A. Sastry

Fellows' perspective of HPB training programs in North America: results of a survey

BACKGROUNDnSixteen hepatopancreatobiliary fellowship programs in North America are accredited by the Fellowship Council. This study aims to assess fellows perceptions of their training program.nnnMETHODSnA multiple-choice questionnaire was sent to 35 fellows to assess how they perceived their training: academics, research, operative experiences, autonomy, mentorship, program quality and weaknesses. The survey was developed using the SurveyMonkey® tool.nnnRESULTSnTwenty-four of 35 fellows completed the survey. Sixteen fellows reported structured didactics; 10 reported mandatory research. As to operative experiences; 9 fellows reported exposure to minimally-invasive liver surgery; 5 reported exposure to robotics. Fourteen fellows reported using ablation; 5 reported using ablation laparoscopically; 8 reported using mostly radiofrequency ablation; 1 reported using irreversible electroporation. Eighteen fellows reported excellent training; 20 reported mentorship; 19 reported operative autonomy. Limited exposure to medical oncology/multidisciplinary care, portal hypertension surgery, and robotics surgery were perceived as program weaknesses by 7, 9, and 7 fellows, respectively.nnnCONCLUSIONnMost fellows ranked their program quality and academic content as excellent, but they perceived a need for more exposure to medical oncology, portal hypertension surgery, and minimally-invasive surgery, with an emphasis on robotics. Fellowship training may need to integrate fellows desires for enhanced proficiency in these clinical areas.

Robotic-assisted completion Cholecystectomy: a safe and effective minimally invasive approach to a challenging surgical scenario

Average LOS 1.1 days TP20-02 ROBOTIC-ASSISTED COMPLETION CHOLECYSTECTOMY: A SAFE AND EFFECTIVE MINIMALLY INVASIVE APPROACH TO A CHALLENGING SURGICAL SCENARIO W. Lyman, M. Passeri, A. Sastry, D. Iannitti, D. Vrochides, E. Baker and J. Martinie Department of General Surgery, and Division of HPB Surgery, Carolinas Medical Center, United States Background: Subtotal cholecystectomy remains a viable and safe option when intraoperative conditions preclude visualization of the Critical View of Safety. 1.8% of these patients eventually require a reoperation. Traditionally, completion cholecystectomy following subtotal cholecystectomy required an open approach. In this study, we present our institutional experience with 16 robotic-assisted completion cholecystectomies following previous subtotal cholecystectomy. Methods: Operating room logs were reviewed from 20102017 to identify all robotic cholecystectomies performed at our institution. Review of all operative reports identified 16 completion cholecystectomies following a previous subtotal cholecystectomy. All additional variables including demographics, operative variables, and postoperative outcomes were collected from EMR records. Results: Median time from previous subtotal cholecystectomy to robotic completion cholecystectomy was 84 months (7 years). 58.3% of patients previously underwent an open subtotal cholecystectomy. The remaining patients underwent a laparoscopic subtotal cholecystectomy. Additional demographics and outcomes can be seen in Table 1. One patient required oral antibiotics for incisional site erythema. No patients required a conversion to an open procedure and average length of stay was 1.1 days. Conclusions: Although traditionally performed with an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion

A Complete Pathological Response to Pembrolizumab following ex vivo Liver Resection in a Patient with Colorectal Liver Metastases

Advances in the systemic treatment of stage IV colorectal cancer with liver metastases has offered improved survival rates for patients who otherwise face a dismal prognosis. However, a pathologically complete response (PCR) to chemotherapy for colorectal liver metastases is still rare, and its significance is not fully understood. In this case report, we describe a patient who achieved PCR after neoadjuvant immunotherapy with pembrolizumab and a left hepatectomy using an ex vivo resection technique.

The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy

Introduction Optimal fluid balance is critical to minimize anastomotic edema in patients undergoing pancreaticoduodenectomy. We examined the effects of decreased fluid administration on rates of postoperative pancreatic leak and delayed gastric emptying. Methods Retrospective study of 105 patients undergoing pancreaticoduodenectomy at a single institution from January 2015 through July 2016. Stroke volume variation (SVV) was tracked and titrated during the procedure. A comparative analysis of postoperative complications was performed between patients with a median SVVu202f<u202f12 during the extirpative and reconstructive phases of the procedure compared with patients with an SVVu202f≥u202f12. Results Of 64 patients who met selection criteria, 42 (65.6%) had a SVVu202f<u202f12 and 22 (34.4%) had a SVVu202f≥u202f12. Patients with an SVVu202f≥u202f12 during the extirpative phase of the procedure had lower rates of postoperative pancreatic leaks compared to patients with an SVVu202f<u202f12 (5.9% vs 21.3%)). Patients with an SVVu202f≥u202f12 during the extirpative phase had lower rates of postoperative delayed gastric emptying compared to patients with an SVVu202f<u202f12 (41.2% vs 46.8%). Conclusion Goal-directed fluid restriction before the reconstructive phase of pancreaticoduodenectomy may contribute to lower postoperative rates of pancreatic leak and delayed gastric emptying.

A novel 3-dimensional electromagnetic guidance system increases intraoperative microwave antenna placement accuracy

BACKGROUNDnFailure to locate lesions and accurately place microwave antennas can lead to incomplete tumor ablation. The Emprint™ SX Ablation Platform employs real-time 3D-electromagnetic spatial antenna tracking to generate intraoperative laparoscopic antenna guidance. We sought to determine whether Emprint™ SX affected time/accuracy of antenna-placement in a laparoscopic training model.nnnMETHODSnTargets (7-10xa0mm) were set in agar within a laparoscopic training device. Novices (no surgical experience), intermediates (surgical residents), and experts (HPB-surgeons) were asked to locate and hit targets using a MWA antenna (10-ultrasound only, 10-Emprint™ SX). Time to locate target, number of attempts to hit the target, first-time hit rate, and time from initiating antenna advance to hitting the target were measured.nnnRESULTSnParticipants located 100% of targets using ultrasound, with experts taking significantly less time than novices and intermediates. Using ultrasound only, successful hit-rates were 70% for novices and 90% for intermediates and experts. Using Emprint™ SX, successful hit rates for all 3-groups were 100%, with significantly increased first-time hit-rates and reduced time required to hit targets compared to ultrasound only.nnnDISCUSSIONnEmprint™ SX significantly improved accuracy and speed of antenna-placement independent of experience, and was particularly beneficial for novice users.