Robotic versus laparoscopic surgery for sporadic benign insulinoma: Short- and long-term outcomes.

BACKGROUND: Minimally invasive surgery is the optimal treatment for insulinoma. The present study aimed to compare short- and long-term outcomes of laparoscopic and robotic surgery for sporadic benign insulinoma. METHODS: A retrospective analysis of patients who underwent laparoscopic or robotic surgery for insulinoma at our center between September 2007 and December 2019 was conducted. The demographic, perioperative and postoperative follow-up results were compared between the laparoscopic and robotic groups. RESULTS: A total of 85 patients were enrolled, including 36 with laparoscopic approach and 49 with robotic approach. Enucleation was the preferred surgical procedure. Fifty-nine patients (69.4%) underwent enucleation; among them, 26 and 33 patients underwent laparoscopic and robotic surgery, respectively. Robotic enucleation had a lower conversion rate to laparotomy (0 vs. 19.2%, P = 0.013), shorter operative time (102.0 vs. 145.5 min, P = 0.008) and shorter postoperative hospital stay (6.0 vs. 8.5 d, P = 0.002) than laparoscopic enucleation. There were no differences between the groups in terms of intraoperative blood loss, the rates of postoperative pancreatic fistula and complications. After a median follow-up of 65 months, two patients in the laparoscopic group developed a functional recurrence and none of the patients in the robotic group had a recurrence. CONCLUSIONS: Robotic enucleation can reduce the conversion rate to laparotomy and shorten operative time, which might lead to a reduction in postoperative hospital stay.

"Parenchyma transection-first" strategy is superior to "tunnel-first" strategy in robotic spleen-preserving distal pancreatectomy with conservation of splenic vessels.

BACKGROUND: Creating a tunnel between the pancreas and splenic vessels followed by pancreatic parenchyma transection ("tunnel-first" strategy) has long been used in spleen-preserving distal pancreatectomy (SPDP) with splenic vessel preservation (Kimura's procedure). However, the operation space is limited in the tunnel, leading to the risks of bleeding and difficulties in suturing. We adopted the pancreatic "parenchyma transection-first" strategy to optimize Kimura's procedure. METHODS: The clinical data of consecutive patients who underwent robotic SPDP with Kimura's procedure between January 2017 and September 2022 at our center were retrieved. The cohort was classified into a "parenchyma transection-first" strategy (P-F) group and a "tunnel-first" strategy (T-F) group and analyzed. RESULTS: A total of 91 patients were enrolled in this cohort, with 49 in the T-F group and 42 in the P-F group. Compared with the T-F group, the P-F group had significantly shorter operative time (146.1 ± 39.2 min vs. 174.9 ± 46.6 min, P < 0.01) and lower estimated blood loss [40.0 (20.0-55.0) mL vs. 50.0 (20.0-100.0) mL, P = 0.03]. Failure of splenic vessel preservation occurred in 10.2% patients in the T-F group and 2.4% in the P-F group (P = 0.14). The grade 3/4 complications were similar between the two groups (P = 0.57). No differences in postoperative pancreatic fistula, abdominal infection or hemorrhage were observed between the two groups. CONCLUSIONS: The pancreatic "parenchyma transection-first" strategy is safe and feasible compared with traditional "tunnel-first strategy" in SPDP with Kimura's procedure.

First two-stage robotic ALPPS in HCC patients with hepatic vein invasion: a step-by-step procedure from a clinical case.

BACKGROUND: The associating liver partitioning and portal vein occlusion for staged hepatectomy (ALPPS) procedure is gaining interest because it brings hope to patients who cannot undergo radical surgical resection due to insufficient remnant liver volume. However, the indications and technical aspects of this procedure are still under debate. This report demonstrates the technical aspects of the first two-stage robotic ALPPS for HCC. CASE PRESENTATION: A 55-year-old man with type II portal vein variation was diagnosed with hepatocellular carcinoma. Preoperative 3D reconstruction of the liver based on CT showed a future liver remnant/standard liver volume (FLR/SLV) of 24.45%. The ALPPS procedure was performed using the da Vinci Si system. At the first stage of the operation, we removed the gallbladder and ligated the right anterior branch of the portal vein and the right posterior branch. Following blocking of the hepatic hilum, the liver parenchyma was removed 1 cm away from the right side of the falciform ligament in an incision manner from the top to the bottom and from shallow to deep. The second-stage operation was performed on the 12th postoperative day with a FLR/SLV of 45.13%. During this step, the right hemiliver plus left medial section was separated and removed. Postoperative pathology showed a negative margin. The operative times were 195 and 217 min, respectively. Estimated blood loss was 250 and 500 ml, respectively. There was no need for transfusion or hospitalization in intensive care. The patient was discharged on the 6th postoperative day. Recovery was uneventful after both stages, and the patient did not present any sign of liver failure. Elevation of liver enzymes was minimal. The patient had no evidence of the disease 14 months after the procedure. CONCLUSIONS: The two-stage robotic ALPPS procedure is a safe and feasible technique for select patients with HCC.

