The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma.

Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.

A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS.

BACKGROUND: The increasing use of robotic systems for anti-reflux operations prompted this study to evaluate and compare the efficacy of robotic and Laparo-Endoscopic Single-Site (LESS) approaches. METHODS: From 2012, 228 robotic fundoplication and 518 LESS fundoplication patients were prospectively followed, analyzing perioperative metrics. Data are presented as median (mean ± SD); significance at p ≤ 0.05. RESULTS: Patients undergoing a robotic vs. LESS fundoplication were 67 (64 ± 13.7) vs. 61 (59 ± 15.1) years-old with BMIs of 25 (25 ± 3.2) vs. 26 (25 ± 3.9) kg/m2 (p = 0.001 and 1.00, respectively). 72% of patients who underwent the robotic approach had a previous abdominal operation(s) vs 44% who underwent the LESS approach (p = 0.0001). 38% vs. 8% had a re-operative fundoplication (p = 0.0001), 59% vs. 45% had a type IV hiatal hernia (p = 0.0004). Operative duration was 160 (176 ± 76.7) vs. 130 (135 ± 50.5) min (p = 0.0001). There were 0 (robotic) vs. 5 (LESS) conversions to a different approach (p = 0.33). 5 Patients vs. 3 patients experienced postoperative complications (p = 0.06), and length of stay (LOS) was 1 (2 ± 2.6) vs. 1 (1 ± 3.2) days (p = 0.0001). Patient symptomatic dysphagia preoperatively for the robotic vs. LESS approach was scored as 2 (2.4 ± 1.9) vs. 1 (1.9 ± 1.6). Postoperatively, symptomatic dysphagia was scored as 1 (1.5 ± 1.6) vs. 1 (1.7 ± 1.7). The change in these scores was - 1 (- 1 ± 2.2) vs. 0 (- 0.5 ± 2.2) (p = 0.004). CONCLUSION: Despite longer operative times and LOS in older patients, the robotic approach is efficient in undertaking very difficult operations, including patients with type IV or recurrent hiatal hernias. Furthermore, preoperative anti-reflux operations were more likely to be undertaken with the robotic approach than the LESS approach. The patient's postoperative symptomatic dysphagia improved relatively more than after the LESS approach. The vast majority of patients who underwent the LESS approach enjoyed improved cosmesis, thus, making LESS a stronger candidate for more routine operations. Despite patient selection bias, the robotic and LESS approaches to anti-reflux operations are safe, efficacious, and should be situationally utilized.

Unplanned conversions of robotic pancreaticoduodenectomy: short-term outcomes and suggested stepwise approach for a safe conversion.

OBJECTIVE: With the increased adoption of robotic pancreaticoduodenectomy, the effects of unplanned conversions to an 'open' operation are ill-defined. This study aims to describe the impact of unplanned conversions of robotic pancreaticoduodenectomy on short-term outcomes and suggest a stepwise approach for safe unplanned conversions during robotic pancreaticoduodenectomy. METHODS: This is an analysis of 400 consecutive patients undergoing robotic pancreaticoduodenectomy in a single high-volume institution. Data are presented as median (mean ± SD), and significance is accepted with 95% probability. RESULTS: Between November 2012 and February 2023, 184 (46%) women and 216 (54%) men, aged 70 (68 ± 11.0) years, underwent a robotic pancreaticoduodenectomy. Unplanned conversions occurred in 42 (10.5%) patients; 18 (5%) were converted due to unanticipated vascular involvement, 13 (3%) due to failure to obtain definitive control of bleeding, and 11 (3%) due to visceral obesity. Men were more likely to require a conversion than women (29 vs. 13, p = 0.05). Conversions were associated with shorter operative time (376 (323 ± 182.2) vs. 434 (441 ± 98.7) min, p < 0.0001) but higher estimated blood loss (675 (1010 ± 1168.1) vs. 150 (196 ± 176.8) mL, p < 0.0001). Patients that required an unplanned conversion had higher rates of complications with Clavien-Dindo scores of III-V (31% vs. 12%, p = 0.003), longer length of stay (8 (11 ± 11.6) vs. 5 (7 ± 6.2), p = 0.0005), longer ICU length of stay (1 (2 ± 5.1) vs. 0 (0 ± 1.3), p < 0.0001) and higher mortality rates (21% vs. 4%, p = 0.0001). The conversion rate significantly decreased over time (p < 0.0001). CONCLUSIONS: Unplanned conversions of robotic pancreaticoduodenectomy significantly and negatively affect short-term outcomes, including postoperative mortality. Men were more likely to require a conversion than women. The unplanned conversions rates significantly decreased over time, implying that increased proficiency and patient selection may prevent unplanned conversions. An unplanned conversion should be undertaken in an organized stepwise approach to maximize patient safety.

