The Role of Italy in the Use of Advanced Plant Genomic Techniques on Fruit Trees: State of the Art and Future Perspectives.

Climate change is deeply impacting the food chain production, lowering quality and yield. In this context, the international scientific community has dedicated many efforts to enhancing resilience and sustainability in agriculture. Italy is among the main European producers of several fruit trees; therefore, national research centers and universities undertook several initiatives to maintain the specificity of the 'Made in Italy' label. Despite their importance, fruit crops are suffering from difficulties associated with the conventional breeding approaches, especially in terms of financial commitment, land resources availability, and long generation times. The 'new genomic techniques' (NGTs), renamed in Italy as 'technologies for assisted evolution' (TEAs), reduce the time required to obtain genetically improved cultivars while precisely targeting specific DNA sequences. This review aims to illustrate the role of the Italian scientific community in the use of NGTs, with a specific focus on Citrus, grapevine, apple, pear, chestnut, strawberry, peach, and kiwifruit. For each crop, the key genes and traits on which the scientific community is working, as well as the technological improvements and advancements on the regeneration of local varieties, are presented. Lastly, a focus is placed on the legal aspects in the European and in Italian contexts.

Breaking down the silos of artificial intelligence in surgery: glossary of terms.

BACKGROUND: The literature on artificial intelligence (AI) in surgery has advanced rapidly during the past few years. However, the published studies on AI are mostly reported by computer scientists using their own jargon which is unfamiliar to surgeons. METHODS: A literature search was conducted in using PubMed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. The primary outcome of this review is to provide a glossary with definitions of the commonly used AI terms in surgery to improve their understanding by surgeons. RESULTS: One hundred ninety-five studies were included in this review, and 38 AI terms related to surgery were retrieved. Convolutional neural networks were the most frequently culled term by the search, accounting for 74 studies on AI in surgery, followed by classification task (n = 62), artificial neural networks (n = 53), and regression (n = 49). Then, the most frequent expressions were supervised learning (reported in 24 articles), support vector machine (SVM) in 21, and logistic regression in 16. The rest of the 38 terms was seldom mentioned. CONCLUSIONS: The proposed glossary can be used by several stakeholders. First and foremost, by residents and attending consultant surgeons, both having to understand the fundamentals of AI when reading such articles. Secondly, junior researchers at the start of their career in Surgical Data Science and thirdly experts working in the regulatory sections of companies involved in the AI Business Software as a Medical Device (SaMD) preparing documents for submission to the Food and Drug Administration (FDA) or other agencies for approval.

Ensemble deep learning for the prediction of proficiency at a virtual simulator for robot-assisted surgery.

BACKGROUND: Artificial intelligence (AI) has the potential to enhance patient safety in surgery, and all its aspects, including education and training, will derive considerable benefit from AI. In the present study, deep-learning models were used to predict the rates of proficiency acquisition in robot-assisted surgery (RAS), thereby providing surgical programs directors information on the levels of the innate ability of trainees to facilitate the implementation of flexible personalized training. METHODS: 176 medical students, without prior experience with surgical simulators, were trained to reach proficiency in five tasks on a virtual simulator for RAS. Ensemble deep neural networks (DNN) models were developed and compared with other ensemble AI algorithms, i.e., random forests and gradient boosted regression trees (GBRT). RESULTS: DNN models achieved a higher accuracy than random forests and GBRT in predicting time to proficiency, 0.84 vs. 0.70 and 0.77, respectively (Peg board 2), 0.83 vs. 0.79 and 0.78 (Ring walk 2), 0.81 vs 0.81 and 0.80 (Match board 1), 0.79 vs. 0.75 and 0.71 (Ring and rail 2), and 0.87 vs. 0.86 and 0.84 (Thread the rings 2). Ensemble DNN models outperformed random forests and GBRT in predicting number of attempts to proficiency, with an accuracy of 0.87 vs. 0.86 and 0.83, respectively (Peg board 2), 0.89 vs. 0.88 and 0.89 (Ring walk 2), 0.91 vs. 0.89 and 0.89 (Match board 1), 0.89 vs. 0.87 and 0.83 (Ring and rail 2), and 0.96 vs. 0.94 and 0.94 (Thread the rings 2). CONCLUSIONS: Ensemble DNN models can identify at an early stage the acquisition rates of surgical technical proficiency of trainees and identify those struggling to reach the required expected proficiency level.