Robotic anatomic isolated complete caudate lobectomy: Left-side approach and techniques.

BACKGROUND: To demonstrate the surgical procedures and techniques of the robotic anatomical isolated complete caudate lobectomy. METHODS: A retrospective analysis was performed on the demographic, operative, postoperative outcomes of seven patients who underwent robotic anatomical isolated complete caudate lobectomy at our department from January 2018 to November 2019. Mobilization of the left lateral and Spiegel lobe, dissection of the short hepatic veins and liver parenchyma transection from the dorsal plane of middle and right hepatic vein were crucial procedures for the robotic left-side approach. Anatomic complete caudate lobectomy was defined as total removal of the caudate lobe, in which the dorsal middle and right hepatic vein, the inferior vena cava and its right side were fully exposed on the raw surface. RESULTS: All patients successfully underwent the robotic anatomical isolated caudate lobectomy with a left-side approach without conversion to laparotomy, and without Clavien-Dindo Grade III or higher complications. The average tumor diameter was 65.00 ± 10.61 mm, the average operation time was 212.00 ± 74.53 min, the median bleeding loss was 100 mL, and the average postoperative hospital stay was 8.71 ± 4.89 d, respectively. There were four patients with primary hepatocellular carcinoma, one with tumor recurrence five months after surgery and three patients were free of recurrence. All patients survived at the last follow-up. CONCLUSION: Robotic anatomical isolated complete caudate lobectomy with a left-sided approach is safe and feasible for selected patients.

Adjuvant nab-paclitaxel plus gemcitabine vs gemcitabine alone for resected pancreatic ductal adenocarcinoma: A single center experience in China.

BACKGROUND: Nab-paclitaxel plus gemcitabine (AG) has resulted in higher tumor response and survival rates for metastatic or advanced pancreatic ductal adenocarcinoma (PDAC) compared with gemcitabine (GEM) alone. AIM: To examine the feasibility and safety of AG adjuvant chemotherapy of resectable PDAC. METHODS: We retrospectively analyzed patients with resected PDAC who received AG or GEM as postoperative adjuvant treatment between January 2013 and December 2016 at the Chinese People's Liberation Army General Hospital, Beijing, China. The patients adopted combined nab-paclitaxel (125 mg/m2) and GEM (1 g/m2) or GEM (1 g/m2) alone treatment, on days 1 and 8 every 3 wk for six cycles, unless intolerable adverse events or disease progression occurred. The disease-free survival, overall survival (OS) and adverse events of the two groups were statistically analyzed. RESULTS: Compared with GEM, median disease-free survival (12.2 mo vs 15.8 mo, P = 0.039) and OS (20.6 mo vs 28.3 mo, P = 0.028) were significantly improved in the AG group. The 2-year OS rates were 63.3% and 43.3% in the AG and GEM groups, respectively. However, the incidence of sensory neuropathy was increased significantly in the AG than the GEM group (53.3% vs 23.3%, P < 0.001). CONCLUSION: In our initial experience, AG significantly improved disease-free survival and OS of patients with resected PDAC. AG may be a potential option for postoperative adjuvant chemotherapy of resectable PDAC.

Clinical diagnosis and management of pancreatic mucinous cystadenoma and cystadenocarcinoma: Single-center experience with 82 patients.

