Splenocystojejunostomy for the treatment of a symptomatic splenic pseudocyst.

Pancreatic pseudocyst is a widely recognised local complication following acute pancreatitis. Typically occurring more than four weeks after acute pancreatitis, a pseudocyst is a mature, encapsulated collection found within the peripancreatic tissues manifesting as abdominal pain, structural compression, gastroparesis, sepsis and organ dysfunction. Therapeutic interventions include endoscopic transpapillary or transmural drainage, percutaneous catheter drainage and open surgery. We present our management of idiopathic chronic pancreatitis complicated by a pancreatic pseudocyst extending to the splenic capsule in a 38-year-old man. A trial of conservative management was sought, but later escalated to percutaneous fluoroscopic drainage. Despite a period of volume reduction of the pseudocyst, reaccumulation occurred. We describe successful surgical treatment via means of a splenocystojejunostomy and subsequent pain reduction.

Prognostic relevance of the posterior resection margin for predicting disease free survival in ampullary adenocarcinoma.

BACKGROUND: Pancreaticoduodenectomy is the only curative treatment option for patients with resectable ampullary adenocarcinoma (AA). Excellent disease free survival (DFS) can be achieved in patients with clear resection margins but it is poorly understood which patients are at increased risk of recurrence and hence would benefit from adjuvant chemotherapy. There is evolving evidence that the anatomical location of incomplete resection margins influences DFS in pancreatic adenocarcinoma. It is unknown if this also pertains to AA and therefore this study aimed to assess individual resection margin status and other predictors of DFS in AA. MATERIAL & METHODS: Consecutive patients undergoing pancreaticoduodenectomy for AA at our institution from 1996 to 2017 were analysed. Pancreas neck, posterior and superior mesenteric vein margins were assessed individually. Cox proportional hazards modelling was used to identify predictors of 5-year DFS. Factors with p < 0.1 on univariate analysis were included for multivariate analysis. RESULTS: Analysis of 104 patients revealed median OS and DFS of 56 and 34 months, respectively. Predictors associated with worse DFS on multivariate analysis were T3-stage (HR 3.6, p = 0.048), N1 (HR 2.9, p = 0.01) and N2 -stage (HR 3.6, p = 0.006), R1 status at the posterior margin (HR 3.0, p = 0.009) and a visible mass on CT (HR 2.0, p = 0.039). CONCLUSION: Routine histopathological assessment of individual resection margins may aid in predicting recurrence of AA. Future studies to assess if routine mesopancreas excision during pancreaticoduodenectomy can reduce the incidence of R1 status at the posterior margin are warranted.

Immunological combination treatment holds the key to improving survival in pancreatic cancer.

Advances in surgery, peri-operative care and systemic chemotherapy have not significantly improved the prognosis of pancreatic cancer for several decades. Early clinical trials of immunotherapy have yielded disappointing results proposing other means by which the tumour microenvironment serves to decrease the immune response. Additionally, the emergence of various subtypes of pancreatic cancer has emerged as a factor for treatment responses with immunogenic subtypes carrying a better prognosis. Herein we discuss the reasons for the poor response to checkpoint inhibitors and outline a rationale why combination treatments are likely to be most effective. We review the therapies which could provide optimal synergistic effects to immunotherapy including chemotherapy, agents targeting the stroma, co-stimulatory molecules, vaccinations and methods of immunogenic tumour priming including radiofrequency ablation. Finally, we discuss reasons why peri-operative and in particular neoadjuvant combination treatments are likely to be most effective and should be considered for early clinical trials.

Comparison of manual and semi-automatic registration in augmented reality image-guided liver surgery: a clinical feasibility study.

