Initial experience with 3D laparoscopic choledochal cyst (CDC) excision and hepatico-duodenostomy (HD) in 21 children.

INTRODUCTION: Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically challenging procedure that requires advanced intracorporeal suturing skills, and hence, has a steep learning curve. Robotic surgery has the advantages of 3D vision, articulating hand instruments making suturing easy and thus is ideal. However, the non-availability, high costs and necessity for large-size ports are the major limiting factors for robotic procedures in the paediatric population. Use of 3D laparoscopy incorporates the advantage of 3D vision and at the same time allows the use of small-sized conventional laparoscopic instruments. With this background, we discuss our initial experience with the use of 3D laparoscopy using conventional hand instruments in CDC management. AIM: To study our initial experience in the management of CDC in paediatric patients with 3D laparoscopy in terms of feasibility and peri-operative details. MATERIALS AND METHOD: All patients under 12 years of age treated for choledochal cyst in a period of initial 2 years were retrospectively analysed. Demographic parameters, clinical presentation, intra-operative time, blood loss, post-operative events and follow-up were studied. RESULTS: The total number of patients were 21. The mean age was 5.3 years with female preponderance. Abdominal pain was the most common presenting symptom. All patients could be completed laparoscopically. No patient needed conversion to open procedure or re-exploration. The average blood loss was 26.67 ml. None of the patients required a blood transfusion. One patient developed a minor leak postoperatively and was managed conservatively. CONCLUSION: 3D laparoscopic management of CDC in the paediatric age group is safe and feasible. It offers the advantages of depth perception aiding intracorporeal suturing, with the use of small-sized instruments. It is thus a 'bridging the gap' asset between conventional laparoscopy and robotic surgery. LEVEL OF EVIDENCE: Treatment study level IV.

Study of Operative Events and Time Requirement of Hepaticoduodenostomy for the Treatment of Type I Choledochal Cyst- the Experience at BSMMU Hospital.

Of all varieties, Type I Choledochal cyst causing saccular or fusiform dilatation of the extra-hepatic biliary ductal system is the commonest (90.0 - 95.0%). Its presentations vary. To restore the continuity of the extra-hepatic biliary tract after excision of type I Choledochal cyst, surgeons have few alternatives to use, with their advantages and disadvantages. Roux en-Y Hepatico-jejunostomy (RYHJ) has been very popular and long studied standard surgical treatment for type I Choledochal cyst. But now Hepatico-duodenostomy (HD) is also being practiced and studied in different centers all over the world for the treatment of the same disease. For the last five years, we, at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, have been using Hepatico-duodenostomy as preferred anastomotic option in treating type I Choledochal cyst. Here, we are presenting our experience at BSMMU Hospital, regarding operative events and time requirement of Hepaticoduodenostomy for the treatment of type I Choledochal cyst and, to show whether this procedure can be safely practiced, producing acceptable results. It is a retrospective document study, from January 2013 to December 2017, at BSMMU Hospital, on forty two, MRCP confirmed type I Choledochal cyst patients of pediatric age. Patients' particulars, history, physical examination, investigations (including MRCP confirmation), assessment, surgical plan were collected from relevant medical records and documented in duly coded individual data collection sheet maintaining standard privacy protocol. Information regarding presentations, operative findings and procedural events including per-operative mortality, injury to the vital structures during operation, conversion to RYHJ, operative time (minutes), blood loss and transfusion requirements (ml) of Heaticoduodenostomy for type I Choledochal cyst, were specially searched for. There was no operative mortality. None of these patients required per-operative blood transfusion. Nor there was any inadvertent injury to the adjacent structures. The mean operative time required for Hepaticoduodenostomy was 88 minutes with a range of 75 to 125 minutes. Through this study, at BSMMU Hospital, operative events and time requirement of Hepatico-duodenostomy for treating type I Choledochal cyst, was found to be yielding acceptable results, for safe practice.

