Management of Chronic Pancreatitis- Step Up?

( Peeyush Varshney ),( Rk Singh ),( Anu Behari ),( Ashok Kumar ),( Vk Kapoor ),( Rajan Saxena ) 대한간학회 2020 춘·추계 학술대회 (KASL) Vol.2020 No.1

Aims: Endoscopic treatment is used in several units prior to surgical treatment for pain in chronic pancreatitis. There is limited information on patients who undergo surgical ‘salvage’ after endoscopic failure. We conducted a comparative study between patients who had undergone surgery after prior non-surgical intervention and upfront surgery. Methods: Patients who underwent surgical drainage in our institution over the last 6 years were reviewed, in two groups- Group A (n=29) - surgery with prior non-surgical interventions (ESWL and/or endoscopy); Group B (n=79) - upfront surgery. Pain scores and QOL scores were measured prospectively. Results: The two groups were comparable for baseline characteristics except that group A patients had more strictures/ stones in body and tail region (P<0.05). Short term morbidity was more in Group A vs Group B (65% vs 26%, P<0.01) - wound infection (45% vs 10%, P<0.01; Gastroparesis (10% vs nil, P<0.01). On long term followup complete pain relief was worse in Group A patients (37% vs 68%, P=0.05). Quality of life scores (WHOQOL- BREF) in social domain was significantly better in Group B. Improvement in exocrine and endocrine insufficiency was similar in both groups. Conclusions: Patients with chronic pancreatitis who undergo ‘salvage’ surgery after non-surgical interventions are at increased risk of postoperative morbidity, lower quality of life and poor pain control as compared to those who undergo upfront surgery. Patients with pancreatic body/tail strictures/ stones have poor outcomes with non-surgical interventions and may be considered for upfront surgery.

Total robotic right hepatectomy for multifocal hepatocellular carcinoma using vessel sealer

Peeyush Varshney,Vaibhav Kumar Varshney 한국간담췌외과학회 2023 Annals of hepato-biliary-pancreatic surgery Vol.27 No.1

Rapid adoption of a robotic approach as a minimally invasive surgery tool has enabled surgeons to perform more complex hepatobiliary surgeries than conventional laparoscopic surgery. Although various types of liver resections have been performed robotically, parenchymal transection is challenging as commonly used instruments (Cavitron Ultrasonic Surgical Aspirator [CUSA] and Harmonic) lack articulation. Further, CUSA also requires a patient-side assistant surgeon with hepatobiliary laparoscopic skills. We present a case report of total robotic right hepatectomy for multifocal hepatocellular carcinoma in a 70-year-old male using ‘Vessel Sealer’ for parenchymal transection. Total operative time was 520 minutes with a blood loss of ~400 mL. There was no technical difficulty or instrument failure encountered during surgery. The patient was discharged on postoperative day five without any significant complications such as bile leak. Thus, Vessel Sealer, a fully articulating instrument intended to seal vessels and tissues up to 7 mm, can be a promising tool for parenchymal transection in a robotic surgery.

Laparoscopic Witzel feeding jejunostomy: a procedure overlooked!

Peeyush Varshney,Vignesh N,Vaibhav Kumar Varshney,Subhash Soni,Selvakumar B,Lokesh Agarwal,Ashish Swami 대한내시경로봇외과학회 2023 Journal of Minimally Invasive Surgery Vol.26 No.1

