Do pre-operative endoscopic procedures, impact the surgical outcomes of robotic pancreaticoduodenectomy?

The role and risks of pre-operative endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound with fine needle aspiration (EUS/FNA), in patients undergoing robotic pancreaticoduodenectomy are not well-defined despite a broad consensus on the utility of these interventions for diagnostic and therapeutic purposes prior to major pancreatic operations. This study investigates the impact of such preoperative endoscopic interventions on perioperative outcomes in robotic pancreaticoduodenectomy. With Institutional Review Board (IRB) approval we retrospectively analyzed 772 patients who underwent robotic pancreatectomies between 2012 and 2023. Specifically, 430 of these patients underwent a robotic pancreaticoduodenectomy were prospectively evaluated: 93 (22%) patients underwent ERCP with EUS and FNA, 45 (10%) ERCP only, and 31 (7%) EUS and FNA, while 261 (61%) did not. Statistical analyses were performed using chi-square tests and Student's t-tests to compare perioperative outcomes between the two cohorts. Statistically significant differences were observed in patients who underwent a pre-operative endoscopic intervention and were more likely to have converted to an open operation (p = 0.04). The average number of harvested lymph nodes for patients who underwent preoperative endoscopic intervention was statistically significant compared to those who did not (p = 0.0001). All other perioperative variables were consistent across all cohorts. Patients who underwent endoscopic intervention before robotic pancreaticoduodenectomy were more likely to have an unplanned open operation. This study demonstrates the increased operative difficulties introduced by preoperative endoscopic interventions. Although there was no impact on overall patient outcomes, surgeons' experience can minimize the associated risks.

A comparative assessment of ACS NSQIP-predicted and actual surgical risk outcomes of robotic transhiatal esophagectomy for esophageal adenocarcinoma resection at a high volume institution.

Esophageal adenocarcinoma incidence is increasing in Western nations. There has been a shift toward minimally invasive approaches for transhiatal esophagectomy (THE). This study compares the outcomes of robotic THE for esophageal adenocarcinoma resection at our institution with the predicted metrics from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). With Institutional Review Board (IRB) approval, we prospectively followed 83 patients who underwent robotic THE from 2012 to 2023. Predicted outcomes were determined using the ACS NSQIP Surgical Risk Calculator. Our outcomes were compared with these predicted outcomes and with general outcomes for transhiatal esophagectomy reported in ACS NSQIP, which includes a mix of surgical approaches. The median age of patients was 70 years, with a body mass index (BMI) of 26.4 kg/m2 and a male prevalence of 82%. The median length of stay was 7 days. The rates of any complications and in-hospital mortality were 16% and 5%, respectively. Seven patients (8%) were readmitted within a 30-day postoperative window. The median survival is anticipated to surpass 95 months. Our outcomes were generally aligned with or surpassed the predicted ACS NSQIP metrics. The extended median survival of over 95 months highlights the potential effectiveness of robotic THE in the resection of esophageal adenocarcinoma. Further exploration into its long-term survival benefits and outcomes is warranted, along with studies that provide a more direct comparison between robotic and other surgical approaches.

A single institution's experience with robotic resections of biliary tract cancers: an analysis of the short-term outcomes and long-term survival.

INTRODUCTION: Perihilar cholangiocarcinoma, intrahepatic cholangiocarcinoma (IHCC), and gall bladder cancer are difficult malignancies to treat and are characterized by a tendency for local recurrence and a generally unfavorable prognosis. Surgical resection offers the only potential cure, conventionally performed via the open approach. Although minimally invasive approaches show promise, data remain limited. METHODS: With the institutional review board's approval, we prospectively followed 100 patients between 2013 and 2023 who underwent robotic surgical resection for perihilar, IHCC, and gallbladder cholangiocarcinoma. Data are presented as median (mean ± SD). Significance was accepted at P ≤ .05. RESULTS: The median patient age was 70 years, and the median operative duration was 333 min, with an estimated blood loss of 200 mL. Importantly, no unplanned conversions occurred, and only 1 intraoperative complication occurred within the IHCC cohort. The median length of stay was 4 days. There were a total of 19 postoperative complications and 19 readmissions within 30 days. Additionally, there were 3 in-hospital mortalities and 5 90-day mortalities. R0 resection was achieved in 87% of patients and R1 resection in 13%. At a median follow-up of 36 months, 62% of patients demonstrated disease-free survival, whereas 6% continued to live with the disease, and 32% did not survive. CONCLUSION: Our experience demonstrates the feasibility and safety of robotic resection for these complex malignancies, yielding promising short-term outcomes. Further investigation is required to ascertain the long-term oncologic outcomes.

