Minimally invasive RAMPS in well-selected left-sided pancreatic cancer within Yonsei criteria: long-term (>median 3 years) oncologic outcomes.

BACKGROUND: Although minimally invasive techniques for distal pancreatectomy with or without splenectomy have been regarded as a feasible and safe treatment option for benign and borderline malignant lesions of the pancreas, the management of left-sided pancreatic cancer remains controversial. METHODS: From June 2007 to November 2010, 12 patients underwent laparoscopic or robotic radical antegrade modular pancreatosplenectomy (RAMPS) for well-selected left-sided pancreatic cancer. The Yonsei criteria for patient selection included the following conditions: (1) tumor confined to the pancreas, (2) intact fascial layer between the distal pancreas and the left adrenal gland and kidney, and (3) tumor located more than 1-2 cm from the celiac axis. We compared the clinicopathologic factors and oncologic outcomes of the minimally invasive surgery (MIS) and the conventional open surgery groups for treating left-sided pancreatic cancer. RESULTS: In the MIS group, the mean tumor size was 2.75 ± 1.32 cm, and the mean number of retrieved lymph nodes was 10.5 ± 7.14. The resection margins were confirmed to be negative for malignancy in all patients. The MIS group and open group (n = 78) were statistically different in terms of tumor size (2.8 ± 1.3 vs. 3.5 ± 1.9 cm, p = 0.05) and length of hospital stay (12.3 ± 6.8 vs. 22.4 ± 21.6 days, p = 0.002). On survival analysis, the MIS group had longer disease-free survival (DFS) and overall survival (OS) than the open group (DFS: 47.6 vs. 24.7 months, p = 0.027; OS: 60.0 vs. 30.7 months, p = 0.046). In order to overcome the heterogeneity of subjects between the MIS and the open group, we performed statically matched comparisons using the propensity score analysis and then divided the open group into two subgroups according to the Yonsei criteria. There were no significant differences in median overall survival between the MIS group and the open group that met the Yonsei criteria (60.00 vs. 60.72 months, p = 0.616). CONCLUSIONS: Minimally invasive RAMPS is not only technically feasible but also oncologically safe in cases of well-selected left-sided pancreatic cancer. Our selection criteria for minimally invasive RAMPS needs to be further validated based on additional large-volume studies.

A five-year survivor without recurrence following robotic anterior radical antegrade modular pancreatosplenectomy for a well-selected left-sided pancreatic cancer.

Radical antegrade modular pancreatosplenectomy (RAMPS) is regarded as a reasonable approach for margin-negative and systemic lymph node clearance in left-sided pancreatic cancer. We present a patient with more than 5 years disease-free survival after robotic anterior RAMPS for pancreatic ductal adenocarcinoma in the body of the pancreas. The distal part of pancreas, soft tissue around the celiac trunk, and the origin of splenic vessels was dissected with the underlying fascia between the pancreas and adrenal gland. Resected specimen was removed through small vertical abdominal incision. Robot working time was about 8 hours, and blood loss was about 700 mL without blood transfusion. He returned to an oral diet on the postoperative first day and recovered without any clinically relevant complications. There was no lymph node metastasis, perineural or lymphovascular invasion. Both the pancreatic resection margin and the tangential posterior margin were free of carcinoma. The patient received only postoperative adjuvant radiotherapy around the tumor bed. The patient has survived for more than 5 years without evidence of cancer recurrence. Minimally invasive radical left-sided pancreatectomy with splenectomy may be oncologically feasible in well-selected pancreatic cancer.

Robotic pylorus preserving pancreaticoduodenectomy with mini-laparotomy reconstruction in patient with ampullary adenoma.