Purpose: Feeding jejunostomy (FJ) is a critical procedure to establish a source of enteral nutrition for upper gastrointestinal disorders. Minimally invasive surgery has the inherent benefit of better patient outcomes, less postoperative pain, and early discharge. This study aims to describe our total laparoscopic technique of Witzel FJ and to compare its outcome with its open counterpart. Methods: A retrospective database analysis was performed in patients who underwent laparoscopic (n = 20) and open (n = 21) FJ as a stand-alone procedure from July 2018 to July 2022. A readily available nasogastric tube (Ryles tube) and routine laparoscopic instruments were used to perform laparoscopic FJ. Perioperative data and postoperative outcomes were analyzed. Results: Baseline preoperative variables were comparable in both groups. The median operative duration in the laparoscopic FJ group was 180 minutes vs. 60 minutes in the open FJ group (p = 0.01). Postoperative length of hospital stay was 3 days vs. 4 days in the laparoscopic and open FJ groups, respectively (p = 0.08). Four patients in the open FJ group suffered from an immediate postoperative complication (none in the laparoscopic FJ group). After a median follow-up of 10 months, fewer patients in the laparoscopic FJ group had complications such as tube clogging, tube dislodgement, surgical-site infection, and small bowel obstruction. Conclusion: Laparoscopic FJ with the Witzel technique is a safe and feasible procedure with a comparable outcome to the open technique. Patient selection is vital to overcome the initial learning curve.

Robotic-assisted resection of proximal jejunal ischemic stricture and intracorporeal robot-sewn anastomosis

Vishu Jain,Peeyush Varshney,Subhash Chandra Soni,Vaibhav Kumar Varshney,B Selvakumar 대한내시경로봇외과학회 2022 Journal of Minimally Invasive Surgery Vol.25 No.4

With the advent of robotic surgery as an effective means of minimally invasive surgery in the last decade, more and more surgeries are being performed robotically in today’s world. Robotic surgery has several advantages over conventional laparoscopic surgery, such as three-dimensional vision with depth perception, magnified view, tremor filtration, and, more importantly, degrees of freedom of the articulating instruments. While the literature is abundant on robotic cholecystectomy and highly complex hepatobiliary surgeries, there is hardly any literature on robotic small bowel resection with intracorporeal anastomosis. We present a case of a 50-year-old male patient with a symptomatic proximal jejunal ischemic stricture who underwent robotic-assisted resection and robot-sewn intracorporeal anastomosis in two layers. He did well in the postoperative period and was discharged on postoperative day 4 with uneventful recovery. We hereby discuss the advantages and disadvantages of robotic surgery in such a scenario with a review of the literature.

Open injury, robotic repair—moving ahead! Total robotic Roux-en-Y hepaticojejunostomy for post-open cholecystectomy Bismuth type 2 biliary stricture using indocyanine green dye

Kaushal Singh Rathore,Peeyush Varshney,Subhash Chandra Soni,Vaibhav Kumar Varshney,Selvakumar B,Lokesh Agarwal,Chhagan Lal Birda 대한내시경로봇외과학회 2023 Journal of Minimally Invasive Surgery Vol.26 No.3

Hepaticojejunostomy is currently the best treatment for post-cholecystectomy biliary strictures. Laparoscopic repair has not gained popularity due to difficult reconstruction. We present case of 43-year-old-female with Bismuth type 2 stricture following laparoscopic converted open cholecystectomy with bile duct injury done elsewhere. Position was modified Llyod-Davis position and four 8-mm robotic ports (including camera) and 12-mm assistant port were placed. The procedure included noticeable steps such as adhesiolysis, identification of gallbladder fossa, identification of common hepatic duct, lowering of hilar plate etc. Operating and console time were 420 and 350 minutes and blood loss was 100 mL. Patient was discharged on postoperative day 4. Robotic repair (hepaticojejunostomy) of biliary tract stricture after cholecystectomy is safe and feasible with good outcomes.

