Preliminary results of laparoscopic versus open pancreaticoduodenectomy in Vietnam: A retrospective analysis from a multi-center research

IntroductionThe goal of this study was to compare the results of LPD with those of open pancreaticoduodenectomy (OPD).MethodData were retrospectively collected from a database of patients who underwent PD from January 2010 to May 2020. Intraoperative, postoperative, and follow-up assessment studies were conducted.ResultsA total of 149 patients were selected. Compared with OPD, LPD was fewer intraoperative blood transfusions (p = 0.015), a longer median operative time (p < 0.001), hospital stay (p = 0.034), a higher rate of bile leakage (p = 0.02), overall morbidity (p = 0.045), and re-operation (p = 0.044). There was no difference between the two groups in severe pancreatic fistula, postoperative bleeding, delayed gastric emptying, Clavien-Dindo classification ≥ III, or 30-day mortality. LPD had a similar number of excised lymph nodes, R0 resection rate, and long-term survival cases involving malignant tumors, ampulla of Vater cancer, and pancreatic ductal adenocarcinoma.ConclusionIn the early period, the benefit of LPD has not been found as there was a high rate of conversion to laparotomy, morbidity, and re-operation. Despite that, LPD is a feasible oncological approach with long-term survival comparable to OPD.     

Outcomes of high versus low ligation of the inferior mesenteric artery with lymph node dissection for distal sigmoid colon or rectal cancer

We compared the complication rates and oncologic and functional outcomes of high versus low ligation of the inferior mesenteric artery (IMA). We reviewed data retrospectively from 776 patients, divided into high and low IMA ligation groups. Low ligation was performed with lymph node dissection around the IMA root. Postoperative complications and oncologic and functional outcomes were analyzed. There were 613 patients in the high ligation group and 163 patients in the low ligation group. Most clinicopathological variables were similar. There were no significant differences in complication rates (25.1% vs. 28.8%; p = 0.336), anastomotic leakage (2.8% vs. 2.5%; p = 1.000), colonic ischemia (2.8% vs. 1.2%; p = 0.393), 5-year overall survival (79.6% vs. 81.3%; p = 0.137) or 5-year relapse-free survival (77.4% vs. 73.3%; p = 0.973) between the groups. In terms of functional outcomes, both techniques were equivalent. The International Prostate Symptom Score and Fecal Incontinence Severity Index were significantly better in the low ligation group 12 months postoperatively than 3 months postoperatively. The oncologic and functional outcomes, as well as postoperative complications, after low ligation of the IMA with lymph node dissection are not significantly different from those after high ligation of the IMA.     

Laparoscopic and open surgery in rectal cancer patients in Germany: short and long-term results of a large 10-year population-based cohort

Rectal cancer is frequent in Germany and worldwide. Several studies have assessed laparoscopic surgery as a treatment option and most have shown favorable results. However, long-term oncologic safety remains a controversial issue. The current dataset derives from 30 clinical cancer registries in Germany and includes 16,378 patients diagnosed with rectal cancer between 2007 and 2016. Outcomes were 90-day mortality, overall survival (OS), local recurrence-free survival (RFS) and relative survival of patients treated with either open or laparoscopic surgery. Multivariable logistic regression was used to evaluate factors that affected the probability of a patient undergoing laparoscopic surgery as well as to evaluate short-term mortality. OS and RFS were analyzed by Kaplan–Meier plots and multivariable Cox regression conducted separately for UICC stages I–III, tumor location, and sex as well as by propensity score matching followed by univariable and multivariable survival analysis. Of 16,378 patients, 4540 (27.7%) underwent laparoscopic surgery, a trend which increased during the observation period. Patients undergoing laparoscopy attained better results for 90-day mortality (odds ratio, OR 0.658, 95% confidence interval, CI 0.526–0.822). The 5-year OS rate in the laparoscopic group was 82.6%, vs. 76.6% in the open surgery group, with a hazard ratio (HR) of 0.819 in multivariable Cox regression (95% CI 0.747–0.899, p < 0.001). The laparoscopic group showed a better 5-year RFS, with 81.8 vs. 74.3% and HR 0.770 (95% CI 0.705–0.842, p < 0.001). The 5-year relative survival rates were also in favor of laparoscopy, with 93.1 vs. 88.4% (p = 0.012). Laparoscopic surgery for rectal cancer can be performed safely and, according to this study, is associated with an oncological outcome superior to that of the open procedure. Therefore, in the absence of individual contraindications, it should be considered as a standard approach.     

