The Application of Indocyanine Green Fluorescence Imaging During Robotic Liver Resection: A Case-Matched Study.

BACKGROUND: The ICG fluorescence properties are progressively gaining momentum in the HPB surgery. However, the exact impact of ICG application on surgical outcomes is yet to be established. METHODS: Twenty-five patients who underwent ICG fluorescence-guided robotic liver resection were case-matched in a 1:1 ratio to a cohort who underwent standard robotic liver resection. RESULTS: In the ICG group, six additional lesions not diagnosed by preoperative workup and intraoperative ultrasound were identified and resected. Four of the lesions were proved to be malignant. Despite the similar operative time (288 vs. 272 min, p = 0.778), the risk of postoperative bile leakage (0% vs. 12%, p = 0.023), R1 resection (0% vs. 16%, p = 0.019) and readmission (p = 0.023) was reduced in the ICG group compared with the no-ICG group. CONCLUSIONS: The ICG fluorescence is a real-time navigation tool which enables surgeons to enhance visualization of anatomical structures and overcome the disadvantages of minimally invasive liver resection. The procedure is not time-consuming, and its applications can reduce the postoperative complication rate in robotic liver surgery.

Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery.

BACKGROUND: To audit the safety of the early hospital discharge care model offered by a Hospital-at-home (HAH) unit during early postoperative follow-up of these patients, and to determine whether this care model is more efficient compared to the traditional care model. METHODS: A prospective study of 50 patients included consecutively for 1 year in an early discharge programme after laparoscopic colorectal surgery was performed. As of day 3 after surgery, if the patient met the relevant inclusion criteria they were transferred to the HAH unit. The domiciliary protocol consists of daily clinical follow-up and a series of analytical controls with the purpose of early detection of postoperative complications. If the clinical course was favourable on day 7 after the postoperative period the patient was discharged. RESULTS: A total of 66% were males, and the mean age was 60.6 years. The surgical procedure most commonly performed was sigmoidectomy. The mean stay was 5.5 days. There were no deaths during follow-up. The average estimated cost per day of stay in a HAH system was EUR 174.29 whilst the same average cost on a surgery ward stood at EUR 1,032.42. CONCLUSIONS: For patients undergoing major colorectal surgery with minimally invasive surgical technique, an early hospital discharge care programme by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

Robotic Assisted Transanal Polypectomies: Is There Any Indication? / Polipectomía transanal asistida por robot: ¿tiene alguna indicación?

OBJECTIVES: Robotic assisted transanal polipectomy may have advantages compared with the conventional transanal minimally invasive surgery technique. We evaluate the safety, feasibility and advantages of this technique. METHODS: Between February 2014 and October 2015, 9patients underwent robotic transanal polypectomy. We performed a retrospective study in which we analyse prospectively collected data regarding patient and tumor characteristics, perioperative outcomes, pathological report, morbidity and mortality. RESULTS: A total of 5 male and 4 female patients underwent robotic TAMIS. Lesions were 6,22cm from the anal verge. Mean size was 15,8cm2. All procedures were performed in the lithotomy position. Closure of the defect was performed in all cases. Mean blood loss was 39,8ml. Mean operative time was 71,9min. No severe postoperative complications or readmissions occured. Median hospital stay was 2,5 days. CONCLUSIONS: Robotic TAMIS is useful to treat complex rectal lesions. Our transanal platform allowed a wider range of movements of the robotic arms and to perform all procedures in the lithotomy position.

[Initial results of robotic esophagectomy for esophageal cancer]. / Resultados iniciales de la esofaguectomía robótica en el cáncer de esófago.

INTRODUCTION: There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. PATIENTS AND METHODS: Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. RESULTS: Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). CONCLUSIONS: Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

[Effects of surgical simulation on the implementation of laparoscopic colorectal procedures]. / Efecto de la simulación quirúrgica en la implementación clínica de procedimientos colorrectales laparoscópicos.

