Burnout and motivation to study medicine among students during the COVID-19 pandemic

Aim

To investigate medical students' burnout and motivation levels in each of the six years of their studies during the COVID-19 pandemic and identify independent predictors of burnout and motivation.

Methods

An anonymous cross-sectional survey was sent to the students of all six years within our school. Burnout was measured with the adapted Oldenburg Burnout Inventory questionnaire (OLBI-S) and motivation with the updated Strength of Motivation for Medical School (SMMS-R) questionnaire. Univariate analysis was performed with the Kruskal-Wallis test and Spearman's correlation, while multivariable analysis with linear regression models.

Results

A total of 333 medical students (52% of student body) responded. Higher burnout levels correlated with lower motivation to study medicine (rho = -0.30, p < 0.001). Burnout levels differed between the six years of medical studies, peaking in years two and four whereas being the lowest in year one (p = 0.01). Motivation levels differed significantly as well, peaking in years one and four whereas being the lowest in years five and six (p = 0.012). In the multivariable linear regression models, being a female (b = 2.22, p = 0.016), studying in the fourth year vs. first year (b = 2.54, p = 0.049), having a perceived beginner/intermediate vs. advanced/expert technology level (b = 2.05, p = 0.032) and a perceived poor school support system (b = 6.35, p < 0.001) were independently associated with higher burnout levels. Furthermore, studying in the fifth year vs. first year (b = -5.17, p = 0.019) and a perceived poor school support system (b = -3.09, p = 0.01) were independently associated with a reduced motivation to study medicine.

Conclusion

Our study highlighted potential areas for intervention to decrease the rate of burnout and low motivation among medical students. However, further research is needed to unravel the full effect of the pandemic on medical students.

Incidence and risk factors of symptomatic Petersen's hernias in bariatric and upper gastrointestinal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study was to investigate the actual incidence of symptomatic Petersen's hernias (PH) as well as identify risk factors for their occurrence.

METHODS

Search was performed in Medline (via PubMed), Web of Science, and Cochrane library, using the keywords "Petersen Or Petersen's AND hernia" and "Internal hernia." Only studies of symptomatic PH were eligible. Fifty-three studies matched our criteria and were included. Risk of bias for each study was independently assessed using the checklist modification by Hoy et al. Analysis was performed using random-effects models, with subsequent subgroup analyses.

RESULTS

A total of 81,701 patients were included. Mean time interval from index operation to PH diagnosis was 17.8 months. Total small bowel obstruction (SBO) events at Petersen's site were 737 (0.7%). SBO incidence was significantly higher in patients without defect closure (1.2% vs 0.3%, p < 0.01), but was not significantly affected by anastomosis fashion (retrocolic 0.7% vs antecolic 0.8%, p = 0.99). SBO incidence was also not significantly affected by the surgical approach (laparoscopic = 0.7% vs open = 0.1%, p = 0.18). However, retrocolic anastomosis was found to be associated with marginally, but not significantly, increased SBO rate in patients with Petersen's space closure, compared with the antecolic anastomosis (p = 0.09).

CONCLUSION

PH development may occur after any gastric operation with gastrojejunal anastomosis. Contrary to anastomosis fashion and surgical approach, defect closure was demonstrated to significantly reduce SBO incidence. Limitations of this study may include the high heterogeneity and the possible publication bias across the included studies.

A Standardized Workshop for Peer-Teaching Simple Interrupted Sutures to Medical Students: Analysis of the Student Factors That Affect Outcomes