Safety and feasibility of laparoscopic pancreaticoduodenectomy in octogenarians

IntroductionWith continued technical advances in surgical instruments and growing surgical expertise, many laparoscopic pancreaticoduodenectomies (LPDs) have been safely performed with favorable outcomes, and this approach is being used more frequently. With an increase in the life expectancy, interest in treatments for elderly patients has increased. In this study, we investigated the safety and feasibility of LPD in octogenarians.MethodsFrom September 2005 to February 2020, resectable/borderline resectable periampullary tumors (PATs) were diagnosed in 71 octogenarians at Sincheon Severance Hospital and CHA Bundang Medical Center. Patients were divided into two groups: those who underwent surgery (PD, N = 38) and those who did not (NPD, N = 33). The group that underwent surgery was further divided into two groups: those who underwent open PD (OPD, N = 19), and those who underwent LPD (LPD, N = 19). Perioperative outcomes, including long-term survival, were retrospectively compared between these groups.ResultsThere was no significant difference in age, sex, comorbidities, diagnosis, and chemo-radiotherapy between the surgery and non-surgery groups. The PD group had a better survival rate than the NPD group (p < 0.05). The baseline characteristics and postoperative outcomes were not significantly different between the OPD and LPD groups. Only three and two patients in the OPD and LPD groups had a biochemical leak (p > 0.999). There was no significant difference in overall survival and disease-free survival between the OPD and LPD groups (p = 0.816, p = 0.446, respectively).ConclusionsLPD is a good alternative for octogenarians with PAT requiring PD.     

Laparoscopic common bile duct exploration for elderly patients with choledocholithiasis: a systematic review and meta-analysis

Laparoscopic common bile duct exploration (LCBDE) has been becoming more and more popular in patients with symptomatic choledocholithiasis. However, the safety and effectiveness of LCBDE in elderly patients with choledocholithiasis is still uncertain. This meta-analysis is aimed to appraise the safety and feasibility of LCBDE for elderly patients with choledocholithiasis. Studies comparing elderly patients and younger patients who underwent LCBDE for common bile duct stone were reviewed and collected from the PubMed, Medline, EMBASE, and Cochrane Library. Primary outcomes were stone clearance rate, overall complication rate, and mortality rate. Secondary outcomes were operative time, conversion rate, pulmonary complication, bile leakage, reoperation, residual stone rate, and recurrent stone rate. Nine studies, including two prospective studies and seven retrospective studies, met the inclusion criteria. There were 2004 patients in this meta-analysis, including 693 elderly patients and 1311 younger patients. There was no statistically significant difference between elderly patients and younger patients regarding stone clearance rate (OR 0.73; 95% CI 0.42–1.26; p = 0.25), overall complication rate (OR 1.31; 95% CI 0.94–1.82; p = 0.12), and mortality rate (OR 2.80; 95% CI 0.82–9.53; p = 0.10). Similarly, the operative time, conversion rate, bile leakage, reoperation, residual stone rate, and recurrent stone rate showed no significant difference between two groups (p > 0.05). While elderly patients showed high risk for pulmonary complication (OR 4.41; 95% CI 1.78–10.93; p = 0.001) compared with younger patients. Although there is associated with higher pulmonary complication, LCBDE is still considered as a safe and effective treatment for elderly patients with choledocholithiasis.     

EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis

In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD. We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated. Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03–13.44; p = 0.0006; I2 = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00–8.66; p = 0.0001; I2 = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77–2.22; p = 0.33, I2 = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14–0.79; p = 0.01; I2 = 0%)]. There was low heterogeneity in the analyses. EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.     

腹腔镜与开腹胰十二指肠切除治疗十二指肠乳头腺癌疗效比较

目的:比较腹腔镜胰十二指肠切除(LPD)与开腹胰十二指肠切除(OPD)治疗十二指肠乳头腺癌的近期及远期疗效。方法:回顾性分析2012年1月—2017年12月共89例行胰十二指肠切除术的十二指肠乳头腺癌患者的临床资料。其中50例行OPD,39例行LPD,比较两组患者的相关临床资料。结果:两组患者一般资料具有可比性。两组手术时间与术中输血例数无明显差异(均P0.05),但LPD组术中出血量明显少于OPD组(P0.05)。LPD组术后住院时间明显短于OPD组(P0.05),但两组术后各并发症发生率、二次手术率、术后30 d死亡方面均无明显差异(均P0.05)。两组R_0切除率及其他术后病理结果均无明显差异(均P0.05)。两组1、3年总生存率与无病生存率均无明显差异(均P0.05)。结论:与OPD比较,LPD治疗十二指肠乳头腺癌患者具有相同的肿瘤根治性,且不增加并发症的发生率,两者远期疗效也相似。     

Multivariate analysis of the factors affecting the prognosis of walled-off pancreatic necrosis after endoscopic ultrasound-guided drainage

Endoscopic ultrasound (EUS)-guided drainage has become the treatment of choice for walled-off pancreatic necrosis (WOPN). However, no consensus exists on the most significant patient- and procedure-related factors that affect prognosis. The aim of the study is to investigate the correlation between patient- and procedure-related factors and post-procedure complications after EUS-guided drainage. A retrospective analysis of the clinical characteristics of patients with WOPN who underwent EUS-guided drainage at our endoscopy center between November 2011 and August 2017 was performed. Chi-square analysis and binary logistic regression statistical methods were used to analyze the correlation between influencing factors and prognosis. A total of 85 patients (male/female, 50/35) with WOPN were included in the study. The average age was 44.95 years. The cyst diameter was 10.58 ± 4.78 cm. Multivariate analysis showed that WOPN with higher solid content (> 30%) increased the probability of endoscopic necrosectomy (OR 6.798; 95% CI 1.423, 32.470; p = 0.016). The use of a metal stent increased the probability of endoscopic necrosectomy (OR 3.503; 95% CI 1.251, 9.810; p = 0.017) and the length of hospitalization (OR 3.315; 95% CI 1.192, 9.215; p = 0.022). Female patients had a higher probability of requiring endoscopic necrosectomy (OR 2.683; 95% CI 1.027, 7.007; p = 0.044) and prolonged hospitalization (OR 2.675; 95% CI 1.065, 6.721; p = 0.036). The solid content of WOPN, type of stent, and sex of patients were associated with increased probability of endoscopic necrosectomy.     

Surgical Outcomes in Esophageal Cancer Patients with Tumor Recurrence After Curative Esophagectomy

This study aimed to identify predictive factors and to evaluate appropriate treatments for recurrence of esophageal cancer after curative esophagectomy. About 166 consecutive patients, who underwent curative esophagectomy, were enrolled between April 1994 and March 2003. Recurrence was classified as loco-regional or distant. Logistic regression analysis was used to identify predictive factors for recurrence. Prognostic factors were evaluated by Log-rank test and Cox proportional hazard regression analysis. The disease-specific 5-year survival was 56.8%. Recurrence was observed in 72 patients (43.4%), with 64 of these occurring within 3 years. The number of metastatic lymph nodes and lymphatic invasion independently predicted recurrence. There were significant differences in time to recurrence and survival time between loco-regional, distant recurrence, and combined recurrence. The 5-year survival time in patients with recurrence was 11.9%, and median survival time was 24 months. There was also a significant difference in survival after recurrence between treatment methods (no treatment vs chemo-radiotherapy, p = 0.0063; chemotherapy, p = 0.0247; and radiotherapy, p < 0.0001). Meticulous, long-term follow-up is particularly necessary in patients with four or more metastatic lymph nodes to achieve early detection of recurrence. Randomized controlled trials should be used to develop effective modalities for each recurrence pattern to improve therapeutic outcomes.     

