Robotic Approach for Perihilar Cholangiocarcinoma IIIA Type: Step-by-Step Procedure.

BACKGROUND: Perihilar cholangiocarcinoma is a challenging technique to be performed by minimally invasive approach being the type III among the most complex procedure. Nowadays, the robotic approach is gaining increasing interest among the surgical community, and more and more series describing robotic liver resection have been reported. However, few cases of minimally invasive Bismuth type IIIA cholangiocarcinoma have been reported. Robotic approach allows for a better dissection and suture thanks to the flexible and precise instruments movements, overcoming some of the limitations of the laparoscopic technique. Therefore, robotic technique can facilitate some of the critical steps of a technically demanding procedure, such as the extended right hepatectomy for perihilar cholangiocarcinoma Bismuth IIIA type. METHODS: In this multimedia video we describe, for the first time in the literature, a full robotic surgical step-by-step technique with some tips and tricks for treating a perihilar cholangiocarcinoma Bismuth IIIA type, performing a radical extended right hemihepatectomy, including segment I combined with regional lymphadenectomy anf left bile duct reconstruction. A 55-year-old woman with obstructive jaundice (10 mg/dl) was referred to our center. The endobiliary brushing confirmed adenocarcinoma, and MRI/CT showed a focal perihilar lesion of 2 cm, including the main biliary duct bifurcation and extending up to the right duct (Bismuth Type IIIA hilar cholangiocarcinoma). After endoscopic biliary stents placement and 6 weeks after right portal vein embolization, the future liver remnant, including segments II and III, reached an enough hypertrophy volume with a ratio of 30%. A right hemihepatectomy with caudate lobe, including standard standard lymphadenectomy and left biliary duct reconstruction was performed. RESULTS: The operation lasted 670 min with an estimated blood loss of 350 ml. Postoperative pathological examination revealed a moderately differentiated adenocarcinoma pT1N0 with 15 retrieved nodes and free margins. The patient experienced a type A biliary fistula and was discharged on the 21st postoperative day without abdominal drainage. CONCLUSIONS: Through the tips and tricks presented in this multimedia article, we show the advantages of the robotic approach for performing correctly one of the most complex surgeries.1-7.

Levels of Robotic Mesopancreas Dissection According to Malignancy and Vascular Anatomy: What Surgeons Need to Know.

INTRODUCTION: The robotic approach is attracting increasing interest among the surgical community, and more and more series describing robotic pancreatoduodenectomy have been reported. Thus, surgeons performing robotic pancreatoduodenectomy should be confident with this critical step's potential scenarios. MATERIALS AND METHODS: According to Yosuke et al., there are three different levels of mesopancreas dissection. We describe the main steps for a safe mesopancreas dissection by robotic approach. RESULTS: This multimedia article provides, for the first time in literature, a comprehensive step-by-step overview of the mesopancreas dissection during robotic pancreatoduodenectomy (PD) and its three different levels according to tumor type. CONCLUSIONS: Through the tips and indications presented in this multimedia article, we aim to familiarize surgeons with the mesopancreas dissections levels according to type of malignancy and vascular anatomy.

Minimally Invasive Left Hepatectomy: Choosing the Suitable Surgical Strategy.

BACKGROUND: Numerous surgical techniques are currently available for minimally invasive left hepatic resection, each offering its own advantages and disadvantages. PATIENTS AND METHODS: This multimedia manuscript delves into the primary approaches for minimally invasive left hepatectomy, with a focus on particular topics such as left hepatic vein approach, transection and middle hepatic vein exposure, and Glissonean approach. We examine key factors that surgeons should consider when choosing among these methods and provide practical recommendations. RESULTS: To enhance understanding, our article includes video footage from multiple centres, showcasing expertly executed surgeries for each approach along with their main considerations. CONCLUSIONS: This multimedia resource will serve as a valuable guide for surgeons, aiding in the selection of the most suitable strategy for minimally invasive left hepatectomies, tailored to the specific needs of the patient and the characteristics of the lesion.

Cost-effectiveness of robotic vs laparoscopic distal pancreatectomy. Results from the national prospective trial ROBOCOSTES.

