Novel prognostic factors after radical resection of hepatocellular carcinoma: Updating an old issue.

In this editorial, I comment on the article by Li et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2023, investigating the role of some novel prognostic factors for early survival after radical resection of liver cancer. Liver cancer is an important burden among Asian and Western populations, despite recent advances in both medicine (from virus eradication to systemic target therapies) and surgery. However, survival after proven radical surgery remains poor, with recurrences being the rule. Many prognostic scores have been developed and validated to select those patients who will best benefit from radical liver surgery, although the final general and oncological outcomes continue to be highly jeopardized. Unfortunately, no single biomarker can resolve all these issues for hepatocellular carcinoma, and it remains to be proven whether some of them maintain predictive power in the long-term follow-up. In the ongoing era of "precision" medicine, the novel prognostic markers, including immune inflammatory and nutritional indexes could be of great help in better stratify surgical candidates.

The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis.

BACKGROUND: Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity between these tumors. Therefore, this study aimed to evaluate the role of MIPD compared to open pancreatoduodenectomy (OPD) in patients with non-pancreatic periampullary cancer (NPPC). METHODS: A systematic review of Pubmed, Embase, and Cochrane databases was performed by two independent reviewers to identify studies comparing MIPD and OPD for NPPC (ampullary, distal cholangio, and duodenal adenocarcinoma) (01/2015-12/2021). Individual patient data were required from all identified studies. Primary outcomes were (90-day) mortality, and major morbidity (Clavien-Dindo 3a-5). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood-loss, length of hospital stay (LOS), and overall survival (OS). RESULTS: Overall, 16 studies with 1949 patients were included, combining 928 patients with ampullary, 526 with distal cholangio, and 461 with duodenal cancer. In total, 902 (46.3%) patients underwent MIPD, and 1047 (53.7%) patients underwent OPD. The rates of 90-day mortality, major morbidity, POPF, DGE, PPH, blood-loss, and length of hospital stay did not differ between MIPD and OPD. Operation time was 67 min longer in the MIPD group (P = 0.009). A decrease in DFS for ampullary (HR 2.27, P = 0.019) and distal cholangio (HR 1.84, P = 0.025) cancer, as well as a decrease in OS for distal cholangio (HR 1.71, P = 0.045) and duodenal cancer (HR 4.59, P < 0.001) was found in the MIPD group. CONCLUSIONS: This individual patient data meta-analysis of MIPD versus OPD in patients with NPPC suggests that MIPD is not inferior in terms of short-term morbidity and mortality. Several major limitations in long-term data highlight a research gap that should be studied in prospective maintained international registries or randomized studies for ampullary, distal cholangio, and duodenum cancer separately. PROTOCOL REGISTRATION: PROSPERO (CRD42021277495) on the 25th of October 2021.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy.

Because distal pancreatectomy (DP) has no reconstructive steps and less frequent vascular involvement, it is thought to be the easier counterpart of pancreaticoduodenectomy. This procedure has a high surgical risk and the overall incidences of perioperative morbidity (mainly pancreatic fistula), and mortality are still high, in addition to the challenges that accompany delayed access to adjuvant therapies (if any) and prolonged impairment of daily activities. Moreover, surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes. From this perspective, new surgical approaches, and aggressive techniques, such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection, could lead to improved survival in those affected by more locally advanced tumors. Conversely, minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress. The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications, length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy. Because a dedicated multidisciplinary team is crucial to pancreatic surgery, hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign, borderline, and malignant diseases of the pancreas. The purpose of this review is to examine the state of the art in distal pancreatectomies, with a special focus on minimally invasive approaches and oncological-directed techniques. The widespread reproducibility, cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

A national survey on the current status of minimally invasive gastric practice on behalf of GIRCG.

Italian Research Group for Gastric Cancer (GIRCG), during the 2013 annual Consensus Conference to gastric cancer, stated that laparoscopic or robotic approach should be limited only to early gastric cancer (EGC) and no further guidelines were currently available. However, accumulated evidences, mainly from eastern experiences, have supported the application of minimally invasive surgery also for locally advanced gastric cancer (AGC). The aim of our study is to give a snapshot of current surgical propensity of expert Italian upper gastrointestinal surgeons in performing minimally invasive techniques for the treatment of gastric cancer in order to answer to the question if clinical practice overcome the recommendation. Experts in the field among the Italian Research Group for Gastric Cancer (GIRCG) were invited to join a web 30-item survey through a formal e-mail from January 1st, 2020, to June 31st, 2020. Responses were collected from 46 participants out of 100 upper gastrointestinal surgeons. Percentage of surgeons choosing a minimally invasive approach to treat early and advanced gastric cancer was similar. Additionally analyzing data from the centers involved, we obtained that the percentage of minimally invasive total and partial gastrectomies in advanced cases augmented with the increase of surgical procedures performed per year (p = 0.02 and p = 0.04 respectively). It is reasonable to assume that there is a widening of indications given by the current national guideline into clinical practice. Propensity of expert Italian upper gastrointestinal surgeons was to perform minimally invasive surgery not only for early but also for advanced gastric cancer. Of interest volume activity correlated with the propensity of surgeons to select a minimally invasive approach.

