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Background: This study analyzed the Quality of Life (QoL) and cost-effectiveness of laparoscopic (LDP) versus robotic distal pancreatectomy (RDP)., Methods: Consecutive patients submitted to LDP or RDP from 2010 to 2020 in four high-volume Italian centers were included, with a minimum of 12 months of postoperative follow-up were included. QoL was evaluated using the EORTC QLQ-C30 and EQ-5D questionnaires, self-reported by patients. After a propensity score matching, which included BMI, gender, operation time, multiorgan and vascular resections, splenic preservation, and pancreatic stump management, the mean differential cost and Quality-Adjusted Life Years (QALY) were calculated and plotted on a cost-utility plane., Results: The study population consisted of 564 patients. Among these, 271 (49%) patients were submitted to LDP, while 293 (51%) patients to RDP. After propensity score matching, the study population was composed of 159 patients in each group, with a median follow-up of 59 months. As regards the QoL analysis, global health and emotional functioning domains showed better results in the RDP group (p = 0.037 and p = 0.026, respectively), whereas the other did not differ. As expected, the median crude costs analysis confirmed that RDP was more expensive than LDP (16,041 Euros vs. 10,335 Euros, p < 0.001). However, the robotic approach had a higher probability of being more cost-effective than the laparoscopic procedure when a willingness to pay more than 5697 Euros/QALY was accepted., Conclusion: RDP was associated with better QoL as explored by specific domains. Crude costs were higher for RDP, and the cost-effectiveness threshold was set at 5697 euros/QALY., (© 2024. The Author(s).)

Background: Robotic pancreatoduodenectomy is increasingly being implemented worldwide, with good results reported from individual expert centers. However, it is unclear to what extent outcomes will continue to improve during the learning curve, as large international studies are lacking., Methods: An international retrospective multicenter case series, including consecutive patients after robotic pancreatoduodenectomy from 18 centers in 8 countries in Europe, Asia, and South America until December 31, 2019, was conducted. A cumulative sum analysis was performed to determine the inflection points for the feasibility (operative time and blood loss) and proficiency (postoperative pancreatic fistula grade B/C and major morbidity) learning curves. Outcomes were compared in 3 groups on the basis of the learning curve inflection points., Results: Overall, 2,186 patients after robotic pancreatoduodenectomy were included. The feasibility learning curve was reached after 30-45 robotic pancreatoduodenectomy procedures and the proficiency learning curve after 90 robotic pancreatoduodenectomy procedures. These inflection points created 3 phases, which were associated with major morbidity (24.7%, 23.4%, and 12.3%, P < .001) but not 30-day mortality (2.1%, 2.0%, and 1.5%, P = .670). Other outcomes mostly continued to improve, including median operative time 432, 390, and 300 minutes (P < .0001), conversion 6.0%, 4.7%, and 2.7% (P = .002), bile leakage 7.2%, 4.1%, and 2.4% (P < .001), postpancreatectomy hemorrhage 6.5%, 6.1%, and 1.8% (n = 21) but not R0 resection (pancreatic ductal adenocarcinoma only) 78.5%, 73.9%, and 82.8% (P = .35), and 90-day mortality rate 3.1%, 3.5%, and 2.1% (P = .191). Centers performing >20 robotic pancreatoduodenectomies annually had lower rates of conversion, reoperation, and shorter median operative time as compared with centers performing 10-20 robotic pancreatoduodenectomies annually., Conclusion: This international multicenter study demonstrates that most outcomes of robotic pancreatoduodenectomy continued to improve during 3 learning curve phases without a negative effect on 90-day mortality. Randomized studies are needed in high-volume centers that have surpassed the first learning curves, to compare these outcomes with the open approach., (Copyright © 2024. Published by Elsevier Inc.)

