Predicting response to neoadjuvant chemotherapy for colorectal liver metastasis using deep learning on prechemotherapy cross-sectional imaging.

BACKGROUND AND OBJECTIVES: Deep learning models (DLMs) are applied across domains of health sciences to generate meaningful predictions. DLMs make use of neural networks to generate predictions from discrete data inputs. This study employs DLM on prechemotherapy cross-sectional imaging to predict patients' response to neoadjuvant chemotherapy. METHODS: Adult patients with colorectal liver metastasis who underwent surgery after neoadjuvant chemotherapy were included. A DLM was trained on computed tomography images using attention-based multiple-instance learning. A logistic regression model incorporating clinical parameters of the Fong clinical risk score was used for comparison. Both model performances were benchmarked against the Response Evaluation Criteria in Solid Tumors criteria. A receiver operating curve was created and resulting area under the curve (AUC) was determined. RESULTS: Ninety-five patients were included, with 33,619 images available for study inclusion. Ninety-five percent of patients underwent 5-fluorouracil-based chemotherapy with oxaliplatin and/or irinotecan. Sixty percent of the patients were categorized as chemotherapy responders (30% reduction in tumor diameter). The DLM had an AUC of 0.77. The AUC for the clinical model was 0.41. CONCLUSIONS: Image-based DLM for prediction of response to neoadjuvant chemotherapy in patients with colorectal cancer liver metastases was superior to a clinical-based model. These results demonstrate potential to identify nonresponders to chemotherapy and guide select patients toward earlier curative resection.

Enhanced Recovery after Surgery recommendations that most impact patient care: A multi-institutional, multidiscipline analysis in the United States.

BACKGROUND: Compliance to the entire Enhanced Recovery after Surgery (ERAS) protocol improves surgical recovery, where higher compliance improves outcomes. However, specific items may predict improved recovery more than others. Studies have evaluated the impact of individual ERAS recommendations though they are either single center, not based in the United States (US), or focus on colorectal procedures only. This study aims to evaluate compliance on surgical outcomes in two large healthcare systems in the US across four surgery types. METHODS: Compliance to individual recommendations, limited patient characteristics, and outcomes data from two US ERAS Centers of Excellence (CoE) for hepatectomy, pancreatectomy, radical cystectomy, and head and neck (HN) resections were evaluated. Outcomes included 30-day Clavien-Dindo≥3, readmission, mortality, and length of stay (LOS). Multivariate regressions were performed as appropriate for the data for each surgery type. Clavien≥3 was included to control for severity of complications, and the CoE variable was force-retained. RESULTS: A total of 2886 records were analyzed. Controlling for CoE and severity of patient complications, early removal of Foley catheter was associated with significant reductions in LOS in the liver, pancreas, and HN procedures and reductions in complications in the liver and pancreas. Limited use of NG tubes reduced LOS in the pancreas and complications in urology. Oral carbohydrate loading reduced LOS in the pancreas, and patient education reduced mortality in HN patients. CONCLUSIONS: This study reports the effect of ERAS compliance on outcomes, by surgery type, in a multi-institutional US setting. Future studies should validate these findings and consider surgery-specific predictive models comprised of individual ERAS recommendations in real-world applications.

Management of long-term complications from immunosuppression.

This review discusses long-term complications from immunosuppressants after liver transplantation and the management of these complications. Common complications of calcineurin inhibitors include nephrotoxicity and metabolic diseases. Nephrotoxicity can be managed by targeting a lower drug level and/or adding an immunosuppressant of a different class. Metabolic disorders can be managed by treating the underlying condition and targeting a lower drug level. Gastrointestinal adverse effects and myelosuppression are common complications of antimetabolites that are initially managed with dose reduction or discontinuation if adverse events persist. Mammalian targets of rapamycin inhibitors are associated with myelosuppression, proteinuria, impaired wound healing, and stomatitis, which may require dose reduction or discontinuation. Induction agents and agents used for steroid-refractory rejection or antibody-mediated rejection are reviewed. Other rare complications of immunosuppressants are discussed as well.

Are enhanced recovery protocols after pancreatoduodenectomy still efficient when applied in elderly patients? A systematic review and individual patient data meta-analysis.