The aim of this study is to demonstrate whether the implementation of standardized Peer Assisted Learning (PAL) suturing workshops can aid the attainment of a technically competent interrupted suturing technique by medical students. The European University Cyprus (EUC) Division of Surgery and the students of the EUC Surgery Club compiled a standardized 1 hour and 15 minutes suturing workshop. During a one-week period 14 peer-teacher school of medicine students trained 147 fellow students. At the end of each workshop the students were assessed for the learning outcome of simple interrupted suturing with instruments by two peer-teachers, with the use of a standardized scoring rubric. The workshop primary outcomes were the rubric score and the time to complete a suture. These were correlated to student characteristics such as sex, year of studies, prior experience in suturing, previous participation in a similar workshop, previous training at home or in a hospital, and an interest in pursuing a surgical career. Univariate and multivariate statistical analysis was performed. Statistical analysis showed that gender and previous suturing experience did not impact the rubric score of students, nor the time required. The student year of studies, having recently passed the course of General Surgery and having interest to pursue a surgical specialization positively affected the students' score. Surgical peer teaching provided an effective method of teaching of the simple interrupted suturing technique. Interest in surgery, previous workshop experience and having recently completed the general surgery module helped students score higher in the assessment.

The learning experience for endoscopic submucosal dissection in a non-academic western hospital: a single operator's untutored, prevalence-based approach

Background

Studies of learning experience in endoscopic submucosal dissection (ESD) commonly originate from the East. Little is known about the performance of ESD in low-volume western centers. Furthermore, it is unclear whether ESD can be self-taught without a tutored approach.

Methods

We performed a retrospective analysis of consecutive ESDs, performed in an untutored prevalence-based fashion by a single operator at a private Greek hospital from 2016-2020. Out of 60 lesions, standard ESD was applied for 54 and enucleation for 6; 41 were mucosal and 19 submucosal; 3 esophageal, 24 gastric, one duodenal, 12 colonic, and 20 rectal.

Results

Pathology revealed carcinoma (n=14), neuroendocrine tumor (n=7), precancerous lesion (n=27), or other submucosal tumors (n=12). The rates of en bloc and R0 resection were 98% and 91%, respectively. The median resection speed was <3 cm²/h for the first 20 cases, but improved progressively to ≥9 cm²/h after 40 cases. Two patients underwent laparoscopic surgery for colonic perforation, and one received a blood transfusion because of delayed bleeding (serious adverse event rate: 5%). No deaths occurred. The median hospital stay was 1.3 days. Variables associated with improvement in ESD speed during the second period of the study were the application of countertraction and the experience acquired through other endosurgical techniques.

Conclusions

ESD was safe and effective in a low-volume center, with an acceptable adverse events rate. At least 40 mixed cases were needed to achieve a high resection speed. Additive experience gained through other endosurgical procedures probably contributed to the improvement in performance.

Outpatient Hysterectomy versus Inpatient Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim was to investigate whether outpatient hysterectomy (OH) has benefits when compared with inpatient hysterectomy (IH) regarding postoperative complications, readmissions, operative outcomes, cost, and patient quality of life.

DATA SOURCES

A systematic search for studies comparing OH with IH was conducted through PubMed, SAGE, and Scopus from January 2010 to March 2020, without limitations regarding language and study design.

METHODS OF STUDY SELECTION

Studies reporting on the differences between same-day discharge and overnight stay after hysterectomy were included. The study outcomes were overall complication rate, type of complication, readmission after discharge, surgery duration, estimated blood loss, payer savings, hospital savings, and health-related quality of life (HrQoL). Median and range are used to describe non-normal data, while mean ± SD and confidence interval are used to descibe data with normal distribution. A meta-analysis with sensitivity analysis and subgroup analyses was performed.

TABULATION, INTEGRATION, AND RESULTS

Eight studies published between 2011 and 2019 with 104,466 patients who underwent hysterectomy were included in this systematic review and meta-analysis. All included studies except 1 were found to have a high risk of bias. OH in comparison with IH had a lower overall complication rate (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.60-0.82) and lower rates of wound infection (OR 0.60; 95% CI, 0.43-0.84), urinary tract infection (OR 0.64; 95% CI, 0.52-0.78), need for transfusion (OR 0.36; 95% CI, 0.22-0.59), sepsis (OR 0.33; 95% CI, 0.17-0.64), uncontrolled pain (OR 0.79; 95% CI, 0.66-0.95), and bleeding requiring medical attention (OR 0.82; 95% CI, 0.73-0.94). In addition, patients who underwent OH had a lower readmission rate (OR 0.81; 95% CI, 0.75-0.87), surgery duration (standardized mean difference -0.35; 95% CI, -0.61 to -0.08), and estimated blood loss (standardized mean difference -0.63; 95% CI, -0.93 to -0.33) than those who underwent IH. A qualitative analysis found that OH had a poorer patient HrQoL and a lower cost for the hospital as well as the payer.