Oncologic and Perioperative Outcomes Following Selective Application of Laparoscopic Pancreaticoduodenectomy for Periampullary Malignancies

Background

Data are sparse regarding patient selection criteria or evaluating oncologic outcomes following laparoscopic pancreaticoduodenectomy (LPD). Having prospectively limited LPD to patients with resectable disease defined by National Comprehensive Cancer Network (NCCN) criteria, we evaluated perioperative and long-term oncologic outcomes of LPD compared to a similar cohort of open pancreaticoduodenectomy (OPD).

Methods

Consecutive patients (November 2010–February 2014) undergoing pancreaticoduodenectomy (PD) for periampullary adenocarcinoma were reviewed. Patients were excluded from further analysis for benign pathology, conversion to OPD for portal vein resection, and contraindications for LPD not related to their malignancy. Outcomes of patients undergoing LPD were analyzed in an intention-to-treat manner against a cohort of patients undergoing OPD.

Results

These selection criteria resulted in offering LPD to 77 % of all cancer patients. Compared to the OPD cohort, LPD was associated with significant reductions in wound infections (16 vs. 34 %; P?=?0.038), pancreatic fistula (17 vs. 36 %; P?=?0.032), and median hospital stay (9 vs. 12 days; P?=?0.025). Overall survival (OS) was not statistically different between patients undergoing LPD vs. OPD for periampullary adenocarcinoma (median OS 27.9 vs. 23.5 months; P?=?0.955) or pancreatic adenocarcinoma (N?=?28 vs. 22 patients; median OS 20.7 vs. 21.1 months; P?=?0.703).

Conclusions

The selective application of LPD for periampullary malignancies results in a high degree of eligibility as well as significant reductions in length of stay, wound infections, and pancreatic fistula. Overall survival after LPD is similar to OPD.

     

腹腔镜与开放胰十二指肠切除术疗效的对比观察

目的：探讨腹腔镜胰十二指肠切除术（LPD）的手术和肿瘤学安全性,并与开放胰十二指肠切除术（OPD）进行疗效对比。方法回顾性分析2012年1月至2013年6月中山大学附属第三医院胃肠外科收治并行胰十二指肠切除术患者的临床资料,根据所行术式分为LPD组和OPD组,对比分析手术时间、术中出血量、清扫淋巴结数目、术后第1天腹腔引流量、术后排气时间、恢复流质饮食时间、术后发热天数、术后住院天数、术后并发症发生率、1年生存率和复发率等指标。结果两组患者性别、年龄、ASA分级、手术时间、清扫淋巴结数目、病理分期、术后发热天数、术后引流管拔除时间、术后并发症发生情况以及术后1年生存率和肿瘤复发情况等指标差异均无统计学意义（P＞0．05）。而LPD组相比OPD组,术中出血量[（168．2±87．4） ml比（353．5±140．1） ml,P＝0．000]及术后第1天腹腔引流量[（157．7±69．7） ml比（289．1±197．0） ml,P＝0．039]减少,术后排气时间[（4．1±0．9） d比（6．6±3．4） d,P＝0．024]、恢复流质饮食时间[（5．8±1．3） d比（8．2±3．5） d,P＝0．040]、下床活动时间[（3．6±1．4） d比（6．2±1．5） d,P＝0．000]和术后住院天数[（17．0±2．2） d比（25．7±13．8） d, P＝0．047）明显缩短。结论与传统开放手术相比,LPD能够保证肿瘤根治性切除和手术安全的同时,在减少术中出血和促进术后恢复过程方面具有明显优势。     