Robotic surgical system provides many unique advantages which might compensate the limitations of usual laparoscopic surgery. By using robotic surgical system, we performed robot-assisted laparoscopic pancreaticoduodenectomy (PD). A Sixty-two year old female patient with an ampullary mass underwent robot assisted PD due to imcomplete treatment of endoscopic ampullectomy. The removal of specimen and reconstruction were performed through small upper midline skin incision. Robot working time was about 8 hours, and blood loss was about 800 ml without blood transfusion. She returned to an oral diet on postoperative day 3. Grade B pancreatic leak was noted during the postoperative period, but was successfully managed by conservative management alone. We successfully performed da Vinci-assisted laparoscopic PD, and robot surgical system provided three-dimensional stable visualization and wrist-like motion of instrument facilitated complex operative procedures. More experiences are necessary to address real role of robot in far advanced laparoscopic pancreatic surgery.

Robotic central pancreatectomy with pancreaticogastrostomy (transgastric approach) in a solid pseudopapillary tumor of the pancreas.

Function preserving minimal invasive pancreatectomy is thought to be ideal approach for benign and borderline malignant tumors of the pancreas because these tumors can be expected for longterm survival. Pancreatic tumor in the neck of the pancreas is a challenging issue. Pancreaticoduodenectomy and distal pancreatectomy with/without splenectomy are the usual modes of surgery for them. Central pancreatectomy is a rare surgical procedure, even in open surgery. With the development of laparoscopic experiences, a few cases of laparoscopic central pancreatectomy have begun to be reported, but they are believed to be still demanding tremendous laparoscopic skills and experiences. However, advancements in technology have encouraged surgeons to overcome the limitations of conventional laparoscopic surgery. Herein, we report a case of robot-assisted central pancreatectomy with pancreaticogastrostomy (transgastric approach). Wrist-like movements of effector instruments and stable 3-D visualization provided by the robot surgical system are believed to enhance the precise and safe laparoscopic performance. More experiences need to be accumulated in order to evaluate the real value of robot pancreatic surgery.

Robot-assisted spleen-preserving laparoscopic distal pancreatectomy.

BACKGROUND: Spleen-preserving laparoscopic distal pancreatectomy would be an ideal approach for benign and borderline malignant tumors in the distal pancreas.1 However, this procedure requires advanced surgical experience and technique because of the disadvantages of conventional laparoscopic surgery.2 METHODS: A 35-year-old female patient visited our institution because of a growing pancreatic mass during follow-up. A preoperative image study showed a cystic tumor of about 3.0 × 2.5 cm in size in the body of the pancreas. Under the impression of a growing serous cystic tumor of the pancreas, she was scheduled to undergo robot-assisted spleen-preserving laparoscopic distal pancreatectomy. RESULTS: Under general anesthesia, the patient was placed in the supine position with her head and left side elevated. A total of five ports were used. Among them, one 12-mm port was placed for the assistant surgeon's intervention during the procedure. Stable 3-dimensional operative image, endo-wrist function of the instruments, and no tremor were thought to be very helpful for fine dissection of the pancreas from splenic vessels. The total operation time was 300 min, and the estimated intraoperative blood loss was 380 ml. No transfusion was required. The patient's postoperative recovery was uneventful. She was able to go home on the 6th postoperative day without a drain. CONCLUSIONS: The unique characteristics of a robotic surgical system were thought to be very helpful during the spleen-preserving laparoscopic distal pancreatectomy.2 (-) 6 However, cost is one of the main obstacles for the procedure's popular clinical practice.2.

The first experience of robot assisted spleen-preserving laparoscopic distal pancreatectomy in Korea.

Spleen-preservation has recently been emphasized in benign and borderline malignant pancreatic diseases requiring distal pancreatectomy. Reports to suggest that laparoscopic distal pancreatectomy is feasible and safe have been increasingly published. Robotic surgical system has been introduced and is expected to provide unique advantages in laparoscopic surgery. However, robot-assisted pancreatic surgery has not yet been performed by many surgeons. A 45-year-old female patient with abdominal discomfort was found to have pancreatic cyst in the body of the pancreas. Mucinous cystic tumor of the pancreas was the most favourable preoperative diagnosis. She underwent spleen-preserving laparoscopic distal pancreatectomy by using da Vinci surgical robot system. Splenic artery and vein were so tightly adherent to the pancreatic cyst that segmental resection of splenic vessels was required. Postoperative course was uneventful. She was able to come home in 5 days after surgery. Postoperative follow up color doppler ultrasound scan, taken on 2 weeks after surgery, showed minimal fluid collection around surgical field and no evidence of splenic infarction with good preservation of splenic perfusion. Robot-assisted spleen preserving distal pancreatectomy is thought to be feasible and safe. Several unique advantages of robotic system are expected to enhance safer and more precise surgical performance in near future. More experiences are mandatory to confirm real benefit of robot surgery in pancreatic disease.