BACKGROUND: The laparoscopic approach to liver resection may reduce morbidity and hospital stay. However, uptake has been slow due to concerns about patient safety and oncological radicality. Image guidance systems may improve patient safety by enabling 3D visualisation of critical intra- and extrahepatic structures. Current systems suffer from non-intuitive visualisation and a complicated setup process. A novel image guidance system (SmartLiver), offering augmented reality visualisation and semi-automatic registration has been developed to address these issues. A clinical feasibility study evaluated the performance and usability of SmartLiver with either manual or semi-automatic registration. METHODS: Intraoperative image guidance data were recorded and analysed in patients undergoing laparoscopic liver resection or cancer staging. Stereoscopic surface reconstruction and iterative closest point matching facilitated semi-automatic registration. The primary endpoint was defined as successful registration as determined by the operating surgeon. Secondary endpoints were system usability as assessed by a surgeon questionnaire and comparison of manual vs. semi-automatic registration accuracy. Since SmartLiver is still in development no attempt was made to evaluate its impact on perioperative outcomes. RESULTS: The primary endpoint was achieved in 16 out of 18 patients. Initially semi-automatic registration failed because the IGS could not distinguish the liver surface from surrounding structures. Implementation of a deep learning algorithm enabled the IGS to overcome this issue and facilitate semi-automatic registration. Mean registration accuracy was 10.9 ± 4.2 mm (manual) vs. 13.9 ± 4.4 mm (semi-automatic) (Mean difference - 3 mm; p = 0.158). Surgeon feedback was positive about IGS handling and improved intraoperative orientation but also highlighted the need for a simpler setup process and better integration with laparoscopic ultrasound. CONCLUSION: The technical feasibility of using SmartLiver intraoperatively has been demonstrated. With further improvements semi-automatic registration may enhance user friendliness and workflow of SmartLiver. Manual and semi-automatic registration accuracy were comparable but evaluation on a larger patient cohort is required to confirm these findings.

Comparison of gaze behaviour of trainee and experienced surgeons during laparoscopic gastric bypass.

BACKGROUND: Eye tracking presents a novel tool that could be used to profile skill levels in surgery objectively. The primary aim of this study was to identify differences in gaze behaviour between expert and junior surgeons performing a laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity. METHODS: This prospective observational study used a lightweight eye-tracking apparatus to determine the difference in gaze behaviours between expert (more than 75 procedures) and junior (75 or fewer procedures) surgeons at defined stages of LRYGB. Primary endpoints were normalized dwell time and fixation frequency. Secondary endpoints were blink rate, maximum pupil size and rate of pupil change. RESULTS: A total of 20 procedures (12 junior, 8 expert) were analysed. Compared with juniors, experts showed a prolonged dwell time on the screen during angle of His dissection (median (range) 91·20 (83·40-94·40) versus 68·95 (59·80-87·60) per cent; P = 0·001), formation of the retrogastric tunnel (91·50 (85·80-95·50) versus 73·60 (34·60-90·50) per cent; P = 0·001) and gastric pouch formation (86·95 (83·60-90·20) versus 67·60 (37·10-80·00) per cent P < 0·001). Juniors had a greater blink frequency throughout all recorded segments (P < 0·010) and had a larger maximum pupil size during all recorded operative segments (P < 0·010). Rate of pupil change was greater in juniors in all analysed segments (P < 0·010). CONCLUSION: These results suggest that experts display more focused attention on significant stimuli, alongside experiencing a reduced mental workload and having increased concentration. This has the potential for future use in validation of surgical skill in high-stakes assessment.

Meta-analysis of determinants of survival following treatment of recurrent hepatocellular carcinoma.

BACKGROUND: Intrahepatic recurrence of hepatocellular carcinoma (HCC) following resection is common. However, no current consensus guidelines exist to inform management decisions in these patients. Systematic review and meta-analysis of survival following different treatment modalities may allow improved treatment selection. This review aimed to identify the optimum treatment strategies for HCC recurrence. METHODS: A systematic review, up to September 2016, was conducted in accordance with MOOSE guidelines. The primary outcome was the hazard ratio for overall survival of different treatment modalities. Meta-analysis of different treatment modalities was carried out using a random-effects model, with further assessment of additional prognostic factors for survival. RESULTS: Nineteen cohort studies (2764 patients) were included in final data analysis. The median 5-year survival rates after repeat hepatectomy (525 patients), ablation (658) and transarterial chemoembolization (TACE) (855) were 35·2, 48·3 and 15·5 per cent respectively. Pooled analysis of ten studies demonstrated no significant difference between overall survival after ablation versus repeat hepatectomy (hazard ratio 1·03, 95 per cent c.i. 0·68 to 1·55; P = 0·897). Pooled analysis of seven studies comparing TACE with repeat hepatectomy showed no statistically significant difference in survival (hazard ratio 1·61, 0·99 to 2·63; P = 0·056). CONCLUSION: Based on these limited data, there does not appear to be a significant difference in survival between patients undergoing repeat hepatectomy or ablation for recurrent HCC. The results also identify important negative prognostic factors (short disease-free interval, multiple hepatic metastases and large hepatic metastases), which may influence choice of treatment.

