ASO Author Reflections: The Role of Robotic Surgery on Central Pancreatectomy.

Central pancreatectomy (CP) is indicated for benign or low-grade pancreatic tumors located in the neck or proximal pancreatic body. This procedure is demanding and has a high rate of postoperative complications. Minimally invasive surgery is now commonly used for CP but it is still unclear whether the robotic approach offers any advantages over conventional pancreatic minimally invasive surgery. Most studies on robotic CP are limited to case reports or case series; however, there are two important studies on this topic. Currently, the evidence on robotic CP remains limited, making it challenging to draw definitive conclusions in favor of one technique over the other. The use of a robotic platform, with its integrated tools such as intraoperative ultrasound, can guide the surgeon in performing this technically demanding procedure in a safer manner. The controversy regarding the best minimally invasive surgery approach for CP is still ongoing and requires further research.

Essential Elements in Synoptic Operative Reports for Hepato-Pancreato-Biliary Cancer Surgery: An HPB/CGSO Training Program Survey.

BACKGROUND: Synoptic operative reports (SORs) are checklists or templates that contain standardized elements of an operation. These elements are associated with standardized inclusion of critical elements of the operative report that translate into numerous potential benefits. Whereas SORs for melanoma, breast, and colorectal cancer surgery have already been widely implemented, similar templates for hepato-pancreato-biliary (HPB) cancer surgery are currently lacking. METHODS: An anonymous voluntary online survey was distributed to HPB attendings and fellows at HPB and complex general surgical oncology (CGSO) fellowship programs. RESULTS: The 54 participants in this study comprised 31 (57%) HPB surgery attendings, 15 (28%) HPB surgery fellows, and 8 (15%) CGSO fellows. Notably, only six (11%) participants reported consistent use of an HPB SOR. The most commonly reported barriers to SOR uptake were the "lack of a readily available template" (55%) and the "lack of consensus/guidelines" (49%). Despite these limiting factors, a majority of respondents indicated a strong willingness to use a standardized and readily available HPB SOR (mean, 4.13/5 ± 1.23). This interest did not differ between attendings and fellows (p = 0.52) or between the participants stratified by surgical experience (p = 0.58). Finally, the participants were provided a comprehensive list of possible elements to incorporate into a standardized pancreatic and hepatobiliary SOR. After the exclusion of elements with less than 75% agreement, the pancreatic SORs included 17 (57%) of 30 possible elements, and the hepatobiliary SORs included 19 (76%) of 25 possible elements. CONCLUSION: Broad consensus on several elements of the HPB SOR suggests that uptake should be accelerated in HPB surgery.

10 years, 100 robotic major hepatectomies: a single-center experience.

INTRODUCTION: Adoption of robotic liver resections has been gradually increasing throughout the HPB surgical community over the past decade. Currently there is limited literature which demonstrates a significant benefit of robotic surgery for major hepatectomies over open or laparoscopic. As one of the first centers to develop a robotic HPB program, we have experienced improved outcomes over time with increasing utilization of robotics. Herein, we present our 10-year experience and outcomes for major robotic liver resections. METHODS: From 2012 to 2022, 361 robotic liver procedures were performed, including 100 major hepatectomies. A retrospective data review of the electronic medical record was performed evaluating outcomes after robotic major hepatectomy. Outcomes for the first 50 cases (Group A) and second 50 cases (Group B) were compared to identify any improvements in practice. Demographic and clinical outcome variables were analyzed. Data were assessed for normality, and Wilcoxon rank-sum, χ2 tests, and a logistic regression model were performed appropriate for the data. Stata v.17 was utilized, and significance was set as p < .05. RESULTS: There was no difference in median operative time (258 vs 256 min), EBL (500 vs 500 mL), median LOS (5 vs 3.5 days), 90-day readmission (14% vs 24%), major complications (14% vs 20%), and 90-day mortality (6% vs 4%) between early and late cases, respectively. ICU admissions and conversion rates were significantly lower in group B (14.0% vs 48.0%), while expert level difficulty indices were higher (82% vs 58%). CONCLUSION: Development of a robotic liver program with good outcomes is feasible over time. Our data suggest that our institutional learning curve for robotic major hepatectomy plateaued at approximately 50 cases.

