Robotic Dual-Console Distal Pancreatectomy: Could it be Considered a Safe Approach and Surgical Teaching even in Pancreatic Surgery? A Retrospective Observational Study Cohort.

BACKGROUND: The study aims to assess the safety and feasibility of the robotic dual-console during a robotic distal pancreatectomy METHODS: The data of the consecutive patients submitted to RDP from 2012 to 2019 at the Verona University were retrieved from a prospectively maintained database. The patients submitted to RDP were divided into the dual-console platform group (DG) and compared to the standard robotic procedure group (SG). RESULTS: In the study period, 102 robotic distal pancreatectomies were performed, of whom 42 patients (41%) belonged to the DG and 60 patients (59%) to the SG. Higher operation time was recorded in the DG compared to the SG (410 vs. 265 min, p < 0.001). The overall conversion rate of the series was 7% (n 7 patients). All the conversions were observed in the SG (p = 0.021). No differences in morbidity or pancreatic fistula rate were recorded (p > 0.05). No mortality events in the 90th postoperative days were reported in this series. CONCLUSIONS: The robotic dual-console approach for distal pancreatectomy is safe, feasible, and reproducible. The postoperative surgical outcomes are comparable to the standard RDP with the single-console da Vinci Surgical System®. This surgical technique can widely and safely improve the robotic surgical training program.

Clinical presentation, genotype-phenotype correlations, and outcome of pancreatic neuroendocrine tumors in Von Hippel-Lindau syndrome.

PURPOSE: Data regarding the clinical management and follow-up of pancreatic neuroendocrine tumors (PanNETs) associated with Von Hippel-Lindau (VHL) syndrome are limited. This study aimed to assess clinical presentation, genotype-phenotype correlations, treatment and prognosis of PanNETs in a series of VHL syndrome patients. METHODS: Retrospective analysis of data of patients observed between 2005 and 2020. RESULTS: Seventeen patients, including 12 probands and 5 relatives (mean age 30.8 ± 18.4; 7 males), were recruited. PanNETs were found in 13/17 patients (77.5%) at a median age of 37 years: 4/13 (30.7%) at the time of VHL diagnosis and 9 (69.3%) during follow up. Six (46.1%) PanNET patients underwent surgery, whereas seven were conservatively treated (mean tumor diameter: 40 ± 10.9 vs. 15 ± 5.3 mm respectively). Four patients (30.7%) had lymph node metastases and a mean tumor diameter significantly larger than the nonmetastatic PanNETs (44.2 ± 9.3 vs. 17.4 ± 7 mm, p = 0.00049, respectively). Five (83.3%) operated patients had stable disease after a median follow up of 3 years whereas one patient showed liver metastases. Six (85.7%) non-resected PanNETs were stable after a median follow-up of 2 years, whereas one patient developed a new small PanNET and a slight increase in diameter of a pre-existing PanNET. No correlation was found between the type of germline mutation and malignant behavior of PanNETs. CONCLUSIONS: PanNETs are a common disease of the VHL syndrome and can be the presenting feature. Tumor size rather than genetic mutation is a prognostic factor of malignancy.

Sporadic non-functioning pancreatic neuroendocrine tumours: multicentre analysis.