The Implications of Readmission on Cost and Patient Outcomes Following Distal Pancreatectomy and Splenectomy.

BACKGROUND: Robotic platform usage for distal pancreatectomy and splenectomy has grown exponentially in recent years. This study aims to identify the impact of readmission following robotic distal pancreatectomy and splenectomy and to analyze the financial implications of these readmissions. METHODS: We prospectively followed 137 patients after robotic distal pancreatectomy and splenectomy. Readmission was defined as rehospitalization within 30 days post-discharge. Total cost incorporated initial and readmission hospital costs, when applicable. Outcomes were analyzed using chi-square/Fisher's exact test and Student's t test. Data are presented as median (mean ± SD). RESULTS: Of 137 patients, 20 (14%) were readmitted. Readmitted patients were 67 (66 ± 10.3) years old and had a BMI of 30 (30 ± 7.0) kg/m2; 9 (45%) had previous abdominal operations. Non-readmitted patients were 67 (62 ± 14.7) years old and had a BMI of 28 (28 ± 5.7) kg/m2; 37 (32%) had previous abdominal operations (P = NS, for all). Readmitted patients vs non-readmitted patients had operative durations of 327 (363 ± 179.1) vs 251 (293 ± 176.4) minutes (P = .10), estimated blood loss (EBL) of 90 (159 ± 214.6) vs 100 (244 ± 559.4) mL (P = .50), and tumor diameter of 3 (4 ± 2.0) vs 3 (4 ± 2.9) cm (P = 1.00). Initial length of stay (LOS) for readmitted patients vs patients who were not readmitted was 5 (5 ± 2.7) vs 4 (5 ± 3.0) days (P = 1.00); total hospital cost of those readmitted, including both admissions, was $29,095 (32,324 ± 20,227.38) vs $24,663 (25,075 ± 10,786.45) (P = .018) for those not readmitted. DISCUSSION: Despite a similar perioperative course, readmissions were associated with increased costs. We propose thorough consideration before readmission and increased patient education initiatives will reduce readmissions after robotic distal pancreatectomy and splenectomy.

Comparative Analysis of NSQIP National Outcomes and Projected Outcomes versus Our Institutional Outcomes for Robotic Gastrectomy: The Future of Gastric Resection.

