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Introduction Vascular infiltration in pancreatic cancer represents the main limitation for surgery in locally advanced disease. Therefore an accurate preoperative study is mandatory to plan the most adequate surgical strategy. In the latest years, medical image fusion and three dimensional reconstruction models have gained wider acceptance in general surgery, especially in the hepatic field. Also for what concernes the pancreatic surgery, 3D reconstruction may allow a better preoperative staging if compared to traditional imaging studies. The aim of this study is to compare 3D imaging reconstruction model with conventional CT scan, MRI and Ecoendoscopy performance in patients undergoing pancreatic surgery with associated vascular resection. Materials and Methods Patients with pancreatic cancer who underwent surgery with vascular resection at the Sanchinarro University Hospital from June 2020 to June 2021 were retrospectively reviewed. For each patient a preoperative 3D reconstruction with 3D Cella Medical Solutions (3D-MSP®) model was realised and then compared with traditional imaging methods (CT, MRI and Eco endoscopy). Results We enrolled 10 patients who underwent pancreatic surgery with associated vascular resection. The diagnostic accuracy in detection of celiac trunk involvement was of 100%, 80%, 70% and 90% for 3D-reconstruction, CT Scan, MRI and Ecoendoscopy groups respectively. On the other hand, in relation to the portal-mesenteric trunk invasion, 3D-reconstruction has demonstrated a 100% rate of accuracy comparing with an accuracy of 25%, 50% and 30% of CT scan, MRI and Ecoendoscopy respectively. As concerning the precision in estabilishing the tumor size, 3D model was superior to the CT and MRI at the Bland–Altman comparison. Conclusion 3D imaging reconstruction technique is a helpful preoperatory tool in patients affected by pancreatic cancer with vascular involvement. More studies with larger series are needed to confirm these preliminary results.

Background: The aim of this study is to evaluate the future liver remnant after major hepatectomy with 3D modelling treated, respectively, with associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) and portal vein embolization (PVE). Methods: Patients submitted to ALPPS at our centre were compared with a group of patents submitted to the PVE followed by major hepatectomy. 3D reconstruction was realised before and after surgical treatment, and anatomic future liver remnant (FRL) and functional future liver remnant (FRFx) were calculated and compared with clinical outcomes. Results: From May 2011 to October 2019, 11 ALPPS procedures were realised at Sanchinarro University Hospital, Madrid. They were compared to a control group composed of 13 patients who underwent PVE followed by hepatectomy. The increase of anatomical FRL (iFRL) was superior in the ALPPS group (120%) with respect to the PVE group (73%) (p=0,041), while the increase of functional FRFX (iFRFx) was 35% in the ALLPS group and 46% in the PVE group (p>0,05), showing no difference in the two groups. PHLF grade B and C occurred in 6 patients. The ROC curve showed a better AUC for FRFxVpost (74%) with respect to FRLVpost (54%) in prediction PHLF>B. Conclusion: The 3D reconstruction model can allow optimal surgical planning, and through the use of specific algorithms, can contribute to differential functioning liver parenchyma of the FLR.

The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis. This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective. Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p

Enucleation has widely spread as an alternative strategy in the treatment of small pancreatic tumours and cystic lesions. To date there are limited data on perioperative outcomes after pancreatic enucleation performed using a minimally invasive robotic technique, particularly regarding the risk factors associated with postoperative pancreatic fistula (POPF). We perform a comparative study of robotic pancreatic enucleation (RPE) and open enucleation (OPE) with the aim of evaluating clinical and cost-effective outcomes.This is a case-matched analysis of patients who underwent robotic and open pancreatic enucleation performed at Sanchinarro University Hospital, Madrid, from October 2014 to December 2021. Patient data were obtained retrospectively. Clinicopathologic characteristics and perioperative and postoperative outcomes were recorded and analysed. Two groups of demographically similar patients were analysed: the robotic group (n = 20) and the open group (n = 20). The patient characteristics of the two groups have been compared. From February 2015, quality-adjusted life years (QALYs) are also included and prospectively recorded in the database and used to measure the effectiveness of the treatment.A total of 20 RPE and 20 OPE have been included. The incremental cost of the robotic approach versus open was €2617.85(CI 95% 1601.48; 3634.24) and the incremental utility was 0.0879 QALYs (CI 95% 0.0834; 0.0925). The estimated ICER for patients was €29,782.13 (CI 95% 17,313.29; 43,576.01) per QALY gained. Robotic resection resulted a shorter postoperative hospital stay, less wound infections, faster recovery diet and a similar operating time. The two groups had similar complication rates. Pathological data were similar for both procedures.RPE resulted in a shorter hospital stay and less blood loss and morbidity, comparable with the outcomes of open enucleation. RPE may also be acceptable in terms of cost-effectiveness.

