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BackgroundFew studies have compared the oncological benefit of laparoscopic (LPD) and open pancreatoduodenectomy (OPD) for ampullary carcinoma. The aim of this study was to compare the oncological results of these two approaches.MethodsBetween 2011 and 2020, 103 patients who underwent PD for ampullary carcinoma, including 31 LPD and 72 OPD, were retrospectively analyzed. Patients were matched on a 1:2 basis for age, sex, body mass index, American Society of Anaesthesiologists score, and preoperative biliary drainage. Short- and long-term outcomes of LPD and OPD were compared. ResultsThe 31 LPD were matched (1:2) to 62 OPD. LPD was associated with a shorter operative time (298 vs. 341 min, p = 0.02) than OPD and similar blood loss (361 vs. 341 mL, p = 0.747), but with more intra- and post-operative transfusions (29 vs. 8%, p = 0.008). There was no significant difference in postoperative mortality (6 vs. 2%), grades B/C postoperative pancreatic fistula (22 vs. 21%), delayed gastric emptying (23 vs. 35%), bleeding (22 vs. 11%), Clavien ≥ III morbidity (22 vs. 19%), or the length of hospital stay (26 vs. 21 days) between LPD and OPD, respectively, but there were more reinterventions (22 vs. 5%, p = 0.009). Pathological characteristics were similar for tumor size (21 vs. 22 mm), well differentiated tumors (41 vs. 38%), the number of harvested (23 vs. 26) or invaded lymph nodes (48 vs. 52%), R0 resection (84 vs. 90%), and other subtypes (T1/2, T3/4, phenotype). With a comparable mean follow-up (41 vs. 37 months, p = 0.59), there was no difference in 1-, 3-, and 5-year overall (p = 0.725) or recurrence-free survival (p = 0.155) which were (93, 74, 67% vs. 97, 79, 76%) and (85, 58, 58% vs. 90, 73, 73%), respectively.ConclusionThis study showed a similar long-term oncological results between LPD and OPD for ampullary carcinoma. However, the higher morbidity observed with LPD compared to OPD, restricting its use to experienced centers.

BackgroundRecent studies have reported trocar site hernia (TSH) rates after bariatric surgery ranging from 0 to 45.2% based on imaging assessment. The objective of this study was to evaluate the TSH rate after sleeve gastrectomy (SG) comprising routine 12 mm epigastric trocar site closure (TSC).MaterialProspective observational study with retrospective control cohort of a group of patients undergoing primary SG with routine 12 mm epigastric TSC. The “before” group (control group) was a previously published group of patients without 12 mm epigastric TSC and the “after” group (closure group) concerned patients with routine 12 mm epigastric TSC. Primary endpoint was the TSH rate after routine epigastric TSC. Secondary endpoints were comparison of the TSH rate, TSC feasibility and causes of failure, TSC-related morbidity, evaluation of TSC time and its course, and identification of risk factors for TSH.ResultsOne hundred twenty-three patients were analyzed during the study period. Feasibility of epigastric TSC was 97.3% without related morbidity. Mean epigastric TSC time was 44.2 s (18–150). Epigastric TSC time was always less than 60 s after 10–15 procedures. At 1 year, 10 patients presented TSH (8.1%): epigastric in 6.5% (n = 8) cases and after open laparoscopy in 1.6% (n = 2) cases. Comparison of the two groups revealed a lower TSH rate in the closure group (8.1% vs. 17.0%; p = 0.02), due to a lower epigastric TSH rate (6.5% vs. 14.8%; p = 0.02). Routine epigastric TSC was a protective factor for TSH (p = 0.03; relative risk of 0.43).ConclusionRoutine epigastric TSC during SG is rapid and provides effective prevention of TSH.

ObjectivesIntraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: visualising anatomy, assessing tissue perfusion, identifying/localising cancer and mapping lymphatic systems. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging used to visualise anatomical structures using the IDEAL framework, a framework designed to describe the stages of innovation in surgery and other interventional procedures.DesignIDEAL staging based on a thorough literature review.SettingAll publications on intraoperative fluorescence imaging for visualising anatomical structures reported in PubMed through 2020 were identified for five surgical procedures: cholangiography, hepatic segmentation, lung segmentation, ureterography and parathyroid identification.Main outcome measuresThe IDEAL stage of research evidence was determined for each of the five procedures using a previously described approach.Results225 articles (8427 cases) were selected for analysis. Current status of research evidence on fluorescence imaging was rated IDEAL stage 2a for ureterography and lung segmentation, IDEAL 2b for hepatic segmentation and IDEAL stage 3 for cholangiography and parathyroid identification. Enhanced tissue identification rates using fluorescence imaging relative to conventional white-light imaging have been documented for all five procedures by comparative studies including randomised controlled trials for cholangiography and parathyroid identification. Advantages of anatomy visualisation with fluorescence imaging for improving short-term and long-term postoperative outcomes also were demonstrated, especially for hepatobiliary surgery and (para)thyroidectomy. No adverse reactions associated with fluorescent agents were reported.ConclusionsIntraoperative fluorescence imaging can be used safely to enhance the identification of anatomical structures, which may lead to improved postoperative outcomes. Overviewing current research knowledge using the IDEAL framework aids in designing further studies to develop fluorescence imaging techniques into an essential intraoperative navigation tool in each surgical field.

PurposeResection of hepatic lesions can be difficult and requires careful analysis of pre-operative imaging. The aim of this study is to highlight the use of multiplanar CT reconstruction in liver surgery, which helps to anticipate intra-operative technical difficulties.MethodsWe retrospectively selected the imaging of several patients managed for liver lesions in specific locations: liver dome (IVa, VIII), the left lobe (intra-parenchymal, left edge), and the antero-inferior edge of segment VI. The IWATE classification was used to grade the difficulty of these resections.ResultsMultiplanar analysis has made it possible to change the level of difficulty of liver resection and to anticipate intra-operative difficulties. Frontal and/or sagittal section in addition to axial sections analysis increased the IWATE score.ConclusionMulti-planar reconstruction must be a tool used by the liver surgeon pre-operatively in order to limit intra-operative complications.

BackgroundManagement of abdominal drainage after surgery for secondary lower gastrointestinal tract peritonitis (LGTP) is not a standardized procedure. A monocentric study was carried out in 2016 in our centre. (PI study) to evaluate the interest of drainage. Our objective was to revaluate, our actual use of abdominal drainage after peritonitis (PII study).Study designWe examined retrospectively patients who underwent surgery for secondary sub-mesocolic community-acquired peritonitis (January 2016–December 2019). Study exclusion criteria were primary peritonitis, peritoneal dialysis, nosocomial peritonitis, postoperative peritonitis, upper gastrointestinal tract peritonitis, peritonitis due to appendicitis, peritonitis requiring the implementation of Mikulicz’s drain, and peritonitis in which the peritoneum was not described in the surgical report (i.e., the same criteria that the PI study which included 141 patients from January 2009 to January 2012). The primary endpoint was the rate of abdominal drainage. The secondary endpoints were the patient rate without a peritoneum description, major complications rate (Clavien ≥III), abscess rate, mortality rate and the length of stay in the non-drain group (D – ) and in the drain group (D + ) in PII study. Primary and secondary endpoints were also compared between PI and PII studies. Risk factors for post-operative abscess were also research.ResultsOf the 150 patients included 33% were drained vs 84% of the 141 patients included in PI study (p < 0.001). In PII study peritoneum was described in 80.3% of patients vs 69% in PI study (NS, p = 0.06). Comparing the two groups D –  and D + , no significant differences were found in major complications (respectively 45% vs 32%, p = 0.1), reoperation rate (respectively 25% vs 22%, p = 0.7), death rate (respectively 25% vs 14%; p = 0.1) and mean length of stay (respectively 12 days vs 13 days, p = 0.9). The abscess rate was significantly lower in the D –  group (10% vs 30%, p = 0.002). Comparing PI and PII studies, there was no difference about major complications (35% vs 35%, p = 0.1), reoperation (16% vs 17.5%, p = 0.5), abscess rate (15% vs 8.5%, p = 0.1) and mortality (14.5% vs 17.5%, p = 0.7). The length of stay was longer in PI study than in P II (14 days vs 9 days, p = 0.03). Drainage (p = 0.005; OR = 4.357; CI [1.559–12.173]) and peritonitis type (p = 0.032; OR = 3.264; CI [1.106–9.630]) were abscess risk factors.ConclusionThis study therefore showed that drainage after surgery for LGTP may not be necessary and that, at least at the local level, surgeons seem to be inclined to discontinue it systematically. It may therefore be worthwhile to conduct a randomised control trial to establish recommendations on drainage after surgery for LGTP.