BACKGROUND: The robotic approach has vast applications in surgery; however, the utility of robotic gastrectomy has yet to be clearly defined. This study aimed to compare outcomes following robotic gastrectomy at our institution to the national patient-specific predicted outcomes data provided by the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). METHODS: We prospectively studied 73 patients who underwent robotic gastrectomy under our care. ACS NSQIP outcomes after gastrectomy and predicted outcomes for our patients were compared with our actual outcomes utilizing students t test and chi-square analysis, where applicable. Data are presented as median (mean ± SD). RESULTS: Patients were 65 (66 ± 10.7) years old with a BMI of 26 (28 ± 6.5) kg/m2. 35 patients had gastric adenocarcinomas and 22 had gastrointestinal stromal tumors Operative duration was 245 (250 ± 114.7) minutes, estimated blood loss was 50 (83 ± 91.6) mL, and there were no conversions to 'open'. 1% of patients experienced superficial surgical site infections compared to the NSQIP predicted rate of 10% (P < .05). Length of stay (LOS) was 5 (6 ± 4.2) days vs NSQIP's predicted LOS of 8 (8 ± 3.2) days (P < .05). Three patients died during their postoperative hospital course (4%), due to multi-system organ failure and cardiac arrest. 1-year, 3-year, and 5-year estimated survival for patients with gastric adenocarcinoma was 76%, 63%, and 63%, respectively. DISCUSSION: Robotic gastrectomy yields salutary patient outcomes and optimal survival for varying gastric diseases, particularly gastric adenocarcinoma. Our patients experienced shorter hospital stays and reduced complications relative to patients in NSQIP and predicted outcome for our patients. Gastrectomy undertaken robotically is the future of gastric resection.

Simultaneous Resection of Colorectal Carcinoma and Hepatic Metastases is Safe and Effective: Examining the Role of the Robotic Approach.

BACKGROUNDS AND OBJECTIVES: Up to 50% of patients with colorectal carcinoma (CRC) present with liver metastases (CLM) throughout their course. Complete resection of both sites provides the only chance for cure. Either a staged or simultaneous resection is feasible. The latter avoids delays in adjuvant systemic chemotherapy but may increase technical complexity and perioperative complications. We aim to evaluate our initial outcomes of simultaneous CRC and CLM resections with a focus on the robotic technique. METHOD: With institutional review board approval, we followed 26 consecutive patients who underwent simultaneous/concomitant liver and colorectal resection. Major liver resection is defined as resection of ≥3 contiguous Couinaud segments. Data are presented as median (mean ± SD). RESULTS: Patients were 64 (63 ± 14.0) years old. Body mass index was 29 (29 ± 5.7) kg/m2. 54% of patients had prior abdominal operation(s). A majority of patients were >ASA class III (73%), underwent major liver resection (62%) with robotic approach (77%). In the robotic cohort, there were no unplanned conversions to open. Estimated blood loss was 150 (210 ± 181.8) ml. Total operative duration was 446 (463 ± 93.6) minutes. Negative margins (R0) were obtained in all patients. Postoperative complication of Clavien-Dindo≥3 occurred in three patients, including one requiring reoperation with end ileostomy for anastomotic leak. Length of stay was 5 (6 ± 3.5) days. Three patients were readmitted within 30 days after discharge, none for reoperation. There was no 90-day mortality. CONCLUSION: Our cohort of concomitant CRC and CLM resection demonstrates safety and efficacy via both the open and robotic approach.

Survival and Robotic Approach for Pancreaticoduodenectomy: A Propensity Score-Match Study.