Background: The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This study aimed to compare outcomes after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy in a pan-European cohort., Methods: An international multicenter retrospective study including patients after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy from 50 centers in 12 European countries (2009-2020). Propensity score matching was performed in a 1:1 ratio. The primary outcome was major morbidity (Clavien-Dindo ≥III)., Results: Among 2,082 patients undergoing minimally invasive pancreatoduodenectomy, 1,006 underwent robot-assisted pancreatoduodenectomy and 1,076 laparoscopic pancreatoduodenectomy. After matching 812 versus 812 patients, the rates of major morbidity (31.9% vs 29.6%; P = .347) and 30-day/in-hospital mortality (4.3% vs 4.6%; P = .904) did not differ significantly between robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy, respectively. Robot-assisted pancreatoduodenectomy was associated with a lower conversion rate (6.7% vs 18.0%; P < .001) and higher lymph node retrieval (16 vs 14; P = .003). Laparoscopic pancreatoduodenectomy was associated with shorter operation time (446 minutes versus 400 minutes; P < .001), and lower rates of postoperative pancreatic fistula grade B/C (19.0% vs 11.7%; P < .001), delayed gastric emptying grade B/C (21.4% vs 7.4%; P < .001), and a higher R0-resection rate (73.2% vs 84.4%; P < .001)., Conclusion: This European multicenter study found no differences in overall major morbidity and 30-day/in-hospital mortality after robot-assisted pancreatoduodenectomy compared with laparoscopic pancreatoduodenectomy. Further, laparoscopic pancreatoduodenectomy was associated with a lower rate of postoperative pancreatic fistula, delayed gastric emptying, wound infection, shorter length of stay, and a higher R0 resection rate than robot-assisted pancreatoduodenectomy. In contrast, robot-assisted pancreatoduodenectomy was associated with a lower conversion rate and a higher number of retrieved lymph nodes as compared with laparoscopic pancreatoduodenectomy., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Pancreatic adenocarcinoma (PC) is one of the most lethal malignancies; even after resection the patients' 5-year disease-free survival (DFS) is lower than 26%. The genetic mutational landscape of PC is dominated by activating KRAS mutations, that have been reported in approximately 90% of cases; however, beyond KRAS - direct mutations, several KRAS-targeting miRNAs appear to be downregulated, strengthening the already activated RAS signaling. In addition, the interplay between miRNAs and RAS includes poorly investigated downstream miRNAs. The aim of this study was to determine the prognostic value of some of these candidate KRAS-related miRNAs., Patients and Methods: Between 2015 and 2022, 44 patients with pathologically confirmed PC, who received surgery and were enrolled by the Clinical Oncology Unit, Careggi University Hospital, Florence (Italy). PC Total RNA was extracted from FFPE sections, retro-transcribed and the resulting cDNA was then used for qPCR analysis. A panel of KRAS-related miRNA (miR-155, miR-206 and miR-143) was analyzed., Results: In this observational study patients sex distribution was unequal with 34.1% being male and 65.9% female. The most frequent tumor localization was the head of the pancreas (65.9%) and the pathological stages were pT1-2 (45.5%), pT3 (54.5%), pN0 (22.7%), pN+ (77.3%). Adjuvant therapy was administered to 63.6% of patients; disease recurrence was observed in 69% of cases. Twenty-three patients, whose RNA was of adequate quality, were used in the mRNAs expression studies. When comparing the miRNA expression between PC and a pool of healthy tissues, miR-155 was overexpressed and miR-206 downregulated in PC, while miR-143 expression was unchanged. However, when categorized in low- and high- miR-143 expressing PC (according to the median value), high miR-143 was associated with nodal involvement (pN+) (p=0.029), who in turn was linked with shorter DFS (p=0.009) and overall survival (OS) (p=0.021) compared to pN0. A trend toward inferior DFS was observed for higher expression of miR-206 (p=0.095) and miR-143 (p=0.092). Finally, responders to a first-line treatment for advanced disease had miR-155 overexpressed (p=0.048)., Conclusions: miRNAs are involved in PC tumorigenesis and metastatic spread. In light of miR-143 association with lymphatic spread and poor prognosis, a comprehensive analysis of miRNA interplay with KRAS deserves further investigation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lavacchi, Polvani, Taddei, Scolari, Messerini, Caliman, Moraldi, Guidolin, Grazi, Galli, Pillozzi and Antonuzzo.)

This retrospective analysis of the prospective IGOMIPS registry reports on 1191 minimally invasive pancreatic resections (MIPR) performed in Italy between 2019 and 2022, including 668 distal pancreatectomies (DP) (55.7%), 435 pancreatoduodenectomies (PD) (36.3%), 44 total pancreatectomies (3.7%), 36 tumor enucleations (3.0%), and 8 central pancreatectomies (0.7%). Spleen-preserving DP was performed in 109 patients (16.3%). Overall incidence of severe complications (Clavien-Dindo ≥ 3) was 17.6% with a 90-day mortality of 1.9%. This registry analysis provided some important information. First, robotic assistance was preferred for all MIPR but DP with splenectomy. Second, robotic assistance reduced conversion to open surgery and blood loss in comparison to laparoscopy. Robotic PD was also associated with lower incidence of severe postoperative complications and a trend toward lower mortality. Fourth, the annual cut-off of ≥ 20 MIPR and ≥ 20 MIPD improved selected outcome measures. Fifth, most MIPR were performed by a single surgeon. Sixth, only two-thirds of the centers performed spleen-preserving DP. Seventh, DP with splenectomy was associated with higher conversion rate when compared to spleen-preserving DP. Eighth, the use of pancreatojejunostomy was the prevalent reconstruction in PD. Ninth, final histology was similar for MIPR performed at high- and low-volume centers, but neoadjuvant chemotherapy was used more frequently at high-volume centers. Finally, this registry analysis raises important concerns about the reliability of R1 assessment underscoring the importance of standardized pathology of pancreatic specimens. In conclusion, MIPR can be safely implemented on a national scale. Further analyses are required to understand nuances of implementation of MIPR in Italy., (© 2023. The Author(s).)

