Robot-assisted versus laparoscopic pancreatoduodenectomy: a pan-European multicenter propensity-matched study.

BACKGROUND: The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This study aimed to compare outcomes after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy in a pan-European cohort. METHODS: An international multicenter retrospective study including patients after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy from 50 centers in 12 European countries (2009-2020). Propensity score matching was performed in a 1:1 ratio. The primary outcome was major morbidity (Clavien-Dindo ≥III). RESULTS: Among 2,082 patients undergoing minimally invasive pancreatoduodenectomy, 1,006 underwent robot-assisted pancreatoduodenectomy and 1,076 laparoscopic pancreatoduodenectomy. After matching 812 versus 812 patients, the rates of major morbidity (31.9% vs 29.6%; P = .347) and 30-day/in-hospital mortality (4.3% vs 4.6%; P = .904) did not differ significantly between robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy, respectively. Robot-assisted pancreatoduodenectomy was associated with a lower conversion rate (6.7% vs 18.0%; P < .001) and higher lymph node retrieval (16 vs 14; P = .003). Laparoscopic pancreatoduodenectomy was associated with shorter operation time (446 minutes versus 400 minutes; P < .001), and lower rates of postoperative pancreatic fistula grade B/C (19.0% vs 11.7%; P < .001), delayed gastric emptying grade B/C (21.4% vs 7.4%; P < .001), and a higher R0-resection rate (73.2% vs 84.4%; P < .001). CONCLUSION: This European multicenter study found no differences in overall major morbidity and 30-day/in-hospital mortality after robot-assisted pancreatoduodenectomy compared with laparoscopic pancreatoduodenectomy. Further, laparoscopic pancreatoduodenectomy was associated with a lower rate of postoperative pancreatic fistula, delayed gastric emptying, wound infection, shorter length of stay, and a higher R0 resection rate than robot-assisted pancreatoduodenectomy. In contrast, robot-assisted pancreatoduodenectomy was associated with a lower conversion rate and a higher number of retrieved lymph nodes as compared with laparoscopic pancreatoduodenectomy.

Brain and cancer associated binding domain mutations provide insight into CTCF's relationship with chromatin and its ability to act as a chromatin organizer.

Although only a fraction of CTCF motifs are bound in any cell type, and few occupied sites overlap cohesin, the mechanisms underlying cell-type specific attachment and ability to function as a chromatin organizer remain unknown. To investigate the relationship between CTCF and chromatin we applied a combination of imaging, structural and molecular approaches, using a series of brain and cancer associated CTCF mutations that act as CTCF perturbations. We demonstrate that binding and the functional impact of WT and mutant CTCF depend not only on the unique binding properties of each protein, but also on the genomic context of bound sites and enrichment of motifs for expressed TFs abutting these sites. Our studies also highlight the reciprocal relationship between CTCF and chromatin, demonstrating that the unique binding properties of WT and mutant proteins have a distinct impact on accessibility, TF binding, cohesin overlap, chromatin interactivity and gene expression programs, providing insight into their cancer and brain related effects.

Robotic surgery for inguinal and ventral hernia repair: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis assessed the effectiveness of robotic surgery compared to laparoscopy or open surgery for inguinal (IHR) and ventral (VHR) hernia repair. METHODS: PubMed and EMBASE were searched up to July 2022. Meta-analyses were performed for postoperative complications, surgical site infections (SSI), seroma/hematoma, hernia recurrence, operating time (OT), intraoperative blood loss, intraoperative bowel injury, conversion to open surgery, length of stay (LOS), mortality, reoperation rate, readmission rate, use of opioids, time to return to work and time to return to normal activities. RESULTS: Overall, 64 studies were selected and 58 were used for pooled data analyses: 35 studies (227 242 patients) deal with IHR and 32 (158 384 patients) with VHR. Robotic IHR was associated with lower hernia recurrence (OR 0.54; 95%CI 0.29, 0.99; I2: 0%) compared to laparoscopic IHR, and lower use of opioids compared to open IHR (OR 0.46; 95%CI 0.25, 0.84; I2: 55.8%). Robotic VHR was associated with lower bowel injuries (OR 0.59; 95%CI 0.42, 0.85; I2: 0%) and less conversions to open surgery (OR 0.51; 95%CI 0.43, 0.60; I2: 0%) compared to laparoscopy. Compared to open surgery, robotic VHR was associated with lower postoperative complications (OR 0.61; 95%CI 0.39, 0.96; I2: 68%), less SSI (OR 0.47; 95%CI 0.31, 0.72; I2: 0%), less intraoperative blood loss (- 95 mL), shorter LOS (- 3.4 day), and less hospital readmissions (OR 0.66; 95%CI 0.44, 0.99; I2: 24.7%). However, both robotic IHR and VHR were associated with significantly longer OT compared to laparoscopy and open surgery. CONCLUSION: These results support robotic surgery as a safe, effective, and viable alternative for IHR and VHR as it can brings several intraoperative and postoperative advantages over laparoscopy and open surgery.

