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Pancreatic neuroendocrine tumors (P-NETs) are highly heterogeneous with wide spectrum of biological behaviors and growth patterns. Here, we aimed to assess the impact of tumor grading on P-NETs prognosis and survival outcomes.Patients with P-NET were recruited to determine correlations between grades and clinicopathological factors, survival outcomes and prognostic factors.A total of 152 patients with P-NETs were enrolled. G1 P-NET were associated with significantly lower rates of perineural invasion, lymphovascular invasion, lymph node involvement and distant metastasis. The pancreatic head was the most common location of P-NETs. The 1-year, 5-year and 10-year overall survival rates of the patients were 94.4%, 89.1% and 78.8%, respectively. Majority of pancreatic neuroendocrine carcinoma (P-NEC) were unresectable (90.9%), and P-NECs patients had poor survival rates (1-year, 20% and no 5-year). Male sex, tumor size ≥2.5 cm, perineural invasion, lymph node invasion, metastasis, and advanced stage were significantly associated with poorer survival outcomes. Tumor grade and sex were independent survival predictors. Moreover, tumor grade was the most powerful prognostic factor.Tumor grade, sex, perineural invasion, tumor size, lymph node involvement, metastasis, and stage are survival predictors for patients with P-NETs. Tumor grade is the most powerful independent prognostic factor.

Robotic pancreaticoduodenectomy (RPD) in ampullary cancer has never been studied. This study aimed to clarify the feasibility and justification of RPD in ampullary cancer in terms of surgical risks, and oncological and survival outcomes. A propensity score-matching comparison of RPD and open pancreaticoduodenectomy (OPD) based on seven factors commonly used to predict the survival outcomes in ampullary cancer patients. A total of 147 patients were enrolled, of which 101 and 46 underwent RPD and OPD, respectively. After propensity score-matching with a 2:1 ratio, 88 and 44 patients in the RPD and OPD groups were included. The operation time was of no significant difference after matching. The median intraoperative blood loss was much less in those who underwent RPD, both before (median, 120 c.c. vs. 320 c.c. P P

The study of robotic pancreaticouodenectomy (RPD) focusing on delayed gastric emptying (DGE) is seldom reported. This study explored the incidence of DGE in RPD with extracorporeal hand-sewn gastrojejunostomy involving downward positioning of the stomach. Patients with periampullary lesions undergoing RPD or open pancreaticouodenectomy (OPD) were included for comparison. A variety of clinical factors were evaluated for the risk of developing DGE. There were 409 (68.2%) RPD and 191 (31.8%) OPD in this study. DGE occurred in 7.7% of patients after pancreaticoduodenectomy, with 4.4% in RPD and 14.7% in OPD, p 200 c.c. was the other factor related to DGE (11.2% vs. 4.4% in those with blood loss ≤ 200 c.c.). None of the postoperative complications was significantly associated with DGE. Hospital stay was significantly longer in the group with DGE (median, 37 vs. 20 days in the group without DGE). After multivariate analysis by binary logistic regression, compared with OPD, RPD was the only independent factor associated with a lower incidence of DGE. RPD with extracorporeal hand-sewn antecolic, antiperistaltic, and inframesocolic gastrojejunostomy via a small umbilical wound involving careful downward positioning of the stomach was associated with a low incidence of DGE and presented as the most powerful independent predictor of this condition.

This study is to clarify the feasibility of and justification for robotic pancreaticoduodenectomy (RPD) in patients with pancreatic adenocarcinoma. A 1-to-1 propensity score-matched comparison of RPD and open pancreaticoduodenectomy (OPD) was performed based on six covariates commonly used to predict the survival outcome for pancreatic adenocarcinoma. A total of 130 patients were enrolled, with 65 in each study group after propensity score matching. The median operating time was longer for RPD (8.3 h vs. 7.0 h, P = 0.002). However, RPD was associated with less blood loss, lower overall surgical complication rate, and lower incidence of delayed gastric emptying. The resection radicality was oncologically similar between these two groups, but the median lymph node yield was higher for RPD (18 vs. 16, P = 0.038). Before propensity score matching, the 5-year survival was better in RPD (27.0% vs. 17.6%, P = 0.006). After matching, there was still a trend towards improved overall survival in the RPD group; however, the difference in 5-year survival between RPD and OPD was not significant (24.5% vs. 19.7%, P = 0.088). RPD is not only technically feasible with no increase in surgical risk but also oncologically justifiable without compromising survival outcome. However, unlike randomized control trials, the limitations in this propensity score-matched analysis only accounted for 6 observed covariates commonly used to predict the survival outcome in patients with pancreatic adenocarcinoma, and confounders not included in this study could also affect our results.

