First worldwide report on rectal resections with Hugo™ surgical system: description of docking angles and tips for an effective setup.

BACKGROUNDS: Rectal robotic surgery gained momentum in the last decade, but it is still associated with not-negligible costs. In order to reduce costs, recently different robotic systems have received approval for clinical use. This study aims to present the first case series of rectal resection with the novel cost-effective platform Robotic Assisted Surgery (RAS) Hugo™. Tips for effective set up of the system and detailed configuration of tilt and docking angles are also provided. METHODS: Three cases of rectal resection with Hugo RAS™ system are reported. After the first two cases of resection with partial mesorectal excision in which surgeries were performed with the setup proposed by the vendor company, in the third case we tested a novel setup that allowed a full robotic low rectal resection performing vascular ligations, TME and colonic splenic flexure mobilization without the need of any de-docking. RESULTS: Our first three robotic rectal resections with the Hugo RAS™ system were completed without complications with a median docking time of 12 min (range 8-15) and a median console time of 345 minutes (range 271-475). In the first two cases, hybrid robotic and laparoscopic surgeries were performed to obtain an adequate haemostasis and traction during the pelvic phase. In the third case, a full robotic TME was successfully accomplished. CONCLUSION: Our experience demonstrates that a full robotic low rectal resection with TME with Hugo™ RAS system is feasible, safe and associated with satisfactory postoperative outcomes.

Full robotic cholecystectomy: first worldwide experiences with HUGO RAS surgical platform.

BACKGROUND: The Hugo RAS™ system (Medtronic, Minneapolis, MN, USA), approved for gynaecological and urological procedures, has been recently certified for the use in few general surgeries. Only bariatric and colorectal procedures have been described so far. METHODS: Here, we report the first worldwide experience with three cases of full-robotic cholecystectomies with the Hugo RAS™ system. RESULTS: A description of the operative room setup, of the docking angles and details of the procedures is reported. Docking time was 12, 10, and 6 min, respectively. The total operative time was 105 min in the first case, 100 min in the second and 88 in the third case. Intra- and post-operative courses were uneventful. CONCLUSIONS: With this pre-defined set up, the innovative conformation of Hugo RAS™ system can safely allow performing full robotic cholecystectomy avoiding the need for additional ports.

Right hepatic artery anomalies in pancreatoduodenectomy-a risk for arterial resection but not for postoperative outcomes.

Background: Pancreatoduodenectomy (PD) is a complex surgical procedure known for its significant morbidity rates, and the presence of an aberrant hepatic artery (AHA) introduces additional challenges. The impact of AHA on post-PD outcomes has been a subject of conflicting findings in the medical literature. This study aimed to investigate how variations in hepatic arterial anatomy influence intra-operative variables and postoperative morbidity. Methods: A retrospective analysis was conducted on 113 PD cases. Patients with variant hepatic arterial anatomy (n=38) were categorized as Group 1, while those without vascular abnormalities comprised Group 2. Perioperative and postoperative outcomes were examined. Results: Patients in Groups 1 and 2 exhibited similar characteristics, and no notable differences in surgical complications were observed. There was, however, a noticeable trend towards a higher incidence of postpancreatectomy hemorrhage (PPH) in Group 1 (31.6% vs. 20.0%; P=0.17). Furthermore, a statistically significant increase in the rate of arterial resections was noted in patients with vascular anomalies (10.5% vs. 1.33%; P=0.02). Conclusions: The prevalence of vascular abnormalities in the hepatic arterial circulation is more frequent than initially anticipated. These anomalies present additional complexities to the already intricate PD procedure, leading to a heightened necessity for arterial resection, albeit without any discernible impact on postoperative complications.

Preoperative CA19.9 level predicts lymph node metastasis in resectable adenocarcinoma of the head of the pancreas: A further plea for biological resectability criteria.

