Robotic pancreatoduodenectomy for a solid pseudopapillary tumor in a ten-year-old child

BACKGROUND: Pancreatoduodenectomy (Whipple resection) in children is feasible though rarely indicated. In several pediatric malignancies of the pancreas, however, it may be the only curative strategy [1]. With the emergence of robotic pancreatoduodenectomy as at least a clinically equivalent alternative to open surgery [2], it remains to be determined whether the pediatric population may potentially benefit from this minimally invasive procedure. Here we present, for the first time, a video of setup and surgical technique of robotic pancreatoduodenectomy in a child. METHODS: A 10-year-old girl presented with complaints of fullness and abdominal pain in the upper quadrants. Investigations including a diffusion-weighted, pancreatic MR scan suggested the diagnosis of solid pseudopapillary tumor (Frantz's tumor). The patient was considered for robotic pancreatoduodenectomy. RESULTS: After anesthesia, the patient was placed supine on a split-leg table. Trocar placement was adjusted to accommodate the child's length and body weight, according to pre-operatively calculated positions that would allow for maximum working space and minimize inadvertent collision between the robotic arms. The da Vinci Si surgical robot was positioned in-line towards the surgical target and all four robotic arms were docked, while two additional laparoscopic ports were placed for tableside assistance. After standard pancreatoduodenectomy, a conventional loop reconstruction was performed including an end-to-side pancreaticojejunostomy with duct-to-mucosa technique and stapled side-to-side gastrojejunostomy. We suggest that in this patient group, pylorus preserving pancreatoduodenectomy with end-to-side duodenojejunostomy may be a suitable alternative. Postoperative recovery was complicated by delayed gastric emptying but otherwise unremarkable. Hospital length of stay was 12 days. Final pathology demonstrated a solid pseudopapillary tumor with negative surgical margins. CONCLUSION: This case illustrates the feasibility of robotic pancreatoduodenectomy in children. Essential elements of this procedure are a well-running robotic pancreatic surgery program as well as careful preoperative port placement planning

Robotic pancreatoduodenectomy for a solid pseudopapillary tumor in a ten-year-old child

BACKGROUND: Pancreatoduodenectomy (Whipple resection) in children is feasible though rarely indicated. In several pediatric malignancies of the pancreas, however, it may be the only curative strategy [1]. With the emergence of robotic pancreatoduodenectomy as at least a clinically equivalent alternative to open surgery [2], it remains to be determined whether the pediatric population may potentially benefit from this minimally invasive procedure. Here we present, for the first time, a video of setup and surgical technique of robotic pancreatoduodenectomy in a child. METHODS: A 10-year-old girl presented with complaints of fullness and abdominal pain in the upper quadrants. Investigations including a diffusion-weighted, pancreatic MR scan suggested the diagnosis of solid pseudopapillary tumor (Frantz's tumor). The patient was considered for robotic pancreatoduodenectomy. RESULTS: After anesthesia, the patient was placed supine on a split-leg table. Trocar placement was adjusted to accommodate the child's length and body weight, according to pre-operatively calculated positions that would allow for maximum working space and minimize inadvertent collision between the robotic arms. The da Vinci Si surgical robot was positioned in-line towards the surgical target and all four robotic arms were docked, while two additional laparoscopic ports were placed for tableside assistance. After standard pancreatoduodenectomy, a conventional loop reconstruction was performed including an end-to-side pancreaticojejunostomy with duct-to-mucosa technique and stapled side-to-side gastrojejunostomy. We suggest that in this patient group, pylorus preserving pancreatoduodenectomy with end-to-side duodenojejunostomy may be a suitable alternative. Postoperative recovery was complicated by delayed gastric emptying but otherwise unremarkable. Hospital length of stay was 12 days. Final pathology demonstrated a solid pseudopapillary tumor with negative surgical margins. CONCLUSION: This case illustrates the feasibility of robotic pancreatoduodenectomy in children. Essential elements of this procedure are a well-running robotic pancreatic surgery program as well as careful preoperative port placement planning

Minimizing blood loss in liver transplantation: Progress through research and evolution of techniques

Blood loss during liver transplantation has long been recognized as an important cause of morbidity and, especially in the early days, also mortality. It is well known that blood transfusions are associated with an increased risk of postoperative complications, such as infections, pulmonary complications, protracted recovery, and a higher rate of reoperations. Many studies have been performed during the past decades to elucidate the mechanisms of increased blood loss in liver transplantation. In the late 1980s, primary hyperfibrinolysis was identified as an important mechanism of bleeding during liver transplantation. This has provided the scientific basis for the use of antifibrinolytic drugs in liver transplant recipients. Several randomized, controlled studies have shown the efficacy of these compounds in reducing blood loss and transfusion requirements during liver transplantation. In addition, increasing experience and improvements in surgical technique, anesthesiological care and better graft preservation methods have contributed to a steady decrease in blood transfusion requirements in most liver transplant programs. Several centers are now reporting liver transplantation without any need for blood transfusion in up to 30% of their patients. Despite these improvements, most patients undergoing liver transplantation still require blood transfusions that have a negative impact on outcome, emphasizing the need for further attempts to control blood loss by surgeons and anesthesiologists. This paper provides an overview of the clinical and research developments, which have contributed to a reduction in blood loss and transfusion requirements, resulting in an important reduction in morbidity and mortality after liver transplantation during the last two decades

Reduced need for vasopressors in patients receiving aprotinin during orthotopic liver transplantation

Background: Graft reperfusion in orthotopic liver transplantation is often associated with significant hemodynamic changes, including decreased systemic vascular resistance and arterial blood pressure. Vasopressive drugs are often required to maintain adequate perfusion pressure during the early postreperfusion period. The exact mechanism of this postreperfusion syndrome is unknown, but release of bradykinin, a potent vasodilatator, via the kallikrein system may play a role. Aprotinin is a broad-spectrum inhibitor of serine proteases such as kallikrein and therefore may ameliorate the postreperfusion syndrome and reduce the need for vasopressors. Methods: In a randomized, double-blind study, the authors compared hemodynamic variables (systemic vascular resistance, cardiac index, arterial blood pressure, mean pulmonary artery pressure, central venous pressure) and the requirement of epinephrine during transplantation in 67 patients who received either high-dose aprotinin (2 x 10(6) kallikrein inhibitor units [KIU] at induction, continuous infusion of 1 x 10(6) KIU/h, 1 x 10(6) KIU before reperfusion; n = 24), regular-dose aprotinin (2 x 10(6) KIU at induction, continuous infusion of 0.5 x 10(6) KIU/h; n = 21), or placebo (n = 22). Results: Baseline characteristics were similar for all three groups. Erythrocyte transfusion requirement was significantly higher in the placebo group compared with both aprotinin-treated groups. No major differences in hemodynamic variables were found between the three groups. The total amount of epinephrine (median, range) used during transplantation, however, was significantly lower in patients who received aprotinin (high dose, 20, 0-170 mug; regular dose, 30, 0-140 mug), compared with patients who received placebo (70, 0-2,970 mug; P = 0.0017). This difference was largely attributable to differences in the early postreperfusion period. Conclusions: Prophylactic use of aprotinin ameliorates the postreperfusion syndrome in orthotopic liver transplantation, as reflected by a significant reduction in vasopressor requirements