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Background: Robotic surgery may improve surgical performance during minimally invasive pancreatoduodenectomy as compared to 3D- and 2D-laparoscopy but comparative studies are lacking. This study assessed the impact of robotic surgery versus 3D- and 2D-laparoscopy on surgical performance and operative time using a standardized biotissue model for pancreatico- and hepatico-jejunostomy using pooled data from two randomized controlled crossover trials (RCTs). Methods: Pooled analysis of data from two RCTs with 60 participants (36 surgeons, 24 residents) from 11 countries (December 2017–July 2019) was conducted. Each included participant completed two pancreatico- and two hepatico-jejunostomies in biotissue using 3D-robotic surgery, 3D-laparoscopy, or 2D-laparoscopy. Primary outcomes were the objective structured assessment of technical skills (OSATS: 12–60) rating, scored by observers blinded for 3D/2D and the operative time required to complete both anastomoses. Sensitivity analysis excluded participants with excess experience compared to others. Results: A total of 220 anastomoses were completed (robotic 80, 3D-laparoscopy 70, 2D-laparoscopy 70). Participants in the robotic group had less surgical experience [median 1 (0–2) versus 6 years (4–12), p < 0.001], as compared to the laparoscopic group. Robotic surgery resulted in higher OSATS ratings (50, 43, 39 points, p =.021 and p <.001) and shorter operative time (56.5, 65.0, 81.5 min, p =.055 and p <.001), as compared to 3D- and 2D-laparoscopy, respectively, which remained in the sensitivity analysis. Conclusion: In a pooled analysis of two RCTs in a biotissue model, robotic surgery resulted in better surgical performance scores and shorter operative time for biotissue pancreatic and biliary anastomoses, as compared to 3D- and 2D-laparoscopy. [ABSTRACT FROM AUTHOR]

Introduction: We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum.Methods: All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum.Results: Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017).Conclusion: A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the Critical View of Safety during LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study is to evaluate the utility of using a functional lumen imaging probe (EndoFLIP™) intra-operatively during hiatal hernia repair and fundoplication. Additionally, we hypothesize that these measurements correlate with long-term outcomes.Methods: A prospectively maintained quality database was queried. Between 2013 and 2018, 175 patients underwent laparoscopic fundoplication, the majority of which also had a hiatal hernia repair. The EndoFLIP™ was used to measure minimum diameter (Dmin), balloon pressure, and distensibility index (DI) at different timepoints throughout the operation. Clinical outcomes were measured up to 2 years after treatment.Results: Crural closure and fundoplication resulted in a significant increase in balloon pressure and decrease in DI when compared to initial measurements as well as measurements taken after hernia reduction. After 1 year, patients with a final DI < 2.0 mm2/mmHg reported significantly more gas bloat and dysphagia than those with a final DI ≥ 2.0 mm2/mmHg (p = 0.040 and p = 0.025, respectively). This disparity became even more dramatic at 2 years (p = 0.006 and p = 0.004, respectively), with a final DI < 2.0 mm2/mmHg being significantly associated with higher prevalence of daily gas bloat (43.8% vs. 12.0%; p = 0.03). Additionally, patients with a final DI between 2.0 and 3.5 mm2/mmHg reported significantly lower Reflux Symptom Index scores at one year compared to those with a final DI < 2.0 or > 3.5 mm2/mmHg (p = 0.042).Conclusion: EndoFLIP™ measurements correlate well with patient outcomes, with a final DI between 2 and 3.5 mm2/mmHg potentially being ideal. The EndoFLIP™ can be a useful adjunct in the operating room by providing objective measurements of esophageal distensibility after crural closure and fundoplication. [ABSTRACT FROM AUTHOR]

