 24 months after procedure. RESULTS: At 6 months follow-up, patients with 30 mm GJ had better %EWL (53.3) and %TWL (23.4) than other patients with 45 mm GJ (42.6 and 18.2 respectively). However, at 12 and 24 months the %TWL and %EWL difference between the two groups have disappeared. CONCLUSION: Patients with narrower stoma size (30 mm) of OAGB tend initially to lose more weight than patients with wider stoma (45 mm). However, this difference disappears at mid-term follow-up after 2 years.

Post-hepatectomy liver failure after hepatic resection for hepatocellular carcinoma: a single center experience.

PURPOSE: Post-hepatectomy liver failure (PHLF) is one of the most feared morbidities after liver resection (LR) for hepatocellular carcinoma (HCC). We aimed to investigate the incidence and predictors of PHLF after LR for HCC and its impact on survival outcomes. METHODS: We reviewed the patients who underwent LR for HCC during the period between January 2010 and 2019. RESULTS: Two hundred sixty-eight patients were included. Patients were divided into two groups according to the occurrence of PHLF, defined according to ISGLS. The non-PHLF group included 138 patients (51.5%), while the PHLF group included 130 patients (48.5%). Two hundred forty-six patients (91.8%) had hepatitis C virus. Major liver resections were more performed in the PHLF group (40 patients (30.8%) vs. 18 patients (13%), p = 0.001). Longer operation time (3 vs. 2.5 h, p = 0.001), more blood loss (1000 vs. 500 cc, p = 0.001), and transfusions (81 patients (62.3%) vs. 52 patients (37.7%), p = 0.001) occurred in PHLF group. The 1-, 3-, and 5-year Kaplan-Meier overall survival rates for the non-PHLF group were 93.9%, 79.5%, and 53.9% and 73.2%, 58.7%, and 52.4% for the PHLF group, respectively (log rank, p = 0.003). The 1-, 3-, and 5-year Kaplan-Meier disease-free survival rates for the non-PHLF group were 77.7%, 42.5%, and 29.4%, and 73.3%, 42.9%, and 25.3% for the PHLF group, respectively (log rank, p = 0.925). Preoperative albumin, bilirubin, INR, and liver cirrhosis were significant predictors of PHLF in the logistic regression analysis. CONCLUSION: Egyptian patients with HCC experienced higher PHLF incidence after LR for HCC. PHLF significantly affected the long-term survival of those patients.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study.

BACKGROUND: Bile duct injury (BDI) after cholecystectomy remains a significant surgical challenge. No guideline exists to guide the timing of repair, while few studies compare early versus late repair BDI. This study aimed to analyze the outcomes in patients undergoing immediate, intermediate, and delayed repair of BDI. METHODS: We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020. The patients were divided into three groups based on the time of BDI reconstruction. Group 1 underwent an immediate reconstruction (within the first 72 hours post-cholecystectomy, n = 156); group 2 underwent an intermediate reconstruction (from 4 days to 6 weeks post-cholecystectomy, n = 75), and group 3 underwent delayed reconstruction (after 6 weeks post-cholecystectomy, n = 181). RESULTS: Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3. Favorable outcome was observed in 111 (71.2%) patients in group 1, 31 (41.3%) patients in group 2, and 157 (86.7%) patients in group 3 (P = 0.0001). Multivariate analysis identified that complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1, the use of external stent was an independent factor of favorable outcome in group 2, and level E4 BDI was an independent factor of unfavorable outcome in group 3. Transected BDI and level E4 BDI were independent factors of unfavorable outcome. CONCLUSIONS: Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI. Complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Laparoscopic Pancreaticodudenectomy for Periampullary Tumor: Should it be a Routine? A Propensity Score-matched Study.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (LPD) is a complex and challenging procedure even with experienced surgeons. The aim of this study is to evaluate the feasibility and surgical and oncological outcomes of LPD compared with open pancreaticoduodenectomy (OPD). PATIENTS AND METHOD: This is a propensity score-matched analysis for patients with periampullary tumors who underwent PD. Patients underwent LPD and matched group underwent OPD included in the study. The primary outcome measure was the rate of total postoperative morbidities. Secondary outcomes included operative times, hospital stay, wound length and cosmosis, oncological outcomes, recurrence rate, and survival rate. RESULTS: A total of 111 patients were included in the study (37 LPD and 74 OPD). The conversion rate from LPD to OPD was 4 cases (10.8%). LPD provides significantly shorter hospital stay (7 vs. 10 d; P=0.004), less blood loss (250 vs. 450 mL, P=0.001), less postoperative pain, early oral intake, and better cosmosis. The length of the wound is significantly shorter in LPD. The operative time needed for dissection and reconstruction was significantly longer in LPD group (420 vs. 300 min; P=0.0001). Both groups were comparable as regards lymph node retrieved (15 vs. 14; P=0.21) and R0 rate (86.5% vs. 83.8%; P=0.6). No significant difference was seen as regards postoperative morbidities, re-exploration, readmission, recurrence, and survival rate. CONCLUSIONS: LPD is a feasible procedure; it provided a shorter hospital stay, less blood loss, earlier oral intake, and better cosmosis than OPD. It had the same postoperative complications and oncological outcomes as OPD.

