Pancreatoduodenectomy without vascular resection in patients with primary resectable adenocarcinoma and unilateral venous contact:A matched case study

Purpose. To investigate the oncological outcome and survival of patients following a conservative approach on the portal- mesenteric axis, in an intraoperative ultrasound-selected group of pancreatoduodenectomy (PD), performed on patients with primary resectable with vascular contact (prVC) pancreatic ductal adenocarcinoma (PDAC). Methods. A consecutive series of patients who underwent PD for PDAC at our tertiary care center, between 2008 and 2017, were reviewed. A total of 156 PDs and 88 total pancreatectomies were performed during the study period, including 35 vascular resections. We identified a group of 40 (25.6%) patients with prVC-PDAC in whom after checking the feasibility with intraoperative ultrasound, we were able to perform PD by separation of the tumor from the portomesenteric axis avoiding vascular resection, without residual macroscopic disease (no vascular resection, nvrPD), and compared this group, using case-matched methodology, with the standard PD (sPD) group of primary resectable without vascular contact- (prwVC-) PDAC. Results. The median follow-up was 28.5 ± 23.2 months in the sPD group and 23.8 ± 20.8 months in the nvrPD group (p = 0 35). Isolated local recurrence rate was 2/40 (5%) in both groups. Additionally, there were no statistical differences in the systemic progression of the disease (42.5% sPD vs. 45% nvrPD, p = 0 82) or local plus synchronous systemic disease rates (2.5% sPD vs. 7.5% nvrPD, p = 0 30). The median survival was 22 months for the sPD group and 23 months for the nvrPD group, p = 0 86. The overall survival was similar in the two groups (1 y: 76.3% sPD vs. 70.0% nvrPD; 3 y: 35.6% vs. 31.6%; and 5 y: 28.5% vs. 25.3%; p = 0 80). Conclusions. PD without vascular resection can be considered safe and oncologically acceptable in selected patients with preoperative diagnosis of prVC-PDAC. The poor prognosis of PDAC is related to the aggressive biology and systemic spread of the tumor, rather than the local control of the disease

Structured cost analysis of robotic TME resection for rectal cancer:a comparison between the da Vinci Si and Xi in a single surgeon's experience

Background: Robotic-assisted surgery by the da Vinci Si appears to benefit rectal cancer surgery in selected patients, but still has some limitations, one of which is its high costs. Preliminary studies have indicated that the use of the new da Vinci Xi provides some added advantages, but their impact on cost is unknown. The aim of the present study is to compare surgical outcomes and costs of rectal cancer resection by the two platforms, in a single surgeon’s experience. Methods: From April 2010 to April 2017, 90 robotic rectal resections were performed, with either the da Vinci Si (Si-RobTME) or the da Vinci Xi (Xi-RobTME). Based on CUSUM analysis, two comparable groups of 40 consecutive Si-RobTME and 40 consecutive Xi-RobTME were obtained from the prospectively collected database and used for the present retrospective comparative study. Data costs were analysed based on the level of experience on the proficiency–gain curve (p–g curve) by the surgeon with each platform. Results: In both groups, two homogeneous phases of the p–g curve were identified: Si1 and Xi1: cases 1–19, Si2 and Xi2: cases 20–40. A significantly higher number of full RAS operations were achieved in the Xi-RobTME group (p < 0.001). A statistically significant reduction in operating time (OT) during Si2 and Xi2 phase was observed (p < 0.001), accompanied by reduced overall variable costs (OVC), personnel costs (PC) and consumable costs (CC) (p < 0.001). All costs were lower in the Xi2 phase compared to Si2 phase: OT 265 versus 290 min (p = 0.052); OVC 7983 versus 10231.9 (p = 0.009); PC 1151.6 versus 1260.2 (p = 0.052), CC 3464.4 versus 3869.7 (p < 0.001). Conclusions: Our experience confirms a significant reduction of costs with increasing surgeon’s experience with both platforms. However, the economic gain was higher with the Xi with shorter OT, reduced PC and CC, in addition to a significantly larger number of cases performed by the fully robotic approach

The use of da Vinci Xi and the increased surgeon's experience could change the perspective over the cost-benefit ratio of robot-assisted surgery

