Implementation of an enhanced recovery after surgery program with robotic surgery in high-risk patients obtains optimal results after colorectal resections.

Enhanced recovery after surgery programs reduce postoperative complications and length of stay after laparoscopic colorectal surgery, but are still under evaluation after robotic colorectal surgery. To evaluate potential benefits in terms of length of stay and complications of an Enhanced recovery after surgery program in colorectal surgery. A subanalysis was performed to assess what combination of surgical approach and perioperative care had better outcomes. Prospective observational cohort study. 300 consecutive colorectal surgery patients: 150 were prospectively included in the enhanced recovery after Surgery program group and 150 retrospectively in the traditional care group, and subdivided according to the type of surgery, in Hospital Marques de Valdecilla, between 2013 and 2016. Postoperative complications decreased significantly (p = 0.002) from 46 to 28% (traditional care vs program group). The length of stay was decreased by 2 days (p < 0.001). Multivariate analysis indicated similar effect sizes after adjusting for age, gender, Charlson score, and type of surgery. Type of surgery was an independent predictive factor for postoperative complications and length of stay. Compared to open surgery, postoperative complications decreased by 50% (p < 0.001) after robotic surgery and by 40% (p = 0.01) after laparoscopic surgery, while the median length of stay decreased by three days (p < 0.001) after minimally invasive surgery. Enhanced recovery after surgery program and minimally invasive surgery were associated with decreased morbidity and length of stay after colorectal surgery compared to open surgery and traditional care. An enhanced recovery after surgery program with robotic surgery in high-risk patients might be beneficial.

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes.

BACKGROUND: Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV). METHODS: Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics. RESULTS: Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004). CONCLUSIONS: RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

Resección robótica asistida del segmento VII del hígado: vídeo de demostración técnica / Robot-assisted resection of liver segment vii: A technique demonstration video

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Robotic-assisted Pancreaticoduodenectomy: Technique Description and Performance Evaluation After 60 Cases.

PURPOSE: Robotic pancreaticoduodenectomy (RPD) remains one of the most challenging abdominal operations. During the implementation of new surgical technologies, safety and efficacy outcomes must be rigorously monitored and the learning curve clearly identified. MATERIALS AND METHODS: The authors investigated their experience during the adoption of RPD, analyzing the outcomes of our first 60 consecutive cases, divided into group A (1 to 30) and group B (31 to 60). The cumulative sum (CUSUM) analysis was used to define the learning curve. RESULTS: The authors observed a reduction in operative time (125 min) and estimated blood loss (185 mL) between the firsts 1 to 30 and the latest 30 cases. The overall rate of complications showed the tendency to decrease during the experience (46.7% vs. 23.3%, P=0.02), conversely, severe complications and the rate of clinically relevant postoperative pancreatic fistula did not show a significant reduction in the incidence (P=0.37 and P=0.67, respectively). The mean number of lymph nodes harvested improved significantly after 30 cases (P=0.004). CONCLUSION: Surgical performance improved significantly after the first 30 cases.

Robotic-assisted versus open pancreaticoduodenectomy: the results of a case-matched comparison.

Robotic-assisted pancreaticoduodenectomy (RPD) is progressively gaining momentum. It seems to provide some potential advantages over open approach. Unfortunately, only few studies investigated the impact of RPD on the oncologic outcomes. We performed a 1:1 case-matched comparison between two groups of 35 patients affected by a malignant tumor who underwent RPD and open (OPD) pancreaticoduodenectomy from August 2014 to April 2016. Operative time was longer in the RPD group compared to OPD (355 vs 262 min, p = 0.023), whereas median blood loss (235 vs 575 ml, p = 0.016) and length of hospitalization (6.5 vs 8.9 days, p = 0.041) were lower for RPD. A significant reduction of overall postoperative morbidity rate was found in the RPD group compared to the OPD group (31.4% vs 48.6% p = 0.034). No statistically significant difference was found between the two groups in terms of overall pancreatic fistula rate, R0 resection rate, and number of harvested lymph nodes. The overall and disease-free survival at 1 and 3 years were similar. RPD is a safe and effective technique. It reduces the estimated blood loss, the length hospital of stay and the rate of complications after pancreaticoduodenectomy, while preserving a good oncologic adequacy.

The application of indocyanine green-fluorescence imaging during robotic-assisted liver resection for malignant tumors: a single-arm feasibility cohort study.

