Overview
This manuscript summarizes an excellent debate from the 2021 SSAT/Pancreas Club symposium on arterial resection in pancreas cancer. Two world-recognized experts, Professor Ugo Boggi from ...Pisa, IT, and Dr. Mark Truty from the Mayo Clinic in Rochester, MN, offered their views on the role of arterial resection in locally advanced pancreas ductal adenocarcinoma. Both speakers have extensive experience pushing the technical envelope with extended vascular resection in pancreatectomy. However, both highlight important concepts of resectability extending well beyond technique: namely, patient global physiology, tumor biology, and response to chemotherapy. The debate was spirited, and this subsequent review is an excellent look at the status quo. N. J. Zyromski, MD, Indianpolis, IN, November, 2021.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The robotic surgical system has been applied in liver surgery. However, controversies concerns exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness ...of robotic surgery. To promote the development of robotic hepatectomy, this study aimed to evaluate the current status of robotic hepatectomy and provide sixty experts' consensus and recommendations to promote its development. Based on the World Health Organization Handbook for Guideline Development, a Consensus Steering Group and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 22 topics were prepared analyzed and widely discussed during the 4 meetings. Based on the published articles and expert panel opinion, 7 recommendations were generated by the GRADE method using an evidence-based method, which focused on the safety, feasibility, indication, techniques and cost-effectiveness of hepatectomy. Given that the current evidences were low to very low as evaluated by the GRADE method, further randomized-controlled trials are needed in the future to validate these recommendations.
Objectives
A laparoscopic approach improves short-term outcomes and maintains long-term outcomes compared to an open approach. In turn, the recent development of robotic surgery raises the question ...whether it performs as well as laparoscopic surgery. The aim of this study was to compare the short- and long-term outcomes of laparoscopic liver resection (LLR) and robotic liver resection (RLR) for malignancies.
Method
From 2011 to 2017, the study population included 111 patients in the LLR group and 61 in the RLR group. Short- and long-term outcomes were compared before and after propensity score matching (PSM).
Results
Operative mortality rate was nil. The intraoperative blood transfusion rate was higher during RLR (15% vs. 2%,
p
= 0.0009). Major morbidity and hospital stay were not different between the two groups. The resection margin width (LLR 7 mm vs. RLR 10 mm,
p
= 0.13) and R1 resection rates (resection margin width < 1 mm; LLR 15% vs. RLR 11%,
p
= 0.49) were similar. After PSM (55 patients in each group), the blood transfusion, major morbidity, hospital stay and R1 resection were similar between the two groups. When considering the largest subset of patients with hepatocellular carcinoma including 114 patients (66%), the 3-year overall survival rate was 80% in the LLR group and 97% in the RLR group (
p
= 0.10) and remained similar after PSM (
p
= 0.27). The 3-year recurrence-free survival rate was 50% in the LLR group and 64% in the RLR group (
p
= 0.30) and remained similar after PSM (
p
= 0.26).
Conclusions
No differences were found in blood transfusion, incidence of positive resection margins and long-term outcomes between the two techniques. RLR does not compromise short-term and oncologic outcomes in patients with liver cancers.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The benefits of pure laparoscopic and robot‐assisted liver resections (LLR and RALR) are known in comparison to open surgery. The aim of the present retrospective comparative study is to ...investigate the role of RALR and LLR according to different levels of difficulty.
Methods
The institutional databases of six high‐volume hepatobiliary centers were retrospectively reviewed. The study population was divided in two groups: LLR and RALR. The procedures were stratified for difficulty levels accordingly to three classifications. A propensity score matching was implemented to mitigate selection bias. Short‐term outcomes were the object of comparison.
Results
Nine hundred and thirty‐six LLR and 403 RALR were collected. RALR exhibited fewer cases of intraoperative blood loss, lower transfusion and conversion rates (especially for oncological radicality) than LLR in the setting of highly difficult operations, whereas LLR had lower postoperative morbidity and fewer low‐grade complications. For intermediate and low‐difficulty resections, the intraoperative advantages of RALR gradually decreased to nonsignificant results and LLR remained associated with lower postoperative morbidity.
Conclusion
Robot‐assisted liver resections do not show operative nor clinically significant benefits over LLR for low‐ and intermediate‐difficulty resections. By reducing conversion rates, RALR can favour the operative feasibility of difficult resections possibly extending the indications of minimally invasive approaches for liver resection.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
The recent development of 3D vision in laparoscopic and robotic surgical systems raises the question of whether these two procedures are equivalent. The aim of this study was to evaluate ...the surgical and long-term oncological outcomes of 3D laparoscopic (3D-LLR) and robotic liver resection (RLR) for hepatocellular carcinoma (HCC).
Methods
The data for operative time, morbidity, margins, and survival were reviewed for 3D-LLR and compared with RLR.