Multimedia article. Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic cancer: technical feasibility and interim results.

BACKGROUND: Laparoscopic distal pancreatectomy with splenectomy is regarded as a safe and effective treatment for benign and borderline malignant pancreatic lesions [1, 2]. However, its application for left-sided pancreatic cancer is still debatable [3, 4]. No general consensus, no standardized technique, and no surgical indication exist in applying the laparoscopic approach to left-sided pancreatic cancer. METHODS: According to our institutional experiences of treating left-sided pancreatic cancer, bloodless and margin-negative resection was found to be important. Bloodless and margin-negative laparoscopic distal pancreatosplenectomy would be technically possible in suspicious pancreatic cancers with these tentative conditions: (1) pancreas-confined suspicious pancreatic cancer on preoperative image study (cT2), (2) intact fascia layer between the pancreas and left adrenal gland/left kidney, and (3) tumor more than 1 cm from the celiac axis. A 59-year-old female patient was found to have suspicious left-sided pancreatic cancer. Therefore, we performed laparoscopic anterior radical antegrade modular pancreatosplenectomy (RAMPS) [5, 6] with a curative intent based on selection criteria. RESULTS: The margin-negative (resectional and tangential) curative resection could be obtained by applying laparoscopic anterior RAMPS in well-selected left-sided pancreatic cancer. The operation time was 180 min and estimated blood loss was 100 ml. The diagnosis from pathology was that the tumor was ductal adenocarcinoma of the pancreas (pT3) with lymph node metastasis (pN1, 2 of 23 lymph nodes). The patient went home on the 7th postoperative day. Adjuvant chemotherapy began within 2 weeks after surgery. From June 2007 to August 2010, nine patients underwent minimally invasive (5 laparoscopic and 4 robot-assisted) anterior RAMPS based on the selection criteria. The perioperative outcomes and short-term oncologic results are summarized. CONCLUSION: Laparoscopic modified anterior RAMPS is thought to be technically feasible for curative resection in well-selected pancreatic cancer. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. More careful study is necessary.

Initial experiences using robot-assisted central pancreatectomy with pancreaticogastrostomy: a potential way to advanced laparoscopic pancreatectomy.

BACKGROUND: Benign and borderline malignant pancreatic tumors are increasing. Function-preserving and minimally invasive pancreatectomy may be an ideal approach for these tumors. METHODS: The authors retrospectively evaluated their initial experiences with five consecutive robotic central pancreatectomies (CPs). They also compared the perioperative outcome for open CPs performed in their institution. RESULTS: The five women in the study had a median age of 45 years (range 36-64 years). A solid pseudopapillary tumor of the pancreas was found in four patients, and a pancreatic endocrine tumor was found in one patient. The tumor was relatively small (median size, 1.5 cm; range, 1-2 cm). All remnant pancreases were managed using pancreaticogastrostomy. The median operation time was 480 min (range 360-480 min), and the median estimated intraoperative bleeding was 200 ml (range 100-600 ml). No transfusion was given during the perioperative period. The median hospital stay was 12 days (range 9-28 days). Only one patient experienced postoperative pancreatic fistula (grade B), which was managed using the percutaneous drainage procedure. No operative morality was noted. In a comparative analysis with open CP, the robotic CP group demonstrated a smaller asymptomatic (17 out of 10 patients vs none, p = 0.026) tumor (5.9 ± 6.4 vs 1.4 ± 0.4 cm; p = 0.055), a longer operation time (286.5 ± 90.2 vs 432.0 ± 65.7 min, p = 0.013), and less intraoperative bleeding (432.0 ± 65.7 vs 286.5 ± 90.2 ml, p = 0.013). CONCLUSION: Central pancreatectomy can be selected carefully as an appropriate surgical option for benign and borderline malignant lesions limited to the pancreatic neck area. The robotic surgical system may allow surgeons to perform complex and difficult laparoscopic procedures more easily, effectively, and precisely.

