Robotic pancreatic surgery: minimally invasive approach to challenging operations.

BACKGROUND: Pancreatic surgery is still associated with high perioperative morbidity and mortality. The purpose of this study was to present the short-term outcomes of robot-assisted pancreatic surgery, including pancreaticoduodenectomy (RAPD), distal pancreatectomy (RDP) with or without splenectomy, enucleation (REN), and atypical resection (RAR), for benign, borderline, and malignant lesions at a high-volume center. METHODS: A single-center, prospective database was used to retrospectively analyze the early outcomes of robotic pancreatic procedures completed between 2014 and 2020. Out of 124 attempted operations, 3 patients received palliative robotic surgery (2.4%). Of the remaining 121, 14 (11.6%) were converted to open surgery. The robotic procedures included 107 patients: 56 underwent RAPD, 31 underwent RDP (28 with and 3 without splenectomy), 16 underwent REN, and 4 underwent RAR (2 central and 2 total pancreatectomies). RESULTS: The preoperative baseline characteristics and comorbidities were consistent with those of a Western population. The overall incidence of complications was 43.9%, with the more severe (Clavien-Dindo III-IV) occurring after RAPD (19.6%). We collected 7 (13.1%) postoperative pancreatic fistulae after RAPD, 5 (16.1%) after RADP, and 2 (12.5%) after REN. The two central pancreatectomies developed a biochemical leak without sequelae. Three patients (2.8%) died within 90 days after surgery. Early refeeding was achieved in those who did not experience severe complications, while the median hospital stay was 8 days. The median number of harvested lymph nodes was 22, with non-R1 microscopic residual tumors found. CONCLUSIONS: Robotic pancreatic surgery is a safe and oncologically adequate technique to manage benign and malignant diseases arising from the head, body, and tail of the pancreas.

Robotic versus open pancreaticoduodenectomy: Is there any difference for frail patients?

BACKGROUND: Old age and frailty are predictors of early postoperative results after pancreatic surgery. We analysed the results of robotic and open pancreatoduodenectomy in elderly and frail patients. METHODS: Data from the local robotic pancreatoduodenectomy database were reviewed and matched with those from open operations during the same period (2014-2020). Both old age and frailty were used to determine any correlation with postoperative outcomes. Elderly patients were defined as patients aged 70 years or more, while frailty was classified according to the validated modified Frailty Index. RESULTS: A total of 118 pancreatoduodenectomies were included in the analysis: 65 (55.1%) robotic and 53 (44.9%) open. More than 50% of patients were frail. Overall, 7.6% of patients experienced grade IV Clavien-Dindo complications, and 3.4% died within 90 days after surgery. Frail patients experienced a similar rate of severe complications after robotic vs. open operations (5.3 vs. 11.6; p = 0.439) but earlier refeeding (3 days vs. 4 days; p = 0.006) and earlier drain removal (6 days vs. 7 days; p = 0.046) when operated on by a robotic approach. The oncological outcomes, including limphnodes retrieval, residual disease, recurrences, and survival, were not influenced by the surgical approach. Non-elderly patients also showed more benefits with the robotic approach (lower complication index, earlier refeeding, and drain removal). CONCLUSIONS: Robotic pancreatoduodenectomy is associated with risks of major complications that are comparable to those of open operation in frail patients. Some perioperative parameters (refeeding, drain removal) seem to favour robotics in frail patients and younger patients, although at the price of longer operating times.

Robotic enucleation for oesophageal benign and borderline tumours: Less is more?

BACKGROUND: Oesophageal benign to borderline tumours are rare entities, and their optimal treatment strategy remains controversial. Surgical robotic enucleation is an option to optimize their management. METHODS: We prospectively collected data on seven consecutive oesophageal benign to borderline tumours operated robotically over a 4-year period. Patient baseline characteristics, perioperative outcomes and medium-term follow-ups were reviewed and analysed retrospectively. RESULTS: Two patients underwent a robotic oesophagectomy and five underwent a simple enucleation. These last were the objective of the final analysis. Median operative time was 150 min. Neither deaths nor postoperative complications occurred. Median oral feeding started on postoperative day 3.5. The median postoperative stay was 5 days. Final histopathology confirmed two gastrointestinal stromal tumours, two leiomyomas and one simple cyst. CONCLUSIONS: Robotic enucleation of oesophageal benign to borderline tumours is a feasible procedure in a dedicated oesophageal unit, with optimal perioperative outcomes in a small series of cases with limited follow-up.

Correction to: Single-centre comparison of robotic and open pancreatoduodenectomy: a propensity score-matched study.

In the Abstract, in the Methods section the sentence "Of the 121 included patients, 78 underwent RAPD and 43 underwent OPD." Should read: Of the 121 included patients, 77 underwent OPD and 44 underwent RAPD."

Single-centre comparison of robotic and open pancreatoduodenectomy: a propensity score-matched study.

BACKGROUND: Pancreatoduodenectomy for pancreatic head and periampullary cancers is still associated with high perioperative morbidity and mortality. The aim of this study was to compare the short-term outcomes of robot-assisted pancreatoduodenectomy (RAPD) and open pancreatoduodenectomy (OPD) performed in a high-volume centre. METHODS: A single-centre, prospective database was used to retrospectively compare the early outcomes of RAPD procedures to standard OPD procedures completed between January 2014 and December 2018. Of the 121 included patients, 78 underwent RAPD and 43 underwent OPD. After propensity score matching (PSM), 35 RAPD patients were matched with 35 OPD patients with similar preoperative characteristics. RESULTS: There were no statistically significant differences in most of the baseline demographics and perioperative outcomes in the two groups after PSM optimization with the exception of the operative time (530 min (RAPD) versus 335 min (OPD) post-match, p < 0.000). No differences were found between the two groups in terms of complications (including pancreatic leaks, 11.4% in both OPD and RAPD), perioperative mortality, reoperations or readmissions. Earlier refeeding was obtained in the RAPD group vs. the OPD group (3 vs. 4 days, p = 0.002). Although the differences in the length of the hospital stay and blood transfusions were not statistically significant, both parameters showed a positive trend in favour of RAPD. The number of harvested lymph nodes was similar and oncologically adequate. CONCLUSIONS: RAPD is a safe and oncologically adequate technique to treat malignancies arising from the pancreatic head and periampullary region. Several perioperative parameters resulted in trends favouring RAPD over OPD, at the price of longer operating time. Data should be reinforced with a larger sample to guarantee statistical significance.

Feasibility of robotic resection of gastrointestinal stromal tumors along the entire gastrointestinal tract.

Robotic surgery has been proposed over the last decade as a valid option to treat gastrointestinal malignancies in a minimally invasive method, yielding encouraging results. The authors examine the outcomes of a consecutive series of patients with stromal gastrointestinal neoplasms who were operated on using a totally robotic technique. There were 36 patients in the study, with median age 70 years. Resected tumors were located in the esophagus, stomach, duodenum, small intestine and rectum. Perioperative morbidity was 8% and no mortality occurred. R0 resection was achieved in all cases. At a median follow-up of 25 months, 35 patients were disease free while there was one case of death related to metastatic disease. Robotic surgery is a valid option to resect gastrointestinal stromal tumors anywhere along the gastrointestinal tract in a minimally invasive manner.