Adoption of Robotic Liver, Pancreatic and Biliary Surgery in Singapore: A Single Institution Experience with Its First 100 Consecutive Cases.

INTRODUCTION: Presently, robotic hepatopancreatobiliary surgery (RHPBS) is increasingly adopted worldwide. This study reports our experience with the first 100 consecutive cases of RHPBS in Singapore. METHODS: Retrospective review of a single-institution prospective database of the first 100 consecutive RHPBS performed over 6 years from February 2013 to February 2019. Eighty-six cases were performed by a single surgeon. RESULTS: The 100 consecutive cases included 24 isolated liver resections, 48 pancreatic surgeries (including 2 bile duct resections) and 28 biliary surgeries (including 8 with concomitant liver resections). They included 10 major hepatectomies, 15 pancreaticoduodenectomies, 6 radical resections for gallbladder carcinoma and 8 hepaticojejunostomies. The median operation time was 383 minutes, with interquartile range (IQR) of 258 minutes and there were 2 open conversions. The median blood loss was 200ml (IQR 350ml) and 15 patients required intra-operative blood transfusion. There were no post-operative 90-day nor in-hospital mortalities but 5 patients experienced major (> grade 3a) morbidities. The median post-operative stay was 6 days (IQR 5 days) and there were 12 post-operative 30-day readmissions. Comparison between the first 50 and the subsequent 50 patients demonstrated a significant reduction in blood loss, significantly lower proportion of malignant indications, and a decreasing frequency in liver resections performed. CONCLUSION: Our experience with the first 100 consecutive cases of RHPBS confirms its feasibility and safety when performed by experienced laparoscopic hepatopancreatobiliary surgeons. It can be performed for even highly complicated major hepatopancreatobiliary surgery with a low open conversion rate.

Close air support: enhancing emergency care in the COVID-19 pandemic.

The COVID-19 pandemic has taken the world by storm and overwhelmed healthcare institutions even in developed countries. In response, clinical staff and resources have been redeployed to the areas of greatest need, that is, intensive care units and emergency rooms (ER), to reinforce front-line manpower. We introduce the concept of close air support (CAS) to augment ER operations in an efficient, safe and scalable manner. Teams of five comprising two on-site junior ER physicians would be paired with two CAS doctors, who would be off-site but be in constant communication via teleconferencing to render real-time administrative support. They would be supervised by an ER attending. This reduces direct viral exposure to doctors, conserves precious personal protective equipment and allows ER physicians to focus on patient care. Medical students can also be involved in a safe and supervised manner. After 1 month, the average time to patient disposition was halved. General feedback was also positive. CAS improves efficiency and is safe, scalable and sustainable. It has also empowered a previously untapped group of junior clinicians to support front-line medical operations, while simultaneously protecting them from viral exposure. Institutions can consider adopting our novel approach, with modifications made according to their local context.

Changing trends and outcomes associated with the adoption of minimally-invasive pancreato-biliary surgery: Contemporary experience of a 'self-taught' early adopter in Southeast Asia.

BACKGROUND: Minimally-invasive pancreato-biliary surgery (MIPBS) is increasingly reported worldwide. This study examines the changing trends, safety and outcomes associated with the adoption of MIPBS based on a contemporary experience of an early adopter in Southeast Asia. METHODS: Retrospective review of 114 consecutive patients who underwent MIPBS by a single surgeon over 86 months from 2011. The study population was stratified into three equal groups of 38 patients. Comparison was also performed between minimally-invasive pancreato surgery (MIPS) and minimally-invasive biliary surgery (MIBS). RESULTS: There were 70 MIPS and 44 MIBS. Sixty-three cases (55.3%) were performed using robotic assistance and fourteen (12.3%) were hybrid procedures with open reconstruction. Forty-four (38.6%) procedures were performed for malignancy. There were 8 (7.0%) open conversions and median operation time was 335 (range, 60-930) min. There were nine extended pancreatectomies including seven involving vascular reconstructions. Major morbidity (>Grade 2) occurred in 20 (17.5%) patients including 6 (5.3%) reoperations and there was no mortality. Comparison across the three groups demonstrated that with increasing experience, there was a significant trend in a higher proportion of higher ASA score patients, increasing frequency of procedures requiring anastomosis and increasing the use of robotic assistance without significant difference in key perioperative outcomes such as open conversion rate, morbidity and hospital stay. Comparison between MIPS and MIBS demonstrated that MIPS was associated with significantly longer operation time, increased blood loss, increased transfusion rate, longer hospital stay, increased readmission rate and increased morbidity. CONCLUSION: MIPBS can be safely adopted today with a low open conversion rate.

