Fadhel Samir Ftériche

Laparoscopic Pancreaticoduodenectomy Should Not Be Routine for Resection of Periampullary Tumors

BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is a difficult procedure that has become increasingly popular. Nevertheless, comparative data on outcomes remain limited. Our aim was to compare the outcomes of LPD and open pancreaticoduodenectomy (OPD). STUDY DESIGN Between April 2011 and April 2014, 46 LPD were performed and compared with 46 OPD, which theoretically can be done by the laparoscopic approach. Patients were also matched for demographic data, associated comorbidities, and underlying disease. Patient demographics and perioperative and postoperative outcomes were studied from our single center prospective database. RESULTS Lower BMI (23 vs 27 kg/m(2), p < 0.001) and a soft pancreas (57% vs 47%, p = 0.38) were observed in patients with LPD, but there were no differences in associated comorbidities or underlying disease. Surgery lasted longer in the LPD group (342 vs 264 minutes, p < 0.001). One death occurred in the LPD group (2.1% vs 0%, p = 0.28) and severe morbidity was higher (28% vs 20%, p = 0.32) in LPD due to grade C pancreatic fistula (PF) (24% vs 6%, p = 0.007), bleeding (24% vs 7%, p = 0.02), and revision surgery (24% vs 11%, p = 0.09). Pathologic examination for malignant diseases did not identify any differences between the LPD and OPD as far as size (2.51 vs 2.82 cm, p = 0.27), number of harvested (20 vs 23, p = 0.62) or invaded (2.4 vs 2, p = 0.22) lymph nodes, or R0 resection (80% vs 80%; p = 1). Hospital stays were similar (25 vs 23 days, p = 0.59). There was no difference in outcomes between approaches in patients at a lower risk of PF. CONCLUSIONS This study found that LPD is associated with higher morbidity, mainly due to more severe PF. Laparoscopic pancreaticoduodenectomy should be considered only in the subgroup of patients with a low risk of PF.

Laparoscopic left lateral resection is the gold standard for benign liver lesions: a case–control study

INTRODUCTION A left lateral section is the first choice for a laparoscopic anatomic liver resection. The objective of this case-control study was to assess the surgical outcome after a laparoscopic left lateral resection for benign liver lesions compared with the open approach. METHODS From January 2004 to April 2011, 31 laparoscopic left lateral resections were matched with 31 open left lateral resections by selection based on pathology of the lesion, size of the lesion, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), age and gender of the patient. RESULTS Duration of the operation (laparoscopic: 182 ± 71 versus open: 244 ± 105 min; P = 0.04), blood loss (223 ± 281 versus 455 ± 593 ml; P = 0.03), duration of hospital stay (4.1 ± 1.7 versus 8.1 ± 4.4 days; P < 0.001) and total cost of hospitalization (7475 ± 2679 versus 11504 ± 7776 Euros; P < 0.001) were significantly lower in the laparoscopic group. CONCLUSIONS This matched case-control study demonstrated procedural safety, excellent post-operative outcomes and economic benefits for a laparoscopic liver resection. A laparoscopic left lateral liver sectionectomy is recommended as a gold standard for benign liver lesions.

Hanging Maneuver for Stomach Traction in Laparoscopic Distal Pancreatic Resections: An Original Technique Applied in 218 Patients

Background: Stomach traction done to expose the pancreas is still a problem in laparoscopic left pancreatic resections. We developed a simple hanging maneuver to retract the stomach rapidly and effectively. Methods: After dividing the gastrocolic ligament, the stomach was encircled with a tape, turned along its horizontal axis and pulled with an epigastric trocar, which was later removed. This technique was used in all patients who underwent laparoscopic left pancreatic resections including 165 distal pancreatectomies (DP), 35 central pancreatectomies (CP) and 18 enucleations (En). Demographics, surgical and postoperative outcome data were recorded. Results: There were no mortalities. The mean operative time for DP, CP and En were 174, 191 and 104 min, respectively. The transfusion (0-4%) and conversion (0-3%) rates were low for all procedures. Morbidity was mainly represented by pancreatic fistula and grades (B + C) for DP, CP and En were observed in 26, 22 and 17%, respectively. No complication related to hanging of the stomach, like gastric perforation, was observed. Re-intervention and the mean hospital stay for DP, CP and En were observed in 5, 11 and 0% and were 16, 22 and 12, respectively. The readmission rate was low (0-9%). Conclusions: Hanging maneuver of the stomach is a simple procedure to rapidly, safely and effectively retract the stomach during left laparoscopic pancreatic resections.

Robot-assisted Minimally Invasive Distal Pancreatectomy Is Superior to the Laparoscopic Technique.

published in the January 2013 issue of Annals of Surgery, titled ‘‘Robot-Assisted Minimally Invasive Distal Pancreatectomy Is Superior to the Laparoscopic Technique,’’ with great interest. This experienced pioneer team compared its experience with laparoscopic distal pancreatectomy (LDP; n 1⁄4 94) performed between 2004 and 2007 mainly by 7 surgeons (80%; 14 cases per surgeon) with robot-assisted distal pancreatectomy (RADP; n 1⁄4 30) performed between 2008 and 2011 mainly by 1 surgeon (22; 73%) and concluded that RADP was more frequently used for adenocarcinoma than LDP (43% vs 15%; P < 0.05) and was associated with less conversion (0% vs 16%) and blood loss (375 vs 550; P < 0.05). Their results also showed that RADP was better than LDP for the resection of surgical margins and harvested lymph nodes (LNs). In the era of robotassisted surgery, these results are very important and encouraging for the robotic approach. In relation to our experience in more than 170 laparoscopic pancreatic resections (nonrobotic) and 98 LDPs, we have certain questions to confirm that these results are related to RADP and not to other confounding factors. The first remark is that on the basis of a calculation by a surgeon, more cases were performed by RADP than by LDP (22 vs 14) and RADP was performed after having solid experience and a learning curve in LDP. In relation to the causes, it is normal that adenocarcinomas were more frequently resected during the second period because

The use of a liver with a gunshot injury as a donor for auxiliary liver transplantation: Case report

INTRODUCTION liver transplantation can be the only treatment for acute liver failure. PRESENTATION OF CASE A 59 year-old female patient with acute liver failure due to mushroom poisoning underwent auxiliary liver transplantation. The liver graft was harvested from a brain-dead donor with a deep gunshot wound in the posterior sector of the graft. The postoperative course was uneventful with rapid recovery of the recipient and no complications associated with the gunshot wound. DISCUSSION Patients scheduled for urgent liver transplantation should have rapidly a liver graft otherwise the mortality rate is high. In our case, an injured liver graft by gunshot was successfully used allowing liver transplantation and increasing the pool of liver grafts. CONCLUSION A gunshot liver graft can be used if the major vascular or biliary structures are not injured.