Background Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis. Recurrent acute pancreatitis, chronic pancreatitis or chronic abdominal pain are the main clinical syndromes at presentation and occur in only 5% of the patients with pancreas divisum. This review aimed to discuss diagnosis and treatment strategies in patients with symptomatic pancreas divisum. Data sources We report a literature review from 1990 up to January 2018 to explore the various diagnostic modalities and surgical techniques and results reported in the surgical treatment of pancreas divisum. Results There are limited reports available on this topic in the literature. We analyzed and described the main indications in the treatment of pancreas divisum, focusing on surgical treatment and a discussion of the different approaches. Furthermore, we report the results from our experience in two cases of pancreas divisum treated by pancreatic head resection with segmental duodenectomy (the Nakao procedure). Conclusions Pancreas divisum is a common pancreatic malformation in which only a few patients develop a symptomatic disease. Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications. Many techniques, of greater or lesser complexity, have been proposed.

BRCA gene mutations are found in up to 10% of pancreatic adenocarcinoma cases. We present a description of 4 cases along with a review of the current literature regarding pathogenesis, target treatment, response and survival rates in these types of malignancies. We describe four cases of pancreatic adenocarcinoma, in three of which the BRCA2 mutation was identified, in one - BRCA1 gene alteration. Two patients underwent surgery following the neoadjuvant treatment with Folfirinox and radiotherapy; in the first case, a distal pancreatectomy with splenectomy was performed and in the second one - the Whipple's procedure. In both cases, a complete pathological response was reported. Other 2 patients were treated with Folfirinox after BRCA mutation identification and acceptable life expectancy was obtained. The association of pathologic complete response (PCR) with lower rates of local recurrence and better survival in patients with various types of adenocarcinomas is well known. Identification of such patients carrying BRCA mutations could provide an application of better personalized treatment. In some patients with pancreatic cancer, especially when there is clinical or demographic reason to suspect a genetic predisposition, a confirmation of the presence of BRCA mutations could provide an opportunity to use target treatment with beneficial outcomes regarding survival.

Objectives: Neoadjuvant radiochemotherapy (nCRT) is universally considered to be a valid treatment to achieve downstaging, improve local disease control and obtain better resectability in locally advanced rectal cancer (LARC). The aim of this study is to correlate the change in tumor 18F -FDG PET-CT standardized uptake value (SUV) before and after nCRT, in order to obtain an early prediction of pathologic response (pR) achieved in patients with LARC.Data description: We performed a retrospective analysis of patients with LARC diagnosis who underwent curative resection. All patients received nCRT and surgical treatment was carried after 8/12th. All patients underwent a baseline 18F -FDG PET-CT scan within the week prior to the initiation of the treatment (PET-CT SUV1) and a second scan (PET-C T SUV2) within six weeks of the completion of nCRT. Furthermore, we evaluated the prognostic value of 18F -FDG PET-CT in terms of disease free survival (DFS) and overall survival (OS) in patients with LARC.A total of 133 patients with LARC were included in the study. Patients were divided in two groups according to the TRG (tumor regression grade): 107 (80%) as Responders group (TRG0-TRG1) and 26 (25%) as the No-Responders group (TRG2-TRG3). We obtained a significant difference in Δ%SUV between the two different groups responders vs no responders (p

This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side hemicolectomy, focusing on oncological outcomes, mortality and morbidity rates. A systematic literature search was performed on MEDLINE and EMBASE archives, including studies on CME in right-side colon cancer. Primary outcomes were five-year disease-free survival and five-year overall survival. Secondary outcomes investigated were mortality and morbidity rates, intraoperative blood loss, anastomotic leakage, postoperative ileus, day of postoperative flatus, pulmonary infection, duration of hospital stay and number of lymph nodes harvested. Seventeen studies have been included in this meta-analysis for a total of 3918 patients. The five-year disease-free survival (DFS) and overall survival (OS) results improved in the CME group with respect to conventional right-side colectomy with an OR 1.88 (95% CI 1.02–3.45) and OR 2.77 (95% CI 1.33–5.74), respectively. The incidence of mortality and morbidity was comparable between the two groups. Moreover, conventional surgery time was faster than CME (MD 33.69 min, 95% CI 12.79–54.59), while no significant differences were reported in mean blood loss and hospital stay. Furthermore, the CME group showed a higher mean number of harvested lymph nodes (MD 7.08 lymph nodes 95% CI 4.90–9.27). Complete mesocolic excision of the right-side colectomy improves oncological outcomes without increasing mortality and morbidity rates compared to standard right-side hemicolectomy. CME should therefore be routinely performed in the treatment of right-side colon cancer.