Isoforms of the orphan nuclear receptor COUP­TFII differentially modulate pancreatic cancer progression.

The expression of the nuclear receptor transcription factor (TF) COUP­TFII is broadly associated with cell differentiation and cancer development, including of pancreatic ductal adenocarcinoma (PDAC), a devastating disease with one of the poorest prognoses among cancers worldwide. Recent studies have started to investigate the pathological and physiological roles of a novel COUP­TFII isoform (COUP­TFII_V2) that lacks the DNA­binding domain. As the role of the canonical COUP­TFII in PDAC was previously demonstrated, the present study evaluated whether COUP­TFII_V2 may have a functional role in PDAC. It was demonstrated that COUP­TFII_V2 naturally occurs in PDAC cells and in primary samples, where its expression is consistent with shorter overall survival and peripheral invasion. Of note, COUP­TFII_V2, exhibiting nuclear and cytosolic expression, is linked to epithelial to mesenchymal transition (EMT) and cancer progression, as confirmed by nude mouse experiments. The present results demonstrated that COUP­TFII_V2 distinctively regulates the EMT of PDAC and, similarly to its sibling, it is associated with tumor aggressiveness. The two isoforms have both overlapping and exclusive functions that cooperate with cancer growth and dissemination. By studying how PDAC cells switch from one isoform to the other, novel insight into cancer biology was gained, indicating that this receptor may serve as a novel possible target for PDAC management.

Neonatal Nav1.5 Protein Expression in Human Colorectal Cancer: Immunohistochemical Characterization and Clinical Evaluation.

Voltage-gated Na+ channels (VGSCs) are expressed widely in human carcinomas and play a significant role in promoting cellular invasiveness and metastasis. However, human tissue-based studies and clinical characterization are lacking. In several carcinomas, including colorectal cancer (CRCa), the predominant VGSC is the neonatal splice variant of Nav1.5 (nNav1.5). The present study was designed to determine the expression patterns and clinical relevance of nNav1.5 protein in human CRCa tissues from patients with available clinicopathological history. The immunohistochemistry was made possible by the use of a polyclonal antibody (NESOpAb) specific for nNav1.5. The analysis showed that, compared with normal mucosa, nNav1.5 expression occurred in CRCa samples (i) at levels that were significantly higher and (ii) with a pattern that was more delineated (i.e., apical/basal or mixed). A surprisingly high level of nNav1.5 protein expression also occurred in adenomas, but this was mainly intracellular and diffuse. nNav1.5 showed a statistically significant association with TNM stage, highest expression being associated with TNM IV and metastatic status. Interestingly, nNav1.5 expression co-occurred with other biomarkers associated with metastasis, including hERG1, KCa3.1, VEGF-A, Glut1, and EGFR. Finally, univariate analysis showed that nNav1.5 expression had an impact on progression-free survival. We conclude (i) that nNav1.5 could represent a novel clinical biomarker ('companion diagnostic') useful to better stratify CRCa patients and (ii) that since nNav1.5 expression is functional, it could form the basis of anti-metastatic therapies including in combination with standard treatments.

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 Liver Resection in Hepatocarcinoma: Surgical and Oncological Outcomes.

BACKGROUND: Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited. MATERIALS AND METHODS: We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma. RESULTS: No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203). CONCLUSIONS: The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach.

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.

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.

Association Between Compliance to an Enhanced Recovery Protocol and Outcome After Elective Surgery for Gastric Cancer. Results from a Western Population-Based Prospective Multicenter Study.