To the Editor: We read with great interest the article by Khorgami et al. entitled “The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample” [1] recently published on Surgical Endoscopy. The introduction of robotic systems in surgery was intended to overcome the known limitations of conventional laparoscopic surgery, while preserving the advantages of the minimally invasive surgery [2], justifying the growing interest in robotic technology for abdominal surgery worldwide. However, the costs of robot-assisted surgery (RAS) still represent a critical issue for its widespread adoption. The study of Khorgami et al. is a very well structured retrospective analysis of the 2012–2014 Healthcare Cost and Utilization Project-National Inpatient Sample which is the largest inpatient health care database in the United States, collecting data from more than 7 million hospital admissions annually. A total of 91,630 abdominal major and minor surgeries (87,965 laparoscopic, 3,665 robotic) were analyzed, including cholecystectomy, ventral hernia repair, right and left hemicolectomy, sigmoidectomy, abdominoperineal resection, and total abdominal hysterectomy. The average cost for the laparoscopic group was $10,227 ±$4986 versus $12,340 ±$5880 for the robotic cases (p < 0.001), suggesting that RAS is more costly when compared to conventional laparoscopic surgery. However, robotic total abdominal hysterectomy showed the lowest increased cost and was the only procedure to be performed more often robotically. This suggests that although RAS costs are higher, the difference may be offset with more routine performance of procedures using the robot. Some recent published studies of our group on rectal surgery [3,4] support this theory, showing a significant decrease of RAS overall variable costs with surgeon’s experience. This means that a possible major bias of the current economic evaluations such as those of this article, unfavorable to RAS when compared to standard laparoscopy, is that they are referred mainly to results obtained by comparing expert laparoscopists with novice robotic surgeons. A second possible bias, is that the study of Khorgami et al. refers to the years 2012-2014, when the new da Vinci Xi robotic platform was not available yet. Indeed, recent works have reported that the use of the new da Vinci Xi represents an improvement on its Si predecessor in robot-assisted colorectal resections, being associated with shorter operative time, reduced docking time and higher full robotic resection rates and significantly reducing RAS-associated costs [3-5]. In conclusion, the article by Khorgami et al. deals with a very interesting topic analyzing a huge sample size. However, the use of the new da Vinci Xi platform, as well as of new robots, by robotic surgeons with an adequate experience could nowadays change the perspective over the cost-benefit ratio of RAS

Is there a role of robotic surgery in abdominal organs transplantations?

Abdominal organs transplantations represent the only poten-tially curative treatment in several end stage-diseases, but despite the improvement of the surgical techniques and the overall good outcomes, the invasiveness of these procedures is still very high. Therefore, the possible application of mini-mally invasive surgery in this field would be of great interest.Until a few years ago this application was not even con-sidered because of the kinematic limitations of laparoscopy which makes very challenging to carry out the reconstruc-tive phases of the transplant. Instead, more recently, since the successful introduction of the da Vinci Surgical System, the possible application of robot-assisted Surgery (RAS) in organ transplantation has become a reality [1].Indeed, with RAS, several limitations of laparoscopic technique for minimally invasive surgical procedures have been overcome, particularly with its latest version, the da Vinci Xi, capable to ensure an easy docking, a wide range of motion with its small, thin arms, the ability to attach the endoscope to any arm, and a highly flexible access to differ-ent anatomical regions [2]. Thus, thanks to these features, the execution of vascular anastomoses has become feasible, offering a new impetus in proposing a minimally invasive approach to patients suitable for an abdominal solid organ transplantation.However, although the technical feasibility of RAS to certain abdominal transplantations procedures has been recently demonstrated by several groups [1], we think that its use in this field is still affected by some main limita-tions that prevent its wide diffusion. In fact, the first critical issue is related to the donor organ’s insertion and manipula-tion through a narrow incision, with the associated risk of organ damage and/or difficult positioning. Furthermore, this limitation together with the longer execution time of vascu-lar anastomoses, could negatively impact on the ischemia time, the reduction of which is instead crucial, especially nowadays that organs procurement from deceased marginal donors is becoming more and more frequent to shorten the continuously growing waiting lists [3, 4].For all these reasons, although dedicated clinical postop-erative follow-up strategies [5, 6] and optimized immuno-suppressant therapies [7, 8] have contributed today to very good outcomes in abdominal solid organs transplantations even with marginal donors, the reduction of operative time for the reconstructive phase is still a major critical factor, and can represent a major limitation for a wide application of RAS.Finally, the use of RAS for organ transplantations on a wider scale could clash with two other non-clinical funda-mental matters, such as the necessity of a continuous avail-ability of the robotic system for a non-elective surgery and the economical sustainability of this approach [9].In conclusion, we think that RAS in transplant surgery is an appealing and promising technique, and without any doubt it represents an open window out to the future, but today it is still far to become the new standard approach, particularly for deceased donor organs transplantation

The role of hand-assisted laparoscopic splenectomy for mega spleens in the da Vinci era