Meta-analysis of adjuvant therapy following curative surgery for periampullary adenocarcinoma.

BACKGROUND: Periampullary cancers are uncommon malignancies, often amenable to surgery. Several studies have suggested a role for adjuvant chemotherapy and chemoradiotherapy in improving survival of patients with periampullary cancers, with variable results. The aim of this meta-analysis was to determine the survival benefit of adjuvant therapy for periampullary cancers. METHODS: A systematic review was undertaken of literature published between 1 January 2000 and 31 December 2015 to elicit and analyse the pooled overall survival associated with the use of either adjuvant chemotherapy or chemoradiotherapy versus observation in the treatment of surgically resected periampullary cancer. Included articles were also screened for information regarding stage, prognostic factors and toxicity-related events. RESULTS: A total of 704 titles were screened, of which 93 full-text articles were retrieved. Fourteen full-text articles were included in the study, six of which were RCTs. A total of 1671 patients (904 in the control group and 767 who received adjuvant therapy) were included. The median 5-year overall survival rate was 37·5 per cent in the control group, compared with 40·0 per cent in the adjuvant group (hazard ratio 1·08, 95 per cent c.i. 0·91 to 1·28; P = 0·067). In 32·2 per cent of patients who had adjuvant therapy, one or more WHO grade 3 or 4 toxicity-related events were noted. Advanced T category was associated worse survival (regression coefficient -0·14, P = 0·040), whereas nodal status and grade of differentiation were not. CONCLUSION: This systematic review found no associated survival benefit for adjuvant chemotherapy or chemoradiotherapy in the treatment of periampullary cancer.

Portobiliary fistula following laparoscopic cholecystectomy.

The laparoscopic approach has replaced open surgery as the gold standard for cholecystectomy. This technique is, however, associated with a greater incidence of bile duct injuries (BDIs). We report a case of portobiliary fistula (PBF), a rare complication of BDI, occurring post laparoscopic cholecystectomy (LC). PBF has been reported after procedures such as endoscopic retrograde cholangiopancreatography and pathologies such as liver abscesses, but only once previously in the setting of LC. We discuss the management of this patient with apparent dual pathology, and summarise other aetiologies that may give rise to this condition.

Development and validation of a symptom-based severity score for haemorrhoidal disease: the Sodergren score.

AIM: One major obstacle in assessing the efficacy of treatment of haemorrhoids and the comparison of trials has been the lack of a standardized, validated symptom severity score. This study aimed to develop an objective, validated symptom-based score of severity for haemorrhoids that can be used to compare treatments, monitor disease and assist in surgical decisions. METHOD: A symptom and quality-of-life questionnaire was developed from the literature in conjunction with expert surgical opinion. The questionnaire was circulated to patients with confirmed haemorrhoids. A statistical model was used to derive a weighted score of symptoms most affecting patients' quality of life. Patients who were offered operative treatment were independently judged by specialists to have more severe symptoms, with further validation of the scoring system against treatment. RESULTS: Forty-five patients were included in final validation analysis, of whom 44 (98%) reported multiple symptoms, the most common being rectal bleeding. Patient-reported effects on quality of life were 47.5 ± 36.3 (1-100 visual analogue scale). Calculated symptom severity scores were used to compare patients receiving operative or ambulatory care, with significant difference in the scores (7.7 ± 3.9 vs 2.8 ± 3.5, P = 0.002) and a receiver operating characteristic area under the curve of 0.842. CONCLUSION: A novel validated score for the assessment of haemorrhoidal disease adopting a standardized global score for symptom severity may have important implications in future for research, assessment and the management of this common pathology.

A pilot randomised controlled trial evaluating postoperative packing of the perianal abscess.