INTRODUCTION: Advanced laparoscopic surgery requires supplementary training outside the operating room. Clinical simulation with animal models or cadavers facilitates this learning. OBJECTIVE: We measured the impact on clinical practice of a laparoscopic colorectal resection training program based on surgical simulation. MATERIAL AND METHODS: Between March 2007 and March 2012, 163 surgeons participated in 30 courses that lasted 4 days, of 35 hours (18 h in the operating room, 12h in animal models, and 4h in seminars). In May 2012, participants were asked via an on-line survey about the degree of implementation of the techniques in their day-to-day work. RESULTS: Seventy surgeons (47%) from 60 different hospitals answered the survey. Average time elapsed after the course was 11.5 months (2-60 months). A total of 75% initiated or increased the number of surgeries performed after the training. The increase in practice was>10 cases/month in 19%, and<5 cases/month in 56% of surgeons. 38% of participants initiated this surgical approach. CONCLUSIONS: Seventy five percent of the surveyed surgeons increased the clinical implementation of a complicated surgical technique, such as laparoscopic colorectal surgery, after attending a training course based on clinical simulation.

[Transanal endoscopic operations for rectal tumours]. / Cirugía endoscópica transanal en tumores rectales.

BACKGROUND: Transanal endoscopic operation (TEO) may be the technique of choice for the treatment of rectal lesions, both benign and selected malignant lesions, with similar survival rates to conventional surgery but with lower morbidity. METHODS: In this article we present a series of 70 patients operated on with this procedure (TEO) in our center. The indications were benign rectal lesions and malignant lesions at early stages (T1) 86%. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-surgery,…). RESULTS: The indication in 43 patients was a benign lesion (adenoma), in the other 27 the diagnosis was adenocarcinoma. After the resection, 61% of the series had a malignant lesion in the pathology report: 13 patients of the 43 with a benign lesion initially had a malignant lesion in the pathology report. Postoperative morbidity was 36%, Clavien III (5,7%). 3 patients (4%) needed emergency surgery. All of the benign lesions were completely excised, but 7 malignant lesions had resection margin involvement The median follow-up time was 26,4 months (range, 1-71 months), the overall recurrence for benign tumors was 9%, 8% for malignant pT1 and 12,5% for malignant pT2. Early salvage surgery was performed on 8 patients. CONCLUSIONS: TEO allows us to excise benign rectal lesions that could not be excised with a conventional approach (endoscopic or transanal resection) with a low morbidity rate. TEO can be used for malignant rectal tumors in early stages (pT1) with pathological confirmation.

New technique of transanal proctectomy with completely robotic total mesorrectal excision for rectal cancer.

Anterior resection with total mesorectal excision is the standard method of rectal cancer resection. However, this procedure remains technically difficult in mid and low rectal cancer. A robotic transanal proctectomy with total mesorectal excision and laparoscopic assistance is reported in a 57 year old male with BMI 32 kg/m2 and rectal adenocarcinoma T2N1M0 at 5 cm from the dentate line. Operating time was 420 min. Postoperative hospital stay was 6 days and no complications were observed. Pathological report showed a 33 cm specimen with ypT2N0 adenocarcinoma at 2 cm from the distal margin, complete TME and non affected circumferential resection margin. Robotic technology might reduce some technical difficulties associated with TEM/TEO or SILS platforms in transanal total mesorectal excision. Further clinical trials will be necessary to assess this technique.

Adherence to recommendations by infectious disease consultants and its influence on outcomes of intravenous antibiotic-treated hospitalized patients.

BACKGROUND: Consultation to infectious diseases specialists (ID), although not always performed by treating physicians, is part of hospital's daily practice. This study analyses adherence by treating physicians to written ID recommendations (inserted in clinical records) and its effect on outcome in hospitalized antibiotic-treated patients in a tertiary hospital in Spain. METHODS: A prospective, randomized, one-year study was performed. Patients receiving intravenous antimicrobial therapy prescribed by treating physicians for 3 days were identified and randomised to intervention (insertion of written ID recommendations in clinical records) or non-intervention. Appropriateness of empirical treatments (by treating physicians) was classified as adequate, inadequate or unnecessary. In the intervention group, adherence to recommendations was classified as complete, partial or non-adherence. RESULTS: A total of 1173 patients were included, 602 in the non-intervention and 571 in the intervention group [199 (34.9%) showing complete adherence, 141 (24.7%) partial adherence and 231 (40.5%) non-adherence to recommendations]. In the multivariate analysis for adherence (R2 Cox=0.065, p=0.009), non-adherence was associated with prolonged antibiotic prophylaxis (p=0.004; OR=0.37, 95%CI=0.19-0.72). In the multivariate analysis for clinical failure (R2 Cox=0.126, p<0.001), Charlson index (p<0.001; OR=1.19, 95%CI=1.10-1.28), malnutrition (p=0.006; OR=2.00, 95%CI=1.22-3.26), nosocomial infection (p<0.001; OR=4.12, 95%CI=2.27-7.48) and length of hospitalization (p<0.001; OR=1.01, 95%CI=1.01-1.02) were positively associated with failure, while complete adherence (p=0.001; OR=0.35, 95%CI=0.19-0.64) and adequate initial treatment (p=0.010; OR=0.39, 95%CI=0.19-0.80) were negatively associated. CONCLUSIONS: Adherence to ID recommendations by treating physicians was associated with favorable outcome, in turn associated with shortened length of hospitalization. This may have important health-economic benefits and stimulates further investigation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN83234896. http://www.controlled-trials.com/isrctn/sample_documentation.asp.

