Mario Antonio Belluomini

Robotic giant hiatal hernia repair: 3 year prospective evaluation and review of the literature

While conventional laparoscopic repair for giant hiatal hernias is considered difficult, robotic technology is likely to result in an improved postoperative course.

Left Hepatectomy: Robot-Assisted Approach

Laparoscopy is now the standard approach for left lateral segmentectomy and is the preferred method for resection of liver tumors measuring <5 cm located in anterior segments [1, 2]. In properly selected patients managed at high- volume centers, laparoscopic liver surgery (LLS) is associated with reduced blood loss, diminished need for blood transfusions, low rate of microscopically positive margins, and improved outcome in cirrhotic patients [3]. Despite the fact that gifted hepatic surgeons facile with complex laparoscopic maneuvers have successfully performed posterior segmentectomies and major hepatectomies [1–3], the inherent limitations of the laparoscopic technique have significantly limited its acceptance for challenging hepatic resections [1,2].

Total Robotic Pancreaticoduodenectomy

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

Pancreatic Metastasis from Colorectal Cancer

Context Pancreatic metastases are rare (2% of all pancreatic carcinomas). Very few cases about surgical treatment of colorectal cancer metastases to the pancreas are reported. Case report We report a case of single colorectal cancer metastasis to the pancreas managed by distal splenopancreatectomy in a patient undergone to left hemicolectomy for the primary tumor eight years before and to middle lung lobectomy for metastasis one year before. A 61-year-old asymptomatic woman with a history of colorectal cancer was admitted to our department after that during the oncological imaging follow-up a thoracic-abdominal contrast-enhanced computed tomography (CT) demonstrated a single 25 mm hypodense lesion in the pancreatic tail. She also presented high levels of CEA (61.7 ng/mL) and CA 19-9 (82.9 U/mL) before the admission. Eight years before the patient underwent to left hemicolectomy for a B2-Dukes classification colorectal cancer. The resected margins were free of tumor and no regional lymph nodes were positive. One year before the patient underwent to a lung lobectomy for a single 30 mm pulmonary metastases. Considering history and imaging findings, the pancreatic lesion was suspected a colorectal cancer metastasis. A distal splenopancreatectomy was performed. The patient was discharged in healthy conditions. Final pathology disclosed the pancreatic lesion was a colorectal cancer metastasis (CD20+, CK7-) with infiltration of the peri-pancreatic adipose tissue. The resected margins were free of tumor and no lymph nodes were metastasized. The patient is still alive. Conclusion Metastases to the pancreas are commonly considered rare, especially those from colorectal cancer. The improvement of imaging techniques has led to an increase of diagnoses and surgical procedures for metastases to the pancreas. Secondary tumors may be considered in the differential diagnosis of primitive pancreatic lesions. The diagnosis may be facilitated by clinical history and serum markers assessment. Metastatic colorectal cancer to the pancreas is an indication for pancreatic resection to increase the overall survival and, as palliative procedure, to treat symptoms like jaundice and pain.

Robotic Pancreatectomy for Pancreatic and Periampullary Cancer

Context Minimally invasive surgery, when feasible, should accept no oncologic compromise in the setting of pancreatic and periampullary cancer since local radicality is key for all these tumor types. Objective We herein report on 50 patients undergoing robotic pancreatic resection because of pancreatic or periampullary cancer. Methods Fifty patients diagnosed with malignant tumors were selected for laparoscopic robot-assisted pancreatectomy between October 2008 to June 2012. There were 28 males (56%) and 22 females (44%), with a mean age of 60 years (range 24-78 years). Twenty-five patients underwent pancreaticoduodenectomy (PD) (50%), 16 distal pancreatectomy (DP) (32%), 7 total pancreatectomy (TP) (14%), and 2 to central pancreatectomy (CP) (4%). Results Final pathology disclosed neuroendocrine carcinoma (NEC) in 7 patients (14%), cancer arising on IPMN in 9 cases (18%), ductal adenocarcinoma (DA) in 19 cases (38%), cholangiocarcinoma (CHC) in 5 patients (10%), carcinoma of the papilla of Vater in 5 cases (10%) (4 PD), solid pseudopapillary tumor in 2 (4%) and adenosquamous carcinoma in 1 case (2%). Resection margins were all negative. A mean number of 30 lymph nodes (range 5-74) was retrieved en-bloc with the specimen. 22 patients had lymph node metastasis (44%) including 11 diagnosed with DA (60%), 4 with CHC (80%) and 4 with NEC (5.7%). After a mean follow-up period of 14.1 months (range 1-42 months) all but 2 patients are disease-free (96%). Conclusions After a learning curve, best completed on patients with benign pancreatic diseases, laparoscopic robot-assisted pancreatic resection seems to offer the potential for radical tumor clearance in selected patients without locally advanced pancreatic and periampullary cancer. Further experience and longer follow-up are both needed before any final conclusion can be drawn.

