International consensus guidelines on robotic pancreatic surgery in 2023

Background:With the rapid development of robotic surgery,especially for the abdominal surgery,robotic pancreatic surgery(RPS)has been applied increasingly around the world.However,evidence-based guidelines regarding its application,safety,and efficacy are still lacking.To harvest robust evidence and comprehensive clinical practice,this study aims to develop international guidelines on the use of RPS.Methods:World Health Organization(WHO)Handbook for Guideline Development,GRADE Grid method,Delphi vote,and the AGREE-II instrument were used to establish the Guideline Steering Group,Guideline Development Group,and Guideline Secretary Group,formulate 19 clinical questions,develop the recommendations,and draft the guidelines.Three online meetings were held on 04/12/2020,30/11/2021,and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts.All the experts focusing on minimally invasive surgery from America,Europe and Oceania made great contributions to this consensus guideline.Results:After a systematic literature review 176 studies were included,19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence.Conclusions:The international RPS guidelines can guide current practice for surgeons,patients,medical societies,hospital administrators,and related social communities.Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

The differential benefit of laparoscopic over open minor liver resection for lesions situated in the anterolateral or posterosuperior segments

Background:It is well known that laparoscopic liver surgery can offer advantages over open liver surgery in selected patients.However,what type of procedures can benefit most from a laparoscopic approach has been investigated poorly thus far.The aim of this study is thus to define the extent of advantages of laparoscopic over open liver surgery for lesions in the anterolateral(AL)and posterosuperior(PS)segments.Methods:In this international multicentre retrospective cohort study,laparoscopic and open minor liver resections for lesions in the AL and PS segments were compared after propensity score matching.The differential benefit of laparoscopy over open liver surgery,calculated using bootstrap sampling,was compared between AL and PS resections and expressed as a Delta of the differences.Results:After matching,3,040 AL and 2,336 PS resections were compared,encompassing open and laparoscopic procedures in a 1:1 ratio.AL and PS laparoscopic liver resections were more advantageous in comparison to open in terms of blood loss,transfusion rate,complications,and length of stay.However,AL resections benefitted more from laparoscopy than PS in terms of overall and severe complications(D-difference were 4.8%,P=0.046 and 3%,P=0.046)and blood loss(D-difference was 195 mL,P<0.001).Similar results were observed in the subset for high-volume centres,while in recent years no significant differences were found in the differential benefit between AL and PS segments.Conclusions:The advantage of laparoscopic over open liver surgery is greater in the AL segments than in the PS segments.

Short-and long-term outcomes after hemihepatectomy for perihilar cholangiocarcinoma:does left or right side matter?

Background:The only potentially curative option for patients with perihilar cholangiocarcinoma(PHC)is resection,typically an extrahepatic bile duct resection in combination with(extended)liver resection.Complications such as bile leakage and liver failure have been suggested to be more common after right-sided resections compared to left-sided resections,whilst superior oncological outcomes have been reported after right-sided resections.However,data on outcomes after right-sided or left-sided liver resections in PHC are scarce.Therefore,we aimed to investigate short-and long-term outcomes after left and right hemihepatectomy in patients with PHC.Methods:In this retrospective study,patients undergoing major liver resection for suspected PHC in a tertiary center between 2000-2018 were included.Patients who had undergone left-sided resections were compared to patients with right-sided resections in terms of complications(90-day mortality,overall and severe morbidity and specific complications).For long-term outcomes,only patients with pathologically proven PHC were included in the survival analysis.Results:A total of 178 patients undergoing hemihepatectomy for suspected PHC were analysed,including 76 left-sided and 102 right-sided resections.Overall 90-day mortality was 14%(24 out of 178),with no significant difference after left-sided resection(11%;8 out of 76)versus right-sided resection(16%;16 out of 102)(P=0.319).Severe morbidity(Clavein Dindo≥3)was also comparable in both groups:54%versus 61%(P=0.361).No differences in specific complications including bile leakage were observed,although liver failure appeared to occur more frequently after right hemihepatectomy(22%versus 11%,P=0.052).Five-year overall survival for pathologically proven PHC,excluding in-hospital mortality,did not differ;43.7%after left-sided resection vs.and 38.2%after right-sided resection(P=0.553).Conclusions:Both short-and long-term outcomes between patients undergoing left and right hemihepatectomy for PHC were comparable.Post-hepatectomy liver failure was more common after right-sided resection.