BACKGROUND: Mucinous cystic neoplasm (MCN) of the pancreas is characterized by mucin-producing columnar epithelium and dense ovarian-type stroma and at risk for malignant transformation. Early diagnosis and treatment of MCN are particularly important. AIM: To investigate the clinical characteristics of and management strategies for pancreatic mucinous cystadenoma (MCA) and mucinous cystadenocarcinoma (MCC). METHODS: The clinical and pathological data of 82 patients with pancreatic MCA and MCC who underwent surgical resection at our department between April 2015 and March 2019 were retrospectively analyzed. RESULTS: Of the 82 patients included in this study, 70 had MCA and 12 had MCC. Tumor size of MCC was larger than that of MCA (P = 0.049). Age and serum levels of tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and CA12-5 were significantly higher in MCC than in MCA patients (P = 0.005, 0.026, and 0.037, respectively). MCA tumor size was positively correlated with serum CA19-9 levels (r = 0.389, P = 0.001). Compared with MCC, MCA had a higher minimally invasive surgery rate (P = 0.014). In the MCA group, the rate of major complications was 5.7% and that of clinically relevant pancreatic fistula was 8.6%; the corresponding rates in the MCC group were 16.7% and 16.7%, respectively. CONCLUSION: Tumor size, age, and serum CEA, CA19-9, and CA12-5 levels may contribute to management of patients with MCN. Surgical resection is the primary treatment modality for MCC and MCA.

Robotic isolated partial and complete hepatic caudate lobectomy: A single institution experience.

BACKGROUND: Current reports on robotic hepatic caudate lobectomy are limited to Spiegel lobectomy. This study aimed to compare the safety and feasibility of robotic isolated partial and complete hepatic caudate lobectomy. METHODS: Clinical data of 32 patients who underwent robotic resection of the hepatic caudate lobe in our department from May 2016 to January 2020 were retrospectively analyzed. The patients were divided into three groups according to the lobectomy location: left dorsal segment lobectomy (Spiegel lobectomy), right dorsal segment lobectomy (caudate process or paracaval portion lobectomy), and complete caudate lobectomy. General information and perioperative results of the three groups were compared and analyzed. RESULTS: Among the 32 patients, none had conversion to laparotomy, three received intraoperative blood transfusion (9.38%), and none had complications of Clavien-Dindo grade III or higher or died in the perioperative period. Among them, 17 patients (53.13%) underwent Spiegel lobectomy, 7 (21.88%) underwent caudate process or paracaval portion lobectomy, and 8 (25.00%) underwent complete caudate lobectomy. The operative time and blood loss in the left dorsal segment lobectomy group were significantly better than those in the right dorsal segment lobectomy and complete caudate lobectomy groups (operative time: P = 0.010 and P = 0.005; blood loss: P = 0.005 and P = 0.017, respectively). The postoperative hospital stay in the left dorsal segment lobectomy group was significantly shorter than that in the complete caudate lobectomy group (P = 0.003); however, there was no difference in the postoperative hospital stay between the left dorsal segment lobectomy group and right dorsal segment lobectomy group (P = 0.240). CONCLUSIONS: Robotic isolated partial and complete caudate lobectomy is safe and feasible. Spiegel lobectomy is relatively straightforward and suitable for beginners.

Successful robotic radical resection of hepatic echinococcosis located in posterosuperior liver segments.

BACKGROUND: Radical resection is an important treatment method for hepatic echinococcosis. The posterosuperior segments of the liver remain the most challenging region for laparoscopic or robotic hepatectomy. AIM: To demonstrate the safety and preliminary experience of robotic radical resection of cystic and alveolar echinococcosis in posterosuperior liver segments. METHODS: A retrospective analysis was conducted on the clinical data of 5 patients with a median age of 37 years (21-56 years) with cystic and alveolar echinococcosis in difficult liver lesions admitted to two centers from September to December 2019. The surgical methods included total pericystectomy, segmental hepatectomy, or hemihepatectomy. RESULTS: Among the 5 patients, 4 presented with cystic echinococcosis and 1 presented with alveolar echinococcosis, all of whom underwent robotic radical operation successfully without conversion to laparotomy. Total caudate lobectomy was performed in 2 cases, hepatectomy of segment VII in 1 case, total pericystectomy of segment VIII in 1 case, and right hemihepatectomy in 1 case. Operation time was 225 min (175-300 min); blood loss was 100 mL (50-600 mL); and postoperative hospital stay duration was 10 d (5-19 d). The Clavien-Dindo complication grade was I in 4 cases and II in 1 case. No recurrence of echinococcosis was found in any patient at the 3 mo of follow-up. CONCLUSION: Robotic radical surgery for cystic and selected alveolar echinococcosis in posterosuperior liver segments is safe and feasible.

An end-to-end pancreatic anastomosis in robotic central pancreatectomy.

