Robotic Ultrasound-Guided Central Pancreatectomy with Main Pancreatic Duct Endoscopy Evaluation for High-Risk, Mixed-Type Intraductal Papillary Mucinous Neoplasm.

BACKGROUND: Central pancreatectomy (CP) is a parenchymal-sparing technique indicated for the resection of selected lesions of the neck or proximal body of the pancreas.1,2 The risk of postoperative complications is theoretically doubled because the surgeon has to manage two cut surfaces of the pancreas. The video shows a fully robotic CP to treat a 62-year-old male patient with a mixed-type intraductal papillary mucinous neoplasm (IPMN) of the pancreatic neck, using ultrasound (US) and Wirsung endoscopic evaluation to guide the pancreatic resection and ensure optimal resection margins. MATERIALS AND METHODS: A US-guided robotic CP was carried out, and an intraoperative endoscopic evaluation of the MPD was performed to determine the distal transection level. A transmesocolic, end-to-side, robot-sewn Wirsung-jejunostomy with internal MPD stenting was then created. The procedure was completed with a side-to-side jejunojejunostomy. RESULTS: The operative time was 290 min, with negligible blood loss. During the postoperative course, the patient experienced bleeding from a branch of the gastroduodenal artery with subsequent fluid collection, which was successfully treated with angioembolization and percutaneous drainage. He was discharged home on postoperative day 22. Final pathology revealed a non-invasive IPMN with low-grade dysplasia and free surgical margins. At 12 months of follow-up, the patient was doing well, with no evidence of local recurrence and endocrine or exocrine pancreatic insufficiency. CONCLUSIONS: The combination of robotic surgery with intraoperative US and Wirsungoscopy may offer distinct technical advantages for challenging pancreatectomies that follow the principles of parenchymal-sparing surgery.

ASO Author Reflections: The Role of Robotic Surgery on Central Pancreatectomy.

Central pancreatectomy (CP) is indicated for benign or low-grade pancreatic tumors located in the neck or proximal pancreatic body. This procedure is demanding and has a high rate of postoperative complications. Minimally invasive surgery is now commonly used for CP but it is still unclear whether the robotic approach offers any advantages over conventional pancreatic minimally invasive surgery. Most studies on robotic CP are limited to case reports or case series; however, there are two important studies on this topic. Currently, the evidence on robotic CP remains limited, making it challenging to draw definitive conclusions in favor of one technique over the other. The use of a robotic platform, with its integrated tools such as intraoperative ultrasound, can guide the surgeon in performing this technically demanding procedure in a safer manner. The controversy regarding the best minimally invasive surgery approach for CP is still ongoing and requires further research.

Association Between Cross-Stapling Technique In Mechanical Colorectal Anastomosis and Short-term Outcomes.

BACKGROUND: The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described aiming to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered as possible risk factors for anastomotic leakage. OBJECTIVE: The purpose of this study was to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis following minimally invasive surgery. DATA SOURCES: A systematic review was undertaken of the published literature. PubMed/MEDLINE, Web of Science, and EMBASE databases were screened up to July 2023. STUDY SELECTION: Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction as compared to the conventional method of double-stapled anastomosis were included. INTERVENTIONS: Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared. MAIN OUTCOME MEASURES: The rate of anastomotic leak was the primary endpoint of interest. Perioperative details including postoperative morbidity were also appraised. RESULTS: There were 2537 patients from 12 studies included for data extraction, with no significant differences on age, body mass index and proportion of high American Society of Anesthesiologists Score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure compared to the conventional procedure (odds ratio = 0.38 [95% CI: 0.26, 0.56]. The incidences of overall postoperative morbidity (odds ratio = 0.57 [95% CI: 0.45, 0.73] and major morbidity (odds ratio = 0.48 [95% CI: 0.32, 0.72] following were significantly lower than following conventional double-stapled anastomosis. LIMITATIONS: The retrospective nature of most included studies is a main limitation, essentially due to the lack of randomization, and the risk of selection and detection bias. CONCLUSIONS: The available evidence supports the modification of the conventional double-stapled technique with elimination of one of both dog-ears as it is associated with lower incidence of anastomotic-related morbidity.

Conversion to open surgery in obese patients undergoing minimally invasive distal pancreatectomy: results from a multicenter analysis.

