Robotic Pancreatic Surgery for Solid, Cystic, and Mixed Lesions

Deconstructing the Operative Times of Robotic Pancreaticoduodenectomy

INTRODUCTION

Despite numerous benefits offered, robotic procedures take longer than "open" procedures. With the intent to reduce operative duration, we examined the degree each operative step contributes to operative duration in robotic pancreaticoduodenectomy.

MATERIALS AND METHODS

With IRB approval, we prospectively followed 88 patients to determine the duration of robotic pancreaticoduodenectomy, and the duration of 12 key steps. Each operative step was regressed against the operation date, from most distant to most recent operation date. Data are presented as median (mean ± SD) for illustrative purposes.

RESULTS

Patients were 73 (71 ± 10.2) years old; 53% were men. Total time patient spent in the operating room was 471 (488 ± 93.3) minutes. Total operative time was 399 (421 ± 90.7) minutes. Total console time was 293 (297 ± 68.0) minutes. The 3 longest portions of the operation were (1) mobilization of the specimen and specimen extraction; (2) construction of the duodenojejunostomy; and (3) closure.

CONCLUSION

A third of the operative time is spent off the console. Over half of the steps required more than 20 minutes each to complete. Since robotic operations are associated with shorter LOS and without increased complication rates relative to "open" operations, salutary benefit can be gained by decreasing operative times of robotic procedures. Operative duration is an important metric that needs to be addressed. We need to target the most time-consuming steps, and break them into smaller pieces, to reach optimal efficiency and provide the benefits of decreased operative duration to the patients, hospitals, and providers.

Hypoxic pancreatic stellate cell-derived exosomal mirnas promote proliferation and invasion of pancreatic cancer through the PTEN/AKT pathway

Pancreatic stellate cells (PSCs) are important components of the tumor microenvironment in pancreatic cancer (PC) and contribute to its development and metastasis through mechanisms that remain incompletely characterized. Tumor hypoxia affects the function and behavior of PC and stromal cells, and can alter exosomal content to modify cell-cell communication. The present study explored the effects of exosomal miRNAs produced by hypoxia-preconditioned PSCs on the growth and metastatic potential of PC cells. Subcutaneous xenografts and liver metastasis mouse models revealed increased tumorigenic potential upon co-implantation of PC cells and PSCs as compared to PC cells alone. Screening miRNA profiles of mouse plasma exosomes and cultured PSCs, followed by miRNA overexpression and inhibition assays, enabled us to identify miR-4465 and miR-616-3p as prominent hypoxia-induced, PSC-derived, exosomal miRNAs promoting PC cell proliferation, migration, and invasion. Proteomics analysis of PC cells incubated with exosomes derived from hypoxic PSCs showed significant downregulation of PTEN. Dual-luciferase reporter assays and western blotting showed that both miR-4465 and miR-616-3p target PTEN and activate AKT signaling in PC cells. We conclude that hypoxia upregulates miR-4465 and miR-616-3p expression in PSC-derived exosomes. Following exosome uptake, these miRNAs promote PC progression and metastasis by suppressing the PTEN/AKT pathway.