Impact of nasogastric tube exclusion after minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study in India

Vignesh N,Vaibhav Kumar Varshney,Selvakumar B,Subhash Soni,Peeyush Varshney,Lokesh Agarwal 대한내시경로봇외과학회 2024 Journal of Minimally Invasive Surgery Vol.27 No.1

Purpose: This study examines the impacts of omitting nasogastric tube (NGT) placement following cervical esophagogastric anastomosis (CEGA) in Enhanced Recovery After Surgery (ERAS) protocols, comparing outcomes to those from early NGT removal. Methods: In a retrospective cohort of esophagectomy patients treated for esophageal cancer, participants were divided into two groups: group 1 had the NGT inserted post-CEGA and removed by postoperative day 3, while group 2 underwent the procedure without NGT placement. We primarily investigated anastomotic leak rates, also analyzing hospital stay duration, pulmonary complications, and NGT reinsertion. Results: Among 50 esophageal squamous cell carcinoma patients, 30 in group I were compared with 20 in group II. The baseline demographic and tumor characteristics were similar between both groups. The overall incidence of anastomotic leak was 14.0%, comparable in both groups (16.7% vs. 10.0%, p = 0.63). The postoperative hospital stay was significantly shorter in the no NGT group (median of 7 days vs. 6 days, p = 0.03) with similar major morbidity (Clavien-Dindo grade ≥IIIa; 13.3% vs. 5.0%, p = 0.63). There was no 30-day mortality, and one patient in each group had reinsertion of NGT for conduit dilatation. Conclusion: The exclusion of an NGT across CEGA after esophagectomy did not influence the anastomotic leak rate with comparable complications and a shorter hospital stay.

Pancreas-preserving limited duodenal resection: Minimizing morbidity without compromising oncological adequacy

Ajay Sharma,Anand Nagar,Peeyush Varshney,Maunil Tomar,Shashwat Sarin,Rajendra Prasad Choubey,V. K. Kapoor 한국간담췌외과학회 2022 Annals of hepato-biliary-pancreatic surgery Vol.26 No.2

Backgrounds/Aims: Pancreaticoduodenectomy is the most common procedure for the management of duodenal pathologies. However, it is associated with substantial morbidity and a low risk of mortality. Pancreas-preserving limited duodenal resection (PPLDR) can be performed under specific scenarios. We share our experience with PPLDR and its outcome. Methods: We retrospectively analyzed a prospectively maintained database of patients undergoing limited duodenal resection in the form of wedge (sleeve) resection or segmental resection of one or more duodenal segments from March 2016 to March 2021 at a tertiary care center in North India. Results: During the study period, 10 patients (including 9 males) underwent PPLDR. Five of these 10 patients showed primary duodenal or proximal jejunal pathology, while the remaining five had duodenal pathology involving an adjacent organ tumor. Four patients underwent wedge (sleeve) resection, while the remaining six underwent segmental duodenal resection of one or more duodenal segments. Mean hospital stay was 6 days (range, 3–11 days) without 30-day mortality. Morbidity occurred in 4 patients (Grade I–II, n = 3; Grade III, n = 1). All patients were alive and disease-free at the time of last follow-up. The mean follow-up duration was 23 months (range, 2–48 months). Conclusions: PPLDR is a safe and effective alternative for pancreaticoduodenectomy when selected carefully for specific tumor types and location.

Cystic duct patch closure of remnant bile duct in living donor hepatectomy when primary closure is difficult: An easy solution

Subash Gupta,Rajasekhar Kandagaddala,Shaleen Agarwal,Rajesh Dey,Selvakumar Naganathan,Peeyush Varshney,Nilesh Patil 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.4

Backgrounds/Aims: In living donor hepatectomy, hepatic duct division is a crucial step and often a technical challenge, with the aim of obtaining a good hepatic duct for anastomosis in the recipient and an adequate stump in the donor for closure. Very rarely, after duct division, the remaining stump may not be adequate for primary closure. In such a difficult situation, the options would be either to close stump transversely or a Roux-en-Y Hepaticojejunostomy. Methods: We describe a novel surgical technique of “Cystic duct patch repair”, utilizing the available local tissues for closure of bile duct wall. Results: Two year follow up of this technique showed satisfactory results with no evidence of stricture and normal liver functions. Conclusions: In living donor hepatectomy, “Cystic duct patch closure” may be used if the post closure cholangiogram is not satisfactory. Although the best method is prevention by ensuring a stump for closure, very rarely this error can occur and can be sorted by cystic duct patch repair.