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A review of ergonomic positions to improve musculoskeletal distress in hepatobiliary pancreatic surgeons according to open, laparoscopic, and robotic surgeries

Young Jae CHO ; Jin-Young JANG

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):433-439. doi:10.14701/ahbps.24-127

Advances in surgical ergonomics are essential for the performance, health, and career longevity of surgeons. Many surgeons experience work-related musculoskeletal disorders (WMSDs) resulting from various surgical modalities, including open, laparoscopic, and robotic surgeries. To prevent WMSDs, individual differences may exist depending on the surgical method; however, the key is to maintain a neutral posture, and avoid static postures. This review aims to summarize the concepts of ergonomics and WMSDs; identify the ergonomic challenges of open, laparoscopic, and robotic surgeries; and discuss ergonomic recommendations to improve them.

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Minimally invasive versus open central pancreatectomy:A systematic review and meta-analysis

Shahab HAJIBANDEH ; Shahin HAJIBANDEH ; Nicholas George MOWBRAY ; Matthew MORTIMER ; Guy SHINGLER ; Amir KAMBAL ; Bilal AL-SARIREH

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):412-422. doi:10.14701/ahbps.24-093

To compare the procedural outcomes of minimally invasive and open central pancreatectomy. A systematic review in compliance with PRISMA statement standards was conducted to identify and analyze studies comparing the procedural outcomes of minimally invasive (laparoscopic or robotic) central pancreatectomy with the open approach. Random effects modeling using intention to treat data, and individual patient as unit of analysis, was used for analyses. Seven comparative studies including 289 patients were included. The two groups were comparable in terms of baseline characteristics. The minimally invasive approach was associated with less intraoperative blood loss (mean difference [MD]: −153.13 mL, p = 0.0004); however, this did not translate into less need for blood transfusion (odds ratio [OR]: 0.30, p = 0.06). The minimally invasive approach resulted in less grade B−C postoperative pancreatic fistula (OR: 0.54, p = 0.03); this did not remain consistent through sensitivity analyses. There was no difference between the two approaches in operative time (MD: 60.17 minutes, p = 0.31), Clavien–Dindo ≥ 3 complications (OR: 1.11, p = 0.78), postoperative mortality (risk difference:−0.00, p = 0.81), and length of stay in hospital (MD: −3.77 days, p = 0.08). Minimally invasive central pancreatectomy may be as safe as the open approach; however, whether it confers advantage over the open approach remains the subject of debate. Type 2 error is a possibility, hence adequately powered studies are required for definite conclusions; future studies may use our data for power analysis.

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Survival after vascular resections in patients with borderline resectable or locally advanced pancreatic head cancer: A systematic review

Menelaos PAPAKONSTANTINOU ; Stylianos FIFLIS ; Alexandros GIAKOUSTIDIS ; Grigorios CHRISTODOULIDIS ; Athanasia MYRISKOU ; Eleni LOURI ; Lavrentios PAPALAVRENTIOS ; Vasileios N. PAPADOPOULOS ; Dimitrios GIAKOUSTIDIS

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):423-432. doi:10.14701/ahbps.24-118

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive tumors, and the most common cause of cancer-related deaths.In the past, vascular infiltration of the tumor rendered the disease unresectable. However, today, venous or arterial involvement of a PDAC is classified as borderline resectable (BR) or locally advanced (LA) disease. Pancreaticoduodenectomy (PD) with vascular resections is a promising intervention intended for complete resection of BR- and LA-PDAC. This study aims to assess the overall survival of patients undergoing PD with vascular resections, compared to those without. A PubMed search was conducted for cohort studies that included patients with BR- or LA-PDAC treated with vascular resections. The retrieved publications were screened following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. The study protocol was registered at the International Prospective Register for Systematic Reviews (PROSPERO). Sixteen cohort studies were included in our systematic review.Fourteen of them included patients undergoing PD with venous-only resections for PDAC. The 5-year overall survival rates ranged from 8.0% to 22.2% for vascular resection patients, and 4.0% to 24.3% for standard PD patients. Three cohorts included patients with PDAC and arterial and/or venous involvement who were treated with arterial resections. Their median overall survival ranged from 13.7 to 17.0 months, similar to that of patients who did not undergo vascular resections. PD with vascular resections in patients with BR- and LA-PDAC could lead to similar overall survival to that after standard PD.

