Transition from laparoscopic to robotic liver surgery: clinical outcomes, learning curve effect, and cost-effectiveness.

The reproducibility of the implementation of robotic liver surgery (RLS) is still debated. The aim of the present study is to evaluate short-term outcomes and cost differences during the implementation of RLS, performed by an early adopter in laparoscopic liver surgery (LLS). Patients undergoing RLS between February 2020 and May 2021 were included. Short-term outcomes of the robotic group (RG) were compared to the "Initial Phase" group (IP) of 120 LLS cases and the 120 most recent laparoscopic cases or "Mastery Phase" group (MP). A cost analysis per procedure for the three groups was performed. Seventy-one patients underwent RLS during the study period. Median operative time in the RG was comparable to the IP, but significantly shorter in the MP (140 vs 138 vs 120 min, p < 0.001). Median intraoperative blood loss in the RG was lower than in both laparoscopic groups (40 ml [20-90 ml] vs 150 ml [50-250 ml] vs 80 ml [30-150 ml], p < 0.001). Median hospital stay in the RG was significantly shorter than the IP group (p < 0.001). There were no significant differences in postoperative complication, conversion, or readmission rates. Procedural cost analysis was in favor of robotic surgery (€5008) compared to the IP (€ 6913) and the MP (€6099). Surgeons with sufficient experience in LLS can rapidly overcome the learning curve for RLS. In our experience, the short-term outcomes of the implementation phase of RLS are similar to the mastery phase of LLS. The total average cost per procedure is lower for RLS compared to LLS.

Five-year single center experience of sacral neuromodulation for isolated fecal incontinence or fecal incontinence combined with low anterior resection syndrome.

PURPOSE: Sacral neuromodulation (SNM) has proven to be a safe and effective treatment for fecal incontinence (FI). For low anterior resection syndrome (LARS), however, SNM efficacy is still poorly documented. The primary aim of this study was to report on efficacy of SNM therapy for patients with isolated FI or LARS. Furthermore, we evaluated the safety of the procedure and the relevance of adequate follow-up. METHODS: A retrospective analysis was performed upon a prospectively maintained database of all patients who underwent SNM therapy for isolated FI or LARS between January 2014 and January 2019. The Wexner and LARS scores were evaluated at baseline, during test phase, after definitive implantation and annually during follow-up. Treatment success was defined as at least 50% improvement of the Wexner score or a reduction to minor or no LARS. RESULTS: Out of 89 patients with isolated FI or LARS who had a SNM test phase, 62 patients were eligible for implantation of the permanent SNM device. At baseline, 3 weeks, and 1, 2, 3, 4 and 5 years after definitive implantation the median Wexner score of all patients was 18, 2, 4.5, 5, 5, 4 and 4.5, respectively, and 18, 4, 5.5, 5, 4, 3 and 4, respectively, for patients with FI and LARS. Patients with LARS more frequently required changes in program settings. CONCLUSIONS: SNM therapy is a safe and effective treatment for patients with isolated FI and patients with FI and LARS. Adequate follow-up is essential to ensure long-term effectivity, especially for LARS patients.

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection.

INTRODUCTION: Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure. METHODS: A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis. RESULTS: A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes. CONCLUSION: LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

Sacral neurostimulation for low anterior resection syndrome after radical resection for rectal cancer: evaluation of treatment with the LARS score.

PURPOSE: Sacral neurostimulation (SNS) has proven to be an effective treatment modality for low anterior resection syndrome (LARS). The primary aim of this study is to investigate the impact of SNS on all symptoms of LARS, not merely on fecal incontinence. Furthermore, we wanted to evaluate whether the LARS score could be useful as a tool to evaluate SNS treatment. METHODS: All patients diagnosed with minor or major LARS, unresponsive to conservative therapy for fecal incontinence, who underwent sacral neuromodulation for LARS at Groeninge Hospital, Kortrijk, Belgium, were prospectively enrolled in the study. The primary endpoint was the reduction in the severity of LARS. This was assessed by validated questionnaires: the LARS score and the Wexner score. RESULTS: Eleven patients underwent definite implantation of the SNS device. All patients showed a substantial decrease in their Wexner scores: The mean score was reduced from 17.7 to 4.6 (Z: 2.93; p: 0.0033). Additionally, the mean LARS score dropped from 36.9 to 11.4 (Z: 2.93; p: 0.0033). Furthermore, there was a significant amelioration of all symptoms of LARS. CONCLUSIONS: Our study shows that SNS is effective for all symptoms of LARS. The authors believe that in patients who receive SNS for LARS, it could be useful to determine the LARS score to evaluate the complexity of the symptoms and their response to treatment.