Pharmacological and In Silico Analysis of Oat Avenanthramides as EGFR Inhibitors: Effects on EGF-Induced Lung Cancer Cell Growth and Migration.

Avena sativa L. is a wholegrain cereal and an important edible crop. Oats possesses high nutritional and health promoting values and contains high levels of bioactive compounds, including a group of phenolic amides, named avenanthramides (Avns), exerting antioxidant, anti-inflammatory, and anticancer activities. Epidermal growth factor receptor (EGFR) represents one of the most known oncogenes and it is frequently up-regulated or mutated in human cancers. The oncogenic effects of EGFR include enhanced cell growth, angiogenesis, and metastasis, and down-regulation or inhibition of EGFR signaling has therapeutic benefit. Front-line EGFR tyrosine kinase inhibitor therapy is the standard therapy for patients with EGFR-mutated lung cancer. However, the clinical effects of EGFR inhibition may be lost after a few months of treatment due to the onset of resistance. Here, we showed the anticancer activity of Avns, focusing on EGFR activation and signaling pathway. Lung cancer cellular models have been used to evaluate the activity of Avns on tumor growth, migration, EMT, and anoikis induced by EGF. In addition, docking and molecular dynamics simulations showed that the Avns bind with high affinity to a region in the vicinity of αC-helix and the DGF motif of EGFR, jeopardizing the target biological function. Altogether, our results reveal a new pharmacological activity of Avns as EGFR tyrosine kinase inhibitors.

First Report on Genome Editing via Ribonucleoprotein (RNP) in Castanea sativa Mill.

Castanea sativa is an important tree nut species worldwide, highly appreciated for its multifunctional role, in particular for timber and nut production. Nowadays, new strategies are needed to achieve plant resilience to diseases, climate change, higher yields, and nutritional quality. Among the new plant breeding techniques (NPBTs), the CRISPR/Cas9 system represents a powerful tool to improve plant breeding in a short time and inexpensive way. In addition, the CRISPR/Cas9 construct can be delivered into the cells in the form of ribonucleoproteins (RNPs), avoiding the integration of exogenous DNA (GMO-free) through protoplast technology that represents an interesting material for gene editing thanks to the highly permeable membrane to DNA. In the present study, we developed the first protoplast isolation protocol starting from European chestnut somatic embryos. The enzyme solution optimized for cell wall digestion contained 1% cellulase Onozuka R-10 and 0.5% macerozyme R-10. After incubation for 4 h at 25 °C in dark conditions, a yield of 4,500,000 protoplasts/mL was obtained (91% viable). The transfection capacity was evaluated using the GFP marker gene, and the percentage of transfected protoplasts was 51%, 72 h after the transfection event. The direct delivery of the purified RNP was then performed targeting the phytoene desaturase gene. Results revealed the expected target modification by the CRISPR/Cas9 RNP and the efficient protoplast editing.

CRISPR/Cas9-Based Knock-Out of the PMR4 Gene Reduces Susceptibility to Late Blight in Two Tomato Cultivars.

Phytophthora infestans, the causal agent of late blight (LB) in tomato (Solanum lycopersicum L.), is a devastating disease and a serious concern for plant productivity. The presence of susceptibility (S) genes in plants facilitates pathogen proliferation; thus, disabling these genes may help provide a broad-spectrum and durable type of tolerance/resistance. Previous studies on Arabidopsis and tomato have highlighted that knock-out mutants of the PMR4 susceptibility gene are tolerant to powdery mildew. Moreover, PMR4 knock-down in potato has been shown to confer tolerance to LB. To verify the same effect in tomato in the present study, a CRISPR-Cas9 vector containing four single guide RNAs (sgRNAs: sgRNA1, sgRNA6, sgRNA7, and sgRNA8), targeting as many SlPMR4 regions, was introduced via Agrobacterium-tumefaciens-mediated transformation into two widely grown Italian tomato cultivars: 'San Marzano' (SM) and 'Oxheart' (OX). Thirty-five plants (twenty-six SM and nine OX) were selected and screened to identify the CRISPR/Cas9-induced mutations. The different sgRNAs caused mutation frequencies ranging from 22.1 to 100% and alternatively precise insertions (sgRNA6) or deletions (sgRNA7, sgRNA1, and sgRNA8). Notably, sgRNA7 induced in seven SM genotypes a -7 bp deletion in the homozygous status, whereas sgRNA8 led to the production of fifteen SM genotypes with a biallelic mutation (-7 bp and -2 bp). Selected edited lines were inoculated with P. infestans, and four of them, fully knocked out at the PMR4 locus, showed reduced disease symptoms (reduction in susceptibility from 55 to 80%) compared to control plants. The four SM lines were sequenced using Illumina whole-genome sequencing for deeper characterization without exhibiting any evidence of mutations in the candidate off-target regions. Our results showed, for the first time, a reduced susceptibility to Phytophtora infestans in pmr4 tomato mutants confirming the role of KO PMR4 in providing broad-spectrum protection against pathogens.

