Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study.

BACKGROUND: Minimally invasive pancreatoduodenectomy (MIPD) is increasingly being performed because of perceived patient benefits. Whether conversion of MIPD to open pancreatoduodenectomy worsens outcome, and which risk factors are associated with conversion, is unclear. METHODS: This was a post hoc analysis of a European multicentre retrospective cohort study of patients undergoing MIPD (2012-2017) in ten medium-volume (10-19 MIPDs annually) and four high-volume (at least 20 MIPDs annually) centres. Propensity score matching (1 : 1) was used to compare outcomes of converted and non-converted MIPD procedures. Multivariable logistic regression analysis was performed to identify risk factors for conversion, with results presented as odds ratios (ORs) with 95 per cent confidence intervals (c.i). RESULTS: Overall, 65 of 709 MIPDs were converted (9.2 per cent) and the overall 30-day mortality rate was 3.8 per cent. Risk factors for conversion were tumour size larger than 40 mm (OR 2.7, 95 per cent c.i.1.0 to 6.8; P = 0.041), pancreatobiliary tumours (OR 2.2, 1.0 to 4.8; P = 0.039), age at least 75 years (OR 2.0, 1.0 to 4.1; P = 0.043), and laparoscopic pancreatoduodenectomy (OR 5.2, 2.5 to 10.7; P < 0.001). Medium-volume centres had a higher risk of conversion than high-volume centres (15.2 versus 4.1 per cent, P < 0.001; OR 4.1, 2.3 to 7.4, P < 0.001). After propensity score matching (56 converted MIPDs and 56 completed MIPDs) including risk factors, rates of complications with a Clavien-Dindo grade of III or higher (32 versus 34 per cent; P = 0.841) and 30-day mortality (12 versus 6 per cent; P = 0.274) did not differ between converted and non-converted MIPDs. CONCLUSION: Risk factors for conversion during MIPD include age, large tumour size, tumour location, laparoscopic approach, and surgery in medium-volume centres. Although conversion during MIPD itself was not associated with worse outcomes, the outcome in these patients was poor in general which should be taken into account during patient selection for MIPD.

Robotic versus laparoscopic distal pancreatectomy: multicentre analysis.

BACKGROUND: The role of minimally invasive distal pancreatectomy is still unclear, and whether robotic distal pancreatectomy (RDP) offers benefits over laparoscopic distal pancreatectomy (LDP) is unknown because large multicentre studies are lacking. This study compared perioperative outcomes between RDP and LDP. METHODS: A multicentre international propensity score-matched study included patients who underwent RDP or LDP for any indication in 21 European centres from six countries that performed at least 15 distal pancreatectomies annually (January 2011 to June 2019). Propensity score matching was based on preoperative characteristics in a 1 : 1 ratio. The primary outcome was the major morbidity rate (Clavien-Dindo grade IIIa or above). RESULTS: A total of 1551 patients (407 RDP and 1144 LDP) were included in the study. Some 402 patients who had RDP were matched with 402 who underwent LDP. After matching, there was no difference between RDP and LDP groups in rates of major morbidity (14.2 versus 16.5 per cent respectively; P = 0.378), postoperative pancreatic fistula grade B/C (24.6 versus 26.5 per cent; P = 0.543) or 90-day mortality (0.5 versus 1.3 per cent; P = 0.268). RDP was associated with a longer duration of surgery than LDP (median 285 (i.q.r. 225-350) versus 240 (195-300) min respectively; P < 0.001), lower conversion rate (6.7 versus 15.2 per cent; P < 0.001), higher spleen preservation rate (81.4 versus 62.9 per cent; P = 0.001), longer hospital stay (median 8.5 (i.q.r. 7-12) versus 7 (6-10) days; P < 0.001) and lower readmission rate (11.0 versus 18.2 per cent; P = 0.004). CONCLUSION: The major morbidity rate was comparable between RDP and LDP. RDP was associated with improved rates of conversion, spleen preservation and readmission, to the detriment of longer duration of surgery and hospital stay.

The role of tibial nerve stimulation for enhanced postoperative recovery after colorectal surgery: a double-blind, parallel-group, randomized controlled trial.

