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INTRODUCTION: The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis. PATIENTS AND METHODS: Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis. RESULTS: Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications. CONCLUSION: A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.

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Laparoscopic pancreaticoduodenectomy (LPD) remained a formidable challenge owing to retroperitoneal location, difficult dissection near great vessels and critical intracorporeal anastomoses. Recent reviews of literature have established the feasibility and comparable short term outcomes of laparoscopic pancreaticoduodenectomy (LPD) with that of open pancreaticoduodenectomy (OPD). This study was undertaken to compare the pathological radicality of LPD with OPD. A prospective database of all patients who underwent standard pancreaticoduodenectomy from Mar 2006 to Feb 2011 was taken up for this study. 45 patients who underwent LPD and 118 patients who underwent OPD for periampullary and pancreatic head malignancy were taken up for analysis. The study groups were comparable in terms of age of presentation, ASA grades, comorbidity, type of surgery and BMI. There was no statistically significant difference with regard to tumor size, lymph node yield, node positivity rates, R1 rates and margin lengths. The pathological radicality of laparoscopic pancreaticoduodenectomy is comparable with that of open approach when performed by experienced minimal-access surgeons. Standardized protocols for evaluation of the resection margins should be mandatory in studies reporting outcomes of pancreaticoduodectomy.

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BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD), although an advanced surgical procedure, is being increasingly used for pancreatic head and periampullary tumors. We present our experience of 15 years with the largest series in total LPD for periampullary and pancreatic head tumors with data on oncological outcome and long-term survival. MATERIALS AND METHODS: Prospective and retrospective data of patients undergoing LPD from March 1998 to April 2013 were reviewed. Of the 150 cases, 20 cases of LPD (7 cases done for chronic pancreatitis and 13 cases for benign cystic tumors of the pancreas) have been excluded, which leaves us with 130 cases of LPD performed for malignant indications. RESULTS: In total, 130 patients were chosen for the study. The male:female ratio was 1:1.6, with a median age of 54 years. We had one conversion to open surgery in our series, the overall postoperative morbidity was 29.7%, and the mortality rate was 1.53%. The pancreatic fistula rate was 8.46%. The mean operating time was 310±34 minutes, and the mean blood loss was 110±22 mL. The mean hospital stay was 8±2.6 days. Resected margins were positive in 9.23% of cases. The mean tumor size was 3.13±1.21 cm, and the mean number of retrieved lymph nodes was 18.15±4.73. The overall 5-year actuarial survival was 29.42%, and the median survival was 33 months. CONCLUSIONS: LPD has evolved over a period of two decades and has the potential to become the standard of care for select periampullary and pancreatic head tumors with acceptable oncological outcomes, especially in high-volume centers. Randomized controlled trials are needed to establish the advantages of LPD.

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Roux-en-Y hepaticojejunostomy stricture is a substantial problem that develops in 10%-30% of patients and requires frequent intervention. Although endoscopic/percutaneous approaches are preferred, especially for refractory stricture, open surgical reconstruction remains the gold standard. However, such an operation may be highly challenging. The recently developed covered, self-expanding metallic stent is a useful option for such difficult cases. We present a case of recurrent Roux-en-Y hepaticojejunostomy stricture complicated by densely packed intrahepatic stones and suppurative cholangitis with failed percutaneous biliary draining. Enteroscopic manipulations were unfeasible, and the case was successfully managed by the laparoendoscopic approach. If treating surgeons have the necessary expertise, this technique may be considered in such difficult scenarios.

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