INTRODUCTION: Lymph-nodal involvement (N+) represents an adverse prognostic factor after pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Preoperative diagnostic and staging modalities lack sensitivity for identifying N+. This study aimed to investigate preoperative CA19.9 in predicting the N+ stage in resectable-PDAC (R-PDAC). METHODS: Patients included in a multi-institutional retrospective database of PDs performed for R-PDAC from January 2000 to June 2021 were analyzed. A preoperative laboratory value of CA19.9 >37 U/L was used in univariate and multivariate logistic regression analysis to determine a possible association with N+. Additionally, different cut-offs of CA19.9 related to the preoperative clinical T (cT) stage was assessed to evaluate the risk of N+. RESULTS: A total of 2034 PDs from thirteen centers were included in the study. CA19.9>37 U/L was significantly associated with higher N+ at univariate and multivariate analysis (P<0.001). CA19.9 levels >37 U/L were associated with N+ in 75.9%, 81.3%, and 85.7% of patients, respectively, in cT1, cT2, and cT3 tumors and with higher cut-off values for all cT stages. CONCLUSION: Lymph nodal involvement is strongly related to preoperative CA19.9 levels. Specially in patients staged as cT3 the CA 19.9 could represent a valid and easy tool to suspect nodal involvement. Due to these findings, R-PDAC patients with elevated CA19.9 values should be considered in a more biologically advanced stage.

Hepatocellular Carcinoma and Non-Alcoholic Fatty Liver Disease: A Modern Context for an Ancient Disease.

Hepatocellular Carcinoma (HCC) is a leading cause of cancer-related deaths worldwide [...].

Neoadjuvant Treatments for Pancreatic Ductal Adenocarcinoma: Where We Are and Where We Are Going.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) represents a challenging disease for the surgeon, oncologist, and radiation oncologist in both diagnostic and therapeutic settings. Surgery is currently the gold standard treatment, but the role of neoadjuvant treatment (NAD) is constantly evolving and gaining importance in resectable PDACs. The aim of this narrative review is to report the state of the art and future perspectives of neoadjuvant therapy in patients with PDAC. METHODS: A PubMed database search of articles published up to September 2022 was carried out. RESULTS: Many studies showed that FOLFIRINOX or Gemcitabine-nab-paclitaxel in a neoadjuvant setting had a relevant impact on overall survival (OS) for patients with locally advanced and borderline resectable PDAC without increasing post-operative complications. To date, there have not been many published multicentre randomised trials comparing upfront surgery with NAD in resectable PDAC patients, but the results obtained are promising. NAD in resectable PDAC showed long-term effective benefits in terms of median OS (5-year OS rate 20.5% in NAD group vs. 6.5% in upfront surgery). NAD could play a role in the treatment of micro-metastatic disease and lymph nodal involvement. In this scenario, given the low sensitivity and specificity for lymph-node metastases of radiological investigations, CA 19-9 could be an additional tool in the decision-making process. CONCLUSIONS: The future challenge could be to identify only selected patients who will really benefit from upfront surgery despite a combination of NAD and surgery.

Postoperative procalcitonin is a biomarker for excluding the onset of clinically relevant pancreatic fistula after pancreaticoduodenectomy.

Background: Early detection and therapy of pancreatic fistula after pancreaticoduodenectomy is crucial to improve outcomes of this surgery. Since it is not clear if procalcitonin (PCT), can predict the onset of clinically relevant post-operative pancreatic fistula (CR-POPF), we aimed to investigate this ability. Methods: One-hundred-thirty pancreaticoduodenectomies (PD) were analyzed. Receiver Operating Characteristic curves analysis defined the optimal cut-offs for PCT and drains amylase levels (DAL). Complications were compared using chi-square for proportions test. Results: DAL ≥2,000 U/L in postoperative day (POD) 2 had 71% positive predictive value (PPV) and 91% negative predictive value (NPV) for CR-POPF (P<0.001). In POD2, PCT ≥0.5 ng/mL showed NPV 91% (P<0.045) and increased DAL PPV for CR-POPF to 81%. In POD3, POD4 and POD5, DAL (cut-offs 780, 157 and 330 U/L, respectively) showed NPV for CR-POPF >90% (P<0.0001). PCT ≥0.5 ng/mL showed NPV for CR-POPF of about 90%. In POD5, combining DAL (cut-off 330 U/L) and PCT (cut-off 0.5 ng/mL), a PPV for CR-POPF of 81% was detected. A progressive increased risk of CR-POPF from POD2 [odds ratio (OR) =3.05; P=0.0348] to POD5 (OR =4.589; P=0.0082) was observed. In POD2 and 5, PCT ≥0.5 ng/mL, alone and in combination with DAL, may be a reliable marker for identifying patients at highest risk of CR-POPF after PD. Conclusions: This association could be proposed to select high risk patients that could benefit of "intensive" postoperative management.

