Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder

AIM:To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy (SILC) for acute inflamed gallbladder (AIG).METHODS:One hundred and ten consecutive patients underwent original SILC for gallbladder disease without any selection criteria and 15 and 11 of these were diagnosed with acute cholecystitis and acute gallstone cholangitis,respectively.A retrospective review was performed not only between SILC for AIG and non-AIG,but also between SILC for AIG and traditional laparoscopic cholecystectomy (TLC) for AIG in the same period.RESULTS:Comparison between SILC for AIG and nonAIG revealed that the operative time was longer in SILC for AIG (97.5min vs 85.0min,P=0.03).The open conversion rate (2/26 vs 2/84,P=0.24) and complication rate (1/26 vs 3/84,P=1.00) showed no differences,but a need for additional trocars was more frequent in SILC for AIG (5/24 vs 3/82,P=0.01).Comparison between SILC for AIG and TLC for AIG revealed no differences based on statistical analysis.CONCLUSION:Our original SILC technique was ade-quately safe and feasible for the treatment of acute cholecystitis and acute gallstone cholangitis.

Liver resection for hepatocellular carcinoma using a microwave tissue coagulator: Experience of 1118 cases

A I M : To present our extensive experience of hepatectomy for hepatocellular carcinoma using a microwave tissue coagulator to demonstrate the effectiveness of this device. METHODS: A total of 1118 cases(1990-2013) were reviewed,with an emphasis on intraoperative blood loss,postoperative bile leakage and fluid/abscess formation,and adaptability to anatomical resection and hepatectomy with hilar dissection.RESULTS: The median intraoperative blood loss was 250 m L; postoperative bile leakage and fluid/abscess formation were seen in 3.0% and 3.3% of cases,respectively. Anatomical resection was performed in 275 cases,including 103 cases of hilar dissection that required application of microwave coagulation near the hepatic hilum. There was no clinically relevant biliary tract stricture or any vascular problems due to heat injury. Regarding the influence of cirrhosis on intraoperative blood loss,no significant difference was seen between cirrhotic and non-cirrhotic patients(P = 0.38),although cirrhotic patients tended to have smaller tumors and underwent less invasive operations. CONCLUSION: This study demonstrated outcomes of an extensive experience of hepatectomy using heat coagulative necrosis by microwave tissue coagulator.

Retroperitoneal cavernous hemangioma resected by a pylorus preserving pancreaticoduodenectomy

A retroperitoneal hemangioma is a rare disease. We report on the diagnosis and treatment of a retroperitoneal hemangioma which had uncommonly invaded into both the pancreas and duodenum, thus requiring a pylorus preserving pancreaticoduodenectomy (PpPD). A 36-year-old man presented to our hospital with abdominal pain. An enhanced computed tomography scan without contrast enhancement revealed a 12 cm × 9 cm mass between the pancreas head and right kidney. Given the high rate of malignancy associated with retroperitoneal tumors, surgical resection was performed. Intraoperatively, the tumor was inseparable from both the duodenum and pancreas and PpPD was performed due to the invasive behavior. Although malignancy was suspected, pathological diagnosis identified the tumor as a retroperitoneal cavernous hemangioma for which surgical resection was the proper diagnostic and therapeutic procedure. Reteoperitoneal cavernous hemangioma is unique in that it is typically separated from the surrounding organs. However, clinicians need to be aware of the possibility of a case, such as this, which has invaded into the surrounding organs despite its benign etiology. From this case, we recommend that combined resection of inseparable organs should be performed if the mass has invaded into other tissues due to the hazardous nature of local recurrence. In summary, this report is the first to describe a case of retroperitoneal hemangioma that had uniquely invaded into surrounding organs and was treated with PpPD.