Minimally invasive (laparoscopic and robot-assisted) approach for solid pseudopapillary tumor of the distal pancreas: a single-center experience.

BACKGROUND/PURPOSE: A single-institutional experiences of solid pseudopapillary tumor (SPT) in the distal pancreas were retrospectively reviewed with special reference to a minimally invasive approach. METHODS: Thirty-five patients with SPT of the distal pancreas treated during the past 20 years were retrospectively evaluated. We divided the patients into 2 groups based on the surgical approach: the laparoscopic/robot-assisted surgery (LR) group and the conventional open surgery (O) group. We reviewed the chronological changes and characteristics of SPT. A comparative analysis of the two groups (LR vs. O) was conducted in terms of perioperative surgical outcomes. RESULTS: The discovery of relatively small SPTs without symptoms seemed to be increasing (p < 0.05). Eleven of the 35 patients were assigned to the LR group. Ten patients were female and 1 was male, and they had a median age of 32 years (range 24-62 years) and a median tumor size of 3.6 cm (range 1-8.5 cm). Eight patients underwent laparoscopic distal pancreatectomy with or without splenectomy, and the remaining 3 underwent robot-assisted central pancreatectomy with pancreaticogastrostomy. In the comparative analysis of the LR and O groups, smaller tumor size, earlier oral intake, and shorter hospital stay, without increasing morbidity, were noted in the LR group (p < 0.05). CONCLUSIONS: A minimally invasive (laparoscopic/robot-assisted) approach for SPT of the distal pancreas is thought to be more appropriate than and preferable to conventional open surgery in well-selected patients.

Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have clinical advantages?

BACKGROUND: Function-preserving minimally invasive pancreatectomy is thought to be an ideal approach for pancreatic benign and borderline malignant lesions requiring pancreatectomy. However, it is not that easy to accomplish this goal with the conventional laparoscopic approach. It requires extensive surgeon experience and learned techniques. A robot surgical system was recently introduced to overcome these limitations and it may potentially provide precise and safe laparoscopic surgery. METHODS: Between March 2006 and July 2010, a total of 45 patients underwent laparoscopic or robot-assisted pancreatectomy performed by a single pancreatic surgeon to preserve the spleen. Twenty-five patients underwent the conventional laparoscopic approach (Lap group) and the other 20 patients underwent robot-assisted surgery (Robot group). The perioperative clinicopathologic variables (age, gender, length of resected pancreas, tumor size, tumor location, amount of bleeding, operation time, length of hospital stay, complications, mortality, and cost) were compared between the two groups, as well as the spleen preservation rate. RESULTS: Younger patients preferred robot-assisted surgery to conventional laparoscopic surgery (44.5±15.9 vs. 56.7±13.9 years, p=0.010), and the mean operation time was longer in the Robot group (258.2±118.6 vs. 348.7±121.8 min, p=0.016). The spleen-preserving rate of the Robot group was considerably superior to that of the Lap group (fail/success, 9/16 vs. 1/19, p=0.027). However, robot surgery cost the patients about USD 8,300 (USD 8,304.8±870.0), which was more than twice the amount for the Lap group (USD 3,861.7±1,724.3). There were no significant differences in other clinicopathologic variables. CONCLUSION: Robot-assisted pancreatic surgery could provide an increased chance for spleen preservation in spite of higher cost and longer operation time. More experiences are needed to specifically address the role of robot surgery in the advanced laparoscopic era.

