Optimal treatment and complications of patients with the perforated upper gastrointestinal tract.

PURPOSE: The perforation of the upper gastrointestinal tract is still associated with a high risk of complications and mortality. We aimed to evaluate the optimal treatment and post-treatment complications for this condition. METHODS: This was a retrospective, single-center study conducted between 2010 and 2019. We analyzed 50 patients with intraperitoneal free air caused by peptic ulcer (44 cases) or cancer (six cases). RESULTS: All patients initially received either conservative therapy (n = 7) or surgery (n = 43). The nonsurgically cured patients were significantly younger and had mild peritonitis and also had a shorter hospital stay. Two patients were converted to surgery due to worsening symptoms, and one of them was elderly and had a long perforation-to-treatment time. Regarding postoperative complications, patients with Grade II-V (n = 21) were significantly older and had a poorer physical status, longer perforation-to-surgery time, and higher preoperative CRP and lactate than those with Grade 0-I (n = 24). Multivariable analyses identified elevated preoperative lactate as an independent risk factor for postoperative complications. The patients with noncurative surgery for perforated advanced gastric cancer all died within 1 year after surgery. CONCLUSIONS: Consideration should be given to the nonsurgical indications in elderly and delayed treatment patients and the postoperative outcomes of patients with preoperatively elevated lactate levels.

Prognostic Factors for Gastric Cancer Patients With One Stage IV Factor who Underwent Conversion Surgery.

BACKGROUND/AIM: To identify prognostic factors for patients with stage IV gastric cancer (GC) and a single stage IV factor before chemotherapy who underwent conversion surgery (R0 resection). PATIENTS AND METHODS: This study retrospectively analysed 32 GC patients with a single stage IV factor before chemotherapy and who underwent conversion surgery (R0 resection) between January 2001 and September 2015. The univariate and multivariate analyses were performed to identify independent prognostic factors. RESULTS: The five-year survival rate was 39.6%, and the median survival time was 47.0 months. In the univariate analysis, diffuse-type according to Lauren classification was significantly associated with worse overall survival (p<0.001). In the multivariate analysis, diffuse-type was selected as an independent prognostic factor (hazard ratio=15.970, 95% confidence interval=3.804-67.043, p<0.001). CONCLUSION: Diffuse-type may be a useful prognostic factor in GC patients with a single stage IV factor who undergo conversion surgery (R0 resection).

What influences conversion to open surgery during laparoscopic colorectal resection?

INTRODUCTION: We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across a group of subspecialist surgeons with expertise in minimally invasive techniques. METHODS: We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016 at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed, open procedures) with x2 and t tests and used the Bonferroni Correction to account for multiple statistical testing. RESULTS: From a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted (29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p < 0.001). Converted cases had the longest operative time (222 ± 102 min), compared to lap completed (177 ± 110), and open procedures (183 ± 89). There were no differences in mortality, sepsis complications, anastomotic leaks, or unplanned returns to the operating room across the three operative groups. CONCLUSIONS: Although aggregate morbidity of Lap converted procedures is higher than in Lap completed procedures, it remains less than in matched open procedures. Compared to Lap completed procedures, the additional morbidity of Lap converted procedures appears to be related to additional surgical site infection risk. Our data suggest that surgeons should not necessarily be influenced by additional complications associated with conversion when contemplating complex laparoscopic colorectal procedures.

Perioperative outcomes after laparoscopic cholecystectomy in elderly patients: a systematic review and meta-analysis.

BACKGROUND: Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients. METHOD: A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay. RESULTS: This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00-2.78), major complication (OR 1.79, CI95% 1.45-2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84-2.55), risk of bile leaks (OR 1.50, CI95% 1.07-2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41-11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24-3.18). CONCLUSION: Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent.

Single-Port Robotic Urological Surgery Using Purpose-Built Single-Port Surgical System: Single-Institutional Experience With the First 100 Cases.