One-Hundred and Six Robot-Assisted Pancreatectomies

Context Laparoscopy has revolutionized abdominal surgery becoming the standard approach for many operations. The “da Vinci” surgical system overcomes most of the inherent technical limitations of laparoscopy. Objective We test whether the robotic approach can improve the outcome of pancreatic resections, which often require challenging dissection and complex digestive reconstructions. Methods One-hundred and six consecutive robotic pancreatic resections were performed between October 2008 and June 2012. There were 40 males and 66 females (62%), with a mean age of 57 years (range 21-80 years) and a mean BMI of 24.6 Kg/m 2 . Thirty-nine patients underwent pancreaticoduodenectomy (PD) (37%), 47 distal pancreatectomy (DP) (44%), 10 total pancreatectomy (10%), 7 tumor enucleation (6%) and 3 central pancreatectomy (3%). Since our activity spans over about a 4-year period, data were analyzed according to the time of surgery, to verify progress in the learning curve: 17 patients were operated on between October 2008 and September 2009, 22 patients between October 2009 and September 2010, 32 patients between October 2010 and September 2011 and 35 patients during the last 9 months (from October 2011 to June 2012). Results No patient was converted to laparoscopy or open surgery. Mean operative time (OT) was 442.8 minutes. In the first period OT was 512 min for PD and 420 for DP. The mean number of lymph nodes examined (LN) was 16.8; 31.2 for PD and 11.9 for DP. Pancreatic fistula (PF) occurred in 41% of the patients. In the second, OT was 596 min for PD and 402 for DP. The LN was 16.7; 27.2 for PD and 10.0 for DP. PF was amounted 36.3%. In the third, OT was 583 min for PD and 288 for DP. The LN was 28.7; 36.0 for PD and 19.1 for DP. PF was amounted 36.6%. In the fourth, OT was 590 min for PD and 250 for DP. The LN was 30; 32 for PD and 20 for DP. PF was amounted 35%. Fifty-six benign/low-grade tumors and 50 cancers were diagnosed. Surgical margins were all negative. Post-operative mortality was nil, morbidity was 56% and mean hospital stay was 16 days. Conclusions Robot-assisted pancreatic resections can be safely performed in selected patients. Despite the existence of a learning curve, experienced pancreatic surgeons are not expected to pay to robotics the same price that they would have been asked for by laparoscopy.

Resection of an Isolated Arterial Segment During Pancreatectomy

Context Isolated involvement of an arterial segment in pancreatic tumors occurs infrequently and does not necessarily mean tumor unresctability being possibly caused by tumor location rather than by excessive growth. Objective We report on the outcome of a highly selected group of patients undergoing pancreatectomy plus resection of an isolated arterial segment at a single Institution. Methods From January 1993 to May 2011 resection of an isolated arterial segment was performed during 26 pancreatectomies. There were 12 males (46.2%) and 14 females (53.8%) with a mean age of 63.6 years. One patient was operated by robotic surgery. Two patients underwent total pancreatectomy (7.7%), 5 pancreaticoduodenectomy (19.2%) and 19 distal splenopancreatectomy (73.1%). Resected arterial segments were celiac trunk (CT) (n=14), hepatic artery (HA) (n=8), CT and HA (n=4). In 6 patients the hepatic arterial flow was re-established by end-to-end anastomosis (n=1), transposition of the left gastric artery (n=1) and interposition of a saphenous vein jump-graft (n=4). Multivisceral resection was required in 9 patients. Results Final pathology disclosed ductal adenocarcinoma (DA) in 18 patients (69.2%), other pancreatic tumor types or periampullary carcinoma in 5 (19.2%) patients and metastatic tumor in 3 patients (11.5%). Fifteen DA patients were node positive (83.3%). Post-operative morbidity and mortality were 55.5% and 3.8%, respectively. After a mean follow up period of 111 months (range 5-225 months), actual survival rate was 64% at 1 year and 20% at 3 years. Equivalent figures for DA were 30% and 15%, respectively. These data favorably compare with an historical cohort of patients with locally advanced DA undergoing palliation without resection. No patient developed local recurrence, despite none received pre- or post-operative radiation. Conclusions In patients affected by DA the resection remains key for cure and possibly provides the best palliative treatment. Highly selected patients with isolated involvement of CT and/or HA may undergo pancreatectomy with results similar to patients without vascular involvement and superior to those offered by palliation or medical therapy alone. The lack of local recurrence seems to be a relevant treatment endpoint.