Advancing minimally invasive hepato-pancreato-biliary surgery: ensuring safety with implementation.

BACKGROUND: Although minimally invasive hepato-pancreato-biliary (MIS HPB) surgery can be performed with good outcomes, there are currently no standardized requirements for centers or surgeons who wish to implement MIS HPB surgery. The aim of this study was to create a consensus statement regarding safe dissemination and implementation of MIS HPB surgical programs. METHODS: Sixteen key questions regarding safety in MIS HPB surgery were generated after a focused literature search and iterative review by three field experts. Participants for the working group were then selected using sequential purposive sampling and snowball techniques. Review of the 16 questions took place over a single 2-h meeting. The senior author facilitated the session, and a modified nominal group technique was used. RESULTS: Twenty three surgeons were in attendance. All participants agreed or strongly agreed that formal guidelines should exist for both institutions and individual surgeons interested in implementing MIS HPB surgery and that routine monitoring and reporting of institutional and surgeon technical outcomes should be performed. Regarding volume cutoffs, most participants (91%) agreed or strongly agreed that a minimum annual institutional volume cutoff for complex MIS HPB surgery, such as major hepatectomy or pancreaticoduodenectomy, should exist. A smaller proportion (74%) agreed or strongly agreed that a minimum annual surgeon volume requirement should exist. The majority of participants agreed or strongly agreed that surgeons were responsible for defining (100%) and enforcing (78%) guidelines to ensure the overall safety of MIS HPB programs. Finally, formal MIS HPB training, minimum case volume requirements, institutional support and infrastructure, and mandatory collection of outcomes data were all recognized as important aspects of safe implementation of MIS HPB surgery. CONCLUSIONS: Safe implementation of MIS HPB surgery requires a thoughtful process that incorporates structured training, sufficient volume and expertise, a proper institutional ecosystem, and monitoring of outcomes.

Integrated control strategy for dual sludge ages in the high-concentration powder carrier bio-fluidized bed (HPB) technology: Enhancing municipal wastewater treatment efficiency.

The high-concentration powder carrier bio-fluidized bed (HPB) technology is an emerging approach that enables on-site upgrading of wastewater treatment plants (WWTPs). HPB technology promotes the formation of biofilm sludge with micron-scale composite powder carriers as the core and suspended sludge mainly composed of flocs surrounding the biofilm sludge. This study proposed a novel integrated strategy for assessing and controlling the sludge ages in suspended/bio-film activated sludge supported by micron-scale composite powder carrier. Utilizing the cyclone unit and the corresponding theoretical model, the proposed strategy effectively addresses the sludge ages contradiction between denitrifying bacteria and polyphosphate-accumulating organisms (PAOs), thereby enhancing the efficiency of municipal wastewater treatment. The sludge age of the suspended (25 d) and bio-film (99 d) sludge, calculated using the model, contribute to the simultaneous removal of nitrogen and phosphorus. Meanwhile, the model further estimates distinct contributions of suspended and bio-film sludge to chemical oxygen demand (COD) and total nitrogen (TN), which are 55% and 42% for COD, 20% and 57% for TN of suspended sludge and bio-film sludge, respectively. This suggests that the contribution of suspended sludge and bio-film sludge to COD and TN removal efficiency can be determined and controlled by the operational conditions of the cyclone unit. Additionally, the simulation values for COD, ammonia nitrogen (NH4+-N), TN and total phosphorus (TP) closely align with the actual values of WWTPs over 70 days (p < 0.001) with the correlation coefficients (R2) of 0.9809, 0.9932, 0.9825, and 0.837, respectively. These results support the theoretical foundation of HPB technology for simultaneous nitrogen and phosphorus removal in sewage treatment plants. Therefore, this model serves as a valuable tool to guide the operation, design, and carrier addition in HPB technology implementation.

Impact of Food Insecurity on Outcomes Following Resection of Hepatopancreaticobiliary Cancer.