Functional assessment of liver regeneration after major hepatectomy

Background: Liver regeneration is crucial to restore the functional liver mass after liver resection. The aim of this study was to evaluate the early postoperative changes in remnant liver function, volume and liver stiffness after major liver resection and their correlation with postoperative outcomes. Methods: Patients undergoing major liver resection (≥3 segments) between February and November 2018 underwent both functional assessment using technetium-99m mebrofenin hepatobiliary scintigraphy (HBS) and CT-volumetry of the (future) remnant liver on preoperative day 1, the 5th postoperative day, and 4-6 weeks after resection. At the same time points, patients underwent transient elastography (TE) for the assessment of liver stiffness. Severe postoperative complications (Clavien-Dindo ≥ 3A) and mortality were correlated with the functional and volumetric increases of the remnant liver. Liver failure was graded according to the International Study Group of Liver Surgery (ISGLS) criteria. Results: A total of 18 patients were included of whom 10 (56%) had severe complications and one patient (5%) developed liver failure. Function and volume of the remnant liver had increased by the 5th postoperative day from 6.9 (5.4-10.9) to 9.6 (6.7-13.8) %/min/m2, P=0.004 and from 795.5 (538.3-1,037.5) to 1,080.0 (854.0-1,283.3) mL, P<0.001, respectively. After 4-6 weeks, remnant liver volume had further increased [from 1,080.0 (854.0-1,283.3) to 1,222.0 (1,016.0-1,380.5) mL, P=0.035], however, liver function did not show any significant, further increase [from 9.6 (6.7-13.8) to 10.9 (8.8-13.6) %/min/m2, P=0.177]. Liver elasticity of the future remnant liver (FRL) increased [from 10.8 (5.7-18.7) to 17.5 (12.4-22.6) kPa, P=0.018] and gradually recovered after 4-6 weeks to a median of 10.9 (5.7-18.8) kPa (T3 vs. T4, P=0.079). Patients who had severe postoperative complications did not show a significant increase in liver function on the 5th postoperative day (P=0.203), despite increase of volume (P<0.01). Conclusions: Functional regeneration of the remnant liver predominantly occurs during the first 5 days after resection. In case of severe complications, functional regeneration is delayed, in contrast to volume increase.

International assessment and validation of the prognostic role of lymph node ratio in patients with resected pancreatic head ductal adenocarcinoma

Background:Lymph node ratio(LNR;positive/harvested lymph nodes)was identified as overall survival predictor in several cancers,including pancreatic adenocarcinoma.It remains unclear if LNR is predictive of overall survival in pancreatic adenocarcinoma patients staged pN2.This study assessed the prognostic overall survival role of LNR in pancreatic adenocarcinoma patients in relation with lymph node involvement.Methods:A retrospective international study in six different centers(Europe and United States)was performed.Pancreatic adenocarcinoma patients who underwent pancreatoduodenectomy from 2000 to 2017 were included.Patients with neoadjuvant treatment,metastases,R2 resections,or missing data regarding nodal status were excluded.Survival curves were calculated using Kaplan-Meier method and compared using log-rank test.Multivariable Cox regressions were performed to find independent overall survival predictors adjusted for potential confounders.Results:A total of 1,327 patients were included.Lymph node involvement(pN+)was found in 1,026 patients(77%),561 pN1(55%)and 465 pN2(45%).Median LNR in pN+patients was 0.214[interquartile range(IQR):0.105-0.364].On multivariable analysis,LNR was the strongest overall survival predictor in the entire cohort[hazard ratio(HR)=5.5;95%confidence interval(CI):3.1-9.9;P<0.001]and pN+patients(HR=3.8;95%CI:2.2-6.6;P<0.001).Median overall survival was better in patients with LNR<0.225 compared to patients with LNR≥0.225 in the entire cohort and pN+patients.Similar results were found in pN2 patients(worse overall survival when LNR≥0.225).Conclusions:LNR appeared as an important prognostic factor in patients undergoing surgery for pancreatic adenocarcinoma and permitted to stratify overall survival in pN2 patients.LNR should be routinely used in complement to tumor-node-metastasis(TNM)stage to better predict patient prognosis.