PURPOSE: Traditional management of a perianal abscess involves incision and drainage followed by packing of the cavity until healing by secondary intention is complete. The evidence supporting this is lacking however, and regular postoperative packing is time-consuming, painful and costly. This pilot study aimed to assess whether healing could be achieved safely without packing and to obtain preliminary results to enable sample size calculation in order to facilitate the implementation of a large multicentre randomised controlled trial. ClinicalTrials.gov Identifier: NCT01853267. METHODS: Fourteen patients with perianal abscesses were randomised to packing or non-packing of the abscess cavity postoperatively. Outcome measures were time to healing, abscess recurrence, fistula formation and postoperative pain. RESULTS: Healing in the non-packing group was faster compared to the packing group: mean 26.8 days (95 % confidence interval 22.7 to 30.7) vs 19.5 days (13.6 to 25.4); P = 0.047. There were no differences in recurrence rates between the groups (37.5 % packing group vs 33.3 % non-packing group; P = 0.580) at a median follow-up of 90.0 weeks (interquartile range (IQR) 26.0). In patients presenting with recurrence, one fistula was found in the packing group with no fistulas in the non-packing group. The non-packing group reported less pain 2 weeks postoperatively: median (IQR) 2.00 (3.00) vs 0.00 (1.00); (P = 0.030). CONCLUSION: Within the limitations of a small sample population, the results of this pilot study suggest that not packing the perianal abscess cavity after incision and drainage is safe. Our results show not packing confers less pain with a faster healing time compared with the conventional packing method, and this is a novel finding. These results need to be corroborated in the setting of a larger multicentre randomised controlled trial.

A case of gossypiboma mimicking intrahepatic cholangiocarcinoma.

INTRODUCTION: A gossypiboma refers to a cotton-based foreign body left inadvertently in the human body following a surgical procedure. Although a rare event, they tend to be found in the abdomen but few are known to be intrahepatic. CASE HISTORY: We report the case of a 44 year-old man who presented with recurrent episodes of jaundice and cholangitis, on a background of a right hepatectomy for hydatid cyst excision 20 years previously. This case was discussed at our hepatobiliary multidisciplinary team meetings on several occasions and a presumed diagnosis of intrahepatic cholangiocarcinoma was made. Biopsies of the mass had purely shown inflammation and remained inconclusive. It was decided that the patient should undergo a complete extended right hepatectomy with resection and reconstruction of the left branch of the portal vein. On attempting to obtain intraoperative frozen section specimens prior to resection, open excision revealed two large swabs encased in a calcified cavity. Removal of the swabs resulted in resolution of the mass and obstructive symptoms. CONCLUSIONS: Gossypiboma should be a rare differential diagnosis in all patients following a laparotomy presenting with obstructive symptoms, particularly in countries where strict surgical protocols may not be in place. This case also highlights the need to perform an intraoperative biopsy in any uncertain case of a liver lesion as we have shown that an extensive operation with its increased morbidity can occasionally be avoided.

Clinical outcome following Doppler-guided haemorrhoidal artery ligation: a systematic review.

AIM: Doppler-guided haemorrhoidal artery ligation (DGHL) has experienced wider uptake and has recently received National Institute for Health and Clinical Excellence (NICE) approval in the UK. A systematic review of the literature was conducted to assess its safety and efficacy. METHOD: This review was conducted in keeping with PRISMA guidelines. MEDLINE, EMBASE, Google Scholar and Cochrane Library databases were searched. Studies describing DGHL as a primary procedure and reporting clinical outcome were considered. Primary end-points were recurrence and postoperative pain. Secondary end-points included operation time, complications and reintervention rates. Studies were scored for quality with either Jadad score or NICE scoring guidelines. RESULTS: Twenty-eight studies including 2904 patients were included in the final analysis. They were of poor overall quality. Recurrence ranged between 3% and 60% (pooled recurrence rate 17.5%), with the highest rates for grade IV haemorrhoids. Postoperative analgesia was required in 0-38% of patients. Overall postoperative complication rates were low, with an overall bleeding rate of 5% and an overall reintervention rate of 6.4%. The operation time ranged from 19 to 35 min. CONCLUSION: DGHL is safe and efficacious with a low level of postoperative pain. It can be safely considered for primary treatment of grade II and III haemorrhoids.

