Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major ...intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background
This study analyzed the time trends of demographic, operative, and pathologic variables in a consecutive series of patients undergoing laparoscopic distal pancreatectomy (LDP). In ...addition, we assessed the parameters potentially related to the learning curve, and evaluated the long-term outcomes.
Methods
LDP performed between 1999 and 2012 (minimum follow-up of 1 year) were included in the study. The time trends were studied categorizing the operative sequence in three equal groups, and the parameters related to the learning curve were assessed using local regression techniques. All the analyses were stratified by operation type (associated splenectomy vs. spleen-preserving procedures).
Results
The study population consisted of 100 patients. There were 57 LDP with associated splenectomy and 41 spleen-preserving LDP; conversion was necessary in 2 cases. The time trend analysis showed that there was not a tendency toward broadening the indications or selecting more difficult cases. Similarly, the study of learning curve components did not show any significant variation over time. Only 45 splenectomized patients received prophylactic vaccinations, and one unvaccinated patient developed an overwhelming post-splenectomy infection. At a median follow-up of 72.5 months, 12 patients developed diabetes mellitus, while 8 patients undergoing spleen-preserving LDP developed gastric and perigastric varices.
Conclusion
This analysis did not identify parameters related to the patient selection process and the learning curve in LDP. The incidence of new-onset diabetes was lower than reported in other series. The possibility of serious infections following splenectomy has to be taken into account, such that a strict adherence to vaccine protocols is strongly recommended.
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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
<p data-select-like-a-boss="1">Objective: The aim of this study was to compare oncological outcomes after minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) in ...patients with pancreatic ductal adenocarcinoma (PDAC).
Background: Cohort studies have suggested superior short-term outcomes of MIDP vs. ODP. Recent international surveys, however, revealed that surgeons have concerns about the oncological outcomes of MIDP for PDAC.
Methods: This is a pan-European propensity score matched study including patients who underwent MIDP (laparoscopic or robot-assisted) or ODP for PDAC between January 1, 2007 and July 1, 2015. MIDP patients were matched to ODP patients in a 1:1 ratio. Main outcomes were radical (R0) resection, lymph node retrieval, and survival.
Results: In total, 1212 patients were included from 34 centers in 11 countries. Of 356 (29%) MIDP patients, 340 could be matched. After matching, the MIDP conversion rate was 19% (n = 62). Median blood loss 200 mL (60–400) vs 300 mL (150–500), P = 0.001 and hospital stay 8 (6–12) vs 9 (7–14) days, P < 0.001 were lower after MIDP. Clavien-Dindo grade ≥3 complications (18% vs 21%, P = 0.431) and 90-day mortality (2% vs 3%, P > 0.99) were comparable for MIDP and ODP, respectively. R0 resection rate was higher (67% vs 58%, P = 0.019), whereas Gerota's fascia resection (31% vs 60%, P < 0.001) and lymph node retrieval 14 (8–22) vs 22 (14–31), P < 0.001 were lower after MIDP. Median overall survival was 28 95% confidence interval (CI), 22–34 versus 31 (95% CI, 26–36) months ( P = 0.929).
Conclusions: Comparable survival was seen after MIDP and ODP for PDAC, but the opposing differences in R0 resection rate, resection of Gerota's fascia, and lymph node retrieval strengthen the need for a randomized trial to confirm the oncological safety of MIDP.
Pancreatic neuroendocrine tumors (pan-NENs) represent an increasingly common indication for pancreatic resection, but there are few data regarding possible recurrence after surgery. The aim of the ...study was to describe the frequency, timing, and patterns of recurrence after resection for pan-NENs with consequent implications for postoperative follow-up.
We performed a retrospective analysis of pan-NENs resected between 1990 and 2015 at The Pancreas Institute, University of Verona Hospital Trust. Predictors of recurrence were assessed. Survival analysis was conducted using the Kaplan-Meier and conditional survival (CS) methods.
The cohort consisted of 487 patients with a median follow-up of 71 months. Recurrence developed in 12.3%: 54 (11.1%) liver metastases, 11 (2.3%) local recurrence, 10 (2.1%) nodal recurrence, and 8 (1.6%) metastases in other organs. Thirty-one (6.4%) died due to disease recurrence. Size > 21 mm, G3 grade, nodal metastasis, and vascular infiltration were independent predictors of overall recurrence. Recurrence occurred either during the first year of follow-up (n = 9), or after 10 years (n = 4). CS analysis revealed that nonfunctioning G1 pan-NEN ≤20 mm without nodal metastasis or vascular invasion had a negligible risk of developing recurrence. In the present series, after 5 years of follow-up without developing recurrence, tumor recurrence occurred only in the form of liver metastases.