First experience with robotic pancreatoduodenectomy in Singapore.

INTRODUCTION: Recent studies reported that laparoscopic pancreatoduodenectomy (LPD) is associated with superior perioperative outcomes compared to the open approach. However, concerns have been raised about the safety of LPD, especially during the learning phase. Robotic pancreatoduodenectomy (RPD) has been reported to be associated with a shorter learning curve compared to LPD. We herein present our initial experience with RPD. METHODS: A retrospective review of a single-institution prospective robotic hepatopancreaticobiliary (HPB) surgery database of 70 patients identified seven consecutive RPDs performed by a single surgeon in 2016-2017. These were matched at a 1:2 ratio with 14 open pancreatoduodenectomies (OPDs) selected from 77 consecutive pancreatoduodenectomies performed by the same surgeon between 2011 and 2017. RESULTS: Seven patients underwent RPD, of which five were hybrid procedures with open reconstruction. There were no open conversions. Median operative time was 710.0 (range 560.0-930.0) minutes. Two major morbidities (> Grade 2) occurred: one gastrojejunostomy bleed requiring endoscopic haemostasis and one delayed gastric emptying requiring feeding tube placement. There were no pancreatic fistulas, reoperations or 90-day/in-hospital mortalities in the RPD group. Comparison between RPD and OPD demonstrated that RPD was associated with a significantly longer operative time. Compared to open surgery, there was no significant difference in estimated blood loss, blood transfusion, postoperative stay, pancreatic fistula rates, morbidity and mortality rates, R0 resection rates, and lymph node harvest rates. CONCLUSION: Our initial experience demonstrates that RPD is feasible and safe in selected patients. It can be safely adopted without any compromise in patient outcomes compared to the open approach.

Changing trends and outcomes associated with the adoption of minimally invasive pancreatic surgeries: A single institution experience with 150 consecutive procedures in Southeast Asia.

BACKGROUND: Minimally invasive pancreatic surgeries (MIPS) are increasingly adopted worldwide. However, it remains uncertain if these reported experiences are reproducible throughout the world today. This study examines the safety and evolution of MIPS at a single institution in Southeast Asia. METHODS: This is a retrospective review of 150 consecutive patients who underwent MIPS between 2006 and 2018 of which 135 cases (90%) were performed since 2012. To determine the evolution of MIPS, the study population was stratified into 3 equal groups of 50 patients. Comparison was also made between pancreatoduodenectomies (PD), distal pancreatectomies (DP) and other pancreatic surgeries. RESULTS: One hundred and fifty patients underwent MIPS (103 laparoscopic, 45 robotic and 2 hand-assisted). Forty-three patients underwent PD, 93 DP and 14 other MIPS. There were 21 (14.0%) open conversions. There was an exponential increase in caseload over the study period. Comparison across the 3 time periods demonstrated that patients were significantly more likely to have a higher American Society of Anesthesiologists score, older, undergo PD and a longer operation time. The conversion rate decreased from 28% to 0% and increased again to 14% across the 3 time periods. Comparison between the various types of MIPS demonstrated that patients who underwent PD were significantly older, more likely to have symptomatic tumours, had longer surgery time, increased blood loss, increased frequency of extended pancreatectomies, increased frequency of hybrid procedures, longer post-operative stay, increased post-operative morbidity rate and increased post-operative major morbidity rate. CONCLUSION: The case volume of MIPS increased rapidly at our institution over the study period. Furthermore, although the indications for MIPS expanded to include more complex procedures in higher risk patients, there was no change in key perioperative outcomes.

Initial single institution experience with robotic biliary surgery and bilio-enteric anastomosis in southeast Asia.

BACKGROUND: Presently, experience with robotic biliary surgery (RBS) is increasing worldwide although widespread adoption remains limited. In this study, we report our initial experience with RBS. METHODS: Retrospective review of a single institution prospective database of 95 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2018. Of these, 27 patients who underwent RBS were included in this study. RBS was performed by three principal console surgeons of whom one surgeon performed 23 (85%) and supervised all cases. Additionally, to evaluate our initial outcomes with bilio-enteric anastomoses, eight consecutive pancreatoduodenectomies were included. RESULTS: Of the 27 RBS performed, these included 10 hepaticojejunostomies with bile duct resections (including two concomitant pancreatoduodenectomies and one right hepatectomy) for choledochal cysts, bile duct strictures and biliary malignancies; five liver resections with hilar lymph node clearance for gallbladder cancer; four for Mirizzi syndrome; two cholecystectomies with cholecystoenteric fistula and two bile duct exploration after failed endoscopic treatment of choledocholithiasis. There were no open conversions, no 90-day mortality and four (14.8%) major (>Grade II) morbidities. The median post-operative stay was 6 (range 1-29) days and there was one (3.7%) 30-day readmissions. Of our first 18 robotically constructed bilio-enteric anastomoses, there was only one (5.5%) early anastomotic complication (bile leak requiring reoperation). CONCLUSION: Our initial experience demonstrated that RBS can be adopted safely with a low open conversion rate. Robotically constructed bilio-enteric anastomosis can be performed safely with a low anastomotic complication rate.

