The outcomes and biliary complications of a staged biliary reconstruction in living donor liver transplantation: a propensity score matched analysis.

BACKGROUND: Uncontrolled massive bleeding and bowel edema are critical issues during liver transplantation. Temporal intra-abdominal packing with staged biliary reconstruction (SBR) yields acceptable outcomes in deceased donor liver transplantation; however, data on living donor liver transplantation (LDLT) are scarce. METHODS: A retrospective analysis of 1269 patients who underwent LDLT was performed. After one-to-two propensity score matching, patients who underwent LDLT with SBR were compared with those who underwent LDLT with one-stage biliary reconstruction (OSBR). The primary outcomes were graft survival (GS) and overall survival (OS), and the secondary outcomes were postoperative biliary complications. RESULTS: There were 55 and 110 patients in the SBR and OSBR groups, respectively. The median blood loss was 6500 mL in the SBR and 4875 mL in the OSBR group. Patients receiving SBR-LDLT had higher incidence of sepsis (69.0% vs. 43.6%; P < 0.01) and intra-abdominal infections (60.0% vs. 30.9%; P < 0.01). Biliary complication rates (14.5% vs. 19.1%; P = 0.47) and 1-and 5-year GS (87.27%, 74.60% vs. 83.64%, 72.71%; P = 0.98) and OS (89.09%, 78.44% vs. 84.55%, 73.70%; P = 0.752) rates were comparable between the two groups. CONCLUSIONS: SBR could serve as a life-saving procedure for patients undergoing complex critical LDLT, with GS, OS, and biliary outcomes comparable to those of OSBR.

The combined effect and mechanism of antiangiogenic drugs and PD-L1 inhibitor on cell apoptosis in triple negative breast cancer.

Background: Breast cancer is the most common cancer worldwide, and triple-negative breast cancer (TNBC) has the worst prognosis. Standard systemic treatment includes chemotherapy and immunotherapy. Poly ADP-ribose polymerase (PARP) inhibitors are considered in breast cancer (BRCA) susceptibility genes mutated tumors. The role of antiangiogenic drugs is controversial. Immunotherapy with immune checkpoint inhibitor is now a standard of care for TNBC in the US, but its use in combination with anlotinib, an inhibitor of angiogenesis, on TNBC cells was never investigated. Methods: We tested the effects of anlotinib and programmed cell death-ligand 1 (PD-L1) inhibitor on the proliferation, apoptosis, migration, and invasion of MDA-MB-468 and BT-549 TNBC cells through 3-(4,5-dimethylthiazol-2-Yl)-2,5-diphenyltetrazolium bromide (MTT) assays, cell apoptosis assay, wound healing and transwell matrix assays, and verified whether the combination of the two drugs had synergistic effect. Western blotting was used to detect the effect of anlotinib and PD-L1 inhibitor on the protein expression levels of PI3K, p-PI3K, AKT, p-AKT, Bcl-xl in MDA-MB-468 and BT-549 cells. The effects of anlotinib, PD-L1 inhibitor and the combination of the two drugs on the transplanted tumor of TNBC mice were tested by animal experiments. Results: Anlotinib and PD-L1 inhibitor inhibited the proliferation and promote cell apoptosis of MDA-MB-468 and BT-549 cells, and the combination demonstrated the synergetic effect. Anlotinib and PD-L1 inhibitor inhibited cell migration and invasion, and the effect was strongest in the combination group. Both anlotinib and PD-L1 inhibitor reduced the expression of p-PI3K, p-AKT and Bcl-xl proteins in cells and the effects were the strongest in the combination group. Both anlotinib and PD-L1 inhibitor inhibited the growth of transplanted tumors in mice, and the combined group demonstrated the strongest growth suppression. Conclusions: Anlotinib and PD-L1 inhibitor can inhibit cell proliferation, migration, and invasion of TNBC and promote cell apoptosis, and the two drugs show combined anti-tumor effects in vivo and in vitro. The combination of anlotinib and PD-L1 inhibitor may promote apoptosis of TNBC cells through PI3K/AKT/Bcl-xl signaling pathways, which might offer potential clinical treatment roles for these.

