Alberto Patriti

Multicentric Study on Robotic Tumor-Specific Mesorectal Excision for the Treatment of Rectal Cancer

BackgroundRecently, traditional laparoscopic anterior resection has been used for rectal cancer, offering good functional results compared with open resection and resulting in better early postoperative outcomes. Few studies investigating the role of robot-assisted tumor-specific rectal surgery (RTSRS) have been carried out to show its feasibility. The aim of the study was to verify on a multicentric basis the perioperative and oncologic outcome of RTSRS.MethodsOne hundred forty-three consecutive patients undergoing RTSR in three centers were reviewed. Pathologic data, and postoperative and oncologic outcome measures were prospectively collected and analyzed by an independent researcher.ResultsA total of 112 restorative surgeries and 31 abdominoperineal resections were carried out. Conversion rate was 4.9%, mean blood loss was 283xa0ml, and mean operative time was 297xa0min. The number of harvested nodes (14.1xa0±xa06.5) and margin status compared favorably with those of open series (mean distal margin 2.9xa0±xa01.8xa0cm; negative radial margin in 142 cases). The 3-year overall survival rate was 97%, and no isolated local recurrences were found at mean follow-up of 17.4xa0months.ConclusionRTSRS is a safe and feasible procedure that may facilitate mesorectal excision. Randomized clinical trials and longer follow-up are needed to evaluate a possible influence of RTSRS on patient survival.

Robot-assisted laparoscopic total and partial gastric resection with D2 lymph node dissection for adenocarcinoma

BackgroundLymph node dissection and esophageal anastomosis, considered the more demanding steps of laparoscopic gastrectomy for gastric adenocarcinoma, can be performed with the use of a remote-controlled robot.MethodsThirteen patients with a histologically proved gastric cancer (six stage I, six stage II, and one stage III) were enrolled in a prospective study to assess feasibility and safety of the Da Vinci surgical system in total and partial gastrectomy with extended lymph node dissection. Outcome measures were conversion rate, intra- and postoperative morbidity and mortality, operative time, blood loss, number of lymph nodes harvested, and macroscopic and microscopic evaluation of resection margins.ResultsEight distal, four total, and one proximal laparoscopic gastrectomies were completed without conversion. Extended lymph node dissection, and esophagojejunal and esophagogastric anastomoses were successfully carried out using the da Vinci System. Mean operative time was 286xa0±xa032.6xa0min and blood loss was 103xa0±xa087.5xa0ml. Mean number of nodes retrieved was 28.1xa0±xa08.3 and all resection margins were negative. There was no mortality. Trocar bleeding requiring laparoscopy was the only major complication encountered. No recurrence occurred during a mean follow-up time of 12.2xa0±xa04.5xa0months.ConclusionsRobot-assisted laparoscopic lymph node dissection and esophageal anastomosis are feasible and safe. Longer follow-up time and randomized studies are needed to evaluate long-term outcome and clinical advantages of this new technology.

Robot-assisted parenchymal-sparing liver surgery including lesions located in the posterosuperior segments

ObjectiveThe aim of the study is to describe techniques of robot-assisted parenchymal-sparing liver surgery.BackgroundLaparoscopy provides the same oncologic outcomes as open liver resection and better early outcome. Limitations of laparoscopy remain resections in posterior and superior liver segments, frequently approached with laparoscopic right hepatectomy, bleeding from the section line, and prolonged operative times when a combined procedure is needed.MethodsWe retrospectively analyzed our series of robot-assisted liver resections between 2008 and September 2010 to evaluate whether robot assistance can overcome the limitations of laparoscopy.ResultsA total of 23 patients underwent robot-assisted liver resection for a total of 21 subsegmentectomies, 6 segmentectomies, 2 segmentectomies S6xa0+xa0subsegmentectomies S7, 1 bisegmentectomy S2–3, and 2 pericystectomies. In ten cases (47.8%) liver nodules were located in the posterior and superior liver segments. In three cases the tumor was in contact with a main portal branch and in two cases with a hepatic vein. In one case the tumor had contact with both hepatic vein and portal branch. In the latter cases a no-margin resection was carried out. In 16 cases (65.5%) liver resection was associated with a concomitant procedure (10 laparoscopic colectomies, 1 robotic rectal resection, 3 laparoscopic radiofrequency ablations, and 2 extensive adhesiolyses). Mean operative time was 280xa0±xa0101xa0min, blood loss was 245xa0±xa0254xa0ml, and mean hospital stay was 8.9xa0±xa09.4xa0days. Mortality was nil. One case of biliary leakage and two of intraoperative hemorrhage requiring transfusion were the main complications encountered.ConclusionsRobot assistance allows optimal access to all liver segments and facilitates parenchymal-sparing surgery also for lesions located in the posterosuperior segments or in contact with main liver vessels.