Initial experience with laparoscopic and robotic surgery for the treatment of periampullary tumours: single institution experience with the first 30 consecutive cases.

BACKGROUND: Concerns have been raised about the safety of minimally invasive surgery (MIS) for pancreatoduodenectomy (PD) during the early learning phase. In this study, we present our initial experience with MIS for periampullary tumours. METHODS: Retrospective review of the first 30 consecutive patients who underwent laparoscopic (LS)/robotic surgery (RS) for periampullary tumours between 2014 and 2017. RESULTS: Twenty-seven patients underwent PD, including three total pancreatectomies (TPs) and three underwent palliative bypasses. Twenty underwent LS, of which 18 were hybrid PDs, including two TPs and two bypasses. Ten patients underwent RS, of which nine were PDs, including one TP and one bypass. Five of 10 RSs were totally MIS procedures. There were four PDs with venous resection, of which three were by RS. There were four (13.3%) open conversions all in the LS cohort. There were five (16.7%) major (>grade 2) morbidities, including three pancreatic fistulas (two grade B and one grade C). There was no 30-day and one (3.3%) 90-day mortality. Comparison between RS and LS demonstrated that RS had a higher likelihood of being completed via totally MIS (five (50%) versus 0, P = 0.002), tended to have a shorter post-operative stay (eight (range 6-36) versus 14.5 (range 6-62) days, P = 0.058) but tended to be associated with a longer operation time (670 (range 500-930) versus 577 (range 235-715) min, P = 0.056). CONCLUSION: Our initial experience demonstrated that both LS and RS can be safely adopted for the treatment of periampullary tumours. The learning curve for RS seemed to be shorter than LS as we could transition more quickly from hybrid PDs to totally MIS safely.

Initial experience with robotic pancreatic surgery in Singapore: single institution experience with 30 consecutive cases.

BACKGROUND: Presently, the worldwide experience with robotic pancreatic surgery (RPS) is increasing although widespread adoption remains limited. In this study, we report our initial experience with RPS. METHODS: This is a retrospective review of a single institution prospective database of 72 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2017. Of these, 30 patients who underwent RPS were included in this study of which 25 were performed by a single surgeon. RESULTS: The most common procedure was robotic distal pancreatectomy (RDP) which was performed in 20 patients. This included eight subtotal pancreatectomies, two extended pancreatecto-splenectomies (en bloc gastric resection) and 10 spleen-saving-RDP. Splenic preservation was successful in 10/11 attempted spleen-saving-RDP. Eight patients underwent pancreaticoduodenectomies (five hybrid with open reconstruction), one patient underwent a modified Puestow procedure and one enucleation of uncinate tumour. Four patients had extended resections including two RDP with gastric resection and two pancreaticoduodenectomies with vascular resection. There was one (3.3%) open conversion and seven (23.3%) major (>Grade II) morbidities. Overall, there were four (13.3%) clinically significant (Grade B) pancreatic fistulas of which three required percutaneous drainage. These occurred after three RDP and one robotic enucleation. There was one reoperation for port-site hernia and no 30-day/in-hospital mortalities. The median post-operative stay was 6.5 (range: 3-36) days and there were six (20%) 30-day readmissions. CONCLUSION: Our initial experience showed that RPS can be adopted safely with a low open conversion rate for a wide variety of procedures including pancreaticoduodenectomy.

Outcomes After Metabolic Surgery in Asians-a Meta-analysis.