A 10-miRNA risk score-based prediction model for pathological complete response to neoadjuvant chemotherapy in hormone receptor-positive breast cancer.

Patients with hormone receptor (HR)-positive tumors breast cancer usually experience a relatively low pathological complete response (pCR) to neoadjuvant chemotherapy (NAC). Here, we derived a 10-microRNA risk score (10-miRNA RS)-based model with better performance in the prediction of pCR and validated its relation with the disease-free survival (DFS) in 755 HR-positive breast cancer patients (273, 265, and 217 in the training, internal, and external validation sets, respectively). This model, presented as a nomogram, included four parameters: the 10-miRNA RS found in our previous study, progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) status, and volume transfer constant (Ktrans). Favorable calibration and discrimination of 10-miRNA RS-based model with areas under the curve (AUC) of 0.865, 0.811, and 0.804 were shown in the training, internal, and external validation sets, respectively. Patients who have higher nomogram score (>92.2) with NAC treatment would have longer DFS (hazard ratio=0.57; 95%CI: 0.39-0.83; P=0.004). In summary, our data showed the 10-miRNA RS-based model could precisely identify more patients who can attain pCR to NAC, which may help clinicians formulate the personalized initial treatment strategy and consequently achieves better clinical prognosis for patients with HR-positive breast cancer.

Comparison of 2D versus 3D in the Basic Single Incision Laparoscopy Training. A Randomized Controlled Trial.

Background: Single incision laparoscopic surgery is a technically challenging procedure. The use of 3D laparoscopy can potentially improve training results. The aim of the present study was to compare the short-term effects of the 2D vs 3D single incision laparoscopy training. Methods: Forty novices (25 males and 15 females) with no prior experience in single incision laparoscopic surgery participated in the study. The participants were randomized into 2D or 3D training mode. Results: Twenty participants were assigned to 2D and twenty to 3D training group. Time to finish the first task with the polypropylene ball transfer was significantly shorter in the 3D group with no difference in the total number of errors during the task (p=0.007). Overall number of attempts and number of successful attempts were similar between the groups while the number of errors was significantly higher in the 2D group during the needle grasping task (p=0.033). In the intracorporeal knot tying test the probability of completing the task was significantly higher in the 3D group (p=0.02). Conclusion: 3D training in basic single incision laparoscopy techniques seems to offer advantage over standard 2D training mode.

Robotic-Assisted Left Hepatectomy: A Video Technique.

The robotic liver surgery is gaining momentum and several centers worldwide reported their promising results in terms of shorter recovery, less post-operative pain when compared to the open counterpart. Despite the benefits in terms of better ergonomic, enhanced visualization and microsuturing capabilities in comparison to the laparoscopic surgery, this approach is still confined to high selected centers and the reproducibility of the results published are still questioned. Herein, we report our surgical technique for a robotic-assisted left hepatectomy in a step-by-step fashion. The patient is located in left-side up supine position and four robotic and one laparoscopic trocarts are inserted. After the mobilization of the liver, a meticolous intraoperative ultrasound is performed with the aim to assess the tumor location and its relationship with main vascular structures. The hepatic hylum is dissected and both left hepatic artery and portal vein are clipped and divided. The Pringle maneuver is not routinely performed. The parenchymal transection is performed employing the "clamp-crush" technique and the sharp technique. The left bile duct is controlled intraparenchymally. The left hepatic vein is transected by a robotic stapler (white load). The transection surface is inspected to check for potential bile leaks and finally a fibrin glue is over it. A drain is place close to the liver remnant. (video article https://www.revistachirurgia.ro/pdfs/video/Robotic-Assisted-Hepatectomy-2280.mp4).