The influence of acute water stresses on the biochemical composition of bell pepper (Capsicum annuum L.) berries.

BACKGROUND: Crops are exposed to recurrent and acute drought stress episodes during their vegetative and reproductive cycles, and these episodes are increasingly frequent due to ongoing climate change. Sweet pepper (Capsicum annuum), alias bell pepper, is one of the most widely cultivated vegetables and is grown in open fields worldwide. Here we assessed the effect of acute water stress, applied to a breeding line of sweet pepper at three stages of plant development: five true-leaves (Stage 1), production of the third flower (Stage 2) and setting of the first fruit (Stage 3), on the production and biochemical composition of its ripe fruits. RESULTS: The water stress at Stages 1 and 2 induced a delay in fruit ripening, while at Stage 3 caused a drop in production. The biochemical composition of ripe fruits was assessed by quantifying their content in vitamin C, sugars, organic acids, flavonoids as well as 190 volatile organic compounds, mainly belonging to the chemical classes of hydrocarbons, alcohols, ketones, esters, terpenes, aldehydes and ethers. Our results highlight that, at different stages of plant development, acute water stresses modulate differently the accumulation of bioactive compounds in fruits, which play a key role in setting the redox-status and osmotic adjustment of the plant. This was also the case for volatile compounds since, within each chemical class, different compounds varied their content in ripe fruits. CONCLUSIONS: On the whole, our results demonstrate that water stresses potentially affect the organoleptic and sensory qualities of bell pepper fruits depending on when they occur. © 2021 Society of Chemical Industry.

Proving the Effectiveness of the Fundamentals of Robotic Surgery (FRS) Skills Curriculum: A Single-blinded, Multispecialty, Multi-institutional Randomized Control Trial.

OBJECTIVE: To demonstrate the noninferiority of the fundamentals of robotic surgery (FRS) skills curriculum over current training paradigms and identify an ideal training platform. SUMMARY BACKGROUND DATA: There is currently no validated, uniformly accepted curriculum for training in robotic surgery skills. METHODS: Single-blinded parallel-group randomized trial at 12 international American College of Surgeons (ACS) Accredited Education Institutes (AEI). Thirty-three robotic surgery experts and 123 inexperienced surgical trainees were enrolled between April 2015 and November 2016. Benchmarks (proficiency levels) on the 7 FRS Dome tasks were established based on expert performance. Participants were then randomly assigned to 4 training groups: Dome (n = 29), dV-Trainer (n = 30), and DVSS (n = 32) that trained to benchmarks and control (n = 32) that trained using locally available robotic skills curricula. The primary outcome was participant performance after training based on task errors and duration on 5 basic robotic tasks (knot tying, continuous suturing, cutting, dissection, and vessel coagulation) using an avian tissue model (transfer-test). Secondary outcomes included cognitive test scores, GEARS ratings, and robot familiarity checklist scores. RESULTS: All groups demonstrated significant performance improvement after skills training (P < 0.01). Participating residents and fellows performed tasks faster (DOME and DVSS groups) and with fewer errors than controls (DOME group; P < 0.01). Inter-rater reliability was high for the checklist scores (0.82-0.97) but moderate for GEARS ratings (0.40-0.67). CONCLUSIONS: We provide evidence of effectiveness for the FRS curriculum by demonstrating better performance of those trained following FRS compared with controls on a transfer test. We therefore argue for its implementation across training programs before surgeons apply these skills clinically.

