Intraductal papillary mucinous neoplasms of the pancreas and European guidelines: importance of the surgery type in the decision-making process.

BACKGROUND: The European Consensus 2018 established a new algorithm with absolute and relative criteria for intraductal papillary mucinous neoplasms of the pancreas (IPMN) management. The aim of this study was to validate these criteria and analyse the outcomes in function of the surgical procedure and IPMN subtype. METHODS: Clinical, radiological and surgical data (procedure, morbidity/mortality rates) of patients who underwent surgery for IPMN between 2007 and 2017. The predictive value of the different criteria was analysed. RESULTS: 124 patients (men 67%; mean age 65 years) underwent surgery for IPMN (n = 62 malignant tumours; 50%). Jaundice, cyst ≥4 cm and Wirsung duct size 5-9.9 mm or ≥ 10 mm were significantly associated with malignancy (4.77 < OR < 11.85 p < 0.0001). The positive predictive value of any isolated criterion ranged from 71 to 87%, whereas that of three relative criteria together reached 100%. The mortality and morbidity (grade III-IV complications according to the Dindo-Clavien classification) rates were 3 and 8%, respectively. Morbidity/mortality after duodenopancreatectomy and total pancreatectomy were significantly higher for benign IPMN (p = 0.01). CONCLUSION: Considering the morbidity associated with extended surgery, particularly for benign IPMN, the results of the present study suggest that high-risk surgery should be considered only in the presence of three relative criteria and including the surgery type in the decision-making algorithm.

Parallel, component training in robotic total mesorectal excision.

There has been widespread adoption of robotic total mesorectal excision (TME) for rectal cancer in recent years. There is now increasing interest in training robotic novice surgeons in robotic TME surgery using the principles of component-based learning. The aims of our study were to assess the feasibility of delivering a structured, parallel, component-based, training curriculum to surgical trainees and fellows. A prospective pilot study was undertaken between January 2021 and May 2021. A dedicated robotic training pathway was designed with two trainees trained in parallel per each robotic case based on prior experience, training grade and skill set. Component parts of each operation were allocated by the robotic trainer prior to the start of each case. Robotic proficiency was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and the EARCS Global Assessment Score (GAS). Three trainees participated in this pilot study, performing a combined number of 52 TME resections. Key components of all 52 TME operations were performed by the trainees. GEARS scores improved throughout the study, with a mean overall baseline score of 17.3 (95% CI 15.1-1.4) compared to an overall final assessment mean score of 23.8 (95% CI 21.6-25.9), p = 0.003. The GAS component improved incrementally for all trainees at each candidate assessment (p < 0.001). Employing a parallel, component-based approach to training in robotic TME surgery is safe and feasible and can be used to train multiple trainees of differing grades simultaneously, whilst maintaining high-quality clinical outcomes.

Integrating a tumour appropriate transanal or robotic assisted approach to total mesorectal excision in high-volume rectal cancer practice is safe and cost-effective.

Total mesorectal excision (TME) is accepted as the gold standard for oncological resection in rectal cancer. The best approach to TME is debated and often surgeons will select a preferred approach. In this study, we aimed to describe how both robotic (R-TME) and transanal (TaTME) TME can be integrated into high-volume rectal cancer surgeon practice with a comparison of clinical and oncological outcomes and cost analysis. A prospective comparative cohort study was performed in a high-volume rectal cancer centre comparing the previous 50 R-TME and 50 TaTME performed by the same surgeon. A comparison of tumour characteristics was performed to highlight a specific role for each technique. Clinical outcomes (operative duration, length of stay (LOS) and perioperative morbidity), cancer quality indicators (resection margin and completeness of TME) and cost analysis were compared. Statistical analysis was performed using IBM SPSS, version 20. R-TME was preferred in mid-rectal cancer, compared to TaTME preferred in low rectal cancer (9 cm vs. 5 cm, p < 0.001). Operative duration was longer in R-TME compared to TaTME (265 vs. 179 min, p < 0.001). Major complications (CD III-IV complications) were experienced in 10% of R-TME and 14% of TaTME (p = 0.476). A 98% (n = 49) clear R0 resection margin was achieved with both R-TME and TaTME and mesorectum quality defined as 'complete' in 86% (n = 43) in R-TME and 82% (n = 41) in TaTME. Length of hospital stay was shorter in R-TME (5 vs. 7 days, p = 0.624). An overall difference of €131 was observed favouring TaTME. In high-volume rectal cancer surgery practice, both R-TME and TaTME can be practised and tailored according to patients and tumour characteristics, with comparable clinical and cancer outcomes and is cost-effective.