The assessment of liver function is crucial in predicting the risk of post-hepatectomy liver failure (PHLF) in patients undergoing liver resection, especially in cases of hepatocellular carcinoma (HCC) which is often associated with cirrhosis. There are currently no standardized criteria for predicting the risk of PHLF. Blood tests are often the first- and least invasive expensive method for assessing hepatic function. The Child-Pugh score (CP score) and the Model for End Stage Liver Disease (MELD) score are widely used tools for predicting PHLF, but they have some limitations. The CP score does not consider renal function, and the evaluation of ascites and encephalopathy is subjective. The MELD score can accurately predict outcomes in cirrhotic patients, but its predictive capabilities diminish in non-cirrhotic patients. The albumin-bilirubin score (ALBI) is based on serum bilirubin and albumin levels and allows the most accurate prediction of PHLF for HCC patients. However, this score does not consider liver cirrhosis or portal hypertension. To overcome this limitation, researchers suggest combining the ALBI score with platelet count, a surrogate marker of portal hypertension, into the platelet-albumin-bilirubin (PALBI) grade. Non-invasive markers of fibrosis, such as FIB-4 and APRI, are also available for predicting PHLF but they focus only on cirrhosis related aspects and are potentially incomplete in assessing the global liver function. To improve the predictive power of the PHLF of these models, it has been proposed to combine them into a new score, such as the ALBI-APRI score. In conclusion, blood test scores may be combined to achieve a better predictive value of PHLF. However, even if combined, they may not be sufficient to evaluate liver function and to predict PHLF; thus, the inclusion of dynamic and imaging tests such as liver volumetry and ICG r15 may be helpful to potentially improve the predictive capacity of these models.