BACKGROUND: Although minimally invasive distal pancreatectomy (MIDP) is considered a standard approach it still presents a non-negligible rate of conversion to open that is mainly related to some difficulty factors, as obesity. The aim of this study is to analyze the preoperative factors associated with conversion in obese patients with MIDP. METHODS: In this multicenter study, all obese patients who underwent MIDP at 18 international expert centers were included. The preoperative factors associated with conversion to open surgery were analyzed. RESULTS: Out of 436 patients, 91 (20.9%) underwent conversion to open, presenting higher blood loss, longer operative time and similar rate of major complications. Twenty (22%) patients received emergent conversion. At univariate analysis, the type of approach, radiological invasion of adjacent organs, preoperative enlarged lymphnodes and ASA ≥ III were significantly associated with conversion to open. At multivariate analysis, robotic approach showed a significantly lower conversion rate (14.6 % vs 27.3%, OR = 2.380, p = 0.001). ASA ≥ III (OR = 2.391, p = 0.002) and preoperative enlarged lymphnodes (OR = 3.836, p = 0.003) were also independently associated with conversion. CONCLUSION: Conversion rate is significantly lower in patients undergoing robotic approach. Radiological enlarged lymphnodes and ASA ≥ III are also associated with conversion to open. Conversion is associated with poorer perioperative outcomes, especially in case of intraoperative hemorrhage.

Robotic versus laparoscopic distal pancreatectomy in obese patients.

BACKGROUND: Although robotic distal pancreatectomy (RDP) has a lower conversion rate to open surgery and causes less blood loss than laparoscopic distal pancreatectomy (LDP), clear evidence on the impact of the surgical approach on morbidity is lacking. Prior studies have shown a higher rate of complications among obese patients undergoing pancreatectomy. The primary aim of this study is to compare short-term outcomes of RDP vs. LDP in patients with a BMI ≥ 30. METHODS: In this multicenter study, all obese patients who underwent RDP or LDP for any indication between 2012 and 2022 at 18 international expert centers were included. The baseline characteristics underwent inverse probability treatment weighting to minimize allocation bias. RESULTS: Of 446 patients, 219 (50.2%) patients underwent RDP. The median age was 60 years, the median BMI was 33 (31-36), and the preoperative diagnosis was ductal adenocarcinoma in 21% of cases. The conversion rate was 19.9%, the overall complication rate was 57.8%, and the 90-day mortality rate was 0.7% (3 patients). RDP was associated with a lower complication rate (OR 0.68, 95% CI 0.52-0.89; p = 0.005), less blood loss (150 vs. 200 ml; p < 0.001), fewer blood transfusion requirements (OR 0.28, 95% CI 0.15-0.50; p < 0.001) and a lower Comprehensive Complications Index (8.7 vs. 8.9, p < 0.001) than LPD. RPD had a lower conversion rate (OR 0.27, 95% CI 0.19-0.39; p < 0.001) and achieved better spleen preservation rate (OR 1.96, 95% CI 1.13-3.39; p = 0.016) than LPD. CONCLUSIONS: In obese patients, RDP is associated with a lower conversion rate, fewer complications and better short-term outcomes than LPD.

Fully Robotic Side-to-Side Linear-Stapled Anastomosis During Robotic Ivor Lewis Esophagectomy.

BACKGROUND: The adoption of robotic surgery for esophageal cancer has been expanding rapidly over the recent years. In the setting of two-field esophagectomy, different techniques exist for intrathoracic esophagogastric anastomosis, although the superiority of one over another has not been clearly demonstrated. Potential benefits in terms of anastomotic leakage and stenosis have been reported in association with a linear-stapled anastomosis as compared to the more widespread techniques of circular mechanical and hand-sewn reconstructions, however, there is still limited reported evidence on its application to robotic surgery. We here report our fully robotic technique of side-to-side, semi-mechanical anastomosis. METHODS: All consecutive patients undergoing fully robotic esophagectomy featuring intrathoracic side-to-side stapled anastomosis by a single surgical team were included in this analysis. Operative technique is detailed, and perioperative data are assessed. RESULTS: A total of 49 patients were included. There were no intraoperative complications and no conversion occurred. The rate of overall postoperative morbidity was 25, 14% being the relative rate of major complications. With anastomotic-related morbidity in particular, one patient developed minor anastomotic leakage. CONCLUSIONS: Our experience demonstrates that a linear, side-to-side fully robotic stapled anastomosis can be created with a high technical success and minimal incidence of anastomosis-related morbidity.

