The Evolution of Surgical Strategies for Pancreatic Neuroendocrine Tumors (Pan-NENs): Time-trend and Outcome Analysis From 587 Consecutive Resections at a High-volume Institution.

OBJECTIVE: The objective of the present analysis is 2-fold: first, to define the evolution of time trends on the surgical approach to pancreatic neuroendocrine neoplasms (Pan-NENs); second, to perform a complete analysis of the predictors of oncologic outcome. BACKGROUND: Reflecting their rarity and heterogeneity, Pan-NENs represent a clinical dilemma. In particular, there is a scarcity of data regarding their long-term follow-up after surgical resection. METHODS: From the Institutional Pan-NEN database, 587 resected cases from 1990 to 2015 were extracted. The time span was arbitrarily divided into 3 discrete clusters enabling a balanced comparison between patient groups. Analyses for predictors of recurrence and survival were performed, together with conditional survival analyses. RESULTS: Among the 587 resected Pan-NENs, 75% were nonfunctioning tumors, and 5% were syndrome-associated tumors. The mean age was 54 years (±14 years), and 51% of the patients were female. The median tumor size was 20 mm (range 4 to 140), 62% were G1, 32% were G2, and 4% were G3 tumors. Time trends analysis revealed that the number of resected Pan-NENs constantly increased, while the size (from 25 to 20 mm) and G1 proportion (from 65% to 49%) decreased during the study period. After a mean follow-up of 75 months, recurrence analysis revealed that nonfunctioning tumors, tumor grade, N1 status, and vascular invasion were all independent predictors of recurrence. Regardless of size, G1 nonfunctioning tumors with no nodal involvement and vascular invasion had a negligible risk of recurrence at 5 years. CONCLUSIONS: Pan-NENs have been increasingly diagnosed and resected during the last 3 decades, revealing reliable predictors of outcome. Functioning and nodal status, tumor grade, and vascular invasion accurately predict survival and recurrence with resulting implications for patient follow-up.

A prospective non-randomised single-center study comparing laparoscopic and robotic distal pancreatectomy.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is increasing in popularity thanks to the benefits that have been recently demonstrated by many authors. The Da Vinci(®) Surgical System could overcome some limits of laparoscopy, helping the surgeons to perform safer and faster difficult procedures. Nowadays, prospective clinical trials comparing LDP to robotic distal pancreatectomy (RDP) are lacking. The aim of this study is to present a prospective comparison between the two techniques. METHODS: Since November 2011, all patients suitable for minimally invasive distal pancreatectomy were assigned either to LDP or RDP, depending on the availability of the Da Vinci(®) Surgical System for our Surgical Unit. Demographics, clinical, and intra- and postoperative data, including estimated costs of the procedure, were prospectively collected. Follow-up included cross-sectional imaging ended on April 2014. RESULTS: Twenty-two patients underwent RDP and 21 LDP; patients' characteristics were similar. The median operative time was longer and procedures' cost was double in RDP group. The conversion to open rate and the median length of postoperative hospital stay were 4.5 % and 7 days, respectively, in both groups. Pancreatic fistula developed in 57.1 % (12/21) and 50 % (11/22) of LDP and RDP, respectively (p = 0.870), being grade A the most frequent. Mortality was nil and an R0 resection was achieved in all Patients. The overall number of lymph nodes harvested was similar between the two groups. CONCLUSIONS: Both RDP and LDP are valid techniques for the treatment of distal pancreatic tumors. The advantages of RDP are claimed by many but still under investigation. Some of these advantages are more subjective than objective, and it seems difficult to demonstrate a real superiority of one technique over the other in a standardized fashion. In our experience, laparoscopy has not been abandoned in favor of the robot: we continue to perform both approaches choosing upon single patient's characteristics.

Minimally invasive approach to incisional hernia in elective and emergency surgery: a SICE (Italian Society of Endoscopic Surgery and new technologies) and ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) online survey.

Minimally invasive abdominal wall surgery is growing worldwide, with a constant and fast improvement of surgical techniques and surgeons' confidence in treating both primary and incisional hernias (IH). The Italian Society of Endoscopic Surgery and new technologies (SICE) and the ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) worked together to investigate state of the art in IH treatment in elective and emergency settings in Italy. An online open survey was designed, and Italian surgeons interested in abdominal wall surgery were invited to fill out a 20-point questionnaire on IH surgical procedures performed in their departments. Surgeons were asked to express their points of view on specific questions about technical and clinical variables in IH treatment. Preferred approach in elective IH surgery was minimally invasive (59.7%). Open surgery was the preferred approach in 40.3% of the responses. In emergency settings, open surgery was the preferred approach (65.4%); however, 34.5% of the involved surgeons declare to prefer the laparoscopic/endoscopic approach. Most respondents opted for conversion to open surgery in case of relevant surgical field contamination, with a non-mesh repair of abdominal wall defects. Among those that used the laparoscopic approach in the emergent setting, the majority (74%) used the size of the defect of 5 cm as a decisional cut-off. The spread of minimally invasive approaches to IH repair in emergency surgery in Italy is gaining relevance. Code-sharing through scientific societies can improve clinical practice in different departments and promote a tailored approach to IH surgery.

Extended totally extraperitoneal Rives-Stoppa (eTEP-RS) technique for ventral hernia: initial experience of The Wall Hernia Group and a surgical technique update.

The enhanced-view extended totally extraperitoneal (eTEP) approach for ventral hernia repair is a novel surgical technique. We present the results from the initial experience with eTEP repair Rives-Stoppa (eTEP-RS) at two Italian centers, and we provide an update on this approach. Between December 2018 and July 2020, 19 patients suffering from ventral hernia were treated with the eTEP-RS. Patients' characteristics, operative details, and complications were analyzed. The median follow-up time was 16 (range 6-24) months. Thirteen (68.4%) patients with ventral incisional hernias and 6 (31.6%) with primary ventral hernia underwent an eTEP-RS procedure. The average defect area was 21 cm2 and the prosthesis's average size was 380 cm2. We registered complications in two cases (10.5%); 1 patient had an asymptomatic seroma (Clavien-Dindo grade 1), and another had intestinal obstruction on the 10th postoperative day (Clavien-Dindo grade 3B). The mean hospital stay was 3.9 (range: 2-6) days. There was no hernia recurrence. The eTEP-RS is a feasible and safe approach in ventral hernia repair with minimally invasive surgery. Further studies are needed to define patients' selection and to know long-term outcomes.