The microbiota impact on human diseases is well-known, and a growing body of literature is providing evidence about the complex interplay between microbiota-immune system-human physiology/pathology, including cancers. Together with the defined risk factors ( e.g. , smoke habits, diet, diabetes, and obesity), the oral, gut, biliary, and intrapancreatic microbiota contribute to pancreatic cancer development through different pathways including the interaction with the immune system. Unfortunately, a great majority of the pancreatic cancer patients received a diagnosis in advanced stages not amenable to be radically treated and potentially cured. Given the poor pancreatic cancer prognosis, complete knowledge of these complicated relationships could help researchers better understand the disease pathogenesis and thus provide early potential non-invasive biomarkers, new therapeutic targets, and tools for risk stratification that might result in greater therapeutic possibilities and eventually in a better and longer patient survival., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Pancreatic surgery is still a challenge even in high-volume centers. Clinically relevant postoperative pancreatic fistula (CR-POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study, we compared robotic distal pancreatectomy (RDP) to open distal pancreatectomy (ODP) in terms of CR-POPF development and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC)., Methods: We collected data from five high-volume centers for pancreatic surgery and performed a matched comparison analysis to compare short and long-term outcomes after ODP or RDP. Patients were matched with a 2:1 ratio according to age, ASA (American Society of Anesthesiologists) score, body mass index (BMI), final pathology, and TNM (Tumour, Node, Metastasis) staging system VIII ed., Results: Two hundred and forty-six patients who underwent 82 RDPs and 164 ODPs were included. No differences were found in the incidence of CR-POPF. In the PDAC group, median DFS and OS were 10.8 months and 14.8 months in the ODP group and 10.4 months and 15 months in the RDP group, respectively., Conclusions: Robotic distal pancreatectomy is a safe surgical strategy for PDAC and incidence of CR-POPF is equivalent between RDP and ODP. RDP should be considered equivalent to ODP in terms of oncological efficacy when performed in high-volume and proficient centers., (© 2020 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: Hepatocellular carcinoma (HCC) is frequently diagnosed as multinodular. This study aims to assess prognostic factors for survival and identify patients with multiple HCC who may benefit from surgery beyond the Barcelona Clinic Liver Cancer classification indications., Methods: This retrospective study included all the consecutive patients from 4 Italian tertiary centers receiving liver resection for naive multiple HCC between 1990 and 2012 to have a potential follow-up of 5 years., Results: Included patients were 144. Ninety-day morbidity and mortality rates were 38.3% and 8.3%, respectively. The 5-year overall and disease-free survival rates were 33.3% and 19.1%, respectively. Tumor size <3 cm, bilirubin, Child-Pugh A, BCLC-A stage, being within "up-to-7" criteria, and minor resections resulted in prognostic factors. The Child-Pugh score resulted in an independent prognostic factor., Conclusions: Surgery may be related to good outcomes in selected patients with multiple HCC., Competing Interests: Declaration of competing interest The authors declare that they have no financial relationship or any conflict of interests and they have nothing to disclose. All authors acknowledge absence of conflict of interest of their co-authors, to the best of their knowledge., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Old age and frailty are predictors of early postoperative results after pancreatic surgery. We analysed the results of robotic and open pancreatoduodenectomy in elderly and frail patients., Methods: Data from the local robotic pancreatoduodenectomy database were reviewed and matched with those from open operations during the same period (2014-2020). Both old age and frailty were used to determine any correlation with postoperative outcomes. Elderly patients were defined as patients aged 70 years or more, while frailty was classified according to the validated modified Frailty Index., Results: A total of 118 pancreatoduodenectomies were included in the analysis: 65 (55.1%) robotic and 53 (44.9%) open. More than 50% of patients were frail. Overall, 7.6% of patients experienced grade IV Clavien-Dindo complications, and 3.4% died within 90 days after surgery. Frail patients experienced a similar rate of severe complications after robotic vs. open operations (5.3 vs. 11.6; p = 0.439) but earlier refeeding (3 days vs. 4 days; p = 0.006) and earlier drain removal (6 days vs. 7 days; p = 0.046) when operated on by a robotic approach. The oncological outcomes, including limphnodes retrieval, residual disease, recurrences, and survival, were not influenced by the surgical approach. Non-elderly patients also showed more benefits with the robotic approach (lower complication index, earlier refeeding, and drain removal)., Conclusions: Robotic pancreatoduodenectomy is associated with risks of major complications that are comparable to those of open operation in frail patients. Some perioperative parameters (refeeding, drain removal) seem to favour robotics in frail patients and younger patients, although at the price of longer operating times., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Pancreatic surgery is still associated with high perioperative morbidity and mortality. The purpose of this study was to present the short-term outcomes of robot-assisted pancreatic surgery, including pancreaticoduodenectomy (RAPD), distal pancreatectomy (RDP) with or without splenectomy, enucleation (REN), and atypical resection (RAR), for benign, borderline, and malignant lesions at a high-volume center., Methods: A single-center, prospective database was used to retrospectively analyze the early outcomes of robotic pancreatic procedures completed between 2014 and 2020. Out of 124 attempted operations, 3 patients received palliative robotic surgery (2.4%). Of the remaining 121, 14 (11.6%) were converted to open surgery. The robotic procedures included 107 patients: 56 underwent RAPD, 31 underwent RDP (28 with and 3 without splenectomy), 16 underwent REN, and 4 underwent RAR (2 central and 2 total pancreatectomies)., Results: The preoperative baseline characteristics and comorbidities were consistent with those of a Western population. The overall incidence of complications was 43.9%, with the more severe (Clavien-Dindo III-IV) occurring after RAPD (19.6%). We collected 7 (13.1%) postoperative pancreatic fistulae after RAPD, 5 (16.1%) after RADP, and 2 (12.5%) after REN. The two central pancreatectomies developed a biochemical leak without sequelae. Three patients (2.8%) died within 90 days after surgery. Early refeeding was achieved in those who did not experience severe complications, while the median hospital stay was 8 days. The median number of harvested lymph nodes was 22, with non-R1 microscopic residual tumors found., Conclusions: Robotic pancreatic surgery is a safe and oncologically adequate technique to manage benign and malignant diseases arising from the head, body, and tail of the pancreas.

Background: Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited., Materials and Methods: We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma., Results: No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203)., Conclusions: The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pancreatoduodenectomy for pancreatic head and periampullary cancers is still associated with high perioperative morbidity and mortality. The aim of this study was to compare the short-term outcomes of robot-assisted pancreatoduodenectomy (RAPD) and open pancreatoduodenectomy (OPD) performed in a high-volume centre., Methods: A single-centre, prospective database was used to retrospectively compare the early outcomes of RAPD procedures to standard OPD procedures completed between January 2014 and December 2018. Of the 121 included patients, 78 underwent RAPD and 43 underwent OPD. After propensity score matching (PSM), 35 RAPD patients were matched with 35 OPD patients with similar preoperative characteristics., Results: There were no statistically significant differences in most of the baseline demographics and perioperative outcomes in the two groups after PSM optimization with the exception of the operative time (530 min (RAPD) versus 335 min (OPD) post-match, p < 0.000). No differences were found between the two groups in terms of complications (including pancreatic leaks, 11.4% in both OPD and RAPD), perioperative mortality, reoperations or readmissions. Earlier refeeding was obtained in the RAPD group vs. the OPD group (3 vs. 4 days, p = 0.002). Although the differences in the length of the hospital stay and blood transfusions were not statistically significant, both parameters showed a positive trend in favour of RAPD. The number of harvested lymph nodes was similar and oncologically adequate., Conclusions: RAPD is a safe and oncologically adequate technique to treat malignancies arising from the pancreatic head and periampullary region. Several perioperative parameters resulted in trends favouring RAPD over OPD, at the price of longer operating time. Data should be reinforced with a larger sample to guarantee statistical significance.