Robotic-assisted versus open left pancreatectomy for cystic tumours: A single-centre experience.

BACKGROUND: Cystic pancreatic lesions (CPLs) are being identified increasingly, and some benefit from surgical treatment. With the increasing use of robotic-assisted surgery (RAS) for neoplasms of the pancreas, the aim of the present comparative study is to establish whether the RAS offered any advantages over conventional open surgery (OS) in the management of CPLs. PATIENTS AND METHODS: Twenty-seven out of 37 robot-assisted left-sided pancreatectomy (LSP) performed between January 2010 and April 2017 were carried out for CPLs. The surgical outcome and histopathology were compared retrospectively with a control group of 27 patients who had undergone open LSP for CPLs, selected using a one-to-one case-matched methodology (OS-Group) from the prospectively collected institutional database. RESULTS: The spleen was preserved in a significantly higher percentage of patients in the RAS-group (63% vs. 33.3%,P < 0.05). There was no difference in the post-operative course (pancreatic fistula and morbidity) between the two groups. The median post-operative hospital stay was significantly shorter in the RAS-group: 8 days (range 3-25) versus 12 days (range 7-26) in the OS-group (P < 0.01). No conversion to open approach was reported in the RAS-group. CONCLUSIONS: Robotically assisted LSP is a safe and effective procedure. It is accompanied by a significantly higher spleen preservation rate compared to the open approach. In addition, because of the reduced trauma, RAS incurred a shorter post-operative hospital stay and faster return to full recovery, particularly important in patients undergoing surgery for relative indications. However, these benefits of RAS for LSP require confirmation by prospective randomised controlled studies.

Gastrointestinal stromal tumours of stomach: Robot-assisted excision with the da Vinci Surgical System regardless of size and location site.

Aims: The role of minimally invasive surgery of gastrointestinal stromal tumours (GISTs) of the stomach remains uncertain especially for large and/or difficult located tumours. We are hereby presenting a single-centre series of robot-assisted resections using the da Vinci Surgical System (Si or Xi). Subjects and Methods: Data of patients undergoing robot-assisted treatment of gastric GIST were retrieved from the prospectively collected institutional database and a retrospective analysis was performed. Patients were stratified according to size and location of the tumour. Difficult cases (DCs) were considered for size if tumour was >50 mm and/or for location if the tumour was Type II, III or IV sec. Privette/Al-Thani classification. Results: Between May 2010 and February 2017, 12 consecutive patients underwent robot-assisted treatment of GIST at our institution. DCs were 10/12 cases (83.3%), of which 6/10 (50%) for location, 2/10 (25%) for size and 2/10 (25%) for both. The da Vinci Si was used in 8 patients, of which 6 (75%) were DC, and the da Vinci Xi in 4, all of which (100%) were DC. In all patients, excision was by wedge resection. All lesions had microscopically negative resection margins. There was no conversion to open surgery, no tumour ruptures or spillage and no intraoperative complications. Conclusion: Our experience suggests a positive role of the robot da Vinci in getting gastric GIST removal with a conservative approach, regardless of size and location site. Comparative studies with a greater number of patients are necessary for a more robust assessment.

Distribution of innate psychomotor skills recognized as important for surgical specialization in unconditioned medical undergraduates.