Pancreaticoduodenectomy, so‐called “Whipple operation,” is a time‐consuming and technically demanding complex operation. Traditionally, this procedure has been performed most usually by open approach, which results in a large and painful wound. With the introduction of laparoscopic and robotic surgery, minimally invasive surgery (MIS) has emerged as a worldwide trend to improve wound cosmesis and to minimize wound pain. Although MIS for pancreaticoduodenectomy has also been attempted at some centers, the role of MIS, either robotic or laparoscopic approach, has not been well‐established for complex pancreaticoduodenectomy. Given that laparoscopic pancreaticoduodenectomy has been limited by its technical complexity and the high level of advanced laparoscopic skills required for pancreatic reconstruction, a robotic surgical system is introduced to overcome several limitations related to the laparoscopic approach. Providing high‐quality three‐dimensional (3‐D) vision, high optical magnification, articulation of robotic instruments, greater precision with suture targeting, and elimination of surgeon tremor, robotic surgical systems innovatively perform more delicate and complex procedures involving extensive dissection and suturing techniques such as pancreaticoduodenectomy. Although associated with longer operative time, robotic pancreaticoduodenectomy (RPD) has been claimed to have the benefits of less delayed gastric emptying, less blood loss, shorter length of postoperative stay, and lower wound infection rate, as compared with the traditional open pancreaticoduodenectomy (OPD). Moreover, RPD seems to be not only technically feasible but also justified without compromising the survival outcomes for pancreatic head and ampullary adenocarcinomas. Therefore, RPD could be recommended not only to surgeons but also to patients in terms of surgical feasibility, surgical outcomes, and patient satisfaction., Robotic approach allows surgeons to perform more complicated and delicate procedures such as pancreaticoduodenectomy involving extensive dissection and restoration of digestive tract continuity for the pancreas, bile duct, and gastrointestinal tract. Robotic pancreaticoduodenectomy has been reported as associated with less blood loss, less delayed gastric emptying, shorter length of postoperative stay, and lower wound infection rate, but longer operative time, as compared with the traditional open pancreaticoduodenectomy.

There are no reports of performing mesopancreas dissections in robotic pancreaticoduodenectomy. This study evaluated the feasibility and justification for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy.Surgical outcomes after robotic pancreaticoduodenectomy and open pancreaticoduodenectomy were evaluated and compared.There were 289 robotic pancreaticoduodenectomy and 162 open pancreaticoduodenectomy patients included in the study. Postoperative diarrhea occurred in 34.5% of mesopancreas level 3 dissection cases and was higher than in levels 2 and 1 dissection cases, P.001. Blood loss in the robotic pancreaticoduodenectomy group was higher for mesopancreas level 3 dissection, with a median loss of 263 mL (P = .015). The rate of R0 resection with margin1 mm was higher for mesopancreas level 3 dissection (93.8%) than for level 2 dissection (72.2%) (P.001). The lymph node yield was higher for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy; the median lymph node yield was 21 for level 3, 18 for level 2, and 14 for level 1 (P.001). Compared with mesopancreas levels 1 and 2 dissections in the robotic pancreaticoduodenectomy groups, level 3 dissection did not show increased surgical mortality or postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound infection. Compared with open pancreaticoduodenectomy, mesopancreas level 3 dissection in robotic pancreaticoduodenectomy had less blood loss, no delayed gastric emptying, and lower chyle leakage.Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy is feasible without compromising surgical safety. Therefore, robotic pancreaticoduodenectomy can be recommended as a safe alternative to open pancreaticoduodenectomy for mesopancreas level 3 dissection.

