Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: a multicenter propensity score-matched study

Background: The role of laparoscopy in the treatment of intrahepatic cholangiocarcinoma (ICC) remains unclear. This multicenter study examined the outcomes of laparoscopic liver resection for ICC. Methods: Patients with ICC who had undergone laparoscopic or open liver resection between 2012 and 2019 at four European expert centers were included in the study. Laparoscopic and open approaches were compared in terms of surgical and oncological outcomes. Propensity score matching was used for minimizing treatment selection bias and adjusting for confounders (age, ASA grade, tumor size, location, number of tumors and underlying liver disease). Results: Of 136 patients, 50 (36.7%) underwent laparoscopic resection, whereas 86 (63.3%) had open surgery. Median tumor size was larger (73.6 vs 55.1 mm, p¼ 0.01) and the incidence of bi-lobar tumors was higher (36.6 vs 6%, p< 0.01) in patients undergoing open surgery. After propensity score matching baseline characteristics were comparable although open surgery was associated with a larger fraction of major liver resections (74 vs 38%, p< 0.01), lymphadenectomy (60 vs 20%, p< 0.01) and longer operative time (294 vs 209 min, p< 0.01). Tumor characteristics were similar. Laparoscopic resection resulted in less complications (30 vs 52%, p¼ 0.025), fewer reoperations (4 vs 16%, p¼ 0.046) and shorter hospital stay (5 vs 8 days, p< 0.01). No differences were found in terms of recurrence, recurrence-free and overall survival. Conclusion: Laparoscopic resection seems to be associated with improved short-term and with similar long-term outcomes compared with open surgery in patients with ICC. However, possible selection criteria for laparoscopic surgery are yet to be defined

Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy

BACKGROUND Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks. METHODS Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years. RESULTS A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass. CONCLUSION The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer

Pain intensity in hospitalized adults: a multilevel analysis of barriers and facilitators of pain management

Background: Despite an enhanced interest and evolution in pain management, prevalence remains high. Interventions to optimize pain-related care can only be effective if barriers are identified and accounted for. Aim: To assess pain intensity and examine its association with patient-(including health literacy defined in this study as "requiring help to read health information"), nurse-, and system-related (including social capital defined as "the importance of network and norms at work") barriers/facilitators to pain management. Methods: A two-center, cross-sectional study was performed between October 2012 and April 2013. The study included patients and nurses of 39 noncritical wards of two hospitals in Belgium. Patients who were 18 years of age or older and without impaired cognition or consciousness were eligible to take part. All nurses working in the included ward were invited to participate. Pain intensity and patient-related barriers were collected by a structured and standardized questionnaire, completed in dialogue with the patient. Nurses completed the questionnaire on the nurse-and system-related barriers and the social capital scale. Multilevel analysis was used to analyze the data because of the hierarchical structure of the data. Results: The average pain of all patients across all wards on a 0-10 scale was 2.2 (SD = 3.6). The multilevel analysis indicates that pain intensity can be explained by variables at patient and ward levels. A significant independent association was found between higher pain intensity and younger age, receiving pain medication, the conviction of patients that pain medication does not improve pain, inadequate health literacy in patients, nurses without advanced education, and nurse's concerns about side effects. Social capital did not emerge as predictor of pain intensity. Discussion: Patient and nurse level factors should be taken into account in hospitals when setting up strategies to improve pain management

Laparoscopic liver resection for liver tumours in proximity to major vasculature: A single-center comparative study

Background: With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs). The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs. Methods: This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011–August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs. Results: Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0–9.0) VS 5.0 (IQR: 3.0–6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140–210) VS 120min (IQR: 75–150), p < 0.001) and blood loss was higher (190 ml (IQR: 100–325) VS 75 ml (IQR: 50–220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12). Conclusion: In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results

One-stage laparoscopic parenchymal sparing liver resection for bilobar colorectal liver metastases: safety, recurrence patterns and oncologic outcomes

Background and Purpose: Laparoscopic liver resections (LLR) of bilobar colorectal liver metastases (CRLM) are challenging and the safety and long-term outcomes are unclear. In this study, the short- and long-term outcomes and recurrence patterns of one-stage LLR for bilobar CRLM were compared to single laparoscopic resection for CRLM. Methods: This single-center study consisted of all patients who underwent a parenchymal sparing LLR for CRLM between October 2011 and December 2018. Demographics, perioperative outcomes, short-term outcomes, oncologic outcomes and recurrence patterns were compared. Data were retrieved from a prospectively maintained database. Results: Thirty six patients underwent a LLR for bilobar CRLM and ninety patients underwent a single LLR. Demographics were similar among groups. More patients received neoadjuvant chemotherapy in the bilobar group (55.6% vs 34.4%, P = 0.03). There was no difference in conversion rate, R0 resection and transfusion rate. Blood loss and operative time were higher in the bilobar group (250 ml (IQR 150–450) vs 100 ml (IQR 50–250), P < 0.001 and 200 min (IQR 170–230) vs 130 min (IQR 100–165), P < 0.001) and hospital stay was longer (5 days (IQR 4–7) vs 4 days (IQR 3–6), P = 0.015). The bilobar group had more technically major resections (88.9% vs 56.7%, P < 0.001). Mortality was nil in both groups and major morbidity was similar (2.8% vs 3.3%, P = 1.0). There was no difference in recurrence pattern. Overall survival (OS) was similar (1 yr: 96% in both groups and 5 yr 76% vs 66%, P = 0.49), as was recurrence-free survival (RFS) (1 yr: 64% vs 73%, 3 yr: 38 vs 42%, 5 yr: 38% vs 28%, P = 0.62). Conclusion: In experienced hands, LLR for bilobar CRLM can be performed safely with similar oncologic outcomes as patients who underwent a single LLR for CRLM

Laparoscopic liver resection for liver tumours in proximity to major vasculature: A single-center comparative study

BACKGROUND: With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs). The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs. METHODS: This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011-August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs. RESULTS: Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0-9.0) VS 5.0 (IQR: 3.0-6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140-210) VS 120min (IQR: 75-150), p < 0.001) and blood loss was higher (190 ml (IQR: 100-325) VS 75 ml (IQR: 50-220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12). CONCLUSION: In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results.status: publishe

Laparoscopic right posterior sectionectomy: single-center experience and technical aspects

PURPOSE: Laparoscopic right posterior sectionectomy (LRPS) is a technically demanding procedure. The aim of this article is to share our experience with LRPS and to highlight technical aspects of this procedure. METHODS: This is a single-center retrospective analysis of all patients who underwent LRPS between September 2011 and October 2017. Data were retrieved from a prospectively maintained database. Video-in-picture (VIP) technology is used to facilitate and to highlight the technical aspects of this procedure. RESULTS: In total, 18 patients underwent LRPS. Indication for surgery was mainly liver metastases (n = 11) and hepatocellular carcinoma (n = 6). The Glissonean approach for inflow control was used in 13 patients. Median operative time was 162 (140-190) minutes. Median blood loss was 325 mL (IQR: 150-450). One conversion (5.5%) was required. There were two minor complications and one major complication. Median hospital stay was 6 days (range 5-8 days). All patients had an R0 resection. There was no 90-day mortality. CONCLUSION: The results of our experience in LRPS add weight to the feasibility and safety of this approach.status: publishe