The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence.

PURPOSE: Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). METHODS: All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups. RESULTS: Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013). CONCLUSION: The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

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.

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.

Establishment of a pancreatic adenocarcinoma molecular gradient (PAMG) that predicts the clinical outcome of pancreatic cancer.

BACKGROUND: A significant gap in pancreatic ductal adenocarcinoma (PDAC) patient's care is the lack of molecular parameters characterizing tumours and allowing a personalized treatment. METHODS: Patient-derived xenografts (PDX) were obtained from 76 consecutive PDAC and classified according to their histology into five groups. A PDAC molecular gradient (PAMG) was constructed from PDX transcriptomes recapitulating the five histological groups along a continuous gradient. The prognostic and predictive value for PMAG was evaluated in: i/ two independent series (n = 598) of resected tumours; ii/ 60 advanced tumours obtained by diagnostic EUS-guided biopsy needle flushing and iii/ on 28 biopsies from mFOLFIRINOX treated metastatic tumours. FINDINGS: A unique transcriptomic signature (PAGM) was generated with significant and independent prognostic value. PAMG significantly improves the characterization of PDAC heterogeneity compared to non-overlapping classifications as validated in 4 independent series of tumours (e.g. 308 consecutive resected PDAC, uHR=0.321 95% CI [0.207-0.5] and 60 locally-advanced or metastatic PDAC, uHR=0.308 95% CI [0.113-0.836]). The PAMG signature is also associated with progression under mFOLFIRINOX treatment (Pearson correlation to tumour response: -0.67, p-value < 0.001). INTERPRETATION: PAMG unify all PDAC pre-existing classifications inducing a shift in the actual paradigm of binary classifications towards a better characterization in a gradient. FUNDING: Project funding was provided by INCa (Grants number 2018-078 and 2018-079, BACAP BCB INCa_6294), Canceropole PACA, DGOS (labellisation SIRIC), Amidex Foundation, Fondation de France, INSERM and Ligue Contre le Cancer.

Prospective study on predictability of complications by pancreatic surgeons.

PURPOSE: We evaluated the intuition of expert pancreatic surgeons, in predicting the associated risk of pancreatic resection and compared this "intuition" to actual operative follow-up. The objective was to avoid major complications following pancreatic resection, which remains a challenge. METHODS: From January 2015 to February 2018, all patients who were 18 years old or more undergoing a pancreatic resection (pancreaticoduodenectomy [PD], distal pancreatectomy [DP], or central pancreatectomy [CP]) for pancreatic lesions were included. Preoperatively and postoperatively, all surgeons completed a form assessing the expected potential occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF: grade B or C), postoperative hemorrhage, and length of stay. RESULTS: Preoperative intuition was assessed for 101 patients for 52 PD, 44 DP, and 5 CP cases. Overall mortality and morbidity rates were 6.9% (n = 7) and 67.3% (n = 68), respectively, and 38 patients (37.6%) developed a POPF, including 27 (26.7%) CR-POPF. Concordance between preoperative intuition of CR-POPF occurrence and reality was minimal, with a Cohen's kappa coefficient (κ) of 0.175 (P value = 0.009), and the same result was obtained between postoperative intuition and reality (κ = 0.351; P < 0.001). When the pancreatic parenchyma was hard, surgeons predicted the absence of CR-POPF with a negative predictive value of 91.3%. However, they were not able to predict the occurrence of CR-POPF when the pancreas was soft (positive predictive value 48%). CONCLUSIONS: This study assessed for the first time the surgeon's intuition in pancreatic surgery, and demonstrated that pancreatic surgeons cannot accurately assess outcomes except when the pancreatic parenchyma is hard.

Visceral Obesity and Open Passive Drainage Increase the Risk of Pancreatic Fistula Following Distal Pancreatectomy.

BACKGROUND: The predictive risk factors of clinically relevant pancreatic fistula (CR-PF) following distal pancreatectomy (DP) remain to be identified. METHODS: This is a retrospective cohort analysis of a single-institution database of patients undergoing DP, taking into account usual demographic, operative, and pathologic variables and visceral fat area (VFA), total muscle area (TMA), and surface muscle index (SMI) measured on preoperative CT scan. The primary end point was CR-PF. All variables associated with a p value < 0.05 on univariate analysis were included in a logistic regression model for multivariate analysis. RESULTS: From 2012 to 2016, 208 patients operated by 4 pancreatic surgeons underwent DP including 32 (15%) who developed CR-PF. Risk factors of CR-PF on univariate analysis were: BMI ≥ 25 kg/m2 (p = 0.050), VFA ≥ 92 cm2 (p = 0.006), laparotomy (p = 0.023), main pancreatic duct dilatation (p = 0.035), open passive drainage (versus closed suction drainage) (p = 0.001), and blood loss ≥ 225 ml (p = 0.001). Sarcopenia did not influence the risk of CR-PF (p = 0.076). On multivariate analysis, VFA ≥ 92 cm2 (OR 3.14; IC 95% (1.18-8.31), p = 0.022), blood loss ≥ 225 ml (OR: 2.72; IC 95% (1.06-6.96), p = 0.037), and open passive drainage (OR 3.72; IC 95% (1.40-9.87) p = 0.008) were three independent predictive factors of CR-PF. A CR-PF risk score was developed, predicting a 0% risk of CR-PF when no risk factors were present and a 39% risk when the 3 risk factors were present. CONCLUSIONS: Visceral obesity, blood loss ≥ 225 ml and open passive drainage significantly increase the risk of CR-PF following DP.

Experimental Procedure of Compression Anastomosis Using Fragmented Rings: A Porcine Model.

BACKGROUND: Compression anastomosis has been recently abandoned because of a nonsuperiority compared to stapling anastomosis. Nonremoval of the rings has frequently been reported and this technique does not support a routine use. The aim of this experimental study was to assess the feasibility of anastomosis using compression with a device consisting of fragmented rings. METHODS: A new compression device, the "Anastocom," was compared to standard double-stapled colocolonic anastomosis in 2 groups of 8 pigs. In each group, colocolonic anastomosis was performed with a circular stapler (DST Series EEA Staplers) in 4 pigs and with the Anastocom device for the other 4 pigs. RESULTS: The anastomotic rings were expelled between postoperative day 7 and day 13 from the 4 animals sacrificed at day 30. The anastomosis was clean and intact in all pigs. After sacrifice, there was no difference in the bursting pressure at day 7 ( P = .226) or at day 30 ( P = .885) between the 2 types of anastomosis. After sacrifice at day 7, the mean bursting pressure values for the Anastocom and EEA anastomoses were 128.6 mm Hg (range 119-143 mm Hg) and 218.9 mm Hg (range 84-240 mm Hg), respectively. After sacrifice at day 30, the mean bursting pressure values for the Anastocom and EEA anastomoses were 111 mm Hg (range 59-234 mm Hg) and 105 mm Hg (range 81-130 mmHg), respectively. CONCLUSION: No bowel obstruction was observed with Anastocom. This fragmentation mechanism should better prevent nonexpulsion compared to basic compression anastomosis.