Anastomotic Leakage is Associated with Poor Long-Term Outcome in Patients After Curative Colorectal Resection for Malignancy

The impact of anastomotic leakage on long-term outcomes after curative surgery for colorectal cancer has not been well documented. This study aimed to investigate the effect of anastomotic leakage on survival and tumor recurrence in patients who underwent curative resection for colorectal cancer. Prospectively collected data of the 1,580 patients (904 men) of a median age of 70 years (range: 24–94), who underwent potentially curative resection for colorectal cancer between 1996 and 2004, were reviewed. Cancer-specific survival and disease recurrence were analyzed using Kaplan Meier method, and variables were compared with log rank test. Cox regression model was used in multivariate analysis. The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage: n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3 vs 2.0%, p < 0.001). The 5-year cancer-specific survivals were 56.9% in those with leakage and 75.9% in those without leakage (p = 0.012). The 5-year systemic recurrence rates were 48.4 and 22.6% in patients with and without anastomotic leak, respectively (p = 0.001), whereas the 5-year local recurrence rates were 12.9 and 5.7%, respectively (p = 0.009). Anastomotic leakage remained an independent factor associated with a worse cancer-specific survival (p = 0.043, hazard ratio: 1.63, 95% CI: 1.02–2.60) and a higher systemic recurrence rate (hazard ratio: 1.94, 95% CI: 1.23–3.06, p = 0.004) on multivariate analysis. In rectal cancer, anastomotic leakage was an independent factor for a higher local recurrence rate (hazard ratio: 2.55, 95% CI: 1.07–6.06, p = 0.034). In conclusion, anastomotic leakage is associated with a poor survival and a higher tumor recurrence rate after curative resection of colorectal cancer. Efforts should be undertaken to avoid this complication to improve the long-term outcome. This work was presented in the plenary session of the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract at the Digestive Disease Week in Los Angeles on 22 May 2006.     

Prognostic significance of pancreatic fistula and postoperative complications after pancreaticoduodenectomy in patients with pancreatic ductal adenocarcinoma

BackgroundThe influence of postoperative complications, specifically, pancreatic fistula (PF), on long-term oncologic outcome in patients with pancreatic ductal adenocarcinoma (PDAC) is unclear.MethodsProspectively collected data of patients who underwent pancreaticoduodenectomy (PD) for PDAC between 2008 and 2016 were retrospectively reviewed and analyzed. Deaths within 90 days were excluded. Median follow-up time was 22 months for the entire cohort (range 2–102 months). PF was graded as biochemical leak, grade B, or grade C according to the criteria of the International Study Group on Pancreatic Fistula. Postoperative complications were graded according to the Clavien-Dindo classification (CDC). Data on clinical and pathological characteristics as well as on recurrence and survival were collected.ResultsTwenty-nine of the 148 identified patients (19%) developed PF, of whom 17 (11.4%) had a PF grade B or C. 29 patients developed a postoperative complication CDC grade 3 or 4. The respective 3-year disease-free survival was 15.5% and 19.2% (P = 0.725), and the 5-year overall survival was 20% and 16% (P = 0.914) in patients with and without PF. On multivariate analysis, the use of adjuvant chemotherapy, lymph node involvement, surgical margin involvement, and tumor grade were associated with patient survival. PF and postoperative complications CDC grade 3 or 4 were not associated with decreased long-term survival, disease-free survival or local recurrence rate.ConclusionsWhile acknowledging the limited sample size, no association was seen between PF or postoperative complications and overall or disease-free survival in patients undergoing PD for PDAC.     