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Robotic management of huge hepatic angiomyolipoma:A case report and literature review

Andrew PARK ; Kush SAVSANI ; Anjelica ALFONSO ; Ester JO ; Bryce HATFIELD ; Daisuke IMAI ; Aamir KHAN ; Amit SHARMA ; Irfan SAEED ; Vinay KUMARAN ; Adrian COTTERELL ; David BRUNO ; Yuzuru SAMBOMMATSU ; Seung LEE

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):527-534. doi:10.14701/ahbps.24-033

Hepatic angiomyolipoma (HAML) is a rare, benign mesenchymal liver tumor encountered in Asia, primarily in females, and can be found within the right hepatic lobe, but also in other areas of the liver. Immunohistochemically, HAMLs are characteristically positive for human melanoma black-45 antigen (HMB-45) and can histochemically vary in the composition of angiomatous, lipomatous, and myomatous tissue, together with the presence of epithelioid cells. In this case report, we discuss a previously healthy patient presenting with bloating and previously documented concern of liver lesions, found to have HAML confirmed by surgical pathology. Surgery was decided, as HAMLs greater than 10 cm are at risk of rupture. This is one of the first documented cases of HAML resected through robot-assisted bisegmentectomy and cholecystectomy, and therefore, intraoperative images have been included to assist in the planning of future robotic cases.

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Impact of longitudinal tumor location on postoperative outcomes in gallbladder cancer: Fundus and body vs. neck and cystic duct, a retrospective multicenter study

Kil Hwan KIM ; Ju Ik MOON ; Jae Woo PARK ; Yunghun YOU ; Hae Il JUNG ; Hanlim CHOI ; Si Eun HWANG ; Sungho JO

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):474-482. doi:10.14701/ahbps.24-117

Background: s/Aims: Systematic investigations into the prognostic impact of the longitudinal tumor location in gallbladder cancer (GBC) remain insufficient. To address the limitations of our pilot study, we conducted a multicenter investigation to clarify the impact of the longitudinal tumor location on the oncological outcomes of GBC. Methods: A retrospective multicenter study was conducted on 372 patients undergoing radical resections for GBC from January 2010 to December 2019 across seven hospitals that belong to the Daejeon–Chungcheong branch of the Korean Association of Hepato-Biliary-Pancreatic Surgery. Patients were divided into GBC in the fundus/body (FB-GBC) and GBC in the neck/cystic duct (NC-GBC) groups, based on the longitudinal tumor location. Results: Of 372 patients, 282 had FB-GBC, while 90 had NC-GBC. NC-GBC was associated with more frequent elevation of preoperative carbohydrate antigen (CA) 19-9 levels, requirement for more extensive surgery, more advanced histologic grade and tumor stages, more frequent lymphovascular and perineural invasion, lower R0 resection rates, higher recurrence rates, and worse 5-year overall and disease-free survival rates. Propensity score matching analysis confirmed these findings, showing lower R0 resection rates, higher recurrence rates, and worse survival rates in the NC-GBC group. Multivariate analysis identified elevated preoperative CA 19-9 levels, lymph node metastasis, and non-R0 resection as independent prognostic factors, but not longitudinal tumor location. Conclusions NC-GBC exhibits more frequent elevation of preoperative CA 19-9 levels, more advanced histologic grade and tumor stages, lower R0 resection rates, and poorer overall and disease-free survival rates, compared to FB-GBC. However, the longitudinal tumor location was not analyzed as an independent prognostic factor.

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Deep learning-based surgical phase recognition in laparoscopic cholecystectomy

Hye Yeon YANG ; Seung Soo HONG ; Jihun YOON ; Bokyung PARK ; Youngno YOON ; Dai Hoon HAN ; Gi Hong CHOI ; Min-Kook CHOI ; Sung Hyun KIM

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):466-473. doi:10.14701/ahbps.24-091