INTRODUCTION: Food insecurity (FI) may predispose individuals to suboptimal nutrition, leading to chronic disease and poor health outcomes. We sought to assess the impact of county-level FI on postoperative outcomes among patients undergoing resection of hepatopancreaticobiliary (HPB) cancer. METHODS: Patients who were diagnosed with HPB cancer between 2010 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Data on annual county-level FI were obtained from the Feeding America: Mapping the Meal Gap report and were categorized into tertiles. Textbook outcome was defined as no extended length of stay, perioperative complications, 90-day readmission, and 90-day mortality. Multiple logistic regression and Cox regression models were used to assess outcomes and survival relative to FI. RESULTS: Among 49,882 patients (hepatocellular: n = 11,937, 23.9%; intrahepatic cholangiocarcinoma: n = 2111, 4.2%; extrahepatic cholangiocarcinoma: n = 4047, 8.1%; gallbladder: n = 2853, 5.7%; pancreatic: n = 28,934, 58.0%), 6702 (13.4%) patients underwent a surgical resection. Median age was 75 years (interquartile range 69-82), and most patients were male (n = 25,767, 51.7%) and self-identified as White (n = 36,381, 72.9%). Overall, 5291 (10.6%) and 39,664 (79.5%) individuals resided in low or moderate FI counties, respectively, while 4927 (9.8%) patients resided in high FI counties. Achievement of textbook outcome (TO) was 56.3% (n = 6702). After adjusting for competing risk factors, patients residing in high FI counties had lower odds to achieve a TO versus individuals living in low FI counties (odds ratio 0.69, 95% confidence interval [CI] 0.54-0.88, p = 0.003). In addition, patients residing in moderate and high FI counties had a greater risk of mortality at 1- (referent, low, moderate: hazard ratio [HR] 1.09, 95% CI 1.05-1.14; high: HR 1.14, 95% CI 1.08-1.21), 3- (referent, low, moderate: HR 1.09, 95% CI 1.05-1.14; high: HR 1.14, 95% CI 1.08-1.21), and 5- (referent, low, moderate: HR 1.05, 95% CI 1.01-1.09; high: HR 1.07, 95% CI 1.02-1.13) years versus individuals from low FI counties. CONCLUSIONS: FI was associated with adverse perioperative outcomes and long-term survival following resection of an HPB malignancy. Interventions directed towards mitigating nutritional inequities are needed to improve outcomes among vulnerable HPB populations.

The essential requirements for an HPB centre to deliver high-quality outcomes.

The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in 'virtual' HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre's beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of "centre of reference" limited to actual, as opposed to virtual, centres.

Unmet needs in the treatment of intrahepatic cholangiocarcinoma harboring FGFR2 gene rearrangements.

Intrahepatic cholangiocarcinoma, a malignancy of the intrahepatic bile ducts, is the second most common primary liver malignancy and has been rising in incidence over the past several decades. Given its poor prognosis and diagnosis at a late stage, novel therapies are urgently needed to improve outcomes. Intrahepatic cholangiocarcinoma harbors a high rate of targetable mutations, spurring an increased interest in drug development in this disease. FGFR2 gene rearrangements occur in approximately 10-16% of these tumors and this underscores the importance of next generation sequencing in this population. There are now several FGFR inhibitors in development, and these agents may help improve outcomes for these patients. However, both primary and secondary resistance remain a challenge.

Intrahepatic cholangiocarcinoma is a type of cancer that occurs in the liver. This type of cancer is becoming increasingly common over the past several decades. New types of treatments are urgently needed to improve outcomes in this disease. Intrahepatic cholangiocarcinomas often have changes in their genetic makeup that may be used to help treat the disease. Changes in the FGFR2 occur in 10­16% of these tumors. There are now several US FDA approved medications that can help target this change in the tumor. However, these drugs may lose effectiveness after several months as the tumor may become resistant to the medication. There are new drugs currently in development that may be able to overcome this problem.

Role of laparoscopy in the immediate, intermediate, and long-term management of iatrogenic bile duct injuries during laparoscopic cholecystectomy.

