Safety of robotic cholecystectomy as index training procedure: the UK experience.

AIMS: To evaluate the safety profile of robotic cholecystectomy performed within the United Kingdom (UK) Robotic Hepatopancreatobiliary (HPB) training programme. METHODS: A retrospective evaluation of prospectively collected data from eleven centres participating in the UK Robotic HPB training programme was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. RESULTS: A total of 600 patients were included. The median age was 53 (IQR 65-41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600), and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). CONCLUSION: The current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low bile leak rate, low conversion to open surgery, and low need for subtotal cholecystectomy.

Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy.

BACKGROUND: There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure. METHODS: A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media. RESULTS: 638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m2, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy. CONCLUSIONS: This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.

Surgical drainage procedures for paediatric chronic pancreatitis: a scoping review.

Paediatric chronic pancreatitis (CP) is a relatively rare entity, but it can be accompanied by debilitating complications such as pseudocysts, chronic pain and pancreatic duct obstruction. Surgical drainage procedures, such as pancreaticojejunostomy or cystogastrostomy/jejunostomy to address these complications may be required; however, there is a paucity of evidence as to the efficacy and long-term outcomes of these operations in the paediatric population. A scoping review of contemporary (post-2000) studies detailing surgical pancreatic drainage procedures performed in children (< 18 years) was undertaken. After screening, 24 case series detailing a total of 248 patients met the inclusion criteria. Longitudinal pancreaticojejunostomy and cystogastrostomy were the most common surgical procedures performed in children with CP and pseudocysts, respectively. Overall generally favourable outcomes were reported, but all studies were considered to have a high risk of bias. Operative management for paediatric CP is infrequently required; therefore, large prospective studies or trials focusing on this population are infeasible, limiting the best available evidence on the topic to case series, level IV. Recommendations to improve the quality of surgical care in the paediatric CP population could include centralisation and the formation of registries to allow accurate long-term follow-up.

SARS-CoV-2 infection in acute pancreatitis increases disease severity and 30-day mortality: COVID PAN collaborative study.

OBJECTIVE: There is emerging evidence that the pancreas may be a target organ of SARS-CoV-2 infection. This aim of this study was to investigate the outcome of patients with acute pancreatitis (AP) and coexistent SARS-CoV-2 infection. DESIGN: A prospective international multicentre cohort study including consecutive patients admitted with AP during the current pandemic was undertaken. Primary outcome measure was severity of AP. Secondary outcome measures were aetiology of AP, intensive care unit (ICU) admission, length of hospital stay, local complications, acute respiratory distress syndrome (ARDS), persistent organ failure and 30-day mortality. Multilevel logistic regression was used to compare the two groups. RESULTS: 1777 patients with AP were included during the study period from 1 March to 23 July 2020. 149 patients (8.3%) had concomitant SARS-CoV-2 infection. Overall, SARS-CoV-2-positive patients were older male patients and more likely to develop severe AP and ARDS (p<0.001). Unadjusted analysis showed that SARS-CoV-2-positive patients with AP were more likely to require ICU admission (OR 5.21, p<0.001), local complications (OR 2.91, p<0.001), persistent organ failure (OR 7.32, p<0.001), prolonged hospital stay (OR 1.89, p<0.001) and a higher 30-day mortality (OR 6.56, p<0.001). Adjusted analysis showed length of stay (OR 1.32, p<0.001), persistent organ failure (OR 2.77, p<0.003) and 30-day mortality (OR 2.41, p<0.04) were significantly higher in SARS-CoV-2 co-infection. CONCLUSION: Patients with AP and coexistent SARS-CoV-2 infection are at increased risk of severe AP, worse clinical outcomes, prolonged length of hospital stay and high 30-day mortality.

Mid-Term Remission of Type 2 Diabetes Mellitus After Laparoscopic Roux En-Y Gastric Bypass.

BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) is an established therapeutic modality for type 2 diabetes mellitus (T2DM). However, there is paucity of data on the outcomes of LRYGB on T2DM beyond 2 years. This study aimed to examine the medium-term effects of LRYGB on T2DM and determine the predictors of T2DM resolution. METHODS: Prospective data were collected for all consecutive LRYGB performed from September 2009 to November 2010. The American Diabetes Association guidelines were used to define complete (CR) or partial (PR) remission of diabetes. Diabetes status was considered improved when there was >50 % reduction in the dose of medications or when glycaemic control was achieved after stopping insulin. The effects of baseline characteristics, diabetes data and weight loss data at 4 years on T2DM remission were studied. RESULTS: Forty-six patients with T2DM underwent LRYGB with mean ± SD age and body mass index (BMI) of 48.6 ± 9.6 years and 50.4 ± 6.5 kg/m2, respectively. Median (IQR, interquartile range) duration of T2DM preoperatively was 60 (36-126) months. Median (IQR) follow-up was 52 (50-57) months. T2DM remission was achieved in 64 % of patients (44 % CR, 20 % PR), and a further 28 % of patients had improvement in their diabetes status. Multivariate analyses demonstrated significant excess weight loss (EWL) [P = 0.008] and lower BMI [P = 0.04] at 4 years to be the only independent predictors of T2DM medium-term outcomes. CONCLUSION: The medium-term effects of LRYGB on T2DM remission/improvement were maintained in 92 % of patients. EWL and lower BMI at 4 years were independent predictors of T2DM remission.