OBJECTIVES: To present a comprehensive report regarding our experience with single-port robotic surgery in our first 100 consecutive patients. We describe the diversity of procedures that can be performed with this platform as well as the challenges and complications we had with the application of this novel technology. METHODS: Between September 2018 and August 2019, data on 100 patients who underwent single-port robotic surgery were consecutively collected. Preoperative, intraoperative and early postoperative outcomes after various urologic procedures were recorded and analyzed. RESULTS: During the study period, 100 patients (age [range] 35-84 years; 88 [88%] Male) underwent various single-port robotic surgeries for different indications (Retroperitoneal [n = 14], Pelvic surgeries [n = 86]). Transperitoneal (n = 37), extraperitoneal (n = 53) and transvesical (n = 10) approaches have been used to access the target organs. Of these procedures, 73 (73%) were for different oncological indications: Radical prostatectomy (n = 60), Partial nephrectomy (n = 6), Retroperitoneal lymph node dissection (n = 1) and Radical cystectomy with intracorporeal diversion (n = 6). Surgery was successfully completed in all but 1 patient, in whom the surgery was converted to open surgery due to dense adhesions and failure to progress. Grades II-III postoperative complications were detected in (n = 9) patients. CONCLUSION: The purpose-built single-port robotic platform can be safely incorporated into the minimally invasive armamentarium. A wide range of pelvic and retroperitoneal urological procedures can be done with different approaches using this platform. Randomized trials with adequate sample size and postoperative follow up period is advisable for further evaluation of the outcomes and to determine the added value of this emerging technology.

Risk Factors and Impact of Conversion to Thoracotomy From 20,565 Cases of Thoracoscopic Lung Surgery.

BACKGROUND: Intraoperative conversion to thoracotomy from video-assisted thoracoscopic surgery is a major concern and can be associated with increased adverse outcomes. Therefore, this study was conducted to identify any possible clinical risk factors and related outcomes. METHODS: This monocentric retrospective study was conducted between January 2016 and December 2018 and included 20,565 consecutive patients who were undergoing thoracoscopic lung operations. Planned thoracotomy, complete pneumonectomies, angioplastic or bronchoplastic or chest wall resections, bilateral lung resections, or cases with missing data were excluded. Univariate and multivariate analyses were performed to identify risk factors for conversion to thoracotomy. A 1:1 propensity score matching analysis was conducted to verify postoperative outcomes. RESULTS: The overall incidence of conversion to thoracotomy was 1.0% (205 of 20,565). The most common cause of conversion was vascular injury, found in 60 patients (29.3%). Multivariable logistic regression analysis identified age older than 60 years, male sex, preoperative chemotherapy, lesion diameter of 1.4 cm or larger, clinical nodal involvement, lymph node calcification, pleural adhesions, type of resection, location of resection, ipsilateral reoperation, and lower surgical experience as independent risk factors of conversion. Among patients who underwent conversion to thoracotomy and who had any complications, the percentages of pulmonary complications, chest tube duration, intensive care unit stay, and hospital length of stay were higher. Within the conversion groups, emergency (37 of 205; 18%) and nonemergency (168 of 205; 82%) conversion groups were similar for overall postoperative complications. CONCLUSIONS: The study identified 11 potential risk factors of conversion to thoracotomy, which was associated with increased postoperative complications. The findings may be important for operative planning, preoperative patient counseling and risk adjustment, and eventually reducing conversion rates and related outcomes.

Minimally invasive distal pancreatectomy and the cost of conversion.

BACKGROUND: Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. METHODS: A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. RESULTS: There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. CONCLUSIONS: Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.

Incidence, associated risk factors, and impact of conversion to laparotomy in elective minimally invasive sigmoidectomy for diverticular disease.

BACKGROUND: Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes. METHODS: The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases. RESULTS: The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases. CONCLUSIONS: Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.

Predictors and outcomes of converted minimally invasive pancreaticoduodenectomy: a propensity score matched analysis.