Rate of Post-Operative Pancreatic Fistula after Robotic-Assisted Pancreaticoduodenectomy with Pancreato-Jejunostomy versus Pancreato-Gastrostomy: A Retrospective Case Matched Comparative Study.

BACKGROUND: Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported. METHODS: The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula. RESULTS: Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients. CONCLUSIONS: The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula.

Hepatic inflammatory pseudotumor related with IgG4 / Seudotumor inflamatorio hepático relacionado con IgG4

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Robotic pancreatic surgery: old concerns, new perspectives.

BACKGROUND: Described for the first time in 2003, the robotic pancreatic surgery shows interesting results. The evaluation of post-operative outcomes is necessary once we describe an innovative surgical approach. METHODS: We have performed a retrospective analysis of a prospectively maintained database on robotic pancreatic surgery including malignant and benign indications for surgery. RESULTS: A total of 50 consecutive patients underwent robotic pancreatic surgery (26 pancreatico duodenectomy and 24 distal pancreatectomy) between January 2012 and July 2015 in a single centre. The overall operative time was 425 (390-620) min. In a subgroup of highly selected malignant tumours, we were able to achieve 88% of R0 resection with robotic approach. A number of lymphnodes rose significantly with growing experience (p = .025). The overall major complication rate (15%), as well as pancreatic fistula rate (16%) were acceptable. The two-year overall survival for the whole group was 65%. CONCLUSION: The robotic pancreatic surgery in a highly selected group of patients seems safe and feasible. The cost-effectiveness and long-term oncologic outcomes need further investigations.

Robotic Pancreaticoduodenectomy: Technical Considerations.

Robotic surgery can help to overcome some technical limitations of laparoscopic pancreaticoduodenectomy thanks to EndoWrist instrumentations and the 3D view. Despite the potential benefits, its employment is still low and controversial. We focused on some important technical details crucial for a safe robotic pancreatectomy. After performing 52 robotic pancreatic resections that included 10 pancreatoduodenectomies, the authors describe their technique. The review of literature on robotic and laparoscopic duodenopancreatectomy is also performed in order to evaluate possible benefits of the robotic platform. We describe the step-by-step surgical procedure, analyzing all possible troubleshooting occurring in an initial center experience. The estimated blood loss as well as the length of stay was reduced by the robotic approach. We did not observe any significant increase of pancreatic fistula rate and all other postoperative complications despite our initial learning curve. Robotic pancreatoduodenectomy is a technically advanced procedure that requires important laparoscopic and robotic skills but it shows to be safe, feasible with some clear advantages in the bleeding control and in the reconstructive phase of the procedure.

Correction to: Robotic Pancreaticoduodenectomy: Technical Considerations.

[This corrects the article DOI: 10.1007/s12262-017-1628-9.].

¿Colecistitis aguda, crónica o cáncer de vesícula biliar? / Acute cholecystitis, chronic cholecystitis or gallbladder cancer?

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Laparoscopic and open liver resection - a literature review with meta-analysis.

INTRODUCTION: In recent years laparoscopic approach to liver resections has gained important attention from surgeons worldwide. The aim of this review was to compare the results of laparoscopic and open liver resections. MATERIAL AND METHODS: We have performed a search in Medline, Embase and the Cochrane Library databases. Studies comparing laparoscopic and open liver resections were included. RESULTS: No randomized clinical trial were identified. In the 16 observational studies included in the analysis there were 927 laparoscopic and 1049 open liver resections. The laparoscopy group had lower blood loss (MD = 244.93 ml, p < 0.00001), lower odds of transfusion (OR = 0.35, p = 0.0002), lower odds of positive margins on pathology report (OR = 0.22, p < 0.00001), lower odds of readmission (OR = 0.36, p = 0.04), lower odds of pulmonary (OR = 0.38, p = 0.003) and cardiac complications (OR = 0.30, p = 0.02) and lower odds of postoperative liver failure (OR = 0.24, p = 0.001), but in many cases the results were based on a low number of events reported in included studies. CONCLUSIONS: Laparoscopic resection of liver yields complications rates comparable to open resection, but the results are based on low quality evidence from nonrandomised studies.