BACKGROUND: The fluorescence properties of Indocyanine Green (ICG) make it a useful technique in the armamentarium of liver surgeons in order to enhance the visualization of anatomical structures by providing a real-time liver mapping. METHODS: We have analyzed the impact of ICG-fluorescence staining technique in 40 consecutive patients who underwent robotic-assisted liver resection for malignancies from June 2014 to November 2017. RESULTS: For the 55% of patients the surgical indication was colorectal liver metastasis followed by hepatocarcinoma in 35% of cases. The R0 resection rate was 100%, and the mean resection margin was 12 mm. Twenty percent of patients experienced tumor recurrence. The 1-year and 2-year overall survival rates were 91% and 84%, respectively. The 1-year and 2-year disease free survival were 77.2% and 65%, respectively. The previously marked transaction line was changed after the staining method in 12 out of 40 patients. Through intra-operative ultrasonography and white-light exploration of the liver surface 43 lesions were detected, whereas with the ICG-F 52 lesion of the liver surface were identified, including two superficial colorectal metastases missed at the intra-operative ultrasonography. CONCLUSION: The ICG-F is a promising navigational tool, that can potentially overcome the limitations of the minimally invasive liver surgery.

The Application of Indocyanine Green Fluorescence Imaging During Robotic Liver Resection: A Case-Matched Study.

BACKGROUND: The ICG fluorescence properties are progressively gaining momentum in the HPB surgery. However, the exact impact of ICG application on surgical outcomes is yet to be established. METHODS: Twenty-five patients who underwent ICG fluorescence-guided robotic liver resection were case-matched in a 1:1 ratio to a cohort who underwent standard robotic liver resection. RESULTS: In the ICG group, six additional lesions not diagnosed by preoperative workup and intraoperative ultrasound were identified and resected. Four of the lesions were proved to be malignant. Despite the similar operative time (288 vs. 272 min, p = 0.778), the risk of postoperative bile leakage (0% vs. 12%, p = 0.023), R1 resection (0% vs. 16%, p = 0.019) and readmission (p = 0.023) was reduced in the ICG group compared with the no-ICG group. CONCLUSIONS: The ICG fluorescence is a real-time navigation tool which enables surgeons to enhance visualization of anatomical structures and overcome the disadvantages of minimally invasive liver resection. The procedure is not time-consuming, and its applications can reduce the postoperative complication rate in robotic liver surgery.

Polipectomía transanal asistida por robot: ¿tiene alguna indicación? / Robotic Assisted Transanal Polypectomies: Is There Any Indication?

Objetivos: La polipectomía transanal asistida por robot puede tener ventajas respecto a la cirugía laparoscópica transanal convencional. Evaluamos la seguridad, factibilidad y ventajas potenciales de esta técnica. Métodos: Entre febrero de 2014 y octubre de 2015, se realizaron un total de 9 polipectomías transanales en nuestro centro. Realizamos un estudio retrospectivo de datos recogidos prospectivamente referentes a las características de los pacientes, tumores tratados, resultados perioperatorios, informe anatomopatológico y morbimortalidad. Resultados: Fueron tratados 5 hombres y 4 mujeres mediante polipectomía robótica transanal. Las lesiones se encontraban a una distancia media de 6,2 cm respecto al margen anal. La superficie media de las lesiones fue de 15,8 cm2. Todos los procedimientos fueron realizados en posición de litotomía, independientemente de la localización de la lesión. Se realizó cierre del defecto en todos los casos. El sangrado intraoperatorio medio fue de 39,8 mL. El tiempo quirúrgico medio fue de 71,9 min. No se objetivaron complicaciones graves postoperatorias ni reingresos y la estancia mediana fue de 2,5 días. Conclusiones: La polipectomía transanal asistida por robot es útil para tratar lesiones rectales complejas o voluminosas. Nuestra plataforma de acceso transanal permitió un amplio rango de movimientos con los pacientes en litotomía (AU)

Objectives: Robotic assisted transanal polipectomy may have advantages compared with the conventional transanal minimally invasive surgery technique. We evaluate the safety, feasibility and advantages of this technique. Methods: Between February 2014 and October 2015, 9 patients underwent robotic transanal polypectomy. We performed a retrospective study in which we analyse prospectively collected data regarding patient and tumor characteristics, perioperative outcomes, pathological report, morbidity and mortality. Results: A total of 5 male and 4 female patients underwent robotic TAMIS. Lesions were 6,22 cm from the anal verge. Mean size was 15,8 cm2. All procedures were performed in the lithotomy position. Closure of the defect was performed in all cases. Mean blood loss was 39,8 ml. Mean operative time was 71,9 min. No severe postoperative complications or readmissions occured. Median hospital stay was 2,5 days. Conclusions: Robotic TAMIS is useful to treat complex rectal lesions. Our transanal platform allowed a wider range of movements of the robotic arms and to perform all procedures in the lithotomy position (AU)

Robotic Assisted Transanal Polypectomies: Is There Any Indication? / Polipectomía transanal asistida por robot: ¿tiene alguna indicación?