Recurrence of pan-NENs is rare and is predicted by tumor size, nodal metastasis, grading, and vascular invasion. Patients with G1 pan-NEN without nodal metastasis and vascular invasion may be considered cured by surgery. After 5 years without recurrence, follow-up should focus on excluding the development of liver metastases.
Purpose
Minimally invasive surgery has increasingly gained popularity as a treatment of choice for pancreatectomy with encouraging initial results in robotic distal pancreatectomy (RDP). However, few ...data are available on the comparison between RDP and laparoscopic distal pancreatectomy (LDP) for pancreatic neuroendocrine tumors (pNETs). Our aim, thus, is to compare perioperative and long-term outcomes as well as total costs of RDP and LDP for pNETs.
Methods
All RDPs and LDPs for pNETs performed in four referral centers from 2008 to 2016 were included. Perioperative outcomes, histopathological results, overall (OS) and disease-free survival (DFS), and total costs were evaluated.
Results
Ninety-six RDPs and 85 LDPs were included. Demographic and clinical characteristics were comparable between the two cohorts. Operative time was 36.5 min longer in the RDP group (
p
= 0.009) but comparable to LDP after removing the docking time (247.9 vs 233.7 min;
p
= 0.6). LDP related to a lower spleen preservation rate (44.7% vs 65.3%;
p
< 0.0001) and higher blood loss (239.7 ± 112 vs 162.5 ± 98 cc;
p
< 0.0001). Advantages in operative time for RDP were documented in case of the spleen preservation procedures (265 ± 41.52 vs 291 ± 23 min;
p
= 0.04). Conversion rate, postoperative morbidity, and pancreatic fistula rate were similar between the two groups, as well as histopathological data, OS, and DFS. Significant advantages were evidenced for LDP regarding mean total costs (9235 (± 1935) € vs 11,226 (± 2365) €;
p
< 0.0001).
Conclusions
Both RDP and LDP are safe and efficacious for pNETs treatment. However, RDP offers advantages with a higher spleen preservation rate and lower blood loss. Costs still remain the main limitation of the robotic approach.
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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
Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally ...invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon’s movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.
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EMUNI, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, SBNM, UL, UM, UPUK
Introduction. Despite the widespread use of the robotic technology, only a few studies with small sample sizes report its application to pancreatic diseases treatment. Our aim is to present the ...results of a multicenter study on the safety and feasibility of robot-assisted distal pancreatectomy (RDP). Materials and Methods. All RDPs for benign, borderline, and malignant diseases performed in 5 referral centers from 2008 to 2016 were included. Perioperative outcomes were evaluated. Results. Two hundred thirty-six patients were included. Spleen preservation was performed in 114 cases (48.3%). Operative time was 277.8 ± 93.6 minutes. Progressive improvement in operative time was observed over the study period. Conversion rate was 6.3%. Morbidity occurred in 102 cases (43.2%), mainly due to grade A fistulas. Reoperation was required in 10 patients. Postoperatively, 2 patients died of sepsis due to a grade C fistula. Hospital readmission was necessary in 11 cases. A R0 resection was always achieved, with a mean number of 16.2 ± 15 harvested lymph nodes. Conclusion. To our knowledge, this is one of the largest RDP series. Safety and feasibility including the low conversion rate, the high spleen preservation rate, the adequate operative time, and the acceptable morbidity and mortality rates confirm the validity of this technique. Appropriate oncological outcomes have been also obtained.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Minimally invasive pancreatic surgery - a review Damoli, Isacco; Butturini, Giovanni; Ramera, Marco ...
Videosurgery and Other Miniinvasive Techniques/Wideochirurgia i Inne Techniki Mało Inwazyjne,
07/2015, Volume:
10, Issue:
2
Journal Article
Peer reviewed
Open access
During the past 20 years the application of a minimally invasive approach to pancreatic surgery has progressively increased. Distal pancreatectomy is the most frequently performed procedure, because ...of the absence of a reconstructive phase. However, middle pancreatectomy and pancreatoduodenectomy have been demonstrated to be safe and feasible as well. Laparoscopic distal pancreatectomy is recognized as the gold standard treatment for small tumors of the pancreatic body-tail, with several advantages over the traditional open approach in terms of patient recovery. The surgical treatment of lesions of the pancreatic head via a minimally invasive approach is still limited to a few highly experienced surgeons, due to the very challenging resection and complex anastomoses. Middle pancreatectomy and enucleation are indicated for small and benign tumors and offer the maximum preservation of the parenchyma. The introduction of a robotic platform more than ten years ago increased the interest of many surgeons in minimally invasive treatment of pancreatic diseases. This new technology overcomes all the limitations of laparoscopic surgery, but actual benefits for the patients are still under investigation. The increased costs associated with robotic surgery are under debate too. This article presents the state of the art of minimally invasive pancreatic surgery.
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IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UL, UM, UPUK
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