Minimally invasive surgery for pancreatic tumors: laparoscopy versus robotic surgery

Chirurgia tumorilor pancreatice reprezintă un domeniu în care dezvoltarea tehnologică încearcă să aducă progrese semnificative în ceea ce privește tehnica chirurgicală, mai ales atunci când se indică un abord minim invaziv. Lucrarea de față subliniază principalele indicații, avantaje, dezavantaje și rezultate ce însoțesc tehnicile minim invazive laparoscopice și robotice, prin prisma ultimelor date din literatura de specialitate și experiența autorilor, alături de conduita intraoperatorie, în funcție de localizarea tumorală: cefalopancreatică sau corporeo-caudală pancreatică.Surgery for pancreatic tumors represents an area in which technological development to day seeks to bring significant advances in surgical technique, especially when a minimally invasive approach is indicated. The present paper emphasizes the main indications, advantages, disadvantages and results accompanying the minimally invasive laparoscopic and robotic techniques, in the light of the latest data from the specialized literature and the authors' experience, along with the intraoperative tactical aspects, according to the tumoral topography: cephalopancreatic or corporeo-caudal pancreatic

The importance of prehabilitation of patients prior to esophagectomy

Scop: Momentan, nu există un standard de aur referitor la preoptimizarea pacienților înainte de esofagectomie, în timp ce multiple studii raportează rezultate postoperatorii îmbunătățite după implementarea diverselor programe de pregătire. Una dintre principalele probleme rămâne aderența la programul de pregătire; un program la domiciliu poate ajuta semnificativ cu aceasta problema, făcând preoptimizarea mai accesibilă. Material și metode: Prin studiul de față raportăm o serie de pacienți înrolați într-un program de pregătire preoperatorie la domiciliu. Studiul a demarat în 2022 și este în curs de desfășurare. Programul de pregătire cuprinde optimizarea nutrițională (alimentație hiperproteică și suplimente proteice precum pudra de proteine sau băuturi proteice, suplimentare cu micronutrienți, montare jejunostomie de alimentație la nevoie), terapie fizică (plimbări zilnice și exerciții fizice ușoare), terapie respiratorie (exerciții inspiratorii și expiratorii folosind spirometrul de exerciții), șsi optimizare psihologica (suportul familiei și a prietenilor). Rezultate: Douăzeci și unu de pacienți au fost incluși în studiu. Câteva din beneficiile percepute includ status nutrițional și respirator îmbunătățit la internare, impact psihologic pozitiv prin implicarea directă a pacientului în procesul de tratament, mobilizarea postoperatorie independenta mai precoce, rata de complicații pulmonare postoperatorii mai scăzută. Concluzii: Preoptimizarea pacienților înainte de esofagectomie poate îmbunătăți semnificativ rezultatele postoperatorii. Programele bazate la domiciliu pot fi soluția pentru implementarea pe scară largă.Aim: There is currently no standard of care regarding prehabilitation programs before esophagectomy, while several studies report improved postoperative outcomes with different programs. One of the main issues remains the difficulties with adherence to the programs; a home-based approach might significantly help with this issue, making prehabilitation more affordable and patient-friendly. Methods: We report a prospective series of cases that were enrolled in a home-based prehabilitation program. The study started in 2022 and is ungoing. The prehabilitation program includes nutritional optimization (protein-rich foods and supplements like protein powder or protein drinks, micronutrient supplements, feeding jejunostomy – when needed), physical therapy (daily walks and basic exercises), respiratory training (Inspiratory and expiratory muscle training - spirometer) and psychological optimization (family and friends support). Results: Twenty-one patients were enrolled in our study. Some of the perceived benefits of the prehabilition program includes: better nutritional and physical status at admission, psychological benefit due to the patient being involved into the treatment process, earlier postoperative independent mobilization, lower postoperative pulmonary complications. Conclusions: Prehabilitation in patients undergoing esophagectomy can significantly improve outcomes. Home-based programs are efficient and might be the solution for implementing prehabilitation on a large scale

A step-by-step laparoscopic suturing skills educational program for surgical resident trainees

