Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: a systematic review and meta-analysis

Background: While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor. Methods: PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD). Results: From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17). Conclusions: Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections. Keywords: Colorectal cancer; Laparoscopic hepatectomy; Laparoscopic surgery; Liver tumor; Metastasectomy; Minimally invasive surgery

SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM)

Background: Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. Methods: Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. Results: The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. Conclusions: These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM. Keywords: Colorectal cancer; Colorectal liver metastases; Minimally invasive hepatectomy; Open hepatectomy

S054: incidence and management of jejunojejunal intussusception after Roux-en-Y gastric bypass: a large case series

INTRODUCTION: Jejunojejunal intussusception after Roux-en-Y gastric bypass (RYGBP) for morbid obesity is a rare but potentially catastrophic complication. There are limited data regarding the incidence of intussusception and the different surgical options for management of this disease. METHODS: This is a retrospective review of all patients that underwent RYGBP and subsequently developed intussusception at the jejunojejunostomy. Data were collected between 1/1/2008 and 5/31/2018 and included demographics, details related to the index procedure, presentation, and management of intussusception. Perioperative outcomes and complications were also collected. RESULTS: 665 patients underwent RYGBP. A total of 34 patients developed intussusception, with 31 (4.7%) of them having undergone RYGBP in our hospital. Demographics included age, gender, and BMI at both the index surgery and at the time of intussusception. The jejunojejunostomy was created during RYGBP using a linear stapler in all patients with 64.5% of them achieving a length of 90 mm. All intussuscepted patients presented acutely with abdominal pain. All but one patient required surgical intervention. 42.4% of the patients were found to have intraoperative intussusception which appeared to be retrograde in 78.6% of them. Reduction followed by enteropexy or just enteropexy was performed in 20 patients (60.6%) that required surgery. No immediate post-operative complications were noted but 8 patients (26.5%) had recurrence of intussusception requiring another surgical intervention. In the reoperated group, 75% of the patients were treated with reduction followed by enteropexy or just enteropexy. CONCLUSIONS: This is the largest case series describing jejunojejunal intussusception following RYGBP. All patients that developed intussusception had jejunojejunostomy length greater than 60 mm. The most commonly performed surgical repair was reduction of the intussuscepted segment (if present) followed by enteropexy. Jejunojejunostomy length greater than 60 mm might be associated with the occurrence of intussusception and could explain the higher incidence noted in our series. Minimal intervention with enteropexy can offer effective treatment for most patients

Perioperative Considerations During Emergency General Surgery in the Era of COVID-19: A U.S. Experience

The novel coronavirus SARS-CoV-2 (COVID-19) strain has caused a pandemic that affects everyday clinical practice. Care of patients with acute surgical problems is adjusted to minimize exposing health care providers to this highly contagious virus. Our goal is to describe a specific and reproducible perioperative protocol aiming to keep health care providers safe and, simultaneously, not compromise standard of care for surgical patients

Long term results on the severity of acute appendicitis during COVID-19 pandemic

Background: Acute appendicitis cases increased in severity following COVID-19 related restrictions in March, 2020 [1,2]. We investigated if similar changes occurred during Wave 2. Methods: Acute appendicitis patients during Wave 1 were grouped 8 weeks before (Group A) and after (Group B) stay-at-home restrictions were initiated on March 15, 2020. Cases in Wave 2 were grouped 8 weeks before (Group C) and after (Group D) November 6, 2020. Groups were compared to equivalent time frames in 2018/2019. Results: Group A vs B revealed 42.6% decrease (CI: - 59.4, - 25.7) in uncomplicated appendicitis, and 21.1% increase (CI: 4.8, 37.3) in perforated appendicitis. Similar patterns were noted comparing Group C vs D without statistical significance. The changes seen in Wave 1 were significantly different than in 2018/2019. This trend continued in Wave 2. Conclusions: Similar to Wave 1, acute appendicitis cases increased in severity during wave 2 of COVID-19, but with less prominence. Keywords: Appendicitis; COVID-19; Incidence; Pandemic; Severity

Increasing incidence of complicated appendicitis during COVID-19 pandemic

Background: The novel coronavirus (COVID-19) strain has resulted in restrictions potentially impacting patients presenting with acute appendicitis and their disease burden. Methods: All acute appendicitis admissions (281 patients) between 1/1/2018-4/30/2020 were reviewed. Two groups were created: 6 weeks before (Group A) and 6 weeks after (Group B) the date elective surgeries were postponed in Massachusetts for COVID-19. Acute appendicitis incidence and disease characteristics were compared between the groups. Similar time periods from 2018 to 2019 were also compared. Results: Fifty-four appendicitis patients were categorized in Group A and thirty-seven in Group B. Those who underwent surgery were compared and revealed a 45.5% decrease (CI: 64.2,-26.7) in uncomplicated appendicitis, a 21.1% increase (CI:3.9,38.3) in perforated appendicitis and a 29% increase (CI:11.5,46.5) in gangrenous appendicitis. Significant differences in the incidence of uncomplicated and complicated appendicitis were also noted when comparing 2020 to previous years. Conclusions: The significant increase in complicated appendicitis and simultaneous significant decrease in uncomplicated appendicitis during the COVID-19 pandemic indicate that patients are not seeking appropriate, timely surgical care. Keywords: Acute appendicitis; COVID-19; Complicated appendicitis

Expert laparoscopist performance on virtual reality simulation tasks with and without haptic features

Background: Virtual reality (VR) simulation for laparoscopic training is available with and without haptic feedback features. Currently, there is limited data on haptic feedback\u27s effect on skill development. Our objective is to compare expert laparoscopists\u27 skills characteristics using VR delivered laparoscopic tasks via haptic and nonhaptic laparoscopic surgical interfaces. Methods: Five expert laparoscopists performed seven skills tasks on two laparoscopic simulators, one with and one without haptic features. Tasks consisted of 2-handed instrument navigation, retraction and exposure, cutting, electrosurgery, and complicated object positioning. Laparoscopists alternated platforms at default difficulty settings. Metrics included time, economy of movement, completed task elements, and errors. Progressive change in performance for the final three iterations were determined by repeated measures ANOVA. Iteration quartile means were determined and compared using paired t-tests. Results: No change in performance was noted in the last three iterations for any metric. There were no significant differences between platforms on the final two quartiles for most metrics except avoidance of over-stretch error for retraction; and cutting task was significantly better with haptics on all iteration quartiles (p \u3c 0.03). Economy of movement was significantly better with haptics for both hands for clip application (p \u3c 0.01) and better for right hand on complex object positioning (p \u3c 0.05). Accuracy was better with haptics for retraction and cutting (p \u3c 0.05) and clip application (p \u3c 0.05). Conclusion: Results showed higher performance in accuracy, efficient instrument motion, and avoidance of excessive traction force on selected tasks performed on VR simulator with haptic feedback compared to those performed without haptics feedback. Laparoscopic surgeons interpreted machine-generated haptic cues appropriately and resulted in better performance with VR task requirements. However, our results do not demonstrate an advantage in skills acquisition, which requires additional study. Keywords: Haptic feedback; Surgical simulation; Virtual reality