Implementation of an enhanced recovery after surgery program with robotic surgery in high-risk patients obtains optimal results after colorectal resections.

Enhanced recovery after surgery programs reduce postoperative complications and length of stay after laparoscopic colorectal surgery, but are still under evaluation after robotic colorectal surgery. To evaluate potential benefits in terms of length of stay and complications of an Enhanced recovery after surgery program in colorectal surgery. A subanalysis was performed to assess what combination of surgical approach and perioperative care had better outcomes. Prospective observational cohort study. 300 consecutive colorectal surgery patients: 150 were prospectively included in the enhanced recovery after Surgery program group and 150 retrospectively in the traditional care group, and subdivided according to the type of surgery, in Hospital Marques de Valdecilla, between 2013 and 2016. Postoperative complications decreased significantly (p = 0.002) from 46 to 28% (traditional care vs program group). The length of stay was decreased by 2 days (p < 0.001). Multivariate analysis indicated similar effect sizes after adjusting for age, gender, Charlson score, and type of surgery. Type of surgery was an independent predictive factor for postoperative complications and length of stay. Compared to open surgery, postoperative complications decreased by 50% (p < 0.001) after robotic surgery and by 40% (p = 0.01) after laparoscopic surgery, while the median length of stay decreased by three days (p < 0.001) after minimally invasive surgery. Enhanced recovery after surgery program and minimally invasive surgery were associated with decreased morbidity and length of stay after colorectal surgery compared to open surgery and traditional care. An enhanced recovery after surgery program with robotic surgery in high-risk patients might be beneficial.

Treatment of symptomatic macromastia in a breast unit.

BACKGROUND: Patients suffering from symptomatic macromastia are usually underserved, as they have to put up with very long waiting lists and are usually selected under restrictive criteria. The Oncoplastic Breast Surgery subspeciality requires a cross-specialty training, which is difficult, in particular, for trainees who have a background in general surgery, and not easily available. The introduction of reduction mammaplasty into a Breast Cancer Unit as treatment for symptomatic macromastia could have a synergic effect, making the scarce therapeutic offer at present available to these patients, who are usually treated in Plastic Departments, somewhat larger, and accelerating the uptake of oncoplastic training as a whole and, specifically, the oncoplastic breast conserving procedures based on the reduction mammaplasty techniques such as displacement conservative techniques and onco-therapeutic mammaplasty. This is a retrospective study analyzing the outcome of reduction mammaplasty for symptomatic macromastia in our Breast Cancer Unit. METHODS: A cohort study of 56 patients who underwent bilateral reduction mammaplasty at our Breast Unit between 2005 and 2009 were evaluated; morbidity and patient satisfaction were considered as end points. Data were collected by reviewing medical records and interviewing patients. RESULTS: Eight patients (14.28%) presented complications in the early postoperative period, two of them being reoperated on. The physical symptoms disappeared or significantly improved in 88% of patients and the degree of satisfaction with the care process and with the overall outcome were really high. CONCLUSION: Our experience of the introduction of reduction mammaplasty in our Breast Cancer Unit has given good results, enabling us to learn the use of different reduction mammaplasty techniques using several pedicles which made it possible to perform oncoplastic breast conserving surgery. In our opinion, this management policy could bring clear advantages both to patients (large-breasted and those with a breast cancer) and surgeons.