Total laparoscopic donor right hepatectomy (TLDRH) for adult living liver donors has been reported by a few experienced centers, but with limited cases, its safety and feasibility remain controversial. We report our experience initiating TLDRH using a stepwise approach to gradually convert laparoscopy-assisted donor right hepatectomy (LADRH) to TLDRH. We retrospectively analyzed the data of 61 LADRHs, 56 conventional open donor right hepatectomies (CODRHs), and 3 TLDRHs performed between March 2014 and June 2018. There were no significant differences in perioperative outcomes between donors undergoing LADRH and CODRH, except for a slight elevations in the operative time (436.5 vs 392.9 min, p

Theoretically, pancreas transplant alone in uremic (PTAU) patients could also be one of the options for those waiting for both pancreas and kidney grafts, but it has never been reported. There were 160 cases of pancreas transplant in this study, including 16% PTAU. The 5-year patient survival was 66.2% after PTAU, 94.5% after SPK, 95.8% after PAK, and 95.4% after PTA. Rejection of pancreas graft was significantly lower in PTAU group (3.8%), followed by 16.7% in pancreas after kidney transplant (PAK), 29.8% in simultaneous pancreas and kidney transplant (SPK) and 37.0% in pancreas transplant alone (PTA). Fasting blood sugar and serum HbA1c levels after PTAU were not significantly different from those by other subgroups. The 5-year death-censored pancreas graft survival was 100% after PTAU and PAK, and 97.0% after SPK and 77.9% after PTA. However, the 5-year death-uncensored pancreas graft survival was 67.0% after PTAU, 100% after PAK, 91.3% after SPK, and 74.0% after PTA. The superior graft survival in the PTAU group was achieved only if deaths with a functioning graft were censored. In conclusion, given the inferior patient survival outcome, PTAU is still not recommended unless SPK and PAK is not available. Although PTAU could be a treatment option for patients with diabetes complicated by end-stage renal disease (ESRD) in terms of surgical risks, endocrine function, and immunological and graft survival outcomes, modification of the organ allocation policies to prioritize SPK transplant in eligible patients should be the prime goal.

To evaluate the surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV)/portal vein (PV) resection by either robotic PD (RPD) or open PD (OPD). Data of patients with periampullary lesions undergoing PD were retrieved from a prospectively collected computer database. Surgical risks as well as oncological and survival outcomes were compared between patients with (vein resection group) and without SMV/PV resection (without vein resection group). A total of 391 patients undergoing pancreaticoduodenectomy were enrolled, including 43 (11.0%) and 384 (89.0%) patients with and without vein resection, respectively. Eleven (25.6%) of PDs with vein resection were performed using the robotic approach. Operation time in the vein resection group was significantly longer (median of 8 vs. 7 h). Blood loss, curative resection (R0) rate, and harvested lymph node number were similar between these two groups. Surgical outcomes including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), chyle leakage, wound infection, and hospital stay were not significantly different between the two groups. There was no survival difference between these groups, with 1- and 3-year survival rates of 92.6% and 26.5%, respectively, for vein resection group, vs. 70.3% and 37.2%, respectively, for the without vein resection group. PD with vein resection is technically feasible by OPD and RPD in selected patients. Additional SMV/PV would not increase the surgical risks of PD and could achieve similar survival outcomes for pancreatic head adenocarcinoma when compared to PD without vein resection.

Theoretically, pancreas before kidney transplant (PBK) could also be one of the options for those waiting for both pancreas and kidney grafts, but it has never been reported. This study is to clarify the justification and feasibility of PBK. There were 160 cases of pancreas transplant in this study, including 26 (16%) PBK. Rejection (3.8%) of pancreas graft was significantly lower in PBK group, followed by 16.7% in pancreas after kidney transplant (PAK), 29.8% in simultaneous pancreas and kidney transplant (SPK) and 37.0% in pancreas transplant alone (PTA). There was no chronic rejection in PBK and PAK groups. Fasting blood sugar and serum HbA1c levels after PBK were not significantly different from those by other subgroups. The serum C-peptide levels were significantly higher in PBK group than those by other subgroups. The 5-year pancreas graft survival was 100% for PBK and PAK, 97.0% for SPK and 77.9% for PTA. In conclusion, PBK could be a treatment option for patients with diabetes complicated by end-stage renal disease (ESRD) in terms of surgical risks, endocrine function, and immunological and graft survival outcomes. However, given the inferior patient survival outcome, PBK is still not recommended unless SPK and PAK is not available.

