AIMTo evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors.METHODSThis is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017).RESULTSThe frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods.CONCLUSIONSurgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Background: A variety of bariatric procedures are being practiced nowadays. Laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB) are two commonly practiced bariatric procedures. Recently, single anastomosis sleeve jejunal bypass (SASJ) has emerged as a novel effective procedure with a decreased risk of malnutrition due to the presence of two pathways for food. Herein, we compared outcomes of these three procedures regarding short-term weight loss, complications, comorbidity resolution and quality of life.Patients and methods: We included a total of 60 cases in this prospective randomized study, and they were divided into three equal groups; SASJ, LSG and OAGB groups. The three procedures were performed by the same surgical team adapting standardized techniques. Weight loss parameters were our primary objectives, while secondary outcomes included post-operative complications, nutritional status, improvement/resolution of comorbidities and quality of life.Results: Operative time was significantly prolonged in the SASJ group, compared to the other two groups. Nevertheless, the incidence of post-operative complications did not significantly differ between the three groups, apart from GERD, that was more encountered in LSG group (20% of cases). Percentage of total weight loss (%TWL) were comparable among the 3 procedures; (SASJ 39.4 and 56.85%), (LSG 46.05 and 65.6%) and (OAGB 43 and 61.4%) at 6 and 12 months respectively. Comorbidity improvement, quality of life and nutritional status didn’t differ among the three study groups.Conclusion: SASJ bypass is an effective bariatric procedure regarding weight loss and comorbidity resolution, with a safe perioperative outcome comparable to OAGB and LSG.

Management of CBDS in patients with borderline CBD represents a surgical challenge. Borderline CBD increases the technical difficulty of ERCP and increases the risk of PEP. Conservative management of CBDS in borderline CBD not only avoids the risks inherent in ERCP and unnecessary preoperative ERCP, but it is also effective in clearing CBDS. The hepatobiliary surgeon should consider a conservative line of treatment in CBDS in borderline CBD in order to decrease the cost and avoid unnecessary ERCP.

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