BACKGROUND: The association between compliance to an enhanced recovery protocol (ERAS) and outcome after surgery for gastric cancer has been poorly investigated, particularly in Western patients. The aim of the study was to evaluate whether the rate of adherence to the ERAS program was correlated with outcome and time of discharge. METHODS: A prospective, observational, multicenter study was designed to be performed at Italian referral centers for gastric surgery. The protocol was discussed and approved by the Italian Research Group on Gastric Cancer. Twenty-three ERAS domains were applied. A multivariate logistic regression was used to assess the association between ERAS compliance and overall and major complication rates. The Poisson regression model (measured as mean ratios) was used to assess the association of ERAS compliance rate and length of stay (LOS). RESULTS: Eight centers participated and 290 subjects with a median age of 73 years were enrolled. The overall rates of adherence to pre-, intra-, and postoperative ERAS items were 69.8%, 60.3%, and 82.5%, respectively. At the multivariate model, there was an association between overall rate of morbidity and an overall ERAS compliance rate greater than 70% (OR 0.413; 95% CI 0.235-0.7240; P 0.002). A similar association was found for major complications (OR 0.328; 95% CI 0.151-0.709; P 0.005). The Poisson regression showed that in patients with ERAS compliance rate >70%, LOS was reduced of approximately 20% (mean ratio 0.812; 95% CI 0.694-0.950; P 0.009). CONCLUSIONS: These results suggest a moderate compliance to an ERAS program and a significant association between adherence and outcomes.

Robotic distal pancreatectomy with selective closure of pancreatic duct: surgical outcomes.

Pancreatic fistula is the main post-operative complication of distal pancreatectomy associated with other further complications, such as intra-abdominal abscesses, wound infection, sepsis, electrolyte imbalance, malabsorption and hemorrhage. Surgeons have tried various techniques to close the stump of the remaining pancreas, but the controversy regarding the impact of stapler closure and suture closure of the pancreatic stump is far from resolved. In this study, we reported our technique and results of robotic assisted distal pancreatectomy with ultrasound identification and consequent selective closure of pancreatic duct. Twenty-one patients underwent consecutive robotic-assisted distal pancreatectomy were included in our study. We describe our technique and analyzed the operative and peri-operative data including mean operative time, intra-operative bleeding, blood transfusions necessity, conversion rate, mortality and morbidity rate, pancreatic fistula rate and grade, time of refeeding and canalization, length of hospital stay and readmission. Median operative time was 260 min. No conversion occurred. Estimated blood loss was 100 mL (range 50-200). No blood transfusions were performed. Mortality rate was 0%. One (5%) patient had a major complication, while 9 (43%) patients had minor complications (grade I). Three (14%) patients developed pancreatic fistula (grade B), while two (10%) patients had a biochemical leak. No late pancreatic fistula and re-operation occurred. The refeeding was started at second day (range 1^-6^) and the median canalization time was 4 days (range 2-7). The median hospital stay was 6 days (range 3-25) with a readmission rate of 0%. Robotic distal pancreatectomy can be considered safe and feasible. Our technique is easily reproducible, with good surgical results.

Robotic enucleations of pancreatic benign or low-grade malignant tumors: preliminary results and comparison with robotic demolitive resections.

BACKGROUND: The incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. The surgical management of these patients is still under debate. The aim of this paper is to evaluate the safety and feasibility of robotic enucleations and to compare the outcomes with non-parenchymal sparing robotic resections. METHODS: The study included a total of 25 patients. Nine of them underwent a robotic enucleation (EN Group) and 16 patients received a robotic demolitive resection (DR Group). Perioperative and medium-term outcomes were compared between the two groups. RESULTS: Patients' baseline characteristics were similar in the two groups except for presence of symptoms and tumor size, due to the inclusion criteria. Operative time was significantly shorter and postoperative results were better for EN group, including a significant shorter hospitalization (5 vs. 8 days, p = 0.027), reduced pancreatic leaks (22% vs. 50%, p = 0.287) and a better preservation of glandular function (100% vs. 62.5%, p = 0.066). Mortality rate was zero in both groups, with all patients free from disease at a median follow-up of 18 months. CONCLUSIONS: The risks of under/overtreatment remain still unavoidable for benign to low-grade malignant small pancreatic neoplasms. Simple enucleation should be performed whenever oncological appropriate, to achieve the best postoperative outcomes. The adoption of robotic technique might widen the indications for parenchymal sparing, minimally invasive surgery.

Ultrasound-Guided Robotic Enucleation of Pancreatic Neuroendocrine Tumors.

BACKGROUND: Pancreatic neuroendocrine tumors (PanNETs) are relatively rare neoplasms with a low to mild malignant potential. They can be further divided into functioning and nonfunctioning, according to their secretive activity. Surgery is an optimal approach, but the classic open approach is challenging, with some patients having long hospitalization and potentially life-threatening complications. The robotic approach for PanNETs may represent an option to optimize their management. METHODS: We retrospectively reviewed our prospectively maintained databases from 2 high-volume Italian centers for pancreatic surgery. Demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. RESULTS: Twelve patients with final diagnosis of PanNET were included. The mean age of the patients was 53.8 years (25-77). The median body mass index was 26 (24-29). Three lesions were functioning insulinomas, while the others were nonfunctioning tumors. No deaths occurred. Mild postoperative complications occurred, except for 1 grade B pancreatic fistula. The mean postoperative stay was 3.9 days (2-5). CONCLUSIONS: Our results confirm that robotic enucleation is a feasible and safe approach for the treatment of PanNETs, with short hospital stay and low incidence of morbidity.