Background: s/Aims: Artificial intelligence (AI) technology has been used to assess surgery quality, educate, and evaluate surgical performance using video recordings in the minimally invasive surgery era. Much attention has been paid to automating surgical workflow analysis from surgical videos for an effective evaluation to achieve the assessment and evaluation. This study aimed to design a deep learning model to automatically identify surgical phases using laparoscopic cholecystectomy videos and automatically assess the accuracy of recognizing surgical phases. Methods: One hundred and twenty cholecystectomy videos from a public dataset (Cholec80) and 40 laparoscopic cholecystectomy videos recorded between July 2022 and December 2022 at a single institution were collected. These datasets were split into training and testing datasets for the AI model at a 2:1 ratio. Test scenarios were constructed according to structural characteristics of the trained model. No pre- or post-processing of input data or inference output was performed to accurately analyze the effect of the label on model training. Results: A total of 98,234 frames were extracted from 40 cases as test data. The overall accuracy of the model was 91.2%. The most accurate phase was Calot’s triangle dissection (F1 score: 0.9421), whereas the least accurate phase was clipping and cutting (F1 score:0.7761). Conclusions Our AI model identified phases of laparoscopic cholecystectomy with a high accuracy.

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The impact of myosteatosis on postoperative outcomes and survival of patients undergoing pancreatoduodenectomy for suspected/confirmed malignancy

Paul JENKINS ; Andrew MACCORMICK ; Adam STREETER ; Mark PUCKETT ; Gemma MILES ; Somaiah AROORI

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):494-499. doi:10.14701/ahbps.23-115

Background: s/Aims: While the effects of myosteatosis are emerging, the evidence for its use as a predictor of outcomes in patients undergoing pancreatoduodenectomy (PD) still needs to be established. The study aims to evaluate the effect of myosteatosis on the shortand long-term outcomes of PD. Methods: We analyzed the effect of myosteatosis on the short- and long-term outcomes of patients who underwent PD between July 2006 and May 2013. Myosteatosis was measured retrospectively from preoperative computed tomography (CT) at the L3 vertebra level, and dichotomized as a binary exposure variable as < 38.5 Hounsfield unit (HU) for males, and < 36.1 HU for females. Results: A total of 214 patient (median age 62 years, range: 41−80 years) CTs were analyzed for myosteatosis. Overall, 120/214 (56.1%) patients were classed as having myosteatosis. Both groups had similar comorbidity profiles. The presence of myosteatosis was not shown to increase the rate of any short- or long-term complication. However, pancreatic leak (29.8% vs. 13.3%; p = 0.006) and postoperative bleeding (13.8% vs. 5.0%; p = 0.034) were higher in the non-myosteatosis group. The median intensive care (2 days) and hospital stay (12 days) were the same in both groups. The 30-day mortality (myosteatosis: 3.3% vs. non-myosteatosis: 3.2%; p = 0.95), and 5-year overall survival (myosteatosis: 26.7% vs. non-myosteatosis: 31.9%; p = 0.5), were similar in both groups. Conclusions We have found no evidence supporting myosteatosis affecting either the short-term or long-term outcomes of patients undergoing PD for suspected/confirmed malignant tumors.

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Comparative accuracy of four guidelines to predict high-grade dysplasia or malignancy in surgically resected pancreatic intraductal papillary mucinous neoplasms:Small nuances between guidelines lead to vastly different results

Irene C. PEREZ ; Andrew BIGELOW ; Vanessa M. SHAMI ; Bryan G. SAUER ; Andrew Y. WANG ; Daniel S. STRAND ; Alexander J. PODBOY ; Todd W. BAUER ; Victor M. ZAYDFUDIM ; Allan TSUNG ; Ross C. D. BUERLEIN

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):483-493. doi:10.14701/ahbps.24-049