BACKGROUND: Postoperative ileus (POI) is the most common cause of prolonged hospital stay following abdominal surgery, despite an optimized enhanced recovery after surgery (ERAS) program. The aim of the study was to evaluate the role of postoperative transcutaneous electrical tibial nerve stimulation (TTNS) in the recovery of bowel function and in shortening hospital stay after colonic resection. METHODS: Patients having elective laparoscopic colonic surgery within an ERAS program at our institution between June 2016 and June 2019 were enrolled and randomly assigned to a treatment protocol with TTNS or sham electrical stimulation. The primary endpoint was the time of recovery of gastrointestinal motility, measured as the first passage of stool. Secondary endpoints included: first passage of flatus, length of hospital stay, and complication rate related to the use of TTNS. RESULTS: One hundred and seventy patients who had right hemicolectomy (median age 71 years (range 43-89 years); 47.5% women) and 170 patients who had left colectomy (median age 67 years range (37-92 years); 41.5% women) were enrolled. The only factor significantly affected by TTNS was time to first passage of flatus after right hemicolectomy (reduced from 46 to 33 h, p = 0.04). However, if only patients with low compliance to early oral nutrition (63 of 340; 18.5%) were considered, a statistically significant difference in time until first flatus (p < 0.01) and first bowel movement (p < 0.0001) and a shorter time until discharge (median 5 vs 7 days) were found in both left and right colectomies groups, respectively. CONCLUSIONS: TTNS may have a positive effect on gastrointestinal tract motility and recovery from POI after colorectal surgery in a selected group, who has low compliance with an ERAS program, without increasing the risk of complications.

Role of transanal irrigation in the treatment of anterior resection syndrome.

BACKGROUND: Transanal irrigation(TAI) has been reported to be an inexpensive and effective treatment for low anterior resection syndrome(LARS). The aim of the present prospective study was to evaluate the use of TAI in patients with significant LARS symptoms at a single medical center. METHODS: Patients who had low anterior resection for rectal cancer between April 2015 and May 2016 at the Careggi University Hospital were assessed for LARS using the LARS and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (MSKCC BFI) questionnaires 30-40 days after  surgery or ileostomy closure (if this was done). Quality of life was evaluated using a visual analog scale and the Short Form-36 Health Survey. All patients with LARS score of 30 or higher were included (early LARS) as were all patients with a LARS score of 30 or higher referred 6 months or longer after surgery performed elsewhere (chronic LARS) in the same study period. Study participants were trained to perform TAI using the Peristeen™ System for 6 months, followed by 3 months of enema therapy following a similar protocol. RESULTS: Thirty-three patients were enrolled in the study. Six patients stopped the treatment. The 27 patients (19 early LARS and 8 chronic LARS) who completed the study had a significant decrease in the number of median daily bowel movements [baseline 7 (range 0-14); 6 months 1 (range 0-4); 9 months 4 (range 0-13)]. The median LARS Score fell from 35.1 (range 30-42) (baseline) to 12.2 (range 0-21) after 6 months (p < 0.0001) and then rose to 27 (range 5-39) after 3 months of enema therapy. There was no difference in LARS score decrease at 6 months between the patients with early and chronic LARS (22.5 and 23.9 respectively; p=0.7) and there were no predictors of score decrease. Four components of the SF-36 significantly improved during the TAI period. The MSKCC BFI score significantly improved in several domains. Twenty-three patients (85%) asked to continue the treatment with TAI after the study ended. CONCLUSIONS: TAI appears to be an effective treatment for LARS and results in a marked improvement of continence and quality of life.  Patients may be assessed and treated for LARS early after surgery since the treatment benefit is similar to that observed in patients with LARS diagnosed  6 months or longer after surgery. The potential rehabilitative role of TAI for LARS is promising and should be further investigated.

[Splenic artery pseudoaneurysm: a rare case of gastrointestinal haemorrhage in a patient with chronic pancreatitis]. / Pseudoaneurisma dell'arteria splenica: insolito caso di emorragia gastrointestinale in paziente con pancreatite cronica.

A bleeding pseudoaneurysm in patients with chronic pancreatitis is a rare and potentially lethal complication. This diagnosis may be very difficult and the optimal treatment remains controversial. We report the case of 80 years old female with calcific pancreatitis and severe intestinal bleeding due to a pseudoaneurysm of the splenic artery treated with interventional radiographic embolization.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study.

INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

[Laparoscopic versus open resection for colorectal cancer: meta-analysis of the chief trials]. / Laparoscopia vs. laparotomia nelle resezioni per cancro colorettale. Metanalisi dei principali trial.

BACKGROUND: The objective of this study is in the critical analysis of the results of the lap and open surgery in the colorectal carcinoma, through the meta-analysis of the principal trials. PATIENTS AND METHODS: A systematic search of the comparative studies has been made among lap and open surgery in the colorectal carcinoma, using PubMed and Cochrane Library. Among these, have been selected perspective studies containing the description of the surgical techniques, the perioperative results and the oncological long term results. Statistic analysis has been performed with the program NCSS (Kaysville 2006, Utah). RESULTS: From the revision of the literature, 7 perspective studies have checked fit to a meta-analysis, for a total of 3580 patients. Among the operative outcomes, has been observed, with statistically significant, a reduction of the blood loss and of the morbidity, an earlier resumption to passing flatus and to normal diet, a reduction of the postoperative hospitalization for the lap; shorter operative time is releaved for the open surgery. Statistically significant differences have emerged neither on the other surgical outcomes (included mortality) nor on relapset of illness (regional or metastasis), crab-correlated mortality, long term survival. CONCLUSIONS: The laparoscopic can be considered a valid alternative to the traditional open surgery in the therapy of the colorectal carcinoma: the advantages consist in smaller trauma and reduction of morbidity and postoperative stay. The oncological results are the same of the open surgery.

Surgical and oncological outcomes of our first 59 cases of robotic pancreaticoduodenectomy.

PURPOSE: Robotics has shown encouraging results for a number of technically demanding abdominal surgeries including pancreaticoduodenectomy, which has originally represented a relative contraindication to the application of the minimally-invasive technique. We aimed to investigate the perioperative, clinicopathologic, and oncological outcomes of robot-assisted pancreaticoduodenectomy by assessing a consecutive series of totally robotic procedures. METHODS: All consecutive patients who underwent robotic pancreaticoduodenectomy were included in the present analysis. Perioperative, clinicopathologic and oncological outcomes were examined. In order to investigate the role of the learning curve, surgical outcomes were also used to compare the early and the late phase of our experience. RESULTS: A total of 59 patients underwent surgery. Median hospital stay was 9 days (5 - 110), with an overall morbidity and mortality of 37% and 3%, respectively. Of note, the rate of clinically relevant pancreatic fistula was 11.8%. R0 resections were achieved in 96% of patients and the 3-year disease-free and overall survivals were 37.2 and 61.9%, respectively. Overall, surgical outcomes did not vary significantly between the first and the late phase of the series. CONCLUSIONS: Robotic pancreaticoduodenectomy can be performed competently. It satisfies all features of oncological adequacy and may offer a number of advantages over standard procedures in terms of surgical results.

Robot-assisted gastrectomy for cancer.

BACKGROUND: Laparoscopic gastrectomy for cancer is commonly considered a challenging procedure. The technical drawbacks of laparoscopy have been addressed by robotic technology, which can facilitate demanding reconstructions and fine dissection. These features confer potential advantages in the execution of lymphadenectomy. OBJECTIVES: Here, we illustrate our technique of robotic gastrectomy and discuss advantages and drawbacks by reviewing the current literature. MATERIALS AND METHODS: We describe our technique for robot-assisted distal and total gastrectomy for cancer and assess the current literature dealing with short-term outcomes, immediate oncologic measures, and long-term oncologic outcomes of robot-assisted gastrectomy, in comparison with conventional laparoscopic and open surgery. RESULTS: The robotic procedure seems to be as safe and effective as conventional gastrectomy for gastric cancer, with a longer operative time and decreased blood loss in comparison with laparoscopic gastrectomy. CONCLUSION: The technical advantages offered by robotics could help to standardize minimally invasive D2 lymphadenectomy and enable surgeons to perform this procedure routinely. Despite the scarcity of long-term data on survival, immediate oncological measures (lymph node yield and margin status) are encouraging. Further studies investigating the long-term oncological outcomes are required.

[Robot-assisted gastrectomy for cancer. German version]. / Roboterassistierte Magenresektion beim Karzinom.