The Cholegas trial: long-term results of prophylactic cholecystectomy during gastrectomy for cancer-a randomized-controlled trial.

BACKGROUND: The incidence of cholelithiasis has been shown to be higher for patients after gastrectomy than for the general population, due to vagal branch damage and gastrointestinal reconstruction. The aim of this trial was to evaluate the need for routine concomitant prophylactic cholecystectomy (PC) during gastrectomy for cancer. METHODS: A multicenter, randomized, controlled trial was conducted between November 2008 and March 2017. Of the total 130 included patients, 65 underwent PC and 65 underwent standard gastric surgery only for curable cancers. The primary endpoint was cholelithiasis-free survival after gastrectomy for gastric adenocarcinoma. Cholelithiasis was detected by ultrasound exam. RESULTS: After a median follow-up of 62 months, eight patients (12.3%) in the control group developed biliary abnormalities (four cases of gallbladder calculi and four cases of biliary sludge), with only three (4.6%) being clinically relevant (two cholecystectomies needed, one acute pancreatitis). One patient in the PC group had asymptomatic biliary dilatation during sonography after surgery. The cholelithiasis-free survival did not show statistical significance between the two groups (P = 0.267). The number needed to treat with PC to avoid reoperation for cholelithiasis was 1:32.5. CONCLUSIONS: Concomitant PC during gastric surgery for malignancies, although reducing the absolute number of biliary abnormalities, has no significant impact on the natural course of patients.

Current Management of Pancreatic Neuroendocrine Tumors: From Demolitive Surgery to Observation.

Incidental diagnosis of pancreatic neuroendocrine tumors (PanNETs) greatly increased in the last years. In particular, more frequent diagnosis of small PanNETs leads to many challenging clinical decisions. These tumors are mostly indolent, although a percentage (up to 39%) may reveal an aggressive behaviour despite the small size. Therefore, there is still no unanimity about the best management of tumor smaller than 2 cm. The risks of under/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery. The importance of the Ki-67 index as a prognostic factor is still debated as well. Whenever technically feasible, parenchyma-sparing surgeries lead to the best chance of organ preservation. Lymphadenectomy seems to be another important prognostic issue and, according to recent findings, should be performed in noninsulinoma patients. In the case of enucleation of the lesion, a lymph nodal sampling should always be considered. The relatively recent introduction of minimally invasive techniques (robotic) is a valuable option to deal with these tumors. The current management of PanNETs is analysed throughout the many available published guidelines and evidences with the aim of helping clinicians in the difficult decision-making process.

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC.

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.

Minimally invasive versus open pancreatic enucleation. Systematic review and meta-analysis of surgical outcomes.

Parenchymal sparing procedures are gaining interest in pancreatic surgery and recent studies have reported that minimally invasive pancreatic enucleation may be associated with enhanced outcomes when compared with traditional surgery. By meta-analyzing the available data from the literature, minimally invasive surgery is not at higher risk of pancreatic fistula and offers a number of advantages over conventional surgery for pancreatic enucleation.

Laparoscopic ventral hernia repair: Results of a two thousand patients prospective multicentric database.

Laparoscopic incisional and ventral hernia repair (LIVHR) has been largely employed by the surgical community worldwide, despite the use of different types of mesh and fixation devices. A large nationwide prospective multicentric database collected 2005 operations from 8 high-volume centers, to investigate the perioeperative and long-term outcomes. The laparoscopic operations were completed in 1979 patients (98.7%), with a mean age of 60.7 years and a Body Mass Index of 28.8 kg/m2. Two hundred and one patient (18.8%) had a previous failed open repair. The average surface areas of the major defects were 47.4 and 18.2 cm 2 for postincisional and primary hernias. The mean operation time and postoperative stay were 94.4 min and s 3.7 days, respectively. We collected a total of 50 (2.5%) intraoperative and 414 (20.6%) postoperative complications, with reoperation needed in 38 cases (1.8%). After a mean follow-up period of 24 months, we recorded 62 (3.8%) confirmed recurrences. Length of surgery, hospital stay, and a previous recurrence were all risk factors for recurrence. Primary hernias had better perioperative outcomes compared to incisional hernias, except for the pain. The laparoscopic approach of both post-incisional and primary hernias seemed to be safe and feasible in short-to medium-term periods.