Background: s/Aims: The guidelines regarding the management of intraductal papillary mucinous neoplasms (IPMNs) all have slightly different surgical indications for high-risk lesions. We aim to retrospectively compare the accuracy of four guidelines in recommending surgery for high-risk IPMNs, and assess the accuracy of elevated CA-19-9 levels and imaging characteristics of IPMNs considered high-risk in predicting malignancy or high-grade dysplasia (HGD). Methods: The final histopathological diagnosis of surgically resected high-risk IPMNs during 2013−2020 were compared to preoperative surgical indications, as enumerated in four guidelines: the 2015 American Gastroenterological Association (AGA), 2017 International Consensus, 2018 European Study Group, and 2018 American College of Gastroenterology (ACG). Surgery was considered “justified” if histopathology of the surgical specimen showed HGD/malignancy, or there was postoperative symptomatic improvement. Results: Surgery was postoperatively justified in 26/65 (40.0%) cases. All IPMNs with HGD/malignancy were detected by the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines. The combined (“high-risk stigmata” and “worrisome features”) 2017 International guideline missed 1/19 (5.3%) IPMNs with HGD/malignancy. The 2015 AGA guideline missed the most cases (11/19, 57.9%) of IPMNs with HGD/malignancy. We found the features most-associated with HGD/malignancy were pancreatic ductal dilation, and elevated CA-19-9 levels. Conclusions Following the 2015 AGA guideline results in the highest rate of missed HGD/malignancy, but the lowest rate of operating on IPMNs without these features; meanwhile, the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines result in more operations for IPMNs without HGD/malignancy, but the lowest rates of missed HGD/malignancy in IPMNs.

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Impact of post-hepatectomy biliary leaks on long-term survival in different liver tumors:A single institute experience

Devesh Sanjeev BALLAL ; Shraddha PATKAR ; Aditya KUNTE ; Sridhar SUNDARAM ; Nitin SHETTY ; Kunal GALA ; Suyash KULKARNI ; Mahesh GOEL

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):451-457. doi:10.14701/ahbps.24-078

Background: s/Aims: A postoperative biliary leak is one of the most morbid complications occurring after a liver resection, the longterm impact of which remains unknown. Methods: Retrospective analysis of consecutive liver resections performed from 1 January 2011 to 31 December 2021. Primary endpoint of disease-free survival (DFS) was compared between patients with and without a bile leak, stratifying for tumor type. Survival curves were plotted using Kaplan–Meier estimates, and differences between them were analyzed using the log–rank test. Results: In toto, 862 patients were analyzed, and included 306 (35.5%) hepatocellular carcinomas, 212 (24.6%) metastatic colorectal cancers, and 111 (12.9%) cholangiocarcinomas (69 intrahepatic cholangiocarcinomas, 42 hilar cholangiocarcinomas). Occurrence of a bile leak was associated with significantly poorer DFS only in patients with cholangiocarcinoma (median DFS 9.9 months vs. 24.9 months, p = 0.013), and further analysis was restricted to this cohort. A Cox regression performed for factors associated with DFS detriment in patients with cholangiocarcinoma showed that apart from node positivity (hazard ratio [HR]: 2.482, p = 0.033) and margin positivity (HR: 2.65, p = 0.021), development of a bile leak was independently associated with worsening DFS on both univariate and multiple regression analyses (HR: 1.896, p = 0.033). Conclusions Post-hepatectomy biliary leaks are associated with significantly poorer DFS only in patients with cholangiocarcinoma, but not in patients with hepatocellular carcinoma or metastatic colorectal cancer. Methods to mitigate this survival detriment need to be explored.

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Segments 4, 7, and 8 liver resection: A case report

Pilar LEAL-LEYTE ; Carlos Ulises CAMARILLO-SÁNCHEZ ; Daniel ZAMORA-VALDÉS

Annals of Hepato-Biliary-Pancreatic Surgery.2024;28(4):522-526. doi:10.14701/ahbps.24-092

Right superior resection (segments 7 and 8) is an uncommon resection for liver malignancies, with most of the literature limited to case reports and small series. Resection of segments 4, 7, and 8 has been reported in only a few cases. When the right hepatic vein is resected, venous reconstruction or identification of one or more right inferior hepatic veins is considered mandatory, to maintain segmentary function of segments 5 and 6. We present a case of liver resection of segments 4, 7, and 8 including the right and middle hepatic veins for symptomatic benign liver disease with no right hepatic vein reconstruction, nor a prominent right inferior hepatic vein(s). After the resection, there was no change in liver function tests, and the patient made an unremarkable recovery. Three months after the operation, partial atrophy of segments 5 and 6 with hypertrophy of the left lateral section was observed, while two and one half years after resection, the patient is asymptomatic. When right hepatic vein reconstruction would add unnecessary operative time, and there is low likelihood of the need for repeated resection, particularly when the hepatic vein is difficult to dissect, this approach can be safe and useful, while providing an adequate postoperative liver mass in the short-term to recover uneventfully from major liver resection.

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