A retrospective comparative study of robotic distal pancreatectomy with or without splenic vessel and spleen preservation.

BACKGROUND: Robotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP). METHODS: Between March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group. RESULTS: The two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group. CONCLUSION: Apart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS.

Robotic colonic surgery: is it advisable to commence a new learning curve?

BACKGROUND: Robotic surgery has potential advantages in rectal and pelvic surgery, in which the dissection is performed within a confined operative field. However, the position of robotic colonic surgery remains largely undefined with limited insight of whether it offers any potential advantages over open or laparoscopic colon surgery. OBJECTIVES: The aim of this systematic review was to compare the short-term outcomes of the published robotic colonic surgery with those of laparoscopic colonic surgery. DATA SOURCES: The search was performed in September 2012 with the use of PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. The search terms used were "colorectal," "colon," "colectomy," and "robotic/robot." DATA SELECTION: All studies reporting outcomes on robotic colonic resection were included in the review process. Colonic robotic data were compared with data on the short-term outcomes of laparoscopic colonic surgery from a Cochrane review and 4 main randomized controlled trials. INTERVENTIONS: A comparison was conducted of robotic colonic surgery vs standard laparoscopic colonic surgery. MAIN OUTCOME MEASURES: Short-term outcomes and the complication profile of colonic robotic surgery were compared with conventional multiple-port laparoscopic colonic surgery. RESULTS: Fifteen robotic colonic surgery articles with 351 patients (173 males, 178 females) were considered for analysis. The operative time and financial cost of robotic colonic surgery was greater than standard laparoscopic colonic surgery with comparable short-term outcomes and early postoperative complications profile. CONCLUSIONS: The present evidence on robotic colonic surgery has shown both feasibility and a safety profile comparable to standard laparoscopic colonic surgery. However, operative time and cost were greater in robotic colonic surgery, with no difference in the length of postoperative stay in comparison with standard laparoscopic colonic surgery. Whether the general surgical community should embark on a new learning curve for robotic colonic surgery can only be answered in the light of future studies.

A case series of emergency pancreaticoduodenectomies: What were their indications and outcomes?

Emergency pancreaticoduodenectomy (EPD) is a rarely performed operation. It is important to know the indications and outcomes of EPD to have a better understanding of its application in clinical practice. A review of eight consecutive cases of EPD was done. Between January 2003 and December 2021, 8 out of 370 patients (2.2%) in a single center received pancreaticoduodenectomy as emergency. There were six males and two females with a median age of 45.5 years. The indications were trauma in three patients, bleeding tumors in two patients, and one patient each in obstructing duodenal tumor, postoperative complication and post-endoscopic retrograde cholangiopancreatography (ERCP) complication. The median operative time and blood loss were 427.5 minutes and 1,825 mL, respectively. There was no operative mortality. Seven patients (87.5%) had postoperative complications. Three patients (37.5%) developed postoperative grade B pancreatic fistula. The median postoperative hospital stay was 23.5 days. Five patients were still alive while three patients survived for 13, 31, and 42 months after the operation. The causes of death were recurrent tumors in two patients, and sepsis in one patient. According to this case series, EPD is associated with increased morbidity and pancreatic fistula, but is still deserved in life-threatening situations and long-term survival is possible after EPD.

Topical Application of Mesenchymal Stromal Cells Ameliorated Liver Parenchyma Damage After Ischemia-Reperfusion Injury in an Animal Model.

BACKGROUND: Ischemia-reperfusion injury (IRI) is commonly encountered after liver surgery. This study evaluated the hepatoprotective effects of topically applied adipose-derived mesenchymal stromal cells (ADMSCs) on hepatic IRI in a rat model. METHODS: ADMSCs from transgenic green fluorescent protein Sprague-Dawley rats were topically applied to the liver surface of Sprague-Dawley rats after hepatic IRI and fixed in position by fibrin glue (group A, n = 24). An equivalent amount of ADMSCs were administered through the portal (group B, n = 24) or tail vein (group C, n = 24). In the control group (group D, n = 20), no treatment was given to the IRI liver. RESULTS: All the rats in group A and group D survived. Within 2 days after hepatic IRI, only 50% of rats survived in group B, and ADMSCs were detected in thromboemboli within large vessels. 62.5% of the rats died in group C because most of the ADMSCs were trapped in the lungs. ADMSCs migrated across the liver capsule and homed to the injured liver parenchyma 3 days after topical application in group A. The homed ADMSCs expressed hepatocyte nuclear factor-4α and hepatocyte nuclear factor-1. Compared with group D, the rate of hepatic regeneration in group A was enhanced with less inflammation, smaller necrotic areas, and improved liver function. Proinflammatory cytokines IL-6, IL-21, and CD70 were significantly downregulated in group A by 6.3-, 2.7-, and 12.7-fold, respectively (P < 0.05). The neurogenic locus NOTCH homolog protein pathway was activated in the topical ADMSCs. CONCLUSIONS: Topically applied adipose-derived mesenchymal stromal cells demonstrated hepatoprotective effects on hepatic IRI in an animal model.

Are natural orifice transluminal endoscopic surgery and single-incision surgery viable techniques for cholecystectomy?

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision surgery (SIS) are less invasive alternatives to traditional laparoscopic techniques. Concerns exist over the safety of these new approaches, and randomized controlled trials have yet to confirm a net benefit. If NOTES and SIS techniques are to become standard practice, then they should be shown to be safe and hold clear benefits to patients. We aim at comparing the available results by using these techniques in a standard laparoscopic operation (cholecystectomy). METHODS: A systematic review using available databases (MEDLINE, EMBASE, and the Cochrane Controlled Trials Register) and the published English language medical literature was performed. All the archived articles were cross-referenced. Outcome data obtained from a Cochrane review of laparoscopic cholecystectomy were used as the control group. All the operations performed via a single incision were grouped under SIS, and operations in which a natural orifice (alone or as a hybrid technique) was analyzed, under NOTES group. Mortality and complications were the primary outcome measures. RESULTS: One hundred thirty-five papers including 4703 patients (714 NOTES, 3989 SIS) were selected for analysis. Overall complication rate was 4.2% in the NOTES group versus 4.3% in the SIS group, with a distinct complication profile. No mortality was reported in either group. NOTES procedures had a longer mean operative time than SIS techniques (107 versus 79 minutes). The conversion rate between NOTES and SILS was similar (3.4% versus 3.3%, respectively). DISCUSSION: No difference in the incidence of complications was observed with the newer techniques. Adequately powered randomized control trials are needed to clarify whether SIS/NOTES cholecystectomy has a similar length of hospital stay to traditional laparoscopic cholecystectomy. The increased occurrence of specific types of complications and their use in acute pathology needs further investigation to warrant further use in routine surgical practice.