Background Though nowadays a palliative pancreaticoduodenectomy (PD) can be performed safely with relatively low mortality and acceptable morbidity rates in experienced centers, there have been no studies on the routine use of a palliative PD or on the advantages of performing surgical resection as a debulking procedure. Furthermore, the impact of resection margins on survival outcomes has been a matter of controversy. Therefore, this study aimed to clarify the role of robotic pancreaticoduodenectomy (RPD) in pancreatic and periampullary adenocarcinomas with positive resection margins. Methods Patients undergoing RPDs and open pancreaticoduodenectomies (OPDs) were included in this study. Based on the resection margins, the patients were divided into the R0, R1, and R2 PD groups. Surgical risks and survival outcomes were analyzed. Results There were 348 pancreaticoduodenectomies, including 29 (8.3%) palliative and 319 (91.7%) curative. Primary tumor origin, tumor sizes, perineural invasions, and abnormal serum CEA levels were factors leading to palliative resection. The multivariate analysis showed that only pancreatic head adenocarcinomas and abnormal serum CEA levels (> 5 ng/mL) were independent predictors. The surgical risks between curative and palliative PD were similar. There were no significant differences in the surgical risks and other surgical parameters between palliative RPDs and OPDs. For curative resection, RPDs resulted in less blood loss, greater harvested lymph nodes yield, less postoperative complications, less delayed gastric emptying, and shorter hospital stays than OPDs. The survival outcome was significantly better following R0 resection in overall periampullary adenocarcinomas, whereas a significant survival difference was shown only between the R0 and R2 resections for pancreatic head adenocarcinomas. Conclusion Compared with R0 PDs, palliative R1 PDs could benefit patients with pancreatic head adenocarcinomas when considering survival outcomes without increasing surgical risks. RPD can be considered for curative purposes and as an alternative for palliative management.

Circulating cell-free DNA (cfDNA) in ampullary cancer patients was measured to clarify the correlation between cfDNA and clinicopathological factors and the impact of cfDNA on survival outcomes. Patients with ampullary cancer undergoing pancreaticoduodenectomy were included. Correlations between cfDNA and clinicopathological and prognostic factors were determined. The cfDNA levels in patients ranged from 1282 to 21,674 copies/mL, with a median of 6687 copies/mL. The cfDNA level was significantly higher in patients with lymph node involvement, lymphovascular invasion, abnormal serum carcinoembryonic antigen (CEA) level, and stage II and III cancer. Poor prognostic factors for ampullary cancer included high cfDNA &gt, 6687 copies/mL, lymph node involvement, abnormal serum CEA &gt, 5 ng/mL, and advanced stage II and III cancer. The 1- and 5-year survival rates were 92.0% and 66.5%, respectively, for patients with low cfDNA &lt, 6687 copies/mL and 84.0% and 49.9%, respectively, for patients with high cfDNA &gt, 6687 copies/mL (p &lt, 0.001). After multivariate analysis, only the cfDNA level and stage were independent prognostic factors of ampullary cancer. Thus, the cfDNA level could act as a surrogate marker of both disease extent and biological aggressiveness of ampullary cancer. Moreover, cfDNA plays a significant role in the prognosis of resectable ampullary cancer.

Summary Background/objective This study is to assess immunological and graft survival outcomes after pancreas transplant at a single institute in Asia. Methods Patients undergoing pancreas transplant with enteric drainage were included. Clinical data and outcomes were evaluated and compared between each subgroup. Results There were 165 cases of pancreas transplant, including 38 (23 %) simultaneous pancreas-kidney transplant (SPK), 24 (15 %) pancreas after kidney transplant (PAK), 75 (46 %) pancreas transplant alone (PTA), and 28 (17 %) pancreas before kidney transplant (PBK). The overall surgical complication rate was 46.1 %, with highest (62.5 %) in PAK and lowest (32.0 %) in PTA, P = 0.008. The late complications included 32.7 % infection and 3.6 % malignancy. Overall rejection of pancreas graft was 24.8 % including 18.2 % acute and 9.7 % chronic rejection. Rejection was highest in PTA group (36.0 %) and lowest in PBK (3.6 %). There were 56 cases (33.9 %) with graft loss in total, with highest graft loss rate in PTA (38.7 %). The 1-year, 5-year and 10-year pancreas graft survivals for total patients were 98.0 %, 87.7 % and 70.9 % respectively. Conclusions Enteric drainage in pancreas transplant could be applied safely not only in SPK but also in other subgroups. Enteric drainage itself would not compromise the immunological and graft survival outcomes.