CONCLUSION

OHs present fewer complications and have a lower readmission rate and estimated blood loss as well as a shorter surgery duration than IHs. OHs also have a cost benefit in comparison with IHs. But patients seem to have a worse HrQoL in the first postoperative week after OH. The high risk of bias of the included studies indicates that well-designed clinical trials and standardization of surgical complication reporting are essential to better address this issue.

Gastric ischemic preconditioning may reduce the incidence and severity of anastomotic leakage after οesophagectomy: a systematic review and meta-analysis

Anastomotic leakage after esophagectomy is a severe and life-threatening complication. Gastric ischemic preconditioning is a strategy for the improvement of anastomotic healing. Aim of this systematic review and meta-analysis is to investigate the impact of gastric ischemic preconditioning on postoperative morbidity. A systematic literature search was performed to identify studies comparing patients undergoing gastric ischemic preconditioning before esophagectomy with nonpreconditioned patients. Meta-analysis was conducted for the overall incidence of anastomotic leakage, severe anastomotic leakage, anastomotic stricture, postoperative morbidity, and mortality. Mantel-Haenszel odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed concerning preconditioning technique, the interval between preconditioning and surgery and the extent of preconditioning. Fifteen cohort studies were identified. Gastric preconditioning was associated with reduced overall incidence of anastomotic leakage (OR 0.73; 95% CI, 0.53-1.0; P = 0.050) and severe anastomotic leakage (OR 0.27; 95% CI, 0.14-0.50; P < 0.010), but not with anastomotic stricture (OR 1.18; 95% CI 0.38 to 3.66; P = 0.780), major postoperative morbidity (OR 1.03; 95% CI 0.45 to 2.36; P = 0.940) or mortality (OR 0.69; 95% CI 0.39 to 1,23; P = 0.210). Subgroup analyses did not identify any differences between embolization and ligation while increasing the interval between preconditioning and esophagectomy as well as the extent of preconditioning might be beneficial. Gastric ischemic preconditioning may be associated with a reduced incidence of overall and severe anastomotic leakage. Randomized studies are necessary to further evaluate its impact on leakage, refine the technique and define patient populations that will benefit the most.

LINX® reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies

BACKGROUND

Gastroesophageal reflux disease (GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication (LF) constitutes the gold-standard method. However, magnetic sphincter augmentation (MSA) using the LINX^® Reflux Management System has recently emerged and disputes the standard therapeutic approach.

AIM

To investigate the device’s safety and efficacy in resolving GERD symptoms.

METHODS

This is a systematic review conducted in accordance to the PRISMA guidelines. We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019.

RESULTS

Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor (PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups (e.g., bariatric or large hiatal-hernias) had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD.

CONCLUSION

The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.

New insights into irritable bowel syndrome: from pathophysiology to treatment

Irritable bowel syndrome (IBS) is the most common reason to visit a gastroenterologist. IBS was believed to be a functional disease, but many possible pathophysiologic mechanisms can now explain the symptoms. IBS patients are classified into subtypes according to their predominant bowel habit, based on the Rome IV criteria. These include diarrhea-predominant and constipation-predominant IBS, as well as the mixed type, a combination of the two. Usually, IBS treatment is based on the predominant symptoms, with many options for each subtype. A new promising treatment option, fecal microbiota transplantation, seems to have beneficial effects on IBS. However, treating the pathophysiological causative agent responsible for the symptoms is an emerging approach. Therefore, before the appropriate therapeutic option is chosen for treating IBS, a clinical evaluation of its pathophysiology should be performed.