Impact of the Myotomy Extent on Gastric Side on Surgical Outcome After Heller's Cardiomotomy for Achalasia.

BACKGROUND: Laparoscopic Heller cardiomyotomy (LHM) with Dor fundoplication represents the most commonly accepted surgical management for achalasia. The ideal extent of myotomy on the gastric side remains a matter of continuous debate. The aim of this study was to compare the impact of the extent of myotomy on the gastric side on the outcome of LHM. PATIENTS AND METHODS: Patients with achalasia who underwent LHM included in the study. The patients were classified according to the length of the gastric myotomy into 3 groups (group I: <1.5 cm, group II: 1.5 to 2.5 cm, and group III: >2.5 cm). RESULTS: In total, 212 patients (94 males and 118 females) with achalasia treated by LHM and Dor fundoplication included in the study. No statistically significant differences were found among the 3 groups as regards preoperative data, intraoperative mucosal perforation, operative time, blood loss, and hospital stay. The incidence of persistent dysphagia was significantly higher in the group I. Postoperative GERD symptoms were significantly higher in group III (23.3%, P<0.0001). Recurrent achalasia was significantly higher in group I with 11 patients (15.9%), 8 patients in group II (7.1%), and nil in group III (P<0.02). CONCLUSIONS: Longer myotomy on the gastric side (>2.5 cm) ensures complete division of the LES with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative GERD. Therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative GERD.

Surgical Loupe at 4.0× Magnification in Pancreaticoduodenectomy-Does It Affect the Surgical Outcomes? A Propensity Score-Matched Study.

BACKGROUND: There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD. PATIENTS AND METHOD: This is a propensity score-matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay. RESULTS: The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct <3 mm, body mass index >25, and soft pancreas. CONCLUSION: Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.

Biliary leakage following pancreaticoduodenectomy: Prevalence, risk factors and management.

BACKGROUND: Few studies investigated biliary leakage after pancreaticoduodenectomy (PD) especially when compared to postoperative pancreatic fistula (POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. METHODS: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group (1) included patients who developed biliary leakage and group (2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. RESULTS: The study included 555 patients. Forty-four patients (7.9%) developed biliary leakage. Ten patients (1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography (ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients (90.9%). Only 4 patients (9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group (6.8% vs 3.9%, P = 0.05). CONCLUSIONS: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: A retrospective study of 5-year survivors.