BACKGROUND: Data-driven patient selection guidelines are not available to optimize outcomes in minimally invasive pancreaticoduodenectomy (MIPD). We aimed to define risk factors associated with conversion from MIPD to open PD and to determine the impact of conversion on post-operative outcomes. METHODS: We conducted a retrospective review of MIPD using NSQIP from 2014 to 2015. Propensity score was used to match patients who underwent completed MIPD to converted MIPD. RESULTS: 467 patients were included: 375 (80.3%) MIPD and 92 (19.7%) converted. Converted patients were more often male (64% vs. 52%, p = 0.030), had higher rates of dyspnea (10% vs. 3%, p = 0.009), underwent more vascular (44% vs. 14%, p < 0.001) or multivisceral resection (19% vs. 6%, p = 0.0005), and were more likely attempted laparoscopically compared to robotically (76% vs. 51%, p < 0.001). Robotic approach was independently associated with reduced risk of conversion (OR 0.40, 95% CI 0.23-0.69), while male gender (OR 1.70, 95% CI 1.02-2.84), history of dyspnea (OR 3.85, 95% CI 1.49-9.96), vascular resection (OR 4.32, 95% CI 2.53-7.37), and multivisceral resection (OR 2.18, 95% CI 1.05-4.52) were associated with increased risk. Major complications were more common in converted patients (68% vs. 37%, p < 0.001). Converted patients had increased odds of non-home discharge (OR 3.25, 95% CI 1.06-9.97) and an associated increased length of stay of 3 days (95% CI 0.1-6.7). CONCLUSION: Patients with a history of dyspnea or tumors requiring vascular or multivisceral resection were at increased risk of conversion, and the robotic platform was associated with a lower rate of conversion. Conversion was independently associated with increased overall complications, increased length of stay, and non-home discharge.

Late open conversion after endovascular abdominal aortic aneurysm repair: experience of three-high volume centers.

BACKGROUND: Accumulated endovascular aneurysm repair (EVAR) procedures will increase number of patients requiring conversion to open repair of abdominal aortic aneurysms (AAA). In most cases, patients undergo late open surgical conversion (LOSC), many months, or years, after initial EVAR. The aim of this study is to analyze results of LOSC after EVAR in elective and urgent setting, including presenting features, surgical techniques, as well as to review the clinical outcomes and their predictors. METHODS: Retrospective review of all consecutive patients undergoing LOSC after EVAR was performed at three distinct, high volume, vascular centers. Patients that required primary conversion within 30 days after EVAR have not been included in this study. Between January 1st 2010 and January 1st 2017 total of 31 consecutive patients were treated. LOSC were performed either in elective or in urgent setting, thus dividing patients in two groups. Primary outcome was 30-day mortality and secondary postoperative complications. RESULTS: LOSC rate after EVAR was 4.51%. Most common indication for LOSC was type I endoleak (N.=20, 64.51%). All patients that presented with ruptured AAA had some form of endoleak (type I endoleak was present in five from six cases). Most common site for aortic cross-clamping was infrarenal (51.61%). Stent-graft was removed completely in 18 patients (58.06%) and partially in 13 (41.93%). 30-day mortality rate was 16.12% (5 patients) and most common cause of death was myocardial infarction (60%). Following univariate factors were isolated as predictors for 30-day mortality: preoperative coronary artery disease, chronic obstructive pulmonary disease, urgent LOSC, prolonged time until LOSC, ruptured AAA, supraceliac clamp, higher number of red blood cell transfusion, postoperative myocardial infarction, and prolonged intubation (more than 48 hours). CONCLUSIONS: LOSC seems to be safe and effective procedure when preformed in elective manner. On the other side, urgent LOSC after EVAR is associated with very high postoperative mortality and morbidity. Endoleak remains the main indication for open conversion. Further studies are necessary to standardize timing and treatment options for failing EVAR.