Diagnosis to dissection: AI's role in early detection and surgical intervention for gastric cancer.

Gastric cancer remains a formidable health challenge worldwide; early detection and effective surgical intervention are critical for improving patient outcomes. This comprehensive review explores the evolving landscape of gastric cancer management, emphasizing the significant contributions of artificial intelligence (AI) in revolutionizing both diagnostic and therapeutic approaches. Despite advancements in the medical field, the subtle nature of early gastric cancer symptoms often leads to late-stage diagnoses, where survival rates are notably decreased. Historically, the treatment of gastric cancer has transitioned from palliative care to surgical resection, evolving further with the introduction of minimally invasive surgical (MIS) techniques. In the current era, AI has emerged as a transformative force, enhancing the precision of early gastric cancer detection through sophisticated image analysis, and supporting surgical decision-making with predictive modeling and real-time preop-, intraop-, and postoperative guidance. However, the deployment of AI in healthcare raises significant ethical, legal, and practical challenges, including the necessity for ongoing professional education and the development of standardized protocols to ensure patient safety and the effective use of AI technologies. Future directions point toward a synergistic integration of AI with clinical best practices, promising a new era of personalized, efficient, and safer gastric cancer management.

Initial clinical outcomes of robotic resection for perihilar cholangiocarcinoma: Is it safe and effective?

BACKGROUND AND OBJECTIVES: We aimed to describe our outcomes of robotic resection for perihilar cholangiocarcinoma, the largest single institutional series in the Western hemisphere to date. METHODS: Between 2016 and 2022, we prospectively followed all patients who underwent robotic resection for perihilar cholangiocarcinoma. RESULTS: In total, 23 patients underwent robotic resection for perihilar cholangiocarcinoma, 18 receiving concomitant hepatectomy. The median age was 73 years. Operative time was 470 min with an estimated blood loss of 150 mL. No intraoperative conversions to open or other intraoperative complications occurred. Median length of stay was 5 days. Four postoperative complications occurred. Three readmissions occurred within 30 days with one 90-day mortality. R0 resection was achieved in 87% of patients and R1 in 13% of patients. At a median follow-up of 27 months, 15 patients were alive without evidence of disease, two patients with local recurrence at 1 year, and six were deceased. CONCLUSIONS: Utilization of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with excellent perioperative outcomes. Further studies are needed to determine the long-term oncological outcomes.

A decade of experience with 530 minimally invasive robotic hepatectomies from a single tertiary hepatobiliary center: analysis of short-term outcomes and oncologic survival.