Phase II Study of Neoadjuvant Modified FOLFOXIRI in Locally Advanced Pancreatic Cancer

Context FOLFIRINOX has shown high activity in metastatic pancreatic cancer patients and therefore the regimen could be of interest also for patients with inoperable locally advanced disease. Our group had developed a very similar schedule in colorectal cancer named FOLFOXIRI with no bolus 5-fluorouracil and a slight lower dose of irinotecan with good tolerance and activity. Objective We have performed a phase II trial in order to prospectively evaluate the activity of a modified (m)FOLFOXIRI regimen in locally advanced pancreatic cancer. Methods mFOLFOXIRI consisted of: oxaliplatin 85 mg/m 2 , irinotecan 150 mg/m 2 and folinic acid 200 mg/m 2 on day 1, plus infusional 5-fluorouracil 2,800 mg/m 2 administered in 48 hours on days 1 to 3, with cycle repeated every 14 days. The study enrolled patients with diagnosis of pancreatic cancer, stage III locally advanced disease without evidence of metastatic disease, ECOG performance status (PS) 0 or 1, age 18-75 years. The primary end-point of the study was the percentage of patients who achieve radical surgical resection after chemotherapy; the trial was designed with a percentage of low activity of 30% and a percentage of interest of 50% with an α and β errors of 0.05 and 0.20, respectively. Results Twenty-five patients have been so far enrolled; M/F: 8/17; PS 0/1: 10/15. Median age was 60 years (range: 44-75 years). Celiac axis was involved in 9 patients, superior mesenteric artery in 11 cases, both arteries in 5 patients. Baseline computer tomography showed pathological nodes in 21 patients. Twenty-one patients have been evaluated, with 9 partial responses (43%) and 12 stable disease (57%). A local treatment after chemotherapy was received by 13 patients until now: 8 (38%) underwent to radical surgery; 1 had an explorative laparotomy with evidence of liver metastases; 4 received concomitant chemo-radiotherapy with gemcitabine. Median progression-free survival was 24.5 months and median overall survival was 30.1 months. Conclusion Chemotherapy with mFOLFOXIRI seems active in locally advanced pancreatic cancer patients and may allow to obtain a downstaging of disease leading some patients to achieve a curative surgical resection. Longer follow-up is needed to better evaluate long-term outcome of this strategy.

Ninety-Percent Distal Pancreatectomy

Context Brittle diabetes typically plagues the quality of life of patients after total pancreatectomy. Sparing even a small amount of endocrine tissue avoids extreme glycemic fluctuations, by maintaining a source of servo-regulated endogenous production of all pancreatic hormones (insulin, glucagon, somatostatin and pancreatic polypeptide). Objective We report on the outcome of a selected group of patients undergoing ninety-percent distal pancreatectomy (90% DP). Methods From April 2000 to May 2012, 90% DP was performed in 26 patients: 7 males (27%) and 19 females (73%), with a mean age of 68 years (range 40-79 years). Twenty-three patients underwent conventional open resection while 3 had a laparoscopic operation (robot-assisted in 2 of them). Splenectomy was associated in 24 patients (92%), while 2 had a multivisceral resection. Segmental resection of peripancreatic vessels was associated in 4 patients (1 celiac trunk-hepatic artery, and 3 superior mesenteric/portal vein). Results Seventeen patients were diagnosed with ductal adenocarcinoma (65%), 3 with well-differentiated endocrine tumor (12%), 3 with a serous cystadenoma, 1 with a mucinous cystadenocarcinoma (4%), 1 with carcinoma on IPMN, and 1 patient with chronic pancreatitis. Mean operative-time was 330 minutes (range 180-535 minutes). There was no post-operative mortality with a morbidity of 40%. Pancreatic fistula was recorded in 8 patients (32%) and was always managed conservatively. Thirteen patients developed insulin dependent diabetes mellitus (50%) and 16 developed exocrine insufficiency (61%) requiring enzyme supplementation. Conclusions 90% DP may be considered in patients with centrally located pancreatic lesions to avoid the complications due to pancreatic exocrine and endocrine insufficiency. In selected patients 90% DP may be performed laparoscopically, especially if robotic assistance is available. Careful patient selection and extended experience in pancreatic surgery are crucial to achieve the best results.