The prognostic factors for long-term survival after curative resection of pancreatic adenocarcinoma are still poorly understood. The purpose of this study was to identify the prognostic factors of long-term survival after resection of pancreatic adenocarcinoma based on actual 5-year survival including different lymph node status classifications.A total of 106 patients who underwent pancreatectomy were enrolled at our institution and retrospectively analyzed according to actual survival (vs5 years), as well as several currently available node classifications: N0/N1, N0/N1/N2, and lymph-node ratio (LNR) including multivariate logistic regression.The actual 5-year overall survival rate of the series was 12.26%. In a univariate analysis, operative blood loss and blood transfusion, completion of adjuvant treatment, histological differentiation, perineural invasion, N0/N1, N0/N1/N2 and LNR were significant predictive factors for actual long-term survival. A multivariate analysis showed that only N0/N1 was an independent predictive factor for actual 5-year survival (OR: 1.593; 0.730-1.325; p= 0.264).The nodal involved status is the strongest independent unfavorable factor for actual long-term survival after pancreatic resection for adenocarcinoma.

HVH (hepatic vascular hamartoma) is a tumor like malformation arising from the vascular tissue of the liver. HVH has been previously reported in animals and presents distintive features from the most frequent benign tumor like malformation of the liver, the hepatic mesenchymal hamartoma (HMH). Herein we report a case of HVH localized in hepatic segment 4b, involving the gastro hepatic ligament, successfully treated with total excision. We describe the anatomo-pathologic findings focusing on the clinical and radiological presentation, the intraoperative characteristics and the differential diagnosis.

Aim There is no study in the literature that evaluates the cost-effectiveness of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP). We performed a comparative study of RDP and LDP with the aim of evaluating clinical and cost-effective outcomes. Material and methods This is an observational, comparative prospective nonrandomized study. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness to pay of €20 000 and €30 000 per quality-adjusted life year (QALY) was used as a threshold to recognize which treatment was most cost-effective. Results A total of 31 RDP and 28 LDP have been included. The overall mean total cost was similar in both groups (RDP: €9712.15 versus LDP: €9424.68; P > .5). Mean QALYs for RDP (0.652) was higher than that associated with LDP (0.59) (P > .5). Conclusion This study seems to provide data of cost-effectiveness between RDP and LDP approaches, showing some benefits for RDP.

Objective The aim of this study is to compare the clinical and cost-effective outcomes of the open Lichtenstein repair (OL) and laparoscopic trans-abdominal preperitoneal (TAPP) repair for bilateral inguinal hernias. Summary background data A cost-effective analysis of laparoscopic versus open inguinal hernia repair is still not well addressed, especially regarding bilateral hernia. Methods This is a clinical and cost-effectiveness analysis within a randomized prospective study conducted at Sanchinarro University Hospital.Cases of primary, reducible bilateral inguinal hernia were included and randomized using a simple randomization program.The outcome parameters included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio. Results Between March 2013 and January 2017, 165 patients were enrolled in this study (81 of them underwent TAPP and 84 OL).The TAPP procedure had less early postoperative pain (P = 0.037), a shorter length of stay (P = 0.001), and fewer postoperative complications (P = 0.002) when compared with the OL approach. The overall cost of TAPP procedure was higher compared with the OL cost (1,683.93O vs 1192.83O, P = 0.027). The mean QALYs at 1 year for TAPP (0.8094) was higher than that associated with OL (0.6765) (P = 0.018). At a willingness-to-pay threshold of 20,000 O and 30,000 O, there was a 95.38% and 97.96% probability that TAPP was more cost-effective relative to OL. Conclusions The TAPP procedure for bilateral inguinal hernia appears to be more cost-effective compared with OL.

Background Minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. In fact, the indication for robotic surgery in pancreatic disease has been controversial. The present study aimed to assess the safety and feasibility of robotic pancreatic resection. Methods We retrospectively reviewed our experience of robotic pancreatic resection done in Sanchinarro University Hospital. Clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. Results From October 2010 to April 2016, 50 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 50 patients, 26 were male and 24 female. The average age of all patients was 62 years. Operative time was 370 minutes. Among the procedures performed were 16 pancreaticoduodenectomies (PD), 23 distal pan-createctomies (DP), 11 tumor enucleations (TE). The mean hospital stay was 17.6 days in PD group, 9.0 days in DP group and 8.4 days in TE group. Pancreatic fistula occurred in 10 cases (20%), 2 after PD, 3 after DP, and 5 after TE. Four patients had postoperative transfusion in PD group and one in DP group. Conversion to open laparotomy occurred in four patients (8%). No serious intraoperative complications were observed. Conclusions From our early experience, robotic pancreatic surgery is a safe and feasible procedure. Further experience and follow-up are required to confirm the role of robotic approach in pancreatic surgery.

BACKGROUND/AIM Abdominal malignancies invading inferior vena cava present high postoperative morbidity and poor prognosis that has been decreasing in the last years. Our aim was to present and discuss a series of resected tumors invading the inferior vena cava from the origin of the hepatic vein to the common iliac veins (Level I and II). MATERIALS AND METHODS We retrospectively evaluated from 2005 to 2015 short- and long-term results of 20 consecutive surgical resections of tumors with associated inferior vena cava resection at Levels I and II performed at the Sanchinarro Hospital, Madrid, Spain. RESULTS The series included 4 leiomyosarcomas, 3 pancreatic cancers, 2 germinal cancers, 5 renal cancers, 4 liver cancers and 2 adrenal cancers. There were 7 circular cava resections, all of them replaced by polytetrafluoroethylene (PTFE) graft and 13 primary repairs. Sapheno-femoral arterio-venous fistulas have been performed in 6 cases. Early postoperative complications occurred in 11 cases (57.9%) and mortality in one case. Graft thrombosis occurred in one case at 14 months from surgery (1/7, 14.2%). CONCLUSION Surgical resection with combined inferior vena cava resection can be performed in selected patients with acceptable morbidity and mortality in light of the recent advancement in surgical technique.

Rhabdomyosarcoma (RMS) is the most common soft tissue malignancy in childhood and adolescence. Patients with the most aggressive histological variant have an unfavorable prognosis due to a high metastasis incidence. Lysyl oxidase-like 2 (LOXL2) is a lysyl oxidase, member of a family of extracellular matrix (ECM) crosslinking enzymes that recently have emerged as important regulators of tumor progression and metastasis. We report that LOXL2 is overexpressed in RMS, suggesting a potential role for LOXL2 in RMS oncogenic progression. Consistently, transient and stable LOXL2 knockdown decreased cell migratory and invasive capabilities in two ARMS cell lines. Furthermore, introduction of LOXL2 in RMS non-expressing cells using wild type or mutated (catalytically inactive) constructs resulted in increased cell migration, cell invasion and number and incidence of spontaneous lung metastasis in vivo, independently of its catalytic activity. To further study the molecular mechanism associated with LOXL2 expression, a pull-down assay on LOXL2-transfected cells was performed and analyzed by mass spectrometry. The intermediated filament protein vimentin was validated as a LOXL2-interactor. Thus, our results suggest an oncogenic role of LOXL2 in RMS by regulating cytoskeleton dynamics and cell motility capabilities., OMT: Fundación Alba Pérez lucha contra el cáncer infantil. Instituto de Salud Carlos III (CES12/021; PI11/00038; PI15/00035; AC14/00026) and EU's Fondo Europeo de Desarrollo Regional (FEDER) “Una manera de hacer Europa/A way to achieve Europe.” CERCA Program/Generalitat de Catalunya (2017SGR332). OA-R, DH-M: Fundación Científica de la AECC. SG-M, SR-V: Fundación Alba Pérez lucha contra el cáncer infantil. PM: European Union’s Horizon 2020 research and innovation program under Marie Sklodowska-Curie grant agreement ITN: 766214 – ESR 4.

Locally advanced pancreatic cancer (LAPC) is a highly malignant carcinoma with an extremely poor prognosis. Vascular venous invasion is a frequent finding in patients with pancreatic cancer. The aim of this study was to investigate the morbidity, mortality, and survival of patients with advanced pancreatic cancer.We retrospectively reviewed our experience of 65 consecutive pancreatic surgeries with venous resection for pancreatic cancer in three hospitals: Ramon y Cajal (Madrid, Spain) from 2002 to 2004, Monteprincipe University Hospital (Madrid, Spain) from 2005 to 2006 and Sanchinarro University Hospital (Madrid, Spain) from 2007 to December 2017. Prognostic factors were analyzed by the log-rank test and a multivariate proportional hazard regression analysis.Major venous reconstruction was performed by primary lateral venorrhaphy in 11 patients (17%), primary end-to-end anastomosis in 46 (70.7%) and reconstruction with a Gore-Tex® patch (W.L. GoreAssociates, Inc., Flagstaff, AZ) in 8 (12.3%). In 58% of the patients, the pathological examination showed infiltration of the vascular specimen. About 85% of the procedures performed were R0. The perioperative morbidity rate with Dindo-Clavien classification = III was 21.5%. Tumor size and nodal status were the only prognostic variables, which significantly decreased survival by a multivariate analysis.Major vascular resection to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. Nevertheless, it is justified only in carefully selected cases.