INTRODUCTION: Although several studies report that the robotic approach is more costly than laparoscopy, the cost-effectiveness of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) is still an issue. This study evaluates the cost-effectiveness of the RDP and LDP approaches across several Spanish centres. METHODS: This study is an observational, multicenter, national prospective study (ROBOCOSTES). For one year from 2022, all consecutive patients undergoing minimally invasive distal pancreatectomy were included, and clinical, QALY, and cost data were prospectively collected. The primary aim was to analyze the cost-effectiveness between RDP and LDP. RESULTS: During the study period, 80 procedures from 14 Spanish centres were analyzed. LDP had a shorter operative time than the RDP approach (192.2 min vs 241.3 min, p = 0.004). RDP showed a lower conversion rate (19.5% vs 2.5%, p = 0.006) and a lower splenectomy rate (60% vs 26.5%, p = 0.004). A statistically significant difference was reported for the Comprehensive Complication Index between the two study groups, favouring the robotic approach (12.7 vs 6.1, p = 0.022). RDP was associated with increased operative costs of 1600 euros (p < 0.031), while overall cost expenses resulted in being 1070.92 Euros higher than the LDP but without a statistically significant difference (p = 0.064). The mean QALYs at 90 days after surgery for RDP (0.9534) were higher than those of LDP (0.8882) (p = 0.030). At a willingness-to-pay threshold of 20,000 and 30,000 euros, there was a 62.64% and 71.30% probability that RDP was more cost-effective than LDP, respectively. CONCLUSIONS: The RDP procedure in the Spanish healthcare system appears more cost-effective than the LDP.

The impact of vascular margin invasion on local recurrence after pancreatoduodenectomy in pancreatic adenocarcinoma.

PURPOSE: Pancreatic ductal adenocarcinoma (PADC) still has nowadays a very impaired long-term survival. Most studies are focused on overall survival; however, local recurrence occurs about up to 50% of cases and seems to be highly related with margin resection status. We aim to analyze the impact of vascular resection margins on local recurrence (LR) and to assess its impact on overall and disease-free survival. METHODS: Eighty out of 191 patients who underwent pancreatoduodenectomy in a university hospital between 2006 and 2021 with PDAC diagnosis were analyzed and vascular margin status specifically addressed. Univariate and multivariate were performed. Time to LR was compared by using the Kaplan-Meier method and prognostic factors assessed using Cox regression hazards model. RESULTS: LR appeared in 10 (50%) of the overall R1 resections in the venous margin and 9 (60%) in the arterial one. Time to LR was significantly shorter when any margin was overall affected (23.2 vs 44.7 months, p = 0.01) and specifically in the arterial margin involvement (13.7 vs 32.1 months, p = 0.009). Overall R1 resections (HR 2.61, p = 0.013) and a positive arterial margin (HR 2.84, p = 0.012) were associated with local recurrence on univariate analysis, whereas arterial positive margin remained significant on multivariate analysis (HR 2.70, p = 0.031). CONCLUSIONS: Arterial margin invasion is correlated in our cohort with local recurrence. Given the limited ability to modify this margin intraoperatively, preoperative therapies should be considered to improve local margin clearance.

The role of resection in hepatocellular carcinoma BCLC stage B: A multi-institutional patient-level meta-analysis and systematic review.

PURPOSE: The Barcelona Clinic Liver Cancer (BCLC) staging schema is widely used for hepatocellular carcinoma (HCC) treatment. In the updated recommendations, HCC BCLC stage B can become candidates for transplantation. In contrast, hepatectomy is currently not recommended. METHODS: This systematic review includes a multi-institutional meta-analysis of patient-level data. Survival, postoperative mortality, morbidity and patient selection criteria for liver resection and transplantation in BCLC stage B are explored. All clinical studies reporting HCC patients with BCLC stage B undergoing liver resection or transplantation were included. RESULTS: A total of 31 studies with 3163 patients were included. Patient level data was available for 580 patients from 9 studies (423 after resection and 157 after transplantation). The overall survival following resection was 50 months and recurrence-free survival was 15 months. Overall survival after transplantation was not reached and recurrence-free survival was 45 months. The major complication rate after resection was 0.11 (95%-CI, 0.0-0.17) with the 90-day mortality rate of 0.03 (95%-CI, 0.03-0.08). Child-Pugh A (93%), minor resection (60%), alpha protein level less than 400 (64%) were common in resected patients. Resected patients were mostly outside the Milan criteria (99%) with mean tumour number of 2.9. Studies reporting liver transplantation in BCLC stage B were scarce. CONCLUSION: Liver resection can be performed safely in selected patients with HCC BCLC stage B, particularly if patients present with preserved liver function. No conclusion can done on liver transplantation due to scarcity of reported studies.