BACKGROUND: Outcomes after surgery for sporadic pancreatic neuroendocrine neoplasms (Pan-NENs) were evaluated. METHODS: This multicentre study included patients who underwent radical pancreatic resection for sporadic non-functioning Pan-NENs. In survival analysis, the risk of mortality in this cohort was analysed in relation to that of the matched healthy Italian population. Relative survival (RS) was calculated as the rate between observed and expected survival. Factors related to RS were investigated using multivariable modelling. RESULTS: Among 964 patients who had pancreatic resection for sporadic non-functioning Pan-NENs, the overall RS rate was 91.8 (95 per cent c.i. 81.5 to 96.5) per cent. 2019 WHO grade (hazard ratio (HR) 5.75 (s.e. 4.63); P = 0.030) and European Neuroendocrine Tumour Society (ENETS) TNM stage (6.73 (3.61); P < 0.001) were independent predictors of RS. The probability of a normal lifespan for patients with G1, G2, G3 Pan-NENS, and pancreatic neuroendocrine carcinomas (Pan-NECs) was 96.7, 54.8, 0, and 0 per cent respectively. The probability of a normal lifespan was 99.8, 99.3, 79.8, and 46.8 per cent for those with stage I, II, III, and IV disease respectively. The overall disease-free RS rate was 73.6 (65.2 to 79.5) per cent. 2019 WHO grade (HR 2.10 (0.19); P < 0.001) and ENETS TNM stage (HR 2.50 (0.24); P < 0.001) significantly influenced disease-free RS. The probability of disease-free survival was 93.2, 84.9, 45.2, and 6.8 per cent for patients with stage I, II, III, and IV disease, and 91.9, 45.2, 9.4, and 0.7 per cent for those with G1, G2, G3 Pan-NENS, and Pan-NECs, respectively. CONCLUSION: A surgical approach seems without benefit for Pan-NECs, and unnecessary for small G1 sporadic Pan-NENs. Surgery alone may be insufficient for stage III-IV and G3 Pan-NENs.

Robotic spleen-preserving distal pancreatectomy: the Verona experience.

BACKGROUND: The minimally invasive approach in spleen-preserving distal pancreatectomy has currently been emphasized in benign and pre-malignant pancreatic diseases. The study aims to demonstrate the safety and feasibility of our technique of robotic spleen-preserving distal pancreatectomy (RSPDP) by a stepwise approach. METHODS: The data of consecutive patients presented for RSPDP from 2014 to 2019 at Verona University were retrieved from a prospectively maintained database. The patients were divided into two groups based on the surgical procedure performed, such as Kimura's (KG) or Warshaw's (WG) technique, and then compared. RESULTS: In the study period, 32 patients underwent RSPDP. Twenty-three patients presented for the Kimura procedure (72%), while nine patients underwent the Warshaw procedure (28%). A higher body mass index was found in the KG (26 ± 4 vs. 22 ± 3, p = 0.037). Regarding the pathological data, the WG group differed in the tumor dimension, and the lymph nodes harvested (30 ± 2 vs. 17 ± 10, 9 ± 5 vs. 3 ± 4, p = 0.0028, and p = 0.005, respectively). Notably, no conversions and mortality were recorded. The overall morbidity was 25% ( eight patients) with no difference between the groups (p = 0.820). The mean length of stay was 8 days, and was similar between the groups (p = 0.350). CONCLUSIONS: The present study suggests that RSPDP is a valid option for the treatment of benign or pre-malignant pancreatic diseases of the distal pancreas, with comparable morbidity with the standard treatment and no mortality. Further research is needed to standardize the technique and to assess the immunological, surgical, and financial benefits of the procedure.

Clinico-pathological features, treatments and survival of malignant insulinomas: a multicenter study.

INTRODUCTION: Management of malignant insulinomas is challenging due to the need to control both hypoglycaemic syndrome and tumor growth. Literature data is limited to small series. AIM OF THE STUDY: To analyze clinico-pathological characteristics, treatments and prognosis of patients with malignant insulinoma. MATERIALS AND METHODS: Multicenter retrospective study on 31 patients (male: 61.3%) diagnosed between 1988 and 2017. RESULTS: The mean age at diagnosis was 48 years. The mean NET diameter was 41 ± 31 mm, and 70.8% of NETs were G2. Metastases were widespread in 38.7%, hepatic in 41.9% and only lymph nodal in 19.4%. In 16.1% of the cases, the hypoglycaemic syndrome occurred after 46 ± 35 months from the diagnosis of originally non-functioning NET, whereas in 83.9% of the cases it led to the diagnosis of NET, of which 42.3% with a mean diagnostic delay of 32.7 ± 39.8 months. Surgical treatment was performed in 67.7% of the cases. The 5-year survival rate was 62%. Overall survival was significantly higher in patients with Ki-67 ≤10% (P = 0.03), insulin level <60 µU/mL (P = 0.015) and in patients who underwent surgery (P = 0.006). Peptide Receptor Radionuclide Therapy (PRRT) was performed in 45.1%, with syndrome control in 93% of patients. CONCLUSIONS: Our study includes the largest series of patients with malignant insulinoma reported to date. The hypoglycaemic syndrome may occur after years in initially non-functioning NETs or be misunderstood with delayed diagnosis of NETs. Surgical treatment and Ki67 ≤10% are prognostic factors associated with better survival. PPRT proved to be effective in the control of hypoglycaemia in majority of cases.