The differences between the costs of robotic rectal resection and of the laparoscopic approach are still not well known. The aim of this study was to evaluate the cost-effectiveness of robotic versus laparoscopic surgery. We conducted an observational, comparative, prospective, non-randomized study on patients having laparoscopic and robotic rectal resection between February 2014 and March 2018 at the Sanchinarro University Hospital, Madrid. Outcome parameters included surgical and post-operative costs, quality adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER). The primary endpoint was to compare cost effectiveness in the robotic and laparoscopic surgery groups. A willingness-to-pay of 20,000€ and 30,000€ per QALY was used as a threshold to determine the most cost-effective treatment. A total of 81 RRR and 104 LRR were included. The mean operative costs were higher for RRR (4307.09€ versus 3834.58€; p = 0.04), although mean overall costs were similar (7272.03€ for RRR and 6968.63€ for the LLR; p = 0.44). Mean QALYs at 1 year for the RRR group (0.8482) was higher than that associated with LRR (0.6532) (p = 0.018). At a willingness-to-pay threshold of 20,000€ and 30,000€ there was a 95.54% and 97.18% probability, respectively, that RRR was more cost-effective than LRR. Our data regarding the cost-effectiveness of RRR versus LRR shows a benefit for RRR.

In the last decade, there have clearly been important changes in the surgical approach of gastric cancer treatment due to an increased interest in the minimally invasive surgical approach (MIS). The higher cost of robotic surgery procedures remains an important issue of debate. The objective of the study is to compare the main operative and clinical outcomes and to assess the incremental cost-effectiveness ratios (ICERs) of the two techniques. This is a prospective cost-effectiveness and clinical study when comparing the robotic gastrectomy (RG) technique with open gastrectomy (OG) in gastric cancer. Outcome parameters included surgical and post-operative costs, quality-adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). The incremental utility was 0.038 QALYs and the estimated ICER for patients was dominated by robotic approach. The probability that the robotic approach was cost effective was 94.04% and 94.20%, respectively, at a WTP threshold of 20,000€ and 30,000€ per QALY gained. RG for gastric cancer represents a cost-effective procedure compared with the standard OG.

Pathologic complete response (pCR) is observed in 8–24% of the cases of patients with locally advanced rectal cancer (LARC) treated with neoadjuvant radiochemotherapy (RCT) before curative surgery ...

Fibrovascular polyp of the cervical esophagus represents about 0.5% to 1% of all benign oesophageal tumours. Usually asymptomatic, when FP protrudes into the oesophageal lumen, this may cause respiratory obstruction and provoke dysphagia, vomiting, dyspnoea, and retrosternal pain. In this article, we describe a multimodal approach in the treatment of a complex recurrent FP, for which surgical resection represents the safer and less invasive procedure.

Background F-flurodeoxyglucose positron emission tomography (FDG-PET) have been claimed to be an important prognostic tool in different malignancies. However, its predictive prognostic value on pancreatic neuroendocrine tumors (PNETs) is still under investigation. Aim We study the prognostic impact of FDG-PET scan in neuroendocrine pancreatic tumors. Methodology Between 2007 and 2012, 26 patients with no metastastatic histologically confirmed PNETs (mean age: 57 years) were examined with FDG-PET. We studied its captation in relation with the well established hystopathological prognostic markers assessed in the tumoral resected specimen according to the WHO 2004 and ENETS/WHO 2010 classification. Results FDG-PET captation was positive in 17 cases (65.4%). The median follow-up period was 34.4 months and recurrences occurred in 4 cases (15.4%). We found a significant correlation between this captation and Ki 67 index (p = 0.032), mitotic index (p = 0.002), tumor grade (p = 0.017) and tumor size (p = 0.01). Conclusions FDG-PET provides a good prognostic value for PNETs. Present results must be further validated with larger sample studies.

INTRODUCTION The use of robotic surgery in liver resection is still limited. Our aim is to present our early experience of robotic liver resection. MATERIALS AND METHODS It is a retrospective review of Sanchinarro University hospital experience of robotic liver resection performed from 2011 to 2014. Clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. RESULTS Twenty-one procedures have been performed and 13 (65%) of them were for malignancy. There were 2 left hepatectomies, 1 right hepatectomy, 1 associated liver partition and portal vein ligation staged procedure (both steps by robotic approach), 1 bisegmentectomy and 3 segmentectomies, 9 wedge resections, and 3 pericystectomies. The mean operating time was 282 minutes (range, 90 to 540 min). Overall conversion rate and postoperative complication rate were 4.7% and 19%, respectively. The mean length of hospital stay was 13.4 days (range, 4 to 64 d). CONCLUSION From our early experience, robotic liver surgery is a safe and feasible procedure, especially for major hepatectomies.

