In recent times, advances in operative technique and the perioperative care of patients have resulted in a low mortality rate for distal pancreatectomy (DP) as reported by several recent large series.^1-6 However, the morbidity rates have remained high, ranging from 22% to 47%.^4,6-9 The pancreatic fistula (PF) has consistently been reported as the most common complication after DP.^4-6 Although frequently of clinical inconsequence, it may result in numerous clinically significant and potentially life-threatening complications, such as intra-abdominal abscess, intra-abdominal hemorrhage, wound infection, and sepsis,⁶ which often translate to a significant increase in hospitalization costs.⁷ The present report critically analyzes a large single-institution experience with DP, with particular attention to risk factors contributing to postoperative PF formation, its subsequent clinical sequelae, and its management.

OBJECTIVE. Foreign body perforation of the gastrointestinal (GI) tract has diverse clinical manifestations, and the correct preoperative diagnosis is seldom made. We report our experience with the use of CT in the preoperative diagnosis of fish bone perforation of the GI tract in seven patients. To our knowledge, this series is the largest to date addressing the role of CT in the diagnosis of fish bone perforation.CONCLUSION. Clinical presentation and radiography are unreliable in the preoperative diagnosis of fish bone perforation of the GI tract. This limitation can be overcome with the use of CT, which is accurate in showing the offending fish bone. The accuracy of CT is limited by observer dependence. A high index of suspicion should always be maintained for the correct diagnosis to be made.

Background: Minimally invasive hepatectomy (MIH) has become an important option for the treatment of various liver tumours. A major concern is the learning curve required. The aim of this study was to perform a systematic review and summarize current literature analysing the learning curve for MIH. Methods: A systematic review of the literature pertaining to learning curves in MIH to July 2019 was performed using PubMed and Scopus databases. All original full-text articles published in English relating to learning curves for both laparoscopic liver resection (LLR), robotic liver resection (RLR), or a combination of these, were included. To explore quantitatively the learning curve for MIH, a meta-regression analysis was performed. Results: Forty studies relating to learning curves in MIH were included. The median overall number of procedures required in studies utilizing cumulative summative (CUSUM) methodology for LLR was 50 (range 25–58) and for RLR was 25 (16–50). After adjustment for year of adoption of MIH, the CUSUM-derived caseload to surmount the learning curve for RLR was 47.1 (95 per cent c.i. 1.2 to 71.6) per cent; P = 0.046) less than that required for LLR. A year-on-year reduction in the number of procedures needed for MIH was observed, commencing at 48.3 cases in 1995 and decreasing to 23.8 cases in 2015. Conclusion: The overall learning curve for MIH decreased steadily over time, and appeared less steep for RLR compared with LLR.

Minimally invasive approach has been applied in liver resection (LR) for more than 2 decades.¹ While minimally invasive hepatectomy has become standard practice according to various consensus conferences, its role in major LR remains in the exploration phase.^2-5 Several meta-analyses have been performed to evaluate the effectiveness, safety, and efficacy of robotic vs laparoscopic hepatectomy.^6-11 However, most analyzed results from retrospective cases series and studied minor LR or LR at low difficulty level. These studies also included various types of LR resulting in additional confounding factors. Studies focusing on major hepatectomy eg, right hepatectomy (RH) or extended RH (ERH), are limited to date.¹²