BACKGROUND: This research is the first study in the United States to document more than a decade of experience with 530 patients who underwent robotic hepatectomy at a single high-volume institution. METHODS: With institutional review board approval, a prospectively collected database of consecutive patients who underwent robotic hepatectomy from 2012 to January 2024 was reviewed. Data are presented as median (mean ± SD). RESULTS: Of the 530 robotic hepatectomies, 231 (44.0%) were minor resections, 133 (25.0%) were technically major resections, and 166 (31.0%) were major resections. The patients were aged 63.0 (61.0 ± 14.7) years with a body mass index of 28.0 (29.0 ± 7.9) kg/m2. Cirrhosis was present in 80 patients (19.0%), with an American Society of Anesthesiologists score of 3.0 (3.0 ± 0.5) and a Model for End-Stage Liver Disease score of 7.0 (8.0 ± 3.0). Of note, 280 patients (53.0%) had previous abdominal operations, and 44 patients (8%) had previous liver resections. The operative time was 233.0 (260.0 ± 130.7) minutes, and the estimated blood loss was 100.0 (165.0 ± 205.0) mL. Moreover, 353 patients (66%) had hepatectomies for neoplastic disease, and 500 patients (95%) had an R0 resection margin. The tumor size was 4.0 (5.0 ± 3.6) cm. The total 90-day postoperative complications were 45 (8%), of which 21 (4%) were classified as major complications (Clavien-Dindo score of >III). The length of stay was 3.0 (4.0 ± 3.7) days, and the 30-day readmission rate was 86 (16%). The overall survival rates at 1, 3, and 5 years were 82%, 65%, and 59% for colorectal liver metastases, 84%, 68%, and 60% for hepatocellular carcinoma, and 79%, 61%, and 50% for intrahepatic cholangiocarcinoma, respectively. CONCLUSION: After a decade of application and optimization at a high-volume institution, the robotic approach has been demonstrated to be a safe and effective approach to liver resection.

Effect of IWATE laparoscopic difficulty score on postoperative outcomes and costs for robotic hepatectomy: Are complex resections more expensive?

BACKGROUND: The IWATE criteria, a four-level classification system for laparoscopic hepatectomy, measures technical complexity but lacks studies on its impact on outcomes and costs, especially in robotic surgeries. This study evaluated the effects of technical complexity on perioperative outcomes and costs in robotic hepatectomy. METHODS: Since 2013, we prospectively followed 500 patients who underwent robotic hepatectomy. Patients were classified into four levels of IWATE scores; (low [0-3], intermediate [4-6], advanced [7-9], and expert [10-12]) determined by tumor characteristics, liver function and resection extent. Perioperative variables were analyzed with significance accepted at a p-value ≤.05. RESULTS: Among 500 patients, 337 (67%) underwent advanced to expert-level operations. Median operative duration was 213 min (range: 16-817 min; mean ± SD: 240 ± 116.1 min; p < .001) and estimated blood loss (EBL) was 95 mL (range: 0-3500 mL; mean ± SD:142 ± 171.1 mL; p < .001). Both operative duration and EBL showed positive correlations with increasing IWATE scores. Median length of stay (LOS) of 3 days (range: 0-34; mean ± SD:4 ± 3.0 days; p < .001) significantly correlated with IWATE score. Total cost of $25 388 (range: $84-354 407; mean ± SD: 29752 ± 20106.8; p < .001) also significantly correlated with operative complexity, however hospital reimbursement did not. No correlation was found between IWATE score and postoperative complications or mortality. CONCLUSIONS: Clinical variables such as operative duration, EBL, and LOS correlate with IWATE difficulty scores in robotic hepatectomy. Financial metrics such as costs but not reimbursement received by the hospital correlate with IWATE scores.

Robotic Left Hepatectomy with En Bloc Biliary Resection and Roux-en-Y Hepaticojejunostomy: A Technique of Portal Venous Tangential Vascular Reconstruction.