Pylephlebitis: An uncommon complication of sigmoid diverticulitis.

Pylephlebitis is defined as a septic thrombophlebitis of the portal vein, usually secondary to infection in regions contiguous to or drained by the portal system. Although extremely uncommon in the modern era, pylephlebitis still carries an appreciable risk of severe morbidity and mortality, if unrecognized and left untreated. Herein we report the case of severe pylephlebitis in a patient with acute sigmoid diverticulitis. Although highly elusive, prompt diagnosis is crucial to ensure appropriate management and limit associated morbidity.

Robotic Extended Ultrasound-Guided Distal Pancreatectomy for Pancreatic Metastases from Uveal Melanoma.

BACKGROUND: Isolated pancreatic metastasis from melanoma is extremely uncommon and accounts for approximately only 2% of visceral disseminations of melanoma.1-3 Interestingly, pancreatic localizations disproportionately derive from primary ocular melanoma.1,2 Despite the currently available evidence on this argument being scarce, the survival outcomes of patients receiving resection for visceral melanoma metastases are reported to be superior than those managed by non-surgical modalities.4,5 CASE PRESENTATION: A 59-year-old female with a history of uveal melanoma presented with surveillance-detected metastatic disease confined to the pancreas. Computed tomography demonstrated one lesion located in the body of the pancreas and one further lesion in the head. The presented video illustrates the details of an extended, ultrasound-guided, robotic distal pancreatectomy. DISCUSSION: Metastatic ocular melanoma has a highly variable natural history, which ranges from a fulminant course to prolonged stable disease.6 In contrast to cutaneous melanoma derivation, metastases mostly occur via hematogenous spread, in the absence of lymphatic drainage of the eye.6,7 Liver is the most common site of secondary localization and is not involved by metastatic disease in <10% of cases. Interestingly, patients with extrahepatic metastases tend to have significantly better survival rates than those with hepatic disease.6,7 Fewer than 100 cases of pancreatic metastasis from malignant melanoma are reported in the medical literature, including a relatively high percentage of primary ocular malignancies.1,5 Furthermore, the prognosis of these patients is essentially unknown, although metastatic melanoma of both cutaneous and ocular origin generally indicates poor survival.1,5,6 Although no robust evidence is available, a number of reports suggest that pancreatic resection may improve survival in these patients.1-4 A large retrospective review investigating the association between treatment modalities and survival of patients with abdominal visceral melanoma metastases showed that patients receiving resection had a superior median survival compared with patients treated medically. Although patients with metastases of the gastrointestinal tract showed the best outcomes following surgery, patients with pancreas metastasis (of both cutaneous and ocular origin) undergoing resection also exhibited a significant survival advantage compared with those treated non-surgically.5 Minimally invasive pancreatectomy is gaining momentum.8 In fact, in selected patients there are distinct advantages compared with conventional surgery owing to reduced postoperative morbidity and earlier return to daily activities, while maintaining the oncological tenets of resection.8-10 Recent reports suggest that the application of robots may provide some advantages over conventional laparoscopy, especially for patients necessitating technically challenging surgeries.8,11 Such benefits are mainly in relation to the rate of conversion, length of postoperative hospital stay, and number of cases necessary to surmount the learning curve and reach optimal performance; however, no definitive conclusions can be drawn due to the lack of high-level evidence.8,10.

Robotic versus conventional laparoscopic technique for the treatment of left-sided colonic diverticular disease: a systematic review with meta-analysis.

PURPOSE: Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the last decade, there has been a growing interest in the application of robotic approaches for diverticular disease. We aimed at evaluating whether robotic colectomy may offer some advantages over the laparoscopic approach for surgical treatment of diverticular disease by meta-analyzing the available data from the medical literature. METHODS: The PubMed/Medline, EMBASE, and Web Of Sciences electronic databases were searched for literature up to December 2020. Inclusion criteria considered all comparative studies evaluating robotic versus laparoscopic colectomy for diverticulitis eligible. The conversion rate to the open approach was evaluated as the primary outcome. RESULTS: The data of 4177 patients from nine studies were included in the analysis. There were no significant differences in the baseline characteristics. Patients undergoing laparoscopic colectomy compared to those who underwent surgery with a robotic approach had a significantly higher risk of conversion into an open procedure (12.5% vs. 7.4%, p < 0.00001) and abbreviated hospital stay (p < 0.0001) at the price of a longer operating time (p < 0.00001). CONCLUSION: Compared with conventional laparoscopic surgery, the robotic approach offers significant advantages in terms of conversion rate and shortened hospital stay for the treatment of diverticular disease. However, because of the lack of available evidence, it is impossible to draw definitive conclusions.