Right hepatectomy for giant cavernous hemangioma with diffuse hemangiomatosis around Glisson's capsule

Diffuse liver hemangiomatosis with giant cavernous hemangioma in adult is extremely rare. A 35 year-old woman presented to hospital with main complaint of epigastric pain and abdominal fullness. An enhanced computed tomography scan revealed a massive liver tumor in right lobe about 150 mm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. She underwent right hepatectomy. Histologically, it was diagnosed as a cavernous hemangioma. And also, hemangiomatous lesions were scattered around the Glisson's capsule on the back ground liver. These hemangiomatous lesions were not recognized preoperatively. Even if we couldn't diagnose hemangiomatosis around the main giant hemangioma preoperatively, we need to take enough surgical margins because the giant hemangioma has the potential to have small hemangiomatous lesions around the tumor. We reported right hepatectomy for giant cavern-ous hemangioma with diffuse hepatic hemangiomatosis without an extrahepatic lesion in an adult.

Using the win ratio to compare laparoscopic versus open liver resection for colorectal cancer liver metastases

Background:We sought to assess the overall benefit of laparoscopic versus open hepatectomy for treatment of colorectal liver metastases(CRLMs)using the win ratio,a novel methodological approach.Methods:CRLM patients undergoing curative-intent resection in 2001-2018 were identified from an international multi-institutional database.Patients were paired and matched based on age,number and size of lesions,lymph node status and receipt of preoperative chemotherapy.The win ratio was calculated based on margin status,severity of postoperative complications,90-day mortality,time to recurrence,and time to death.Results:Among 962 patients,the majority underwent open hepatectomy(n=832,86.5%),while a minority underwent laparoscopic hepatectomy(n=130,13.5%).Among matched patient-to-patient pairs,the odds of the patient undergoing laparoscopic resection“winning”were 1.77[WR:1.77,95%confidence interval(CI):1.42-2.34].The win ratio favored laparoscopic hepatectomy independent of low(WR:2.94,95%CI:1.20-6.39),medium(WR:1.56,95%CI:1.16-2.10)or high(WR:7.25,95%CI:1.13-32.0)tumor burden,as well as unilobar(WR:1.71,95%CI:1.25-2.31)or bilobar(WR:4.57,95%CI:2.36-8.64)disease.The odds of“winning”were particularly pronounced relative to short-term outcomes(i.e.,90-day mortality and severity of postoperative complications)(WR:4.06,95%CI:2.33-7.78).Conclusions:Patients undergoing laparoscopic hepatectomy had 77%increased odds of“winning”.Laparoscopic liver resection should be strongly considered as a preferred approach to resection in CRLM patients.

Machine learning predicts unpredicted deaths with high accuracy following hepatopancreatic surgery

Background:Machine learning to predict morbidity and mortality-especially in a population traditionally considered low risk-has not been previously examined.We sought to characterize the incidence of death among patients with a low estimated morbidity and mortality risk based on the National Surgical Quality Improvement Program(NSQIP)estimated probability(EP),as well as develop a machine learning model to identify individuals at risk for“unpredicted death”(UD)among patients undergoing hepatopancreatic(HP)procedures.Methods:The NSQIP database was used to identify patients who underwent elective HP surgery between 2012-2017.The risk of morbidity and mortality was stratified into three tiers(low,intermediate,or high estimated)using a k-means clustering method with bin sorting.A machine learning classification tree and multivariable regression analyses were used to predict 30-day mortality with a 10-fold cross validation.C statistics were used to compare model performance.Results:Among 63,507 patients who underwent an HP procedure,median patient age was 63(IQR:54-71)years.Patients underwent either pancreatectomy(n=38,209,60.2%)or hepatic resection(n=25,298,39.8%).Patients were stratified into three tiers of predicted morbidity and mortality risk based on the NSQIP EP:low(n=36,923,58.1%),intermediate(n=23,609,37.2%)and high risk(n=2,975,4.7%).Among 36,923 patients with low estimated risk of morbidity and mortality,237 patients(0.6%)experienced a UD.According to the classification tree analysis,age was the most important factor to predict UD(importance 16.9)followed by preoperative albumin level(importance:10.8),disseminated cancer(importance:6.5),preoperative platelet count(importance:6.5),and sex(importance 5.9).Among patients deemed to be low risk,the c-statistic for the machine learning derived prediction model was 0.807 compared with an AUC of only 0.662 for the NSQIP EP.Conclusions:A prognostic model derived using machine learning methodology performed better than the NSQIP EP in predicting 30-day UD among low risk patients undergoing HP surgery.