Recurrent acute pancreatitis in bowel malrotation.

OBJECTIVE: Recurrent acute pancreatitis is an uncommon diagnosis in teenagers. Excluded alcohol and biliary stones, more prevalent aetiologies in these group of patients are genetic pancreatitis, pancreatic duct system abnormalities, neoplasia, traumas and congenital abnormalities of the duodenum such as duodenal duplication or diverticulum. Two reported cases of recurrent pancreatitis associated to midgut malrotation were described in English literature. Bowel malrotation is a difficult diagnosis in a teenager or a young adult and a common delay is documented. Ladd's procedure is largely recognized to be the standard treatment for a symptomatic malrotation. CASE REPORT: Our Report describes in details a case of recurrent pancreatitis, where a late diagnosis of midgut malrotation was obtained and an endoscopic management was attempted. A literature review and an analysis of two previously reported cases were performed to explore a possible aetiopathogenesis of the recurrent acute pancreatitis in patients with midgut malrotation. RESULTS: 24 months of follow-up showed an asymptomatic patient on a free diet, with a mild deranged Liver Functional Tests and a normal Amylase and Lipase. The recurrence of acute pancreatitis has not been observed until the present day. CONCLUSIONS: Recurrent episodes of acute pancreatitis in young adults, without a history of alcohol abuse or evidence of gallstones, might be an atypical presentation of midgut malrotation and it should be in the differential diagnosis. In this case, a Ladd's operation is beneficial and an endoscopic procedure does not obtain advantages.

[Inguinal endometriosis. Case report and review of the literature]. / L'endometriosi inguinale. Case report e revisione della letteratura.

Endometriosis is a common gynaecological condition which affects women during their reproductive years. It is characterized by ectopic endometrial tissue responding to hormonal changes associated with menstrual cycle. Aetiology is unknown and symptoms are quite aspecific (dysmenorrhoea, pelvic pain, infertility or pelvic mass). Ultrasonography (US) and Magnetic Resonance Imaging (MRI) are accurate diagnostic exams but laparoscopy represents the gold standard in diagnosis and therapy (excision or ablation). Medical treatment pre or postoperatively may be useful prolonging the symptom free interval. In this paper we report the case of a young woman affected by an inguinal mass: diagnostic examinations and histological specimen revealed to be an endometrial focus. We review the literature focusing the diagnostic techniques and relationships between endometriosis and ovarian cancer (endometrioid and clear cell subtypes).

[Mesenteric cyst: case report and review of the literature]. / Cisti mesenteriale: case report e revisione della letteratura.

Mesenteric and retroperitoneal cysts are rare intra-abdominal tumours with an incidence of 1/140.000 in surgery departments and 1/20.000 in paediatric departments. There are no pathognomonic signs or symptoms for the cysts. In the differential diagnosis lymphangiomas, sarcomas, adenocarcinomas and intestinal duplications should be considered. Diagnostic includes abdominal computed tomography, ultrasound and MRI. Barium enema examination or intravenous pyelogram may be used in special cases. Surgical treatment is indicated also in asymptomatic patients; laparoscopic approach is the "gold standard". Laparotomic approach should be used in the cases of impossibility of total enucleation or in the cases of malignant degeneration. Complete enucleation is the treatment of choice for retroperitoneal and mesenteric cysts. If this cannot be accomplished, the alternative should be the excision of the cyst or the marsupialization. In this paper we present a case of young man with a mesenteric cyst mimicking acute appendicitis.