PURPOSE: Bile duct injuries (BDI) during a laparoscopic cholecystectomy still remain as one of the most feared complications in surgery. The use of laparoscopy for its management is a controversial subject of discussion. The purpose of this study is to assess the amount of possibilities that a laparoscopic approach allows in its resolution. METHODS: A retrospective analysis of all the patients diagnosed with BDI at our center was carried out. The analysis was made considering three different scenarios in which laparoscopy can be used: (1) intraoperative management of BDI; (2) postoperative management of bile peritonitis; (3) deferred treatment of BDI. RESULTS: We analyzed 22 patients in total who were divided into three groups according to the different scenarios proposed. In the first group, the applicability of laparoscopy was 45%, some complications occurred in two patients, and primary patency was obtained in seven. In the second group, four of them presented a grade III complication. In the third group, the applicability of laparoscopy was 13.6%. Only one patient presented a IIIa complication and primary patency was obtained in all of them. CONCLUSIONS: Laparoscopy plays a more important role in BDI management every day. This approach, in selected cases, is associated with good long-term results and perioperative advantages of a minimally invasive approach.

Retrospective observational study of patient outcomes with local wound infusion vs epidural analgesia after open hepato-pancreato-biliary surgery.

BACKGROUND: Epidural analgesia is conventionally used as the mainstay of analgesia in open abdominal surgery but has a small life-changing risk of complications (epidural abscesses or haematomas). Local wound-infusion could be a viable alternative and are associated with fewer adverse effects. METHODS: A retrospective observational analysis of individuals undergoing open hepato-pancreato-biliary surgery over 1 year was undertaken. Patients either received epidural analgesia (EP) or continuous wound infusion (WI) + IV patient controlled anaesthesisa (PCA) with an intraoperative spinal opiate. Outcomes analyzed included length of stay, commencement of oral diet and opioid use. RESULTS: Between Jan 2016- Dec 2016, 110 patients were analyzed (WI n=35, EP n=75). The median length of stay (days) was 8 in both the WI and EP group (p=0.846), the median time to commencing oral diet (days) was 3 in WI group and 2 in EP group (p=0.455). There was no significant difference in the amount of oromorph, codeine or tramadol (mg) between WI and EP groups (p=0.829, p=0.531, p=0.073, respectively). CONCLUSIONS: Continuous wound infusion + IV PCA provided adequate analgesia to patients undergoing open hepato-pancreato-biliary surgery. It was non-inferior to epidural analgesia with respect to hospital stay, commencement of oral diet and opioid use.

Polysorbates versus Hydroxypropyl Beta-Cyclodextrin (HPßCD): Comparative Study on Excipient Stability and Stabilization Benefits on Monoclonal Antibodies.

Polysorbates (PS 20 and PS 80) are the most widely used surfactants in biopharmaceutical formulations to protect proteins from denaturation, aggregation, and surface adsorption. To date, around 70% of marketed therapeutic antibodies contain either PS 20 or PS 80 in their formulations. However, polysorbates are chemically diverse mixtures, which are prone to degradation by oxidation and hydrolysis to produce peroxides and fatty acids, which, in turn, induce protein oxidation, aggregation, and insoluble particle formation. These will negatively impact protein quality and stability. Thus, polysorbate degradation has emerged as one of the major challenges in the development and commercialization of therapeutic protein products. KLEPTOSE® HPßCD (hydroxypropyl beta-cyclodextrin), a new multifunctional excipient, has been shown to provide protein stabilization functions in biopharmaceutical downstream processes and in their final formulations. This study aims to evaluate HPßCD, a new molecule of its class, against polysorbates as a stabilizer in biologics formulations. In this study, the chemical stability of KLEPTOSE® HPßCDs is compared with polysorbates (20 and 80) under various stress conditions. When subjected to heat stress, HPßCDs show little change in product recovery (90.7-100.7% recovery for different HPßCDs), while polysorbates 20 and 80 show significant degradation, with only 11.5% and 7.3% undegraded product remaining, respectively. When subjected to other chemical stressors, namely, autoclave, light, and oxidative stresses, HPßCD remains almost stable, while polysorbates show more severe degradation, with 95.5% to 98.8% remaining for polysorbate 20 and 85.5% to 97.4% remaining for polysorbate 80. Further, profiling characterization and degradation analysis reveal that chemical structures of HPßCDs remain intact, while polysorbates undergo significant hydrolytic degradation and oxidation. Lastly, the physicochemical stability of monoclonal antibodies in formulations is investigated. When subjected to light stress, adalimumab, as a model mAb, formulated in the presence of HPßCD, shows a significant decrease in protein aggregation, and superior monomer and total protein recovery compared to PS 80-containing formulations. HPßCD also reduces both agitation and thermal stress-induced protein aggregation and prevents subvisible particle formation compared to PS 80.