BackgroundIn our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results.MethodBetween 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (n = 43), second period (n = 43), and third period (n = 44).ResultsIn the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%, p = 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%; p = 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%; p = 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%; p = 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%; p = 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270; p < 0.001) with less blood loss (300, 200, 125; p < 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%; p = 0.017), bleeding (28%, 21%, 14%; p = 0.26), Clavien-Dindo III–IV (40%, 33%, 16%; p = 0.013), re-interventions (19%, 14%, 9%; p = 0.43), and the hospital stay (26, 19, 18; p = 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%; p = 0.002) with more harvested lymph nodes in the third period (21,19, 25; p = 0.031) and higher R0 resection (70%, 79%, 84%; p = 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m2, and patients operated in the third period.ConclusionThis study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.

Background In two-stage hepatectomy for bilobar liver metastases from colorectal cancer, future liver remnant (FLR) growth can be achieved using several techniques, such as right portal vein ligation (RPVL) or right portal vein embolization (RPVE). A few heterogeneous studies have compared these two techniques with contradictory results concerning FLR growth. The objective of this study was to compare FLR hypertrophy of the left hemi-liver after RPVL and RPVE. Study design This was a retrospective comparative study using a propensity score of patients who underwent RPVL or RPVE prior to major hepatectomy between January 2010 and December 2020. The endpoints were FLR growth (%) after weighting using the propensity score, which included FLR prior to surgery and the number of chemotherapy cycles. Secondary endpoints were the percentage of patients undergoing simultaneous procedures, the morbidity and mortality, the recourse to other liver hypertrophy procedures, and the number of invasive procedures for the entire oncologic program in intention-to-treat analysis. Results Fifty-four consecutive patients were retrospectively included and analyzed, 18 in the RPVL group, and 36 in the RPVE group. The demographic characteristics were similar between the groups. After weighting, there was no significant difference between the RPVL and RPVE groups for FLR growth (%), respectively 32.5% [19.3–56.0%] and 34.5% [20.5–47.3%] ( p  = 0.221). There was no significant difference regarding the secondary outcomes except for the lower number of invasive procedures in RPVL group (median of 2 [2.0, 3.0] in RPVL group and 3 [3.0, 3.0] in RPVE group, p  = 0.001)). Conclusion RPVL and RPVE are both effective to provide required left hemi-liver hypertrophy before right hepatectomy. RPVL should be considered for the simultaneous treatment of liver metastases and the primary tumor.

BackgroundLaparoscopy is nowadays considered as the standard approach for hepatic left lateral sectionectomy (LLS), but its value in the prevention of incisional hernia (IH) has not been demonstrated.MethodsBetween 2012 and 2017, patients undergoing laparoscopic (LLLS) or open LLS (OLLS) in 8 centers were compared. Patients undergoing a simultaneous major abdominal procedure were excluded. The incidence of IH was assessed clinically and morphologically on computed tomography (CT) using inverse probability of treatment weighting (IPTW) and multivariable regression analysis.ResultsAfter IPTW, 84 LLLS were compared to 48 OLLS. Compared to OLLS, LLLS patients had reduced blood loss (100 [IQR: 50–200] ml vs. 150 [IQR: 50–415] ml, p = 0.023) and shorter median hospital stay (5 [IQR: 4–7] days vs. 7 [6–9] days, p < 0.001), but experienced similar rate of postoperative complications (mean comprehensive complication index: 12 ± 19 after OLLS versus 13 ± 20 after LLLS, p = 0.968). Long-term radiological screening was performed with a median follow-up of 27.4 (12.1–44.9) months. There was no difference between the two groups in terms of clinically relevant IH (10.7% [n = 9] after LLLS, 8.3% [n = 4] after OLLS, p = 0.768). The rate of IH detected on computed tomography was lower after LLLS than after OLLS (11.9% [n = 10] versus 29.2% [n = 14], p = 0.013). On multivariable analysis, the laparoscopic approach was the only independent factor influencing the risk of morphological IH (OR = 0.290 [95% CI: 0.094–0.891], p = 0.031). The 2 preferential sites for specimen extraction after LLLS were Pfannenstiel and midline incisions, with rates of IH across the extraction site of 2.3% [n = 1/44] and 23.8% [n = 5/21], respectively (p = 0.011).ConclusionThe laparoscopic approach for LLS decreases the risk of long-term IH as evidenced on morphological examinations, with limited clinical impact. Pfannenstiel’s incision should be preferred to midline incision for specimen extraction after LLLS.