BACKGROUND: There is an increasing interest for a test assessing objectively the innate aptitude for surgery as a craft specialty to complement the current selection process of surgical residents. The aim of this study was to quantify the size of individuals with high, average, and low level of innate psychomotor skills among medical students. METHODS: A volunteer sample of 155 medical students, without prior experience with surgical simulator, executed five tasks at a virtual simulator for robot-assisted surgery. They had to reach proficiency twice consecutively in each before moving to the next one. A weighting based on time and number of attempts needed to reach proficiency was assigned to each task. RESULTS: Nine students (5.8%) out of 155 significantly outperformed all the others on median (i.q.r.) weighted time [44.7 (42.2-47.3) min vs. 98.5 (70.8-131.8) min, p < 0.001], and number of attempts to reach proficiency [14 (12-15) vs. 23 (19-32.75), p < 0.001). Seventeen students (11.0%) scored significantly much worse than the rest on median weighted time [202.2 (182.5-221.0) min vs. 84.3 (65.7-114.4) min, p < 0.001], and number of attempts [42 (40-48) vs. 22 (17.25-28), p < 0.001]. Low correlation between simulator scores and extracurricular activities, like videogames and musical instruments, was found. CONCLUSIONS: The test successfully identified two groups straddling the large cohort with average innate aptitude for psychomotor skills: (i) innately gifted and (ii) with scarce level. Hence, exercises on a virtual simulator are a valid test of innate manual dexterity and can be considered to complement the selection process for a surgical training program, primarily to identify individuals with low innate aptitude for surgery and advise them to consider specialization in other (non-craft) medical specialties.

Robot-assisted total mesorectal excision for rectal cancer: case-matched comparison of short-term surgical and functional outcomes between the da Vinci Xi and Si.

BACKGROUND: Robotic rectal resection with da Vinci Si has some technical limitations, which could be overcome by the new da Vinci Xi. We compare short-term surgical and functional outcomes following robotic rectal resection with total mesorectal excision for cancer, with the da Vinci Xi (Xi-RobTME group) and the da Vinci Si (Si-RobTME group). METHODS: The first consecutive 30 Xi-RobTME were compared with a Si-RobTME control group of 30 patients, selected using a one-to-one case-matched methodology from our prospectively collected Institutional database, comprising all cases performed between April 2010 and September 2016 by a single surgeon. Perioperative outcomes were compared. The impact of minimally invasive TME on autonomic function and quality of life was analyzed with specific questionnaires. RESULTS: The docking and overall operative time were shorter in the Xi-RobTME group (p < 0.001 and p < 0.05 respectively). The mean differences of overall operative time and docking time were -33.8 min (95% CI -5.1 to -64.5) and -6 min (95% CI -4.1 to -7.9), respectively. A fully-robotic approach with complete splenic flexure mobilization was used in 30/30 (100%) of the Xi-RobTME cases and in 7/30 (23%) of the Si-RobTME group (p < 0.001). The hybrid approach in males and patients with BMI > 25 kg/m2 was necessary in ten patients (45 vs. 0%, p < 0.001) and in six patients (37 vs. 0%, p < 0.05), in the Si-RobTME and Xi-RobTME groups, respectively. There were no differences in conversion rate, mean hospital stay, pathological data, and in functional outcomes between the two groups before and at 1 year after surgery. CONCLUSION: The technical advantages offered by the da Vinci Xi seem to be mainly associated with a shorter docking and operative time and with superior ability to perform a fully-robotic approach. Clinical and functional outcomes seem not to be improved, with the introduction of the new Xi platform.

Robotic Colorectal Resection With and Without the Use of the New Da Vinci Table Motion: A Case-Matched Study.

BACKGROUND: The da Vinci Table Motion (dVTM) is a new device that enables patients to be repositioned with instruments in place within the abdomen, and without undocking the robot. The present study was designed to compare operative and short-term outcomes of patients undergoing colorectal cancer surgery with the da Vinci Xi system, with or without use of the dVTM. METHODS: Ten patients underwent robotic colorectal resection for cancer with the use of dVTM (Xi-dVTM group) between May 2015 and October 2015 at our center. The intraoperative and short-term clinical outcome were compared, using a case-control methodology (propensity scores approach to create 1:2 matched pairs), with a similar group of patients who underwent robotic colorectal surgery for cancer without the use of the dVTM device (Xi-only group). RESULTS: Overall robotic operative time was shorter in the Xi-dVTM group ( P = .04). Operations were executed fully robotic in all Xi-dVTM cases, while 2 cases of the Xi-only group required conversion to open surgery because of bulky tumors and difficult exposure. Postoperative medical complications were higher in the Xi-only group ( P = .024). CONCLUSIONS: In this preliminary experience, the use of the new dVTM with the da Vinci Xi in colorectal surgery, by overcoming the limitations of the fixed positions of the patient, enhanced the workflow and resulted in improved exposure of the operative field. Further studies with a greater number of patients are needed to confirm these benefits of the dVTM-da Vinci Xi robotically assisted colorectal surgery.