Robotic Distal Pancreatectomy: A Novel Standard of Care? Benchmark Values for Surgical Outcomes From 16 International Expert Centers.

BACKGROUND AND OBJECTIVE: Robotic distal pancreatectomy (DP) is an emerging attractive approach, but its role compared with laparoscopic or open surgery remains unclear. Benchmark values are novel and objective tools for such comparisons. The aim of this study was to identify benchmark cutoffs for many outcome parameters for DP with or without splenectomy beyond the learning curve. METHODS: This study analyzed outcomes from international expert centers from patients undergoing robotic DP for malignant or benign lesions. After excluding the first 10 cases in each center to reduce the effect of the learning curve, consecutive patients were included from the start of robotic DP up to June 2020. Benchmark patients had no significant comorbidities. Benchmark cutoff values were derived from the 75th or the 25th percentile of the median values of all benchmark centers. Benchmark values were compared with a laparoscopic control group from 4 high-volume centers and published open DP landmark series. RESULTS: Sixteen centers contributed 755 cases, whereof 345 benchmark patients (46%) were included the analysis. Benchmark cutoffs included: operation time ≤300 minutes, conversion rate ≤3%, clinically relevant postoperative pancreatic fistula ≤32%, 3 months major complication rate ≤26.7%, and lymph node retrieval ≥9. The comprehensive complication index at 3 months was ≤8.7 without deterioration thereafter. Compared with robotic DP, laparoscopy had significantly higher conversion rates (5×) and overall complications, while open DP was associated with more blood loss and longer hospital stay. CONCLUSION: This first benchmark study demonstrates that robotic DP provides superior postoperative outcomes compared with laparoscopic and open DP. Robotic DP may be expected to become the approach of choice in minimally invasive DP.

Superior Mesenteric Artery First Approach for Minimally Invasive Pancreaticoduodenectomy: A Step-By-Step Surgical Technique Video.

INTRODUCTION: In the past decade, minimally invasive pancreaticoduodenectomy has been gaining interest. However, minimally invasive pancreaticoduodenectomy remains technically challenging and is associated with a steep learning curve. Additionally, the operating surgeon should be cognizant of replicating the same oncological steps as observed in the typical open approach. In view of this, there exist various maneuvers that are designed to achieve negative margins and a safer mesopancreatic dissection. One of these techniques is the superior mesenteric artery first approach, which is garnering interest among pancreatic surgeons. MATERIAL AND METHODS: According to existing literature, there are several superior mesenteric artery dissections approaches. We describes 5 different minimally invasive approaches. RESULTS: This multimedia manuscript provide, for the first time in literature, a comprehensive step-by-step overview of the superior mesenteric artery first approach for minimally invasive pancreaticoduodenectomy by a team of expert surgeons from various international institutions. CONCLUSIONS: Through the tips and indications presented in this article, we aim to guide the choice of this approach according to tumor location, type of minimally invasive approach and the operating surgeon's experience and increase familiarity with such a complex procedure.

Is occlusion of the main pancreatic duct by thermal ablation really safe? A surgical innovation assessed according to IDEAL recommendations.

INTRODUCTION: Pre-clinical studies suggest that thermal ablation of the main pancreatic duct (TAMPD) is more recommendable than glue for reducing postoperative pancreatic fistula (POPF). Our aims were (1) to analyze the changes in the pancreas of patients after TAMPD and (2) to correlate the clinical findings with those obtained from a study on an animal model. MATERIALS AND METHODS: A retrospective early feasibility study of a marketed device for a novel clinical application was carried out on a small number of subjects (n = 8) in whom TAMPD was conducted to manage the pancreatic stump after a pancreatectoduodenectomy (PD). Morphological changes in the remaining pancreas were assessed by computed tomography for 365 days after TAMPD. RESULTS: All the patients showed either Grade A or B POPF, which generally resolved within the first 30 days. The duct's maximum diameter significantly increased after TAMPD from 1.5 ± 0.8 mm to 8.6 ± 2.9 mm after 7 days (p = .025) and was then reduced to 2.6 ± 0.8 mm after 365 days PO (p < .0001). The animal model suggests that TAMPD induces dilation of the duct lumen by enzymatic digestion of ablated tissue after a few days and complete exocrine atrophy after a few weeks. CONCLUSIONS: TAMPD leads to long-term exocrine pancreatic atrophy by completely occluding the duct. However, the ductal dilatation that occurred soon after TAMPD could even favor POPF, which suggests that TAMPD should be conducted several weeks before PD, ideally by digestive endoscopy.

