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

Resection of an isolated arterial segment during pancreatectomy

Context Isolated involvement of an arterial segment in pancreatic tumors occurs infrequently and does not necessarily mean tumor unresctability being possibly caused by tumor location rather than by excessive growth. Objective We report on the outcome of a highly selected group of patients undergoing pancreatectomy plus resection of an isolated arterial segment at a single Institution. Methods From January 1993 to May 2011 resection of an isolated arterial segment was performed during 26 pancreatectomies. There were 12 males (46.2%) and 14 females (53.8%) with a mean age of 63.6 years. One patient was operated by robotic surgery. Two patients underwent total pancreatectomy (7.7%), 5 pancreaticoduodenectomy (19.2%) and 19 distal splenopancreatectomy (73.1%). Resected arterial segments were celiac trunk (CT) (n=14), hepatic artery (HA) (n=8), CT and HA (n=4). In 6 patients the hepatic arterial flow was re-established by end-to-end anastomosis (n=1), transposition of the left gastric artery (n=1) and interposition of a saphenous vein jump-graft (n=4). Multivisceral resection was required in 9 patients. Results Final pathology disclosed ductal adenocarcinoma (DA) in 18 patients (69.2%), other pancreatic tumor types or periampullary carcinoma in 5 (19.2%) patients and metastatic tumor in 3 patients (11.5%). Fifteen DA patients were node positive (83.3%). Post-operative morbidity and mortality were 55.5% and 3.8%, respectively. After a mean follow up period of 111 months (range 5-225 months), actual survival rate was 64% at 1 year and 20% at 3 years. Equivalent figures for DA were 30% and 15%, respectively. These data favorably compare with an historical cohort of patients with locally advanced DA undergoing palliation without resection. No patient developed local recurrence, despite none received pre- or post-operative radiation. Conclusions In patients affected by DA the resection remains key for cure and possibly provides the best palliative treatment. Highly selected patients with isolated involvement of CT and/or HA may undergo pancreatectomy with results similar to patients without vascular involvement and superior to those offered by palliation or medical therapy alone. The lack of local recurrence seems to be a relevant treatment endpoint

One-Hundred and Six Robot-Assisted Pancreatectomies

Context Laparoscopy has revolutionized abdominal surgery becoming the standard approach for many operations. The “da Vinci” surgical system overcomes most of the inherent technical limitations of laparoscopy. Objective We test whether the robotic approach can improve the outcome of pancreatic resections, which often require challenging dissection and complex digestive reconstructions. Methods One-hundred and six consecutive robotic pancreatic resections were performed between October 2008 and June 2012. There were 40 males and 66 females (62%), with a mean age of 57 years (range 21-80 years) and a mean BMI of 24.6 Kg/m2. Thirty-nine patients underwent pancreaticoduodenectomy (PD) (37%), 47 distal pancreatectomy (DP) (44%), 10 total pancreatectomy (10%), 7 tumor enucleation (6%) and 3 central pancreatectomy (3%). Since our activity spans over about a 4-year period, data were analyzed according to the time of surgery, to verify progress in the learning curve: 17 patients were operated on between October 2008 and September 2009, 22 patients between October 2009 and September 2010, 32 patients between October 2010 and September 2011 and 35 patients during the last 9 months (from October 2011 to June 2012). Results No patient was converted to laparoscopy or open surgery. Mean operative time (OT) was 442.8 minutes. In the first period OT was 512 min for PD and 420 for DP. The mean number of lymph nodes examined (LN) was 16.8; 31.2 for PD and 11.9 for DP. Pancreatic fistula (PF) occurred in 41% of the patients. In the second, OT was 596 min for PD and 402 for DP. The LN was 16.7; 27.2 for PD and 10.0 for DP. PF was amounted 36.3%. In the third, OT was 583 min for PD and 288 for DP. The LN was 28.7; 36.0 for PD and 19.1 for DP. PF was amounted 36.6%. In the fourth, OT was 590 min for PD and 250 for DP. The LN was 30; 32 for PD and 20 for DP. PF was amounted 35%. Fifty-six benign/low-grade tumors and 50 cancers were diagnosed. Surgical margins were all negative. Post-operative mortality was nil, morbidity was 56% and mean hospital stay was 16 days. Conclusions Robot-assisted pancreatic resections can be safely performed in selected patients. Despite the existence of a learning curve, experienced pancreatic surgeons are not expected to pay to robotics the same price that they would have been asked for by laparoscopy.