Use and outcome of minimally invasive pancreatic surgery in the European E-MIPS registry.

BACKGROUND: The European registry for minimally invasive pancreatic surgery (E-MIPS) collects data on laparoscopic and robotic MIPS in low- and high-volume centers across Europe. METHODS: Analysis of the first year (2019) of the E-MIPS registry, including minimally invasive distal pancreatectomy (MIDP) and minimally invasive pancreatoduodenectomy (MIPD). Primary outcome was 90-day mortality. RESULTS: Overall, 959 patients from 54 centers in 15 countries were included, 558 patients underwent MIDP and 401 patients MIPD. Median volume of MIDP was 10 (7-20) and 9 (2-20) for MIPD. Median use of MIDP was 56.0% (IQR 39.0-77.3%) and median use of MIPD 27.7% (IQR 9.7-45.3%). MIDP was mostly performed laparoscopic (401/558, 71.9%) and MIPD mostly robotic (234/401, 58.3%). MIPD was performed in 50/54 (89.3%) centers, of which 15/50 (30.0%) performed ≥20 MIPD annually. This was 30/54 (55.6%) centers and 13/30 (43%) centers for MIPD respectively. Conversion rate was 10.9% for MIDP and 8.4% for MIPD. Overall 90 day mortality was 1.1% (n = 6) for MIDP and 3.7% (n = 15) for MIPD. CONCLUSION: Within the E-MIPS registry, MIDP is performed in about half of all patients, mostly using laparoscopy. MIPD is performed in about a quarter of patients, slightly more often using the robotic approach. A minority of centers met the Miami guideline volume criteria for MIPD.

Robotic Right Posterior Sectionectomy by Intrafascial Approach for Pancreas Neuroendocrine Liver Metastasis.

BACKGROUND: Liver resection is indicated for resectable liver metastases of neuroendocrine tumors.1 Minimally invasive liver resection offers decreased blood loss, reduces pain, reduces postoperative complications, and reduces time to functional recovery.2 However, access to posterior section remains difficult with conventional laparoscopic tools. The robotic approach could overcome these limitations. PATIENTS AND METHODS: A 46-year-old woman had a pancreatic neuroendocrine tumor with synchronous liver metastases (18 mm in segment 6, 29 mm in segment 7, and 31 mm in segment 8). Due to stable disease after 2 years of somatostatin analog treatment, surgical management was decided. The first step was robotic distal pancreatectomy. Two months later, we performed a posterior sectionectomy associated with a wedge resection in segment 8. RESULTS: Da Vinci X robot was used. Surgery was conducted with a second surgeon located between the patient's legs using suction/irrigation device and ultrasonic dissector through laparoscopic ports. The posterior sectorial branches of the hepatic artery and portal vein were controlled via an intra-fascial approach. Robotic parenchymal dissection was performed by a four-hands method,3 with laparoscopic ultrasonic dissector and robotic irrigated bipolar guided by indocyanine green. Transection was led on the right side of right hepatic vein without clamping. Operative duration was 330 min, and estimated blood loss was 50 ml. Postoperative course was complicated by grade B biliary fistula. The patient was discharged on postoperative day 10. CONCLUSIONS: This case illustrates the feasibility and safety of a robotic approach for right posterior liver sectionectomy, which can improve the dexterity of the surgeon and thus the possibility of difficult minimally invasive liver resection.

Ambulatory colectomy for cancer: Results from a prospective bicentric study of 177 patients.