Laparoscopic versus open pancreatoduodenectomy: an individual participant data meta-analysis of randomized controlled trials.

BACKGROUND: Randomized trials have compared laparoscopic pancreatoduodenectomy (LPD) to open pancreatoduodenectomy (OPD) with conflicting results. An IPDMA may give more insight into the differences between LPD and OPD, and could identify high-risk subgroups. METHODS: A systematic literature search was performed in the Pubmed, Embase, and the Cochrane library databases (October 2019). Out of 1410 studies, three randomized trials were identified. Primary outcome was major complications (Clavien-Dindo grade ≥ III). Subgroup analyses were performed for high-risk subgroups including patients with BMI of ≥25 kg/m2, pancreatic duct <3 mm, age ≥70 years, and malignancy. RESULTS: Data from 224 patients were collected. After LPD, major complications occurred in 33/114 (29%) patients compared to 34/110 (31%) patients after OPD (adjusted odds ratio (OR) 0.62; 95% confidence interval (CI) 0.3-1.4, P = 0.257). No differences were seen for major complications and 90-day mortality LPD 8 (7%) vs OPD 4 (4%) (adjusted OR 0.2; 95% CI 0.02-1.3, P = 0.080). With LPD, operative time was longer (420 vs 318 min, p < 0.001) and hospital stay was shorter (mean difference -6.97 days). Outcomes remained stable in the high-risk subgroups. CONCLUSION: LPD did not reduce the rate of major postoperative complications as compared to OPD. LPD increased operative time and shortened hospital stay with 7 days.

Combination of HAI-FUDR and Systemic Gemcitabine and Cisplatin in Unresectable Cholangiocarcinoma: A Dose Finding Single Center Study.

BACKGROUND: Unresectable cholangiocarcinoma has a poor prognosis and treatment options are limited. Combined systemic and intrahepatic chemotherapy may improve local control and enable downsizing. The aim of this study was to determine the maximum tolerated dose (MTD) of intravenous gemcitabine combined with intravenous cisplatin and hepatic arterial infusion (HAI) with floxuridine (FUDR) in patients with unresectable intrahepatic or hilar cholangiocarcinoma. METHODS: Twelve patients were treated within a 3 + 3 dose escalation algorithm with 600, 800, or 1,000 mg/m2 gemcitabine and predefined doses of cisplatin 25 mg/m2 on days 1 and 8, q21, for 4 cycles, and FUDR 0.2 mg/kg on days 1-14 as continuous HAI, q28, for 3 cycles. Safety and toxicity as well as resectability rates after 3 months and preliminary survival data are reported. RESULTS: The determined MTD for gemcitabine was 800 mg/m2. Dose limiting toxicities were neutropenic fever and biliary tract infections. In total, 27% of the patients showed partial remission and 73% stable disease. Although none of the patients achieved resectability after 3 months, the 3-year overall survival rate was 33%, median overall survival 23.9 months (range 1-49), and median progression-free survival 10.1 months (range 2-40). CONCLUSIONS: Intravenous gemcitabine/cisplatin plus HAI-FUDR is feasible and appears effective for disease control. Larger prospective studies evaluating this triplet combination are warranted.

Clinical case report: endoluminal thermal ablation of main pancreatic duct for patients at high risk of postoperative pancreatic fistula after pancreaticoduodenectomy.

PURPOSE: Multiple attempts have been made to manage the pancreatic stump and the pancreatic duct in order to reduce the rate of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), however radiofrequency-based technologies could help to achieve this goal. Previous encouraging clinical and experimental results support the use of endoluminal thermal ablation (ETHA) of the main pancreatic duct to reduce pancreatic exocrine secretion and hence POPF. We here describe our initial clinical experience with ETHA of the main pancreatic duct in two cases at high risk of POPF. METHODS: Two cases underwent PD for malignancy with a high risk of POPF (adenocarcinoma, obese patients, surgical difficulties with heavy intraoperative blood loss, soft pancreas or walled-off pancreatitis and a tight small pancreatic main duct). In both cases, ETHA of the main pancreatic duct was conducted intraoperatively just before Blumgart-type pancreatic-jejunal anastomosis using a ClosureFast catheter (Medtronic, Mansfield, MA, USA) normally used for varicose vein treatment (therefore an off-label use). RESULTS: Although a clear radiological POPF was detected in the second case, the clinical postoperative course in both cases was uneventful. Little pancreatic fluid collected in the abdominal drainage with low levels of amylase enzyme, confirming low exocrine pancreatic function. No other procedure-related complications were detected. CONCLUSION: Endoluminal thermal ablation of the main pancreatic duct may be a feasible and safe technique to reduce the adverse effects of POPF after PD.