BACKGROUND: This meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared to conventional care on postoperative outcomes in patients aged 70 years or older undergoing pancreatoduodenectomy (PD). METHODS: Five databases were systematically searched. Comparative studies with available individual patient data (IPD) were included. The main outcomes were postoperative morbidity, length of stay, readmission and postoperative functional recovery elements. To assess an age-dependent effect, the group was divided in septuagenarians (70-79 years) and older patients (≥80 years). RESULTS: IPD were obtained from 15 of 31 eligible studies comprising 1109 patients. The overall complication and major complication rates were comparable in both groups (OR 0.92 [95% CI: 0.65-1.29], p = .596 and OR 1.22 [95% CI: 0.61-2.46], p = .508). Length of hospital stay tended to be shorter in the ERAS group compared to the conventional care group (-0.14 days [95% CI: -0.29 to 0.01], p = .071) while readmission rates were comparable and the total length of stay including days in hospital after readmission tended to be shorter in the ERAS group (-0.28 days [95% CI: -0.62 to 0.05], p = .069). In the subgroups, the length of stay was shorter in octogenarians treated with ERAS (-0.36 days [95% CI: -0.71 to -0.004], p = .048). The readmission rate increased slightly but not significantly while the total length of stay was not longer in the ERAS group. CONCLUSION: ERAS in the elderly is safe and its benefits are preserved in the care of even in patients older than 80 years. Standardized care protocol should be encouraged in all pancreatic centers.

10 years, 100 robotic major hepatectomies: a single-center experience.

INTRODUCTION: Adoption of robotic liver resections has been gradually increasing throughout the HPB surgical community over the past decade. Currently there is limited literature which demonstrates a significant benefit of robotic surgery for major hepatectomies over open or laparoscopic. As one of the first centers to develop a robotic HPB program, we have experienced improved outcomes over time with increasing utilization of robotics. Herein, we present our 10-year experience and outcomes for major robotic liver resections. METHODS: From 2012 to 2022, 361 robotic liver procedures were performed, including 100 major hepatectomies. A retrospective data review of the electronic medical record was performed evaluating outcomes after robotic major hepatectomy. Outcomes for the first 50 cases (Group A) and second 50 cases (Group B) were compared to identify any improvements in practice. Demographic and clinical outcome variables were analyzed. Data were assessed for normality, and Wilcoxon rank-sum, χ2 tests, and a logistic regression model were performed appropriate for the data. Stata v.17 was utilized, and significance was set as p < .05. RESULTS: There was no difference in median operative time (258 vs 256 min), EBL (500 vs 500 mL), median LOS (5 vs 3.5 days), 90-day readmission (14% vs 24%), major complications (14% vs 20%), and 90-day mortality (6% vs 4%) between early and late cases, respectively. ICU admissions and conversion rates were significantly lower in group B (14.0% vs 48.0%), while expert level difficulty indices were higher (82% vs 58%). CONCLUSION: Development of a robotic liver program with good outcomes is feasible over time. Our data suggest that our institutional learning curve for robotic major hepatectomy plateaued at approximately 50 cases.

Surgical microwave ablation for the treatment of hepatocellular carcinoma in 791 operations.

INTRODUCTION: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality and often arises in the setting of cirrhosis. The present series reviews outcomes following 791 operations. METHODS: Retrospective review surgical MWA for HCC from March 2007 through December 2022 at a high-volume institution was performed using a prospective database. Primary outcome was overall survival. RESULTS: A total of 791 operations in 623 patients and 1156 HCC tumors were treated with surgical MWA. Median tumor size was 2 cm (range 0.25-10 cm) with an average of 1 tumor ablated per operation (range 1-7 tumors). Nearly 90 % of patients had cirrhosis with a median MELD score of 8 (IQR = 6-11). Mortality within 30 days occurred in 13 patients (1.6 %). Per tumor, the rate of incomplete ablation was 2.25 % and local recurrence was 2.95 %. Previous ablation and tumor size were risk factors for recurrence. One-year overall survival was 82.0 % with a median overall survival of 36.5 months (95 % CI 15.7-93.7) and median disease-free survival of 15.9 months (range 5.7-37.3 months). CONCLUSION: Surgical MWA offers a low-morbidity approach for treatment of HCC, affording low rates of incomplete ablation and local recurrence.