Enterotomy Closure after Minimally Invasive Distal Gastrectomy with Intracorporeal Anastomosis: A Multicentric Study.

INTRODUCTION: Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis. METHODS: All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread. RESULTS: Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029). CONCLUSIONS: Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.

The role of resection for melanoma metastases to the pancreas.

BACKGROUND: Among patients with distant metastatic melanoma, the site of metastases is the most significant predictor of survival and visceral-nonpulmonary metastases hold the highest risk of poor outcomes. However, studies demonstrate that a significant percentage of patients may be considered candidates for resection with improved survival over nonsurgical therapeutic modalities. We aimed at analyzing the results of resection in patients with melanoma metastasis to the pancreas by assessing the available evidence. METHODS: The PubMed/MEDLINE, WoS, and Embase electronic databases were systematically searched for articles reporting on the surgical treatment of pancreatic metastases from melanoma. Relevant data from included studies were assessed and analyzed. Overall survival was the primary endpoint of interest. Surgical details and oncological outcomes were also appraised. RESULTS: A total of 109 patients treated surgically for pancreatic metastases were included across 72 articles and considered for data extraction. Overall, patients had a mean age of 51.8 years at diagnosis of pancreatic disease. The cumulative survival was 71%, 38%, and 26% at 1, 3 and 5 years after pancreatectomy, with an estimated median survival of 24 months. Incomplete resection and concomitant extrapancreatic metastasis were the only factors which significantly affected survival. Patients in whom the pancreas was the only metastatic site who received curative resection exhibited significantly longer survival, with a 1-year, 3-year, and 5-year survival rates of 76%, 43%, and 41%, respectively. CONCLUSION: Within the limitations of a review of non-randomized reports, curative surgical resection confers a survival benefit in carefully selected patients with pancreatic dissemination of melanoma.

The risk of conversion in minimally invasive oncological abdominal surgery. Meta-analysis of randomized evidence comparing traditional laparoscopic versus robot-assisted techniques.

PURPOSE: The objective of this study was to investigate the risk of conversion associated with conventional laparoscopic surgery (LAP) versus robot-assisted surgery (ROB) in patients undergoing abdominal oncological surgery. Possible differences between ROB and LAP on postoperative overall and major morbidity, operative time, and length of hospitalization were also assessed. METHODS: We included randomized controlled trials of LAP versus ROB surgery in patients with abdominal malignancy. We searched PubMed, EMBASE, and the Central registries through September 2020. Risk of bias was estimated concerning randomization, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases. RESULTS: A total of 1867 patients from 12 trials were included in this review. The rate of conversion was significantly higher for LAP than for ROB patients (10 trials, 1447 participants, p = 0.03, OR = 0.56 [0.33, 0.95]). There was a nonsignificant advantage of ROB over LAP on the rate of overall postoperative morbidity (12 trials, 1867 participants, p = 0.32, OR = 0.83) and major morbidity (7 trials, 792 participants, p = 0.87, OR= 0.93). ROB was also associated with prolonged operative time and abbreviated postoperative hospitalization as compared to LAP (p = 0.002, MD = 27.87, and p = 0.04, MD = -0.57, respectively). CONCLUSIONS: According to the available highest level of evidence, the application of ROB decreases the incidence of unplanned conversion into an open procedure as compared to standard LAP in the setting of oncological minimally invasive surgery.

Conventional Versus Minimally Invasive Hartmann Takedown: A Meta-analysis of the Literature.

Although end colostomy closure following Hartmann's procedure is a major surgery that is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest toward the application of different minimally invasive techniques. We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature. The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018. Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques. Overall morbidity, rate of anastomotic failure, rate of wound complications and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed. The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients between the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia. The current literature suggests that minimally invasive surgery should be considered in performing Hartmann's reversal, if technically viable. However, due to the low level of the available evidence it is impossible to draw definitive conclusions.