Defining Benchmark Outcomes for Pancreatoduodenectomy With Portomesenteric Venous Resection.

OBJECTIVE: The aim of this study was to establish clinically relevant outcome benchmark values using criteria for pancreatoduodenectomy (PD) with portomesenteric venous resection (PVR) from a low-risk cohort managed in high-volume centers. SUMMARY BACKGROUND DATA: PD with PVR is regarded as the standard of care in patients with cancer involvement of the portomesenteric venous axis. There are, however, no benchmark outcome indicators for this population which hampers comparisons of patients undergoing PD with and without PVR resection. METHODS: This multicenter study analyzed patients undergoing PD with any type of PVR in 23 high-volume centers from 2009 to 2018. Nineteen outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers (NCT04053998). RESULTS: Out of 1462 patients with PD and PVR, 840 (58%) formed the benchmark cohort, with a mean age was 64 (SD11) years, 413 (49%) were females. Benchmark cutoffs, among others, were calculated as follows: Clinically relevant pancreatic fistula rate (International Study Group of Pancreatic Surgery): ≤14%; in-hospital mortality rate: ≤4%; major complication rate Grade≥3 and the CCI up to 6 months postoperatively: ≤36% and ≤26, respectively; portal vein thrombosis rate: ≤14% and 5-year survival for patients with pancreatic ductal adenocarcinoma: ≥9%. CONCLUSION: These novel benchmark cutoffs targeting surgical performance, morbidity, mortality, and oncological parameters show relatively inferior results in patients undergoing vascular resection because of involvement of the portomesenteric venous axis. These benchmark values however can be used to conclusively assess the results of different centers or surgeons operating on this high-risk group.

Benchmarks in Pancreatic Surgery: A Novel Tool for Unbiased Outcome Comparisons.

OBJECTIVE: To use the concept of benchmarking to establish robust and standardized outcome references after pancreatico-duodenectomy (PD). BACKGROUND: Best achievable results after PD are unknown. Consequently, outcome comparisons among different cohorts, centers or with novel surgical techniques remain speculative. METHODS: This multicenter study analyzes consecutive patients (2012-2015) undergoing PD in 23 international expert centers in pancreas surgery. Outcomes in patients without significant comorbidities and major vascular resection (benchmark cases) were analyzed to establish 20 outcome benchmarks for PD. These benchmarks were tested in a cohort with a poorer preoperative physical status (ASA class ≥3) and a cohort treated by minimally invasive approaches. RESULTS: Two thousand three hundred seventy-five (38%) low-risk cases out of a total of 6186 PDs were analyzed, disclosing low in-hospital mortality (≤1.6%) but high morbidity, with a 73% benchmark morbidity rate cumulated within 6 months following surgery. Benchmark cutoffs for pancreatic fistulas (B-C), severe complications (≥ grade 3), and failure-to-rescue rate were 19%, 30%, and 9%, respectively. The ASA ≥3 cohort showed comparable morbidity but a higher in hospital-mortality (3% vs 1.6%) and failure-to-rescue rate (16% vs 9%) than the benchmarks. The proportion of benchmark cases performed varied greatly across centers and continents for both open (9%-93%) and minimally invasive (11%-62%) PD. Centers operating mostly on complex PD cases disclosed better results than those with a majority of low-risk cases. CONCLUSION: The proposed outcome benchmarks for PD, established in a large-scale international patient cohort and tested in 2 different cohorts, may allow for meaningful comparisons between different patient cohorts, centers, countries, and surgical techniques.

Mucormycosis: an unusual cause of gastric perforation and severe bleeding in immunocompetent patients.

Mucormycosis is a rare and often fatal opportunistic infection that especially occurs in immunocompromised patients. Primary gastrointestinal infection is uncommon and accounts for only approximately 7% of all cases of mucormycosis but it is associated with an 85% mortality rate due to perforation and massive bleeding. Very few cases of gastrointestinal mucormycosis in an immunocompetent host have been reported. We describe a case of gastric necrosis and massive bleeding due to fulminant invasive mucormycosis.