A multidisciplinary approach to estimating wolf population size for long-term conservation

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REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer

OBJECTIVE: The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC).SUMMARY BACKGROUND DATA: Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking.METHODS: The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines.RESULTS: Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ).CONCLUSIONS: The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.</p

REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer

OBJECTIVE: The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC).SUMMARY BACKGROUND DATA: Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking.METHODS: The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines.RESULTS: Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ).CONCLUSIONS: The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.</p

LA CHIRURGIA ROBOTICA APPLICATA ALLE EPATECTOMIE MAGGIORI

La vera evoluzione del mondo della chirurgia mininvasiva è stata lo sviluppo della chirurgia robotica. Le epatectomie maggiori sono eseguibili con l’utilizzo di queste tecnologie ed i dati analizzati fino ad ora, seppur pochi, sono soddisfacenti e la procedura si è dimostrata sicura in termini di realizzazione e di decorso post-operatorio e riproducibile. Indubbiamente si aggiungono ad una chirurgia di maggior precisione i vantaggi della mininvasività della tecnica, ed a questo proposito a giovarne soprattutto potrebbero essere proprio quegli interventi a complessità maggiore come le epatectomie, rispetto ad interventi meno complessi come le settoriectomie o le wedge-resection. La chirurgia epatica robotica consente l’accesso alle più piccole e delicate strutture del fegato, e permette al chirurgo di vedere con precisione vasi sanguigni e dotti biliari. La visione 3D offre il vantaggio di un’aumentata percezione della profondità e conseguentemente di una maggiore accuratezza. Inoltre il sistema robotico comporta una minore manipolazione degli organi, con conseguente riduzione del trauma. Nonostante tutte le aspettative attorno a questa nuova strada che si sta aprendo è ancora presto per dare dei giudizi assoluti, i casi sono ancora pochi, così come l’esperienza. Solo in futuro si potrà dire se in effetti la chirurgia robotica, applicata alle epatectomie maggiori, determini una diminuzione delle complicanze a breve e a lungo termine e quindi possa diventare una tecnica di scelta preferenziale per questi tipi di intervento

Laparoscopic robot-assisted resection of tumors located in posterosuperior liver segments

Laparoscopic resection of liver tumors located in the posterosuperior segments is a challenging operation that could be facilitated by robotic assistance. Laparoscopic resection of 12 tumors located in posterosuperior segments (IVa: 1; VII: 5; VIII: 6) was carried out under robotic assistance. All patients had a single tumor nodule. Data were collected prospectively and analyzed retrospectively. Surgery required a mean of 260.4 min (115–430) and was completed laparoscopically in all but one patient, who required conversion to mini-laparotomy because of intolerance of pneumoperitoneum (8.3 %). Mean estimated blood loss was 252.7 ml (50–600), making transfusion necessary in 3 patients (25.0 %). Post-operative complications occurred in 4 patients (33.3 %), being of Clavien–Dindo grade II in 3 patients (25.0 %) and Clavien–Dindo grade IV in 1 patient (8.3 %). Reoperation was required in 1 patient, who subsequently had a long hospital stay, because of decompensated cirrhosis. Median length of hospital stay was 8.5 days (7–96). No patient was readmitted. Pathology showed hepatocellular carcinoma in 7 patients (58.3 %), liver metastasis in 2 patients (16.6 %), and hepatic adenoma, focal nodular hyperplasia, and hemangioma in one patient each (8.3 %). All patients had a margin negative resection. After a mean follow-up period of 21.4 months (±24.4), no patient with malignant histology developed recurrence. Our initial experience confirms that laparoscopic robot-assisted resection of tumors located in the posterosuperior segments is feasible. Further experience is needed before final conclusions can be drawn and meaningful comparison with other surgical techniques becomes possible

Laparoscopic pancreaticoduodenectomy: A systematic literature review

Background Laparoscopic pancreaticoduodenectomy (LPD) is gaining momentum, but there is still uncertainty regarding its safety, reproducibility, and oncologic appropriateness. This review assesses the current status of LPD. Methods Our literature review was conducted in Pubmed. Articles written in English containing five or more LPD were selected. Results Twenty-five articles matched the review criteria. Out of a total of 746 LPD, 341 were reported between 1997 and 2011 and 405 (54.2%) between 2012 and June 1, 2013. Pure laparoscopy (PL) was used in 386 patients (51.7%), robotic assistance (RA) in 234 (31.3%), laparoscopic assistance (LA) in 121 (16.2%), and hand assistance in 5 (0.6%). PL was associated with shorter operative time, reduced blood loss, and lower rate of pancreatic fistula (vs LA and RA). LA was associated with shorter operative time (vs RA), but with higher blood loss and increased incidence of pancreatic fistula (vs PL and RA). Conversion to open surgery was required in 64 LPD (9.1%). Operative time averaged 464.3 min (338–710) and estimated blood 320.7 mL (74–642). Cumulative morbidity was 41.2%, and pancreatic fistula was reported in 22.3% of patients (4.5–52.3%). Mean length of hospital stay was 13.6 days (7–23), showing geographic variability (21.9 days in Europe, 13.0 days in Asia, and 9.4 days in the US). Operative mortality was 1.9%, including one intraoperative death. No difference was noted in conversion rate, incidence of pancreatic fistula, morbidity, and mortality when comparing results from larger (C30 LPD) and smaller (B29 LPD) series. Pathology demonstrated ductal adenocarcinoma in 30.6% of the specimens, other malignant tumors in 51.7%, and benign tumor/disease in 17.5%. The mean number of lymph nodes examined was 14.4 (7–32), and the rate of microscopically positive tumor margin was 4.4%. Conclusions In selected patients, operated on by expert laparoscopic pancreatic surgeons, LPD is feasible and safe

ROBOT ASSISTED LIVER SURGERY: REPORT OF 8 MAJOR HEPATIC RESECTIONS AND 3 LEFT LATERAL SECTIONECTOMIES

ROBOT ASSISTED LIVER SURGERY: REPORT OF 8 MAJOR HEPATIC RESECTIONS AND 3 LEFT LATERAL SECTIONECTOMIE