Robotic versus laparoscopic distal pancreatectomy for pancreatic adenocarcinoma in obese patients.

BACKGROUND: Robotic distal pancreatectomy (RDP) is associated with a lower conversion rate and less blood loss than laparoscopic distal pancreatectomy (LDP). LDP has similar oncological outcomes as open surgery in PDAC. The aim of this study was to compare perioperative and oncological outcomes in obese patients with RDP versus LDP for PDAC. MATERIALS AND METHODS: Retrospectively, all obese patients who underwent RDP or LDP for PDAC between 2012 and 2022 at 12 international expert centres were included. RESULTS: out of 372, 81 patients were included. All baseline features were comparable between the two groups. RDP was associated with decreased blood loss (495mlLDP vs. 188mlRDP; p = 0.003), lower conversion rate (13.5%RDP vs. 36.4%LDP; p = 0.019) and lower rate of Clavien-Dindo ≥3 complications (13.5%RDP vs. 36.4%LDP; p = 0.019). Overall and disease-free survival were comparable. CONCLUSIONS: In obese patients with left-sided PDAC, the robotic approach was associated with improved intraoperative outcomes and fewer severe complications.

Current progress in robotic hepatobiliary and pancreatic surgery at a high-volume center.

There has been steady growth in the adoption of robotic HPB procedures world-wide over the past 20 years, but most of this increase has occurred only recently. Not surprisingly, the vast majority of robotics has been in the United States, with very few, select centers of adoption in Italy, South Korea, and Brazil, to name a few. We began our robotic HPB program in 2008, well before almost all other centers in the world, with the most notable exception of Giullianotti and colleagues. Our program began gradually, with smaller cases carefully selected to optimize the strengths of the original robotic platform and included complex biliary and pancreatic resections. We performed the first reported series of choledochojejunostomy for benign biliary strictures and first series of completion cholecystectomies. We began performing robotic distal pancreatectomies and longitudinal pancreaticojejunostomies, reporting our early experience for each of these procedures. Over time we progressed to robotic pancreaticoduodenectomies. Initially, these were performed with planned conversions until we were able to optimize efficiency. Now we have performed over 200 robotic whipples, reaching a 100% robotic completion rate by 2020. Finally, we have added robotic major hepatectomies, including resections for hilar cholangiocarcinoma to our repertoire. Since the program began, we have performed over 1600 robotic HPB cases. Outcomes from our program have shown superior lymph node harvest, lower DGE rates, shorter hospitalizations, and fewer rehab admissions with similar overall complications to open and laparoscopic procedures, signifying that over time a robotic HPB program is not only feasible but advantageous as well.

Expanding the utility of robotics for pancreaticoduodenectomy: a 10-year review and comparison to international benchmarks in pancreatic surgery.

BACKGROUND: Robotic pancreaticoduodenectomy (RPD) is an emerging alternative to open pancreaticoduodenectomy (OPD). Although RPD offers various theoretical advantages, it is used in less than 10% of all pancreaticoduodenectomies. The aim of this study was to report our 10-year experience and compare RPD outcomes with international benchmarks for OPD. METHODS: A retrospective review of a prospectively maintained institutional database was performed of consecutive patients who underwent RPD between January 2011 and December 2021. Patients were categorized into low-risk and high-risk groups according to the selection criteria set by the benchmark study. Their outcomes were compared to the international benchmark cut off values. Outcomes were then evaluated over time to identify improvements in practice and establish a learning curve. RESULTS: Of 201 RPDs, 36 were low-risk and 165 high-risk patients. Compared to the OPD benchmarks, outcomes of low-risk patients were within the cutoff values. High-risk patients were outside the cutoff for blood transfusions (26% vs. ≤ 23%), overall complications (78% vs. ≤ 73%), grade I-II complications (68% vs. ≤ 62%), and readmissions (22% vs ≤ 21%). Oncologic outcomes for high-risk patients were within benchmark cutoffs. Cases at the end of the learning curve included more pancreatic cancer (42% from 17%) and fewer low-risk patients (10% from 24%) than those at the beginning. After 41 RPD there was a decline in conversion rates and operative time. Between 95 and 143 cases operative time, transfusion rates, and LOS declined significantly. Complications did not differ over time. CONCLUSION: RPD yields results comparable to the established benchmarks in OPD in both low- and high-risk patients. Along the learning curve, RPD evolved with the inclusion of more high-risk cases while outcomes remained within benchmarks. Addition of a robotic HPB surgery fellowship did not compromise outcomes. These results suggest that RPD may be an option for high-risk patients at specialized centers.