Scop: Modelul educațional see one - do one – teach one s-a dovedit ca fiind ineficient în învățarea tehnicilor de chirurgie minim invaziva. Sutura laparoscopică este o tehnică esențială în chirurgia minim invazivă, dar în același timp dificil de învățat. Scopul studiului nostru este să dovedească necesitatea și fezabilitatea unui model de training etapizat pentru introducerea rezidenților din specialitățile chirurgicale în bazele suturii laparoscopice. Material și metode: Studiul nostru este un studiu prospectiv care a inclus rezidenți din specialități chirurgicale fără experiență anterioara în sutura laparoscopică. Au fost organizate trei sesiuni separate de training, pe diferite nivele de dificultate: aptitudini de baza în sutura laparoscopică: exerciții dedicate manipulării acului și efectuării nodurilor chirurgicale; aptitudini intermediare în sutura laparoscopică: suturi continue și întrerupte folosind fire monofilament, multifilament pe materiale sintetice și biologice; aptitudini avansate în sutura laparoscopică: efectuarea anastomozelor intestinale terminoterminale și laterolaterale. Rezultate: Douăzeci de participanți au fost incluși în primele două sesiuni, respectiv 10 participanți fiind incluși în a treia sesiune. Cinci participanți au fost înrolați consecutiv în toate cele 3 sesiuni de training. Comparativ cu participanții care nu au urmat programul etapizat, cei 5 participanți au avut timpi de execuție mai rapizi și tehnică chirurgicală de calitate mai bună, indiferent de anul de rezidențiat. Concluzii: Modelul de training propus permite participanților să învețe noile principii într-o manieră graduală, permițând învățarea eficientă a tehnicilor complexe de sutură, dovedind astfel eficacitatea modelului educațional.Aim: The see one - do one - teach one apprenticeship model has been proved to be ineffective in teaching minimally invasive surgical skills. Laparoscopic suturing is an essential technique for minimally invasive surgery, but as well a very difficult skill to learn. The aim of our study is to prove the necessity and the feasibility of a step-by-step training model for teaching surgical residents the basic of laparoscopic suturing. Methods: We have conducted a prospective study that included surgical residents without previous experience in laparoscopic suturing. Three separate training sessions were organized, based on different competency levels: basic skills in laparoscopic suturing: exercises for needle manipulation and knot tying; intermediate laparoscopic suturing skills: interrupted and continuous sutures using multifilament, monofilament, and barbed wires on synthetic and biologic material; advanced laparoscopic suturing skills: end-to-end and side-to-side intestinal anastomoses. The activity of the participants was evaluated by 5 trainers. Results: Twenty participants were enrolled in the first two sessions and 10 participants were enrolled in the third session. Five participants have consecutively participated in all three training sessions. Compared to the participants that did not follow the step-up program, the 5 participants had faster execution times and higher quality suturing, regardless of their year of study. Conclusions: Our proposed training model allows the trainee to get acquainted with the new patterns of movement in a gradual manner, allowing them to efficiently learn complex suturing skills, proving to be an effective teaching method

Nano-Antimicrobial Solutions Using Synthetic-Natural Hybrid Designs

Nanotechnology potential in antimicrobial therapy is increasingly demonstrated by various data. Results reveal antibacterial properties, comparable to that of conventional antibiotics. Working on parallel experiments, researchers continue to bring evidence demonstrating age-old-recognized antibacterial properties of various natural components of plant and animal origin. Later years brought an increasing trend for combining synthetic and natural composition in new constructs. The tendency aims to bring more on different essential aspects, such as active substance release, improvement of antibacterial effect, and up-regulation of the mechanisms at the structure-cell interface. Present chapter structures the up-to-date achievements in the field, including the concept of design, biological effects, benefits, mechanisms, and limitations of the field. Also, expected future research directions are to be discussed

Iatrogenic bile duct injuries – the road to consensus

Scop: Leziunile iatrogene de cale biliară după colecistectomia laparoscopică reprezintă o problemă serioasă care trebuie manageriată corect din punct de vedere diagnostic și al unui tratament prompt. Multiple clasificări au fost dezvoltate și utilizate pentru descrierea acestor leziuni. Material și metode: Studiul nostru este un studiu de tip retrospectiv descriptiv cu scopul de a identifica rolul unei clasificări uniforme și complete, dar și implicarea acesteia în managementul leziunilor de cale biliară. Au fost incluși pacienți referați în centru nostru terțiar, pentru tratamentul leziunilor de cale biliară survenite după colecistectomia laparoscopică, pe o perioadă de 10 ani (2011-2020). Rezultate: O sută de pacienți au fost incluși în studiu; 15% din leziuni au fost întâmpinate la cazuri operate primar în serviciul nostru. În 73% din cazuri, leziunile nu au fost clasificate, în 23% din cazuri s-a utilizat clasificarea Strasberg, în 3% din cazuri clasificarea Bismuth, iar în 1% din cazuri clasificarea ATOM. După reclasificarea retrospectivă a tuturor cazurilor, s-a observat că clasificarea Straberg, dar chiar și clasificarea Hannover suprasimplifică complexitatea leziunii. Tratamentul în majoritatea cazurilor a fost derivația biliodigestivă (60% din cazuri). Concluzii: Clasificarea ATOM realizează o descriere comprehensivă a leziunilor biliare, putând ghida astfel tratamentul corespunzător în funcție de severitatea fiecărei leziuni. O clasificare uniformă ar trebui adoptată la scară largă pentru a asigura un limbaj comun în discuția referitoare la leziunile de cale biliară.Aim: Iatrogenic bile duct injuries after laparoscopic cholecystectomy represent a significant problem, that needs to be addressed correctly in terms of diagnosis and prompt treatment. Several classifications have been developed and used to describe these lesions. Methods: Our study is a retrospective descriptive study that aims to identify the role of an uniform and comprehensive classification and its implication on the consecutive management of the bile duct injury. We have included patients diagnosed with bile duct injury after laparoscopic cholecystectomy, referred to a tertiary centre, in a ten-year period (2011-2020). Results: We included in our study 100 patients; 15% of the BDI occurred in our center. No classification system was used in 73% of patients; 23% of the BDI were classified by the Strasberg system, 3% were classified by the Bismuth classification, 1% being classified by the ATOM classification. After retrospectively classifying all BDI, we observed that especially the Strasberg classification, as well as Hannover, over-simplifies the characteristics of the injury. Most main bile duct injuries underwent a bilio-digestive anastomosis (60%), as a definitive treatment. Conclusions: The ATOM classification performs a comprehensive description of the bile duct injury and subsequent guidance of the correct treatment according to the severity of each lesion. A consistent classification should be adopted, in order to assure a uniform discussion on iatrogenic bile duct injuries