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard curative treatment for periampullary tumors. The aim of this study is to report the incidence and predictors of long-term survival (≥ 5 years) after PD. METHODS: This study included patients who underwent PD for pathologically proven periampullary adenocarcinomas. Patients were divided into 2 groups: group (I) patients who survived less than 5 years and group (II) patients who survived ≥ 5 years. RESULTS: There were 47 (20.6%) long-term survivors (≥ 5 years) among 228 patients underwent PD for periampullary adenocarcinoma. Patients with ampullary adenocarcinoma represented 31 (66.0%) of the long-term survivors. Primary analysis showed that favourable factors for long-term survival include age < 60 years old, serum CEA < 5 ng/mL, serum CA 19-9 < 37 U/mL, non-cirrhotic liver, tumor size < 2 cm, site of primary tumor, postoperative pancreatic fistula, R0 resection, postoperative chemotherapy, and no recurrence. Multivariate analysis demonstrated that CA 19-9 < 37 U/mL [OR (95% CI) = 1.712 (1.248-2.348), P = 0.001], smaller tumor size [OR (95% CI )= 1.335 (1.032-1.726), P = 0.028] and Ro resection [OR (95% CI) = 3.098 (2.095-4.582), P < 0.001] were independent factors for survival ≥ 5 years. The prognosis was best for ampullary adenocarcinoma, for which the median survival was 54 months and 5-year survival rate was 39.0%, and the poorest was pancreatic head adenocarcinoma, for which the median survival was 27 months and 5-year survival rate was 7%. CONCLUSIONS: The majority of long-term survivors after PD for periampullary adenocarcinoma are patients with ampullary tumor. CA 19-9 < 37 U/mL, smaller tumor size, and R0 resection were found to be independent factors for long-term survival ≥ 5 years.

Surgical Management of Giant Hepatic Hemangioma: Single Center's Experience with 144 Patients.

BACKGROUND: Hepatic hemangioma (HH) is the most common benign solid tumor of the liver. The aim of this study is to review our experiences of surgical treatment for giant HH and to show the impact of HH size and type of surgical resection on surgical outcomes. PATIENTS AND METHODS: This is a retrospective study of the cases who underwent surgery for giant HH during the period from January 2000 to April 2017. RESULTS: Elective surgery was performed for 144 patients who had giant HH. The median diameter of resected HH was 10 cm (5-31 cm). Enucleation was performed for 92 (63.9%) patients and anatomical resection was required in 52 (36.1%) patients. No statistical difference between enucleation and resection as regards intraoperative and postoperative findings. The amount of intraoperative blood loss is significantly more in HH > 10 cm (300 vs. 575 ml, P = 0.007), the need of blood transfusion was significantly more in HH > 10 cm (P = 0.000), and the operation time was significantly longer in HH > 10 cm (120 vs. 180 min, P = 0.000). The size of HH had no significant effect as regards the development of postoperative complications. CONCLUSION: Giant hemangioma can be treated surgically with low incidence of morbidity and mortality. No statistical difference between enucleation and resection as regards surgical outcomes. In left lobe HH, HH located deeper in posterior hepatic segments and in multiple HH, hepatic resection is preferred. The size of the HH had significant impact intraoperative blood loss and operative time.

Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial.

BACKGROUND: The efficacy of octreotide to prevent postoperative pancreatic fistula (POPF) of pancreaticoduodenectomy (PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD. METHODS: This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct < 3 mm were randomized to 2 groups. Group I did not receive postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF. RESULTS: A total of 104 patients were included in the study and were divided into two randomized groups. There were no significant difference in overall complications and its severity. POPF occurred in 11 patients (21.2%) in group I and 10 (19.2%) in group II, without statistical significance (P = 0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage (P = 0.083), delayed gastric emptying (P = 0.472), and early postoperative mortality (P = 0.727). CONCLUSIONS: Octreotide did not reduce postoperative morbidities, reoperation and mortality rate. Also, it did not affect the incidence of POPF and its clinically relevant variants.

Value of preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy: A case-control study.

