Procedure-specific Training for Robot-assisted Distal Pancreatectomy.

OBJECTIVE: To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality. BACKGROUND: RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce. METHODS: A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy. RESULTS: After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP. CONCLUSION: Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

Does surgical approach affect outcomes of enucleation for benign and low-grade pancreatic tumors? An ACS-NSQIP evaluation.

BACKGROUND: Enucleation of low-grade pancreatic tumors achieves oncological outcomes equivalent to resection but conserves parenchyma. Given strict selection criteria, we hypothesized that minimally-invasive (MI) enucleation is associated with decreased composite major morbidity (CMM) compared to open. METHODS: Pancreas-targeted ACS NSQIP (2014 -2016) was queried for enucleation (CPT code: 48120) and analyzed by intended surgical approach regardless of conversion. The primary outcome was CMM, a validated 30-day composite metric of adverse events. RESULTS: Enucleation was performed using an open (n = 71; 62.3%) or MI (n = 43; 37.7%) approach with 7 conversions (16.2%). Both cohorts had interchangeable baseline characteristics. No selection factors governing MI were identified. MI-enucleation reduced median length of stay (4 vs. 5 days; p = 0.003), whereas rates of CMM after open (24; 34%) and MIenucleation (12; 28%) were equivalent (p = 0.541). Multivariable analysis demonstrated an association between CMM and prolonged operative time (OR 2.7, 95% CI 1.14 -6.74), female sex (OR 0.38, 95% CI 0.16 -0.94), and ASA score <3 (OR 0.39, 95% CI 0.16 -0.96) but not surgical approach. CONCLUSION: MI-enucleation was not associated with reduced 30-day CMM compared to open, whereas prolonged operating time and unmodifiable patient factors were correlated with adverse outcomes.

Transversus abdominis plane block reduces pain and narcotic consumption after robot-assisted distal pancreatectomy.

BACKGROUND: Minimizing pain and disability are key postoperative objectives of robot-assisted distal pancreatectomy (RADP). This study tested effects of bupivacaine transversus abdominis plane (TAP) block on opioid consumption and pain after RADP. METHODS: Retrospective case-control study (June 2012 -Oct 2017) evaluating bilateral intraoperative bupivacaine TAP block as an interrupted time series. Linear regression evaluated opioid consumption in terms of intravenous (IV) morphine milligram equivalents (MME) and controlled for preoperative morbidity. Secondary outcomes included numerical rating scale (NRS) pain scores. RESULTS: 81 RADP patients met eligibility, 48 before and 33 after implementation of TAP. Baseline characteristics were equivalent with a trend toward higher age, Charlson comorbidity, and ASA score among the TAP cohort. TAP patients consumed on average 4.52 fewer IV MME than controls during the first six postoperative hours (p = 0.032) and reported lower mean NRS scores at six (p = 0.009) and 12 h (p = 0.006) but not at 24 h (p = 0.129). Postoperative morbidity and lengths of stay (LOS) were equivalent (5 vs. 6 days, p = 0.428). CONCLUSION: Bupivacaine TAP block was associated with significant reductions in opioid consumption and pain after RADP but did not shorten hospital LOS consistent with bupivacaine's limited half-life.

Uso actual del balón de resucitación aórtico endovascular (REBOA) en trauma / Current use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma

ABSTRACT Introduction: Non-compressible torso haemorrhage is the leading cause of death in trauma cases. This has led to the development of new devices to control bleeding, including Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Objective: To perform a non-systematic review of the literature on the use of Resuscitative Endovascular Balloon Occlusion of the Aorta in trauma. Materials and methods: A systematic literature search through Medline was conducted. Articles relevant to our objective were selected. A qualitative and narrative synthesis of results is presented. Results: Our qualitative and narrative results show that Resuscitative Endovascular Balloon Occlusion of the Aorta could be a safe and effective intervention for the control of haemorrhage in abdomino-pelvic trauma. Its use is controversial in thoracic trauma. Finally, the performance of this intervention may cause complications. Conclusion: Resuscitative Endovascular Balloon Occlusion of the Aorta is an alternative that can be used in damage control surgery. It could be effective for early control of bleeding in patients with non-compressible torso haemorrhage. As a complex intervention, REBOA is in its development phase, and the evidence available preclude us from providing strong recommendations.

Resumen Introducción: La hemorragia no compresible del torso es la principal causa de muerte asociada al trauma. Esto ha llevado al desarrollo de nuevos dispositivos para el control hemorrágico, y uno de estos es el balón de resucitación aórtico endovascular (REBOA). Objetivo: Realizar una revisión no sistemática de la literatura con respecto al uso del REBOA en trauma. Materiales y métodos: Se realizó una búsqueda sistemática de la literatura en Medline, se seleccionaron los artículos relevantes para el logro de nuestro objetivo ycon estos se realizó una síntesis cualitativa y narrativa de la literatura disponible. Resultados: Nuestra síntesis cualitativa y narrativa muestra que el REBOA podría ser una intervención segura yefectiva para el control de la hemorragia en trauma abdominopélvico. Su uso es controvertido en trauma torácico. Finalmente, el uso del balón de resucitación aórtico endovascular puede causar complicaciones relacionadas con su aplicación. Conclusión: El REBOA es una alternativa en la cirugía de control de daños que podría ser efectiva en el control de la hemorragia no compresible del torso de origen abdominopélvico. Al ser una intervención compleja, el REBOA se encuentra todavía en fase de desarrollo yla evidencia disponible no es suficiente para proveer recomendaciones fuertes.

