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BackgroundBlood loss is a major determinant of outcomes following hepatectomy. Robotic technology enables hepatobiliary surgeons to mimic open techniques for inflow control and parenchymal transection during major hepatectomy, increasing the ability to minimize blood loss and perform safe liver resections.MethodsInitial experience of 20 consecutive major robotic hepatectomies from November 2018 to July 2020 at two co-located institutions was reviewed. All cases were performed with extrahepatic inflow control and parenchymal transection with the laparoscopic cavitron ultrasonic surgical aspirator (CUSA), and a technical description is illustrated. Clinical characteristics, operative data, and surgical outcomes were retrospectively analyzed.ResultsThe median (range) patient age was 58 years (20–76) and the majority of 14 (70%) patients were ASA III–IV. There were 12 (60%) resections for malignancy and the median tumor size was 6.2 cm (1.2–14.6). Right or extended right hepatectomy was the most common procedure (12 or 60% of cases). There were 7 (35%) left or extended left hepatectomies and 1 (5%) central hepatectomy. The median operative time was 420 (177–622) minutes. Median estimated blood loss was 300 mL (25–800 mL). One (5%) case was converted to open. Two (10%) patients required blood transfusion. The median length of stay was 3 (1–6) days. Major complications included 1 (5%) Clavien–Dindo IIIa bile leak requiring percutaneous drainage placement. There was no 90-day mortality.ConclusionAdvanced techniques to reduce blood loss in robotic hepatectomy may optimize safety and minimize morbidity in these complex minimally invasive procedures.

We analyzed the fecal microbiome by deep sequencing of the 16S ribosomal genes and the metabolomic profiles of 43 intestinal transplant recipients to identify biomarkers of graft function. Stool samples were collected from 23 patients with stable graft function five years or longer after transplant, 15 stable recipients one-year post-transplant and four recipients with refractory rejection and graft loss within one-year post-transplant. Lactobacillus and Streptococcus species were predominant in patients with stable graft function both in the short and long term, with a microbiome profile consistent with the general population. Conversely, Enterococcus species were predominant in patients with refractory rejection as compared to the general population, indicating profound dysbiosis in the context of graft dysfunction. Metabolomic analysis demonstrated significant differences between the three groups, with several metabolites in rejecting recipients clustering as a distinct set. Our study suggests that the bacterial microbiome profile of stable intestinal transplants is similar to the general population, supporting further application of this non-invasive approach to identify biomarkers of intestinal graft function.

Background Intraoperative blood loss is one of the predictors of outcome of open hepatectomy. But the impact of blood loss in laparoscopic hepatectomy (LH) on postoperative outcomes is poorly understood. The aim of this study is to analyze the association between blood loss and postoperative outcomes after LH. Methods A retrospective analysis of prospectively maintained database of patients undergoing LH from 1995 to 2016 was performed. The data were divided into two groups based on the extent of blood loss: Group 1 (<250 ml) and Group 2 (≥250 ml). The basic characteristics and postoperative outcomes were compared between these groups. Results A total of 504 patients underwent 611 LH (Group 1: 414 and Group 2: 197). The mean age was 62.4 years. The most common indication was liver secondaries (71.7%). Major hepatectomy was performed in 37% cases. Mean operative time was 225 ± 110.5 min and estimated blood loss was 239 ± 399.4 ml (range 0–4500 ml). Group 2 had significantly higher number of patients with malignant lesions undergoing major hepatectomy, anatomical resection with higher requirement for blood transfusion, and longer hospital stay. The incidence of conversion rate, overall complications including liver failure, renal failure, and postoperative mortality, was significantly higher in Group 2. However, the bile leak rate was similar in the two groups. Conclusion Intraoperative blood loss is most frequent in patients undergoing major LH. Blood loss ≥250 ml during LH may adversely affect the postoperative outcomes.