Role of preoperative sarcopenia in predicting postoperative complications and survival after pancreatoduodenectomy for pancreatic cancer.

AIM: The aim of this monocentric retrospective study was to investigate the relation between sarcopenia, postoperative complications and survival in patients undergoing radical surgery for pancreatic ductal adenocarcinoma (PDAC). MATERIAL OF STUDY: From a prospective collected database of 230 consecutive pancreatoduodenectomies (PD), data regarding patient's body composition, evaluated on diagnostic preoperative CT scans and defined as Skeletal Muscle Index (SMI) and Intramuscular Adipose Tissue Content (IMAC), postoperative complications and long-term outcomes were retrospectively analysed. Descriptive and survival analyses were performed. RESULTS: Sarcopenia was found in 66% of study population. The majority of patients who developed at least one postoperative complication was sarcopenic. However, sarcopenia did not statistically significantly relate with the development of postoperative complications. However, all pancreatic fistula C occurs in sarcopenic patients. Moreover, there was no significant difference in median Overall Survival (OS) and Disease Free Survival (DFS) between sarcopenic and nonsarcopenic patients (31 versus 31.8 months and 12.9 and 11.1 months respectively). DISCUSSION: Our results showed that sarcopenia was not related to short- and long-term outcomes in PDAC patients undergoing PD. However, the quantitative and qualitative radiological parameters are probably not enough to study the sarcopenia alone. CONCLUSIONS: The majority of early stage PDAC patients undergoing PD were sarcopenic. Cancer stage was a determinant factor of sarcopenia while BMI seems less important. In our study, sarcopenia was associated with postoperative complications and in particular with pancreatic fistula. Further studies will need to demonstrated that sarcopenia can be considered an objective measure of patient frailty and strongly associated with short- and long-term outcomes. KEY WORDS: Pancreatic ductal adenocarcinoma, Pancretoduodenectomy, Sarcopenia.

New Frontiers of Early Diagnosis of Pancreatic Fistula after Pancreaticoduodenectomy.

Although the mortality at 90 days has declined, pancreaticoduodenectomy (PD) is an extremely complex surgical procedure, with a non-negligible rate of major postoperative complications [...].

Role of Neoplastic Markers in Pancreatic Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is considered one of the "Big Five" lethal cancers, which include lung, bowel, breast and prostate cancer [...].

Role of CA 19.9 in the Management of Resectable Pancreatic Cancer: State of the Art and Future Perspectives.

BACKGROUND: Surgery still represents the gold standard of treatment for resectable pancreatic ductal adenocarcinoma (PDAC). Neoadjuvant treatments (NAT), currently proposed for borderline and locally advanced PDACs, are gaining momentum even in resectable tumors due to the recent interesting concept of "biological resectability". In this scenario, CA 19.9 is having increasing importance in preoperative staging and in the choice of therapeutic strategies. We aimed to assess the state of the art and to highlight the future perspectives of CA 19.9 use in the management of patients with resectable pancreatic cancer. METHODS: A PubMed database search of articles published up to December 2021 has been carried out. RESULTS: Elevated pre-operative levels of CA 19.9 have been associated with reduced overall survival, nodal involvement, and margin status positivity after surgery. These abilities of CA 19.9 increase when combined with radiological or different biological criteria. Unfortunately, due to strong limitations of previously published articles, CA 19.9 alone cannot be yet considered as a key player in resectable pancreatic cancer patient management. CONCLUSION: The potential of CA 19.9 must be fully explored in order to standardize its role in the "biological staging" of patients with resectable pancreatic cancer.

Special Issue "Hepatobiliary and Pancreatic Cancers: Novel Strategies for of Diagnosis and Treatments".