Robotic-assisted total mesorectal excision: should it be considered as the technique of choice in the management of rectal cancer?

The feasibility of robotic surgery has been extensively explored over the past decade with a more recent shift towards defining focused clinical applications for which quantifiable patient benefits can be directly attributed to its use. The aim of this article is to review the current literature on the use of daVinci robotic surgery for the management of rectal cancer and identify the potential benefits, if any, that robotic-assisted total mesorectal excision (RTME) may provide over the current conventional approach. A comprehensive search strategy was used to identify relevant evidence in order to explore the oncological, operative and functional outcome measures for the RTME in addition to quantifying the level of evidence which describes the clinical effectiveness of the daVinci robot in oncological surgery. Both robotic assisted techniques and the primary outcomes are discussed. In total, 23 studies were reviewed across 11 institutions, including one pilot randomised control trial. When data repetition is disregarded, a total of 452 robotic assisted laparoscopic anterior resections and 60 robotic-assisted laparoscopic abdomino-perineal excision of the rectum have been published since the introduction of the daVinci into clinical practice. Feasibility of the daVinci robotic assisted total mesorectal excision is demonstrated, with comparable oncological outcomes presented for rectal cancer excision. A demonstration of a reduced open conversion rate as well as of reduced hospital stay with the use of the robot is highlighted, although further trials are required to confirm both these findings. No functional benefit in using the daVinci could be confirmed due to the lack of focused trials in this area.

Value of orientation training in laparoscopic cholecystectomy.

BACKGROUND: It is well established that disorientation during laparoscopic operations such as cholecystectomy is associated with increased morbidity and mortality. The aim of the present study was to evaluate whether high-performance orientation strategies could be taught to a cohort without relevant experience of laparoscopic cholecystectomy, resulting in improved performance and spatial awareness, thereby reducing the need for operative experience to command this skill. METHODS: Thirty medical students participated in a randomized controlled trial, with half randomized to a tutorial teaching orientation strategies at specific stages of laparoscopic cholecystectomy and half to a control group without any teaching. Attention as represented by gaze was captured using eye tracking as subjects were presented with 12 images of various stages of the operation, with the task of interpreting the orientation of the image. The primary outcome measure was subject performance in orientation. Secondary outcome measures were gaze dwell time on relevant anatomical structures within the images and comparison of individual behaviour using a visual behaviour profiling algorithm. RESULTS: The intervention group was significantly more likely to orientate correctly than the control group (mean 75·6 versus 56·1 per cent; P = 0·019). A difference in visual attention behaviour between the two groups was apparent for the majority of images when examining the output of the visual profiling algorithm, in the form of increased homogeneity of visual behaviour and/or an overall difference in orientation strategy. The mean orientation rate of all surgeons under identical conditions in a previously published study was 78·6 per cent. CONCLUSION: Training novices in orientation strategies improved their performance significantly and it could reach the level of a surgeon with several years of experience in laparoscopic surgery.

The role of robotic assisted laparoscopy for oesophagogastric oncological resection; an appraisal of the literature.

The introduction of surgical robotics to the field of surgical oncology brings with it an expectation not only of improved vision, instrumentation, and precision but also as a result, a potential for improved oncological outcomes. The current interest in the field of oesophagogastric oncology is explored in this review together with the benefits, real and potential, that robotic assistance offers surgical cancer resection as well as some of the limiting factors which may be hampering its uptake into current surgical practice. A systematic review of all the published literature up until April 2010 was examined across the field of esophageal and gastric cancer resection. A quantitative assessment of the oncological, operative, and functional outcomes was determined from each procedure. The level of evidence behind the results was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence; Therapy and Prevention. Three hundred and five cases from 19 independent studies were included for review. Nine studies explored the outcomes from robotic-assisted esophagectomy and eight, the robotic-assisted gastrectomy. Two articles included small case series of both procedures. The level of evidence was predominantly based on case series or expert opinion (Level 4 or 5) with only three unmatched or poorly matched comparative trials (Level 4) with no randomized trials evident. Improved operative outcomes and hospital stays were demonstrated with a reduction of 2 days when the robotic-assisted gastrectomy technique was employed compared with the open. No improvement in oncological outcomes could be identified with the use of the robot for either oesophageal or gastric cancer resection; however, in terms of short-term oncological outcomes, these were at least equivalent to the open approach for oesophageal cancer and early stage gastric cancer. Robotic-assisted laparoscopic surgery is a feasible technique to use to perform a safe and oncologically sound resection for oesophageal and early gastric cancer. Operative benefits appear to be encouragingly similar to the laparoscopic approach with some demonstration of improvement over the open technique despite a prolonged operative time. However, the level of evidence is suboptimal and more randomized controlled trials and long-term survival studies within a framework of measured and comparable outcomes is required.

