ABDOMINALE CHIRURGIE

CENTRUM ABDOMINALE CHIRURGIE

ARTIKELS

ABSTRACT 1

A comparison of the learning curves of laparoscopic liver surgeons in differing stages of the IDEAL paradigm of surgical innovation: standing on the shoulders of pioneers.

Halls MC, Alseidi A, Berardi G, D'Hondt M, et al. Annals of Surgery, 2019, 269(2), 221-228

INTRODUCTION/BACKGROUND It is expected that a wider adoption of a laparoscopic approach to liver surgery will be seen in the next few years. Current guidelines stress the need for an incremental, stepwise progression through the learning curve in order to minimize harm to patients. Previous studies have examined the learning curve in Stage 2 of the IDEAL paradigm of surgical innovation; however, LLS is now in stage 3 with specific training being provided to surgeons.

OBJECTIVE To compare the learning curves of the self-taught "pioneers" of laparoscopic liver surgery (LLS) with those of the trained "early adopters" in terms of short- and medium-term patient outcomes to establish if the learning curve can be reduced with specific training.

MATERIALS/METHODS Using risk-adjusted cumulative sum analysis, the learning curves and short- and medium-term outcomes of 4 "pioneering" surgeons from stage 2 were compared with 4 "early adapting" surgeons from stage 3 who had received specific training for LLS.

RESULTS After 46 procedures, the short- and medium-term outcomes of the "early adopters" were comparable to those achieved by the "pioneers" following 150 procedures in similar cases.

CONCLUSION With specific training, "early adapting" laparoscopic liver surgeons are able to overcome the learning curve for minor and major liver resections faster than the "pioneers" who were self-taught in LLS. The findings of this study are applicable to all surgical specialties and highlight the importance of specific training in the safe expansion of novel surgical practice. ABSTRACT 2

Laparoscopic combined resection of liver metastases and colorectal cancer: a multicenter, case-matched study using propensity scores.

van der Poel MJ, Tanis PJ, D'Hondt M, et al. Surgical Endoscopy, 2019, 33(4), 1124-1130

INTRODUCTION/BACKGROUND Combined laparoscopic resection of liver metastases and colorectal cancer (LLCR) may hold benefits for selected patients but could increase complication rates. Previous studies have compared LLCR with liver resection alone. Propensity score-matched studies comparing LLCR with laparoscopic colorectal cancer resection (LCR) alone have not been performed.

MATERIALS/METHODS A multicenter, case-matched study was performed comparing LLCR (2009-2016, 4 centers) with LCR alone (20092016, 2 centers). Patients were matched based on propensity scores in a 1:1 ratio. Propensity scores were calculated with the following preoperative variables: age, sex, ASA grade, neoadjuvant radiotherapy, type of colorectal resection and T and N stage of the primary tumor. Outcomes were compared using paired tests.

RESULTS Out of 1020 LCR and 64 LLCR procedures, 122 (2 × 61) patients could be matched. All 61 laparoscopic liver resections were minor hepatectomies, mostly because of a solitary liver metastasis (n = 44, 69%) of small size (≤ 3 cm) (n = 50, 78%). LLCR was associated with a modest increase in operative time [206 (166-308) vs. 197 (148-231) min, p = 0.057] and blood loss [200 (100-700) vs. 75 (5-200) ml, p = 0.011]. The rate of Clavien-Dindo grade 3 or higher complications [9 (15%) vs. 13 (21%), p = 0.418], anastomotic leakage [5 (8%) vs. 4 (7%), p = 1.0], conversion rate [3 (5%) vs. 5 (8%), p = 0.687] and 30-day mortality [0 vs. 1 (2%), p = 1.0] did not differ between LLCR and LCR.

CONCLUSION In selected patients requiring minor hepatectomy, LLCR can be safely performed without increasing the risk of postoperative morbidity compared to LCR alone.

ABSTRACT 3

Hepatopancreatoduodenectomy -a controversial treatment for bile duct and gallbladder cancer from a European perspective.

D'Souza MA, Valdimarsson VT, D'Hondt M, et al. Hepato-Pancreato-Biliary (HPB) Oxford, 2019, S1365182X(19), 33224-1

INTRODUCTION/BACKGROUND Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist.

OBJECTIVE The purpose of this study was to evaluate safety and effi cacy for HPD in European centers.

MATERIALS/METHODS Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed.

RESULTS In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival.

CONCLUSION HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome. ABSTRACT 4

Laparoscopic right posterior sectionectomy: singlecenter experience and technical aspects.

D'Hondt M, Ovaere S, Knol J, et al. Langenbeck's archives of surgery, 2019, 404(1), 21-29

INTRODUCTION/BACKGROUND Laparoscopic right posterior sectionectomy (LRPS) is a technically demanding procedure.

OBJECTIVE The aim of this article is to share our experience with LRPS and to highlight technical aspects of this procedure.