BACKGROUND: Laparoscopic gastrectomy for cancer is commonly considered a challenging procedure. The technical drawbacks of laparoscopy have been addressed by robotic technology, which can facilitate demanding reconstructions and fine dissection. These features confer potential advantages in the execution of lymphadenectomy. OBJECTIVES: Here, we illustrate our technique of robotic gastrectomy and discuss advantages and drawbacks by reviewing the current literature. MATERIALS AND METHODS: We describe our technique for robot-assisted distal and total gastrectomy for cancer and assess the current literature dealing with short-term outcomes, immediate oncologic measures, and long-term oncologic outcomes of robot-assisted gastrectomy, in comparison with conventional laparoscopic and open surgery. RESULTS: The robotic procedure seems to be as safe and effective as conventional gastrectomy for gastric cancer, with a longer operative time and decreased blood loss in comparison with laparoscopic gastrectomy. CONCLUSION: The technical advantages offered by robotics could help to standardize minimally invasive D2 lymphadenectomy and enable surgeons to perform this procedure routinely. Despite the scarcity of long-termdata on survival, immediate oncological measures (lymph node yield and margin status) are encouraging. Further studies investigating the long-term oncological outcomes are required.

Robot-assisted surgery for gastric carcinoma: Five years follow-up and beyond: A single western center experience and long-term oncological outcomes.

INTRODUCTION: Robot-assisted surgery for the treatment of gastric cancer is considered to be safe and feasible with early post-operative outcomes comparable to open and laparoscopic series. However, data regarding long-term oncological outcomes are lacking. Aim of this study is to evaluate long-term oncological outcomes of a cohort of gastric cancer patients treated surgically with the robot-assisted approach. MATERIALS AND METHODS: A prospectively collected database of robot-assisted gastrectomies performed for gastric cancer at the 'Misericordia Hospital' between September 2001 and October 2011 was retrospectively analysed. Data regarding surgical procedures, early postoperative course, and long-term follow-up were analysed. RESULTS: The study included 98 consecutive robot-assisted gastrectomies. Fifty-nine distal gastrectomies, 38 total gastrectomies, and 1 proximal gastrectomy. Open conversion occurred in seven patients (7.1%) due to locally advanced disease. Postoperative morbidity and mortality were 12.2% and 4.1% respectively. Post-operative staging showed 46 patients (46.9%) with stage I disease, 25 patients (25.5%) with stage II, 26 (26.5%) with stage III and 1 (1.02%) with stage IV. The mean follow-up was 46.9 months. Cumulative 5-year overall survival (OS) was 73.3% (95% CI: 62.2-84.4). Five-year survival by stage subgroups was 100% for patients with stage IA, 84.6% for stage IB, 76.9% for stage II, and 21.5% for stage III. The only patient in stage IV of this series died eight months after surgery. CONCLUSIONS: Robot-assisted gastrectomy for the treatment of gastric cancer is safe and feasible. It provides long-term outcomes comparable to most open and laparoscopic series. Further studies are necessary to better define its indication.

Challenges in robotic distal pancreatectomy: systematic review of current practice.

Over the last decade, robotics has gained popularity and is increasingly employed to accomplish several abdominal surgical procedures. Nevertheless, pancreatectomies are regarded as demanding procedures for which the application of minimally-invasive surgery is still limited and its effectiveness has not been conclusively established. We aimed to investigate the current role of robot-assisted surgery to perform distal pancreatectomy. A systematic review of the English-language literature was conducted for articles dealing with robotic-assisted distal pancreatectomies. All relevant papers were evaluated on surgical and oncological outcomes. A total of 10 articles reporting on robotic distal pancreatectomies were finally considered in the analysis, including 259 patients. Mean operative time was 271 minutes (range 181-398); mean blood loss was 210 mL (range 104-361), in 11.6% of cases conversion to laparotomy occurred, spleen preservation was accomplished in 51.4% of procedures, mean time of postoperative hospital stay was 7 days. Overall, postoperative mortality and morbidity were 0% and 23.4% respectively, the mean number of lymph nodes harvested was 12.7. In all included series, no case of R1 resection was reported. Despite its relatively recent introduction in clinical practice, robotic-assisted surgery has been widely employed to perform distal pancreatectomy worldwide and it should be considered a safe and effective procedure. Both surgical and pathologic data support its application in the management of pancreatic lesions of the body and tail.