腹腔镜与开腹胰十二指肠切除术的安全性和疗效对比研究

目的 比较腹腔镜胰十二指肠切除术（LPD）和开腹胰十二指肠切除术（OPD）的安全性和疗效。方法 回顾性分析2016年1月至2021年8月期间施行胰十二指肠切除术患者的临床资料,将符合标准的49例患者分成LPD组（n=23）和OPD组（n=26）,比较两组患者的手术时间、术中出血量、术后并发症、术后住院时间、术后肿瘤学结果及预后等方面的差异。结果 LPD和OPD两种术式的术中输血率和术后胰瘘、胆瘘、术后出血、胃排空延迟、腹腔感染、并发症发生率等手术安全性指标相近（P>0.05）;LPD组较OPD组手术时间延长,但术中出血量减少（P<0.05）。两种术式术后入住ICU人数、非计划再次手术人数、标本肿瘤长径、术中淋巴结清扫数目、淋巴结阳性患者例数、R0切除率、肿瘤分化程度、术后病理分期、肿瘤来源、出院30 d内再次入院率、术后复发率、术后90 d死亡率及术后1年、2年、3年生存率等手术疗效指标相近（P>0.05）。与OPD相比,LPD术后首次下床活动时间和肛门排气时间提早,术后住院日缩短,术后疼痛评分降低和基本日常生活活动能力评分提高（P<0.05）。结论 与OPD相比,LPD安全可靠,可获得同样的肿瘤学根治效果,手术疗效值得肯定,在临床上是可行的。     

Umbilical Herniorrhapy in Cirrhosis: Improved Outcomes with Elective Repair

Objective This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes. Methods Procedures were identified from the Veterans’ Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables. Results Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1–9.4), diabetes (OR 2.1; 95% CI 1.2–3.8), congestive heart failure (OR 4.0; 95% CI 1.4–11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1–3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3–14.3) was strongly associated with postoperative complications. Conclusion Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.     

Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy

Backgrounds and objective

The technique of minimally invasive pancreatic surgeries has evolved rapidly, including minimally invasive pancreaticoduodenectomy (MIPD). However, controversy on safety and feasibility remains when comparing the MIPD with the open pancreaticoduodenectomy (OPD); therefore, we aimed to compare MIPD and OPD with a systemic review and meta-analysis.

Methods

Multiple electronic databases were systematically searched to identify studies (up to February 2016) comparing MIPD with OPD. Intra-operative outcomes, oncologic data, postoperative complications and postoperative recovery were evaluated.

Results

Twenty-two retrospective studies including 6120 patients (1018 MIPDs and 5102 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (WMD ?312.00 ml, 95 % CI ?436.30 to ?187.70 ml, p < 0.001), transfusion rate (OR 0.41, 95 % CI 0.30–0.55, p < 0.001), wound infection (OR 0.37, 95 % CI 0.20–0.66, p < 0.001) and length of hospital stay (WMD ?3.57 days, 95 % CI ?5.17 to ?1.98 days, p < 0.001). Meanwhile, MIPD group has a higher R0 resection rate (OR 1.47, 95 % CI 1.18–1.82, p < 0.001) and more lymph nodes harvest (WMD 1.74, 95 % CI 1.03–2.45, p < 0.001). However, it had longer operation time (WMD 83.91 min, 95 % CI 36.60–131.21 min, p < 0.001). There were no significant differences between the two procedures in morbidities (p = 0.86), postoperative pancreatic fistula (p = 0.17), delayed gastric empting (p = 0.65), vascular resection (p = 0.68), reoperation (p = 0.33) and mortality (p = 0.90).

Conclusions

MIPD can be a reasonable alternative to OPD with potential advantages. However, further large-volume, well-designed RCTs with extensive follow-ups are suggested to confirm and update the findings of our analysis.