In recent years, hepato-pancreato-biliary (HPB) cancers have been increasing their incidence [...].

CA19.9 Serum Level Predicts Lymph-Nodes Status in Resectable Pancreatic Ductal Adenocarcinoma: A Retrospective Single-Center Analysis.

BACKGROUND: The choice between upfront surgery or neoadjuvant treatments (NAT) for resectable pancreatic ductal adenocarcinoma (R-PDAC) is controversial. R-PDAC with potential nodal involvement could benefit from NT. Ca (Carbohydrate antigen) 19.9 and serum albumin levels, alone or in combination, have proven their efficacy in assessing PDAC prognosis. The objective of this study was to evaluate the role of Ca 19.9 serum levels in predicting nodal status in R-PDAC. METHODS: Preoperative Ca 19.9, as well as serum albumin levels, of 165 patients selected for upfront surgery have been retrospectively collected and correlated to pathological nodal status (N), resection margins status (R) and vascular resections (VR). We further performed ROC curve analysis to identify optimal Ca 19.9 cut-off for pN+, R+ and vascular resection prediction. RESULTS: Increased Ca 19.9 levels in 114 PDAC patients were significantly associated with pN+ (p <0.001). This ability, confirmed in all the series by ROC curve analysis (Ca 19.9 ≥32 U/ml), was lost in the presence of hypoalbuminemia. Furthermore, Ca 19.9 at the cut off >418 U/ml was significantly associated with R+ (87% specificity, 36% sensitivity, p 0.014). Ca 19.9, at the cut-off >78 U/ml, indicated a significant trend to predict the need for VR (sensitivity 67%, specificity 53%; p = 0.059). CONCLUSIONS: In R-PDAC with normal serum albumin levels, Ca 19.9 predicts pN+ and R+, thus suggesting a crucial role in deciding on NAT.

Different Biliary Microbial Flora Influence Type of Complications after Pancreaticoduodenectomy: A Single Center Retrospective Analysis.

BACKGROUND: Bacterobilia is associated with postoperative morbidity after pancreaticoduodenectomy (PD), mostly due to infectious complications. The aim of this study was to investigate the prevalence of bacteria species isolated from intraoperative biliary cultures, and related complications after PD. METHODS: An ANOVA test was used to assess the prevalence of isolated bacterial species and postoperative complications. The odds ratio was computed to evaluate the association between biliary cultures and each complication, Endoscopic Retrograde CholangioPancreatography (ERCP) and each complication, ERCP and biliary cultures, Delayed Gastric Emptying (DGE) and Postoperative Pancreatic Fistula (POPF). RESULTS: Positive biliary cultures were found in 162/244 (66%) PDs. Different prevalences of polymicrobial biliary culture were detected in patients with postoperative complications. In SSIs, a significant prevalence of biliary culture positive for E. coli, Klebsiella pneumoniæ and Enterococcus fæcalis (p < 0.001) was detected. Prevalences of polymicrobial biliary cultures with Escherichia coli, Klebsiella pneumoniæ, Enterococcus fæcalis and Enterococcus fæcium were significantly associated with POPF (p < 0.001). Biliary culture positive for Escherichia coli, Enterococcus fæcalis and Enterococcus fæcium showed a higher prevalence of intra-abdominal collection and DGE (p < 0.001). Notably, Escherichia coli was significantly associated with DGE as a unique complication (OR = 2.94 (1.30-6.70); p < 0.01). CONCLUSIONS: Specific prevalences of polymicrobial bacterobilia are associated with major complications, while monomicrobial Escherichia coli bacterobilia is associated with DGE as a unique complication after PD.

Nanotechnology and pancreatic cancer management: State of the art and further perspectives.