Background: The incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. The surgical management of these patients is still under debate. The aim of this paper is to evaluate the safety and feasibility of robotic enucleations and to compare the outcomes with non-parenchymal sparing robotic resections., Methods: The study included a total of 25 patients. Nine of them underwent a robotic enucleation (EN Group) and 16 patients received a robotic demolitive resection (DR Group). Perioperative and medium-term outcomes were compared between the two groups., Results: Patients' baseline characteristics were similar in the two groups except for presence of symptoms and tumor size, due to the inclusion criteria. Operative time was significantly shorter and postoperative results were better for EN group, including a significant shorter hospitalization (5 vs. 8 days, p = 0.027), reduced pancreatic leaks (22% vs. 50%, p = 0.287) and a better preservation of glandular function (100% vs. 62.5%, p = 0.066). Mortality rate was zero in both groups, with all patients free from disease at a median follow-up of 18 months., Conclusions: The risks of under/overtreatment remain still unavoidable for benign to low-grade malignant small pancreatic neoplasms. Simple enucleation should be performed whenever oncological appropriate, to achieve the best postoperative outcomes. The adoption of robotic technique might widen the indications for parenchymal sparing, minimally invasive surgery.

Aim: Robotic surgery is thought to have a role in widening the application of minimally invasive liver surgery. Nonetheless, data concerning surgical results for liver malignancies are presently still lacking. We aimed to evaluate the surgical and oncological outcomes of ultrasound guided robotic liver resections for hepatic malignancies., Methods: All consecutive patients who received robotic resection of primary and secondary liver malignancies from September 2008 to January 2017 were analyzed. The same surgical team performed all procedures following the principle of parenchymal-sparing surgery., Results: From a total of 51 patients, 13 patients (25%) underwent major and 38 (75%) minor hepatectomy. No mortality occurred. Two procedures were converted to open surgery. Five patients experienced major complications, with a reintervention rate of 6%. Median hospital stay was 5 days., Conclusions: Robotic surgery is a safe and feasible procedure for liver resection even when dealing with malignancies. Our data show that robotic surgery can be considered a valid option to treat patients with liver malignancies in a minimally invasive manner, without compromise the oncological results., (© 2019 John Wiley & Sons, Ltd.)

Pancreatic fistula is the main post-operative complication of distal pancreatectomy associated with other further complications, such as intra-abdominal abscesses, wound infection, sepsis, electrolyte imbalance, malabsorption and hemorrhage. Surgeons have tried various techniques to close the stump of the remaining pancreas, but the controversy regarding the impact of stapler closure and suture closure of the pancreatic stump is far from resolved. In this study, we reported our technique and results of robotic assisted distal pancreatectomy with ultrasound identification and consequent selective closure of pancreatic duct. Twenty-one patients underwent consecutive robotic-assisted distal pancreatectomy were included in our study. We describe our technique and analyzed the operative and peri-operative data including mean operative time, intra-operative bleeding, blood transfusions necessity, conversion rate, mortality and morbidity rate, pancreatic fistula rate and grade, time of refeeding and canalization, length of hospital stay and readmission. Median operative time was 260 min. No conversion occurred. Estimated blood loss was 100 mL (range 50-200). No blood transfusions were performed. Mortality rate was 0%. One (5%) patient had a major complication, while 9 (43%) patients had minor complications (grade I). Three (14%) patients developed pancreatic fistula (grade B), while two (10%) patients had a biochemical leak. No late pancreatic fistula and re-operation occurred. The refeeding was started at second day (range 1^-6^) and the median canalization time was 4 days (range 2-7). The median hospital stay was 6 days (range 3-25) with a readmission rate of 0%. Robotic distal pancreatectomy can be considered safe and feasible. Our technique is easily reproducible, with good surgical results.

Background: Pancreatic neuroendocrine tumors (PanNETs) are relatively rare neoplasms with a low to mild malignant potential. They can be further divided into functioning and nonfunctioning, according to their secretive activity. Surgery is an optimal approach, but the classic open approach is challenging, with some patients having long hospitalization and potentially life-threatening complications. The robotic approach for PanNETs may represent an option to optimize their management., Methods: We retrospectively reviewed our prospectively maintained databases from 2 high-volume Italian centers for pancreatic surgery. Demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected., Results: Twelve patients with final diagnosis of PanNET were included. The mean age of the patients was 53.8 years (25-77). The median body mass index was 26 (24-29). Three lesions were functioning insulinomas, while the others were nonfunctioning tumors. No deaths occurred. Mild postoperative complications occurred, except for 1 grade B pancreatic fistula. The mean postoperative stay was 3.9 days (2-5)., Conclusions: Our results confirm that robotic enucleation is a feasible and safe approach for the treatment of PanNETs, with short hospital stay and low incidence of morbidity.