BACKGROUND/OBJECTIVE: The potential benefit of preoperative biliary drainage (PBD) on postoperative outcomes remains controversial. The aim of this study was to elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with PBD and to show the impact of bilirubin level. METHODS: We retrospectively studied all patients who underwent PD in our center between January 2003 and June 2015. Patients were divided into: Group A (PBD) and Group B (no PBD). The primary outcome was the rate of postoperative complication. RESULTS: A total of 588 cases underwent PD. Group A included 314 (53.4%) patients while Group B included 274 (46.6%) patients. The overall incidence of complications and its severity were higher in Group A (p = 0.03 and p = 0.02). There was significant difference in the incidence of postoperative pancreatic fistula (p = 0.002), delayed gastric emptying (p = 0.005), biliary leakage (p = 0.04), abdominal collection (p = 0.04), and wound infection (p = 0.04) in Group A. The mean length of hospital stay was significantly longer in Group A than in Group B (12.86 ± 7.65 days vs. 11.05 ± 7.98 days, p = 0.01). No significant impact of preoperative bilirubin level on surgical outcome was detected. CONCLUSION: PBD before PD was associated with major postoperative complications and stent-related complications.

Open Cholecystectomy Has a Place in the Laparoscopic Era: a Retrospective Cohort Study.

Laparoscopic cholecystectomy (LC) is considered the gold standard for treatment of symptomatic gallbladder stones and has replaced the traditional open cholecystectomy (OC). The aim of this study is to evaluate the proper indications of the primary OC and conversion from LC and their predictive factors. This study includes all patients who underwent cholecystectomy between January 2011 and June 2016, whether open from the start (group A), conversion from laparoscopic approach (group B), or laparoscopic cholecystectomy (group C). There were 3269 patients underwent cholecystectomy. LC was completed in 3117 (95.4%) patients. The overall conversion rate was 83 (2.5%). The main two causes of conversion were adhesion in 35 (42.2%) patients and unclear anatomy in 29 (34.9%) patients. Primary OC was indicated in 69 (2.1%) patients due to previous history of upper abdominal operations in 16 (23.2%) patients and anesthetic problem in 21 (30.4%) patients. Age >60 years, male sex, diabetic patients, history of endoscopic retrograde cholangiopancreatography, dilated common bile duct, gallbladder status, adhesion, and previous upper abdominal operation were demonstrated to be independent risk factors for OC. Open cholecystectomy still has a place in the era of laparoscopy. Conversion should not be a complication, but it represents a valuable choice to avoid an additional risk. Safe OC required training because of the causes of conversion, usually unsafe anatomy, occurrence of complications, or anesthetic problems, in order to prevent disastrous complications.

Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases.

AIM: To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors. METHODS: This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017). RESULTS: The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods. CONCLUSION: Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases.

BACKGROUND: Pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debatable even for pancreatic surgeons. Ideally, pancreatic reconstruction after PD should reduce the risk of postoperative pancreatic fistula (POPF) and its severity if developed with preservation of both exocrine and endocrine pancreatic functions. It must be tailored to control the morbidity linked to the type of reconstruction. This study was to show the best type of pancreatic reconstruction according to the characters of pancreatic stump. METHODS: We studied all patients who underwent PD in our center from January 1993 to December 2015. Patients were categorized into three groups depending on the presence of risk factors of postoperative complications: low-risk group (absent risk factor), moderate-risk group (presence of one risk factor) and high-risk group (presence of two or more risk factors). RESULTS: A total of 892 patients underwent PD for resection of periampullary tumor. BMI >25 kg/m2, cirrhotic liver, soft pancreas, pancreatic duct diameter <3 mm, and pancreatic duct location from posterior edge <3 mm are risk variables for development of postoperative complications. POPF developed in 128 (14.3%) patients. Delayed gastric emptying occurred in 164 (18.4%) patients, biliary leakage developed in 65 (7.3%) and pancreatitis presented in 20 (2.2%). POPF in low-, moderate- and high-risk groups were 26 (8.3%), 65 (15.7%) and 37 (22.7%) patients, respectively. Postoperative morbidity and mortality were significantly lower with pancreaticogastrostomy (PG) in high-risk group, while pancreaticojejunostomy (PJ) decreases incidence of postoperative steatorrhea in all groups. CONCLUSIONS: Selection of proper pancreatic reconstruction according to the risk factors of patients may reduce POPF and postoperative complications and mortality. PG is superior to PJ as regards short-term outcomes in high-risk group but PJ provides better pancreatic function in all groups and therefore, PJ is superior in low- and moderate-risk groups.