CHIRURGIA ROBOTICA DEL PANCREAS:presente e prospettive future

Il rapido sviluppo che la chirurgia mininvasiva ha avuto negli ultimi decenni è in parte dovuto al prorompente ruolo che le nuove tecnologie hanno avuto nel campo medico e che vedono il suo apice nella robot - assisted surgery . Il sistema robotico Da Vinci®, ad oggi, risulta essere il modello applicativo di questa tecnologia. Nonostante la sua rapida diffusione, l’utilizzo del robot è ancora ad uno stadio embrionale soprattutto per quanto riguarda l’ambito pancreatico dove, a causa dei limitati casi di applicazione, non è possibile stabilire una chiara superiorità rispetto alla chirurgia tradizionale. Le capacità tecniche del Da Vinci Surgical System® hanno permesso di eseguire interventi complessi superando alcune delle limitazioni della chirurgia laparoscopica tradizionale, garantendo un margine di sicurezza anche nelle più difficili fasi ricostruttive delle resezioni cefaliche pancreatiche. Questo studio si propone l’ obbiettivo di analizzare i risultati a breve termine di tutte le resezioni pancreatiche effettuate integralmente con l’ ausilio del Da Vinci Surgical System®. Lo studio si avvale di un gruppo di casistiche raccolte tra il 1 Ottobre 2008 e il mese di Settembre 2011 presso la divisione di Chirurgia Generale e Trapianti nell’Uremico e nel Diabetico della Azienda Ospedaliero-Universitaria Pisana. Gli interventi, eseguiti su lesioni pancreatiche per lo più a basso-moderato grado di malignità, comprendono duodenocefalopancreasectomie, pancreasectomie distali con conservazione o meno della milza e dei vasi splenici, pancreasectomie intermedie, pancreasectomie totali, enucleazioni e cisti-gastrostomie. I risultati, confrontati con casistiche analoghe presenti in letteratura, hanno dimostrato che l’utilizzo del robot Da Vinci® possa essere una valida alternativa all’intervento tradizionale almeno per lesioni a basso-moderato grado di malignità con equiparabili valori percentuali di morbilità e di mortalità. Considerando che questo tipo di chirurgia risulta essere solo agli albori, sarà importante valutare i risultati che essa otterrà nel lungo periodo. Assumerà un ruolo fondamentale la verifica, anche a seguito dell’ingresso di nuove macchine e tecnologie, di come questo tipo di approccio possa essere applicato ad un miglioramento della qualità della vita del paziente e quanto questo possa influire su una reale diminuzione del rapporto costo/beneficio nell’ambito della pancreatologia. Il seguente studio ha lo scopo di analizzare, nell'ambito della chirurgia resettiva e ricostruttiva pancreatica, i risultati a breve termine di un gruppo di interventi eseguiti utilizzando il sistema robotico chirurgico da Vinci®. Lo studio si avvale di dati ottenuti da una serie di pancreasectomie robotiche eseguite tra il 1 ottobre 2008 e il Settembre 2011

Laparoscopic Compared with Open D2 Gastrectomy on Perioperative and Long-Term, Stage-Stratified Oncological Outcomes for Gastric Cancer: A Propensity Score-Matched Analysis of the IMIGASTRIC Database.

The laparoscopic approach in gastric cancer surgery is being increasingly adopted worldwide. However, studies focusing specifically on laparoscopic gastrectomy with D2 lymphadenectomy are still lacking in the literature. This retrospective study aimed to compare the short-term and long-term outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy for gastric cancer. The protocol-based, international IMIGASTRIC (International study group on Minimally Invasive surgery for Gastric Cancer) registry was queried to retrieve data on patients undergoing laparoscopic or open gastrectomy with D2 lymphadenectomy for gastric cancer with curative intent from January 2000 to December 2014. Eleven predefined, demographical, clinical, and pathological variables were used to conduct a 1:1 propensity score matching (PSM) analysis to investigate intraoperative and recovery outcomes, complications, pathological findings, and survival data between the two groups. Predictive factors of long-term survival were also assessed. A total of 3033 patients from 14 participating institutions were selected from the IMIGASTRIC database. After 1:1 PSM, a total of 1248 patients, 624 in the laparoscopic group and 624 in the open group, were matched and included in the final analysis. The total operative time (median 180 versus 240 min, p < 0.0001) and the length of the postoperative hospital stay (median 10 versus 14.8 days, p < 0.0001) were longer in the open group than in the laparoscopic group. The conversion to open rate was 1.9%. The proportion of patients with in-hospital complications was higher in the open group (21.3% versus 15.1%, p = 0.004). The median number of harvested lymph nodes was higher in the laparoscopic approach (median 32 versus 28, p < 0.0001), and the proportion of positive resection margins was higher (p = 0.021) in the open group (5.9%) than in the laparoscopic group (3.2%). There was no significant difference between the groups in five-year overall survival rates (77.4% laparoscopic versus 75.2% open, p = 0.229). The adoption of the laparoscopic approach for gastric resection with D2 lymphadenectomy shortened the length of hospital stay and reduced postoperative complications with respect to the open approach. The five-year overall survival rate after laparoscopy was comparable to that for patients who underwent open D2 resection. The types of surgical approaches are not independent predictive factors for five-year overall survival

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery.

AimTo investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.MethodsThis is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy (RG), laparoscopic gastrectomy (LG), open gastrectomy (OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.ResultsThe present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients (RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery (P = 0.42) and stage of the disease (P = 0.16). Intraoperative blood loss was significantly lower in the LG (95.93 ± 119.22) and RG (117.91 ± 68.11) groups compared to the OG (127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG (27.78 ± 11.45), LG (24.58 ± 13.56) and OG (25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay (P < 0.0001). A similar complications rate was found (P = 0.13). The leakage rate was not different (P = 0.78) between groups.ConclusionLaparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery

A national survey on the current status of minimally invasive gastric practice on behalf of GIRCG

: Italian Research Group for Gastric Cancer (GIRCG), during the 2013 annual Consensus Conference to gastric cancer, stated that laparoscopic or robotic approach should be limited only to early gastric cancer (EGC) and no further guidelines were currently available. However, accumulated evidences, mainly from eastern experiences, have supported the application of minimally invasive surgery also for locally advanced gastric cancer (AGC). The aim of our study is to give a snapshot of current surgical propensity of expert Italian upper gastrointestinal surgeons in performing minimally invasive techniques for the treatment of gastric cancer in order to answer to the question if clinical practice overcome the recommendation. Experts in the field among the Italian Research Group for Gastric Cancer (GIRCG) were invited to join a web 30-item survey through a formal e-mail from January 1st, 2020, to June 31st, 2020. Responses were collected from 46 participants out of 100 upper gastrointestinal surgeons. Percentage of surgeons choosing a minimally invasive approach to treat early and advanced gastric cancer was similar. Additionally analyzing data from the centers involved, we obtained that the percentage of minimally invasive total and partial gastrectomies in advanced cases augmented with the increase of surgical procedures performed per year (p = 0.02 and p = 0.04 respectively). It is reasonable to assume that there is a widening of indications given by the current national guideline into clinical practice. Propensity of expert Italian upper gastrointestinal surgeons was to perform minimally invasive surgery not only for early but also for advanced gastric cancer. Of interest volume activity correlated with the propensity of surgeons to select a minimally invasive approach