Late surgical conversions after abdominal endovascular aortic repair: underlying mechanisms, clinical results and strategies for prevention.

OBJECTIVES: Our goal was to report our results of late surgical conversion after endovascular aneurysm repair (EVAR). METHODS: Variables analysed included baseline data, preinterventional anatomy, type of endovascular intervention, indications for conversion, operative technique, postoperative complications and follow-up survival rate. RESULTS: Between April 2011 and May 2018, 16 patients with late complications after EVAR underwent open surgical conversion at our institution. The mean age was 73.6 [standard deviation (SD) 8.9] years. There were 3 (18.8%) female patients. In 15 patients, the indication for primary EVAR was abdominal aortic aneurysm, and in 1 patient, chronic abdominal aortic dissection. Five patients underwent secondary EVAR service interventions for endoleak treatment between the index EVAR and the final secondary surgical conversion. Thirteen patients underwent surgery in an elective setting and 3 patients underwent emergency surgery. The mean time from EVAR to open surgical conversion was 6.31 (SD 4.0) years (range 1.2-16.0 years). The most common indication for conversion was endoleak formation (n = 12, 75%), followed by 3 cases of aortic rupture (1 patient with primary type 1 endoleak) and 2 cases of stent graft infection-1 with and 1 without an aortoduodenal fistula. One patient died during emergency open surgery of cardiopulmonary instability. Three patients developed postoperative renal dysfunction with recovery of their renal function before discharge. The in-hospital mortality rate was 12.5%. The median follow-up was 16.5 months (interquartile range 21 months). Freedom from death and aortic reintervention was 100%, respectively. After careful review of the index computed tomography scans for EVAR, the majority of failures could have been anticipated due to trade-offs with regard to length, diameter, morphology, shape and angulation of the proximal and/or distal landing zone. CONCLUSIONS: Despite being a challenging operation, late surgical conversion after EVAR yields excellent results with regard to outcome and freedom from the need for further aortic interventions. An anticipative strategy adhering to current recommendations for using or refraining from using EVAR in patients with anatomical challenges will help reduce the need for secondary surgical conversions and keep them to minimum.

The Role of Bowel Preparation in Open, Minimally Invasive, and Converted-to-Open Colectomy.

BACKGROUND: Bowel preparation before colectomy is considered an effective strategy to decrease postoperative complications. However, data regarding the effect of bowel preparation in patients undergoing minimally invasive colectomy are limited. The aim of this study was to investigate the role of different bowel preparation strategies in patients undergoing open, minimally invasive, and converted-to-open elective colectomies. METHODS: We identified 39,355 patients who underwent elective colectomy from the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database (2012-2016). Multivariate logistic regression models were used to assess the impact of different bowel preparation strategies on postoperative complications and mortality in three subapproach groups: open (n = 12,141), minimally invasive (n = 23,057), and converted to open (n = 4157). RESULTS: Overall, a total of 10,066 (25.6%) patients received no preparation (NP), 11,646 (29.5%) mechanical bowel preparation (MBP) alone, 1664 (4.2%) antibiotic bowel preparation (ABP) alone, and 15,979 (40.6%) MBP + ABP. Compared with NP, MBP + ABP showed the strongest protective effects. MBP + ABP was associated with reduced risk of major complications (odds ratio [OR] = 0.60, 95% confidence interval [CI]: 0.55-0.66), infectious complications (OR = 0.50, 95% CI: 0.46-0.54), any complications (OR = 0.55, 95% CI: 0.51-0.60), 30-d mortality (OR = 0.68, 95% CI: 0.48-0.96), anastomotic leak (OR = 0.50, 95% CI: 0.43-0.58), and length of stay ≥ 4 d (OR = 0.64, 95% CI: 0.61-0.67) in overall population. These protective effects, except for 30-d mortality, were observed in open, minimally invasive, and converted-to-open groups. When the analysis was limited to robotic surgery only, MBP + ABP was only associated with reduced risk of major complications (OR = 0.61, 95% CI: 0.38-0.97) compared with NP. The protective effects remained similar over the study time period. CONCLUSIONS: MBP + ABP is a preferred preoperative strategy in open, minimally invasive, and converted-to-open colectomy.