A case of intraductal papillary mucinous tumour following recurrent attacks of pancreatitis lasting 26 years.

We report an interesting case of a patient with neither family nor personal history for pancreatic diseases that was admitted to our department in 1982, at the age of 25 years. At that time, medical history, absence of alcohol abuse, and radiological imaging suggested a diagnosis of idiopathic chronic pancreatitis. The patient underwent a left-pancreatectomy, with histological confirmation of chronic pancreatitis. He was asymptomatic until 1988, when episodes of pain arose, requiring a pancreatico-jejunostomy. No further problems ensued until 2004 when radiological investigation following pain-related symptoms revealed enormous dilation of the pancreatic duct. A pylorus-preserving pancreaticoduodenectomy resulting in total pancreatectomy was performed. Histological examination revealed an intraductal papillary mucinous non-invasive carcinoma. Review of the previously resected specimen revealed former misdiagnosis. This tumour usually affects an elderly population and nowadays is recognised as a possible cause of chronic obstructive pancreatitis. This report represents a slippery case of misdiagnosis and demonstrates that follow-up is always mandatory following a diagnosis of idiopathic chronic pancreatitis.

Treatment of six hepatic artery aneurysms.

Hepatic artery aneurysms are rare lesions but of significant clinical importance because rupture is associated with elevated mortality. Although diagnosis using CT scanning and, more importantly, angiography has been well defined, the therapeutic choices are less clear. We retrospectively selected patients from 1985 to 2000 who were treated with either traditional surgical or percutaneous techniques. In total we treated six patients, four males and two females. This represents 17.6% of 34 patients treated by us for splanchnic artery aneurysms. The treatment was surgical in two cases (33.3%) and percutaneous in four cases (66.6%). All lesions were successfully treated with exclusion/ablation of the aneurysm. Mortality was nil; in one of the surgical cases we reported a transient hepatic failure and in the endovascular group, one right pleural effusion, one small splenic infarction, and one pseudoaneurysm of the gastroduodenal artery. The first therapeutic strategy to be taken into consideration is always the percutaneous approach. However, surgery still has a role in those cases where the lesion cannot be repaired percutaneously. Based on our own experience (good results, no mortality, and few complications) and in accordance with the literature, it is clear that an aggressive approach is warranted in those patients.

Quality control in the conservative treatment of breast cancer: patient dosimetry using silicon detectors.

Twenty patients with early breast cancer were treated with external irradiation, delivered with two tangential beams (6 MV X-rays) using a half-beam block (HBB) and 3-D compensating filters. All patients were immobilized with individualized cellulose acetate casts. Patient dosimetry was performed using p-type silicon detectors. Midline doses were calculated by combined entrance and exit dose measurements. The mean ratio of the measured and the prescribed doses was 96.6 +/- 3.8% at the reference point, 96.8 +/- 4.3% at off-axis points on the central plane and 96.8 +/- 7.6% at off-plane points.

[Personalized low-melting alloy shield for high-energy electrons in the treatment of superficial neoplasms of critical or esthetically important regions]. / Schermature personalizzate in lega bassofondente per elettroni di alta energia nel trattamento di neoplasie superficiali situate in regioni estetiche o critiche.

Individualized Cerrobend beam shapings for high-energy electrons have been utilized in the treatment of superficial tumours located in aesthetic or critical regions. Individualized cellulose acetate masks have been used as immobilization device. Measured transmissions through Cerrobend ranged from 0.5% at 4 MeV to 8.5% at 18 MeV. Phantom dosimetry showed a poor influence of Cerrobend on PDD (percentage depth doses). Output factor variations appeared to depend on electron energy and shielded area. It is very important to perform either empirical measurements or to adopt semiempirical models in order to exactly calculate those output factors. Three clinical examples are presented: the utilization of immobilization device and field shaping are illustrated with the main aim of sparing the dose to critical organs.

