25 research outputs found
Mo1264 - The International Study Group of Pancreatic Surgery Grade B/C Delayed Gastric Emptying in Robot-Assisted Pancreaticoduodenectomy: Analysis of Predictive Factors and Impact of Learning Curve
No full textRobotic-Assisted Pancreatic Resections
No full textBackground: Robotic assistance enhances surgical dexterity and could facilitate wider adoption of laparoscopy for pancreatic resections (PR). Methods: Data were prospectively entered into a database and analyzed retrospectively to assess feasibility and safety of robotic-assisted PR (RAPR). Additionally, robotic-assisted pancreaticoduodenectomy (RAPD) was compared to a contemporary group of open pancreaticoduodenectomies (OPD). Results: Between October 2008 and October 2014, 200 consecutive patients underwent RAPR. Three procedures were converted to open surgery (1.5 %), despite 14 patients required associated vascular procedures. RAPD was performed in 83 patients (41.5 %), distal pancreatectomy in 83 (41.5 %), total pancreatectomy in 17 (8.5 %), tumor enucleation in 12 (6 %), and central pancreatectomy in 5 (2.5 %). Thirty-day and 90-day mortality rates were 0.5 and 1 %, respectively. Both deaths occurred after RAPD with vein resection. Complications occurred in 63.0 % of the patients (≥Clavien-Dindo grade IIIb in 4 %). Median comprehensive complication index was 20.9 (0-26.2). Incidence of grade B/C pancreatic fistula was 28.0 %. Reoperation was required in 14 patients (7.0 %). The risk of reoperation decreased after post-operative day 20 (OR 0.072) (p = 0.0015). When compared to OPD, RAPD was associated with longer mean operative time (527.2 ± 166.1 vs. 425.3 ± 92.7; <0.0001) but had an equivalent safety profile. The median number of examined lymph nodes (37; 28.8–45.3 vs. 36; 28–52.8) and the rate of margin positivity in patients diagnosed with pancreatic cancer were also similar (12.5 vs. 45.5 %). Conclusions: RAPR, including RAPD, are safely feasible in selected patients. The results of RAPD in pancreatic cancer are encouraging but deserve further investigation
Robotic versus open pancreatoduodenectomy: a propensity score-matched analysis based on factors predictive of postoperative pancreatic fistula
No full textBackground: Improvement in morbidity of pancreatoduodenectomy (PD) largely depends on the reduction in the incidence of clinically relevant (CR) postoperative pancreatic fistula (POPF). Methods: After internal validation of the clinical risk score (CRS) of POPF, and identification of other predictive factors for POPF, robotic (RPD), and open (OPD) PDs were stratified into risk categories and matched by propensity scores. The primary endpoint of this study was incidence of CR-POPF. Secondary endpoints were 90-day morbidity and mortality, and sample size calculation for randomized controlled trials (RCT). Results: No patient undergoing RPD was classified at negligible risk for POPF, and no CR-POPF occurred in 7 RPD at low risk. The matching process identified 48 and 11 pairs at intermediate and high risk for POPF, respectively. In the intermediate-risk group, RPD was associated with higher rates of CR-POPF (31.3% vs 12.5%) (p = 0.0026), with equivalent incidence of grade C POPF. In the high-risk group, CR-POPF occurred frequently, but in similar percentages, after either procedures. Starting from an unadjusted point estimate of the effect size of 1.71 (0.91-3.21), the pair-matched odds ratio for CR-POPF after RPD was 2.80 (1.01-7.78) for the intermediate-risk group, and 0.20 (0.01-4.17) for the high-risk group. Overall morbidity and mortality were equivalent in matched study groups. Sample size calculation for a non-inferiority RCT demonstrated that a total of 31,669 PDs would be required to randomize 682 patients at intermediate risk and 1852 patients at high risk. Conclusions: In patients at intermediate risk, RPD is associated with higher rates of CR-POPF. Incidence of grade C POPF is similar in RPD and OPD, making overall morbidity and mortality also equivalent. A RCT, with risk stratification for POPF, would require an enormous number of patients. Implementation of an international registry could be the next step in the assessment of RPD
Acute abdomen caused by greater omentum torsion: A case report and review of the literature. Omentum majus torsiyonunun neden olduğu akut batın: Olgu raporu ve literatürün gözden geçirilmesi
No full textTorsion of the greater omentum is a rare cause of acute abdomen. Based on etiopathogenesis, it can be classified as primary or secondary. However, regardless of the cause, segmentary or diffuse omental necrosis will follow. Preoperative diagnosis is not easy, though abdominal ultrasound and computed tomography (CT) scans may show peculiar features suggestive of omental torsion. Laparoscopic resection of the affected omentum is the treatment of choice. Presently reported was a case of primary omental torsion, in addition to a comprehensive literature review
Induction and Immunosuppressive Management of Pancreas Transplant Recipients
No full textBackground: Despite improved overall outcomes, rejection continues to occur frequently after pancreas transplantation.