Highlights • PPP (pancreatic disease, panniculitis, polyarthritis) syndrome is a rare disease caused by pancreatitis or pancreatic cancer. • Panniculitis and polyarthritis are the main characteristics of the syndrome. • A high mortality rate and chronic sequel are reported. • Surgical and endoscopic treatment may improve the prognosis of this condition., Introduction Pancreatic disease can be complicated by extrabdominal manifestations such as panniculitis and polyarthritis. The symptomatic triad comprising pancreatic disease, panniculitis and polyarthritis is also known as PPP syndrome and is characterized by severe chronic sequels and high mortality rate. We describe a case of PPP syndrome successfully treated with spleen preserving total pancreatectomy; in addition we performed a literature review. Presentation of case A 67 years old male presented panniculitis and polyarthritis without clinical abdominal symptoms. Clinical presentation, laboratory values and radiological findings demonstrated an acute pancreatitis and a pancreatic cancer was suspected; failure of conservatory treatments and high suspicious of malignancy led to perform a spleen preserving total pancreatectomy. Finally histological examination excluded a pancreatic cancer and confirmed a chronic pancreatitis. Patient was discharged with complete resolution of the extrabdominal disease. Discussion In literature only 64 cases of PPP syndrome have been reported. Abdominal symptoms do not often appear at presentation and diagnosis may be delayed. Panniculitis develope in any part of the body but especially on the distal parts of the lower extremities, around the ankles and pretibial regions of the legs. Between osteo-articular manifestations polyarthritis is the most common one, although oligoarthritis, and monoarthritis in have been reported. Conclusion PPP syndrome is a rare disease with a high mortality rate. A timely diagnosis and an aggressive treatment may improve the prognosis of this condition.

Background Robotic techniques are claimed to be an alternative to laparoscopic and open approaches for gastrointestinal stromal tumors (GIST) treatment. Our aim is to present our single center experience and a literature review. Materials and methods From June 2012 to August 2014, six patients with preoperative diagnosis of GIST were treated by robotic surgery at Sanchinarro University Hospital. Results Two GIST tumors were localized in the second part of the duodenum, one in the first portion, two in the gastricantrum and another in the angular notch. Surgical procedures performed were two subtotal gastrectomies, one gastric wedge resection and three duodenal enucleations. None of the interventions needed conversion to open surgery. Mean operative time was 245 min (150–540). Mean hospital stay was 10.5 days (6–24). All lesions had microscopically negative resection margins. Mean follow-up was 24 months (8–33) with a disease-free survival rate of 100%. Conclusions A robotic approach for GIST tumors is a safe and feasible procedure with a well-accepted oncological surgical result. Copyright © 2015 John Wiley & Sons, Ltd.

In recent years, increasingly sophisticated tools have allowed for more complex robotic surgery. Robotic gastrectomy, however, is adopted in only a few selected centers. The goals of this study were to examine the adoption of robotic gastrectomy and to compare outcomes between open and robotic gastric resections. This is a case-matched analysis of patients who underwent robotic and open gastric resection performed at Sanchinarro University Hospital, Madrid from November 2011 to February 2017. Patient data were obtained retrospectively. Clinicopathologic characteristics and perioperative and postoperative outcomes were recorded and analyzed. Two groups of demographically similar patients were analyzed: the robotic group (n = 20) and the open surgery group (n = 19). The patient characteristics of the two groups have been compared. Robotic resection resulted in less blood loss, shorter postoperative hospital stay, and a longer operating time. The two groups had similar complication rates. Pathological data were similar for both procedures. Robotic gastrectomy for locally advanced gastric carcinoma is safe, and long-term outcomes are comparable to those patients who underwent open resection. Robotic gastrectomy resulted in a shorter hospital stay, less blood loss and morbidity comparable with the outcomes of open gastrectomy.

Interest in robotic pancreatectomy has been greatly increasing over the last decade. However, evidence supporting the benefits of robotic over open pancreatectomy is still outstanding. This study aims to assess the safety and efficacy of robotic pancreatectomy compared with the conventional open surgical approach. Propensity score-matched (1:1) was used to balance age, sex, BMI, ASA, tumor size, and malignancy of 17 robotic pancreaticoduodenectomies (PD), 12 pancreatic enucleations (PE), and 28 distal pancreatectomies (DP); and was compared with the open standard approach. Robotic PD was associated with longer operative time (594 vs. 413 min; p = 0.03) and decreased blood loss (190 vs. 394 ml; p = 0.001). Robotic PE showed a lower mean length of hospital stay (8.4 vs. 12.8 days; p = 0.04) and, in addition, robotic DP showed less blood loss (175 vs. 375 ml; p = 0.01), less severe morbidities (7.14 vs. 17.9%; p = 0.02), and a reduced mean length of hospital stay (8.9 vs. 15.1; p = 0.001). Overall, conversion rate was 4 (7%). Robotic pancreatectomy is as safe and effective as the standard open surgical approach with reduced blood loss in PD and DP, length of hospital stay in PE and DP, and severe morbidity in DP.