Factors associated with prolonged length of stay following robotic-assisted partial nephrectomy.

INTRODUCTION: To prospectively analyze the association of clinical and operative variables on patient length of hospital stay (LOS) following robotic-assisted partial nephrectomy (RAPN) and develop an accurate clinical-based scoring system to predict prolonged LOS following RAPN. MATERIALS AND METHODS: We analyzed 304 consecutive RAPNs performed by a single surgeon. Prolonged LOS was defined as greater than 3 days of hospitalization postoperatively. Preoperative clinical factors and operative variables were analyzed for association with LOS. After adjusting for multiple testing, p ≤ 0.004 was considered statistically significant. RESULTS: LOS was 1 day in 17 (5.6%) patients, 2 days in 136 (44.7%) patients, 3 days in 89 (29.3%) patients, and more than 3 days in 62 (20.4%) patients. Lower preoperative hemoglobin (p = 0.004), total operative time (p < 0.001), estimated blood loss (EBL) (p < 0.001), intraoperative complications or conversion (p < 0.001), and renal mass size (p < 0.001) were associated with prolonged LOS. EBL and total operative time were most predictive of prolonged LOS and were used to create the BLOT (blood loss and operative time) predictive scoring system. Blot scores ranged from 0 to 5, to predict prolonged LOS. We observed prolonged LOS in 4.3%, 9.6%, 25.6%, 47.1%, 50.0%, and 100% of patients with scores of 0, 1, 2, 3, 4, and 5, respectively. CONCLUSIONS: Operative time and estimated blood loss are most predictive of prolonged LOS following RAPN. Using these variables, the BLOT score accurately predicts prolonged LOS following RAPN.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis.

BACKGROUND: Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis. METHODS: A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis. RESULTS: Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03). CONCLUSION: These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Short-term outcomes of laparoscopic repeat liver resection after open liver resection: a systematic review.

BACKGROUND: Laparoscopic repeat liver resection (LRLR) still represents a challenge for surgeons especially in case with previous open liver surgery. The aim of the study is to perform a systematic review of the current literature to investigate the feasibility of LRLR after open liver resection (OLR) for liver diseases. METHODS: A computerized search was performed for all English language studies evaluating LRLR. A meta-analysis was performed to evaluate the short-term outcomes in comparative studies between LRLR with previous laparoscopic liver resection (LLR) and OLR. RESULTS: From the initial 55 manuscripts, 8 studies including 3 comparative studies between LRLR after OLR and LLR were investigated. There was a total of 108 patients. Considering initial surgery, the extent of initial liver resection was major liver resection in 20% of patients in whom it was reported. In all the patients, the most frequent primary histology was hepatocellular carcinoma, followed by colorectal liver metastasis. A half of reported patients had severe adhesions at the time of LRLR. The median operative time for LRLR was ranged from 120 to 413 min and the median blood loss ranged from 100 to 400 mL. There were 11% of the patients conversions to open surgery, hand-assisted laparoscopic surgery, or tumor ablation. The overall postoperative morbidity was 15% of all the patients, and there was no postoperative mortality. The median postoperative hospital stay was ranged from 3.5 to 10 days. The meta-analysis shows that LRLR after OLR is associated with a longer operative time and a more important blood loss compared to LRLR after LLR. However, no difference between LRLR after OLR and LLR was shown as far as hospital stay and morbidity rate are concerned. CONCLUSIONS: LRLR after OLR has been described in eight articles with favorable short-term outcomes in highly selected patients.

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.

Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study.