Objective: To review the literature and to provide a state-of-the-art assessment of current practice and developments of immunosuppressive regimens in pancreas transplantation.
Methods: The literature was reviewed and relevant articles were retrieved and analyzed.
Results: Induction therapy is used in approximately 90% of the transplants, with T-cell depleting antibodies being the prevalent therapy (>90%). Despite the initial enthusiasm on steroid-free regimens, maintenance protocols continue to be mostly based on a combination of steroids, tacrolimus, and mycophenolate mofetil. Tacrolimus is used in the majority of recipients. Sirolimus is rarely used at the time of transplant and is introduced later on in approximately 10% of the recipients, mostly in the context of a switching strategy to address the side effects of calcineurin inhibitors. The overall quality of published studies was quite low, because of the retrospective design, the heterogeneity of study groups with respect to PTx categories, the inclusion of mixed recipient categories with respect to immunologic risk profile, and the use of non-standardized concurrent immunosuppressive therapies. In addition, most reported studies were clearly underpowered, and treatment outcomes were not standardized.
Conclusion: Since approximately two decades, immunosuppression in pancreas transplantation mostly consists of induction with depleting antibodies and maintenance therapy using a combination of steroids, tacrolimus, and mycophenolate mofetil. While true novelty would be very much needed, this review confirms the wide use and the clinical efficacy of this regimen
Robot-assisted spleen preserving distal pancreatectomy: case report
No full textA 28-year-old female patient was incidentally diagnosed with a unilocular pancreatic cystic lesion
located in the body-tail of the pancreas. Findings at contrast-enhanced computed tomography scan and
magnetic resonance were both consistent with the diagnosis of mucinous cystadenoma. The patient was then
scheduled for a robot-assisted distal pancreatectomy with preservation of the spleen and the splenic vessels.
The procedure was completed safely in 255 minutes with minimal blood loss. The post-operative course was
uneventful and the patient was discharged on post-operative day 6. Final pathology confirmed the diagnosis
of mucinous cystadenoma. In the video presented herein we show the technique for robot-assisted distal
pancreatectomy with preservation of the spleen and the splenic vessels
EFFETTI DELLA RADIOCHEMIOTERAPIA PREOPERATORIA SUL NUMERO DI LINFONODI ASPORTATI IN CHIRURGIA PER CARCINOMA DEL RETTO EXTRAPERITONEALE. ANALISI RETROSPETTIVA DI 123 PAZIENTI
No full textObiettivi: in chirurgia colo-rettale un numero adeguato di linfonodi asportati fornisce un’accurata stadiazione del tumore e garantisce un miglior controllo locale della malattia. Tuttavia, in caso di tumori del retto extra-peritoneale, l’utilizzo di radio-chemioterapia preoperatoria (RCT) può avere un impatto sul numero di linfonodi reperiti nel pezzo operatorio. Questo studio si pone l’obbiettivo di verificare l’effetto che la RCT neoadiuvante ha sul numero di linfonodi raccolti nel campione operatorio dopo chirurgia per cancro del retto extraperitoneale.
Materiali e metodi: sono stati raccolti i dati di una serie consecutiva di 123 pazienti sottoposti a chirurgia per carcinoma del retto extraperitoneale. 64 pazienti (52%, gruppo A, età media 66 anni) sono stati sottoposti a RCT peoperatoria e 59 (48%, gruppo B, età media 70 anni) direttamente condotti ad intervento chirurgico. La strategia chirurgica comprendeva resezione anteriore
del retto o amputazione addomino-perineale sec. Miles, entrambe inclusive di escissione totale del mesoretto (TME). In 66 pazienti (54% del totale) l’intervento è stato eseguito laparoscopicamente. I due gruppi non differiscono per età, sesso, BMI, comorbidità, e grading tumorale. La distribuzione dello staging tumorale risulta invece differente tra i due gruppi, con una prevalenza di pazienti con stadio T3 nel gruppo B (p<0.05).
