Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs

INTRODUCTION: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. MATERIALS AND METHODS: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. RESULTS: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. CONCLUSION: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy

Continuous Quantum Measurement and the Quantum to Classical Transition

While ultimately they are described by quantum mechanics, macroscopic mechanical systems are nevertheless observed to follow the trajectories predicted by classical mechanics. Hence, in the regime defining macroscopic physics, the trajectories of the correct classical motion must emerge from quantum mechanics, a process referred to as the quantum to classical transition. Extending previous work [Bhattacharya, Habib, and Jacobs, Phys. Rev. Lett. {\bf 85}, 4852 (2000)], here we elucidate this transition in some detail, showing that once the measurement processes which affect all macroscopic systems are taken into account, quantum mechanics indeed predicts the emergence of classical motion. We derive inequalities that describe the parameter regime in which classical motion is obtained, and provide numerical examples. We also demonstrate two further important properties of the classical limit. First, that multiple observers all agree on the motion of an object, and second, that classical statistical inference may be used to correctly track the classical motion.Comment: 12 pages, 4 figures, Revtex

The feasibility, proficiency, and mastery learning curves in 635 robotic pancreatoduodenectomies following a multicenter training program: "Standing on the Shoulders of Giants"

Objective: To assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework.Background: The long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program.Methods: Post hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade >= III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned."Results: Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.56.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome.Conclusions: The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.Surgical oncolog

POSITRON ANNIHILATION STUDIES IN ALKALI HALIDES

La technique d'annihilation positronique par utilisation de la durée de vie et distribution du momentum (par le spectromètre Ge(Li)) est employée pour étudier seize alkali halides. Les cristaux étaient irradiés par les rayons γ. Un composant additionnel de la durée de vie du positron est attribué à l'annihilation du positron piégé au centre coloré. Pour KCl, l'introduction de trous par refroidissement de cristaux non irradiés a été étudiée par les mêmes techniques, l'énergie du défaut Schottky est égale à 1,8 eV.Positron annihilation in a series of 16 alkali halides has been studied using the techniques of both lifetime and Doppler broadening. The crystals were irradiated with γ-rays in order to introduce colour centres. The systematics of the influence of colour centres on the annihilation of positrons has been observed by focussing our attention on an additional lifetime component attributed to the trapping of positrons in colour centres. For one of the alkali halides (KCl) the introduction of vacancies by thermal quenching of unirradiated crystals has been investigated by the same techniques. This has led to a new interpretation of positrons annihilating in pure alkali halides, and furthermore, yielded a determination of the Schottky formation energy of 1.8 eV

Influence of seeding rate and KCl application across the landscape

Non-Peer ReviewedThe development of variable rate controllers for air seeder carts has provided farmers with the opportunity to consider varying the rate of fertilizer and seed at seeding. While considerable work has been completed, or is currently under way, evaluating variable fertilizer rates, little has been done to determine the effect of varying seeding rates. In addition, application of potassium chloride across the landscape has been found to provide variable grain yield responses for CWRS wheat. Field research trials were established in 1997 at St. Louis (Black soil zone) and Watrous (Dark Brown soil zone) to evaluate the effect of varying CWRS wheat seeding rate and KC1 application across the upper, mid and lower slope positions of a hilly landscape. While increasing seeding rate resulted in an increase in plant establishment, this was not reflected in final grain yield. Yield component analysis determined that the increase in grain filled heads at harvest with increased seeding rate was offset by a reduction in the number of kernels per head. Wheat response to KC1 was highly variable, with an increase in grain yield at St. Louis and a decrease at Watrous. While July growing season conditions were dry at both Watrous and St. Louis, we did not collect sufficient crop establishment and yield component data to explain the results obtained