Background: National Cancer Database analysis showed 70% of patients with stage I pancreatic adenocarcinoma (PDA) did not have surgery. We sought to analyze adherence to expected treatment (ET) by stage for PDA and identify factors that led to no treatment (NT) or unexpected treatment (UT) in a recent cohort. Methods: Using our Institutional Cancer Registry (ICR), we identified patients with PDA from 2004 to 2013. ET was defined as surgery ± chemotherapy ± radiation for stages I and II, chemotherapy ± radiation for stage III, and chemotherapy for stage IV, while UT was defined as no surgery for stages I and II, surgery for stage III, or ± surgery ± XRT for stage IV. Results: Overall, 2340 patients were identified (stages I and II = 51%, stage III = 11%, stage IV = 38%; ET = 58%, UT = 18%, NT = 24%). A total of 1183 patients had resectable PDA (stages I and II; ET = 57%, UT = 27%, NT = 16%), with ET demonstrating the best overall survival, but UT showing better survival than NT ( p < 0.0001). In addition, 261 patients had unresectable PDA (stage III; ET = 69%, UT = 12%, NT = 18%), and survival was best in UT, but ET had a survival advantage over NT ( p < 0.0001). Finally, 896 patients had metastatic PDA (stage IV; ET = 55%; UT = 9%; NT = 36%), with the NT group showing worse survival than the ET and UT groups ( p < 0.0001). Conclusions: Unlike previous reports, most patients with early-stage disease had ET. ET and UT were associated with better survival than NT in all stages, and surgical cohorts have improved survival regardless of stage. Younger age, male sex, white race, and less comorbidity were predictors of receiving treatment. [ABSTRACT FROM AUTHOR]

Background: The patient presented with symptomatic postprandial biweekly hypoglycemic seizures. Her hypoglycemic episodes were aggravated by stress and also occurred during sleep. She managed these hypoglycemic episodes with an endocrinologist, trying both nutritional and medical management without successful control of her symptoms. An endoscopic gastrojejunal revision (EGJR) was recommended to provide more restriction and prolong transit time into the Roux limb to decrease the chance of postoperative dumping syndrome and subsequent hypoglycemia. Methods: This video is a case study of an EGJR done for persistent postoperative hypoglycemia. The gastroscope was introduced and using Argon Plasma Coagulation at a flow of 8 liters/min and 30 watts; the mucosa around the gastrojejunal stoma was ablated circumferentially. This was done to decrease bleeding from needle placement and to promote adherence of the mucosa after the sutures were placed. The purse-string technique was favored for this procedure due to an inherent reduction in suture tension. Several full-thickness bites were taken to narrow the stoma from 20 to 4 mm in diameter. Results: The patient was discharged home the same day following the procedure. She was placed on a two week liquid bariatric postoperative diet. At two week follow-up, the patient reported normal blood sugars and no hypoglycemic episodes since surgery. At six month follow-up, the patient reported significant improvement in her hypoglycemia symptoms, and no further syncopal episodes or seizures. Conclusion: We believe this case demonstrates that endoscopic gastrojejunal revision (or EGJR) is an effective treatment option for postprandial hypoglycemia following Roux-en-Y gastric bypass. [ABSTRACT FROM AUTHOR]

Background: Hepatic artery infusion (HAI) chemotherapy is an effective regional therapy for unresectable colorectal liver metastases (U-CRLM).1 2 One of its limitations is the need for a laparotomy, which can delay the use of systemic therapy.3 Here, we describe a purely robotic technique for placement of an HAI pump (Fig 1). Patient: A 62-year-old male presented with a symptomatic ascending colon cancer and multiple bilobar unresectable liver metastases. He underwent laparoscopic right colectomy followed by six cycles of FOLFOXIRI and bevacizumab with stable disease by RECIST (Response Evaluation Criteria in Solid Tumors) criteria, and also underwent robotic HAI pump placement. Technique: The patient was placed supine on a split-leg table, and four robotic and two laparoscopic assistant ports were placed as shown. Use of the robot allowed for precise dissection of the common hepatic artery (CHA) and gastroduodenal artery (GDA), as well as a portal lymphadenectomy. A standard cholecystectomy was performed and the GDA was dissected for a distance of 2-3 cm from its takeoff from the CHA. The robotic scissors were used to create a precise transverse GDA arteriotomy, and the HAI pump catheter tip was advanced to the CHA/GDA junction and secured with two silk ties. Finally, a methylene blue dye injection test was performed to ensure uniform distribution within the liver. Operative time was 147 min, estimated blood loss was 20 ml, and the postoperative course was uneventful. The first dose of HAI with floxuridine was administered on postoperative day 4 (day of discharge) and systemic chemotherapy was administered 2 weeks later. Conclusion: The robotic platform allows for minimally invasive HAI pump placement. [ABSTRACT FROM AUTHOR]