Objective Circulating cell-free DNA (cfDNA) analysis is recently reported as a promising prognostic biomarker in various types of cancer. This study aimed to evaluate the role of cfDNA in pancreatic head adenocarcinoma. Methods Data for pancreatic head adenocarcinoma undergoing pancreaticoduodenectomy were studied for cfDNA. Prognostic factors were determined, and their correlation with cfDNA level was evaluated. Results The median of cfDNA for 97 cases was 7724 copies/mL, with a mean of 10,467, and ranging from 1856 to 44,203. Cell-free DNA was significantly higher in positive lymph node involvement and advanced stage III. Poor prognostic factors included high cfDNA level (>7724 copies/mL), abnormal carbohydrate antigen 19-9, abnormal carcinoembryonic antigen, and advanced stage. The 1- and 5-year survivals for those with high cfDNA were poorer, 70.2% and 21.2%, respectively, as compared with 93.4% and 23.7% for those with low cfDNA level. Only cfDNA level and stage were independent prognostic factors after multivariate analysis. Conclusions The level of cfDNA was correlated with tumor burden. Therefore, it could be an emerging survival predictor for resectable pancreatic head adenocarcinoma, and its detection might be a promising liquid biopsy to monitor both tumor progression and treatment response.

Total laparoscopic donor right hepatectomy (TLDRH) for adult living liver donors has been reported by a few experienced centers, but with limited cases, its safety and feasibility remain controversial. We report our experience initiating TLDRH using a stepwise approach to gradually convert laparoscopy-assisted donor right hepatectomy (LADRH) to TLDRH.We retrospectively analyzed the data of 61 LADRHs, 56 conventional open donor right hepatectomies (CODRHs), and 3 TLDRHs performed between March 2014 and June 2018.There were no significant differences in perioperative outcomes between donors undergoing LADRH and CODRH, except for a slight elevations in the operative time (436.5 vs 392.9 min, p 0.001) and the graft warm ischemic time (5.4 vs 4.0 min, p 0.001) in the LADRH group. The recipients' posttransplant one-year survival rates in the LADRH and CODRH groups were also similar (93.2% and 94.6%, p = 0.384). For three donors in whom TLDRH was converted from LADRH in a stepwise manner, the average operative time and blood loss were 570 min and 316.7 ml, respectively. Donors were discharged on postoperative day 10 without any surgical complications.LADRH can be performed routinely on liver living donors. A stepwise approach could be adopted to "covert" suitable donors from LADRH to a total laparoscopic procedure to maximize donor safety. This strategy is reliable and could be reproduced in most LDLT centers.

This study is to clarify the feasibility and justification of robotic pancreaticoduodenectomy (RPD) by comparing the outcomes between RPD and open pancreaticoduodenectomy (OPD) groups. All perioperative data and outcomes were prospectively collected. There were 304 (63.9%) RPD and 172 (36.1%) OPD. The median operation time was longer in RPD group than OPD (7.5 vs 7.0 h). The blood loss was much lower in RPD group, with a median of 130 vs. 400 c.c. in OPD group. Based on Clavien–Dindo classification, grade 0 (no complication) was 51.8% in RPD group, higher than 43.2% in OPD. Delayed gastric emptying was only 3.5% in RPD group, much lower than 13.6% in OPD. Wound infection rate was also lower in RPD group, 3.2% vs. 7.7% in OPD. The postoperative hospital stay was shorter in RPD group, with a median of 20 days, vs. 24 days in OPD. There was no significant difference regarding the lymph node yield, surgical mortality, postoperative pancreatic fistula, postpancreatectomy hemorrhage, chyle leakage and bile leakage between RPD and OPD groups. For pancreatic head adenocarcinoma, the survival outcome was better in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8% respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD. RPD is not only feasible but also justified without increasing the surgical risks and compromising the survival outcomes. Moreover, RPD might provide benefits of less blood loss, less delayed gastric emptying, lower wound infection rate and shorter length of postoperative stay, as compared with OPD.