Impact of preoperative statin medication on long-term outcomes after pancreatoduodenectomy for ductal adenocarcinoma: an international multicentric cross-sectional study.

PURPOSE: Statin treatment has been shown in certain population studies and meta-analyses to improve survival of patients with pancreatic ductal adenocarcinoma (PDAC). This study assessed if patients with statin treatment had better overall survival (OS) and disease-free survival (DFS) after upfront pancreatoduodenectomy for PDAC. METHODS: Consecutive PDAC patients were retrospectively collected from three centers in Europe and USA (study period: 2000-2017). Adult patients who underwent upfront pancreatoduodenectomy and survived the first 90 postoperative days were included. Patients with metastasis at diagnosis or with macroscopic incomplete resection were excluded. Patients were considered under statin if started at least one month before pancreatoduodenectomy. Survival rates were calculated using Kaplan-Meier method and compared with log-rank test. RESULTS: A total of 496 patients were included. Median age was 67 years (IQR 59-75), 48% (n = 236) were women, and 141 patients (28%) received statin treatment already preoperatively. Patients with and without statin treatment were comparable in terms of demographics and pre-/intraoperative characteristics, except for age and pre-existing diabetes. Median OS and DFS were similar in patients with and without statin treatment (OS: 29, 95% CI 22-36 vs. 27 months, 95% CI 22-32, p = 0.370, DFS: 18, 95% CI 14-22 vs. 16 months, 95% CI 14-18, p = 0.430). On multivariable Cox regression, lymph node involvement (HR 1.9, 95% CI 1.6-2.2, p < 0.001), tumor differentiation (HR 1.3, 95% CI 1.1-1.6, p = 0.003), and postoperative chemotherapy (HR 0.5, 95% CI 0.4-0.7, p < 0.001) were predictors of OS, whereas statin treatment was not a prognostic factor (HR 0.9, 95% CI 0.7-1.2, p = 0.376). CONCLUSION: In this international cohort of PDAC patients, statin treatment did not influence survival after upfront pancreatoduodenectomy. Nodal involvement, tumor differentiation, and postoperative chemotherapy were independent predictors of OS.

Robotic versus laparoscopic distal pancreatectomy in obese patients.

BACKGROUND: Although robotic distal pancreatectomy (RDP) has a lower conversion rate to open surgery and causes less blood loss than laparoscopic distal pancreatectomy (LDP), clear evidence on the impact of the surgical approach on morbidity is lacking. Prior studies have shown a higher rate of complications among obese patients undergoing pancreatectomy. The primary aim of this study is to compare short-term outcomes of RDP vs. LDP in patients with a BMI ≥ 30. METHODS: In this multicenter study, all obese patients who underwent RDP or LDP for any indication between 2012 and 2022 at 18 international expert centers were included. The baseline characteristics underwent inverse probability treatment weighting to minimize allocation bias. RESULTS: Of 446 patients, 219 (50.2%) patients underwent RDP. The median age was 60 years, the median BMI was 33 (31-36), and the preoperative diagnosis was ductal adenocarcinoma in 21% of cases. The conversion rate was 19.9%, the overall complication rate was 57.8%, and the 90-day mortality rate was 0.7% (3 patients). RDP was associated with a lower complication rate (OR 0.68, 95% CI 0.52-0.89; p = 0.005), less blood loss (150 vs. 200 ml; p < 0.001), fewer blood transfusion requirements (OR 0.28, 95% CI 0.15-0.50; p < 0.001) and a lower Comprehensive Complications Index (8.7 vs. 8.9, p < 0.001) than LPD. RPD had a lower conversion rate (OR 0.27, 95% CI 0.19-0.39; p < 0.001) and achieved better spleen preservation rate (OR 1.96, 95% CI 1.13-3.39; p = 0.016) than LPD. CONCLUSIONS: In obese patients, RDP is associated with a lower conversion rate, fewer complications and better short-term outcomes than LPD.