BACKGROUND: The implementation of an Enhanced Recovery After Surgery programme after colectomy reduces postoperative morbidity and shortens the length of hospital stay. OBJECTIVE: To evaluate the short and midterm outcomes of ambulatory colectomy for cancer. METHODS: This was a two-centre, observational study of a database maintained prospectively between 2013 and 2021. Short-term outcome measures were complications, admissions, unplanned consultations and readmission rates. Midterm outcome measures were the delay between surgery and initiation of adjuvant chemotherapy, length of disease-free survival and 2-year disease-free survival rate. RESULTS: A total of 177 patients were included. The overall morbidity rate was 15% and the mortality rate was 0%. The admission rate was 13% and 11% patients left hospital within 24 h of surgery. The readmission rate was 9% and all readmissions occurred before postoperative Day 4. Eight patients underwent repeat surgery because of anastomotic fistula (n = 7) or anastomotic ileocolic bleeding (n = 1). These patients had an uneventful recovery. Sixty-one patients required adjuvant chemotherapy with a median delay between surgery and chemotherapy initiation of 35 days. CONCLUSIONS: Ambulatory colectomy for cancer is feasible and safe. Adjuvant chemotherapy could be initiated before 6 weeks postsurgery. The ambulatory approach may be a step forward to further improve morbidity and oncologic prognosis.

Robotic Left Hepatectomy Extended to Caudate Lobe and Common Biliary Duct for Hilar Cholangiocarcinoma.

BACKGROUND: The safety and efficiency of minimally invasive approaches for liver resection have been confirmed (Wakabayashi in Ann Surg, 2015). However, laparoscopy suffers from several limitations due to technical difficulties, particularly for difficult hepatectomy with lymphadenectomy, biliary, and vascular reconstruction. Robotic assets could improve accessibility for difficult liver resections (Liu in World J Gastroenterol 25: 1432-1444), (Chou in Zhonghua Wai Ke Za Zhi 58: 230-234, 2020). PATIENTS AND METHODS: A 56-year-old woman was treated for a hilar cholangiocarcinoma, Bismuth 3b. RESULTS: A robotic anatomical left hepatectomy extended to caudate lobe and common biliary duct was decided. A Da Vinci X robot was used. The procedure was performed with a second surgeon positioned between the patient's legs. Left hepatectomy was extended to common biliary duct and caudate lobe. A four-hands parenchymal dissection (Camerlo in J Robot Surg, 2020) was performed with laparoscopic ultrasonic dissector and robotic irrigated bipolar, guided by indocyanine green. Axis of deep transection line was maintained using the EndoWrist function and exposure with a fourth arm. No pedicle clamping was necessary. Segment 1 was released with a mediocaudal approach. Lateral portal vein resection was performed after parenchymal transection was completed. Hepaticojejunostomy was done separately to the right anterior and posterior biliary duct. Operation time was 420 min, and estimated blood loss was 100 ml. The postoperative course was uneventful. The patient was discharged on postoperative day 8. Pathological findings revealed a 15-mm hilar cholangiocarcinoma with complete resection and eight lymph nodes, all negative. CONCLUSIONS: Robotic approaches could improve accessibility to minimally invasive liver resection of Klatskin tumor.

Robotic central hepatectomy for hepatocarcinoma by glissonean approach (with video).

BACKGROUND: Central bisegmentectomy of the liver implies excising Couinaud's segments IV, V and VIII (Couinaud and Le Foie, 1957) [1]. In a recent classification of laparoscopic liver resections, it belongs to the highly advanced level procedure group (Kawaguchi and et al., 2018 Jan) [2]. Improvement in laparoscopic devices should lead to a wider accessibility of such indications that are currently expert prerogatives. In order to illustrate the assets of robotic-assistance in the management of highly difficult mini-invasive hepatic resections, we present the case of a robotic central hepatectomy. METHODS: This video illustrates robotic central hepatectomy in a 70-year-old male. A liver tumor involving segments IV, V and VIII was incidentally detected during abdominal ultrasonography. CT scan and MRI suggested the diagnosis of a seventy-millimeter centrally located hepatocellular carcinoma and surgical resection was decided. RESULTS: The patient was placed supine in anti-Trendelenburg position. Four robotic trocars were placed and the da Vinci X robotic system was docked. Two laparoscopic ports were placed for the second surgeon (ultrasonic dissector and suction/irrigation set). Central hepatectomy was performed with a glissonean approach. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Postoperative course was uneventful. The patient was discharged on postoperative day eight. CONCLUSION: The recent publication of an International consensus statement demonstrates the growing involvement of robotics in liver surgery (Liu and et al., 2019 March 28) [3]. Robotic advantages (flexibility, absence of fulcrum effect and visual field stability) could improve accessibility to minimal invasive approach for difficult liver resection.