Risultati: complessivamente, il numero medio di linfonodi asportati è stato di 22 (range 1-71). Il numero di linfonodi raccolti
risulta correlare significativamente con la lunghezza del pezzo operatorio (p<0.001). Nei pazienti sottoposti a RCT preoperatoria
il numero medio di linfonodi reperiti nello specimen è risultato inferiore rispetto ai pazienti che erano stati direttamente operati
(20 vs 23), con una differenza tuttavia non significativa (p=0,34). Nel 78% dei pazienti del gruppo A e nel 80 % dei pazienti del
gruppo B, la linfoadenectomia è da ritenersi adeguata secondo le attuali linee guida (12 o più linfonodi esaminati nel campione;
p=ns). Relativamente a LNR(lymph nodes ratio), la differenza tra i due gruppi non è risultata significativa. Il sesso maschile (p=0.01), e un più basso stadio tumorale (p=0.03) sono invece risultati significativamente associati ad un più basso numero di linfonodi reperiti nel campione operatorio. Età, grading tumorale, tipo di procedura e approccio chirurgico sono risultati i ininfluenti sul numero dei linfonodi reperiti.
Conclusioni: la RCT preoperatoria sembra ridurre il numero di linfonodi reperiti nel campione operatorio dei pazienti sottoposti
a chirurgia per cancro del retto extraperitoneale sebbene questo studio non abbia dimostrato un impatto statisticamente
significativo. La valutazione alla aderenza alle linee guida relative alla adeguatezza del numero di linfonodi asportati deve tuttavia tener conto degli effetti della RCT preoperatoria
Indications, technique, and results of robotic pancreatoduodenectomy
No full textRobotic assistance improves surgical dexterity in minimally invasive operations, especially when fine dissection and multiple sutures are required. As such, robotic assistance could be rewarding in the setting of robotic pancreatoduodenectomy (RPD). RPD was implemented at a high volume center with preemptive experience in advanced laparoscopy. Indications, surgical technique, and results of RPD are discussed against the background of current literature. RPD was performed in 112 consecutive patients. Conversion to open surgery was required in three patients, despite nine required segmental resection and reconstruction of the superior mesenteric/portal vein. No patient was converted to laparoscopy. A pancreato-jejunostomy was created in 106 patients (94.6 %), using either a duct-to-mucosa (n = 82; 73.2 %) or an invaginating (n = 24; 21.4 %) technique. Pancreato-gastrostomy was performed in one patient, the pancreatic duct was occluded in two patients, and a pancreatico-cutaneous fistula was created in three patients. Mean operative time was 526.3 ± 102.4 in the entire cohort and reduced significantly over the course of time. Experience was also associated with reduced rates of delayed gastric emptying and increased proportion of malignant tumor histology. Ninety day mortality was 3.6 %. Postoperative complications occurred in 83 patients (74.1 %) with a median comprehensive complication index of 20.9 (0–30.8). Clinically relevant pancreatic fistula occurred in 19.6 % of the patients. No grade C pancreatic fistula was noted in the last 72 consecutive patients. RPD is safely feasible in selected patients. Implementation of RPD requires sound experience with open pancreatoduodenectomy and advanced laparoscopic procedures, as well as specific training with the robotic platform
Robot-assisted spleen preserving distal pancreatectomy (RA-SPDP): a single center experience
No full textAim: To define the outcome of robot-assisted spleen preserving distal pancreatectomy (RA-SPDP) in a highvolume
center.
Methods: A retrospective analysis of a prospectively maintained database was performed to identify RA-SPDP
performed at our Center between April 2008 to October 2017.
Results: During the study period, RA-SPDP was attempted in 54 patients. The spleen was preserved, always
along with the splenic vessels (Kimura procedure), in 52 patients (96.3%). There were no conversions to open
or laparoscopic surgery. Mean operative time was 260 min (231.3-360.0). Grade B post-operative pancreatic
fistula (POPF) occurred in 19 patients (35.2%). There were no grade C POPF. Two patients required repeat surgery
because of postoperative bleeding and splenic infarction, respectively. There were no post-operative deaths at
90 days. Excluding one patient with known diagnosis of metastasis from renal cell carcinoma, malignancy was
eventually identified in 7 of 53 patients (13.2%).
Conclusion: In the hands of dedicated pancreatic surgeons, robotic assistance results in a high rate of spleen
preservation with good clinical outcomes. Despite careful preoperative selection, several patients can be found to have a malignant tumor. Taken altogether these results suggest that patients requiring these procedures should be preferentially referred to specialized centers