External validation of the Japanese difficulty score for laparoscopic hepatectomy in patients undergoing robotic-assisted hepatectomy.

INTRODUCTION: The Japanese difficulty score (JDS) categorizes laparoscopic hepatectomy into low, intermediate, and high complexity procedures, and correlates with operative and postoperative outcomes. We sought to perform a validation study to determine if the JDS correlates with operative and postoperative indicators of surgical complexity for patients undergoing robotic-assisted hepatectomy. METHODS: Retrospective review of 657 minimally invasive hepatectomy procedures was performed between January 2008 through March 2019. Outcomes included operative time, estimated blood loss (EBL), blood transfusion, complications, post-hepatectomy liver failure (PHLF), length of stay, 30-day readmission, and 30-day and 90-day mortality. Patients were grouped based on JDS defined as: low (< 4), intermediate (4-6), and high (7 +) complexity procedures. Statistical comparisons were analyzed by ANOVA or χ2 test. RESULTS: 241 of 657 patients underwent robotic-assisted resection. Of these patients, 137 were included in the analysis based on JDS: 25 low, 58 intermediate, and 54 high. High JDS was associated with more major resections (≥ 4 contiguous segments) versus minor resections (median JDS 8 vs. 5, P < 0.0001). High JDS was associated with significantly longer operative times, higher EBL, and more blood transfusions. High JDS was associated with higher rates of PHLF at 16.7%, compared with 5.2% intermediate and 0.0% low, (P = 0.018). Complication rates, 30-day readmissions, and mortality rates were similar between groups. Median LOS was longer in patients with high JDS compared with intermediate and low (4 days vs. 3 days vs. 2 days; P = 0.0005). DISCUSSION: Higher JDS was associated with multiple indicators of operative complexity, including greater extent of resection, increased operative time, EBL, blood transfusion, PHLF, and LOS. This validation study supports the ability of the JDS to categorize patients undergoing robotic-assisted hepatectomy by complexity.

The importance of robotic surgery training in HPB fellowship: a survey of the 2022 AHPBA fellows.

BACKGROUND: The 2022 incoming fellows' expectations for their robotics training, as well as their perceptions of the utility of the surgical robot, are not well defined. METHODS: Cross-sectional survey of 24 AHPBA fellows in 2022, analyzed with descriptive statistics and Spearman's rho. RESULTS: Of 33 current AHPBA fellows, 22 completed the survey (66.7%). Study participants had limited-to-moderate experience with robotics prior to fellowship (mean 2.5 ± SD 1.1; range 1-4). Most participants agreed that robotics influenced their fellowship choice (mean 4.14 ± SD 0.87; range 1-5), would make then more marketable (mean 4.77 ± SD 0.52; range 1-5) and improve job prospects (mean 4.68 ± SD 0.87; range 1-5). Of the study participants, 55% responded that robotics training is "essential" in fellowship, while 64% responded that it is "essential" for their careers. Fellows were only slightly satisfied with overall robotics training within their respective programs (mean 3.44 ± SD 1.17; range 1-5) The majority (73.7%) expect that robotics will comprise <25% of their training. Notably, the majority (75%) have no formal robotics training curriculum. DISCUSSION: This survey identifies potential gaps where robotics training could be improved for future incoming AHPBA fellows.

Major hepatectomy in elderly patients: possible benefit from robotic platform utilization.