Hydroxylpropyl-ß-cyclodextrin as Potential Excipient to Prevent Stress-Induced Aggregation in Liquid Protein Formulations.

Due to the growing demand for patient-friendly subcutaneous dosage forms, the ability to increasing protein solubility and stability in formulations to deliver on the required high protein concentrations is crucial. A common approach to ensure protein solubility and stability in high concentration protein formulations is the addition of excipients such as sugars, amino acids, surfactants, approved by the Food and Drug Administration. In a best-case scenario, these excipients fulfil multiple demands simultaneously, such as increasing long-term stability of the formulation, reducing protein adsorption on surfaces/interfaces, and stabilizing the protein against thermal or mechanical stress. 2-Hydroxylpropyl-ß-cyclodextrin (derivative of ß-cyclodextrin) holds this potential, but has not yet been sufficiently investigated for use in protein formulations. Within this work, we have systematically investigated the relevant molecular interactions to identify the potential of Kleptose®HPB (2-hydroxylpropyl-ß-cyclodextrin from Roquette Freres, Lestrem, France) as "multirole" excipient within liquid protein formulations. Based on our results three factors determine the influence of Kleptose®HPB on protein formulation stability: (1) concentration of Kleptose®HPB, (2) protein type and protein concentration, and (3) quality of the protein formulation. Our results not only contribute to the understanding of the relevant interactions but also enable the target-oriented use of Kleptose®HPB within formulation design.

Clinical outcomes of hepato-pancreato-biliary surgical patients during COVID-19 pandemic.

OBJECTIVE: To determine the outcome of hepato-pancreato-biliary patients who were operated upon during the pandemic under a safety protocol devised to minimise the risk of coronavirus disease-2019 infection in patients and staff during the perioperative period. METHODS: The retrospective study was conducted at the Hepato-Pancreatico-Biliary (HPB) Unit of Bahria International Hospital Orchard, Lahore, Pakistan, in February 2021, and comprised data of all patients who were discussed in the multidisciplinary meeting of the Unit between May 1 and December 31, 2020. The coronavirus disease-2019 screening protocol was a negative polymerase chain reaction test just before admission and a second negative test 24-48 hours pre-surgery. All patients had computed tomography scan of chest to rule out atypical pneumonia due to coronavirus disease-2019 infection. Surgery was deferred for positive patients for at least 2 weeks until their test was negative. Surgeries were carried out with full personal protective equipment. Further testing was carried out if clinically indicated. Data was collected of 30-day coronavirus disease-2019-related morbidity and mortality. Data was analysed using SPSS 20. RESULTS: Of the 44 patients, 29(65.9%) were males and 15(34.1%) were females. Overall, 32(72.7%) patients were aged >40 years, 8(18.2%) were aged 20-40 years and 4(9%) were aged <20 years. Of the total, 7(15.09%) patients were found to be positive for coronavirus disease-2019 during preoperative screening. Among them, 5(71.4%) had successful surgery post-recovery, 1(14.3%) died without surgery due to pulmonary complications related to coronavirus disease-2019 and 1(14.3%) patient was lost to follow-up. Among the 42(95.5%) patients who underwent any procedure, 2(4.7%) patients turned positive for coronavirus disease-2019 in the postoperative period. There was 1(2.4%) mortality in the 30-day post-operative period which was not related to coronavirus disease-2019. Complications were seen in 5(11.90%) patients. Three (9.3%) out of 32 staff members were found to be asymptomatic carriers. CONCLUSIONS: Hepato-pancreatico-biliary surgery could be safely carried out during coronavirus disease-2019 pandemic if strict safety protocols were followed.

ERRγ ligand HPB2 upregulates BDNF-TrkB and enhances dopaminergic neuronal phenotype.