Laparoscopic and robot-assisted one-stage resection of colorectal cancer with synchronous liver metastases: a pilot study

BACKGROUND/PURPOSEnOne-stage resection of primary colon cancer and synchronous liver metastases is considered an effective strategy of cure. A laparoscopic approach may represent a safe and advantageous choice for selected patients with the aim of improving the early outcome.nnnMETHODSnBetween January 2008 and October 2008, 7 patients underwent one-stage laparoscopic resection for primary colorectal cancer combined with laparoscopic or robot-assisted liver resection.nnnRESULTSnA total of five laparoscopic left-colon, one right-colon, and one rectal resections were performed. Three patients underwent preoperative left-colon stenting and two received neoadjuvant chemotherapy. The patient with rectal cancer underwent neoadjuvant radiotherapy. Liver procedures included one bisegmentectomy (segments 2, 3), 3 segmentectomies, 6 metastasectomies, and four laparoscopic ultrasound-guided radiofrequency ablations (LUG-RFAs). One patient with multiple liver metastases was managed by a two-stage hepatectomy partially conducted by a totally laparoscopic approach. The overall postoperative morbidity was null. The median hospital stay was 10 days (range 7-10 days).nnnCONCLUSIONSnThis pilot study suggests that laparoscopic one-stage colon and liver resection is feasible and safe. Robot assistance may facilitate liver resection, increasing the number of patients who may benefit from a minimally invasive operation.

Robot assistance in liver surgery: a real advantage over a fully laparoscopic approach? Results of a comparative bi-institutional analysis

Laparoscopic liver resection (LAPR) is safe and feasible with a better postoperative course as compared to open resections. Robot‐assisted liver surgery (ROBR) is a potential alternative to LAPR. In this study we compare outcomes between ROBR and LAPR.

Open vs robot-assisted laparoscopic gastric resection with D2 lymph node dissection for adenocarcinoma: a case-control study.

A population‐based case‐control study was conducted in order to investigate the advantages of robot‐assisted gastric resection (RGR) for gastric cancer as opposed to traditional open gastrectomy (OG).

Comparing fibrin sealant with staples for mesh fixation in laparoscopic transabdominal hernia repair: a case control-study

BackgroundLaparoscopic hernia repair is not as popular as cholecystectomy. We have performed more than 3,000 laparoscopic herniorrhaphies using the trans-abdominal (TAPP) technique. To prevent recurrences we fix the polypropylene mesh with staples. The use of fibrin glue for graft fixation is a possible alternative.MethodsWe have performed 3,130 laparoscopic hernia repairs over 14 years. For mesh fixation we used titanium clips and observed a small number of complications. In July 2003 we started using fibrin glue (Tissucol®). The purpose of this retrospective longitudinal study was to evaluate if the use of fibrin sealant was as safe and effective as conventional stapling and if there were differences in post-operative pain, complications and recurrences.ResultsFrom July 2003 to June 2006 we performed 823 laparoscopic herniorrhaphies. Fibrin glue (Tissucol®) was used in 88 cases. Two homogeneous groups of 68 patients (83 cases) treated with fibrin glue and 68 patients (87 cases) where the mesh was fixed with staples, were compared. Patients with relevant associated diseases or large inguino-scrotal hernias were excluded. Operative times were longer in the group treated with fibrin glue with a mean of 35 minutes (range 22–65 mins) compared to the group treated with staples (25 minutes, range 14–50 mins). The time of hospital stay was the same (24 hours). Post-operative complications, that were more frequent in the stapled group, included trocar site pain, hematomas, intra-operative bleedings and incisional hernias. No significant difference was observed concerning seromas, chronic pain and recurrence rate.ConclusionsLess post-operative pain, and a faster return to usual activities are the main advantages of laparoscopic repair compared to the traditional approach. The use of fibrin sealant reduces in our experience the risk of post- and intra-operative complications such as bleeding and incisional hernia; recurrence rates are similar, but the operative time is longer.