OBJECTIVES: Robotic assisted transanal polipectomy may have advantages compared with the conventional transanal minimally invasive surgery technique. We evaluate the safety, feasibility and advantages of this technique. METHODS: Between February 2014 and October 2015, 9patients underwent robotic transanal polypectomy. We performed a retrospective study in which we analyse prospectively collected data regarding patient and tumor characteristics, perioperative outcomes, pathological report, morbidity and mortality. RESULTS: A total of 5 male and 4 female patients underwent robotic TAMIS. Lesions were 6,22cm from the anal verge. Mean size was 15,8cm2. All procedures were performed in the lithotomy position. Closure of the defect was performed in all cases. Mean blood loss was 39,8ml. Mean operative time was 71,9min. No severe postoperative complications or readmissions occured. Median hospital stay was 2,5 days. CONCLUSIONS: Robotic TAMIS is useful to treat complex rectal lesions. Our transanal platform allowed a wider range of movements of the robotic arms and to perform all procedures in the lithotomy position.

Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery.

BACKGROUND: To audit the safety of the early hospital discharge care model offered by a Hospital-at-home (HAH) unit during early postoperative follow-up of these patients, and to determine whether this care model is more efficient compared to the traditional care model. METHODS: A prospective study of 50 patients included consecutively for 1 year in an early discharge programme after laparoscopic colorectal surgery was performed. As of day 3 after surgery, if the patient met the relevant inclusion criteria they were transferred to the HAH unit. The domiciliary protocol consists of daily clinical follow-up and a series of analytical controls with the purpose of early detection of postoperative complications. If the clinical course was favourable on day 7 after the postoperative period the patient was discharged. RESULTS: A total of 66% were males, and the mean age was 60.6 years. The surgical procedure most commonly performed was sigmoidectomy. The mean stay was 5.5 days. There were no deaths during follow-up. The average estimated cost per day of stay in a HAH system was EUR 174.29 whilst the same average cost on a surgery ward stood at EUR 1,032.42. CONCLUSIONS: For patients undergoing major colorectal surgery with minimally invasive surgical technique, an early hospital discharge care programme by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

Evaluation of Early Cholecystectomy versus Delayed Cholecystectomy in the Treatment of Acute Cholecystitis.

Objective. To evaluate if early cholecystectomy (EC) is the most appropriate treatment for acute cholecystitis compared to delayed cholecystectomy (DC). Patients and Methods. A retrospective cohort study of 1043 patients was carried out, with a group of 531 EC cases and a group of 512 DC patients. The following parameters were recorded: (1) postoperative hospital morbidity, (2) hospital mortality, (3) days of hospital stay, (4) readmissions, (5) admission to the Intensive Care Unit (ICU), (6) type of surgery, (7) operating time, and (8) reoperations. In addition, we estimated the direct cost savings of implementing an EC program. Results. The overall morbidity of the EC group (29.9%) was significantly lower than the DC group (38.7%). EC demonstrated significantly better results than DC in days of hospital stay (8.9 versus 15.8 days), readmission percentage (6.8% versus 21.9%), and percentage of ICU admission (2.3% versus 7.8%), which can result in reducing the direct costs. The patients who benefited most from an EC were those with a Charlson index > 3. Conclusions. EC is safe in patients with acute cholecystitis and could lead to a reduction in the direct costs of treatment.

Papel de la bacteriobilia en las complicaciones postoperatorias / Role of bacteriobilia in postoperative complications

Introducción. Actualmente existe controversia respecto al impacto de la positividad de cultivos biliares en la tasa de morbilidad y mortalidad, y en la incidencia de readmisiones en pacientes con enfermedad biliar. El objetivo de este estudio fue evaluar el papel de la bacteriobilia en las infecciones postoperatorias, la mortalidad o el reingreso hospitalario en estos pacientes. Métodos. La información se obtuvo a partir de los cultivos de vía biliar de los pacientes intervenidos en el Hospital Universitario Marqués de Valdecilla (Santander, España) entre enero y diciembre de 2011. Se analizaron los datos clínicos, epidemiológicos y microbiológicos. Los pacientes fueron seguidos durante dos años. Resultados. Se incluyeron 152 pacientes (65% varones). La media de edad fue de 67 años (DE: 15 años). Los diagnósticos más frecuentes fueron colecistitis aguda (79%) y colangitis (8%). Se realizó colecistectomía laparoscópica en el 42% de los pacientes, colecistectomía abierta en el 45% y colecistostomía percutánea en el 8%. La bacteriobilia estaba presente en 83 pacientes (55%). Los microorganismos más frecuentemente aislados fueron Escherichia coli (31%), Enterococcus faecium (13%) y Klebsiella pneumoniae (13%). Los antibióticos iniciales fueron carbapenémicos en 62 pacientes (44%) y piperacilina-tazobactam en 28 pacientes (18%). Hubo 39 infecciones postoperatorias (26%) y 17 pacientes fallecieron durante el ingreso (11%). Se registraron 21 reingresos (14%). La bacteriobilia no fue un predictor estadísticamente significativo de complicaciones o reingreso hospitalario. Conclusiones. Los cultivos biliares intraoperatorios permitieron orientar la terapia antimicrobiana empírica y el tratamiento antibiótico apropiado; sin embargo no hubo correlación entre la bacteriobilia y las infecciones posoperatorias, la duración del ingreso, la mortalidad o los reingresos (AU)