Effects of hydrogen sulfide (H2S) on mesenteric perfusion in experimental induced intestinal ischemia in a porcine model.

INTRODUCTION: Insufficient mesenteric perfusion is a dramatic complication in critically ill patients. Hydrogen sulfide, a newly recognized endogenous gaseous mediator, acts as an intestinal vasoactive agent and seems to protect against mesenteric ischemic damage. We investigated whether sodium hydrogen sulfide, a hydrogen sulfide donor, can improve mesenteric perfusion in an experimental model of pigs, both in physiological and ischemic conditions. METHODS: The study was conducted at Careggi University Hospital (Florence, IT). Fourteen male domestic pigs (≈10 Kg) were anesthetized and mechanically ventilated. Animals were randomized in control and ischemia groups. Mesenteric ischemia was induced with a positive end-expiratory pressure of 15 cmH2O. After mini-laparotomy, each animal received incremental doses of sodium hydrogen sulfide every 20 minutes. Perfusion of both the jejunal mucosa and sternal skin were measured by laser Doppler flowmeter, and systemic hemodynamic parameters were monitored. RESULTS: In the control group, sodium hydrogen sulfide was able to significantly improve the mesenteric perfusion, showing a 50% increase from the baseline blood flow. In the ischemia group, NaHS-induced a two-fold increase of the mesenteric post-ischemic perfusion with a recovery up to 70% of pre- positive end-expiratory pressure mesenteric blood flow. Sodium hydrogen sulfide did not directly or indirectly (by blood flow redistribution) affect the sternal skin microcirculation, heart rates, or mean arterial pressure, suggesting a tissue-specific micro-vascular action. CONCLUSIONS: In a porcine model, we observed a mesenteric perfusion recovery mediated by administration of hydrogen sulfide donor without affecting general hemodynamic.

Successful surgical repair of a ruptured abdominal aortic aneurysm in a nonagenarian.

Mortality due to the surgical treatment of ruptured abdominal aortic aneurysms (RAAA) is high, more than 40%, especially in elderly patients. The literature concerning RAAA in very elderly patients is analyzed by Internet research (Medline). Only rare examples of emergency surgical management in nonagenarian patients are reported, and even fewer reports of successfully operated patients. A case report of a successful surgical repair of RAAA in a nonagenarian is presented. After ultrasound (US) and CT scans, the patient (in good condition as regards blood pressure, respiratory, cardiac and renal function) underwent uneventful aneurysmectomy and reconstruction of the aorta and common iliac arteries by means of a bifurcated prosthesis. The length of hospitalization was 30 days and the patient is still alive and in good condition four years and two months after the operation. The advisability of emergency surgical repair in these patients, questionable because of the excessive surgical risk and poor survival benefit, is discussed. However many other factors affect the outcome of emergency repair (mainly cardiac, respiratory and renal function), independently of age. The authors conclude that age per se does not limit the indication for or success of surgery in very elderly patients.

Effects of carotid thromboendarterectomy on circulating endothelin-1.

The aim of this study was to investigate the behaviour of circulating ET-1 in patients with carotid atherosclerosis, before and after carotid thromboendarterectomy (TEA), to test the hypothesis that plasma ET-1 decreases after removal of atherosclerotic lesion. Plasma immunoreactive ET-1 levels were determined in 17 patients with symptomatic and/or hemodynamically significant carotid atherosclerosis on the day before TEA, 48 h and 72 h after surgery and, in 11 of them, also after 8 h and 24 h. Compared to controls, ET-1 levels were significantly higher both before and after TEA; after carotid revascularisation (8 h) ET-1 increased; then, from the 24th h, ET-1 gradually decreased and at the 48th h and 72th h the decrease was significant in front of basal values. The increase of plasma ET-1 in the acute postoperative phase may reflect the degree of surgical stress and manipulation in diseased blood vessels; the following decrease may indicate the improvement of vascular dysfunction in the involved carotid site; the persistence of high ET-1 levels 72 h after surgery could suggest the presence of residual ischemia in the involved district and/or the involvement of other sites in ET-1 production.