Impact of different type of cancer treatment on the effectiveness of breast reconstruction.

For women undergoing mastectomy as part of their breast cancer treatment, breast reconstruction is an important part of therapy. However, neoadjuvant, adjuvant treatments as well as other patient-related factors can compromise the results of breast reconstruction techniques. In this article we have reviewed current approaches to the management of complications and risks that neoadjuvant and adjuvant therapies pose on breast reconstruction after mastectomy for breast cancer. Non-treatment related factors influencing reconstruction techniques were reviewed as well.

Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication.

BACKGROUND: Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances. METHOD: A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR. RESULTS: From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16-110) after LT. Biliary reconstruction included duct-to-duct (n = 9) and hepatico-jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in-hospital death. In the follow-up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well. CONCLUSIONS: In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.

Porcine Model In The Laparoscopic Liver Surgery Training.

The aim of the study was to evaluate the possibility to use live anesthetized pigs as a model for laparoscopic liver resection. During two days laparoscopy course two trainees were operating on two live animals performing exposure of the liver, Pringle manoeuver, division of liver ligaments, dissecting of the structures inside the hepatoduodenal ligament, dissection of the hepatic veins and left lateral liver sectionectomy. Exposure of the liver and Pringle manoeuver were performed correctly within 50 and 35 minutes. Left lateral sectionectomy has been performed correctly within 2 hours. The full dissection of the hepatoduodenal ligament and exposure of the hepatic veins were judged as insufficient by experienced laparoscopic tutors. There was one injury to the suprahepatic vena cava that was managed laparoscopically. The porcine model can be used as an advanced training for laparoscopic liver surgery.

The Influence of Micropauses on Surgeons' Precision After Short Laparoscopy Procedures.

UNLABELLED: It has recently been shown that micropauses during long surgical procedures can be beneficial for surgeons' precision and fatigue. The aim of the study was to evaluate the impact of micropauses on surgical precision measured by a simple smartphone application. MATERIAL AND METHODS: Two surgeons performed 40 simple laparoscopic procedures (appendectomy and cholecystectomy) with or without micropauses. After the operation the precision of surgical movements was measured by a simple smartphone application in which the number of successful trials and their mean time were used as a precision surrogate. RESULTS: Mean number of successful trials was significantly higher for appendectomy than for cholecystectomy (5.59 vs 4; p = 0.032). There was a difference between participating surgeons both in terms of number of successful trials (5.80 vs 3.55; p = 0.01) and a mean time of all successful trials (10.03 vs 6.28; p = 0.001). No other statistically significant differences were identified. CONCLUSION: Micropauses had no influence on surgical precision as evaluated after short laparoscopy procedures. The only differences were surgeon-dependent and intervention-dependent.

Application of failure mode and effect analysis in laparoscopic colon surgery training.

AIM: To evaluate if application of failure mode and effect analysis (FMEA) to laparoscopy training can help surgeons acquire laparoscopy skills. METHODS: After preparing a FMEA matrix of laparoscopic sigmoidectomy, we have introduced it during three laparoscopy courses. Forty-eight surgeons, divided into 24 teams of two surgeons, have participated in three courses. During each course, every team has performed three laparoscopic sigmoidectomies in three experimental animals (1 OR session every day). Risk priority number (RPN) has been calculated for every surgery, and the results have been discussed at the end of each training day with all participants. RESULTS: We have observed a decline in the median RPN from 1339 during the first OR session through 62 during second OR session to reach 0 in the third OR session. Only two teams out of 24 were not able to reach a RPN of less than 300 during third OR session. When the type of failures were analysed, we have observed a shift from procedure-type failures to technical failures that depended on each participant technical abilities. CONCLUSION: Application of FMEA principles to laparoscopy training can help acquire non-technical skills necessary for safe laparoscopic surgery.