Duodenopancreatectomía por adenocarcinoma ductal de páncreas en ancianos. ¿Podemos asumirla con seguridad? / Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

Introducción: La cirugía y la quimioterapia han aumentado la supervivencia de los pacientes con neoplasias pancreáticas. La disminución de la morbimortalidad postoperatoria y el aumento de la esperanza de vida han ampliado las indicaciones de la duodenopancreatectomía cefálica (DPC), aunque sigue siendo controvertida en la población geriátrica. Métodos: Estudio observacional retrospectivo sobre una base de datos prospectiva, de pacientes con adenocarcinoma ductal de páncreas sometidos a una DPC entre 2007-2018. El objetivo principal fue analizar la morbimortalidad y supervivencia asociada a la DPC en pacientes≥75 años (ancianos). Resultados: Se incluyeron 79 pacientes, 21 de ellos mayores de 75 años (27%); dentro de este grupo el 23,9% tenían más de 80 años. El ASA de ambos grupos fue similar. Los pacientes≥75años requirieron más transfusiones. No se observaron diferencias en el tiempo operatorio, aunque en los ancianos se realizaron más resecciones vasculares (26 vs. 8,7%; p=0,037).La morbilidad fue mayor en los ancianos (61,9 vs. 46,6%), aunque sin diferencias. Los≥75años presentaron más complicaciones no quirúrgicas (33,3%; p=0,050) siendo la neumonía la más frecuente. La mortalidad postoperatoria fue superior en los≥75años (9 vs. 0%; p=0,017), constituyendo la resección venosa un factor de riesgo (p=0,01). La supervivencia global y la supervivencia libre de enfermedad no mostraron diferencias significativas en ambos grupos. Conclusiones: Los pacientes ancianos presentaron una mayor mortalidad postoperatoria y más complicaciones no quirúrgicas. La supervivencia no mostró diferencias, por lo que, con una adecuada selección de pacientes, la edad no debe constituirse por sí misma como una contraindicación para la DPC(AU).

Introduction: Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. Methods: Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly). Results: 79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups. Conclusions: Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC(AU).

Association between Postoperative Opioid Requirements and the Duration of Smoking Cessation in Male Smokers after Laparoscopic Distal Gastrectomy with Gastroduodenostomy.

Smoking is clinically associated with high postoperative pain scores and increased perioperative analgesic requirements. However, the association between the duration of smoking cessation and postoperative opioid requirements remains unclear. Therefore, this study aimed to evaluate the association between the duration of smoking cessation and postoperative opioid requirements. We retrospectively analyzed the data of 144 male patients who received intravenous patient-controlled analgesia (IV PCA) after laparoscopic distal gastrectomy with gastroduodenostomy. All patients were divided into three groups: G0, nonsmoker; G1, smoker who quit smoking within 1 month preoperatively; G2, smoker who quit smoking over 1 month preoperatively. Analgesic use, pain intensity, and IV PCA side effects were assessed up to postoperative day 2. As the duration of smoking cessation increased, the amount of postoperative opioid consumption decreased (ß = -0.08; 95% confidence interval (CI), -0.11 to -0.04; P < 0.001). The total postoperative opioid requirements in G1 were significantly higher than those in G0 and G2 (G0, 75.5 ± 15.9 mg; G1, 94.6 ± 20.5 mg; and G2, 79.9 ± 19.4 mg (P < 0.001)). A multivariate regression analysis revealed that G1 was independently associated with increased postoperative opioid requirements (ß = 12.80; 95% CI, 5.81-19.80; P < 0.001). Consequently, male patients who had ceased smoking within 1 month of undergoing a laparoscopic distal gastrectomy with gastroduodenostomy had higher postoperative opioid use than patients who had ceased smoking for more than 1 month and nonsmokers.

Robotic duodenal (D3) resection with Roux-en-Y duodenojejunostomy reconstruction for large GIST tumor: Step by step with video.