BACKGROUND: Robotic surgery is a burgeoning minimally invasive approach to pancreaticoduodenectomy. This study was undertaken to compare survival after robotic vs "open" pancreaticoduodenectomy for ductal adenocarcinoma using propensity score-matched patients. STUDY DESIGN: With institutional review board approval, we prospectively followed 521 patients who underwent robotic (n = 311) or open (n = 210) pancreaticoduodenectomy. Patients who underwent robotic (n = 75) or open (n = 75) pancreaticoduodenectomy were propensity score-matched by age, sex, and American Joint Committee on Cancer stage. Neoadjuvant therapy was rarely administered, and adjuvant therapy was stressed (FOLFIRINOX for patients <70 years of age and gemcitabine + nab-paclitaxel for patients >70 years of age). Data are presented as median (mean ± SD). RESULTS: Operative duration was longer and estimated blood loss and length of stay were less with robotic pancreaticoduodenectomy (421 [409 ± 94.0] vs 267 [254 ± 81.2] minutes; 307 [(150 ± 605.3] vs 444 [255 ± 353.1] mL; 7 [5 ± 5.1] vs 11 [8 ± 9.5] days; p < 0.00001 for all). There were no differences in complications (Clavien-Dindo class ≥III, p = 0.30), in-hospital mortality (p = 0.61), or 30-day readmission rates (p = 0.19). Median survival after robotic vs open pancreaticoduodenectomy was 37 vs 24 months (p = 0.08). For propensity score-matched patients, operative duration for robotic pancreaticoduodenectomy was longer (442 [438 ± 117.7] vs 261 [249 ± 67.1] minutes) and estimated blood loss was less (269 [200 ± 296.1] vs 468 [300 ± 394.9] mL), as was length of stay (7 [5 ± 5.1] vs 10 [7 ± 8.6] days; p < 0.00001 for all). There were no differences in complication rates (Clavien-Dindo class ≥ III, p = 0.31) or in-hospital mortality (p = 0.40); 30-day readmissions were fewer after robotic pancreaticoduodenectomy (7% vs 20%, p = 0.03). Median survival for the robotic vs the open approach was 41 vs 17 months (p = 0.02). CONCLUSION: Patients that underwent robotic pancreaticoduodenectomy had longer operations, less estimated blood loss, shorter length of stay, and fewer 30-day readmissions; they lived much longer than patients who underwent open pancreaticoduodenectomy. We believe that robotic pancreaticoduodenectomy provides salutary and survival benefits for reasons yet unknown.

Propensity score matched comparison of robotic and open major hepatectomy for malignant liver tumors.

BACKGROUND: Outcome data on robotic major hepatectomy are lacking. This study was undertaken to compare robotic vs. 'open' major hepatectomy utilizing patient propensity score matching (PSM). METHODS: With institutional review board approval, we prospectively followed 183 consecutive patients who underwent robotic or 'open' major hepatectomy, defined as removal of three or more Couinaud segments. 42 patients who underwent 'open' approach were matched with 42 patients who underwent robotic approach. The criteria for PSM were age, resection type, tumor size, tumor type, and BMI. Survival was individually stratified for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (IHCC), and colorectal liver metastases (CLM). The data are presented as: median (mean ± SD). RESULTS: Operative duration for the robotic approach was 293 (302 ± 131.5) vs. 280 (300 ± 115.6) minutes for the 'open' approach (p = NS). Estimated Blood Loss (EBL) was 200 (239 ± 183.6) vs. 300 (491 ± 577.1) ml (p = 0.01). There were zero postoperative complications with a Clavien-Dindo classification ≥ III for the robotic approach and three for the 'open' approach (p = NS). ICU length of stay (LOS) was 1 (1 ± 0) vs. 2 (3 ± 2.0) days (p = 0.0001) and overall LOS was 4 (4 ± 3.3) vs. 6 (6 ± 2.7) days (p = 0.003). In terms of long-term oncological outcomes, overall survival was similar for patients with IHCC and CLM regardless of the approach. However, patients with HCC who underwent robotic resection lived significantly longer (p = 0.05). CONCLUSION: Utilizing propensity score matched analysis, the robotic approach was associated with a lower EBL, shorter ICU LOS, and shorter overall LOS while maintaining similar operative duration and promoting survival in patients with HCC. We believe that the robotic approach is safe and efficacious and should be considered a preferred alternative approach for major hepatectomy.

Robotic resection of extrahepatic cholangiocarcinoma: Institutional outcomes of bile duct cancer surgery using a minimally invasive technique.