BACKGROUND: Obesity and type 2 diabetes mellitus (T2DM) are now increasingly epidemic in Asia. As obesity and T2DM have different disease patterns in Asians compared to Westerners, outcomes after metabolic surgery may differ. The aim of this meta-analysis was to gather the current available evidence on the outcomes after metabolic surgery in Asians. METHODS: A literature search was conducted in September 2017. Four outcome measures were examined: (1) % excess weight loss (EWL), (2) post-intervention body mass index (BMI), (3) T2DM resolution or improvement, and (4) hypertension resolution. RESULTS: Thirteen publications with a total of 1052 patients were analyzed, of which nine were randomized controlled trials, and four were case-matched studies. All the studies had a minimum follow-up duration of at least 1 year. % EWL was significantly higher in those who have undergone Roux-en-Y gastric bypass (RYGB) (SMD 0.53, 95% CI 0.12 to 0.94) versus sleeve gastrectomy (SG). T2DM resolution/improvement was favorable in those who have undergone RYGB (pooled OR 1.39, 95% CI 0.53 to 3.67) versus SG, although not statistically significant. Hypertension resolution was not significantly different between patients who have undergone SG versus RYGB (pooled OR 0.96, 95% CI 0.44 to 2.11). CONCLUSION: RYGB results in better weight loss compared to SG in Asians, but the rate of T2DM resolution/improvement and improvement of hypertension appears to be similar. In Asian patients without symptoms of gastro-esophageal reflux disease in whom metabolic surgery is performed mainly for T2DM and metabolic syndrome, SG may be the surgery of choice.

Initial experience with minimally invasive extended pancreatectomies for locally advanced pancreatic malignancies: Report of six cases.

BACKGROUND: Recently, there have been several reports on minimally-invasive surgery for extended pancreatectomy (MIEP) in the literature. However, to date, only a limited number of studies reporting on the outcomes of MIEP have been published. In the present study, we report our initial experience with MIEP defined according to the latest the International Study Group for Pancreatic Surgery (ISPGS) guidelines. METHODS: Over a 14-month period, a total of 6 consecutive MIEP performed by a single surgeon at a tertiary institution were identified from a prospectively maintained surgical database. EP was defined as per the 2014 ISPGS consensus. Hybrid pancreatoduodenectomy (PD) was defined as when the entire resection was completed through minimally-invasive surgery, and the reconstruction was performed open through a mini-laparotomy incision. RESULTS: Six cases were performed including 2 robotic extended subtotal pancreatosplenectomies with gastric resection, 1 laparoscopic-assisted (hybrid) extended PD with superior mesenteric vein wedge resection, 2 robotic-assisted (hybrid) PD with portal vein resection (1 interposition Polytetrafluoroethylene graft reconstruction and 1 wedge resection) and 1 totally robotic PD with wedge resection of portal vein. Median estimated blood loss was 400 (250-1500) ml and median operative time was 713 (400-930) min. Median post-operative stay was 9 (6-36) days. There was 1 major morbidity (Grade 3b) in a patient who developed early post-operative intestinal obstruction secondary to port site herniation necessitating repeat laparoscopic surgery. There were no open conversions and no in-hospital mortalities. CONCLUSION: Based on our initial experience, MIEP although technically challenging and associated with long operative times, is feasible and safe in highly selected cases.

Short-Term Outcomes of Extended Pancreatectomy: A Single-Surgeon Experience.

BACKGROUND/AIMS: The International Study Group of Pancreatic Surgery recently published a consensus statement on the definition of extended pancreatectomy (EP). We aimed to determine the safety profile and short-term outcomes of EP compared to standard pancreatectomy (SP). To mitigate surgeon bias, only pancreatectomies performed by a single surgeon were included. METHODS: Ninety consecutive patients who underwent pancreatectomy by a single surgeon over a period of 5 years and who met our study criteria were classified into an SP or an EP group. Sixty-two patients underwent pancreaticoduodenectomy (PD), including total pancreatectomy, and 28 patients underwent distal pancreatectomy. RESULTS: The 25 patients who underwent EP had significantly increased operation time, estimated blood loss, postoperative intensive care unit (ICU) transfer, and postoperative stay compared to the 65 patients who underwent SP. There was 1 (1.1%) 30-day mortality and 4 (4.4%) in-hospital mortalities. Postoperative morbidity and mortality were similar between both groups. Subgroup analysis of the patients who underwent PD demonstrated that the EP group (n = 22) had significantly increased operation time and postoperative ICU transfers. CONCLUSION: Although patients who underwent EP experienced significantly increased operative time, blood loss, and postoperative stay, they did not experience significantly higher postoperative morbidity or mortality compared to patients who underwent SP.

Emergency hand-assisted laparoscopic haemostasis for post-operative haemorrhage following laparoscopic liver resection.

INTRODUCTION: The use of laparoscopic surgery for liver resection and the management of abdominal emergencies has been well established. However, the value of this technique for post-operative haemorrhage in liver resection has not been characterized. CASE DESCRIPTION: We describe a case of post-operative haemorrhage following an elective totally laparoscopic liver resection that was treated with emergency hand-assisted laparoscopic haemostasis. DISCUSSION: Emergency hand-assisted laparoscopic haemostasis in the setting of post-operative haemorrhage after laparoscopic liver resection is feasible and should be considered as a treatment option in suitable patients.