BACKGROUND: Duodenal gastrointestinal stromal tumors (GISTs) are uncommon, making up only 3-5% of all GISTs. [1,2] Historically, the treatment of choice for duodenal GIST tumors was pancreaticoduodenectomy. [3]Currently, newer surgical intervention methods including local resection via laparotomy, endoscopic resection, and robotic resection are feasible. When doing a local resection, the defect can be closed either primarily or via a Roux-en-Y duodenojejunostomy. [3] Case presentation: Our patient is a 64-year- old female who presented initially with shortness of breath and was found to have a pulmonary embolism. She then developed upper GI bleeding from anticoagulation and was found to have an ulcerated GIST tumor in the anti-mesenteric border of the third portion of the duodenum (D3). Initial surgery was postponed due to high pulmonary artery pressure from the pulmonary embolism. The patient underwent argon beam coagulation of the bleeding mass to control the bleeding, followed by localized radiotherapy plus Gleevec. Unfortunately, the tumor grew in size during follow-up. The patient was then taken to the OR for a robot-assisted partial duodenal resection (D3) with Roux-en-Y duodenojejunostomy to reconstruct the large defect. She did well post operatively and her final pathology showed a GIST tumor, c-kit and DOG1 positive, 3.5 cm in size, with negative margins. CONCLUSION: Robotic duodenal resection is a new technique currently being used to resect duodenal GIST tumors. Our video demonstrates the feasibility of D3 partial resection with Roux-en-Y duodenojejunostomy. Duodenal GIST tumor robotic resection offers both decreased morbidity and adequate oncologic outcomes.

Endoscopic ultrasound-guided cholecystostomy for resection of gallbladder polyps with lumen-apposing metal stent.

Laparoscopic cholecystectomy is the routine method to treat gallbladder polyps. Nowadays, endoscopic ultrasound (EUS)-guided cholecystostomy as a bridge for per-oral transmural endoscopic resection of gallbladder polyps is introduced because preservation of gallbladder is increasingly getting attention. The aim of our study was to evaluate the approach in the treatment of patients with gallbladder polyps and symptomatic gallstones.EUS-guided cholecystostomy with the placement of a lumen-apposing metal stent (LAMS) was performed for those patients with accompanying gallbladder polyps and symptomatic gallstones. Several days after the cholecystostomy with LAMS, a gastroscope was introduced into the gallbladder to remove gallbladder polyps.All patients were successfully performed with the procedures of EUS-guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 1) and endoscopic resection of gallbladder polyps. One patient experienced severe peritonitis. During the follow-up at 3 months, 1 patient was performed with laparoscopic cholecystectomy because ultrasonography examination showed the reappeared gallstones. No stone recurrence was found in other patients. During the follow-up of 3 to 15 months, no polyp recurrence was found in all the patients.The approach is novel for performing EUS-guided gallbladder fistulization, which can subsequently allow procedures of per-oral transmural endoscopic resection of gallbladder polyps to avoid cholecystectomy in the patients with gallbladder polyps and gallstones. However, further studies are needed before clinical recommendation because of the complications and stone recurrence.

Durability and outcome of endoscopic ultrasound-guided hepaticoduodenostomy using a fully covered metal stent for segregated right intrahepatic duct dilatation.