Background This study is to clarify the feasibility of robotic pancreaticoduodenectomy in terms of surgical risks, clinically relevant postoperative pancreatic fistula, and oncologic outcomes compared with open pancreaticoduodenectomy by using propensity score matching. Traditional open pancreaticoduodenectomy and robotic pancreaticoduodenectomy have been compared only in small, retrospective, and nonrandomized cohort studies with variable quality. Methods Prospectively collected data for pancreaticoduodenectomy were evaluated. Comparison between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy was carried out after propensity-score matching. A total of 117 robotic pancreaticoduodenectomy and 128 open pancreaticoduodenectomy cases were performed during the study period. After propensity score matching, 87 cases were included for comparison in each cohort. Results Longer operation time, less blood loss, more lymph nodes harvested, and less delayed gastric emptying were noted in the robotic pancreaticoduodenectomy cases. We found no significant difference regarding the overall postoperative complications by Clavien-Dindo classification, postpancreatectomy hemorrhage, wound infection rate, and postoperative hospital stay. Clinically relevant postoperative pancreatic fistula was not significantly different between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy, regardless of the Callery risk factor, with overall clinically relevant postoperative pancreatic fistula of 8.0% by robotic pancreaticoduodenectomy and 12.6% by open pancreaticoduodenectomy after propensity score matching. We found no survival difference between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy when the comparison was specifically performed for each primary periampullary malignancy. Conclusion Robotic pancreaticoduodenectomy is associated with less blood loss, less delayed gastric emptying, and more lymph node yield. Propensity scored–matched analysis revealed that robotic pancreaticoduodenectomy is not inferior to open pancreaticoduodenectomy in terms of clinically relevant postoperative pancreatic fistula, surgical risks, and survival outcomes.

Choledochal cyst is a relatively rare congenital disease. The current standard treatment of choice for choledochal cyst is complete excision with Roux-en-y hepaticojejunostomy due to possible associated complications if left untreated, such as cholangitis, pancreatitis, cirrhosis, portal hypertension, and biliary malignancy. Traditionally, the resection for choledochal cyst is carried out with open surgery because of complex dissection and bilioenteric reconstruction. Recently, minimal invasive approach has gain wide interest, especially with the use of robotic surgical systems which can facilitate complex minimal access procedures. Herein, we present a case of robotic assisted excision of type I choledochal cyst in a young lady with complete intracorporeal reconstruction of Roux-en-y hepaticojejunostomy. Robotic-assisted surgery can be safely applied to the resection of type I choledochal cyst and also provide a complex suturing technique for reconstruction with Roux-en-y hepaticojejunostomy. Although the total operating time for robot-assisted resection of choledochal cysts and hepaticojejunostomy is relatively long for this initial experience, the young lady and family are pleased with the cosmetic results.

Background Chyle leakage is a well-known but poorly characterized complication after pancreaticoduodenectomy (PD). No study examined the chyle leakage after robotic PD (RPD). Methods Data regarding chyle leakage were prospectively collected and analyzed from patients undergoing RPD or open PD (OPD). Results The study included 118 RPD and 165 OPD. Overall chyle leakage rate was 12.0%, with 13.6% for RPD and 10.9% for OPD. Chyle leakage was eventually resolved in all patients through conservative treatment. The drainage volumes were significantly higher in chyle leakage group from postoperative days (PODs) 1-7, with a median of 240 mL on POD 1 and POD 7, as compared to 160 mL on POD 1 and 70 mL on POD 7 for those without chyle leakage. The number of lymph nodes involved and resected and pancreatic head adenocarcinoma affected the risk of developing chyle leakage, whereas the surgical approach used (RPD or OPD) did not. Conclusions Chyle leakage after PD is not rare, and it can eventually be resolved through conservative treatment. The extent and radicality of the surgery probably have a significant effect on the risk of developing chyle leakage, but the surgical approach used does not.

BACKGROUND: Pancreas transplantation remains the best long-term treatment option to achieve physiological euglycemia and insulin independence in patients with labile diabetes mellitus (DM). It is widely accepted as an optimal procedure for type 1 DM (T1DM), but its application in type 2 DM (T2DM) is not unanimously acknowledged. METHODS: In total, 146 diabetes patients undergoing pancreas transplantation were included in this study. Clinical data and outcomes were compared between the T1DM and T2DM groups. RESULTS: Majority (93%) of the pancreas transplantations in T2DM were for uremic recipients. Complications occurred in 106 (73%) patients, including 70 (48%) with early complications before discharge and 79 (54%) with late complications during follow-up period. Overall, rejection of pancreas graft occurred in 37 (25%) patients. Total rejection rate in T2DM recipients was significantly lower than that in T1DM. The short- and long-term outcomes for endocrine function in terms of fasting blood sugar and hemoglobin A1c levels and graft survival rates are comparable between the T2DM and T1DM groups. CONCLUSIONS: T2DM is not inferior to T1DM after pancreas transplantation in terms of surgical risks, immunological and endocrine outcomes, and graft survival rates. Therefore, pancreas transplantation could be an effective option to treat selected uremic T2DM patients without significant insulin resistance.