Pancreatic ductal adenocarcinoma (PDAC) represents a leading cause of cancer death and is often diagnosticated too late to allow adequate treatments. Lots of biomarkers have been discovered in lasts years but, to date, there is a lack of low-cost and non-invasive tools for PDAC early detection. Nonetheless, drugs commonly used in PDAC treatment do not allow achieving long-term satisfying results. Nanotechnology is gaining importance in both PDAC early detection and treatment. The main implications of nanotechnology in cancer diagnosis lay in the ability that nanoparticles have on concentrate the alteration in human proteome caused by cancer. Nanoparticle-enabled blood tests have been demonstrated to reach high rate of sensitivity (up to 85%) and specificity (up to 100%). In the field of cancer therapy nanoparticles can be used as nanocarriers able to reach specific tumour's cells and selectively release the drug they contain into them. A literature review was carried out with the aim to assess the state of the art and highlight the future perspectives of nanotechnology in PDAC early detection and therapy.

The use of an implemented infection prevention bundle reduces the incidence of surgical site infections after colorectal surgery: a retrospective single center analysis.

BACKGROUND: Surgical-site infections (SSIs) represent the most common complications after colorectal surgery (CS). Role of preoperative administration of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP), alone or in combination, in the prevention of SSIs after CS is debated. Aim of this study was to assess the effect of the introduction of an Implemented Infection Prevention Bundle (IIPB) in preventing SSIs in CS. METHODS: A group of 251 patients (Group 1) who underwent CS receiving only preoperative intravenous antibiotic prophylaxis (IAP) was compared to a Group of 107 patients (Group 2) who also received the IIPB. The IIPB consisted of the combination of oral administrations of three doses of Rifaximin 400 mg and MBP the day before surgery and in the administration of a cleansing enema the day of the surgical procedure. RESULTS: At the univariate analysis, Group 2 showed significant lower rates of wound infection (WI) (2.8% vs. 9.9%; p = 0.021) and anastomotic leakage (AL) (2.8% vs. 14.7%; p = 0.001) with shorter hospital stay (5 vs. 6 days; p < 0.0001). The probability of postoperative AL was lower in Group 2; patients in this Group resulted protected from AL; a statistically significant Odds ratio of 0.16 (CI 0.05-0.55 p = 0.0034) was found. In diabetic patients, that were at higher risk of WI (OR 3.53, CI 1.49-8.35 p = 0.002), despite having any impact on anastomotic dehiscence, the use of IIPB significantly reduced the rate of WI (0% vs 28.1%; p = 0.01). CONCLUSION: The use of an IIPB significantly reduces rates of SSIs and post-operative hospital stay after CS.

Laparoscopic total mesorectal excision (L-TME) for rectal cancer surgery: does elective diverting ileostomy really protect? An observational retrospective cohort study.

AIMS: Elective diverting ileostomy may reduce consequences of anastomotic leakage after laparoscopic total mesorectal excision (L-TME); however, its safety is debated because of morbidity related to stoma creation and closure. We aimed to investigate the impact of diverting ileostomy on clinical behavior of anastomotic leakage and complications related to stoma itself. MATERIAL OF THE STUDY: We retrospectively evaluated 150 L-TMEs with (Group 1, 100 patients) or without (Group 2, 50 patients) elective ileostomy for rectal cancer. RESULTS: Overall anastomotic fistula rate was 26% without significant differences between the two groups (28% in the Group 1 and 22% in the Group 2, respectively). In all the series, NAD was significantly associated with higher risk of postoperative complications (OR=2.14, p=0.02). In Group 2, NAD particularly increased the risk of anastomotic fistula (OR=6.6, p=0.014). Instead, patients of Group 1 showed higher odd of post-operative complications (OR: 3.8; CI 95%: 1.8483-8.0492; p = 0.0003) and notably 79 (79%) developed complications related to the ileostomy itself (hydroelectrolytic, metabolic and peristomal skin disorders). Moreover, thirty-two (32%) ileostomies were never reversed; among the reversed patients, 27 (39.7%) developed at least one postoperative complication and in 9 (33.3%) cases an urgent re-intervention was needed. DISCUSSION: Diverting ileostomy may mitigate clinical behavior of anastomotic leakage after L-TME. However, there is non-negligible morbidity of stoma creation and closure. CONCLUSION: Diverting ileostomy should be selectively considered in higher risk patients as those who received NAD. KEY WORDS: Anastomotic leakage, Ileostomy, Rectal cancer.