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.

Nomogram to predict disease recurrence in patients with locally advanced rectal cancer undergoing rectal surgery after neoadjuvant therapy: retrospective cohort study.

INTRODUCTION: Prognostic models can be used for predicting survival outcomes and guiding patient management. TNM staging alone is insufficient for predicting recurrence after chemoradiotherapy (CRT) and surgery for locally advanced rectal cancer. This study aimed to develop a nomogram to better predict cancer recurrence after CRT followed by total mesorectal excision (TME) and tailor postoperative management and follow-up. MATERIALS AND METHODS: Between 2002 and 2019, data were retrospectively collected on patients with rectal adenocarcinoma. Data on sex, age, carcinoembryonic antigen (CEA) level, tumour location, induction chemotherapy, adjuvant chemotherapy, tumour downsizing, perineural invasion, lymphovascular invasion, pathological stage, resection margins (R0 versus R1), and pelvic septic complications were analysed. The variables significantly associated with cancer recurrence were used to build a nomogram that was validated in both the training and validation cohorts. Model performance was evaluated by receiver operating characteristic curve and area under the curve (AUC) analyses. RESULTS: After applying exclusion criteria, 634 patients with rectal adenocarcinoma were included in this study. Eight factors (CEA level, adjuvant chemotherapy, tumour downsizing, perineural invasion, lymphovascular invasion, pathological stage, resection margins (R0 versus R1), and pelvic septic complications) were identified as nomogram variables. Our nomogram showed good performance with an AUC of 0.74 and 0.75 in the training and validation cohorts respectively. CONCLUSION: Our nomogram is a simple tool for predicting cancer recurrence in patients with locally advanced rectal cancer after neoadjuvant CRT followed by TME. It provides an individual risk prediction of recurrence to tailor surveillance.