Pancreas transplantation is currently the most effective and curative treatment for complicated type 1 diabetes mellitus, providing durable and physiological insulin-independent euglycemia, preventing worsening or ameliorating of diabetic complications, and improving quality of life. Currently, more than 31 000 pancreas transplantation procedures have been performed, mainly in the United States. Pancreas transplantation is still an uncommon procedure in Asia, mainly performed in Korea, Taiwan, and Japan. The first pancreas (simultaneous pancreas and kidney transplantation) transplantation was successfully initiated at Taipei Veterans General Hospital on September 19, 2003, and we are the first team to be qualified to perform human pancreas procurement and transplantation by Taiwan Department of Health on August 31, 2007. The technique success rate in our pancreas transplantation is 97%, with 1-year pancreas graft survival rate of 95.8%, 5-year pancreas graft survival rate of 89.9%, and 10-year pancreas graft survival rate of 65.9%.

Summary: Background/Objective: There are no reports available on patient satisfaction and quality-of-life after robotic pancreaticoduodenectomy (RPD). This study aimed to evaluate not only surgical outcomes but also patient satisfaction after RPD. Methods: Prospectively collected data for RPD were analyzed for surgical outcomes. Questionnaires were sent to patients to assess patient satisfaction regarding RPD. Results: The study included 105 patients who underwent RPD, with 44 (41.9%) patients presenting with associated surgical complications. There were no significant differences between the without and with complication groups in median console time (390 min. Vs. 373 min.), blood loss (100 mL vs. 100 mL), and harvested lymph node number (14 vs. 15). There was no surgical mortality in this study. Major complications ≥ Clavien–Dindo III occurred in 7.6% of the total 105 RPD patients. The most common complication was chyle leakage (18.1%), followed by postoperative pancreatic fistula (5.7%), intra-abdominal abscess (4.8%), delayed gastric emptying (3.8%), and post pancreatectomy hemorrhage (3.8%). Almost all of the patients responded to this RPD-related survey with “fair” to “excellent” grades for all items, except 1 (

The aim of this study was to compare perioperative outcomes after Blumgart pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) for pancreatic-enteric reconstruction following pancreaticoduodenectomy.Data of patients undergoing Blumgart PJ and PG were retrieved from prospectively-collected database. Matched patients in each surgical groups were included based on the Callery risk scoring system for clinically relevant postoperative pancreatic fistula (CR-POPF) (grades B and C). Surgical parameters and risks were compared between these two groups.A total of 206 patients undergoing PD were included. Blumgart PJ was associated with shorter postoperative hospital stay (median (range) 25 (10-99) vs. 27 (10-97) days, P = 0.022). There was no surgical mortality in the Blumgart PJ group, but a 4.9% perioperative mortality in the PG, P = 0.030. The CR-POPF by Blumgrt PG is significantly lower than that by PG for overall patients (7% vs. 20%, P = 0.007), especially for those in intermediate fistula risk zone (6% vs. 21%, P =0.048) and high fistula risk zone (14% vs. 47%, P=0.038).Blumgart PJ is superior to PG in terms of pancreatic leakage and surgical mortality. Blumgart PJ can be recommended for pancreatic reconstruction after PD for all pancreatic remnant subtypes.

Gangliocytic paraganglioma (GP) is rare and difficult to be differentiated from other periampullary neoplasms. The clinical characteristics and optimal treatment of periampullary GPs have not been clarified. The data pool for the analysis comprised of cases of periampullary GP encountered in our institution and sporadic cases reported in the English literature. A total of 117 cases with periampullary GP were studied, including 2 from our institute, and among them, duodenal GP was the most common (53.0%). GP size ranged from 0.7 to 19.0 cm, with a median of 2.2 cm. The most common presenting symptom for overall periampullary GPs was epigastric pain in 49.5% cases, followed by gastrointestinal bleeding in 35.4% cases. Most (84.1%) of the periampullary GPs were benign, whereas 15.9% were malignant. Metastasis was noted in 26.3% of periampullary GPs, with 14.5% showing lymph node metastasis and 1.8% showing liver metastasis. Of the periampullary GP cases included, 30.1% were treated with pancreaticoduodenectomy, 40.6% with local excision, and 17.7% with endoscopic resection. Periampullary GP should be considered as a tumor with malignant potential. Endoscopic resection is the treatment of choice for most of the duodenal GPs, whereas pancreaticoduodenectomy is recommended for GPs with possible malignancy, such as large size, with submucosal invasion, or pancreatic GP.