BACKGROUND AND OBJECTIVES: The purpose of this study is to report our early experience and outcomes, the first in North America, of Extrahepatic Cholangiocarcinoma (EHC) resection with Roux-en Y Hepaticojejunostomy reconstruction via the robotic approach. METHODS: With Institutional Review Board approval, 15 patients who underwent robotic resection of EHC were studied. RESULTS: Patients were 74 (73 ± 8.9) years of age. There were 9 men and 6 women. Average body mass index was 24 (27 ± 6.3) kg·m-2 . Mean & Median ASA class was 3. Median Tumor size was 2 (2 ± 1.3) cm. There were no intraoperative complications. Operative duration was 453 (443 ± 85.0) minutes and the estimated blood loss was 150 (182 ± 138.4) ml. No patient required admission to the intensive care unit. Hospital length of stay was 4 (6 ± 3.2) days. There was one patient with Clavien-Dindo Class 3 or greater complication. No mortality was seen in this series. DISCUSSION: Robotic resection of EHC is safe, feasible, and reproducible with excellent clinical outcomes. Consequently, the robotic technique should be considered in some patients requiring EHC resection.

Robotic Extrahepatic Biliary Resection with Roux-en-Y Hepaticojejunostomy for Type 2 Klatskin Tumor.

BACKGROUND: Despite the widespread of laparoscopic technique in hepatobiliary tumor resection, nearly all Klatskin tumor resection is undertaken using an open approach (Marino et al. in Updates Surg 72(3):911-912. https://doi.org/10.1007/s13304-020-00777-8 ; Sucandy et al. in Am Surg, 2020. https://doi.org/10.1177/0003134820956336 , Am Surg, 2020;86(3):200-207; Luberice et al. in HPB (Oxford), 2020. https://doi.org/10.1016/j.hpb.2020.10.008 ; Ciria et al. in J Hepatobiliary Pancreat Sci, 2020. https://doi.org/10.1002/jhbp.869 ; Chong and Choi in J Gastrointest Surg 23(9):1947-19488, 2019. https://doi.org/10.1007/s11605-019-04242-9 ). A minimally invasive approach for malignant extrahepatic biliary resection is rarely used due to technical complexity and concerns of oncological inferiority. In the United States, robotic technique for Klatskin tumor resection has not been adequately described. This video described our technique of robotic extrahepatic biliary resection with Roux-en-Y hepaticojejunostomy (HJ) for type 2 Klatskin tumor. METHODS: A 77-year-old man presented with obstructive jaundice. Endobiliary brushing confirmed adenocarcinoma. MRI/MRCP showed a focal lesion at the cystic duct entrance into the common hepatic duct, extending cephalad toward the biliary bifurcation. No obvious vascular invasion was identified on the CT scan. RESULTS: The operation was undertaken using a six-port technique. Systematic portal dissection was undertaken to identify the bile duct at the level of the pancreas up toward the hepatic hilum. A partial Kocher maneuver was performed to expose the area dorsal to the distal common bile duct, which allows for a more thorough lymphadenectomy and facilitates creation of a later tension-free hepaticojejunostomy. The distal common bile duct was transected, and the distal margin was sent for frozen section. The right hepatic artery coursing posterior to the common hepatic duct was skeletonized and preserved. Biliary duct bifurcation was transected at the level of the right and left duct, removing the cancer completely. Portal lymphadenectomy was completed as part of oncological staging and treatment. A total of eight lymph nodes were removed and all confirmed to be nonneoplastic on the final pathology report. For the purpose of the biliary reconstruction, a standard side-to-side stapled jejunojejunostomy was created. A jejunal mesenteric defect was closed to prevent a future internal herniation. A 60-cm Roux limb was transposed antecolically for the Roux-en-Y hepaticojejunostomy. A running technique was used to create a watertight end-to-side bilioenteric anastomosis, using 3-0 barbed sutures, 6 inches in length. A closed suction drain was placed before closing. Pathology report confirmed intraductal papillary adenocarcinoma with R-0 resection margins (proximal, distal, and radial margin). Perineural invasion was present; however, lymphovascular invasion was not identified. Total operative time was 240 minutes with 75 ml of estimated blood loss. The postoperative recovery was uneventful. One-year follow-up showed no evidence of disease recurrence or HJ anastomotic stricture. CONCLUSIONS: This video demonstrates a safe and feasible application of the robotic platform in extrahepatic bile duct cancer resection requiring fine biliary reconstruction.