Introduction: Laparoscopic cholecystectomy, the gold-standard approach for cholecystectomy, has surprisingly variable outcomes and conversion rates. Only recently has operative grading been reported to define disease severity and few have been validated. This multicentre, multinational study assessed an operative scoring system to assess its ability to predict the need for conversion from laparoscopic to open cholecystectomy. Methods: A prospective, web-based, ethically approved study was established by WSES with a 10-point gallbladder operative scoring system; enrolling patients undergoing elective or emergency laparoscopic cholecystectomy between January 2016 and December 2017. Gallbladder surgery was considered easy if the G10 score < 2, moderate (2 â‰¦ 4), difficult (5 â‰¦ 7) and extreme (8 â‰¦ 10). Demographics about the patients, surgeons and operative procedures, use of cholangiography and conversion rates were recorded. Results: Five hundred four patients, mean age 53.5 (range 18-89), were enrolled by 55 surgeons in 16 countries. Surgery was performed by consultants in 70% and was elective in (56%) with a mean operative time of 78.7 min (range 15-400). The mean G10 score was 3.21, with 22% deemed to have difficult or extreme surgical gallbladders, and 71/504 patients were converted. The G10 score was 2.98 in those completed laparoscopically and 4.65 in the 71/504 (14%) converted. (p <  0.0001; AUC 0.772 (CI 0.719-0.825). The optimal cut-off point of 0.067 (score of 3) was identified in G10 vs conversion to open cholecystectomy. Conversion occurred in 33% of patients with G10 scores of ≥ 5. The four variables statistically predictive of conversion were GB appearance-completely buried GB, impacted stone, bile or pus outside GB and fistula. Conclusion: The G10 operative scores provide simple grading of operative cholecystectomy and are predictive of the need to convert to open cholecystectomy. Broader adaptation and validation may provide a benchmark to understand and improve care and afford more standardisation in global comparisons of care for cholecystectomy.

Retroperitoneoscopic partial nephrectomy in children: a multicentric international comparative study between lateral versus prone approach.

BACKGROUND: Very limited informations are currently available about the best approach to perform retroperitoneoscopic surgery. This multicentric international study aimed to compare the outcome of lateral versus prone approach for retroperitoneoscopic partial nephrectomy (RPN) in children. METHODS: The records of 164 patients underwent RPN in 7 international centers of pediatric surgery over the last 5 years were retrospectively reviewed. Sixty-one patients (42 girls and 19 boys, average age 3.8 years) were operated using lateral approach (G1), whereas 103 patients (66 girls and 37 boys, average age 3.0 years) underwent prone RPN (G2). The two groups were compared in regard to operative time, postoperative outcome, postoperative complications, and re-operations. RESULTS: The average operative time was significantly shorter in G2 (99 min) compared to G1 (160 min) (p = 0.001). Only 2 lateral RPN required conversion to open surgery. There was no significant difference between the two groups as for intraoperative complications (G1:2/61, 3.3%; G2:6/103, 5.8%; p = 0.48), postoperative complications (G1:9/61, 14.7%; G2:17/103, 16.5%; p = 0.80), and re-operations (G1:2/61, 3.3%; G2:4/103, 3.8%; p = 0.85). Regarding postoperative complications, the incidence of symptomatic residual distal ureteric stumps (RDUS) was significantly higher in G2 (7/103, 6.8%) compared to G1 (1/61, 1.6%) (p = 0.001). Most re-operations (4/6, 66.6%) were performed to remove a RDUS . CONCLUSIONS: Both lateral and prone approach are feasible and reasonably safe to perform RPN in children but the superiority of one approach over another is not still confirmed. Although prone technique resulted faster compared to lateral approach, the choice of the technique remains dependent on the surgeon's personal preference and experience. Our results would suggest that the lateral approach should be preferred to the prone technique when a longer ureterectomy is required, for example in cases of vesico-ureteral reflux into the affected kidney moiety, in order to avoid to leave a long ureteric stump that could become symptomatic and require a re-intervention.