Robotic hepatic parenchymal transection: a two-surgeon technique using ultrasonic dissection and irrigated bipolar coagulation.

Liver transection is the most challenging part of hepatectomy due to the risk of hemorrhage which is associated with postoperative morbidity and mortality and reduced long-term survival. Parenchymal ultrasonic dissection (UD) with bipolar coagulation (BPC) has been widely recognized as a safe, effective, and standard technique during open and laparoscopic hepatectomy. We here introduce our technique of robotic liver transection using UD with BPC and report on short-term perioperative outcomes. From a single-institution prospective liver surgery database, we identified patients who underwent robotic liver resection. Demographic, anesthetic, perioperative, and oncologic data were analyzed. Fifty patients underwent robotic liver resection using UD and BPC for liver malignancies (n = 42) and benign lesions (n = 8). The median age of the patients was 67 years and 28 were male. According to the difficulty scoring system, 60% (n = 30) of liver resection were considered difficult. Three cases (6%) were converted to open surgery. The median operative time was 240 min, and the median estimated blood loss was 200 ml; 2 patients required operative transfusions. The overall complication rate was 38% (grade I, 29; grade II, 15; grade III, 3; grade IV, 1). Seven patients (14%) experienced biliary leakage. The median length of hospital stay post-surgery was 7 (range 3-20) days. The R0 resection rate was 92%. Robotic parenchymal transection using UD and irrigated BPC appears a simple, safe, and effective technique. However, our results must be confirmed in larger series or in randomized controlled trials.

Robotic Resection of a Central Liver Solitary Fibrous Tumor (with Video).

BACKGROUND: Solitary fibrous tumor is a mesenchymal tumor rare in liver parenchyma 1 but must be considered as a differential diagnosis of a single large hepatic mass. Surgical resection is the treatment because of its potential malignancy, and previous interventions reported were open hepatectomy 2. Robotic assets could improve accessibility for difficult liver resection 3. We present the video of a robotic left hepatectomy extended to caudate lobe and median hepatic vein for central liver tumor. METHODS: A central liver tumor was incidentally detected during abdominal ultrasonography in a 30-year-old man with no medical history. Laboratory tests were normal. CT scan and MRI revealed a solid mass measuring 9 cm involving segments I-IV-VIII and median/left hepatic veins. Percutaneous biopsy confirmed diagnosis of benign liver solitary fibrous tumor. Surgical resection by left hepatectomy extended to segment 1 and median hepatic vein was planned. RESULTS: Da Vinci X system was docked from patient's head. Four robotic ports were placed in right hypochondrium. Two laparoscopic ports were placed for the second surgeon. Extended left hepatectomy was performed with hilar approach. Parenchymal transection was led on the right side of median hepatic vein using laparoscopic ultrasonic dissector and robotic irrigated bipolar. Segment 1 was released with a mediocaudal approach. Procedure was facilitated by good exposure of operative field with arm 4, stable vision, articulated instrumentation and a "4-hand parenchymal dissection". CONCLUSION: Minimal invasive resection of liver solitary fibrous tumor seems safe and feasible. Because of its advantages compared with laparoscopy, robotic approach could improve accessibility to central tumors liver resection.

The technique and outcomes of central hepatectomy by the Glissonian suprahilar approach.