INTRODUCTION: Robotic surgery has been increasingly utilized, yet its application for hepato-pancreato-biliary (HPB) procedures remains low due to technical complexity, perceived financial burden, and unproven clinical benefits. We hypothesized that the robotic approach would be associated with improved clinical outcomes following major hepatectomy compared with the laparoscopic approach among elderly patients who would benefit from the advantages of minimally invasive surgery. METHODS: A retrospective review of consecutive patients who underwent major hepatectomy between January 2010 and December 2021 at Carolinas Medical Center was performed. Inclusion criteria were age ≥ 65 years and major hepatectomy of three segments or more. Patients who underwent multiple liver resections, vascular/biliary reconstruction, or concomitant extrahepatic procedures (except cholecystectomy) were excluded. Categorical variables were compared using Chi-square or Fisher's exact test when more than 20% of cells had expected frequencies less than five, and Wilcoxon two-sample or Kruskal-Wallis tests were used for continuous or ordinal variables. Results are described as median and interquartile range (IQR). Multivariate analyses were used on postoperative admission days. RESULTS: There were 399 major hepatectomies performed during this time period, of which 125 met the criteria and were included. There were no differences in perioperative demographics among patients who underwent robotic hepatectomy (RH, n = 39) and laparoscopic hepatectomy (LH, n = 32). There was no difference in operative time, blood loss, or major complication rates. However, RH had lower rates of conversion to an open procedure (2.6% versus 31.3%, p = 0.002), shorter length of hospital stay [LOS, 4 (3-7) versus 6 (4-8.5) days, p ≤ 0.0001], cumulative LOS [4 (3-7) versus 6 (4.5-9) days, p ≤ 0.0001], and lower rates of intensive care unit (ICU) admission (7.7% versus 75%, p ≤ 0.001), with a trend toward fewer rehabilitation requirements. CONCLUSIONS: Robot major hepatectomy shows clinical advantages in elderly patients, including shorter hospital and ICU stays. These advantages, as well as reduced rehabilitation requirements associated with minimally invasive surgery, could overcome the current perceived financial disadvantages of robotic hepatectomy.

Impact of nutritional compliance within ERAS protocols for hepatopancreatobiliary, radical cystectomy, and head and neck procedures: A case-matched analysis adjusted for major complications.

BACKGROUND: Enhanced recovery after surgery (ERAS®) pathways aim to improve patient outcomes by applying multimodal practices before, during, and after operative procedures. Compared with standard care before ERAS, we investigated whether compliance to ERAS guidelines for nutritional care, preoperative oral carbohydrate loading and postoperative oral nutrition, was associated with a decrease in hospital length of stay (LOS) after pancreaticoduodenectomy, distal pancreatectomy, hepatectomy, radical cystectomy, and head and neck tumor resection with reconstruction. METHODS: Compliance to ERAS nutrition recommendations was evaluated. Post-ERAS cohort was retrospectively analyzed. Pre-ERAS cohort consisted of case matched patients one year before ERAS: age more than or less than 65 years, body mass index (BMI) more than greater than or less than 30 kg/m2, diabetes mellitus, sex, and procedure. Each cohort consisted of 297 patients. Binary linear regressions evaluated the incremental effect of postoperative nutrition timing and preoperative carbohydrate loading on LOS. Multivariate regressions adjusted for postoperative complications. RESULTS: Compliance with preoperative carbohydrate loading for the post-ERAS cohort was 81.7%. Mean hospital LOS was significantly shorter for the post-ERAS cohort compared with pre-ERAS cohort (8.3 vs 10.0 days, p < 0.001). By procedure, LOS was significantly shorter for patients undergoing pancreaticoduodenectomy (p = 0.003), distal pancreatectomy (p = 0.014), and head and neck procedures (p = 0.024). Early postoperative oral nutrition was associated with a 3.75-day shorter LOS (p < 0.001); no nutrition was associated with a 3.29-day longer LOS (p < 0.001). CONCLUSION: Compliance with ERAS protocols for specific nutritional care practices was associated with a statistically significant decrease in LOS without subsequent increases in 30-day readmission rates and positive financial impact. These findings suggest that ERAS guidelines for perioperative nutrition are a strategic pathway to improved patient recovery and value-based care in surgery.

Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis.

BACKGROUND: Pancreatic necrosectomy with concomitant internal drainage is a single-stage treatment option for walled-off pancreatic necrosis (WOPN). However, an optimal minimally invasive technique has not been established. We evaluated the safety and single-intervention success rate of robotic pancreatic necrosectomy and internal drainage. METHODS: Patients with WOPN undergoing robotic pancreatic necrosectomy and internal drainage at a single institution from 2011-2022 were identified. The primary outcome was the rate of clinical symptom resolution following the index surgical intervention. RESULTS: 57 patients underwent robotic pancreatic necrosectomy and internal drainage, consisting of robotic cystgastrostomy (RCG, n = 37), robotic cystjejunostomy (RCJ, n = 13) and robotic fistulojejunostomy (RFJ, n = 7). Surgery was performed a median of 102 (range 28-1153) days following the onset of necrotizing pancreatitis. The median operative time was 187 (91-344) minutes and there were 2 (3.5%) conversions. The median length of hospital stay was 4 (2-38) days. Postoperative morbidity was 11%, and there was one (1.8%) 90-day mortality. At a median follow-up of 5.5 months, 53 (93%) patients had clinical symptom resolution after their index procedure and did not require any reintervention. CONCLUSION: In select patients, robotic pancreatic necrosectomy and internal drainage is safe and achieves a high single-intervention success rate.