Feed restriction in young bulls alters the onset of puberty in relationship with plasma insulin-like growth factor-I (IGF-I) and IGF-binding proteins.

The objectives of this study were to evaluate the effect of feed restriction and re-alimentation on the onset of puberty and IGF status in peripubertal male calves and to compare the radioimmunoassay (RIA) and western ligand blotting (WLB) methods for bovine IGFBP-2. Twelve prepubertal 290 d-old Belgian Blue bulls (mean weight: +/- 290 kg) were randomly assigned in three groups: a control group (NG; n = 4) receiving a classic fattening diet to induce "normal" growth (1.48 kg/d), a feed restricted group (RG; n = 4) to obtain reduced growth (0.50 kg/d) and, a severely restricted group (SG; n = 4) to nearly stop growth (0.08 kg/d). The feed restriction period was maintained over a period of 114 d. After the period of differential feeding, all animals received the control feed regime over a period of 100 d. Blood samples were collected at fortnightly intervals. Circulating IGF-I was measured by RIA whereas plasma IGFBPs was evaluated by WLB; IGFBP-2 was additionally quantified by RIA procedure. At the beginning of the trial, IGF-I levels were low (<100 ng/ml) and similar in the three groups in accordance with prepubertal status. In the NG group, a progressive rise in IGF-I was observed from Day 42 to Day 142 whereas in the RG and SG groups, IGF-I levels did not change until the experimental restriction period ended. The delay of the rise in plasma IGF-I was longer for the SG group, IGF-I remained low until 2 wk after the end of the period of restricted feeding. Surprisingly, although differences were detected for IGF-I levels between the three groups, the IGFBP-2 and -3 data, evaluated by WLB could only discriminate between NG and SG group and not between NG and RG. However, by using a RIA method, an IGFBP-2 decrease was observed in the NG group coincident with increasing IGF-I levels. For both RG and SG groups, IGFBP-2 levels remained high throughout the feed restriction period whereas plasma IGFBP-2 levels declined upon feeding in both groups. During this feed restriction period, IGFBP-2 was significantly lower in NG than in RG or SG groups. Moreover, SG group animals had higher levels in plasma IGFBP-2 than RG animals. In conclusion, puberty is characterized by developmental changes in plasma IGF-I and IGFBPs that were altered by feed restriction. Moreover, RIA evaluation of plasma IGFBP-2 is able to better reflect group differences than WLB.

A homologous radioimmunoassay for quantification of insulin-like growth factor-binding protein-2 in blood from cattle.

Insulin-like growth factor-I and -II (IGF-I, IGF-II) circulate in biological fluids bound to six different IGF-binding proteins that regulate IGF bioactivity. The IGF-binding protein-2 is regulated by growth hormones, and its concentration depends on nutrition and physiological state. Specific antibodies directed against bovine IGF-binding protein-2 were produced, and IGF-binding protein-2 levels in bovine blood samples were quantified by radioimmunoassay. Parallel displacement curves showed strong cross-reactivity with bovine and ovine plasma, were low with porcine plasma, and no cross-reactivity with rat or chicken plasma. Addition of IGF-I or -II to a control pool of bovine plasma did not significantly alter control IGF-binding protein-2 values in a radioimmunoassay. Six nycthemeral periods, determined for three young bulls bled on two occasions, showed that IGF-binding protein-2 plasma levels were stable throughout the day; two or three samples were sufficient to characterize the animal. Cows treated with recombinant bovine somatotropin (bST) had significantly lower serum levels of IGF-binding protein-2 than did control cows. Furthermore, IGF-binding protein-2 levels were dramatically increased at the onset of lactation. This radioimmunoassay for bovine IGF-binding protein-2, which enables quantitative assessment of IGF-binding protein-2 concentration in cattle, confirmed that IGF-binding protein-2 concentrations are depressed by administration of bST, enhanced after calving, and showed absence of diurnal variation.

Candidate gene markers associated with somatotropic axis and milk selection.

One of the obstacles to progress in dairy cattle selection is that milk production traits are only expressed after the first calving. However, the use of the quantitative trait loci (QTL) technology will improve the efficiency of dairy industry with a positive image for the consumers. QTL are part of the genome showing a preponderant action and explaining the major part of variation of the trait production. At the present time, the two major strategies developed to detect such QTL are the candidate gene approach and the positional genetics approach. The somatotropic axis contains the most promising candidates in this respect, as it strongly regulates milk production. Then, the identification of favorable QTL associated with the somatotropic axis that are significantly correlated with genetic merits for milk production could lead to more effective selection programs.