Results
From 2011 to 2017, 93 patients with HCC, including 58 (62%) with cirrhosis, underwent 3D-LLR 49 (53%) or RLR 44 (47%). No difference was observed in operative time (269 vs. 252 min;
p
= 0.52), overall (27% vs. RLR: 16%;
p
= 0.49) and severe morbidity (4% vs. 2%;
p
= 0.77) or in the surgical margin width (9 vs. 11 mm;
p
= 0.30) between the 3D-LLR and RLR groups. The 3-year overall and recurrence-free survival rates after 3D-LLR and RLR were 82% and 24% and 91% (
p
= 0.16) and 48% (
p
= 0.18), respectively.
Conclusions
The 3D-LLR and RLR systems provide comparable surgical margins with similar short- and long-term oncological outcomes.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
OBJECTIVE:The aim of this study was to investigate the impact of conversion during minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC) on outcome by a ...propensity-matched comparison with open distal pancreatectomy (ODP).
BACKGROUND:MIDP is associated with faster recovery as compared with ODP. The high conversion rate (15%–25%) in patients with PDAC, however, is worrisome and may negatively influence outcome.
METHODS:A post hoc analysis of a retrospective cohort including distal pancreatectomies for PDAC from 34 centers in 11 countries. Patients requiring conversion were matched, using propensity scores, to ODP procedures (1:2 ratio). Indications for conversion were classified as elective conversions (eg, vascular involvement) or emergency conversions (eg, bleeding).
RESULTS:Among 1212 distal pancreatectomies for PDAC, 345 patients underwent MIDP, with 68 (19.7%) conversions, mostly elective (n = 46, 67.6%). Vascular resection (other than splenic vessels) was required in 19.1% of the converted procedures. After matching (61 MIDP-converted vs 122 ODP), conversion did not affect R-status, recurrence of cancer, nor overall survival. However, emergency conversion was associated with increased overall morbidity (61.9% vs 31.1%, P= 0.007) and a trend to worse oncological outcome compared with ODP. Elective conversion was associated with comparable overall morbidity.
CONCLUSIONS:Elective conversion in MIDP for PDAC was associated with comparable short-term and oncological outcomes in comparison with ODP. However, emergency conversions were associated with worse both short- and long-term outcomes, and should be prevented by careful patient selection, awareness of surgeons’ learning curve, and consideration of early conversion when unexpected intraoperative findings are encountered.
Background
Laparoscopic major hepatectomy (LMH), although safely feasible in experienced hands and in selected patients, is a formidable challenge because of the technical demands of controlling ...hemorrhage, sealing bile ducts, avoiding gas embolism, and maintaining oncologic surgical principles. The enhanced surgical dexterity offered by robotic assistance could improve feasibility and/or safety of minimally invasive major hepatectomy. The aim of this study was to compare perioperative outcomes of LMH and robotic-assisted major hepatectomy (RMH).
Methods
Pooled data from four Italian hepatobiliary centers were analyzed retrospectively. Demographic data, operative, and postoperative outcomes were collected from prospectively maintained databases and compared.
Results
Between January 2009 and December 2012, 25 patients underwent LMH and 25 RMH. The two groups were comparable for all baseline characteristics including type of resection and underlying pathology. Conversion to open surgery was required in one patient in each group (4 %). No difference was noted in operative time, estimated blood, and need for allogenic blood transfusions. Intermittent pedicle occlusion was required only in LMH (32 % vs. 0;
p
= 0.004). Length of hospital stay, including time spent in intensive care unit, was similar between the two groups, but patients undergoing LMH showed quicker recovery of bowel activity, with shorter time to first flatus (1 vs. 3 days;
p
= 0.023) and earlier tolerance to oral liquid diet (1 vs. 2 days;
p
= 0.001). No difference was noted in complication rate, 90-day mortality, and readmission rate.
Conclusions
This retrospective multi-institution study confirms that selected patients can safely undergo minimally invasive major hepatectomy, either LMH or RMH. The fact that intermittent pedicle occlusion could be avoided in RMH suggests improved surgical ability to deal with bleeding during liver transection, but further studies are needed before any final conclusion can be drawn.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Both types of diabetes are characterized by beta‐cell failure and death, leading to insulin insufficiency. Very limited information is currently available about the ultrastructural ...alterations of beta cells in human diabetes. Our aim was to provide a comprehensive ultrastructural analysis of human pancreatic islets in type 1 (T1D) and type 2 (T2D) diabetic patients.
Methods
We performed a morphometric electron microscopy evaluation of beta cells obtained from the pancreas of 8 nondiabetic (ND), 5 T1D, and 8 T2D organ donors.
Results
A lower amount of beta cells was found in both T1D and T2D than in ND islets, whereas alpha cells were increased only in T2D. An increased number of bi‐hormonal cells (showing both insulin and glucagon granules in their cytoplasm) were found in T1D. Insulin granules were less represented in T2D than in ND beta cells, whereas no significant changes were found in T1D. Volume density of the endoplasmic reticulum was increased in T2D and unchanged in T1D; mitochondria number and volume were significantly higher in T2D than in ND beta cells, whereas no significant differences were found in T1D. In both T1D and T2D, more beta cells showed signs of apoptosis than in ND.
Conclusions
Our results show that in each type of diabetes, beta cells exhibit specific ultrastructural alterations, whose better understanding might improve therapeutic strategies.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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