Robotic Complex Fundoplication in Patients at High-Risk to Fail.

BACKGROUND: This study was undertaken to analyze our outcomes after robotic fundoplication for GERD in patients with failed antireflux procedures, with type IV (i.e., giant) hiatal hernias, or after extensive intra-abdominal surgery with mesh, and to compare our results to outcomes predicted by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and to national outcomes reported by NSQIP. METHODS: 100 patients undergoing robotic fundoplication for the aforementioned factors were prospectively followed. RESULTS: 100 patients, aged 67 (67 ± 10.3) years with body mass index (BMI) of 26 (25 ± 2.9) kg/m2 underwent robotic fundoplication for failed antireflux fundoplications (43%), type IV hiatal hernias (31%), or after extensive intra-abdominal surgery with mesh (26%). Operative duration was 184 (196 ± 74.3) min with an estimated blood loss of 24 (51 ± 82.9) mL. Length of stay was 1 (2 ± 3.6) day. Two patients developed postoperative ileus. Two patients were readmitted within 30 days for nausea.Nationally reported outcomes and those predicted by NSQIP were similar. When comparing our actual outcomes to predicted and national NSQIP outcomes, actual outcomes were superior for serious complications, any complications, pneumonia, surgical site infection, deep vein thrombosis, readmission, return to OR, and sepsis (P < 0.05); our actual outcomes were not worse for renal failure, deaths, cardiac complications, and discharge to a nursing facility. CONCLUSIONS: Our patients were not a selective group; rather they were more complex than reported in NSQIP. Most of our results after robotic fundoplication were superior to predicted and national outcomes. The utilization of the robotic platform for complex operations and fundoplications to treat patients with GERD is safe and efficacious.

100 Robotic Distal Pancreatectomies: The Future at Hand.

INTRODUCTION: This study was undertaken to examine 100 consecutive robotic distal pancreatectomies with splenectomies, and to compare our outcomes to predicted outcomes as calculated using the American college of surgeons national surgical quality improvement program (ACS NSQIP) Surgical Risk Calculator and to the outcomes contained within NSQIP. METHODS: Outcomes were compared with predicted outcomes, calculated using the ACS NSQIP Surgical Risk Calculator, and with outcomes documented in NSQIP for distal pancreatectomy. For illustrative purposes, data are presented as median (mean ± SD). RESULTS: Patients who underwent robotic distal pancreatectomy were of age 67 (63 ± 13.4) years with a BMI of 29 (29 ± 6.3) kg/m2, with 49% being women. Operative duration was 242 (265 ± 112.2) minutes and estimated blood loss was 110 (211 ± 233.9) mL. Predicted outcomes were similar to those reported in NSQIP. Our actual outcomes were significantly superior to the predicted outcomes for serious complication, any complication, surgical site infection, sepsis, and length of stay. Compared to NSQIP outcomes, our actual outcomes for serious complication, any complication, surgical site infection, sepsis, and delayed gastric emptying were significantly superior. Twelve percent of operations were converted to "open." There were 3 deaths within 30 days, similar to predicted outcomes. Deaths were due to sepsis (2) and respiratory failure (1). CONCLUSION: Our patients' predicted outcomes were the same as national outcomes; our patients were not a select group. However, their actual outcomes were like or significantly superior than those predicted by NSQIP or reported in NSQIP. We believe that the robot has the future of distal pancreatectomy with or without splenectomy.

Robotic Pancreatic Surgery for Solid, Cystic, and Mixed Lesions.

Robotic surgery is flourishing worldwide. Pancreatic cancer is the fourth leading cause of cancer death in the United States. Most pancreatic operations are undertaken for the management of pancreatic adenocarcinoma. Therefore, it is essential for all physicians caring for patients with cancer to understand the role and importance of molecular tumor markers. This article details our technique and application of the robotic platform to robotic pancreatectomy. The use of the robot does not change the nature of pancreatic operations, but it is our belief that it will improve patient outcomes and, possibly, survival by reducing perioperative complications.

