Search

Pancreatic cancer has an incidence that almost matches its mortality. Only a small number of risk factors and 33 susceptibility loci have been identified. so Moreover, the relative rarity of pancreatic cancer poses significant hurdles for research aimed at increasing our knowledge of the genetic mechanisms contributing to the disease. Additionally, the inability to adequately power research questions prevents small monocentric studies from being successful. Several consortia have been established to pursue a better understanding of the genetic architecture of pancreatic cancers. The Pancreatic disease research (PANDoRA) consortium is the largest in Europe. PANDoRA is spread across 12 European countries, Brazil and Japan, bringing together 29 basic and clinical research groups. In the last ten years, PANDoRA has contributed to the discovery of 25 susceptibility loci, a feat that will be instrumental in stratifying the population by risk and optimizing preventive strategies.

Pancreatic ductal adenocarcinoma (PDAC) is among the most lethal cancers. Its poor prognosis is predominantly due to the fact that most patients remain asymptomatic until the disease reaches an advanced stage, alongside the lack of early markers and screening strategies. A better understanding of PDAC risk factors is essential for the identification of groups at high risk in the population. Genome-wide association studies (GWAS) have been a powerful tool for detecting genetic variants associated with complex traits, including pancreatic cancer. By exploiting functional and GWAS data, we investigated the associations between polymorphisms affecting gene function in the pancreas (expression quantitative trait loci, eQTLs) and PDAC risk. In a two-phase approach, we analysed 13 713 PDAC cases and 43 784 controls and identified a genome-wide significant association between the A allele of the rs2035875 polymorphism and increased PDAC risk (P = 7.14 x 10(-10)). This allele is known to be associated with increased expression in the pancreas of the keratin genes KRT8 and KRT18, whose increased levels have been reported to correlate with various tumour cell characteristics. Additionally, the A allele of the rs789744 variant was associated with decreased risk of developing PDAC (P = 3.56 x 10(-6)). This single nucleotide polymorphism is situated in the SRGAP1 gene and the A allele is associated with higher expression of the gene, which in turn inactivates the cyclin-dependent protein 42 (CDC42) gene expression, thus decreasing the risk of PDAC. In conclusion, we present here a functional-based novel PDAC risk locus and an additional strong candidate supported by significant associations and plausible biological mechanisms.