Adrenal Aging and Its Implications on Stress Responsiveness in Humans

Normal aging results in subtle changes both in ACTH and cortisol secretion. Most notable is the general increase in mean daily serum cortisol levels in the elderly, without a noteworthy alteration in the normal circadian rhythm pattern. Glucocorticoid excess seen in the elderly population can have serious consequences in both the structural and functional integrity of various key areas in the brain, including the hippocampus, amygdala, prefrontal cortex, with consequent impairment in normal memory, cognitive function, and sleep cycles. The chronically elevated glucocorticoid levels also impinge on the normal stress response in the elderly, leading to an impaired ability to recover from stressful stimuli. In addition to the effects on the brain, glucocorticoid excess is associated with other age-related changes, including loss of muscle mass, hypertension, osteopenia, visceral obesity, and diabetes, among others. In contrast to the increase in glucocorticoid levels, other adrenocortical hormones, particularly serum aldosterone and DHEA (the precursor to androgens and estrogens) show significant decreases in the elderly. The underlying mechanisms for their decrease remain unclear. While the adrenomedullary hormone, norephinephrine, shows an increase in plasma levels, associated with a decrease in clearance, no notable changes observed in plasma epinephrine levels in the elderly. The multiplicity and complexity of the adrenal hormone changes observed throughout the normal aging process, suggests that age-related alterations in cellular growth, differentiation, and senescence specific to the adrenal gland must also be considered.

Arc of Bühler: the surgical significance of a rare anatomical variation

PURPOSE

The arc of Bühler, an anastomotic vessel between celiac artery and superior mesenteric artery, is a rare anatomic variation. Various radiologic and surgical procedures can be affected by its existence. We aim to review all available information and identify possible clinical implications.

METHODS

A systematic review was conducted in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The following terms were utilized in various combinations: "Bühler", "arc of Bühler", "visceral aneurysm", "pancreaticoduodenal arcades".

RESULTS

Only 53 cases have been described until today in the literature. The arc of Bühler enhances collateral circulation between celiac artery and superior mesenteric artery alongside with pancreaticoduodenal arcades and dorsal pancreatic artery. Computerized tomography and angiography are the main studies used for its detection and evaluation. Aneurysms of Bühler's arc have been rarely described and seem to share common pathophysiological mechanisms with aneurysms of the pancreaticoduodenal arcades.

CONCLUSIONS

Various radiologic and surgical procedures such as embolization or pancreaticoduodenectomy are potentially affected by its existence.

Augmented Reality Guidance for the Resection of Missing Colorectal Liver Metastases: An Initial Experience

BACKGROUND

Modern chemotherapy achieves the shrinking of colorectal cancer liver metastases (CRLM) to such extent that they may disappear from radiological imaging. Disappearing CRLM rarely represents a complete pathological remission and have an important risk of recurrence. Augmented reality (AR) consists in the fusion of real-time patient images with a computer-generated 3D virtual patient model created from pre-operative medical imaging. The aim of this prospective pilot study is to investigate the potential of AR navigation as a tool to help locate and surgically resect missing CRLM.

METHODS

A 3D virtual anatomical model was created from thoracoabdominal CT-scans using customary software (VR RENDER(®), IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM(®), Karl Storz, Tüttlingen, Germany). Virtual and real images were manually registered in real-time using a video mixer, based on external anatomical landmarks with an estimated accuracy of 5 mm. This modality was tested in three patients, with four missing CRLM that had sizes from 12 to 24 mm, undergoing laparotomy after receiving pre-operative oxaliplatin-based chemotherapy.

RESULTS

AR display and fine registration was performed within 6 min. AR helped detect all four missing CRLM, and guided their resection. In all cases the planned security margin of 1 cm was clear and resections were confirmed to be R0 by pathology. There was no postoperative major morbidity or mortality. No local recurrence occurred in the follow-up period of 6-22 months.

CONCLUSIONS

This initial experience suggests that AR may be a helpful navigation tool for the resection of missing CRLM.