Pancreatic groove cancer is very rare and can be indistinguishable from groove pancreatitis. This study is to clarify the characteristics, clinical features, managements, and survival outcomes of this rare tumor. Brief descriptions were made for each case of pancreatic groove cancer encountered at our institute. Individualized data of pancreatic groove cancer cases described in the literature were extracted and added to our database to expand the study sample size for a more complete analysis. A total of 33 patients with pancreatic groove cancer were included for analysis, including 4 cases from our institute. The median tumor size was 2.7 cm. The most common symptom was nausea or vomiting (89%), followed by jaundice (67%). Duodenal stenosis was noted by endoscopy in 96% of patients. The histopathological examination revealed well differentiated tumor in 43%. Perineural invasion was noted in 90%, and lymphovascular invasion and lymph node involvement in 83%. Overall 1-year survival rate was 93.3%, and 3- or 5-year survival rate was 62.2%, with a median survival of 11.0 months. Survival outcome for the well-differentiated tumors was better than those of the moderate/poorly differentiated ones. Early involvement of duodenum causing vomiting is often the initial presentation, but obstructive jaundice does not always happen until the disease progresses. Tumor differentiation is a prognostic factor for survival outcome. The possibility of pancreatic groove cancer should be carefully excluded before making the diagnosis of groove pancreatitis for any questionable case.

Background Gallbladder metastasis from renal cell carcinoma (RCC) is extremely rare. The purpose of this study is to clarify the characteristics of metastatic RCC to gallbladder. Methods The pooled data for analysis were collected from the case of metastatic RCC to gallbladder encountered by our institution along with sporadic cases reported in literature from 1991 to 2015. Results A total of 50 cases of metastatic RCC to gallbladder were recruited for study. Fifty-seven percentage of the primary RCC was from the right kidney and 43% from the left. The median interval between diagnoses of primary and metastatic RCC to gallbladder was 36 months, with the longest duration up to 324 months. Most (70%) were asymptomatic. The size of metastatic RCC to gallbladder ranged from 0.8 cm to 9 cm, with median of 2.6 cm. Majority (91%) of the metastatic RCCs presented as a polypoid mass with narrow stalk, and 82% were hypervascular lesion. The overall 1 year, 3 year and 5 year survival rate was 91.5%, 76.2% and 59.3% respectively, with a median of 26.5 months. Number of the metastatic site, timing of gallbladder metastasis, symptom, tumor size and operation type of cholecystectomy seemed to have no impact on survival. Conclusions Metastatic RCC to the gallbladder should be taken into account for a gallbladder polypoid mass with narrow hypervascular stalk during the diagnosis and/or follow-up of primary RCC. Gallbladder metastasis from RCC is not necessarily to be an advanced stage with poor outcome, and cholecystectomy is recommended whenever possible.

This study sought to identify the learning curves of console time (CT) for robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP). Perioperative outcomes were compared between the early group of surgeries performed early in the learning curve and the late group of surgeries performed after the learning curve. Pancreaticoduodenectomy (PD) is a technically demanding and challenging procedure carrying a high morbidity. Data for RDP and RPD were prospectively collected for analysis. The learning curve was assessed by cumulative sum (CUSUM). Based on CUSUM analyses, patients were divided into the early group and the late group. There were 70 RDP and 61 RPD cases. It required 37 cases to overcome the learning curve for RDP and 20 cases for RPD. The median console time was significantly shorter in the late group for both RDP (112 minutes vs 225 minutes, P

Background Outcomes after robotic distal pancreatectomy with spleen preservation (RDP-SP) by the Warshaw technique and with splenectomy (RDP-S) were compared. Methods All the data for patients undergoing robotic distal pancreatectomy (RDP) were prospectively collected. Results A total of 66 patients were included, with 33 in each group. The console time was significantly shorter in the RDP-SP group than in the RDP-S group (165 minutes vs. 220 minutes). The median blood loss was 50 cm3 in the RDP-SP group and 100 cm3 in the RDP-S group. The surgical morbidity was significantly lower in RDP-SP group (18% vs. 58%). Spleen infarction (15%), gastric varices (6%) and perigastric varices (45%) after RDP-SP were not associated with any subsequent complication. Postoperative platelet count and white blood cell (WBC) count were significantly higher in the RDP-S group. Conclusions Both RDP-SP and RDP-S are feasible in selected patients. RDP-SP is feasible and time-saving. Although gastric/perigastric varices and spleen infarction are not uncommon after RDP-SP, they appear to be clinically irrelevant.