BACKGROUND AND AIMS: Segregated right intrahepatic duct dilatation (IHD) results from complete obstruction of the biliary tract proximal to the hilar level. We aimed to evaluate long-term efficacy and safety of endoscopic ultrasound (EUS) hepaticoduodenostomy (HDS) in segregated right IHD. METHODS: Consecutive patients who had undergone EUS-guided HDS with a fully covered self-expandable metal stent (FCSEMS) in an academic tertiary center were recruited. All patients had segregated right hepatic duct and failed drainage by endoscopic retrograde cholangiopancreatography (ERCP). Demographic data, endoscopic findings, procedure details, and outcome data were extracted from a prospectively maintained database. RESULTS: From 2013 to 2017, there were 35 patients who had undergone EUS-guided HDS with a median follow-up duration of 169 (3-2091) days. Malignancy accounted for 71.4% of the ductal segregation, followed by surgical complication (17.1%). Technical and clinical success rate was 97.1% and 80%, respectively. Early adverse event (AE) happened in seven patients (20%), two of them required endoscopic reintervention, and no percutaneous transhepatic biliary drainage (PTBD) or surgery was performed because of AE. The median stent patency duration was 331 (3-1202) days. The median duration of fistula tract keeping was 1280 (3-1280) days. There was no significant difference in terms of patency rate with respect to whether the underlying pathology was benign or malignant (P = 0.776). EUS-guided HDS for right posterior sectional duct segregation was associated with higher 3-month stent patency rate when compared with right anterior sectional duct (79.1% vs 38.1%, P = 0.012). CONCLUSION: Endoscopic ultrasound-guided HDS with an FCSEMS appears to be a safe and effective treatment as a viable alternative option to PTBD after failed ERCP. It creates a durable and reliable fistula tract for permanent access to an isolated ductal system, and this application deserves more attention.

Billroth-I Reconstruction with Overlap Anastomosis Using an EndoWrist Linear Stapler After Robotic Distal Gastrectomy.

Introduction: Robotic distal gastrectomy (RDG) is now thought to be less invasive than conventional laparoscopic distal gastrectomy (LDG) for gastric cancer. Although the delta-shaped anastomosis is an established, widely performed procedure for intracorporeal Billroth-I (B-I) gastroduodenostomy after LDG, it has some difficulties and is performed in the ischemic region of the duodenum. We therefore developed a novel overlap B-I gastroduodenostomy after RDG. Materials and Methods: We started using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) for RDG in May 2017. The robotic overlap B-I reconstruction was performed via side-to-side anastomosis, as follows: Two small incisions were made, one on the greater curvature of the remnant stomach, 5 cm from the edge of the remnant gastric stump, and one on the superior edge of the anterior wall of the duodenal stump. A 45-mm EndoWrist linear stapler device (EWLS) loaded with a blue cartridge was inserted through the incision. After the remnant stomach and duodenum were attached to the V-shaped form by the EWLS, the incisions were closed by the EWLS. Results: Seven patients underwent RDG followed by a robotic overlap B-I procedure up to March 2019. Short-term outcomes were determined from medical records and operative videos. No intraoperative complications or conversions to open or conventional laparoscopic surgery occurred. The mean time for the anastomosis was 37 (range 29-45 minutes) minutes. No postoperative complications occurred following the robotic overlap B-I procedure. Discussion: RDG followed by an overlap B-I gastroduodenostomy might be feasible and safe. However, long-term follow-up is required to identify additional benefits.

Effectiveness and safety of EUS-guided choledochoduodenostomy using lumen-apposing metal stents (LAMS): a systematic review and meta-analysis.

BACKGROUND: Endoscopic ultrasound-guided choledochoduodenostomy (CDD) is emerging as an alternative technique for biliary drainage in patients who fail conventional endoscopic retrograde cholangiopancreatography (ERCP). The lumen-apposing metal stents (LAMS) are being increasingly used for CDD. We performed a systematic review and meta-analysis to evaluate the effectiveness and safety of CDD using LAMS. METHODS: We performed a systematic search of multiple databases through May 2019 to identify studies on CDD using covered self-expanding metal stents. Pooled rates of technical success, clinical success, adverse events, and recurrent jaundice associated with CDD using LAMS were estimated. A subgroup analysis was performed based on use of LAMS with electrocautery-enhanced delivery system (EC-LAMS). RESULTS: Seven studies on CDD using LAMS (with 284 patients) were included in the meta-analysis. Pooled rates of technical and clinical success (per-protocol analysis) were 95.7% (95% CI 93.2-98.1) and 95.9% (95% CI 92.8-98.9), respectively. Pooled rate of post-procedure adverse events was 5.2% (95% CI 2.6-7.9). Pooled rate of recurrent jaundice was 8.7% (95% CI 4.5-12.8). On subgroup analysis of CDD using EC-LAMS (5 studies with 201 patients), the pooled rates of technical and clinical success (per-protocol analysis) were 93.8% (95% CI 90.4-97.1) and 95.9% (95% CI 91.9-99.9), respectively. Pooled rate of post-procedure adverse events was 5.6% (95% CI 1.7-9.5). Pooled rate of recurrent jaundice was 11.3% (95% CI 6.9-15.7). Heterogeneity (I2) was low to moderate in the analyses. CONCLUSION: CDD using LAMS/EC-LAMS is an effective and safe technique for biliary decompression in patients who failed ERCP. Further studies are needed to assess CDD using LAMS as primary treatment modality for biliary obstruction.