In the recent PORSCH trial, a three-part postpancreatectomy care algorithm was employed with a near 50 ​% reduction in mortality. We hypothesized that clinical care congruent with this protocol would correlate with better outcomes in our patients. Real-world postoperative care was compared to the pathway described by the PORSCH trial and patients were assigned into groups based on congruence with its recommendations. The primary composite outcome (PCO) consisted of 90-day mortality, organ failure, and interventions for bleeding. Of 289 patients, care of 12 ​% was entirely congruent with the PORSCH algorithm. The PCO was recorded in 9 ​% of the PORSCH care group, 8 ​% of the Partial-PORSCH care group, and 19 ​% of the Non-PORSCH care group (p ​= ​0.044). Adverse outcomes were highest when pancreaticoduodenectomy patients received care incongruent with the algorithm's CT imaging recommendations. These results add external validity to the principles of clinical care underlying the PORSCH algorithm. [Display omitted] •Derangements in labwork and vital signs after pancreatectomy warrant investigation.•Early detection and treatment of postpancreatectomy complications improves outcomes.•The PORSCH trial's algorithm may reduce morbidity and mortality in clinical practice.

The diagnosis of choledochal cysts in the adult population is complicated by the expected physiologic dilation of the common bile duct after cholecystectomy. We aimed to compare patients who underwent choledochal cyst resection based on cholecystectomy status. A retrospective analysis was conducted of patients who underwent choledochal cyst resection between 1/1/1998-12/31/2021. Patients were categorized based on whether they had undergone cholecystectomy prior to choledochal cyst diagnosis. Preoperative imaging characteristics, pathology findings, and outcomes were evaluated. Amongst 119 patients who underwent excision, 58 (46 ​%) had and 69 (54 ​%) had not undergone prior cholecystectomy. Preoperative imaging demonstrated no difference in biliary tract diameter although a greater proportion of patients with a gallbladder in place had an anomalous pancreaticobiliary junction (55 ​% v 33 ​%, p ​< ​0.05). Biliary malignancy was observed in a greater proportion of patients with prior cholecystectomy although this was not statistically significant (5 ​% v 3 ​%; p ​= ​0.9). Rates of post-operative complications were statistically similar between patient cohorts. Radiographic and clinical features were similar among patients who had and had not undergone cholecystectomy. Choledochal cyst patients should be managed uniformly regardless of cholecystectomy status. •Biliary duct dilation after cholecystectomy warrants investigation.•Prior cholecystectomy did not alter malignancy rates in choledochal cyst disease.•Choledochal cysts should be managed uniformly regardless of cholecystectomy status.

Currently, there is no reliable method of discerning between low-risk and high-risk intraductal papillary mucinous neoplasms (IPMNs). Operative resection is utilized in an effort to resect those lesions with high-grade dysplasia (HGD) prior to the development of invasive disease. The current guidelines recommend resection for IPMN that involve the main pancreatic duct. Resecting lesions with HGD before their progression to invasive disease and the avoidance of resection in those patients with low-grade dysplasia is the optimal clinical scenario. Therefore, the importance of developing preoperative models able to discern HGD in IPMN patients cannot be overstated. Low-risk patients should be managed with nonsurgical treatment options (typically MRI surveillance), while high-risk patients would undergo resection, hopefully prior to the formation of invasive disease. Current research is evolving in multiple directions. First, there is an ongoing effort to identify reliable markers for predicting malignant transformation of IPMN, mainly focusing on genomic and transcriptomic data from blood, tissue, and cystic fluid. Also, multimodal models of combining biomarkers with clinical and radiographic data seem promising for providing robust and accurate answers of risk levels for IPMN patients.

In spite of difficult anatomic access for tumors of mediastinum, surgical resection remains the best diagnostic and therapeutic approach. Widespread acceptance of video-assisted thoracoscopy (VATS) is restricted by the limiting nature of instruments and suboptimal visualization. Robotic assisted minimally invasive surgery seems to hold most promise in remote, narrow anatomical regions. After obtaining approval from Institutional Review Board (IRB), a retrospective review of prospectively collected database on patients that underwent Robotic VATS between 2009 and 2013 was conducted. Forty-eight patients underwent RVATS resection of mediastinal tumor. One procedure (2.1%) was converted to open. The size of the mass ranged from 0.6 to 12.5 cm in greatest dimension (mean 5.16 cm). The mean duration of procedure was 127.96 min (60–240 min). Five patients (10.4%) had early postoperative complications including chylothorax (1 patient), new onset atrial fibrillation (1 patient), pleural effusion (1 patient), empyema (1 patient), and bleeding (1 patient). Mean follow-up time was 186 days (10–1300 days). Two patients (4%) with invasive thymoma developed local recurrence. The present study documents the feasibility of RVATS in the management of mediastinal tumors irrespective of the location in various mediastinal compartments. The role for careful and complete excision of the tumor, and surveillance afterward on invasive thymoma, was noted in our study, as in literature.