Augmented Reality Guidance for the Resection of Missing Colorectal Liver Metastases: An Initial Experience

BACKGROUND

Modern chemotherapy achieves the shrinking of colorectal cancer liver metastases (CRLM) to such extent that they may disappear from radiological imaging. Disappearing CRLM rarely represents a complete pathological remission and have an important risk of recurrence. Augmented reality (AR) consists in the fusion of real-time patient images with a computer-generated 3D virtual patient model created from pre-operative medical imaging. The aim of this prospective pilot study is to investigate the potential of AR navigation as a tool to help locate and surgically resect missing CRLM.

METHODS

A 3D virtual anatomical model was created from thoracoabdominal CT-scans using customary software (VR RENDER(®), IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM(®), Karl Storz, Tüttlingen, Germany). Virtual and real images were manually registered in real-time using a video mixer, based on external anatomical landmarks with an estimated accuracy of 5 mm. This modality was tested in three patients, with four missing CRLM that had sizes from 12 to 24 mm, undergoing laparotomy after receiving pre-operative oxaliplatin-based chemotherapy.

RESULTS

AR display and fine registration was performed within 6 min. AR helped detect all four missing CRLM, and guided their resection. In all cases the planned security margin of 1 cm was clear and resections were confirmed to be R0 by pathology. There was no postoperative major morbidity or mortality. No local recurrence occurred in the follow-up period of 6-22 months.

CONCLUSIONS

This initial experience suggests that AR may be a helpful navigation tool for the resection of missing CRLM.

Adhesions and Healing of Intestinal Anastomoses

Background. Postoperative adhesions are the result of aberrant peritoneal healing. As they are the leading cause of postoperative bowel obstruction, anti-adherence barriers are advocated for their prevention. This study looks into the effect of these biomaterials on the healing of intestinal anastomoses. Materials and Methods. Thirty-three New Zealand White rabbits underwent laparotomy, transection of the terminal ileum, and creation of an end-to-end anastomosis. Animals were randomized into 3 groups: the Control group (n = 11); the Icodextrin group, receiving icodextrin 4% intraperitonealy (n = 11); and the HA/CMC group, having the anastomosis wrapped with a hyaluronic acid/carboxymethylcellulose film (n = 11). All animals were sacrificed on the seventh postoperative day. Macroscopic adhesions were graded and anastomotic strength was tested by the burst pressure. Histological healing was assessed in a semiquantitative way for the presence of ulceration, reepithelization, granulation tissue, inflammation, eosinophilic infiltration, serosal inflammation, and microscopic adhesions. Univariate and multivariate analysis was used. Results are given as medians with interquartile range. Results. The median adhesion scores were the following: Control 1 (0-3), Icodextrin 0 (0-1), HA/CMC 0 (0-0), P = .017. The burst pressure did not differ between the groups; however, all except one bowel segments tested burst away from the anastomosis. The macroscopic and histological anastomotic healing was comparable in all 3 groups. A poor histological anastomotic healing score was associated with a higher adhesion grade (odds ratio = 1.92; 95% confidence interval = 1.06-3.47; P = .032). Conclusion. Adhesion formation was inhibited by the materials tested without direct detrimental effects on anastomotic healing. Poor anastomotic healing provokes adhesions even in the presence of anti-adhesion barriers.

Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status

AIM: To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors.

METHODS: A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach.

RESULTS: The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described.

CONCLUSION: Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.

Robotic spleen preserving distal pancreatectomy: how I do it (with video)

Laparoscopic hepatobiliary surgery, although technically demanding, gains popularity due to the patient benefits of a mini-invasive approach. Laparoscopic distal pancreatectomy is a technically feasible and reproducible operation that doesn't require complex digestive reconstruction. It requires advanced laparoscopic skill for vascular dissection and control. Due to the absence of trials proving its oncological results it is mainly indicated for benign or borderline tumours of the pancreatic body and tail. Since for these tumours there is no indication for a lymph node dissection, there are benefits for the patient if the spleen is preserved. There is some evidence that robotic assistance facilitates the procedure and makes it accessible to surgeons diminishing the necessity of advanced laparoscopic skills. In this technical multimedia article, we present our method for a robotic mini-invasive spleen preserving distal pancreatectomy with preservation of the splenic vessels. The technique is presented in a stepwise approach with an accompanying video. We believe that the use of the Da Vinci robotic platform facilitates this demanding procedure.