MATERIALS/METHODS This is a single-center retrospective analysis of all patients who underwent LRPS between September 2011 and October 2017. Data were retrieved from a prospectively maintained database. Video-in-picture (VIP) technology is used to facilitate and to highlight the technical aspects of this procedure.

RESULTS In total, 18 patients underwent LRPS. Indication for surgery was mainly liver metastases (n = 11) and hepatocellular carcinoma (n = 6). The Glissonean approach for inflow control was used in 13 patients. Median operative time was 162 (140-190) minutes. Median blood loss was 325 mL (IQR: 150-450). One conversion (5.5%) was required. There were two minor complications and one major complication. Median hospital stay was 6 days (range 5-8 days). All patients had an R0 resection. There was no 90-day mortality.

CONCLUSION The results of our experience in LRPS add weight to the feasibility and safety of this approach.

ABSTRACT 5

Stepwise implementation of laparoscopic pancreatic surgery. Case series of a single centre's experience.

Vandeputte M, D'Hondt M, Willems E, et al. International Journal of Surgery, 2019, 72, 137-143

INTRODUCTION/BACKGROUND Laparoscopic pancreatic surgery still represents a challenge for surgeons. However, in recent decades the experience is expanding. Recent systematic reviews and meta-analyses confirm that laparoscopic pancreatic resection (LPR) is safe,

feasible and worthwhile.

OBJECTIVE This study analyses the first 100 consecutive LPRs in our centre.

MATERIALS/METHODS A retrospective analysis was conducted of the first 100 LPRs in a single supra-regional Belgian centre, performed between January 2012 and January 2019. Pre-, peri- and postoperative data were retrieved from a prospectively maintained database. All procedures were performed laparoscopically by two attending surgeons, specialized in minimally invasive and hepatopancreatobiliary surgery.

RESULTS Of 100 procedures, 62 laparoscopic pancreatoduodenectomies (LPD) and 36 laparoscopic distal pancreatectomies (LDP) were performed, along with 1 enucleation and 1 central pancreatectomy. Indication was malignancy in 70%. Conversion rate was 24,2% in LPD and 11% in LDP. Median operative time was 330 min (IQR 300-360) in LPD and 150 min (IQR 142.5-210) in LDP. Median blood loss was 200 mL (IQR 100-487.5) in LPD and 150 mL (IQR 50-500) in LDP, transfusion rate was 22.6% and 8.3% respectively. Median length of stay (LOS) was 13 days (IQR 10-19.25) in LPD and 9 days (IQR 9-14) in LDP. R0 resection rate was 88.6% (62/70). Major complication rate (Clavien-Dindo grade III-IV) was 12%. Thirty-day mortality was 0%, 90day mortality was 2%.

CONCLUSION Our results confirm that LPR is a feasible and safe alternative to open pancreatic surgery. Safe implementation with a clear strategy is fundamental to gain experience and overcome the learning curve of this technically demanding procedures. ABSTRACT 6

Closure of mesenteric defects is associated with a higher incidence of small bowel obstruction due to adhesions after laparoscopic antecolic Roux-en-y gastric bypass: A retrospective cohort study.

Nuytens F, D'Hondt M, Van Rooy F, Vansteenkiste F, Devriendt D, et al. International Journal of Surgery, 2019, 71, 149-155 INTRODUCTION/BACKGROUND Small bowel obstruction (SBO) is a frequent complication after laparoscopic Roux-en-y gastric bypass (LRYGB).

OBJECTIVE We wanted to evaluate the effect of closure of the mesenteric defects on the incidence of SBO and postoperative complications after LRYGB. Furthermore, we wanted to identify possible risk factors for SBO.

MATERIALS/METHODS This study was a retrospective cohort study of 1364 patients who underwent a LRYGB between July 2003 and October 2015. Cohort 1 contained 724 patients in whom mesenteric defects were not closed. Cohort 2 contained 640 patients in whom mesenteric defects were closed. Main outcome parameters were the incidence of SBO and postoperative complications as well as potential risk factors for SBO.

RESULTS Closure of the mesenteric defects was associated with a reduction in the incidence of SBO due to internal herniation (4.8% vs. 5.5, p = 0.02) but resulted in a higher incidence of SBO due to postoperative adhesions (4.8% vs. 1.7%, p = 0.004). Multivariate analysis identified smoking as a risk factor for SBO (p = 0.0187). We observed a higher incidence of late postoperative pain in cohort 2 (5.3% vs. 2.1%, p = 0.007).

CONCLUSION Although closure of the mesenteric defects is associated with a lower incidence of SBO due to internal herniation, this effect is countered by a higher incidence of SBO due to postoperative adhesions. Smoking is an independent risk factor for SBO after LRYGB. Closure of the mesenteric defects is associated with a higher incidence of late post-

operative pain. ABSTRACT 7

Adverse effects of bevacizumab in metastatic colorectal cancer : a case report and literature review.

Willems E, George C, D'Hondt M, et al. Acta Gastro-enterologica Belgica, 2019, 82(2), 322-325

INTRODUCTION/BACKGROUND Colorectal cancer is one of the most frequently diagnosed malignancies worldwide. One of the most important developments in the management of metastatic colorectal

cancer is targeted therapy.