Background: Liver resection may be complicated by unpredictable intraoperative bleeding. Pringle's maneuver was the first attempt to control bleeding, but the main problem is the duration of ischemia. Robotic surgery thanks to the magnified view, three-dimensional visualization associated and fine movement allow to perform good parenchymal dissection and identification of vascular structure. Aim of study is to evaluate blood loss and the need to perform Pringle maneuver in patients underwent robotic liver resection., Methods: Thirty-three patients underwent robotic liver resections were analyzed, 16 (48%) male and 17 (52%) female, with median age of 64 years. Seven (21%) patients had benign lesions and twenty-six (79%) malignant tumor., Results: Seventeen (52%) patients had anatomical resections, while sixteen (48%) patients had non anatomical resection. Operative time was 270 minutes. Estimated blood loss was 100 mL and Pringle maneuver was carried out on seven patients. Median hospital stay was 4 days., Conclusions: Our results show that liver resections with robotic technique can be performed safely even without systematic Pringle maneuver.

Incidental diagnosis of pancreatic neuroendocrine tumors (PanNETs) greatly increased in the last years. In particular, more frequent diagnosis of small PanNETs leads to many challenging clinical decisions. These tumors are mostly indolent, although a percentage (up to 39%) may reveal an aggressive behaviour despite the small size. Therefore, there is still no unanimity about the best management of tumor smaller than 2 cm. The risks of under/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery. The importance of the Ki-67 index as a prognostic factor is still debated as well. Whenever technically feasible, parenchyma-sparing surgeries lead to the best chance of organ preservation. Lymphadenectomy seems to be another important prognostic issue and, according to recent findings, should be performed in noninsulinoma patients. In the case of enucleation of the lesion, a lymph nodal sampling should always be considered. The relatively recent introduction of minimally invasive techniques (robotic) is a valuable option to deal with these tumors. The current management of PanNETs is analysed throughout the many available published guidelines and evidences with the aim of helping clinicians in the difficult decision-making process.

The optimal delay in the start of chemotherapy following rectal cancer surgery has not yet been identified. However, postponed adjuvant therapy has been proven to be connected with a significant survival detriment. We aimed to investigate whether the time to initiation of adjuvant treatment can be influenced by the application of minimally invasive surgery rather than traditional open surgery. By comprehensively evaluating the available inherent literature, several factors appear to be associated with delayed postoperative chemotherapy. Some of them are strictly related to surgical short-term outcomes. Laparoscopy results in shortened length of hospital stay, reduced surgical morbidity and lower rate of wound infection compared to conventional surgery. Probably due to such advantages, the application of minimally-invasive surgery to treat rectal malignancies seems to impact favorably the possibility to start adjuvant chemotherapy within an adequate timeframe following surgical resection, with potential improvement in patient survival.

Background: Hepatocellular carcinoma (HCC) with the presence of tumor thrombus in hepatic veins and vena cava, until the atrium (RATT), is correlated with poor prognosis and with risk of tricuspid valve occlusion, congestive heart failure, and pulmonary embolism., Methods: Three patients with HCC on cirrhotic liver with RATT were studied. Operative technique, pre-operative and post-operative liver function tests, blood loss and transfusions, post-operative morbidity and mortality, and the overall survival and the disease free survival were analyzed., Results: Mean operative time was 336 ± 66 min. Intra-operative blood loss was 926.6 ± 325.9 ml. No major complications occurred. The times of hospital stay were 10, 21, and 19 days, respectively. The survival times were 90, 161, and 40 days, and the disease-free survival times were 30, 141, and 30 days, respectively., Conclusions: The complete removal of HCC with RATT may be achieved with cardiopulmonary by-pass (CPB) and total hepatic vascular exclusion (THVE). Adding the hypothermic cardiocirculatory arrest (HCCA) to the use of CPB allowed us to have minimal blood loss and hemostasis of the resectional plane. So the use of CPB and HCCA should be considered a good therapeutic alternative to the normothermic CPB with THVE.