Identification and validation of risk factors for postoperative infectious complications following hepatectomy

Postoperative infectious complications (PICs) are associated with significant morbidity after abdominal surgery. Using multivariate analysis of data from a prospective database, our study focused on the risk factors for PICs and the prevention of these complications after hepatectomy, with the goal of improving outcomes and reducing the length of hospital stays.

BACKGROUND

PICs following surgery are associated with significant morbidity, increase the length of hospital stays, and have a negative impact on long-term oncological outcome. The aim of this study was to determine the risk factors for PICs following partial hepatectomy and to validate these results with an external database.

METHODS

Between January 2006 and December 2009, 555 patients underwent elective partial hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PICs, defined as development of one or more of the following conditions: pneumonia, sepsis, Central line-associated bloodstream infection, urinary tract infection, wound infection, and infected intra-abdominal fluid collection. PICs were devised in medical (PIMCs) and surgical (PISCs) complications. The incidence of PICs and validation of the predictive score were determined using an external prospective database of 342 patients.

RESULTS

The multivariate analysis identified three independent risk factors for PICs: the presence of a nasogastric tube (OR = 1.8), blood transfusion (OR = 1.9), and diabetes (OR = 2.4). The multivariate analysis identified only one independent risk factor for PISCs: an associated portal venous resection (OR = 5.5). The multivariate analysis identified four independent risk factors for PIMCs: presence of a biliary drainage (OR = 1.9), blood transfusion (OR = 2.1), diabetes (OR = 2.9), and presence of atrial fibrillation (OR = 3.6). According to the three predictive factors, the observed rates of PICs ranged from 18.8 % to 77.8 % and ranged from 24.2 % to 100 % in the external database. Predicted and observed risks of PICs were not statistically different.

CONCLUSIONS

The correction of modifiable risk factors among the identified factors could reduce the incidence of PICs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

Number and tumor size are not sufficient criteria to select patients for liver transplantation for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is an indication for liver resection or transplantation (LT). In most centers, patients whose HCC meets the Milan criteria are considered for LT. The first objective of this study was to analyze whether there is a correlation between the pathologic characteristics of the tumor, survival and recurrence rate. Second, we focused our attention on vascular invasion (VI).

METHODS

From January 1997 to December 2007, a total of 196 patients who had a preoperative diagnosis of HCC were included. The selection criteria for LT satisfied both the Milan and the San Francisco criteria (UCSF). Demographic, clinical, and pathologic information were recorded.

RESULTS

HCC was confirmed in 168 patients (85.7%). The median follow-up was 74 months. The pathologic findings showed that 106 patients (54.1%) satisfied the Milan criteria, 134 (68.4%) the UCSF criteria of whom 28 (14.3%) were beyond the Milan criteria but within the UCSF criteria, and 34 (17.3%) beyond the UCSF criteria. VI was detected in 41 patients (24%). The 1-, 3-, and 5-year overall survival rates were 90%, 85%, and 77%, respectively, according to the Milan criteria and 90%, 83%, and 76%, respectively, according to the UCSF criteria (P = NS). In univariate and multivariate analyses, tumor size and VI were significant prognostic factors affecting survival (P < 0.001). Two factors were significantly associated with VI: alfa-fetoprotein level of >400 ng/ml and tumor grade G3.

CONCLUSIONS

Tumor size and VI were the only significant prognostic factors affecting survival of HCC patients. Primary liver resection could be a potential selection treatment before LT.