Men surgeons' perceptions of women surgeons: is there a bias against women in surgery?

BACKGROUND: Surgery has long been a man-dominated discipline with gender roles traditionally defined along societal norms. Presumably, as society has evolved, so have men surgeons' perceptions of women surgeons, though data are lacking. This study was undertaken to determine if men surgeons' perceptions of women surgeons represent a bias against women in Surgery. METHODS: 190 men surgeons were queried about attitudes toward women surgeons utilizing a validated questionnaire. The survey included binary, multiple choice, and Likert scale questions (1 = definitely disagree to 5 = definitely agree). RESULTS: 84% of the men surgeons have been attending surgeons for more than 5 years; 80% deem women surgeons as capable as their man colleagues. 80% of respondents consider it possible for a woman to be a good surgeon, mother, and spouse; however, 76% believe women surgeons experience more pressure to balance work and family. 75% of the men surgeons think women surgeons have the same advancement opportunities as men, though 30% believe gender discrimination exists in Surgery. 45% of the respondents consider the "surgical discipline" accountable for fewer women finishing training, yet 57% think the rate of women entering Surgery is not a problem to address. CONCLUSION: While most men surgeons have favorable opinions of the personal and professional abilities of women surgeons, favorable opinions are not universal; a bias against women persists in Surgery. Considering most medical students today are women, the discipline of Surgery dismisses this talent pool only to its detriment. Surgery, and men in Surgery specifically, must evolve to eliminate bias against women in Surgery, promoting an equitable and inclusive work environment for the betterment of Surgery and all its stakeholders, including patients.

THE Big Deal: An Institution's Experience with Robotic Transhiatal Esophagectomy.

As minimally invasive operations evolve, it is imperative to evaluate the advantages and risks involved. The aim of our study was to evaluate our institution's experience in incorporating a robotic platform for transhiatal esophagectomy (THE). Patients undergoing robotic THE were prospectively followed. Data are presented as median (mean ± SD). Forty-five patients were of 67 (67 ± 6.9) years and BMI 26 (27 ± 5.5) kg/m². Nine per cent of operations were converted to "open," but none in the last 25 operations. Operative duration of robotic THE was 334 (364 ± 108.8) minutes and estimated blood loss was 200 (217 ± 144.0) mL, which decreased with time (P = 0.017). Length of stay was 8 (12 ± 11.1) days. Twenty per cent had respiratory failure requiring intubation that resolved, 4 per cent developed pneumonia, 11 per cent developed a surgical site infection, 2 per cent developed renal insufficiency, and 2 per cent developed a UTI. Two per cent (one patient) died within 30 days postoperatively, because of cardiac arrest. Our experience with robotic THE promotes robotic application because we endeavor to achieve high-level proficiency. With experience, we improved estimated blood loss and converted fewer transhiatal esophagectomies to "open." Our length of hospital stay seems long but reflects the ill-health of patients, as does the variety of complications. Our data support the evolving future of THE, which will integrally include a robotic approach.

Age and Achalasia: How Does Age Affect Patient Presentation, Hospital Course, and Surgical Outcomes?