Can superior mesenteric artery syndrome really be treated surgically?

AIM: Superior mesenteric artery (SMA) syndrome is a rare reason of small bowel obstruction (SBO). It is a complicated sickness. We aim to analyze the diagnosis, clinical presentation, SMAS management and postoperative outcomes after laparoscopic duodenojejunostomy. MATERIAL AND METHODS: A total of 19 patients who were diagnosed with SMAS and did not respond to the traditional treatment between January 2010 and November 2017 in Afyon Health Sciences University Hospital were included in the study. RESULTS: Their average age was 22.3 years (17-31 years). Number of males and females were 6 and 13, respectively. Clinical presentations of patients are as follow: 14 patients were referred to as postprandial distress syndrome, 3 were unexplained weight loss, and 2 were gastroesophageal reflux disease. Considering CT angiography findings, 14 patients had duodenal dilatation. The mean aortamesenteric angle was 10.6 mm. The mean of aorta-SMA distance was 5.1 mm. The mean hospital stay and follow-up times were 3.7 days and 40.2 months, respectively. No morbidity or mortality was found within patients. Preoperative, postoperative 6th month and postoperative 12th month CONUT scores were 9.1, 3.7, and 0.8, respectively. CONCLUSIONS: Laparoscopic duodenojejunostomy can be performed safely to the patients who do not benefit from conservative treatment. KEY WORDS: Aortamesenteric angle, Duodenojejunostomy, Weight loss.

Short-term and long-term outcomes after Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy following laparoscopic excision of choledochal cyst in children.

BACKGROUND: Choledochal cysts are congenital dilations of the biliary tree. Complete cyst excision and biliary-enteric reconstruction have been the standard operations. In our center, more than 95% of choledochal cyst excision is now performed laparoscopically. Majority of current studies describe laparoscopic-assisted reconstruction using Roux-en-Y hepaticojejunostomy (HJ). However, only a few have studied laparoscopic hepaticoduodenostomy (HD) as an alternative method of biliary-enteric reconstruction. In this study, we focused on comparing longer-term outcomes between laparoscopic HJ and HD reconstruction following choledochal cyst excision. METHODS: We performed retrospective analysis of 54 children who had undergone laparoscopic choledochal cyst excision and biliary-enteric reconstruction between October 2004 and April 2018. Short-term outcomes including operative time, complications such as anastomotic leakage and bleeding, and hospital stays were included. Long-term outcomes including contrast reflux into biliary tree, cholangitis, anastomotic strictures, and need of reoperation were analyzed. RESULTS: Of the 54 patients, 21 of them underwent laparoscopic HD and 33 underwent laparoscopic Roux-en-Y HJ anastomosis reconstruction. There were no significant differences in gestation, gender, age at operation, antenatal diagnosis, and Todani type of choledochal cyst between HD and HJ group. Operative time was significantly shortened in HD group (p = 0.001). Median time to enteral feeding was 3 days in both groups. Median intensive care unit (p = 0.001) and hospital stay (p = 0.019) were significantly shorter in HD group. There was no perioperative mortality. There was no significant difference in anastomotic leakage requiring reoperation (p = 0.743). There were no significant differences in long-term outcomes including anastomotic stricture (p = 0.097), cholangitis (p = 0.061), symptoms of recurrent abdominal pain or gastritis (p = 0.071), or need of reoperation (p = 0.326). All patients had normal postoperative serum bilirubin level. CONCLUSIONS: Laparoscopic excision of choledochal cyst with HD reconstruction is safe and feasible with better short-term outcomes and comparable long-term outcomes compared to Roux-en-Y HJ reconstruction.