Clinical validation and risk factors for delayed gastric emptying based on the International Study Group of Pancreatic Surgery (ISGPS) Classification.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy (PD). Because an objective, universally accepted definition of DGE does not yet exist, it is impossible to compare complication rates and outcomes of new operative approaches, operative techniques, and clinical trials. The International Study Group of Pancreatic Surgery (ISGPS) has proposed a universal classification for DGE based on clinical outcomes, but this classification has not been tested rigorously and applied to clinical data. Therefore, the aim of this study was to analyze our experience and to identify predictive factors for DGE by applying the ISGPS classification at a high-volume hospital. METHODS: From October 2002 to December 2007, 129 consecutive patients underwent PD at the Department of Surgery, Yonsei University Medical Center. The severity of DGE was determined according to the ISGPS classification, and risk factors were evaluated retrospectively. RESULTS: The overall incidence of DGE was 33.3%, with 16 (12.4%) patients having grade A, 14 (10.9%) grade B, and 13 (10.1%) grade C. Clinical outcomes worsened progressively as clinical relevant DGE increased. In multivariate analysis, clinically relevant pancreatic fistula (grade B/C) and patients with benign pathology were identified as independent factors for DGE. CONCLUSION: Pancreatic leakage is a serious complication after PD and is also associated with DGE. The ISGPS classification is a clear and useful tool to assess clinical outcomes.

Estrogen receptor alpha, estrogen receptor beta, and progesterone receptor as possible prognostic factor in radically resected gallbladder carcinoma.

BACKGROUND: Gallbladder carcinoma is a relatively rare malignancy with a poor prognosis. We have often encountered patients in whom the course of their disease differed substantially from what would be predicted based on their clinical staging, which highlights the needs to consider additional predictive factors. Gallbladder carcinoma occurs more frequently in women than men, yet expression of the estrogen receptor (ER) and progesterone (PR) have not been studied. We applied an immunohistochemical stain to examine the expression of ER(alpha), ER(beta), and PR in radically resected gallbladder carcinoma. MATERIAL AND METHODS: We immunohistochemically investigated 30 specimens of gallbladder adenocarcinoma tissues using ER(alpha), ER(beta), and PR antibodies. RESULTS: Adenocarcinoma of gallbladder is negative for both ER(alpha) and PR. However, 22 of 30 cases (73.3%) were confirmed positive for ER(beta), which was significantly correlated with tumor differentiation. Five-year survival rates of ER(beta) positive and negative patients were 53.3% and 31.1%, respectively (P = 0.034). In multivariate analysis, only a low proportion score of ER(beta) status was a statistically significant factor (P = 0.033). CONCLUSIONS: Evaluation of ER(beta) expression in gallbladder carcinoma may be an important factor in identifying a poor prognostic group of gallbladder carcinoma.

Left hemihepatectomy and caudate lobectomy and complete extrahepatic bile duct resection using transduodenal approach for hilar cholangiocarcinoma arsing from biliary papillomatosis.

BACKGROUND: Biliary papillomatosis (BP) is a rare disease characterized by multiple papillary lesions of variable distribution and extent in the intra and extrahepatic bile duct. Hepatopancreatoduodenectomy (HPD) can be indicated for the resection of diffuse intra and extrahepatic BP that extended to the distal bile duct and ampullary region. The mortality rate for HPD has recently decreased but HPD still has a high morbidity rate. In this study, we present a safe procedure for concomitant intrahepatic and extrahepatic BP. PATIENTS AND METHODS: Preoperative studies showed showed multiple, variable-sized, and nodular papillary masses with mucin in the left intrahepatic ducts, confluence of the right and left hepatic ducts, common hepatic duct, and whole CBD, but peripheral to the right intrahepatic bile ducts were grossly well preserved. We underwent Lt. hepatectomy and the common bile duct and ampulla of Vater were completely resected with transduodenal approach and the pancreatic duct was repositioned to the duodenal mucosa. CONCLUSIONS: Major hepatic resection and transduodenal approach for complete bile duct resection and pancreatic duct repositioning could be an acceptable therapeutic option for concomitant intrahepatic and extrahepatic biliary papillomatosis without the evidence of pancreatic duct involvement in the patients with severe comorbidity.