Robotic assisted common bile duct exploration for management of complex gallstone disease.

BACKGROUND: Minimally invasive cholecystectomy and common bile duct exploration offers single- stage management for complex gallstone disease (cholelithiasis and choledocholithiasis). Robotic platform presents benefits in improving operative precision, which has not been extensively evaluated in the acute setting of managing complex gallstone disease, as well as in performing transcholedochal or post cholecystectomy common bile duct exploration. We report an early series of emergent and expedited robotic assisted cholecystectomy with common bile duct exploration (RC-CBDE) or robotic common bile duct exploration (R-CBDE) alone. MATERIAL AND METHODS: Retrospective analysis from a specialist unit in the United Kingdom was undertaken from April 2022-September 2023 inclusive. All patients that underwent RC-CBDE or R-CBDE were included. Data was collated on patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. RESULTS: Twenty-three consecutive patients were identified. Median (IQR) age was 51 (33-66) years. Median (IQR) Charlson Co-morbidity Index (CCI) was 1 (0-4). Five patients underwent operative intervention as an emergency and 18 on an expedited basis. Two patients underwent post cholecystectomy R-CBDE. Fourteen (61%) were transcholedochal and nine were transcystic (31%) CBDE. Median (IQR) bilirubin was 51 (34-253). Median (IQR) operative time was 176 (124-222) minutes. Median (IQR) post-operative length of stay was 2 (0-4) days. There were no bile leaks requiring intervention. The clearance rate of CBDS was 100%. No patients developed postoperative pancreatitis. One patient required intervention for port site hernia following RC-CBDE. One patient developed subhepatic collection post-operatively and required laparoscopic washout and placement of drains. No patients had retained stones after 3-month follow-up. CONCLUSION: Early experience confirms that RC-CBDE and R-CBDE in feasible, safe, and effective treatment for complex gallstone disease. Integrated adjuncts (intraoperative robotic ultrasound - IORUS and Firefly® - fluorescence guided surgery - FGS) and superior ergonomics of the robotic platform may assist in reducing the learning curve and increase wider uptake of this complex procedure.

Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy: Suitability of APACHE-II Score, ASA Grade, and Tokyo Guidelines 18 Grade as Predictors of Outcome in Patients With Acute Cholecystitis.

INTRODUCTION: Intervention options in acute cholecystitis (AC) include drainage (percutaneous/endoscopic) or surgery. Several scoring systems have been used to risk stratify acute surgical patients, but few have been validated. This study investigated the suitability of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, American Society of Anesthesiologist (ASA) grade, and Tokyo Guidelines 2018 (TG18) grade as predictors of outcome and assess laparoscopic cholecystectomy versus percutaneous cholecystostomy (PC) as treatment options in patients with AC. MATERIALS AND METHODS: Retrospective data was collected from patients that underwent acute inpatient cholecystectomy (index admission), urgent interval cholecystectomy (2 to 4 wk) and PC between 2016 and 2018. Data included baseline demographics, co-morbidities, ASA grade, APACHE-II score, TG18 grade, morbidity, and mortality. A P-value of <0.05 was statistically significant. Area under the receiver operating characteristic curve was calculated to compare accuracy of APACHE-II, ASA and TG18 in predicting morbidity. RESULTS: A total of 344 consecutive patients (266 cholecystectomies and 84 PC) were included in the study. Significant difference in co-morbidities [median Charlson Co-Morbidity Index (CCI) 1 surgery and 4 cholecystostomy (PC) (P<0.05)], median APACHE-II score (3 surgery and 9 PC), median TG18 grade (1 surgery and 2 PC) and mortality rate [0% surgery and 7% cholecystostomy (PC)]. TG18 grade alone predicted postoperative/postprocedure morbidity (receiver operating characteristic; AUC=0.884; 95% confidence interval: 0.845-0.923; odds ratio: 4.38, 96% confidence interval, P<0.05). DISCUSSION: Utilization of the TG18 grade have shown to be more accurate in risk stratifying and predicting outcomes in patients with AC and therefore may appropriately guide biliary intervention.PC can be utilized in a select group of septic and co-morbid patients (myocardial infarction <6 weeks, chest infection and acute cerebrovascular accident) unable to withstand surgical intervention or in those with complex biliary disease (Mirizzi Syndrome). In a proportion, PC drains sepsis to improve critical state of the patient enough to consider an interval cholecystectomy with satisfactory outcomes.

Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach.