Challenges and controversies in open pancreatoduodenectomies

Duodenopancreatectomia cefalopancreatica este o procedura intricata, ce necesita o inalta precizie datorita proximitatii structurilor vitale, sustinuta prin expertiza. O data cu evolutia chirurgiei si aparitia de instrumente inovatoare, mortalitatea a scazut sub 5%, dar morbiditatea a ramas la 30%, in special datorita fistulelor de anastomoza si a evenimentelor hemoragice. In acest sens, chirurgia deschisa confera rezultate mai bune, cu o curba de invatare rezonabila. Cu atat mai mult, cu cat efectuarea de trialuri clinice este dificila in acest domeniu, atat in chirurgia deschisa, cat si minim invaziva, pentru a obtine evidente valoroase, astfel subiectul ramane unul de dezbatere.Whipple procedure is intricate and demands high precision due to the proximity of critical structures, which requires an achieved expertise. With the innovative instruments and evolution of surgery, the perioperative morbidity still stands at 30% with a mortality lower than 5%, primary because of anastomotic leaks and haemorrhagic events. Therefore open surgery provides better outcomes with a decent learning curve. Furthermore, it is challenging to conduct clinical trials in the field of pancreatic surgery both open or minimally-invasive to obtain high-level evidence, remaining a subject open to debate

Laparoscopic approach of acute pancreatitis collections: a serie of four cases

Introduction: Acute pancreatitis (AP) is one of the most unpredictable pathologies of the digestive system. AP can be associated with multiple local or systemic complications. Approximately 15-20% of patients develop moderate severe or severe pancreatitis. The moderate severe form of disease is associated with local complications, as necrosis of the pancreatic and/or peripancreatic tissue and transient organ failure. One of the most common local complications in AP is the development of peripancreatic fluid collections (PFC). Proper management of PFC necessitates accurate diagnosis and treatment by a multidisciplinary team. Moreover, tratment has turned from open surgery (associated with high mortality and morbidity), therefore the latest literature shows data justifying the use of minimally invasive procedures. Case presentantion: We present a serie of 4 patients, with ages comprised between 54 and 70 years old with peripancreatic fluid collections, more precisely, walled-off necrosis (WON), infected WON in the lesser sac and one with ANC treated laparoscopically. Conclusion: Minimally invasive procedures of PFC, especially for acute necrotic collections (ANC) include radiological, endoscopic or surgical approach. Formerly, a primary necrosectomy was the frontrunner treatment, however it is associated with high rates of mortality and morbidity. At the present moment the step-up approach management is preferred. The main and most common issue of all minimally invasive procedures is the difficult removal of the necrotic debris and the adequate drainage of the collection in one procedure. To conclude, even though pancreatitis has an unforeseeable evolution, the minimally invasive techniques seem to be promising in the managament of PFC. Case particularities: This present paper presents a serie of four cases of AP complicated with PFC admitted to the Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca. All cases were managed pure laparoscopically

Added value of intravenous contrast-enhanced ultrasound for characterization of cystic pancreatic masses: a prospective study on 37 patients