Immunonutrition in patients undergoing major upper gastrointestinal surgery: a prospective double-blind randomised controlled study.

INTRODUCTION: current studies suggest immunonutrition decreases the inflammatory process, infection rates and reduces length of hospital stay in surgical patients, however studies are often conducted on heterogeneous groups of patients with varying composition of the immuno-nutrition. We aim to investigate the effect of immunonutrition on patients undergoing major upper gastrointestinal surgery by assessment of (i) the inflammatory and immune response and (ii) changes in clinical outcome when compared to a randomised control receiving conventional feeding. METHOD: a prospective double-blind randomised controlled study was undertaken to compare a feed supplemented with glutamine, arginine, -3 fatty acids and tributyrin, vitamin C, E and B-carotene and micronutrients (zinc, selenium and chromium) to an isonitrogenous, isocaloric control feed in patients undergoing major upper GI surgery. The primary end-points were defined as C-reactive protein (CRP), prealbumin and retinol binding protein (RBP) levels. Secondary end-points included performance scoring systems, length of hospital stay, adverse events and protein and nutrient assays. Variables were measured pre-operatively and routinely up to the 4th post-operative day. RESULTS: there was no statistically significant change in primary end-points between the immunonutrition group and the control group. There was no difference in length of hospital stay between the groups. The vitamin C level in the study group was significantly higher at the end of the study period. Both groups tolerated the feeds well with adequate target feeding rate. There were no other significant changes in clinical outcomes between the two groups. CONCLUSION: this study has not shown a benefit of immunonutrition through changes in inflammatory or nutritional markers, a decrease in length of hospital stay, or other morbidity. This may be because of inadequate numbers recruited to the study. Further, multi-centre, randomised trials on homogeneous patient groups are necessary to investigate the role of immunonutrition in major upper GI surgery.

Seroma formation and method of mesh fixation in laparoscopic ventral hernia repair--highlights of a case series.

INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) is gaining popularity amongst minimally invasive surgeons, promising shorter lengths of hospital stay and decreased morbidity compared to conventional open repair. We aim to report our experience of LVHR performed at a single institution and analyse morbidity to improve outcome. METHODS: A retrospective analysis using a prospectively collected database and patient re-cords was performed on all patients that underwent LVHR. Patient demographics, morbidity and mortality were recorded. Patients with recurrences underwent further analysis. RESULTS: There were a total of 55 laparoscopic ventral hernia operations performed on 50 patients. 24 (48%) were male, and the median BMI was 31 (range 20-41). The median operating time was 50 mins (range 30-120), the median length of stay (LOS) was one day (range 1-14) and the median follow-up period was 14 months (range 3-31). Operative complications occurred in two (3.6%) patients. Minor morbidity occurred in 12 (21.8%) patients. Eight (14.5%) patients developed seromas within the residual hernia sac post-operatively. There were six recurrences following LVHR in five patients. At re-operation, all recurrences appeared to be due to mesh detachment. CONCLUSION: LVHR is safe and the results are comparable to published series. We are encouraged by a shorter LOS and operative time compared to most published data. Post-operative se-roma formation is common. If there is a suspicion of recurrence, these should all be imaged appropriately to avoid unnecessary operative intervention. A higher BMI is an independent risk factor for recurrence in LVHR. Consideration should be given to using transfascial sutures or other fixation methods to improve recurrence rates in this difficult patient group.