An analysis of feasibility of robotic colectomy: post hoc analysis of a phase III randomised controlled trial.

With global expansion of robotic surgery, there is increasing interest in its application in colonic surgery. This study aimed to report the feasibility of robotic assisted colonic resection as a post hoc analysis of a randomised controlled trial (RCT) by comparing outcomes following laparoscopic and robotic colectomy. The PAROS trial was a phase III RCT that compared outcomes in low pressure (LP, 7 mmHg) and standard pressure (SP, 12 mmHg) pneumoperitoneum in elective colectomy. A post hoc analysis was performed to compare clinical and operative outcomes in laparoscopic and robotic colonic resection in a high volume colorectal surgery practice. A health economic comparison was also performed. Data were analysed using IBM SPSS StatisticsTM, version 20. 127 patients were compared [34% (n = 43) robotic, 66% (n = 84) laparoscopic]. LP pneumoperitoneum was practiced in 47% (n = 20) robotic and 50% (n = 42) laparoscopic cases. Cancer procedures were more commonly performed in the robotic group (p = 0.009). Clinical outcomes were comparable including post-operative surgical complications (p = 0.493). Operative times were longer (p = 0.005) but length of hospital stay (LOS) was one day shorter in the robotic group (p = 0.05). Conversion to SP pneumoperitoneum was required in 9.5% (n = 8) of the LP laparoscopic group compared to 2.3% (n = 1) of the LP robotic group. Surgeons reported good operative visibility in all robotic cases and 94% (n = 80) laparoscopic cases. Considering, capital investment and maintenance, instrumentation and LOS, robotic cases were €651 more expensive per case. Robotic-assisted surgery is feasible in colonic resection and may facilitate shorter LOS and the possibility to complete MIS using low pressure pneumoperitoneum.

High Clinical Value of Liquid Biopsy to Detect Circulating Tumor Cells and Tumor Exosomes in Pancreatic Ductal Adenocarcinoma Patients Eligible for Up-Front Surgery.

PURPOSE: Expediting the diagnosis of pancreatic ductal adenocarcinoma (PDAC) would benefit care management, especially for the start of treatments requiring histological evidence. This study evaluated the combined diagnostic performance of circulating biomarkers obtained by peripheral and portal blood liquid biopsy in patients with resectable PDAC. EXPERIMENTAL DESIGN: Liquid biopsies were performed in a prospective translational clinical trial (PANC-CTC #NCT03032913) including 22 patients with resectable PDAC and 28 noncancer controls from February to November 2017. Circulating tumor cells (CTCs) were detected using the CellSearch® method or after RosetteSep® enrichment combined with CRISPR/Cas9-improved KRAS mutant alleles quantification by droplet digital PCR. CD63 bead-coupled Glypican-1 (GPC1)-positive exosomes were quantified by flow cytometry. RESULTS: Liquid biopsies were positive in 7/22 (32%), 13/22 (59%), and 14/22 (64%) patients with CellSearch® or RosetteSep®-based CTC detection or GPC1-positive exosomes, respectively, in peripheral and/or portal blood. Liquid biopsy performance was improved in portal blood only with CellSearch®, reaching 45% of PDAC identification (5/11) versus 10% (2/22) in peripheral blood. Importantly, combining CTC and GPC1-positive-exosome detection displayed 100% of sensitivity and 80% of specificity, with a negative predictive value of 100%. High levels of GPC1+-exosomes and/or CTC presence were significantly correlated with progression-free survival and with overall survival when CTC clusters were found. CONCLUSION: This study is the first to evaluate combined CTC and exosome detection to diagnose resectable pancreatic cancers. Liquid biopsy combining several biomarkers could provide a rapid, reliable, noninvasive decision-making tool in early, potentially curable pancreatic cancer. Moreover, the prognostic value could select patients eligible for neoadjuvant treatment before surgery. This exploratory study deserves further validation.