Abstract The aim of this study was to evaluate the added value of contrast-enhanced ultrasound (CEUS) in the pancreatic cystic mass (PCM) diagnosis by using a qualitative and quantitative analysis in order to make a relevant characterization. Patients and method: Between December 2008 and November 2011, 37 patients with PCM discovered at ultrasound examination were prospectively followed. A qualitative and quantitative CEUS analysis was performed in order to differentiate etiologies of the PCM. In the quantitative analysis several parameters were followed: Peak Intensity (PI), Time to Peak (TTP), maximum ascending gradient (GRAD), Time to maximum gradient (TTG) and Area Under the Curve (AUC). Normalized ratios were also calculated. In all patients a definite cytological or histological diagnosis was obtained. Results: Thirty-seven patients were studied: 12 with pancreatitis-associated pseudocyst and 25 with cystic tumors (10 serous cystic adenoma, 5 mucinous cystic adenoma, 6 cystadenocarcinomas, 2 solid pseudopapillary tumors and 2 intraductal papillary mucinous neoplasms). There was a significant difference of the nAUC and nTTP between pseudocyst and cystic tumors, p=0.03 and p=0.01, respectively. A normalized TTP value above 7 sec was suggestive for the diagnosis of pseudocysts with 79.16 % accuracy. There was a significant difference of nTTP and nTTG between the benign and malignant lesions. nTTP < 9 sec and nTTG < 8.5 sec rules out malignant cysts in almost 90% of cases. Conclusion: The CEUS is useful in the diagnosis of PCM. The quantitative analysis of the enhancement of the cystic wall may discriminate the different types of the PCM

Corrosive esophageal strictures – methods of esophageal conduit reconstruction

Scop: Tratamentul definitiv al stenozelor caustice esofagiene rămâne tratamentul chirurgical, mai ales atunci când tratamentul endoscopic eșuează. Modalitatea ideala de abord chirurgical rămâne o controversă între esofagectomie cu reconstrucție cu conduct gastric sau colonic, și esofagoplastie cu interpoziție de colon. Material și metode: Studiul nostru constă într-un review al literaturii de specialitate pe modalitățile de reconstrucție esofagiană în stenozele caustice și rezultatele postoperatorii asociate, cât și o prezentare a unei serii de cazuri din experiența proprie a centrului nostru. Rezultate: Literatura medicală raportează cazuri tratate prin ambele tehnici chirurgicale, rezultatele postoperatorii favorizând esofagoplastia prin morbimortalitatea perioperatorie mai redusa comparativ cu esofagectomia; în același timp, unii autori preferă esofagectomia pentru a elimina riscul dezvoltării în timp a unui carcinom scuamos esofagian. Raportăm 2 cazuri cunoscute cu ingestie de substanță caustică în scop suicidar, care au dezvoltat stenoze esofagiene severe; ambele cazuri au necesitat pregătire preoperatorie nutrițională – în primul caz s-a montat o jejunostomie, iar în al doilea caz s-a efectuat o gastrostomie endoscopică. În primul caz, s-a efectuat esofagectomie prin triplu abord cu reconstrucție folosind grefon colic stâng, iar in al doilea caz s-a practicat o esofagoplastie cu reconstrucție folosind grefon colic drept ascensionat retrosternal. Primul caz a dezvoltat o fistula anastomotică tratată cu succes conservativ. Concluzii: Tratamentul chirurgical al stenozelor esofagiene caustice trebuie să implice decizii personalizate, bazate pe caracteristicilor fiecărui pacient. Bypass-ul folosind grefon colic ascensionat retrosternal, cât și esofagectomia cu reconstrucție folosind grefon colic sunt opțiuni viabile de tratament.Aim: The definitive treatment of corrosive esophageal strictures remains the surgical treatment, especially when endoscopic treatment fails. The ideal surgical approach remains a controversy between esophagectomy and reconstruction with gastric or colonic conduit and esophageal bypass through colon interposition. Methods: Our study consists in a literature review based on the modalities of esophageal conduit reconstruction in corrosive strictures and the associated postoperative results, as well as a case series from our centre’s experience. Results: The medical literature reports cases treated through both approaches, the postoperative results favouring esophageal bypass due to a lower postoperative morbidity and mortality rate; at the same time, some authors prefer esophagectomy in order to eliminate the risk of squamous cell carcinoma development. We report 2 cases of corrosive substance ingestion in suicidal purposes, that developed severe esophageal strictures; both cases needed preoperative nutritional preparation – in the first case, a jejunostomy was performed, while in the second case, an endoscopic gastrostomy was performed. The first case underwent McKeown esophagectomy with left colon reconstruction, while the second case underwent esophageal bypass with retrosternal right colon interposition. The first case developed an anastomotic fistula that was treated with conservative treatment. Conclusions: The surgical treatment of corrosive esophageal strictures needs to be a personalized choice based on each patient’s characteristics. Esophageal bypass with retrosternal colonic conduit, as well as esophagectomy with colonic conduit reconstruction are viable options to be considered