BACKGROUND: Robotic technology is increasingly utilized in perihilar cholangiocarcinoma treatments, requiring expertise in minimally invasive liver surgeries and biliary reconstructions. These resections often involve vascular and multiple sectoral bile duct reconstructions. Minimally invasive vascular repairs are now emerging with promising outcomes, potentially altering criteria for selecting minimally invasive hepatobiliary tumor resections. In this multimedia article, we describe our technique of robotic portal venous tangential primary reconstruction with right sectoral bile duct unification ductoplasty for the treatment of perihilar cholangiocarcinoma using the robotic approach. METHODS: The robotic technique was chosen in this operation with preoperative anticipation of needing vascular resection and reconstruction due to left portal vein tumor involvement. Additionally, a Roux-en-Y hepaticojejunostomy to the right anterior and posterior sectoral duct was planned for biliary reconstruction. Proximal and distal vascular control of the portal vein bifurcation was obtained by placing vascular bulldog clamps across the main and right portal veins. Once an R0 vascular margin was obtained on the left portal vein, portal bifurcation was tangentially repaired. Perfusion to the liver was then restored, and left hemihepatectomy with en bloc extrahepatic biliary resection was carried out, followed by Roux-en-Y hepaticojejunostomy reconstruction to the right anterior and posterior sectoral bile ducts, as a single anastomosis. RESULTS: The operation was uneventful without vascular or biliary complications. Robotic unification ductoplasty circumvented the need for multiple anastomoses. CONCLUSION: The robotic approach for left-sided perihilar cholangiocarcinoma resections, requiring precise biliovascular management, is safe, feasible, and efficient. This method demonstrates the potential of robotic techniques as an alternative to traditional open surgery.

Learning curve analysis after 500 robotic hepatectomies.

BACKGROUND: The robotic platform is growing in popularity for hepatobiliary resections. Although the learning curve for basic competency has been reported, this is the first study to analyze the learning curve to achieve long-term mastery on a decade of experience with more than 500 robotic hepatectomies. METHODS: After institutional review board approval, 500 consecutive robotic hepatectomies from 2013 to 2023 were analyzed. Cumulative sum (CUSUM) analysis using operative duration was used to determine the learning curves. RESULTS: A total of 500 patients were included in this study: composed of 230 men (46.0 %) and 270 women (54.0 %), aged 63.0 (61.0 ± 14.6) years, with a body mass index of 28.0 (29.0 ± 8.0) kg/m2, a Model for End-Stage Liver Disease score of 7 (8 ± 3.0), an albumin-bilirubin score of -3.0 (-3.0 ± 0.6), and a Child-Pugh score of 5.0 (5.0 ± 0.7). Operative duration was 235.0 (260.1 ± 131.9) minutes, estimated blood loss was 100.0 (165.0 ± 208.1) mL, tumor size was 4.0 (5.0 ± 3.5) cm, and 94.0 % of patients achieved R0 margins. The length of hospital stay was 3.0 (4.0 ± 3.7) days, with 4.0 % of patient having major complications. Of note, 30-day readmission was 17.0 %, 30-day mortality was 2.0 %, and 90-day mortality was 3.0 %. On CUSUM analysis, the learning curve for minor resection (n = 215) was 75 cases, major resection (n = 154) was 100 cases, and technically challenging minor resection (n = 131) was 57 cases. Gaining more experience in performing surgical procedures resulted in shorter operative duration, lower blood loss, higher R0 resections, and lower major postoperative complications. CONCLUSION: The minimum number of robotic hepatectomies to overcome the learning curves for mastery of minor, major, and technically challenging minor resections was significant. Our study can help guide surgeons in their early experience to optimize patient safety and outcomes.

Robotic Biliary Stricturoplasty and Roux-en-Y Hepaticojejunostomy After Hepatic Artery Infusion Pump Injury.