Hepatic resection of tumors invading the retrohepatic vena cava and hepatic veins are a challenge for surgeons, who consider them unresectable most of the time.1 , 2 Ex situ hepatectomy and liver autotransplantation has developed to improve resectability of these malignancies.3,4 The patient was a 51-year-old man who had jaundice secondary to a intrahepatic cholangiocarcinoma 7 cm in diameter in the right lobe of the liver and the caudate lobe. A volumetric scan showed a future liver remnant (segments 2 and 3) not sufficient according to the body weight. The patient was considered to be unresectable by conventional resection due to the critical invasion to the retrohepatic vena cava together with the three hepatic veins. Therefore, an ex vivo extended right hepatectomy and autotransplantation were indicated. The patient underwent biliary decompression through a percutaneous transhepatic catheter and right portal vein embolization for left lobe hypertrophy. During the surgery, the liver was removed with the retrohepatic vena cava, which was replaced by a prosthetic graft without a veno-venous bypass. Ex vivo extended right hepatectomy was performed, and a prosthetic graft was used to replace the vena cava where the remaining left hepatic vein was anastomosed. The surgery duration was 9 h, and the anhepatic time was 4.5 h. The postoperative hospital stay was 19 days, and at this writing, 3 years later, the patient is disease-free. Ex vivo hepatectomy without veno-venous bypass should be considered a valid therapeutic option for selected patients with cholangiocarcinoma invading the retrohepatic vena cava.

The costs involved in performing robotic surgery present a critical issue which has not been well addressed yet. The aims of this study are to compare the clinical outcomes and cost differences of robotic versus laparoscopic surgery in the treatment of rectal cancer and to conduct a literature review of the cost analysis. This is an observational, comparative study whereby data were abstracted from a retrospective database of patients who underwent laparoscopic and robotic rectal resection from October 2010 to March 2017, at Sanchinarro University Hospital, Madrid. An independent company performed the financial analysis, and fixed costs were excluded. A total of 86 robotic and 112 laparoscopic rectal resections were included. The mean operative time was significantly lower in the laparoscopic approach (336 versus 283 min; p = 0.001). The main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (robotic: 5.8%, laparoscopic: 11.6%; p = 0.001). The mean operative costs were higher for robotic surgery (4285.16 versus 3506.11€; p = 0.04); however, the mean overall costs were similar (7279.31€ for robotic and 6879.8€ for the laparoscopic approach; p = 0.44). We found four studies reporting costs, three comparing robotic versus laparoscopy costs, with all of them reporting a higher overall cost for the robotic rectal resection. Robotic rectal resection has similar clinical outcomes to that of the conventional laparoscopic approach. Despite the higher operative costs of robotic rectal resection, overall mean costs were similar in our series.

Background The robotic surgery cost presents a critical issue which has not been well addressed yet. This study aims to compare the clinical outcomes and cost differences of robotic distal pancreatectomy (RDP) versus laparoscopic distal pancreatectomy (LDP). Methods Data were abstracted prospectively from 2011 to 2017. An independent company performed the financial analysis. Results A total of 28 RDP and 26 LDP were included. The mean operative time was significantly lower in the LDP (294 vs 241 min; p = 0.02). The main intra and post-operative data were similar, except for the conversion rate (RDP: 3.6% vs LDP: 19.2%; p = 0.04) and hospital stay (RDP: 8.9 vs LDP 13.1 days; p = 0.04). The mean total costs were similar in both groups (RDP: 9198.64 € vs LDP: 9399.74 €; p > 0.5). Conclusions RDP showed lower conversion rate and shorter hospital stay than LDP at the price of longer operative time. RDP is financially comparable to LDP.

Introduction Neoadjuvant treatment has been reported to prolong survival in patients with potentially resectable pancreatic adenocarcinoma (PA). However, there are currently limited clinical results available using nab-paclitaxel and gemcitabine in PA. This paper compares the oncological results of patients affected by potentially resectable PA who underwent surgery first (SF) versus surgery following neoadjuvant treatment (NAT). Methods This is an observational, comparative study whereby data were abstracted from a prospective database of patients affected by PA from 2007 to 2016. Results We included a total of 81 patients (36 SF and 45 NAT) which resulted in being preoperatively similar. Among the NAT patients, treatment was well tolerated and the resection rate was 68.8% (31/45 patients). There was a trend towards a higher R1 resection rate in the SF group compared with the NAT (13.8% vs 3.2%; p = 0.1). Median overall survival in the resected NAT group was higher (30.6 vs 22.1 months; p = 0.04). In the borderline resectable group, overall survival was found to be four times higher compared with SF (43.6 versus 13.5 months; p = 0.001). Conclusions These data suggest that neoadjuvant treatment with gemcitabine/nab-paclitaxel is a safe and effective option for potentially resectable PA compared with the SF approach.