     

Analysis of Recurrence Pattern and Its Influence on Survival Outcome After Radiofrequency Ablation of Hepatocellular Carcinoma

Background Radiofrequency ablation (RFA) is an effective local ablation therapy for hepatocellular carcinoma (HCC) with favorable long-term outcome. There is no data on the analysis of recurrence pattern and its influence on long-term survival outcome after RFA in HCC patients. Aim of Study To evaluate the tumor recurrence pattern and its influence on long-term survival in patients with HCC treated with RFA. Patients and Methods From April 2001 to January 2005, 209 patients received RFA using internally cooled electrode as the sole treatment modality for HCC. Among them, 117 patients (56%) had unresectable HCC because of bilobar disease, poor liver function, and/or high medical risk for resection; whereas 92 patients (44%) underwent RFA as the primary treatment for small resectable HCC. The ablation procedure was performed through percutaneous (n = 101), laparoscopic (n = 17), or open approaches (n = 91). The tumor recurrence pattern and long-term survival were analyzed. Multivariate analysis was carried out to identify independent prognostic factors affecting the overall survival of patients. Results The mortality and morbidity rates were 0.9 and 15.7%, respectively. Complete tumor ablation was achieved in 192 patients (92.7%). With a median follow-up period of 26 months, local recurrence occurred in 28 patients (14.5%). Same segment and different segment intrahepatic recurrence occurred in 30 patients (15.6%) and 78 patients (40.6%), respectively. Twenty patients (10.4%) developed distant extrahepatic metastases. The overall 1-, 3-, and 5-year survival rates were 87.2, 66.6, and 42%, respectively. Different segment intrahepatic recurrence and distant recurrence after RFA carried significant poor prognostic influence on overall survival outcome. Using multivariate analysis, Child–Pugh grade (risk ratio [RR] = 2.918, 95% confident interval [CI] 1.704–4.998, p = 0.000), tumor size (RR = 1.231, 95% CI 1.031–1.469, p = 0.021), and pattern of recurrence (risk ratio [RR] = 1.464, 95% CI 1.156–1.987, P = 0.020) were identified as independent prognostic factors for overall survival. Conclusion The tumor recurrence pattern after RFA carries significant prognostic value in relation to overall survival. Long-term regular surveillance and aggressive treatment strategy are required for patients with different segment intrahepatic recurrence to optimize the benefits of RFA.     

Cost analysis of open and laparoscopic pancreaticoduodenectomy: a single institution comparison

Introduction

The laparoscopic approach to pancreaticoduodenectomy has been recently more frequently reported and is now being performed at multiple centers across the US. While laparoscopic pancreaticoduodenectomy (LPD) has been shown to be safe and feasible, comparing its cost in relation to open pancreaticoduodenectomy (OPD) has not been examined. The aim of this study is to examine the cost of LPD compared with OPD at a single institution over a 3-year time period.

Methods

An institutional database was analyzed to compare patients who underwent OPD and LPD (including Whipple resections and total pancreatectomy) between May 2009 and June 2012. A cost analysis was performed, which included the use the hospital billing database to assess surgical costs, hospital admission costs, and overall cost of the patient’s care during the index admission. The operative costs were further analyzed with respect to OR time and surgical supplies. Standard statistical analysis was performed to assess for significance.

Results

In the study time period, 123 patients underwent pancreaticoduodenectomy, including 48 OPD (39 %) and 75 LPD (61 %). The groups were similar with respect to age, gender, ASA, vein resection, and indication for surgery. In the LPD group, the use of hand assist or conversion to OPD occurred in 3 (4 %) and 10 (13 %) patients, respectively. Additionally, 10 % of the OPD group underwent total pancreatectomy (n = 5), compared to 21 % of the LPD (n = 16). Mean operative time for OPD and LPD was 355 min (range 199–681) and 551 min (range 390–819) respectively (p < 0.0001). Median hospital stay for OPD and LPD was 8 days (range 5–63), and 7 days (range 4–68) respectively (p = 0.5). Morbidity rates were equal at 31 % for the two groups. The LPD group was associated with significantly higher surgical cost due to both increased time and supply cost. However, mean hospital admission cost associated with OPD was greater in comparison to the LPD group, though not significant. The overall total cost of care was similar between the two groups.

Conclusions

LPD is associated with equivalent overall cost compared with OPD. While operating time and supply costs were higher for LPD, this was balanced by decreased cost of the postoperative admission.