BACKGROUND: Hepatic artery infusion pump (HAIP) with floxuridine/dexamethasone and systemic chemotherapy is an established treatment regimen, which had been reported about converting 47% of patients with stage 4 colorectal liver metastasis from unresectable to resectable.1,2 To this effect, HAIP chemotherapy contributes to prolonged survival of many patients, which otherwise may not have other treatment options. Biliary sclerosis, however, is a known complication of the HAIP treatment, which occurs in approximately 5.5% of patients receiving this modality as an adjuvant therapy after hepatectomy and in 2% of patients receiving HAIP treatment for unresectable disease.3 While biliary sclerosis diffusely affects the perihilar and intrahepatic biliary tree, a dominant stricture maybe found in select cases, which gives an opportunity for a local surgical treatment after failure of endoscopic stenting/dilations. While the use of minimally invasive approach to biliary surgery is gradually increasing,4 there have been no descriptions of its application in this scenario. In this video, we demonstrate the use of minimally invasive robotic technique for biliary stricturoplasty and Roux-en-Y (RY) hepaticojejunostomy to treat persistent right hepatic duct stricture after HAIP chemotherapy. PATIENT: A 68-year-old woman with history of multifocal bilobar stage 4 colorectal liver metastasis presented to our office with obstructive jaundice and recurrent cholangitis that required nine endoscopic retrograde cholangiopancreatographies (ERCPs) and a placement of internal-external percutaneous transhepatic biliary drain (PTBD) by interventional radiology within the past 2 years. Her past surgical history was consistent with laparoscopic right hemicolectomy 3 years prior, followed by a left lateral sectorectomy with placement of an HAIP for adjuvant treatment. The patient had more than ten metastatic liver lesions within the right and left lobe, ranging from 2 to 3 cm in size at the time of HAIP placement. The patient had a histologically normal background liver parenchyma before the HAIP chemotherapy treatment. The patient did not have any history of alcohol use, diabetes mellitus, metabolic syndrome, nonalcoholic steatohepatitis, or other underlying intrinsic liver disorders, which are known to contribute to the development of hepatic fibrosis. Despite a radiologically disease-free status, the patient started to have episodes of acute cholangitis 1 year after the placement of HAIP that required multiple admissions to a local hospital. The HAIP was subsequently removed once the diagnosis of biliary sclerosis was made despite dose reductions and treatment with intrahepatic dexamethasone for almost 1 year. In addition to this finding, the known liver metastases have shown complete radiological resolution. Therefore further treatment with HAIP was deemed unnecessary, and pump removal was undertaken. Magnetic resonance imaging showed a dominant stricture at the junction of the right anterior and right posterior sectoral hepatic duct. The location of the dominant stricture was confirmed by an ERCP and cholangioscopy. Absence of neoplasia was confirmed with multiple cholangioscopic biopsies. Multiple endoscopic and percutaneous attempts with stent placement failed to dilate the area of stricture. Postprocedural cholangiographies showed a persistent significant narrowing, which led to multiple recurrent obstructive jaundice and severe cholangitis. While the use of surgical approach is rarely needed in the treatment of biliary sclerosis, a decision was made after extensive multidisciplinary discussions to perform a robotic stricturoplasty and RY hepaticojejunostomy with preservation of the native common bile duct. TECHNIQUE: The operation began with a laparoscopic adhesiolysis to allow for identification of HAIP tubing (which was later removed) and placement of robotic ports. A peripheral liver biopsy was obtained to evaluate the degree of hepatic parenchymal fibrosis. Porta hepatic area was carefully exposed without causing an inadvertent injury to the surrounding hollow organs. Biopsy of perihepatic soft tissues was taken as appropriate to rule out any extrahepatic disease. The common bile duct and common hepatic duct with ERCP stents within it were identified with the use of ultrasonography. Anterior wall of the common hepatic duct was then opened, exposing the two plastic stents. Cephalad extension of the choledochotomy was made toward the biliary bifurcation and the right hepatic duct. The distal common bile duct was preserved for future endoscopic access to the biliary tree. After lowering the right-sided hilar plate, dense fibrosis around the right hepatic duct was divided sharply with robotic scissors, achieving a mechanical release of the dominant stricture. An intraoperative cholangioscopy was performed to confirm adequate openings of the right hepatic duct secondary and tertiary radicles, as well as patency of the left hepatic duct. A 4-Fr Fogarty catheter was used to sweep the potential biliary debris from within the right and left hepatic lobe. Finally, a confirmatory choledochoscopy was performed to ensure patency and clearance of the right-sided intrahepatic biliary ducts and the left hepatic duct before fashioning the hepaticojejunostomy. A 40-cm antecolic roux limb was next prepared for the RY hepaticojejunostomy. A side-to-side double staple technique was utilized to create the jejunojejunostomy. The common enterotomy was closed in a running watertight fashion. Once the roux limb was transposed to the porta hepatic in a tension-free manner, a side-to-side hepaticojejunostomy was constructed in a running fashion by using absorbable barbed sutures. The index suture was placed at 9 o'clock location, and the posterior wall of the anastomosis was run toward 3 o'clock location. This stabilized the roux limb to the bile duct. The anterior wall of the anastomosis was next fashioned by using a running technique from both corners of the anastomosis toward the middle (12 o'clock), where both sutures were tied together. This completed a wide side-to-side hepaticojejunostomy anastomosis encompassing the upper common hepatic duct, biliary bifurcation, and the right hepatic duct. A closed suction drain was placed before closing.5 RESULTS: The operative time was approximately 4 hr with 60 ml of blood loss. The postoperative course was uneventful. The patient was discharged home on postoperative Day 5 after removal of the closed suction drain, confirming the absence of bile leak. The patient had developed periportal/periductal fibrosis, cholestasis, and moderate-severe parenchymal fibrosis (F3-F4) based on liver biopsy, often seen in patients treated with a long course of floxuridine HAIP chemotherapy. The patient is clinically doing well at 1 year outpatient follow-up without any evidence of recurrent cholangitis at the time of this manuscript preparation. CONCLUSIONS: Robotic biliary stricturoplasty with RY hepaticojejunostomy for treatment of biliary sclerosis after HAIP chemotherapy is safe and feasible. Appropriate experience in minimally invasive hepatobiliary surgery is necessary to achieve this goal.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience.