Introduction. At present there is a controversy regarding the impact of positive bile cultures on morbidity and mortality rates, and on the incidence of readmissions in patients with biliar disease. The aim of this study was to evaluate the role of bacteriobilia in postoperatory infections, mortality or readmissions in these patients. Methods. The information was obtained from all patients with bile cultures admitted to Hospital Universitario Marqués de Valdecilla (Santander, Spain) from January to December 2011. Clinical, epidemiological and microbiological data and laboratory findings were analyzed. The patients were followed for two years. Results. One hundred and fifty-two patients (65% men) were included. Mean age was 67 years (SD= 15 years). The most frequent diagnoses were acute cholecystitis (79%) and cholangitis (8%). Laparoscopic cholecystectomy was performed in 42% of patients, open cholecystectomy in 45% and percutaneous cholecystostomy in 8%. Bacteriobilia was present in 83 patients (55%). The most frecuent microorganisms isolated were Escherichia coli (31%), Enterococcus faecium (13%) and Klebsiella pneumoniae (13%). The initial antimicrobial agent was a carbapenem in 62 patients (44%) and piperacillin-tazobactam in 28 (18%). There were 39 postoperative infections (26%), 21 readmissions (14%) and 17 patients died during admission (11%). The presence of microorganisms in bile cultures was not a statistically significant predictor of neither complications nor readmissions. Conclusions. Intra-operative bile cultures would allow guide early appropriate antibiotic treatment use in case of infection, or empiric antimicrobial therapy, however there was no correlation between bacteriobilia and postoperative infections, length of stay, mortality or readmissions (AU)

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions.

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Apendicitis de muñón. ¿Una realidad infravalorada? / Stump appendicitis. Underrated reality?

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Resultados iniciales de la esofaguectomía robótica en el cáncer de esófago / Initial results of robotic esophagectomy for esophageal cancer

INTRODUCCIÓN: La experiencia con la esofaguectomía robótica en el cáncer de esófago y de la unión esofagogástrica es limitada. El objetivo de este estudio es presentar nuestra experiencia actual. PACIENTES Y MÉTODOS: Estudio prospectivo, de vigilancia observacional, de las primeras 32 esofaguectomías mínimamente invasivas por cáncer con toracoscopia robótica entre septiembre de 2011 y junio de 2014. La plastia gástrica se realizó por vía laparoscópica. La toracoscopia robótica se llevó a cabo con el paciente en decúbito prono y la anastomosis intratorácica, siempre de forma manual. Se evaluaron las siguientes variables: características clínicas y patológicas, técnica quirúrgica, resultados a corto plazo (morbimortalidad) y resultados oncológicos (radicalidad y ganglios extirpados). RESULTADOS: A 32 pacientes con una edad media de 58 años (rango 34-74) se les realizó una esofaguectomía mínimamente invasiva en su totalidad: laparoscopia y toracoscopia robótica (11 McKeown y 21 Ivor Lewis). En 29 casos se administró quimiorradioterapia neoadyuvante. No hubo conversiones a cirugía abierta. El tiempo medio de consola fue 218 min (rango 190-285) y la pérdida de sangre fue de 170 ml (rango 40-255). Un paciente falleció por causa cardiológica y 9 presentaron complicaciones mayores (grado II o más de Dindo-Clavien). No hubo complicaciones respiratorias ni parálisis recurrencial. Hubo 5 fístulas intratorácicas, 4 radiológicas y una clínica, 3 quilotórax, 2 fístulas cervicales y una necrosis de la plastia. La mediana de la estancia hospitalaria fue 12 días (rango 8-50). Todas las resecciones fueron R0 y se extirparon una mediana de 16 (rango 2-23) ganglios linfáticos. CONCLUSIONES: Nuestros resultados indican inicialmente que la esofaguectomía mínimamente invasiva con toracoscopia robótica es segura y respeta los principios oncológicos

INTRODUCTION: There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. PATIENTS AND METHODS: Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. RESULTS: Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218 minutes (190-285). Blood loss was 170 ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). CONCLUSIONS: Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards

Hidatidosis hepática fistulizada a piel / Hepatic hydatid disease fistulized to the skin surface

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[Initial results of robotic esophagectomy for esophageal cancer]. / Resultados iniciales de la esofaguectomía robótica en el cáncer de esófago.

INTRODUCTION: There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. PATIENTS AND METHODS: Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. RESULTS: Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). CONCLUSIONS: Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.