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A single institution experience with robotic and laparoscopic distal pancreatectomies
Shi Qing Lee,Tousif Kabir,Ye-Xin Koh,Jin-Yao Teo,Ser-Yee Lee,Juinn-Huar Kam,Peng-Chung Cheow,Prema Raj Jeyaraj,Pierce K. H. Chow,London L. Ooi,Alexander Y. F. Chung,Chung-Yip Chan,Brian K. P. Goh 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.3
Backgrounds/Aims: This study aims to describe our experience with minimally-invasive distal pancreatectomies, with emphasis on the comparison between robotic distal pancreatectomy (RDP) and laparoscopic distal pancreatectomy (LDP). Methods: Retrospective review of 102 consecutive RDP and LDP from 2006 to 2019 was performed. Results: There were 27 and 75 patients who underwent RDP and LDP, respectively. There were 12 (11.8%) open conversions and 16 (15.7%) patients had major (>grade 2) morbidities. Patients who underwent RDP had significantly higher rates of splenic preservation (44.4% vs. 13.3%, p=0.002), higher rates of splenic-vessel preservation (40.7% vs. 9.3%, p=0.001), higher median difficulty score (5 vs. 3, p=0.002) but longer operation time (385 vs. 245 minutes, p<0.001). The rate of open conversion tended to be lower with RDP (3.7% vs. 14.7%, p=0.175). Conclusions: In our institution practice, both RDP and LDP were safe and effective. The use of RDP appeared to be complementary to LDP, allowing us to perform more difficult procedures with comparable postoperative outcomes.
Yuxin Guo,Ek-Khoon Tan,Nicholas L. Syn,Thinesh-Lee Krishnamoorthy,Chee-Kiat Tan,Reina Lim,Ser-Yee Lee,Chung-Yip Chan,Peng-Chung Cheow,Alexander Y. F. Chung,Prema Raj Jeyaraj,Brian K. P. Goh 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.4
Backgrounds/Aims: Repeat liver resection (RLR) and salvage liver transplantation (SLT) are viable treatment options for recurrent hepatocellular carcinoma (HCC). With possibly superior survival outcomes than RLR, SLT is however, limited by liver graft availability and poses increased perioperative morbidity. In this study, we seek to compare the outcomes of RLR and SLT for patients with recurrent HCC. Methods: Between 1999 and 2018, 94 and 16 consecutive patients who underwent RLR and SLT respectively were identified. Further retrospective subgroup analysis was conducted, comparing 16 RLR with 16 SLT patients via propensity-score matching. Results: After propensity-score adjusted analyses, SLT demonstrated inferior short-term perioperative outcomes than RLR, with increased major morbidity (57.8% vs 5.4 %, p=0.0001), reoperations (39.1% vs 0, p<0.0001), renal insufficiency (30.1% vs 3%, p=0.0071), bleeding (19.8% vs 2.2%, p=0.0289), prolonged intensive care unit stay (median=4 vs 0 days, p<0.0001) and hospital stay (median= 19.8 vs 7.1days, p<0.001). However, SLT showed significantly lower recurrence rate (15.4% versus 70.3%, p=0.0005) and 5-year cumulative incidence of recurrences (19.4% versus 68.4%, p=0.005). Propensity-matched subgroup analysis showed concordant findings. Conclusions: While SLT offers potentially reduced risks of recurrence and trended towards improved long-term survival outcomes relative to RLR, it has poorer short-term perioperative outcomes. Patient selection is prudent amidst organ shortages to maximise allocated resources and optimise patient outcomes.