BACKGROUND: Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes. METHODS: This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD). RESULTS: From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3 ± 0.5; the MELD score was 9 ± 4.1; the Child-Pugh score was 6 ± 1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272 min, and the average blood loss amounted to 79 mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4 days, with a readmission rate of 15% within 30 days. During an average follow-up period of 33 months, one patient had to undergo a revision at 18 months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities. CONCLUSIONS: Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Is the robotic approach the future of distal pancreatectomy with splenectomy? A propensity score matched analysis.

Our study provides a comparative analysis of the Laparo-Endoscopic Single Site (LESS) and robotic surgical approaches for distal pancreatectomy and splenectomy, examining their cosmetic advantages, patient outcomes, and operative efficiencies through propensity score matching (PSM). We prospectively followed 174 patients undergoing either the LESS or robotic procedure, matched by cell type, tumor size, age, sex, and BMI from 2012 to 2023. Propensity score matching (PSM) was utilized for data adjustment, with results presented as median (mean ± SD). Post-PSM analysis showed no significant differences in age or BMI between the two groups. LESS approach exhibited a shorter operative duration (180(180 ± 52.0) vs. 248(262 ± 78.5) minutes, p = 0.0002), but increased estimated blood loss (200(317 ± 394.4) vs. 100 (128 ± 107.2) mL, p = 0.04). Rates of intraoperative and postoperative complications, length of hospital stay, readmissions within 30 days, in-hospital mortalities, and costs were comparably similar between the two procedures. While the robotic approach led to lower blood loss, LESS was more time-efficient. Patient outcomes were similar in both methods, suggesting that the choice between these surgical techniques should balance cosmetic appeal with technical considerations.

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 comparative analysis of robotic versus open pancreaticoduodenectomy in octogenarians.

Old age is a predictor of increased morbidity following pancreatic operations. This study was undertaken to compare the peri-operative variables between robotic and 'open' pancreaticoduodenectomy, in octogenarians (≥ 80 years of age). Since 2012, with IRB approval, we retrospectively followed 69 patients, who underwent robotic (n = 42) and 'open' (n = 27) pancreaticoduodenectomy. Statistical analysis was performed using chi-square test and Student's t test. Data are presented as median(mean ± SD), and significance accepted with 95% probability. Patients who underwent the robotic approach had a greater Charlson Comorbidity Index [6 (6 ± 1.6) vs 5 (5 ± 1.0), (p = 0.01)] and previous abdominal operations [n = 24 (57%) vs n = 9 (33%), (p = 0.04)]. The robotic approach led to longer operative time [426 (434 ± 95.8) vs 240 (254 ± 71.1) minutes, (p < 0.0001)], decreased blood loss [200 (291 ± 289.2) vs 426 (434 ± 95.8) mL (p = 0.008)], and decreased intraoperative blood transfusions (p < 0.05). Patients who underwent robotic pancreaticoduodenectomy had comparable and at times superior outcomes, consistent with the literature regarding robotic and 'open' pancreaticoduodenectomy. This study indicates that robotic pancreaticoduodenectomy continues to offer same benefits for patients of advanced age and demonstrates age should not be a preclusion to robotic operations.