Future liver remnant augmentation preceding ex vivo hepatectomy with IVC replacement: a strategy to achieve R0 margins.

PURPOSE: Ex vivo hepatectomy with autotransplantation (EHAT) provides opportunity for R0 resection. As EHAT outcomes after future liver remnant (FLR) augmentation techniques are not well documented, we examine results of EHAT after augmentation for malignant tumors. METHODS: Retrospective analysis of six cases of EHAT was performed. Of these, four occurred after preoperative FLR augmentation between 2018 and 2022. RESULTS: Six patients were offered EHAT of 26 potential candidates. Indications for resection were involvement of hepatic vein outflow and inferior vena cava (IVC) with metastatic colorectal carcinoma (n = 3), cholangiocarcinoma (n = 2), or leiomyosarcoma (n = 1). Five patients were treated with neoadjuvant chemotherapy and four had preoperative liver augmentation. One hundred percent of cases achieved R0 resection. Of the augmented cases, three patients are alive after median follow-up of 28 months. Postoperative mortality due to liver failure was 25% (n = 1). CONCLUSIONS: For select patients with locally advanced tumors involving all hepatic veins and the IVC for whom conventional resection is not an option, EHAT provides opportunity for R0 resection. In addition, in patients with inadequate FLR volume, further operative candidacy with acceptable results can be achieved by combined liver augmentation techniques. To better characterize outcomes in this small subset, a registry is needed.

Irreversible Electroporation-Assisted Resection for Locally Advanced Pancreas Cancer.

BACKGROUND: A significant number of patients with advanced pancreatic cancer are unable to undergo resection due to vascular involvement. Irreversible electroporation (IRE) has shown promise in improving survival. This study sought to assess a novel IRE application whereby IRE was performed pre-resection to alter tissue plasticity and assist tumor removal from underlying vasculature when surgical excision was otherwise precluded. METHODS: After multidisciplinary evaluation appropriate patients were consented for IRE therapy. All IRE cases were tracked prospectively using an institutional review board-approved database that was retrospectively queried for patients undergoing IRE-assisted resection (IRE-AR) for pancreatic adenocarcinoma located in the head/uncinate process. Patients who underwent other IRE therapy or had disease location elsewhere were excluded. RESULTS: 5 patients met the study inclusion criteria with a mean tumor size of 3.2 cm (range 2.4-4.1 cm). Using IRE-AR median recurrence free survival was 10.6 months, with 21.6 month overall survival. The average comprehensive complication index score was 23.23. One patient had grade 3 [or higher] complications and there were no 90 day mortalities. DISCUSSION: Employing a high-starting voltage for ablation along resection margins allows for resection when margins are anticipated to be positive. Patients with locally advanced pancreatic adenocarcinoma who underwent IRE-AR had promising outcomes. CONCLUSION: This study reports IRE-AR as a novel approach for resecting locally advanced pancreatic adenocarcinoma. A prospective trial of IRE-AR for inoperable pancreatic adenocarcinoma will provide additional data for the long-term application of this approach.

Iatrogenic Portobiliary Fistula following Endoscopic Biliary Stent Placement: A Case Series and Review of the Literature.

Iatrogenic portobiliary fistula is a rare adverse event following endoscopic biliary stent placement. Damage to the portal vein following endoscopic biliary stent placement has previously only been reported as single case reports. Management has ranged from conservative monitoring to surgery. Here, the authors present 4 cases of inadvertent endoscopic placement of a biliary stent into the portal vein. Interventional radiology was called to assist in the management of each of these cases. The experience presented here in conjunction with review of the previously reported cases helps shed light on potential management strategies if this adverse event is encountered in the future.