INTRODUCTION: Central hepatectomy (CH) is technically challenging and seldom-used to treat centrally located tumors. However, CH is a parenchyma-sparing resection that may decrease the risk of postoperative liver failure. This retrospective study presents our technique of CH and assesses the outcomes. METHODS: All CH performed in our department over two decades (1997-2017) were identified. Indications and short-term outcomes were compared between the two decades. Long-term outcomes were assessed. RESULTS: Sixty-four patients underwent CH using a suprahilar approach for hepatocellular carcinoma (HCC: n = 30), metastasis (n = 23), intrahepatic cholangiocarcinoma (IHCCA: n = 9) or other diseases (n = 2). CH represented 6% of 1004 major hepatectomies, (7.4% (n = 35) before 2007 vs 5.4% (n = 29) after 2007). The mean operating time was 219 ±â€¯56 min. A perioperative blood transfusion was required in 14 patients (22%). Intraoperative bile duct injuries occurred in 5 patients (8%), and they were repaired. One patient died postoperatively (1,5%). Ten patients (16%) experienced a major complication. Nine patients (14%) suffered from bile leakage, of which 6 healed spontaneously. Only one patient had low grade liver failure. The R0-resection rate was 69%. After 2007, there were no bile duct injuries (0/29 vs 5/35, p < 0.05), and the average hospital stay was shorter but not significantly (11 vs 14 days). Actuarial 5-year survival was 56% for HCC patients and 34% for those with colorectal metastasis CONCLUSIONS: CH is associated with significant biliary morbidity and may increase positive surgical margins. Nevertheless, it should be recommended in selected patients to avoid the risk of postoperative liver failure.

Do height and weight affect the feasibility of single-incision laparoscopic cholecystectomy?

BACKGROUND: Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. Single-incision laparoscopic surgery has recently emerged as a less invasive potential alternative to conventional three- or four-port laparoscopy. However, the feasibility of single-incision laparoscopic cholecystectomy (SILC) remains unclear, and there are no rigorous criteria in the literature. Identifying patients at risk of failure of this new technique is essential. The aim of our study was to determine risk factors that may predict failure of the procedure. METHODS: From May 2010 to March 2012, 110 consecutive patients underwent SILC and were reviewed retrospectively. The main feasibility criterion was the procedure failure rate, defined as addition of supplementary port(s) and prolonged (>60 min) operative time. The factors evaluated were age, gender, height, weight, body mass index, previous abdominal surgery, indication for surgery and gallbladder suspension. RESULTS: There was conversion in 16 patients (14.5%), and the operative time exceeded 60 min for 20 patients (30.9%). Univariate analysis showed a significant independent association between additional port requirement and each of weight as a continuous value, weight ≥80 kg, BMI >26.5 kg/m(2) and height >172 cm. Univariate analysis also showed a significant independent association between prolonged operative duration (>60 min) and each of height and weight as continuous values, height >172 cm and previous abdominal surgery. In the multivariate analysis, only weight remained independently associated with additional port requirement, and height remained independently associated with prolonged operative duration. CONCLUSION: Preoperative identification of the factors increasing the risk of conversion may assist surgeons in making decisions concerning the management of patients, including appropriate use of SILC.

Which treatment to choose for portal biliopathy with extensive portal thrombosis?

BACKGROUND: Portal biliopathy refers to abnormalities of the biliary tract developing in relation to portal hypertension. Portosystemic splenorenal or mesenterico-caval shunting is a safe and effective method to relieve biliary obstruction in symptomatic patients but is unfeasible in cases of extensive thrombosis of the splenic and superior mesenteric veins. In such cases, a makeshift portosystemic shunt between a suitable portal varix and the caval system can be an interesting alternative. METHODS: This study describes 3 patients admitted for symptomatic portal biliopathy caused by idiopathic portal cavernoma associated with extensive portal thrombosis. A makeshift portosystemic shunt was carried out after preoperative portal imaging had demonstrated the presence of a suitable splanchnic varix. RESULTS: The makeshift portosystemic shunt was performed by direct anastomosis in 2 patients and by prosthetic interposition in 1 case. Shunting was between a splanchnic varix and the inferior vena cava in 2 cases and the left renal vein in 1 case. Postoperative morbidity was nil and follow-up ranging from 2 to 12 years showed good results with no recurrence of biliary obstruction. CONCLUSION: In patients presenting symptomatic portal biliopathy associated with extensive thrombosis of the portal system, a makeshift portosystemic shunt is preferable to repeated endoscopic procedures or intrahepatic biliodigestive bypass, provided that a suitable varix is available.