Outcomes after pancreaticoduodenectomy with or without preoperative hyperbaric oxygen therapy.

Background: Hyperbaric oxygen (HBO2) therapy is an alternative method against the deleterious effects of ischemic/reperfusion (I/R) injury and its inflammatory response. This study assessed the effect of preoperative HBO2 on patients undergoing pancreaticoduodenectomy. Study Design: Patients were randomized via a computer-generated algorithm. Patients in the HBO2 cohort received two sessions of HBO2 the evening before and the morning of surgery. Measurements of inflammatory mediators and self-assessed pain scales were determined pre-and postoperatively. In addition, perioperative variables and long-term survival were collected and analyzed. Data are presented as median (mean ± SD). Results: 33 patients were included; 17 received preoperative HBO2, and 16 did not. There were no intraoperative or postoperative statistical differences between patients with or without preoperative HBO2. Erythrocyte sedimentation rate (ESR), IL-6, and IL-10 increased slightly before returning to normal, while TGF-alpha decreased before increasing. However, there were no differences with or without HBO2. At postoperative day 30, the pain level measured with VAS score (Visual Analog Score) was lower after HBO2 (1 ± 1.3 vs. 3 ± 3.0, p=0.05). Eleven (76%) patients in the HBO2 cohort and 12 (75%) patients in the non- HBO2 had malignant pathology. The percentage of positive lymph nodes in the HBO2 was 7% compared to 14% in the non-HBO2 (p<0.001). Overall survival was inferior after HBO2 compared to the non- HBO2 (p=0.03). Conclusions: Preoperative HBO2 did not affect perioperative outcomes or significantly change the inflammatory mediators for patients undergoing robotic pancreaticoduodenectomy. Long-term survival was inferior after preoperative HBO2. Further randomized controlled studies are required to assess the full impact of this treatment on patients' prognosis.

Deconstructing the Operative Times of Robotic Pancreaticoduodenectomy.

INTRODUCTION: Despite numerous benefits offered, robotic procedures take longer than "open" procedures. With the intent to reduce operative duration, we examined the degree each operative step contributes to operative duration in robotic pancreaticoduodenectomy. MATERIALS AND METHODS: With IRB approval, we prospectively followed 88 patients to determine the duration of robotic pancreaticoduodenectomy, and the duration of 12 key steps. Each operative step was regressed against the operation date, from most distant to most recent operation date. Data are presented as median (mean ± SD) for illustrative purposes. RESULTS: Patients were 73 (71 ± 10.2) years old; 53% were men. Total time patient spent in the operating room was 471 (488 ± 93.3) minutes. Total operative time was 399 (421 ± 90.7) minutes. Total console time was 293 (297 ± 68.0) minutes. The 3 longest portions of the operation were (1) mobilization of the specimen and specimen extraction; (2) construction of the duodenojejunostomy; and (3) closure. CONCLUSION: A third of the operative time is spent off the console. Over half of the steps required more than 20 minutes each to complete. Since robotic operations are associated with shorter LOS and without increased complication rates relative to "open" operations, salutary benefit can be gained by decreasing operative times of robotic procedures. Operative duration is an important metric that needs to be addressed. We need to target the most time-consuming steps, and break them into smaller pieces, to reach optimal efficiency and provide the benefits of decreased operative duration to the patients, hospitals, and providers.