Performances on simulator and da Vinci robot on subjects with and without surgical background.

Objective: To assess whether previous training in surgery influences performance on da Vinci Skills Simulator and da Vinci robot. Material and methods: In this prospective study, thirty-seven participants (11 medical students, 17 residents, and 9 attending surgeons) without previous experience in laparoscopy and robotic surgery performed 26 exercises at da Vinci Skills Simulator. Thirty-five then executed a suture using a da Vinci robot. Results: The overall scores on the exercises at the da Vinci Skills Simulator show a similar performance among the groups with no statistically significant pair-wise differences (p < .05). The quality of the suturing based on the unedited videos of the test run was similar for the intermediate (7 (4, 10)) and expert group (6.5 (4.5, 10)), and poor for the untrained groups (5 (3.5, 9)), without statistically significant difference (p < .05). Conclusion: This study showed, for subjects new to laparoscopy and robotic surgery, insignificant differences in the scores at the da Vinci Skills Simulator and at the da Vinci robot on inanimate models.

Face, content, and construct validity of a simulator for training in endovascular procedures.

Aim: In recent years the interest in structured training programs in endovascular surgical procedures has increased. In this study we assess face, content, and construct validity of a simulator to teach basic skills of endovascular surgery. Material and methods: A cohort of 21 medical students, 26 residents, and 14 expert surgeons participated in the study. Experts assessed face and content validity. Then, they executed four tasks once, while medical students and residents were allowed two attempts to reach a five-minute threshold under expert supervision. Medical students and residents repeated the same exercises during a second session plus three new additional ones, without expert supervision. Results: The simulator was rated as good by experts (four out of five on a Likert scale) in terms of realism (face validity) and usefulness as training tool for the training of basic skills (content). For construct validity, experts outperformed with a statistically significant difference (p < .05) medical students and residents in all tasks, except cannulation of upper mesenteric (p = .053). Differences between novices and intermediates persisted in the second session in the same four tasks and in the three additional ones, with statistically significant difference (p < .05) in the last four exercises. Conclusions: This study showed face, content, and construct validity of BEST simulator.

Full Robotic Colorectal Resections for Cancer Combined With Other Major Surgical Procedures: Early Experience With the da Vinci Xi.

BACKGROUND: The da Vinci Xi has been developed to overcome some of the limitations of the previous platform, thereby increasing the acceptance of its use in robotic multiorgan surgery. METHODS: Between January 2015 and October 2015, 10 patients with synchronous tumors of the colorectum and others abdominal organs underwent robotic combined resections with the da Vinci Xi. Trocar positions respected the Universal Port Placement Guidelines provided by Intuitive Surgical for "left lower quadrant," with trocars centered on the umbilical area, or shifted 2 to 3 cm to the right or to the left, depending on the type of combined surgical procedure. RESULTS: All procedures were completed with the full robotic technique. Simultaneous procedures in same quadrant or left quadrant and pelvis, or left/right and upper, were performed with a single docking/single targeting approach; in cases of left/right quadrant or right quadrant/pelvis, we performed a dual-targeting operation. No external collisions or problems related to trocar positions were noted. No patient experienced postoperative surgical complications and the mean hospital stay was 6 days. CONCLUSIONS: The high success rate of full robotic colorectal resection combined with other surgical interventions for synchronous tumors, suggest the efficacy of the da Vinci Xi in this setting.

Influence of videogames and musical instruments on performances at a simulator for robotic surgery.

OBJECTIVE: To assess if exposure to videogames, musical instrument playing, or both influence the psychomotor skills level, assessed by a virtual reality simulator for robot-assisted surgery (RAS). MATERIALS AND METHODS: A cohort of 57 medical students were recruited: playing musical instruments (group 1), videogames (group 2), both (group 3), and no activity (group 4); all students executed four exercises on a virtual simulator for RAS. RESULTS: Subjects from group 3 achieved the best performances on overall score: 527.09 ± 130.54 vs. 493.73 ± 108.88 (group 2), 472.72 ± 85.31 (group 1), and 403.13 ± 99.83 (group 4). Statistically significant differences (p < .05) between group 3 and group 4 were found for overall score (p = .009) and for time of completion (p = .044). As regards experience with the piano, subjects from group 3 outperformed those from group 1 on overall score (496.98 ± 122.71 vs. 470.25 ± 92.31), but without statistically significant difference (p = .646). CONCLUSIONS: The present study suggests that the level of psychomotor skills in subjects exposed to both musical instrument playing and videogames is higher than that in those practicing either one alone. The effect of videogames appears negligible in individuals playing the piano.