Dengue perinatal: Reporte de caso / Perinatal Dengue: A case Report

Resumen Introducción: El dengue perinatal es una patología de la que poco se sabe, los reportes disponibles describen riesgo de resultados perinatales adversos. Objetivo: Reportar un caso de dengue perinatal, como diagnóstico diferencial de sepsis neonatal, que debe tenerse en cuenta en zonas endémicas. Caso clínico: Recién nacido de una mujer de 23 años quien a las 36 semanas de gestación presentó cuadro de dengue con antígeno Non-Structural Protein 1 (NS1) positivo y anticuerpos anti-dengue negativos. Al sexto día de enfermedad dio a luz a un recién nacido sano, quien, al segundo día de vida, presentó fiebre sin otros hallazgos patológicos al examen físico, asociado a trombocitopenia severa (17.900 plaquetas/uL) y aumento de la proteína C reactiva, antígeno viral NS1 positivo e in-munoglobulina G (IgG) anti dengue positiva. Fue manejado con antibióticoterpia con ampicilina y gentamicina por protocolo de la institución para sepsis neonatal probable. El neonato mostró me joría clínica, con estabilidad hemodinámica y aumento significativo de plaquetas, siendo dado de alta. Conclusiones: El dengue en el embarazo trae consigo el riesgo de resultados perinatales adver sos, particularmente bajo peso al nacer y parto pre-término. Los hijos de madres diagnosticadas con dengue al final del embarazo deberían ser observados estrechamente con realización de hemograma seriado en los primeros días de vida, debido al riesgo de transmisión vertical.

Abstract Introduction: Few reports are available about perinatal dengue, with controversial results in regards the risk of perinatal outcome. Objective: To report a case of perinatal dengue as a differential diagno sis with neonatal sepsis, which must be considered in endemic areas. Clinical case: Male newborn of a 23 year-old female, who presented a Non-Structural Protein 1 (NS1) antigen positive to dengue at 36 weeks of gestation and negative anti-dengue antibodies. At day six of the illness a healthy newborn was born. On the second day of life the neonate presented fever with no other pathological findings on the physical exam, associated with severe thrombocytopenia (17,900 platelets/uL), increased C-reactive protein, a positive NS1 antigen, and positive anti-dengue immunoglobulin G (IgG). He was treated with ampicillin and gentamicin according the Institution protocol of neonatal sepsis. The newborn showed clinical improvement, with hemodynamic stability and significant increase of platelets, receiving the medical discharge. Conclusions: Dengue in pregnancy produces the risk of adverse perinatal outcomes, particularly low birth weight and preterm delivery. Children of mothers diagnosed with dengue at the end of pregnancy should be observed closely with serial hemograms during child's first days of life, due to the high risk of vertical transmission.

Robotic enucleation of benign pancreatic tumors.

Robot-assisted enucleation provides the dual benefits of a minimally-invasive technique and pancreatic parenchymal conservation to selected patients with functional pancreatic neuroendocrine tumors (F-pNETs) and serous cystadenomas. Insulinomas, the most common F-pNETs, are ideal candidates for enucleation when <2 cm given the 80% probability of being benign. Current evidence suggests enucleation for the following: benign, isolated lesions with a distance between tumor and main pancreatic duct ≥3 mm (no focal stricture or dilation), insulinomas, gastrinomas <2 cm, and nonfunctional pancreatic neuroendocrine tumors (NF-pNETs) <1-2 cm and low Ki67 mitotic index. Minimally-invasive enucleation is an imaging-dependent procedure that requires recognizable anatomic landmarks for successful completion, including tumor proximity to the pancreatic duct as well as localization relative to major structures such as the gastroduodenal artery, bile duct, and portal vein. Tumor localization often mandates intraoperative ultrasound aided by duplex studies of intratumoral blood flow and frozen section confirmation. Five patients have undergone robot-assisted enucleation at Beth Israel Deaconess Medical Center between January 2014 and January 2017 with median tumor diameter of 1.3 cm (0.9-1.7 cm) located in the pancreatic head [2] and tail [3]. Surgical indications included insulinoma [2] and NF-pNETs [3]. Median operative time was 204 min (range, 137-347 min) and estimated blood loss of 50 mL. There were no conversions to open or transfusions. Robotic enucleation is a safe and feasible technique that allows parenchymal conservation in a minimally-invasive setting, reducing operative time and length of stay with equivalent pathological outcomes compared to open surgery.

[Perinatal Dengue: A case Report]. / Dengue perinatal: Reporte de caso.

INTRODUCTION: Few reports are available about perinatal dengue, with controversial results in regards the risk of perinatal outcome. OBJECTIVE: To report a case of perinatal dengue as a differential diagno sis with neonatal sepsis, which must be considered in endemic areas. CLINICAL CASE: Male newborn of a 23 year-old female, who presented a Non-Structural Protein 1 (NS1) antigen positive to dengue at 36 weeks of gestation and negative anti-dengue antibodies. At day six of the illness a healthy newborn was born. On the second day of life the neonate presented fever with no other pathological findings on the physical exam, associated with severe thrombocytopenia (17,900 platelets/uL), increased C-reactive protein, a positive NS1 antigen, and positive anti-dengue immunoglobulin G (IgG). He was treated with ampicillin and gentamicin according the Institution protocol of neonatal sepsis. The newborn showed clinical improvement, with hemodynamic stability and significant increase of platelets, receiving the medical discharge. CONCLUSIONS: Dengue in pregnancy produces the risk of adverse perinatal outcomes, particularly low birth weight and preterm delivery. Children of mothers diagnosed with dengue at the end of pregnancy should be observed closely with serial hemograms during child's first days of life, due to the high risk of vertical transmission.