Outcomes of salvage liver transplant for recurrent hepatocellular carcinoma
Yuxin Guo,Ek-Khoon Tan,Thinesh-Lee Krishnamoorthy,Chee-Kiat Tan,Ban-Hock Tan,Thuan-Tong Tan,Ser-Yee Lee,Chung-Yip Chan,Peng-Chung Cheow,Alexander Y. F. Chung,Prema Raj Jeyaraj,Brian K. P. Goh 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.1
Backgrounds/Aims: Salvage liver transplantation (SLT) is a therapeutic strategy for recurrent hepatocellular carcinoma (HCC). However, it remains controversial with compromised survival outcomes and increased perioperative morbidity compared to primary liver transplant (PLT). In the present work, we describe our institution’s experience on SLT by comparing outcomes of SLT to PLT for HCCs. Methods: Retrospective analysis was conducted for 49 transplant patients from 2006-2017. A comparative analysis was carried out between 14 SLT patients and 35 PLT patients. Results: SLT patients demonstrated significantly shorter time to recurrence than PLT patients (median=5.5 versus 23 months, p<0.001) with a trend towards increased perioperative major morbidity (42.9% versus 37%, p=0.711), inferior 5-year overall survival (61% versus 75%, p=0.345) and inferior 5-year recurrence-free survival (57% versus 72%, p=0.263). However, overall survival from the point of primary resection over a 10-year period showed no statistical difference between the 2 groups (SLT=60% versus PLT=61%, p=0.685). Conclusions: SLT is a viable treatment strategy for HCCs. However, it exhibited poorer short-term perioperative and oncologic outcomes than PLT. SLT requires better patient selection with liver donor grafts for optimization of resource allocation in this era of organ shortage. Considering the worldwide shortages in liver grafts, it is hypothesized that optimization of a salvage transplant strategy may improve resource allocation and reap optimal patient outcomes.
Tousif Kabir,Zoe Z. X. Tan,Nicholas Syn,Alexander Y. F. Chung,London L. P. J. Ooi,Brian K. P. Goh 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.3
Backgrounds/Aims: This study aims to evaluate the perioperative outcomes of minimally-invasive enucleation (MIEn) of the pancreas versus open enucleation (OEn). Methods: This is a retrospective review of 20 consecutive patients who underwent pancreatic enucleation at a single institution. Results: Seven patients underwent MIEn, of which 3 were robotic and 4 were laparoscopic. After propensity-adjusted analysis, the only significant difference was a reduced rate of readmissions within 30 days in the MIEn group versus the OEn group [0 vs 4 (30.8%), p=0.0464]. There were no conversions to open in the MIEn group, and median operation time was similar in both groups. There was no difference in median EBL in both groups, and none of the patients in our series required blood transfusions. The overall morbidity rate was 45.0% and the major complication (Clavien-Dindo>2) rate was 15%; which was similar between both groups. Seven (35%) patients had a Grade B/C POPF, and there was no significant difference between the two groups for this. The MIEn group had a shorter median length of stay compared to OEn [5 days (range, 3-24) vs 8.5 days (range, 5-42)] this was not significant on propensity-adjusted analysis (p=0.3195). There was no post-operative 90-day/ in-hospital mortality in all 20 patients. Conclusions: Our experience demonstrates that MIEn was associated with similar perioperative outcomes and fewer readmissions compared to OEn.
Hwee Leong Tan,Ek Khoon Tan,Jin Yao Teo,Juinn Huar Kam,Ser Yee Lee,Peng Chung Cheow,Prema Raj Jeyaraj,Pierce K. Chow,Alexander Y. Chung,London L. Ooi,Chung Yip Chan,Brian K. P. Goh 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.3
Backgrounds/Aims: Solid pseudopapillary neoplasm (SPPN) is typically seen in young healthy females who would likely benefit from minimally-invasive pancreatectomy (MIP). A few comparative studies have suggested that MIP is associated with favorable outcomes when compared to the open approach for SPPN. This study aims to mitigate potential selection bias by performing a matched case-control study comparing MIP vs open pancreatectomy (OP) for SPPN. Methods: We performed a single-institution retrospective electronic chart review of all patients who underwent surgery for pathologically confirmed SPPN between 2000 and 2017. A 2:1 matched comparison using age, gender, tumor size and the type of pancreatectomy was performed between OP and MIP. Results: A total of 40 patients with a median age of 40.3 years (range 16.5-64.4) and female sex predominance (n=34, 85.0%) underwent surgery during the study period. Nine patients underwent MIP. Matched comparison between 18 OP and 9 MIP demonstrated that MIP was associated with a longer median operating time (305 vs 180 min, p=0.046) and shorter median postoperative stay (6 vs 9 days, p=0.015). There were no significant differences in intraoperative blood loss, blood transfusion requirements, postoperative morbidity (including postoperative pancreatic fistula) and mortality, resection margins, lymph node yield and long-term survival. Conclusions: MIP is a safe and viable option in the management of SPPN with the benefit of a shorter postoperative length of stay at the expense of a longer operation time. There was no significant difference in oncologic outcomes between both groups of patients.
