First World Consensus Conference on pancreas transplantation: Part II - recommendations.

Funder: Fondazione Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/100007368Funder: Tuscany Region, Italy; Id: http://dx.doi.org/10.13039/501100009888Funder: Pisa University Hospital, Pisa, ItalyFunder: University of Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/501100007514The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246

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

Indications, technique, and results of robotic pancreatoduodenectomy

Robotic assistance improves surgical dexterity in minimally invasive operations, especially when fine dissection and multiple sutures are required. As such, robotic assistance could be rewarding in the setting of robotic pancreatoduodenectomy (RPD). RPD was implemented at a high volume center with preemptive experience in advanced laparoscopy. Indications, surgical technique, and results of RPD are discussed against the background of current literature. RPD was performed in 112 consecutive patients. Conversion to open surgery was required in three patients, despite nine required segmental resection and reconstruction of the superior mesenteric/portal vein. No patient was converted to laparoscopy. A pancreato-jejunostomy was created in 106 patients (94.6 %), using either a duct-to-mucosa (n = 82; 73.2 %) or an invaginating (n = 24; 21.4 %) technique. Pancreato-gastrostomy was performed in one patient, the pancreatic duct was occluded in two patients, and a pancreatico-cutaneous fistula was created in three patients. Mean operative time was 526.3 ± 102.4 in the entire cohort and reduced significantly over the course of time. Experience was also associated with reduced rates of delayed gastric emptying and increased proportion of malignant tumor histology. Ninety day mortality was 3.6 %. Postoperative complications occurred in 83 patients (74.1 %) with a median comprehensive complication index of 20.9 (0–30.8). Clinically relevant pancreatic fistula occurred in 19.6 % of the patients. No grade C pancreatic fistula was noted in the last 72 consecutive patients. RPD is safely feasible in selected patients. Implementation of RPD requires sound experience with open pancreatoduodenectomy and advanced laparoscopic procedures, as well as specific training with the robotic platform

The learning curve in robotic distal pancreatectomy

No data are available on the learning curve in robotic distal pancreatectomy (RADP). The learning curve in RADP was assessed in 55 consecutive patients using the cumulative sum method, based on operative time. Data were extracted from a prospectively maintained database and analyzed retrospectively considering all events occurring within 90 days of surgery. No operation was converted to laparoscopic or open surgery and no patient died. Post-operative complications occurred in 34 patients (61.8 %), being of Clavien-Dindo grade I-II in 32 patients (58.1 %), including pancreatic fistula in 29 patients (52.7 %). No grade C pancreatic fistula occurred. Four patients received blood transfusions (7.2 %), three were readmitted (5.4 %) and one required repeat surgery (1.8 %). Based on the reduction of operative times (421.1 ± 20.5 vs 248.9 ± 9.3 min; p < 0.0001), completion of the learning curve was achieved after ten operations. Operative time of the first 10 operations was associated with a positive slope (0.47 + 1.78* case number; R (2) 0.97; p < 0.0001*), while that of the following 45 procedures showed a negative slope (23.52 - 0.39* case number; R (2) 0.97; p < 0.0001*). After completion of the learning curve, more patients had a malignant histology (0 vs 35.6 %; p = 0.002), accounting for both higher lymph node yields (11.1 ± 12.2 vs 20.9 ± 18.5) (p = 0.04) and lower rate of spleen preservation (90 vs 55.6 %) (p = 0.04). RADP was safely feasible in selected patients and the learning curve was completed after ten operations. Improvement in clinical outcome was not demonstrated, probably because of the limited occurrence of outcome comparators

Effects of complete immunosuppression suspension after pancreatic graft loss

Background: In the event of loss of function of a pancreatic graft, there are two safe options: suspension of immunosuppressive therapy followed by explantation of the grafted pancreas, or maintenance of reduced doses of mycophenolate without explanting the graft. Methods: A 73-year-old woman, who had received a pancreas transplant alone in 2001 when she was 54, since 2018 suffered the loss of renal function requiring hemodialysis treatment. In 2019, due to repeated acute rejection episodes, she has lost also the function of the grafted pancreas. First, tacrolimus therapy was suspended then, in March 2020 also mycophenolate was interrupted. In September 2020, the patient has accessed the emergency room for massive hematemesis. A contrast-enhanced computed tomography scan of the abdomen showed infected perigraft hematoma with an anastomotic pseudoaneurysm that fistulized in the graft duodenum. Results: The patient was immediately stabilized and underwent a radiological interventional procedure for stent placement in the native right common iliac artery, excluding the native right internal iliac artery and the anastomosis with the common branch of the Y artery graft for the transplanted pancreas. Two days later the patient underwent graft removal with ligation and section of the native right common iliac artery at the level of the anastomosis serving the transplanted pancreas. Due to acute ischemia of the right lower limb, 24 hours later a femoro-femoral arterial crossover was constructed using a cryo-preserved graft. Despite the full restoration of arterial vascularization to the ischemic limb, the patient died five days later. Conclusions: After the loss of a pancreatic graft, if not explanted, it is advisable to maintain immunosuppression at low doses to avoid recurrence of severe acute rejection phenomena with colliquative evolution of the transplanted organ, potentially leading to anastomotic pseudoaneurysms and/or fistulization in the grafted duodenum