Duodenoyeyunostomía laparoscópica como tratamiento del síndrome de Wilkie. Análisis de una serie de cuatro casos / Laparoscopic duodenojejunostomy as a treatment for Wilkie's syndrome. Analysis of a four cases series

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Laparoscopic duodenojejunostomy as a treatment for Wilkie's syndrome. Analysis of a four cases series.

We present 4 cases of Wilkie's syndrome (WS) diagnosis in our Hospital between 2014-2019. WS is an infrequent disease, whose diagnosis can be challenging for patients suffering recurrent digestive symptoms. Our patients refered a history of chronic postprandial abdominal pain associated with vomiting, intestinal transit disorders or an uncontrolled weight loss. Abdominopelvic angio-CT was part of the research in all the cases, objectifying a decrease in the angle between Superior Mesenteric Artery (SAM) and Aorta below 25°. In case of chronic or refractory cases, the surgical treatment may be an option. Laparoscopic duodenojejunostomy constitutes the treatment of choice due its low rate of complications and acceptable results.

Laparoscopic Billroth I Gastroduodenostomy in Robotic Distal Gastrectomy for Gastric Cancers: Fusion Surgery.

PURPOSE: The authors outline their stapling technique and retrospectively compare outcomes of laparoscopic staplers versus robotic staplers in patients undergoing robotic distal gastrectomy (RDG) with Billroth I gastroduodenostomy for gastric cancers. MATERIALS AND METHODS: Of our 28 consecutive patients who underwent RDG, 18 underwent Billroth I gastroduodenostomy using laparoscopic staplers (fusion group); robotic staplers were used in the remaining 10 patients (robot group). All RDG procedures were performed using the da Vinci Surgical System. RESULTS: The duration of reconstruction was significantly longer for the robot group than for the fusion group. There were no conversions to conventional laparoscopy or open surgery in the fusion group, but 1 patient in the robot group required conversion to laparoscopic reconstruction for duodenal injury during anastomosis. No postoperative complications developed in the fusion group. CONCLUSION: Regarding short-term surgical outcomes, robotic-assisted laparoscopic stapling techniques for reconstruction after RDG are both feasible and safe for gastric cancers.

Robotic choledochoduodenostomy for benign distal common bile duct stricture: how we do it.

Benign bile duct stricture poses a significant challenge for gastroenterologists and general surgeons due to the inherent nature of the disease, difficulty in sustaining long-term solutions and fear of pitfalls in performing biliary tract operations. Operative management with an open biliary bypass is mainly reserved for patients who have failed multiple attempts of endoscopic and percutaneous treatments. However, recent advances in minimally invasive technology, notably in the form of the robotics, have provided a new approach to tackling biliary disease. In this technical report, we describe our standardized method of robotic choledochoduodenostomy in a 59-year-old woman with history of Roux-en-Y gastric bypass who presents with benign distal common bile duct stricture following failure of non-operative management. Key steps in this approach involved adequate duodenal Kocherization, robotic portal dissection and creation of a side-to-side choledochoduodenal anastomosis. The operative time was 200 min with no intraoperative complications and estimated blood loss was less than 50 mL. No abdominal drains were placed. The patient was discharged home on postoperative day 1 tolerating regular diet and able to resume her usual activities within 1 week of her operation. A video is attached to this report.