Brain derived neurotrophic factor (BDNF) promotes maturation of dopaminergic (DAergic) neurons in the midbrain and positively regulates their maintenance and outgrowth. Therefore, understanding the mechanisms regulating the BDNF signaling pathway in DAergic neurons may help discover potential therapeutic strategies for neuropsychological disorders associated with dysregulation of DAergic neurotransmission. Because estrogen-related receptor gamma (ERRγ) is highly expressed in both the fetal nervous system and adult brains during DAergic neuronal differentiation, and it is involved in regulating the DAergic neuronal phenotype, we asked in this study whether ERRγ ligand regulates BDNF signaling and subsequent DAergic neuronal phenotype. Based on the X-ray crystal structures of the ligand binding domain of ERRγ, we designed and synthesized the ERRγ agonist, (E)-4-hydroxy-N'-(4-(phenylethynyl)benzylidene)benzohydrazide (HPB2) (Kd value, 8.35 µmol/L). HPB2 increased BDNF mRNA and protein levels, and enhanced the expression of the BDNF receptor tropomyosin receptor kinase B (TrkB) in human neuroblastoma SH-SY5Y, differentiated Lund human mesencephalic (LUHMES) cells, and primary ventral mesencephalic (VM) neurons. HPB2-induced upregulation of BDNF was attenuated by GSK5182, an antagonist of ERRγ, and siRNA-mediated ERRγ silencing. HPB2-induced activation of extracellular-signal-regulated kinase (ERK) and phosphorylation of cAMP-response element binding protein (CREB) was responsible for BDNF upregulation in SH-SY5Y cells. HPB2 enhanced the DAergic neuronal phenotype, namely upregulation of tyrosine hydroxylase (TH) and DA transporter (DAT) with neurite outgrowth, both in SH-SY5Y and primary VM neurons, which was interfered by the inhibition of BDNF-TrkB signaling, ERRγ knockdown, or blockade of ERK activation. HPB2 also upregulated BDNF and TH in the striatum and induced neurite elongation in the substantia nigra of mice brain. In conclusion, ERRγ activation regulated BDNF expression and the subsequent DAergic neuronal phenotype in neuronal cells. Our results might provide new insights into the mechanism underlying the regulation of BDNF expression, leading to novel therapeutic strategies for neuropsychological disorders associated with DAergic dysregulation.

Use of Erector Spinae Fascial Plane Blocks in Enhanced Recovery for Open Abdominal Surgery.

BACKGROUND: Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery. MATERIALS AND METHODS: This retrospective analysis compared historical controls of ERAS patients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared. RESULTS: Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P< 0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019). CONCLUSIONS: ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery.

Planned surgery in the COVID-19 pandemic: a prospective cohort study from Nottingham.

PURPOSE: Globally planned surgical procedures have been deferred during the current COVID-19 pandemic. The study aimed to report the outcomes of planned urgent and cancer cases during the current pandemic using a multi-disciplinary prioritisation group. METHODS: A prospective cohort study of patients having urgent or cancer surgery at a NHS Trust from 1st March to 30th April 2020 who had been prioritised by a multi-disciplinary COVID Surgery group. Rates of post-operative PCR positive and suspected COVID-19 infections within 30 days, 30-day mortality and any death related to COVID-19 are reported. RESULTS: Overall 597 patients underwent surgery with a median age of 65 years (interquartile range (IQR) 54-74 years). Of these, 86.1% (514/597) had a current cancer diagnosis. During the period, 60.8% (363/597) of patients had surgery at the NHS Trust whilst 39.2% (234/597) had surgery at Independent Sector hospitals. The incidence of COVID-19 in the East Midlands was 193.7 per 100,000 population during the study period. In the 30 days following surgery, 1.3% (8/597) of patients tested positive for COVID-19 with all cases at the NHS site. Overall 30-day mortality was 0.7% (4/597). Following a PCR positive COVID-19 diagnosis, mortality was 25.0% (2/8). Including both PCR positive and suspected cases, 3.0% (18/597) developed COVID-19 infection with 1.3% at the independent site compared to 4.1% at the NHS Trust (p=0.047). CONCLUSIONS: Rates of COVID-19 infection in the post-operative period were low especially in the Independent Sector site. Mortality following a post-operative diagnosis of COVID-19 was high.