[An adverse event continuous surveillance system in surgical services of the autonomous region of Cantabria (Spain)]. / Sistema de vigilancia continua de eventos adversos en los servicios quirúrgicos de Cantabria.

OBJECTIVE: To design a continuous surveillance system for adverse events (AEs) in surgical services in the Autonomous Community of Cantabria. Through homogeneous methodology, this system will provide the information needed to prevent and control AEs and avoid their recurrence. MATERIAL AND METHODS: We performed a prospective study of the population undergoing inpatient surgery in our service. The methodology used was an adapted version of the IDEA (Identification of Adverse Events) project. Surgeons had access to an intranet website and introduced the data by using a personal login. A web application allowed feedback through report-generation. RESULTS: During the pilot phase, limited collection of variables requiring calculations and of those related to location and causality was observed. Assessment of the system indicated the need for simplification to obtain valid and useful information, as well as the need to provide help windows. The system was redesigned with two data input screens and currently allows for automatic report generation of registered AEs. Information was gathered on 70% of the patients and an incidence of 11.2 AEs/100 admissions was found. Of these, 47% were defined as surgical complications. CONCLUSIONS: Establishing a continuous surveillance system for AEs is feasible if professionals participate in the process, data input is easy and feedback from the system is rapid and useful for implementing corrective measures. This system can be considered highly useful for obtaining information on AEs and consequently on the potential areas of improvement in surgical activity in Spanish hospitals.

Robotic-assisted versus open pancreaticoduodenectomy: the results of a case-matched comparison.

Robotic-assisted pancreaticoduodenectomy (RPD) is progressively gaining momentum. It seems to provide some potential advantages over open approach. Unfortunately, only few studies investigated the impact of RPD on the oncologic outcomes. We performed a 1:1 case-matched comparison between two groups of 35 patients affected by a malignant tumor who underwent RPD and open (OPD) pancreaticoduodenectomy from August 2014 to April 2016. Operative time was longer in the RPD group compared to OPD (355 vs 262 min, p = 0.023), whereas median blood loss (235 vs 575 ml, p = 0.016) and length of hospitalization (6.5 vs 8.9 days, p = 0.041) were lower for RPD. A significant reduction of overall postoperative morbidity rate was found in the RPD group compared to the OPD group (31.4% vs 48.6% p = 0.034). No statistically significant difference was found between the two groups in terms of overall pancreatic fistula rate, R0 resection rate, and number of harvested lymph nodes. The overall and disease-free survival at 1 and 3 years were similar. RPD is a safe and effective technique. It reduces the estimated blood loss, the length hospital of stay and the rate of complications after pancreaticoduodenectomy, while preserving a good oncologic adequacy.

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes.

BACKGROUND: Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV). METHODS: Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics. RESULTS: Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004). CONCLUSIONS: RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

Oncoplastic techniques extend breast-conserving surgery to patients with neoadjuvant chemotherapy response unfit for conventional techniques.

BACKGROUND: Oncoplastic surgery is extending the role of breast-conserving surgery in an increasing number of patients who are unsuitable for conventional breast-conserving techniques. The aim of this retrospective study was to analyze the surgical approach, oncoplastic surgery guided by bracketing, used in the treatment of patients who required a wide breast tissue excision after neoadjuvant chemotherapy. The parameters evaluated were as follows: margin status, rate of re-excision for positive margin, early ipsilateral recurrence, and cosmetic outcomes. METHODS: A total of 23 patients were treated with an oncoplastic breast-conserving surgery one-stage procedure using volume-replacement (20) and volume-displacement techniques (3). We reviewed medical records, mammograms and magnetic resonance images. Cosmetic assessment was carried out by a mixed panel made up of three women: a general practitioner, a resident general surgeon and a nurse. RESULTS: All margins were negative and none of the patients had to have a re-excision for positive margins. One ipsilateral local recurrence was observed after a 32-month follow-up period. Cosmetic outcome was good, with an overall score of 8 out of 10. CONCLUSIONS: Oncoplastic techniques extend breast-conserving surgery to patients with neoadjuvant chemotherapy response unfit for conventional techniques. The surgical approach combining oncoplastic techniques with bracketing allows breast-conserving surgery to be performed in these patients.