Robotic total mesorectal excision for rectal cancer using four robotic arms.

BACKGROUND: The da Vinci system is a newly developed device for colorectal surgery, therefore experience of its use for rectal cancer surgery is limited and there are no reports describing the use of four robotic arms with this system. The aim of this study is to evaluate the safety and feasibility of the four-arm da Vinci system for total mesorectal excision in rectal cancer patients. METHODS: Clinicopathologic data were prospectively collected on nine patients who underwent robotic total mesorectal excision using four robotic arms for the treatment of mid or low rectal cancer between November 2006 and Febuary 2007. Patient demographics, perioperative clinical outcomes, and pathology results with macroscopic grading (complete, nearly complete, incomplete) were evaluated. RESULTS: nine patients with mid or low rectal cancer underwent robotic total mesorectal excison using four robotic arms without serious complications. The mean length of hospital stay was 7.4 +/- 1.3 days (range 5.0-10.0 days) and the mean operating time was 220.8 +/- 49.4 min (range 153-315 min). Macroscopic grading of the specimen was complete in eight patients and nearly complete in one patient. There were no cases of conversion. CONCLUSION: In the present study, we accomplished nine robot-assisted rectal resections safely and effectively.

Transduodenal local resection for low-risk group ampulla of vater carcinoma.

BACKGROUND: Carcinoma of the ampulla of Vater has a more favorable prognosis, compared to other malignant tumors of the periampullary region, because it usually presents with symptoms in the early stage. However, treatment by local resection only of the ampullary carcinoma remains controversial. The aim of this study was to evaluate the treatment results of the ampulla of Vater carcinoma according to different types of operation in low-risk-group patients. METHODS: We retrospectively reviewed the medical records of 17 low-risk-group patients among a total of 102 patients with ampulla of Vater carcinoma who had underwent curative surgery from 1992 to 2002. All specimens were critically reviewed by a single expert pathologist, and the relationship between surgical outcomes and operation type was assessed. RESULTS: The low-risk group was comprised of 10 men and 7 women with a median age of 57.8 years. Thirteen of 17 patients underwent a pancreaticoduodenectomy (PD) or a pylorus preserving pancreaticoduodenectomy (PPPD), while 4 patients underwent a transduodenal local resection (TDLR). The operation time was significantly shorter in the TDLR group, compared to the PD or PPPD groups. Among the 17 patients, there was only 1 case of recurrence in the inguinal area 33 months after the pancreaticoduodenectomy. CONCLUSIONS: Transduodenal local resection is a comparable mode of operation for low-risk-group patients with Ampulla of Vater carcinoma. In particular, it is essential to evaluate the invasion depth in preoperative endoscopic ultrasonography, cell differentiation in preoperative biopsy, and positivity of resection margin accurately by using frozen section during the operation.

A case of robot-assisted excision of choledochal cyst, hepaticojejunostomy, and extracorporeal Roux-en-y anastomosis using the da Vinci surgical system.

Choledochal cyst is a rare disease in the Western world, but a high incidence is noted in Asia. Complete cyst excision with Roux-en-y hepaticoenterostomy is the treatment of choice for choledochal cyst, which has been attempted laparoscopically with the advancement of laparoscopic experience. Recently, a telemanipulative robotic surgical system was introduced, providing instruments with wrist-type end-effectors and 3-dimensional visualization of the operative field. Herein, we present a case of robot-assisted correction of a choledochal cyst.

The first korean experience of telemanipulative robot-assisted laparoscopic cholecystectomy using the da vinci system.

With the advancement of laparoscopic instruments and computer sciences, complex surgical procedures are expected to be safely performed by robot assisted telemanipulative laparoscopic surgery. The da Vinci system (Intuitive Surgical, Mountain View, CA, USA) became available at the many surgical fields. The wrist like movements of the instrument's tip, as well as 3-dimensional vision, could be expected to facilitate more complex laparoscopic procedure. Here, we present the first Korean experience of da Vinci robotic assisted laparoscopic cholecystectomy and discuss the introduction and perspectives of this robotic system.