Subcutaneous suction drains do not prevent surgical site infections in clean-contaminated abdominal surgery-results of a systematic review and meta-analysis.

PURPOSE: The role of subcutaneous prophylactic drainage in preventing postoperative abdominal wound complications is still controversial. We aimed to elucidate whether any difference in the incidence of surgical site infection (SSI) exists between patients with or without subcutaneous suction drain following clean-contaminated abdominal surgery. METHODS: PubMed, EMBASE, and the CENTRAL were systematically searched for randomized controlled trials (RCT) comparing drained with undrained surgeries featuring gastrointestinal (GI) tract opening. The aim of the analysis was to assess the incidence of wound infection. A meta-analysis of relevant studies was performed using RevMan 5.3. RESULTS: A total of 8 studies, including 2833 patients, were considered eligible to collect data necessary. Globally, 187 patients (83 drained versus 104 undrained) experienced some SSI during the postoperative period. The use of subcutaneous suction drains did not exhibit any significant differences between drained and undrained patients in developing SSI (odds ratio 0.76, 95% CI 0.56-1.02; p = 0.07). CONCLUSIONS: According to the available, high-level evidence, the use of subcutaneous drains should not be encouraged on a routine basis, as it does not confer any advantage in preventing postoperative wound infection following clean-contaminated abdominal surgery. However, this does not exclude that there might be a benefit in a specific risk group of patients.

Clinical use of basophil activation test in drug, food and hymenoptera venom allergies.

The basophil activation is emerging as a reliable and robust in vitro biomarker of in vivo allergy reactions. Basophil Activation Test (BAT), intended as in vitro stimulation of patient blood basophil with allergens, followed by flow cytometric detection and quantification of such activation, is nowadays a well-established assay in a growing number of routine diagnostic labs. The advancements in the standardization of BAT testing and first convincing clinical evidence are behind this spreading of the assay in clinical lab. BAT is essentially an assay with superior specificity compared to any other allergy testing and, if appropriately used, it can have a valuable clinical utility in different field of allergy diagnosis. In drug allergy, very few testing opportunities are available for the numbers of drugs actually in the market. Antibiotics and analgesics are just two of the categories of drugs were BAT testing can have an added value for the limited specificity of IgE testing or limited availability of other lab testing. In food allergy, BAT is emerging as the more accurate assay to predict an in vivo reaction to food, helping in the discrimination of patients that are only sensitized versus the patient really allergic to an allergen. Furthermore, BAT testing determining the basophil sensitivity can be useful for monitoring the natural resolution of allergies and clinical responses to immunomodulatory treatment for food allergies. For this characteristic, BAT has the potential to reduce the need of OFC. In the hymenoptera venom allergy, BAT is an effective tool in identifying primary sensitizing antigen and in the follow up of patient in venom immunotherapy. With this review, we want to present current state of BAT testing focusing on the clinical laboratory parameters and issue of this assay. A highlight on the standardization needs of BAT is provided, together with considerations on further developments and clinical evidences still to be achieved.

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.

A Meta-Analysis of Randomized Controlled Trials on the Use of Suction Drains Following Rectal Surgery.

BACKGROUND: Anastomotic leakage is one of the most feared complications of rectal resections. The role of drains in limiting this occurrence or facilitating its early recognition is still poorly defined. We aimed to study whether the presence of prophylactic pelvic drains affects the surgical outcomes of patients undergoing rectal surgery with extraperitoneal anastomosis. METHODS: PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials comparing drained with undrained anastomoses following rectal surgery. We evaluated possible differences on the relative incidences of anastomotic leakage, pelvic collection or sepsis, bowel obstruction, reoperation rate, and overall mortality. A meta-analysis of relevant studies was performed with RevMan 5.3. RESULTS: A total of 760 patients from 4 randomized controlled studies were considered eligible for data extraction. The use of drains did not show any advantage in terms of anastomotic leak (OR 0.99), pelvic complications (OR 0.87), reintervention (OR 0.84) and mortality. Contrariwise, the incidence of postoperative bowel obstruction was significantly higher in the drained group (OR 1.61). CONCLUSIONS: The routine utilization of pelvic drains does not confer any significant advantage in the prevention of postoperative complications after rectal surgery with extraperitoneal anastomosis. Moreover, a higher risk of postoperative bowel obstruction can be of concern.