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Background: Whether laparoscopic colorectal resection improved recovery within an enhanced recovery program was investigated., Methods: This study was designed as a query of a prospectively maintained colorectal database to identify 350 patients who underwent elective colorectal resection with primary anastomosis for colorectal cancer between January 1, 2005 and December 31, 2009. Patients were categorized into two groups (laparoscopic and open resection), and demographic, treatment, and outcome variables were independently reviewed for accuracy. A detailed fast-track protocol was prepared and distributed to all patients, department doctors, and nurses to standardize the treatment., Results: A total of 209 patients underwent laparoscopic-assisted colorectal resection, and 141 had open surgery. There was no difference between the two groups in terms of age, sex, BMI, ASA, comorbidity, previous abdominal surgery, preoperative chemoradiotherapy, cancer site, and AJCC 2002 staging. Twenty-three patients in the laparoscopic group required conversion to an open procedure due to hemorrhage, tumor extension, or technical difficulties. Laparoscopic patients had earlier tolerance of diet, bowel movement, flatus and stool canalization, mobilization, suction drain removal, and interruption of analgesic drug administration. Length of postoperative stay was shorter (4 vs. 7 days, p = 0.0004) and fewer postoperative nonsurgical complications (3 vs. 13% p = 0.009) were registered for the laparoscopic group., Conclusions: This study suggests that within an enhanced recovery program, laparoscopic resection may provide the best short-term clinical outcomes for patients with resectable colorectal cancer.

In a non-specialized setting, laparoscopic distal gastrectomy (LDG) for locally advanced diseases remains controversial, particularly given to the technical demands of the learning curve required to perform an adequate resection with D2 lymph node dissection. Inclusion criteria for this statistically generated matching controlled study were all patients who underwent subtotal laparoscopic gastrectomies from January 2006 until September 2009 for locally advanced gastric adenocarcinoma (stage II-IIIb), compared with matched patients who underwent the same procedure in an open fashion during the same period. Sixty case-matched patients were evaluated (30 laparoscopic vs. 30 open). Operative time was significantly longer (p < 0.05) for LDG. Benefits for LDG (p < 0.05) were observed among surgical short-term outcome (postoperative hospital stay, ambulation, first bowel movement, first flatus, first stool, first eating and use of analgesic drugs) and postoperative non-surgical site complications (cardiopulmonary, urinary, etc.). The 42 months' overall survival was similar (p = 0.646). Laparoscopic gastrectomy is a safe technique in a non-academic hospital setting for locally advanced gastric cancer; it seems to be adequate in terms of margin status and adequate lymph node retrieval and is associated with additional benefits as a decreased length of hospital stay, a decreased narcotic use and fewer complications.

Aim: Despite the laparoscopic right hemicolectomy has been validated by many randomized prospective trials, clear evidences on the validity of the totally mini-invasive technique, namely, through intracorporeal anastomosis, are still lacking. The aim of this study was the assessment of short-term outcome within three months from laparoscopic right colectomy with intra- or extra-corporeal anastomosis., Methods: With no exclusion, all patients undergoing laparoscopic right hemicolectomy at our institution have been enrolled in this study. Group A included patients undergoing laparoscopic right hemicolectomy with extracorporeal anastomosis (LAC) and Group B, included patients undergoing laparoscopic right hemicolectomy with intracorporeal anastomosis (TLC). Patients' data, surgery details, results of postoperative period and histological tests have been prospectively recorded in a database and analysed., Results: Between December 2006 and December 2008, 45 patients underwent right hemicolectomy, 21 with extracorporeal anastomosis and 24 had intracorporeal ones. As to patients' characteristics and histopathological results there are no difference between the groups. Anastomotic dehiscence occurred one in group A and one in group B (P>0.05). Both patients underwent reoperation. We recorded 6 postoperative ileus with vomiting in the LAC group and only 1 in the TLC group (P<0.05). The incidence of Non-Surgical Site Complications (NSSC) was of 4.54% in LAC group and 8.33% in TLC group (P>0.05). Hospitalization was of 5 days for both groups., Conclusion: In conclusion, we believe that this technique is feasible in terms of safety; it doesn't significatively affect the length of surgical procedure and guarantees maintenance of oncological radicality standards of reference. Besides it significatively improves quality of the post-operative period.

Background: The primary aim of this randomized controlled prospective study (www.clinicaltrials.gov NCT00599144) was assessing effectiveness on pain control after videolaparoscopic cholecystectomy (VLC) of 0.5% Bupivacaine-soaked sheet of regenerated oxidized cellulose positioned in the gallbladder bed., Patients and Methods: We randomized in three equal groups 45 patients that underwent elective videolaparoscopic cholecystectomy: group A - Bupivacaine-soaked sheet of regenerated oxidized cellulose positioned in the gallbladder bed; group B - Bupivacaine infiltrated in the muscular fasciae of the trocars' seat; group C - control group, not using local anesthetic. Six and 24 hours after the intervention we recorded the type of the pain and its intensity, using a visual analog scale (VAS)., Results: We observed no statistically significant difference in pain intensity. Considering the type of pain, 55,56% of patients referred visceral pain, 62,22% parietal pain and 44,44% shoulder pain. Group A shows, at both endpoints, a statistically significant reduction (p < 0.05) of visceral and shoulder pain versus other groups. Moreover, the use of a local anesthetic significantly reduces the use of post-operative pain drugs, both for group A and B., Conclusion: A Bupivacaine-soaked sheet of regenerated oxidized cellulose positioned in the gallbladder bed post-VLC is safe and not economically demanding, and can give advantages in increasing post-operative comfort.