BACKGROUND: Suturing the proximal pancreatic stump and performing pancreaticoenterostomy for the distal pancreatic stump following central pancreatectomy is a conventional procedure. This reconstruction after resection of the pathological pancreatic lesion brings changes in anatomy and physiology. In this study, an innovative one-stage robotic end-to-end pancreatic anastomosis was reported to replace the conventional pancreaticoenterostomy following central pancreatectomy. MATERIALS AND METHODS: The clinical data of 11 consecutive patients who underwent robotic central pancreatectomy with end-to-end pancreatic anastomosis between August 2017 and December 2017 were analyzed retrospectively. RESULTS: All operations were completed successfully without any conversion to open surgery. Nine patients had benign tumors, one had a mass-forming chronic pancreatitis, and one had an isolated pancreatic metastasis from a renal cancer. The mean gap left after central pancreatectomy was 4.3 ± 1.0 cm. The median operative time was 121 (range, 105 to 199) min. The median blood loss was 50 (range, 20 to 100) ml. Seven (63.6%) patients developed complications which included Clavien-Dindo Grade I complications in five patients, a Grade II complication in one patient, and a Grade IIIa complication in one patient. Seven patients developed a Grade B postoperative pancreatic fistula, and two patients a biochemical leak. There was no Grade C or worse pancreatic fistula. Magnetic resonance cholangiopancreatography at postoperative 6 months showed no stricture in any of the main pancreatic ducts. Three patients had an asymptomatic and small pancreatic pseudocyst. CONCLUSION: Robotic central pancreatectomy with end-to-end pancreatic anastomosis was safe and feasible. It restores the normal anatomy of the pancreas. With its good short-and long-term outcomes, it could be an alternative reconstructive method to pancreaticoenterostomy following central pancreatectomy.

Gastric submucosa is inferior to the liver as transplant site for autologous islet transplantation in pancreatectomized diabetic Beagles.

Intraportal transplantation of islets is no longer considered to be an ideal procedure and finding the extrahepatic alternative site is becoming a subject of high priority. Herein, in this study, we would introduce our initial outcomes of using gastric submucosa (GS) and liver as sites of islet autotransplantation in pancreatectomized diabetic Beagles. Total pancreatectomy was performed in Beagles and then their own islets extracted from the excised pancreas were transplanted into GS (GS group, n=8) or intrahepatic via portal vein (PV group, n=5). Forty-eight hours post transplantation, graft containing tissue harvested from the recipients revealed the presence of insulin-positive cells. All recipients in GS group achieved euglycemia within 1 day, but returned to a diabetic state at 6 to 8 days post-transplantation (mean survival time, 7.16±0.69 days). However, all of the animals kept normoglycemic until 85 to 155 days post-transplantation in PV group (mean survival time, 120±28.58 days; P<0.01 vs. GS group). The results of intravenous glucose tolerance test (IVGTT) confirmed that the marked improvement in glycometabolism was obtained in intrahepatic islet autotransplantation. Thus, our findings indicate that the liver is still superior to the GS as the site of islet transplantation, at least in our islet autotransplant model in pancreatectomized diabetic Beagles.

[The research of xeno-lymphocytes apoptosis induced by Sertoli cells isolated by modified methods in vitro].

OBJECTIVE: To modify the isolation and culture method of Sertoli cells and investigate its' effects on xeno-lymphocytes apoptosis. METHODS: Sertoli cells which was isolated from 2 - 4 week-old Sprague Dawley (SD) rats, were successfully prepared by collagenase type V, trypsin and DNase I and then identified by electron microscope. Viability and apoptosis of cultured cells were measured by flow cytometry. The apoptosis rates of Balb/c mouse lymphocytes were examined which were co-cultured with Sertoli cells of SD rats by flow cytometry, too. The expression of FasL, TGF-beta(1) and clusterin on Sertoli cells were detected by immunocytochemistry. RESULTS: In the co-cultured system, Sertoli cells accounted for more than 90%. The viability of Sertoli cells was above 95% and the apoptosis rate was 10.87% +/- 3.87% in this study. The lymphocytes apoptosis ratio was 15.52% +/- 0.17% (P < 0.01). Streptavidin-biotin-peroxidase-complex immunochemistry staining showed that the Sertoli cells could express FasL, TGF-beta(1) and clusterin, respectively. CONCLUSIONS: It indicates that the expression of FasL, TGF-beta(1) on the Sertoli cells might relate to the immune privilege, and it supposed to be benefit for xenotransplantation.