Heller myotomy is the "gold-standard" therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. Observation has suggested many differences between young and old patients with achalasia, raising the question: is achalasia in younger patients a different disorder than it is in older patients? This study was undertaken to answer this question. With Institutional Review Board approval, 648 patients undergoing laparoscopic Heller myotomy from 1992-2016 were prospectively followed up. Patients self-assessed symptom frequency/severity preoperatively and postoperatively using a Likert scale; 0 (never/not bothersome) to 10 (always/very bothersome). Before myotomy, frequency/severity of many symptoms (e.g., "dysphagia," "chest pain," and "regurgitation") inversely correlated with age (P < 0.01 each). Symptom duration and the number of previous abdominal operations correlated with age, as did intraoperative complications (e.g., gastrotomy), postoperative complications (e.g., atrial fibrillation), and length of stay (P < 0.01 for each). Patients experienced amelioration of all symptoms queried, regardless of age (P < 0.01 each). Age did affect outcome because older patients had less frequent and severe symptoms. Age did not affect improvement of symptoms (e.g., dysphagia) (i.e., differences between preoperative and postoperative scores) (P = 0.88). Age did not influence symptom resolution or patient satisfaction (P = 0.98 and P = 0.15, respectively). The presentation with achalasia, hospital course, and outcome after myotomy are significantly impacted by age, whereas patient improvement after myotomy is constant independent of age. Younger and older patients have different presentations, experiences, and outcomes; these patients seem to have "different disorders", but Heller myotomy provides similar significant amelioration of symptoms independent of age.

Regional differences for pancreaticoduodenectomy in Florida: Location matters.

INTRODUCTION: Regionalization of care raises potential for differences in cost of care and outcome. This study was undertaken to determine if costs and outcome after pancreaticoduodenectomy vary by region in Florida, and whether costs and outcome are related. METHODS: Inpatient data for pancreaticoduodenectomy in Florida during 2010-2012 were obtained from the Florida Agency for Health Care Administration. Seven geographically different regions were designated based on "cost of living index" and "urban to rural population ratio". Hospital costs, LOS, in-hospital mortality, and the frequency with which surgeons performed pancreaticoduodenectomy were evaluated for these regions. RESULTS: Median hospital costs for pancreaticoduodenectomy by region ranged from $101,436-$214,971. Median hospital costs by region correlated positively with LOS (p < 0.0001) and in-hospital mortality (p < 0.0001), and negatively with the frequency of pancreaticoduodenectomies performed by high-volume surgeons (p < 0.0001). CONCLUSIONS: There are regional differences for hospital costs and outcome with pancreaticoduodenectomy in Florida. Regions with lower costs had more pancreaticoduodenectomies performed by high-volume surgeons, shorter LOS, and lower in-hospital mortality rates. Regional differences in cost and quality-of-care need to be studied and abrogated to provide uniform optimal care.

Safety Study of Targeted and Localized Intra-Arterial Delivery of Gemcitabine in Patients with Locally Advanced Pancreatic Adenocarcinoma.

Purpose: This is a first-in-man safety study in locally advanced pancreatic cancer (LAPC) using a targeted intra-arterial delivery catheter (RenovoCath™). Methods: Twenty patients were enrolled in a four-stage dose escalation of intra-arterial, locally delivered gemcitabine, at doses up to 1000 mg/m2. Patients' symptoms and laboratory values were monitored for safety and tolerability. Secondary endpoints included the effect on tumor size, tumor markers, and survival. Results: One hundred one treatments were administered to 20 patients. Five patients dropped out early due to adverse events or withdrawing consent. Serious adverse events and complications were as follows: sepsis (n = 3), grade 3 neutropenia (n = 3), guide-mediated vascular dissection (n = 3), and pulmonary toxicity (n = 1). There were no cases of elevated liver or pancreatic enzymes. All sepsis cases occurred in patients with biliary stent/drains, prompting the addition of periprocedural treatment with antibiotics, which effectively prevented further sepsis in the study. Efficacy analysis was limited to 15 patients who received more than two treatments. Fifty-eight percent of these patients had a reduction in CA 19-9 tumor markers, 3 patients had tumor progression, 1 had partial response, and 11 showed disease stability. The survival rate at 12 months was 60%. Conclusions: The results demonstrate feasibility of localized and selective intra-arterial chemotherapy delivery to the pancreas utilizing the RenovoCath. With gemcitabine, this approach is safe, with the sole prerequisite of perioperative antibiotics for patients with prior biliary drainage/stent. Efficacy results suggest a survival benefit when compared to historical control, especially in patients with prior radiation therapy.