Aim: The aim of the "Fast-Track Surgery" program is to decrease the perioperative stress response to surgical trauma and thus to decrease the complication rates after elective surgery. Critics of the "Fast-Track"(FT) rehabilitation may argue that all reports of successful programs came from major specialised hospital units and that implementation in smaller or less specialised units may be difficult, if not impossible., Methods: We retrospectively studied 101 patients that, from November 2004 to October 2007, underwent laparoscopic colorectal surgery in our institute. A detailed "Fast-Track Surgery" protocol was prepared and given to patients, physicians and nurses, with the aim to create a standard treatment. Data about demographics, ASA score, preoperative complicating diseases, diagnosis, type of surgery and postoperative clinical data were analyzed. Univariate analysis of the relationship among all factors (patient characteristics, intervention characteristics, protocol compliance and presence of complications) described here and length of hospital stay was performed., Results: We compared our results to those of major trials previously published and observed no substantial differences in morbidity, mortality and length of postoperative hospital stay between the two. Univariate analysis showed that compliance to the elements of the FT protocol influences the length of postoperative period more significantly than the patient characteristics or surgical procedure., Conclusion: Based on six comparative single-centre studies, the FT program was found to reduce length of hospital stay and was deemed safe for major abdominal surgeries. The present study shows that enhanced recovery or FT program can also be implemented safely in a General Surgery Unit.

Endometriosis affects 10-20% of fertile women, and in 3-37% of them it extends to the bowel. Its location, in the ileal tract of the bowel, usually the end-part, is only the 7%; and the occurrence of intestinal obstruction is no more than 0.15% of patients affected by endometriosis. We present a case of acute bowel obstruction due to ileal endometriosis in a 39 years woman, diagnosed and treated by laparoscopic approach.

Purpose: To verify if in large haemorrhoidal prolapse (independently from the degree) in patients with no symptoms of obstructed defaecation syndrome, the use of a stapled hemorrhoidopexy variant, comprising a double stapler haemorrhoidopexy (DSH), makes it possible to reduce the percentage of failures or relapses and to standardise an objective intraoperative parameter for the purpose of quantifying internal prolapses which can then be used as a guide in determining the type of treatment to be provided., Methods: Between June 2003 and June 2004, 353 patients were treated for haemorrhoidal prolapse. The patients suffering from large haemorrhoidal prolapse occupying more than half of the length of the anal dilator were intraoperatively selected for DSH., Results: Eighty-three patients (23.5%) underwent a DSH. The degrees of the large haemorrhoidal prolapse intraoperatively selected for DSH were sub-divided as follows: 7.2% (second), 24% (third) and 68.6% (fourth). The follow-up period was 48 months. There were three cases (3.6%) of residual illnesses and five cases (6%) of a relapse. The following complications were recorded: urgency at <3 months (7.2%), haemostasis revisions (2.4%) and spontaneously draining anterior haematoma (1.2%). The results of the 270 haemorrhoidal prolapse (38 second degree, 159 third degree and 130 fourth degree) treated with the procedure for prolapse and haemorrhoids were: nine (3.3%) residual illness and 12 (4.44%) relapse illness. The following complications were recorded: urgency at <3 months (6.6%), haemostasis revisions (2.5%) and spontaneously draining anterior haematoma (0.7%)., Conclusions: The intraoperative selection criterion was both efficacious and reproducible. This variant technique, which can be used in large haemorrhoidal prolapses, could allow us to further improve the quality of treatment for haemorrhoidal conditions using stapled haemorrhoidopexy, without increasing the complications.

Introduction: The common removal of smooth muscle during stapled hemorrhoidectomy had raised concerns about its effects on postoperative anorectal function. The purpose of the study is to confirm the high frequency of the involvement of smooth muscle fibers in stapled hemorrhoidectomy and to determine its association with postoperative findings., Methods: This retrospective study evaluated 241 cases of stapled hemorrhoidopexy treated from 2003 to 2006. Data include the most common postoperative complications such as bleeding, anal pain, and recurrence. Histological doughnuts were examined, and the presence of muscle fibers was evaluated., Results: Early complications occurred in 27/241 patients (11.2%) including bleeding (14), anal pain (eight), incontinence (two), abscess (two), hematoma (one). Recurrence was observed in 11 cases (4.5%). Muscularis propria fibers were identified in 217 of 241 (90%) pathologic specimens. Five complications occurred in the group in which muscle fibers were not identified (4/24). The frequency of complications in the group with and without smooth muscle tissue in the resected specimens was 9.6% and 25%, respectively., Conclusions: The presence of muscle fibers is not an occasional finding in the histological specimens, even if the presence of smooth muscle does not seems to influence the outcome of stapled hemorrhoidopexy. The idea of a simple mucosal resection needs to be revised.