Electrochemical investigations for COVID-19 detection-A comparison with other viral detection methods.

Virus-induced infection such as SARS-CoV-2 is a serious threat to human health and the economic setback of the world. Continued advances in the development of technologies are required before the viruses undergo mutation. The low concentration of viruses in environmental samples makes the detection extremely challenging; simple, accurate and rapid detection methods are in urgent need. Of all the analytical techniques, electrochemical methods have the established capabilities to address the issues. Particularly, the integration of nanotechnology would allow miniature devices to be made available at the point-of-care. This review outlines the capabilities of electrochemical methods in conjunction with nanotechnology for the detection of SARS-CoV-2. Future directions and challenges of the electrochemical biosensors for pathogen detection are covered including wearable and conformal biosensors, detection of plant pathogens, multiplexed detection, and reusable biosensors for on-site monitoring, thereby providing low-cost and disposable biosensors.

Preoperative adiposity at bioimpedance vector analysis improves the ability of Fistula Risk Score (FRS) in predicting pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Anthropometric parameters have been associated with increased risk of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Nonetheless, conventional metrics to predict POPF do not include the assessment of body composition. We aimed to validate the most used Fistula Risk Score (FRS), and to assess whether the appraisal of adipose compartment at bioimpedance vector analysis (BIVA) improves the accuracy of FRS in CR-POPF prediction. METHOD: PD patients from 3 Italian academic institutions were prospectively included over a 2-year period. Patients with ASA score ≥3, heart failure, chronic kidney disease, or compartmentalized fluid collections were excluded. BIVA was performed on the day prior to surgery. CR-POPF occurrence and severity were classified per the ISGPS classification. RESULTS: Out of 148 PDs, 84 patients (56.8%) had pancreatic cancer, and 29 (19.6%) experienced CR-POPF. FRS elements, namely soft pancreatic texture (p = 0.009), small pancreatic duct diameter (p = 0.029), but not blood loss (p = 0.450), as well as high BMI (p = 0.004) were associated with CR-POPF. Also, the preoperative fat mass (FM) amount measured at BIVA was significantly higher in patients who developed CR-POPF, compared to those who did not (median FM = 19.4 kg/m2 vs. 14.4 kg/m2, respectively; p = 0.005). The predictive ability of a multivariate model adding FM to the FRS, assessed at the receiver operating characteristics curve showed a higher accuracy than the FRS alone (AUC = 0.774 and AUC = 0.738, respectively). CONCLUSIONS: Assessment of preoperative FM at BIVA can improve the accuracy of FRS in predicting CR-POPF following pancreatoduodenectomy.

Negative-pressure wound therapy does not reduce superficial SSI in pancreatectomy and hepatectomy procedures.

INTRODUCTION: Surgical site infections (SSIs) lead to increased morbidity and cost. Negative-pressure wound therapy (NPWT) removes wound exudate and improves local blood flow, but its effect on SSI is unproven following hepatectomy and pancreatectomy. The aim of this trial was to evaluate the effect of NPWT on SSI in this population. METHODS: Patients were randomized to incisional NPWT or sterile island dressing following surgery. SSI predictive factors were recorded as well as patient comorbidities. Wound complications and type of SSI were recorded prospectively. RESULTS: Forty patients received the standardized perioperative bundle. Twenty patients received sterile island: 11 hepatic and 9 pancreatic resections; 20 patients received NPWT: 11 hepatic and 9 pancreatic resections; 23 patients were male; mean age 60.8 years (SD ±10.3); mean BMI 31.7 (SD ±7.0). There were three incisional wound infections: two with sterile island, one with NPWT; six organ space infections: four sterile island and two NPWT. There were no significant differences in SSI rates between groups (P = .57). CONCLUSION: NPWT does not improve SSI rates over simple sterile dressing following hepatectomy or pancreatectomy. Improvements in SSI must be directed toward organ-space infections, which are unaffected by NPWT.

Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum.

BACKGROUND: Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons. METHODS: In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds. RESULTS: Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training. CONCLUSIONS: Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.