RESULTS Bevacizumab, a monoclonal antibody inhibiting VEGF induced angiogenesis, has been accepted as safe and effi cient in the treatment of metastatic colorectal cancer for more than a decade. Addition of bevacizumab to fluorouracil-based chemotherapy is also associated with severe adverse events.

CONCLUSION We present a case of bevacizumab-induced bowel ischaemia associated with gastrointestinal haemorrhage.

ABSTRACT 8

Updated alternative fistula risk score (ua-frs) to include minimally invasive pancreatoduodenectomy: paneuropean validation.

Mungroop TH, Klompmaker S, Wellner UF, D'Hondt M, et al. Annals of surgery, 2019, Volume Published Ahead of Print, Issue doi: 10.1097/SLA.0000000000003234

INTRODUCTION/BACKGROUND MIPD may be associated with an increased risk of postoperative pancreatic fistula (POPF). The a-FRS could allow for risk-adjusted comparisons in research and improve preventive strategies for high-risk patients. The a-FRS, however, has not yet been validated specifically for laparoscopic, robot-assisted, and hybrid MIPD.

OBJECTIVE The aim of the study was to validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort.

MATERIALS/METHODS A validation study was performed in a pan-European cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. The primary outcome was POPF (International Study Group on Pancreatic Surgery grade B/C). Model performance was assessed using the area under the receiver operating curve (AUC; discrimination) and calibration plots. Validation included univariable screening for clinical variables that could improve performance. RESULTS Overall, 202 of 952 patients (21%) developed POPF after MIPD. Before adjustment, the original a-FRS performed moderately (AUC 0.68) and calibration was inadequate with systematic underestimation of the POPF risk. Single-row pancreatojejunostomy (odds ratio 4.6, 95 confidence interval [CI] 2.8-7.6) and male sex (odds ratio 1.9, 95 CI 1.42.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of body mass index, pancreatic texture, duct size, and male sex, showed good discrimination (AUC 0.75, 95 CI 0.71-0.79) and adequate calibration. Performance was adequate for laparoscopic, robot-assisted, and hybrid MIPD and open pancreatoduodenectomy.

CONCLUSION The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and open pancreatoduodenectomy. The increased risk of POPF in laparoscopic MIPD was associated with single-row pancreatojejunostomy, which should therefore be discouraged.

ABSTRACT 9

Multicentre propensity score-matched study of laparoscopic versus open repeat liver resection for colorectal liver metastases.

van der Poel MJ, Barkhatov L, D'Hondt M, et al. The British Journal of Surgery, 2019, 106(6), 783-789

INTRODUCTION/BACKGROUND Repeat liver resection is often the best treatment option for patients with recurrent colorectal liver metastases (CRLM). Repeat resections can be complex, however, owing to adhesions and altered liver anatomy. It remains uncertain whether the advantages of a laparoscopic approach are upheld in this setting.

OBJECTIVE The aim of this retrospective, propensity score-matched study was to compare the short-term outcome of laparoscopic (LRLR) and open (ORLR) repeat liver resection.

MATERIALS/METHODS A multicentre retrospective propensity score-matched study was performed including all patients who underwent LRLRs and ORLRs for CRLM performed in nine high-volume centres from seven European countries between 2000 and 2016. Patients were matched based on propensity scores

in a 1 : 1 ratio. Propensity scores were calculated based on 12 preoperative variables, including the approach to, and extent of, the previous liver resection. Operative outcomes were compared using paired tests.

RESULTS Overall, 425 repeat liver resections were included. Of 271 LRLRs, 105 were matched with an ORLR. Baseline characteristics were comparable after matching. LRLR was associated with a shorter duration of operation (median 200 (i.q.r. 123273) versus 256 (199-320) min; P < 0·001), less intraoperative blood loss (200 (50-450) versus 300 (100-600) ml; P = 0·077) and a shorter postoperative hospital stay (5 (3-8) versus 6 (5-8) days; P = 0·028). Postoperative morbidity and mortality rates were similar after LRLR and ORLR.

CONCLUSION LRLR for CRLM is feasible in selected patients and may offer advantages over an open approach.

ABSTRACT 10

Laparoscopic liver resection for liver tumours in proximity to major vasculature: A single-center comparative study.

D'Hondt M, Parmentier I, Vansteenkiste F, Verslype C, et al. European Journal of Surgical Oncology, 2020, 46(Issue 4 Part A), 539-547

INTRODUCTION/BACKGROUND With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs).

OBJECTIVE The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs.

MATERIALS/METHODS This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011-August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs. RESULTS Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0-9.0) VS 5.0 (IQR: 3.0-6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140210) VS 120min (IQR: 75-150), p < 0.001) and blood loss was higher (190 ml (IQR: 100-325) VS 75 ml (IQR: 50-220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12).

CONCLUSION In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results.