Context Robotic surgery entails specific issues that are not present, or are not equally relevant, in open surgery or conventional laparoscopy. Instrument traffic (IT) is one of such issues. IT is the time during which surgery is paused because the surgeon at the console is waiting for the action of the surgeon the table (e.g., instrument change, camera cleaning, introduction/withdrawal of needles). Objective We provide the first objective evaluation of IT during robotic pancreaticoduodenectomy (PD). Methods The operative videos of 12 robot-assisted PDs were reviewed to define IT. The analysis included: crude IT time (CITT), relative IT time (RITT) (defined as the percentage of operative time spent for IT), number of robotic instruments changes (RIC), time spent for RIC (TRIC), number of pure laparoscopic actions (PLA), and time spent for PLA (TPLA). Figures were estimated for the entire operation as well as for dissection and reconstruction phases. Details on pancreaticojejunostomy (PJ) or hepaticojejunostomy (HJ) were related to IT to define their relative impact on operative time. Results Mean operative time was 517 min (range 420-600 min). Mean CITT was 3,681.6 sec (RITT 11.89%). Mean RIC or PLA was 315.7. Each RIC or PLA paused surgery for 11.8 sec. Mean RIC was 184.4 (TRIC 2,633.8 sec). Mean PLA was 131.4 (TPLA 1,039.5 sec). Mean dissection time was 326.9 min. Mean CITT was 2,095.1 sec (RITT 10.68%). Mean RIC was 105.8 (TRIC 1,645.2 sec). Mean PLA was 35.7 (TPLA 382.5 sec). Each RIC or PLA paused surgery for 14.4 sec. PJ was made by invaginating technique or duct-to-mucosa. The last one required fewer stitches, but did not reduced CITT or RIC. HJ was performed using either 4 half running sutures or interrupted external stitches plus inner half running sutures. Despite similar CITT the former technique was associated with fewer RIC. Conclusions Some 12% of operative time of laparoscopic robot-assisted PD is wasted because of IT. Since in this series operative time of robotic PD averaged 517 minutes, IT prolonged surgery of more than one hour. Technology improvements and/or refinements in surgical technique are expected to reduce IT during robotic PD., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Intestinal volvulus is an uncommon complication either of open surgery either of mini-invasive surgery. Recent papers report few cases of small bowel obstruction after robotic-assisted surgery, but none due to an intestinal volvulus. In our experience including more than 90 robotic pancreatic resections we have had only one intestinal volvulus. We report the case of a small bowel obstruction because of a volvulus after robotic pancreatico­duodenectomy. Case report A 42-year-old man underwent robot-assisted pancreaticoduodenectomy on July 2011 for choledochus’ adenocarcinoma. On September 2011 he was readmitted to us for an intestinal obstruction. Preoperative imaging included abdomen radiography and computed tomography. The latter showed a twisted small bowel loop with a strong lumen reduction. Robot-assisted pancreatico­duodenectomy was the only previous operation he had had. The patient underwent to a laparotomy, in order to easily diagnose the site of the obstruction. The entire small bowel was found to have rotated clockwise around the mesenteric vessels. Distal ileum, that included the obstruction, was resected. Final pathology disclosed only inflammation and granulation tissue. The postoperative course was uneventful and the patient was discharged on the fifteenth postoperative day. Conclusion The causes of small bowel rotation are not well known. An abnormally mobile bowel or other anatomic predispositions might have a role; another possible causes are post-operative adhesions that may create an axis around which the small bowel can rotate. Our patient have had only pancreaticoduodenectomy that, even if performed robotically, it is a very hard operation but at the repeat surgery the entire small bowel was found to have rotated clockwise around the mesenteric vessels without any adhesion. Robotic surgery needs the pneumoperitoneum induction and tilting table to a suitable position which are possible causes allowing a volvulus creation. In our experience, the posterior repair of peritoneum can avoid the onset of a volvulus and it can be as easily performed by robotic approach as in open surgery., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context The “da Vinci” surgical system reintroduces much of the operative dexterity lost during laparoscopic operations and offers the unique opportunity to verify if pancreaticoduodenectomy (PD) can be safely performed through a minimally invasive approach. Objective We report our technique for total robotic PD employed in 39 consecutive patients. This experience was earned at a high-volume center of pancreatic surgery, having extensive experience in advanced laparoscopy and robotic surgery. Methods Our technique for total robotic PD is unique in several respects: pure laparoscopy is not used at any stage; only the right colonic flexure is mobilized; a total of five ports are used; the camera port is placed along the right pararectal line to allow optimal view of the uncinate process (UP); the third robotic arm is placed on the patient’s left side and it is used to “hang” the duodenum during dissection of the UP; the gallbladder is used to retract the liver; the first jejunal loop is fully mobilized but it is not sectioned until the specimen is ready for removal, to facilitate jejunal rotation behind the mesenteric vessels. Results No PD was converted to open surgery or laparoscopy, despite 3 patients required segmental resection of the mesenteric vein and reconstruction by a jump graft. Mean operative time was 597 minutes (range: 420-960 minutes). Thirty-day operative mortality was nil. No pseudoaneurysm of the gastroduodenal artery was noted. Only 4 patients developed grade B pancreatic fistulas and none grade C fistulas. Mean hospital-stay was 23 days (range: 10-86 days). Malignant tumors were diagnosed in 51% of the patients. Overall, the mean number of lymph nodes retrieved was 32 (range 15-76). None of the margins was positive. Conclusions In selected patients total robotic PD is feasible. As compared to hybrid techniques, coupling laparoscopic dissection with robotic reconstruction, a total robotic procedure spares unnecessary dissections and allows optimal control of large peripancreatic vessels permitting segmental vein resection and tailored reconstruction. Technology refinements and improvement of surgical technique could make robotic PD an appealing alternative to open PD in selected patients., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Funder: Fondazione Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/100007368, Funder: Tuscany Region, Italy; Id: http://dx.doi.org/10.13039/501100009888, Funder: Pisa University Hospital, Pisa, Italy, Funder: University of Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/501100007514, The 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.