Laparoscopic Microwave Liver Ablation and Portal Vein Ligation: An Alternative Approach to the Conventional ALPPS Procedure in Hilar Cholangiocarcinoma.

BACKGROUND: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a new procedure aimed at promoting the overgrowth of small future liver remnants (FLR). The role of ALPPS in hilar cholangiocarcinoma (h-CCA) is currently considered marginal because liver split in the presence of bile duct obstruction increases postoperative morbidity and mortality (Schadde et al. in Ann Surg 260:829-836,2014; Nadalin et al. in Z Gastroenterol 52:35-42,2014). Virtual liver split (Gall et al. in Ann Surg 261:e45-e46,2015) could improve the outcome of ALPPS in h-CCA. METHODS: A 64-year-old woman with a type IIIA h-CCA without evidence of vascular involvement had a small FLR (FLR/body weight: 0.47 cm3/kg). After bilateral percutaneous biliary drainage (PBD) and bilirubin normalization, the patient was planned for laparoscopic step 1 ALPPS using microwave ablation (MWA). Because of possible challenge in hilar dissection in this tumor type, robotic assistance was preferred to conventional laparoscopy for step 1. RESULTS: The patient recovered promptly from step 1, with a 68 % increase in the volume of FLR by postoperative day (POD) 10 (FLR/body weight of 0.79 cm3/kg). On POD 15, the patient underwent open right hepatectomy with en bloc resection of the caudate lobe, bile duct bifurcation, and extrahepatic biliary duct (T2N1M0R0). Estimated blood loss was negligible during step 1 and 150 mL during step 2. The patient recovered well. Chemotherapy was started 6 weeks after ALPPS stage 2, and was well tolerated and full course. Twenty months after resection the patient is alive, well, and disease-free. CONCLUSIONS: Laparoscopic ALPPS (Machado et al. in Ann Surg 256:e13,2012) and MWA on the intended split line (Gringeri and Boetto in Ann Surg 261:e42-e43,2015) have been recently described. The combination of these techniques with PBD allowed successful ALPPS in a patient with h-CCA.

Robot-assisted versus laparoscopic rectal resection for cancer in a single surgeon's experience: a cost analysis covering the initial 50 robotic cases with the da Vinci Si.

PURPOSE: The aim of this study is to compare surgical parameters and the costs of robotic surgery with those of laparoscopic approach in rectal cancer based on a single surgeon's early robotic experience. METHODS: Data from 25 laparoscopic (LapTME) and the first 50 robotic (RobTME) rectal resections performed at our institution by an experienced laparoscopic surgeon (>100 procedures) between 2009 and 2014 were retrospectively analyzed and compared. Patient demographic, procedure, and outcome data were gathered. Costs of the two procedures were collected, differentiated into fixed and variable costs, and analyzed against the robotic learning curve according to the cumulative sum (CUSUM) method. RESULTS: Based on CUSUM analysis, RobTME group was divided into three phases (Rob1: 1-19; Rob2: 20-40; Rob3: 41-50). Overall median operative time (OT) was significantly lower in LapTME than in RobTME (270 vs 312.5 min, p = 0.006). A statistically significant change in OT by phase of robotic experience was detected in the RobTME group (p = 0.010). Overall mean costs associated with LapTME procedures were significantly lower than with RobTME (p < 0.001). Statistically significant reductions in variable and overall costs were found between robotic phases (p < 0.009 for both). With fixed costs excluded, the difference between laparoscopic and Rob3 was no longer statistically significant. CONCLUSIONS: Our results suggest a significant optimization of robotic rectal surgery's costs with experience. Efforts to reduce the dominant fixed cost are recommended to maintain the sustainability of the system and benefit from the technical advantages offered by the robot.