Background In literature, only a few studies have prospectively compared the results of laparoscopic with open inguinal hernia repair yet none have compared bilateral inguinal hernia repair. The aim of this study is to compare the open Lichtenstein repair (OLR) with laparoscopic trans-abdominal preperitoneal (TAPP) repair in patients undergoing surgery for bilateral inguinal hernia. Methods Patients were prospectively randomized between March 2013 and March 2015. Outcome parameters included hospital stay, operation time, postoperative complications, immediate postoperative pain and chronic pain, recurrence and quality of life. Results Sixty-one patients underwent TAPP repair and 73 underwent OLR. TAPP procedure had less early post-operative pain up to 7 days from surgery (p = 0.003), a shorter length of hospital stay (p = 0.001), less postoperative complications (p = 0.012) and less chronic pain (0.04) when compared with the OLR approach. Conclusions TAPP procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications.

Abdominal malignancies invading inferior vena cava present high postoperative morbidity and poor prognosis that has been decreasing in the last years. Our aim was to present and discuss a series of resected tumors invading the inferior vena cava from the origin of the hepatic vein to the common iliac veins (Level I and II).We retrospectively evaluated from 2005 to 2015 short- and long-term results of 20 consecutive surgical resections of tumors with associated inferior vena cava resection at Levels I and II performed at the Sanchinarro Hospital, Madrid, Spain.The series included 4 leiomyosarcomas, 3 pancreatic cancers, 2 germinal cancers, 5 renal cancers, 4 liver cancers and 2 adrenal cancers. There were 7 circular cava resections, all of them replaced by polytetrafluoroethylene (PTFE) graft and 13 primary repairs. Sapheno-femoral arterio-venous fistulas have been performed in 6 cases. Early postoperative complications occurred in 11 cases (57.9%) and mortality in one case. Graft thrombosis occurred in one case at 14 months from surgery (1/7, 14.2%).Surgical resection with combined inferior vena cava resection can be performed in selected patients with acceptable morbidity and mortality in light of the recent advancement in surgical technique.

As surgical resection remains the only hope for cure in pancreatic cancer (PC), more aggressive surgical approaches have been advocated to increase resection rates. Venous resection demonstrated to be a feasible technique in experienced centres, increasing survival. In contrast, arterial resection is still an issue of debate, continuing to be considered a general contraindication to resection. In the past few years there have been significant advances in surgical techniques and postoperative management which have dramatically reduced mortality and morbidity of major pancreatic resections. Furthermore, advances in multimodal neo-adjuvant and adjuvant treatments, as well as the better understanding of tumour biology and new diagnostic options have increased overall survival. In this article we highlight some of the important points that a modern pancreatic surgeon should take into account in the management of PC with arterial involvement in light of the recent advances.

Resumen La reseccion quirurgica representa en la actualidad la unica posibilidad terapeutica para pacientes afectos de carcinoma de pancreas (CP). Procedimientos quirurgicos agresivos han sido descritos en un intento de incrementar la resecabilidad. La reseccion venosa representa en la actualidad una tecnica quirurgica aceptada en centros con importante experiencia en cirugia pancreatica. Por el contrario, la reseccion arterial en enfermos afectos de CP sigue siendo una tecnica muy controvertida. La infiltracion arterial en estos pacientes suele ser considerada un criterio de irresecabilidad. En los ultimos anos, importantes avances en la tecnica quirurgica y en el tratamiento postoperatorio de estos pacientes han permitido reducir la morbimortalidad de las resecciones pancreaticas. Por otra parte, notables mejoras en el tratamiento neoadyuvante y adyuvante asi como un mayor conocimiento en la biologia del tumor ademas de nuevas opciones diagnosticas han permitido mejorar la supervivencia. En el presente articulo, destacamos importantes puntos que un cirujano moderno debe de considerar para tratar a afectados de CP con infiltracion arterial.

Introduction Robotic surgery has gained worldwide acceptance in the past decade, and several studies have shown that this technique is safe and feasible. The aim of this study is to compare main outcomes of laparoscopic and robotic rectal resection. Methods In total, 143 consecutive patients treated for rectal cancer in our department with laparoscopic or robotic-assisted surgery from October 2010 to July 2013 were retrospectively analyzed. Results A total of 87 patients underwent laparoscopic rectal resection, and 56 patients were treated using a robotic approach. The conversion rate was 11.5% in the laparoscopic group and 3.5% in the robotics group (P = 0.09). The low rectal cancer conversion rate was significantly lower in the robotic group (1.8%) than in the laparoscopy group (9.2%) (P = 0.04). Mean operation time was 252 min in the laparoscopic group and 309 min in the robotic group (P = 0.023). Conclusions The robotic approach shows a lower conversion rate in low rectal cancer but with a longer operative time compared with the laparoscopic technique. Copyright © 2014 John Wiley & Sons, Ltd.