Dear Editor, we read with great interest the article by Cavaliere et al., entitled “Robotic vs laparoscopic splenectomy for splenomegaly: A retrospective comparative cohort study” published on International Journal of Surgery [1]. Laparoscopic splenectomy is nowadays considered the gold standard for normal to moderately enlarged spleens. However, in case of more challenging conditions such as mega-spleens or cirrhotic patients, the laparoscopic approach is still associated with high risk of intra-and post-operative bleeding, high conversion rate, and high morbidity. In this setting, the authors compared the robot-assisted laparoscopic surgery (RAS) with the direct manual laparoscopy (DML), reporting possible advantages with the use of the da Vinci System for splenectomy in case of splenomegaly. In particular, they reported improved outcomes with RAS in terms of reduced intraoperative bleeding and less conversions to open surgery, although if they also admitted the limitations of the study, such as its retrospective nature and the small sample size, which prevent to draw definitive conclusions. Furthermore, they reported the longer operative time and the higher costs as two limitations of RAS, respect to DML. We think that, while it is true that the increased dexterity offered by RAS should reasonably help younger or less skilled laparoscopic surgeons to obtain better results in splenectomies for moderate splenomegaly, in case of mega spleens, due to the reduced operative field and to the lack of a tactile feedback, these advantages could not be translated in the same good results, also in expert hands. Indeed, facing with mega spleens, the robot-assisted intra-corporeal manipulation and the exposure of the hilum, as well of the ligaments dissection can still be very difficult, and this difficulty can be accented by the absence of tactile feedback together with the fragility of the parenchyma, which can easily break and bleed. For these reasons, although if we strongly support RAS for several indications in general surgery [2-9], we think that so far, the better option to face a splenectomy in case of mega spleens should be still the Hand Assisted Laparoscopic Surgery (HALS) technique. Indeed, HALS has the advantage of maintaining a minimally invasive surgical approach like DML, without losing the tactile feedback, thanks to the non-dominant hand inserted in the abdomen, with a powerful ability to gently manipulate the spleen and to bluntly dissect. As a consequence, with HALS, the use of the non-dominant hand strongly increases local control, exposure and manipulation. In particular, HALS allows to improve the accuracy of manipulation by direct tactile sense, and by maintaining tactile feedback and hand-eye coordination, the surgeon can bluntly dissect adhesion around the spleen and encircle the splenic pedicle and the space beneath the tail of the pancreas with the hand in the abdominal cavity [10]. Moreover, in case of marked splenomegaly, it is difficult and sometimes impossible to dissociate the spleen using both DML or RAS, due to the limited visualization of this area owing to the large spleen size, while for HALS, these attachments can usually be severed by blunt finger dissection even in areas that are hidden from the endoscopic view because of the retained tactile feedback [11]. For all these reasons we think that, in challenging cases, the HALS approach can increase safety and reduce conversion rates without significantly increasing costs, at the same time maintaining the good post-operative outcomes of DML or RAS in terms of hospitalization and complications, thus maintaining all the advantages of minimally invasive management [10–12]. Finally, the access for the left hand for the HALS technique can be used in malignant diseases, for the extraction of the entire spleen through the subcostal incision used for the hand port. In conclusion, thanks to the possibility to choose between DML, RAS and HALS, the minimally invasive surgery should be always considered as the best approach for splenectomy in case of splenomegaly of any size. The limits of the traditional laparoscopic technique can be increasingly overcome by the technical advantages of the robotic system or by the use of an HALS technique, depending on surgeon’s experience and on spleen size or disease

Comment on “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-center experience from southern India”

To the Editor: We read with great interest the article by Shajahan et al. entitled “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-centre experience from southern India” [1] recently published on Indian Journal of Gastroenterology. ABO-incompatible living donors liver transplantation (ABO-I LDLT) represents a precious opportunity to shorten the waiting time for surgery, avoiding the disease progression that might occur waiting for an ABO-compatible living or deceased donor. However, ABO-I LDLT is still associated with a high risk of antibody-mediated rejection (AMR), lower patient and graft survival and a high risk of vascular thrombosis and ischemic bile duct complications if compared to ABO-compatible LT. The study of Shajahan et al. represents the largest report of ABO-I LDLT from India, even if the sample size is still small. The authors retrospectively analyzed data of 12 patients undergone ABO-I LDLT using Rituximab and preoperative plasmapheresis for desensitisation, adjusting doses after facing a very high mortality rate in the first 7 patients (5 deaths), mostly due to septic complications. Rituximab, a murine/human monoclonal chimeric antibody against CD20 depleting B-lymphocytes, has traditionally been used to treat haematological malignancies and autoimmune diseases. More recently, it has been gained interest as an immunomodulatory agent in solid organ transplantations. [2] Although if current literature is more and more supporting the effectiveness of Rituximab in antibody-mediated rejection (AMR) as a desensitizing regimen, several reports have shown that concerns still remain in the high incidence of complication rates, such as biliary strictures, ischemic-type biliary lesions and postoperative infections. [3,4,5] Particularly this latter complication afflicted the study of Shajahan et al. who faced a dramatically high rate of postoperative infections involving 9 out of 12 patients, of whom 5 died due to overwhelming sepsis from multidrug-resistant pathogens. Several works such as a Japanese multicenter study have demonstrated that multiple or large Rituximab doses significantly increase the incidence of infection [3], advocating for a “minimization” of the desensitizing protocols. Even if authors have reduced the Rituximab doses after the first 7 cases, the overall septic complications and morality rates still remain very high (75% and 50% respectively), raising the issue of the desensitizing regimen’s adequacy. Actually, different modalities of Rituximab free immunosuppressive regimens to prevent AMR have been successfully reported in literature, such as the use of high-dose polyclonal intravenous immunoglobulin associated with plasmapheresis without the use of steroid pulses or monoclonal antibodies, or even of everolimus-based immunosuppressive regimen under a strict monitoring of anti-A/B antibodies titres [6,7]. In conclusion, we strongly believe that more and more efforts should be make to minimize the desensitization regimen in ABO-I LDLT in order to reduce the rates of septic complications and improve patients’ and grafts’ survival. Moreover, prospective studies with bigger sample sizes are required to validate the Indian ABO-I LDLT experience