Surgery or Peroral Esophageal Myotomy for Achalasia: A Systematic Review and Meta-Analysis.

AbstractTo date very few studies with small sample size have compared peroral esophageal myotomy (POEM) with the current surgical standard of care, laparoscopic Heller myotomy (LHM), in terms of efficacy and safety, and no recommendations have been proposed.To investigate the efficacy and safety of POEM compared with LHM, for the treatment of achalasia.The databases of Pubmed, Medline, Cochrane, and Ovid were systematically searched between January 1, 2005 and January 31, 2015, with the medical subject headings (MeSH) and keywords “achalasia,” “POEM,” “per oral endoscopic myotomy,” and “peroral endoscopic myotomy,” “laparoscopic Heller myotomy” (LHM), “Heller myotomy.”All types of study designs including adult patients with diagnosis of achalasia were selected. Studies that did not report the comparison between endoscopic and surgical treatment, experimental studies in animal models, single case reports, technical reports, reviews, abstracts, and editorials were excluded.The total number of included patients was 486 (196 in POEM group and 290 in LHM group).There were no differences between POEM and LHM in reduction in Eckardt score (MDu200a=u200a−0.659, 95% CI: −1.70 to 0.38, Pu200a=u200a0.217), operative time (MDu200a=u200a−0.354, 95% CI: −1.12 to 0.41, Pu200a=u200a0.36), postoperative pain scores (MDu200a=u200a−1.86, 95% CI: −5.17 to 1.44, Pu200a=u200a0.268), analgesic requirements (MDu200a=u200a−0.74, 95% CI: −2.65 to 1.16, Pu200a=u200a0.445), and complications (ORu200a=u200a1.11, 95% CI: 0.5–2.44, Pu200a=u200a0.796). Length of hospital stay was significantly lower for POEM (MDu200a=u200a−0.629, 95% CI: −1.256 to −0.002, Pu200a=u200a0.049). There was a trend toward significant reduction in symptomatic gastroesophageal reflux rate in favors of LHM compared to POEM group (ORu200a=u200a1.81, 95% CI: 1.11–2.95, Pu200a=u200a0.017).All included studied were not randomized. Furthermore all selected studies did not report the results of follow-up longer than 1 year and most of them included patients who were both treatment naive and underwent previous endoscopic or surgical interventions for achalasia.POEM represents a safe and efficacy procedure comparable to the safety profile of LHM for achalasia at a short-term follow-up. Long-term clinical trials are urgently needed.

Surgical management of advanced gastric cancer: An evolving issue

Worldwide, gastric cancer represents the fifth most common cancer and the third leading cause of cancer deaths. Although the overall 5-year survival for resectable disease was more than 70% in Japan due to the implementation of screening programs resulting in detection of disease at earlier stages, in Western countries more than two thirds of gastric cancers are usually diagnosed in advanced stages reporting a 5-year survival rate of only 25.7%. Anyway surgical resection with extended lymph node dissection remains the only curative therapy for non-metastatic advanced gastric cancer, while neoadjuvant and adjuvant chemotherapies can improve the outcomes aimed at the reduction of recurrence and extension of survival. High-quality research and advances in technologies have contributed to well define the oncological outcomes and have stimulated many clinical studies testing multimodality managements in the advanced disease setting. This review article aims to outline and discuss open issues in current surgical management of advanced gastric cancer.

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIMnTo perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.nnnMETHODSnA systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.nnnRESULTSnA total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.nnnCONCLUSIONnLaparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.