Ken Min Chin,Brian K. P. Goh 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.1
Pancreatic neuroendocrine tumors (PNET) comprise up to 10% of all pancreatic solid tumors. There has been much interest in recent years with regards to the role of limited resection and enucleation procedures for this entity. There is no clear guideline today on the optimal type choice of surgery for this condition, with even fewer reporting on the use of a robotic approach for pancreatic uncinate lesions. We describe a case report of a 54-year-old lady who underwent successful robotic enucleation of pancreatic uncinate neuroendocrine tumor. This patient’s recovery was complicated by pancreatitis and a peripancreatic collection, both of which resolved without surgical re-intervention. A literature review was performed with regards to current guidelines on management of PNETs, comparisons between demolitive and parenchymal-preserving procedures, and recent developments in the laparoscopic and robotic approaches for this condition. There is no clear guideline on the optimal type and approach (open vs. laparoscopic vs. robotic) to the surgical management of PNET. We document in this case report a novel approach of robotic enucleation of pancreatic uncinate process NET, that could be considered as an alternative to open/laparoscopic demolitive procedures for small uncinate tumors.
Pyae Pa Pa Kyaw,Brian K. P. Goh 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.2
Completion pancreatectomy (CP), is an effective, and potentially curative option for selected patients with local recurrence of pancreatic neoplasms in the remnant pancreas after initial pancreatoduodenectomy (PD). Traditionally CP has been performed via the open approach. Reports of minimally-invasive CP particularly after previous open PD are rare. We present a case of a 72-year old male who previously underwent open PD 5 years ago for intraductal papillary mucinous neoplasm (IPMN) with high grade dysplasia in the uncinate process. He had multifocal IPMN and low-risk lesions in the body and tail were managed conservatively. On routine surveillance, the cyst in the body was noted to be increasing in size with the development of a non-enhancing solid component confirmed on magnetic resonance imaging and subsequent endoscopic ultrasonography. The patient underwent successful robotic assisted laparoscopic completion pancreatectomy. Final histology confirmed a recurrent IPMN with low-to-intermediate grade dysplasia. The postoperative recovery was uneventful and he was discharged on postoperative day 9.
Ken Min Chin,Ye-Xin Koh,Brian K. P. Goh 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.4
Pancreatic injuries are often associated with trauma and occur most commonly in combination with other solid organ injuries. Management strategies for pancreatic injuries include conservative, endoscopic, percutaneous and surgical intervention. Literature on the laparoscopic approach to management of pancreatic trauma is rare and poorly reviewed. We describe a case report of successful and uncomplicated laparoscopic distal pancreatosplenectomy (LDP) for a patient suffering from isolated traumatic pancreatic tail transection. A literature review was performed with regards to the indications for intervention and different modalities of treatment for traumatic pancreatic lacerations. A review and comparison was also made between the scarce pre-existing reports of the laparoscopic approach to pancreatic resection in the setting of trauma. The laparoscopic approach to pancreatic resection, in the setting of trauma, can be considered as a viable alternative to open surgery. Moving forward, further studies with larger patient numbers will be needed to compare the outcomes between the open and laparoscopic approach.