INTRODUCTION: The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP. MATERIALS AND METHODS: A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution. RESULTS: Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years. CONCLUSION: Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery.

BACKGROUND: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery. METHODS: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol. RESULTS: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count. CONCLUSION: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Lymph node ratio versus number of affected lymph nodes as predictors of survival for resected pancreatic adenocarcinoma.

BACKGROUND: The objective of this study was to compare the prognostic significance of the lymph node ratio (LNR) with the absolute number of affected lymph nodes for resected pancreatic ductal adenocarcinoma. METHODS: Data were collected from 84 patients who had undergone pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period. Patients were categorized into four groups according to the absolute LNR (0, 0-0.199, 0.2-0.299, > or =0.3). Kaplan-Meier and Cox proportional hazard models were used to evaluate the prognostic effect. RESULTS: An LNR of > or =0.2 (median survival 8.1 vs. 35.7 months with LNR < 0.2; p < 0.001) and > or =0.3 (median survival 5.9 vs. 29.6 months with LNR < 0.3; p < 0.001), tumor size (p < 0.017), positive resection margin (p < 0.001), and nodal involvement (p < 0.001) were found to be significant prognostic markers following univariate analysis. Following multivariate analysis, only LNR at both levels [> or =0.2 (p = 0.05; HR 1.8) and LNR of > or =0.3 (p = 0.01; HR 2.7)] were independent predictors of a poor outcome. The number of lymph nodes examined had no effect on overall survival in either node-positive patients (p = 0.339) or node-negative patients (p = 0.473). CONCLUSIONS: The LNR represents a stronger independent prognostic indicator than the absolute number of affected lymph nodes in patients with resected pancreatic ductal adenocarcinoma.

Index Admission Emergency Laparoscopic Cholecystectomy and Common Bile Duct Exploration: Results From a Specialist Center in the United Kingdom.

BACKGROUND: The incidence of common bile duct (CBD) stones is between 10% to 18% in people undergoing cholecystectomy for gallstones. Laparoscopic exploration of the CBD is now becoming routine practice in the elective setting, however its safety and efficacy in emergencies is poorly understood. METHODS: We analyzed our results for index emergency admission laparoscopic cholecystectomy within a specialist center in the United Kingdom. Data from all emergency cholecystectomies in our unit, between 2011 to 2016 were collected and analyzed retrospectively. RESULTS: In total, 494 patients underwent emergency laparoscopic cholecystectomy; 53 (10.7%) patients underwent common bile duct exploration (CBDE), with 1 conversion and 1 bile leak. Indications for CBDE were based on preoperative imaging (41 cases, 81%) or intra-operative cholangiogram (44 cases, 83%) findings. CONCLUSIONS: Index admission laparoscopic cholecystectomy and concomitant CBDE is safe and should be the gold standard treatment for patients presenting with acute biliary complications, reducing readmissions and the need for a 2-stage procedure.

An antiapoptotic role for gastrin and the gastrin/CCK-2 receptor in Barrett's esophagus.

Mechanisms by which premalignant Barrett's metaplasia (BM) progresses to esophageal adenocarcinoma are currently being sought. This study investigated the role played by the polypeptide hormone gastrin, specifically its antiapoptotic effects through activation of protein kinase B/Akt (PKB/Akt). In esophageal cell lines with low basal levels of activated PKB/Akt, phosphorylation could be induced by exogenous amidated gastrin. High basal levels of activated PKB/Akt were linked to endogenous gastrin expression and were reduced by treatment with a cholecystokinin-type 2 receptor (CCK-2R) antagonist. Expression of a constitutively active splice variant of the CCK-2R additionally increased basal activation of PKB/Akt. It is proposed that gastrin acting in an autocrine and endocrine manner via a CCK-2R isoform may activate PKB/Akt and that with expression of gastrin and CCK-2R isoforms increasing in BM samples, gastrin may aid progression of BM through amplification of antiapoptotic pathways. Evidence for this proposal was provided through the observed specific up-regulation of PKB/Akt in BM samples.

Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis?

BACKGROUND: The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post-GSP. METHODS: Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality. RESULTS: One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score (n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% (n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities (P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy. CONCLUSIONS: Only 32.1% were treated as per BSG guidelines. About 19.8% (n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation.

Torsion of epiploic appendix presenting as acute pancreatitis.

Epiploic appendagitis is a little-diagnosed condition capable of mimicking various pathologies. Here, we present a case presenting as acute pancreatitis.

Gastric band erosion, infection and migration causing jejunal obstruction.

Complications of laparoscopic adjustable gastric bands (LAGB) are well documented and may include migration, erosion, slippage, infection, pouch dilatation and, rarely, gastric perforation. We describe a rare case involving three such complications simultaneously, namely, gastric erosion, infection and migration through the pylorus-causing proximal jejunal obstruction. As LAGB is now the commonest performed bariatric procedure for the treatment of morbid obesity, we encourage the practising surgeon to be vigilant of these rare but potentially life-threatening complications.