[Verification of 3 computerized systems for drafting a plan for treatment with electrons]. / Verifica di tre sistemi computerizzati per la stesura dei piani di trattamento con elettroni.

The electron beam treatment planning systems, with the availability of more and more developed hardware for complex calculation algorithms, need quality controls of accuracy and comparability of treatment plans from different systems. In this paper three systems have been evaluated; their similar computation algorithms (pencil beam) have been used but in some conditions (beam reconstruction, oblique incidence and dishomogeneity) different results have been drawn. The basic data (PDD, dose profile, etc.) were the same for every system, therefore it has been observed that different results are mainly due to differences in: a) input of parameter values, b) calculation algorithm approximations, c) image acquisitions and elaboration.

Magnetic resonance diagnosis of intramedullary tumors of the spinal cord.

Fifty patients with intramedullary space occupying lesions were studied with MR from October 1983. Of these 32 were operated on and histological diagnosis together with gross morphological description was available. MR findings were reviewed in search for morphological and signal characteristics capable of providing a better preoperative diagnosis. There were 11 astrocytomas, 10 ependymomas, 5 vascular lesions and 6 "gliomas". All lesions usually had signal characteristics different from those of the normal cord, mainly because of prolonged T1 and T2 relaxation times. No specific patterns related either to morphology or signal were found, capable of differentiating the two main histological types. Vascular malformations may be suspected from the presence of serpiginous areas without signal. Tumor nodules within cysts can however be well recognized, thus providing the neurosurgeon with very useful preoperative information. Some characteristics of signal and morphology, are more common for one or the other of the two main groups of tumors. A tumor involving all the cord with a homogeneously prolonged T2 relaxation time is most likely to be an astrocytoma. A small nodule with signal close to normal parenchyma, associated with extensive cysts, is most likely to be an ependymoma.

Magnetic resonance imaging of cerebral cavernous angiomas.

Magnetic resonance imaging (MRI) proved to be far superior to computed tomography and angiography in detecting cavernous angiomas in 55 patients, with a total of 72 lesions. A cavernous angioma usually appears as a nodular lesion with a relatively short T1 and long T2, circumscribed by a hypointense ring. The MR signal varies according to histopathologic components. Usually, no significant mass effect is detected. Sometimes a rim of edema or gliosis is present (long T2). When a massive bleeding is present, differential diagnosis from chronic hematoma of other origin is not always easy, but may be possible from the clinical presentation and some MR findings.

MR imaging of intradural extramedullary tumors of the cervical spine.

Magnetic resonance imaging was performed in eight patients with extramedullary cervical tumors; two were studied with a 0.15 T resistive system and six with a 0.5 superconductive unit. All tumors were verified surgically: Five meningiomas and three schwannomas were found. Magnetic resonance demonstrated the location and size of the tumors as well as their relationship with and mass effect on the adjacent spinal cord. Meningiomas showed a tendency to have relaxation times close to those of the normal parenchyma; in multiple echo sequences their signal tends to decay in a way similar to that of the spinal cord. The different signal from the surrounding cerebrospinal fluid sometimes provides a visual cleavage to define the extramedullary location of the neoplasm. Schwannomas and neurofibromas have a less constant behavior; their T2 relaxation time may be slightly longer than that of the spinal cord and the tumor may display a more intense signal in the T2 weighted images. Usually, however, the signal intensity of the extramedullary tumors is lower than that of the intramedullary.

MR imaging in Fahr disease.

The calcifications of Fahr disease that are detected by CT in the dentate nuclei of the cerebellum, basal ganglia, and white matter of the cerebral hemispheres displayed three patterns with magnetic resonance imaging using the multiple echo technique: (a) cerebellar calcifications were undetected; (b) basal ganglia calcifications displayed low or no signal and appeared as "black" areas in four echoes; and (c) white matter calcifications displayed a high signal in the four echoes and appeared intensely white. The different behavior of the three calcified sites probably reflects different stages of the disease or different metabolic states with predominance of inert calcium deposits in the basal ganglia. In the white matter there is probably a higher concentration of binding proteins and mucopolysaccharides.