Splenic vein-inferior mesenteric vein anastomosis to lessen left-sided portal hypertension after pancreaticoduodenectomy with concomitant vascular resection

HYPOTHESIS

A splenic vein (SV)-inferior mesenteric vein (IMV) anastomosis reduces congestion of the stomach and spleen after pancreaticoduodenectomy with resection of the SV-mesenteric vein confluence but carries a risk of left-sided venous hypertension.

DESIGN

Comparative retrospective study.

SETTING

Department of Digestive Surgery and Transplantation, University of Strasbourg, Strasbourg, France.

PATIENTS

From January 1, 2002, to February 28, 2010, 39 patients underwent pancreaticoduodenectomy with resection of the SV-mesenteric vein confluence for pancreatic adenocarcinoma. All patients had a terminoterminal portal vein-superior mesenteric vein anastomosis. The SV blood flow into the portal vein was preserved in 11 patients by reimplantation of the SV into the portal vein. Sixteen patients underwent surgical reconstruction of the SV-IMV confluence by anastomosis (group 1), and in 12 patients the natural SV-IMV confluence was preserved (group 2).

MAIN OUTCOME MEASURES

Preoperative and postoperative spleen volume and platelet count.

RESULTS

Demographic characteristics, preoperative tumor staging, pathological outcome, and postoperative complications were comparable in both groups. There was no difference in platelet count between groups 1 and 2 preoperatively (mean [SD], 293.13 [125.37] vs 241.09 [49.12] × 10(3)/μL [to convert to × 10(9)/L, multiply by 1.0], respectively; P = .21) or postoperatively (mean [SD], 231.75 [156.39] vs 164.31 [76.46] × 10(3)/μL, respectively; P = .32). Likewise, no difference was found in the spleen volume preoperatively (mean [SD], 258.96 [179.23] vs 237.31 [122.46] mL, respectively; P = .76) and on postoperative day 15 (mean [SD], 279.08 [158.10] vs 299.12 [153.11] mL, respectively; P = .78).

CONCLUSION

Early assessment shows that SV-IMV anastomosis is as feasible and as safe as the preservation of a natural SV-IMV confluence in patients undergoing pancreaticoduodenectomy with vascular resection for pancreatic head adenocarcinoma.

Robotic resection of duodenal adenoma

BACKGROUND

Duodenal sporadic adenomatous polyps are rare findings during upper endoscopy. Resection is indicated due to their malignant potential.

METHODS

A 55 year-old male patient was diagnosed with a 3 cm duodenal adenomatous polyp with low-grade dysplasia, which could not be safely resected by endoscopy. A transduodenal submucosal robotic-assisted polypectomy was performed.

RESULTS

The operative time was 4.5 h, with an estimated blood loss of 200 ml. The patient had a normal bowel transit on postoperative day 3 and he was discharged on postoperative day 7. Three months follow-up was uneventful. The final histological finding revealed a completely resected duodenal adenomatous polyp without signs of malignancy.

CONCLUSION

Robotic-assisted resection of duodenal polyps is a feasible technique that may be indicated for the local excision of duodenal lesions that cannot be endoscopically resected. Compared to the open and laparoscopic approach, it offers many technical advantages.

Robotic left pancreatectomy for pancreatic solid pseudopapillary tumor

BACKGROUND

Solid pseudopapillary pancreatic tumors of pancreas are a rare entity, seen most often in females in their second or third decades. Although previously believed to be benign, this tumor is currently considered a low-grade malignant epithelial neoplasm with low metastatic rate and high overall survival.1,2 Its resection could be performed by robotic technique with respect to oncological principles to avoid tumor cell dissemination.3

METHODS

In this multimedia article, we present a 28-year-old female with a history of hyperthyroidism who underwent a computed tomography (CT) scan because of a persistent high C-reactive protein level following caesarean section. This CT scan revealed a 7-cm cystic lesion of the pancreatic tail. The serum tumor marker CA 19-9 was normal. Further investigation with an magnetic resonance imaging (MRI) scan showed that the lesion was macrocystic with internal septas compatible with a solid pseudopapillary neoplasm.4 The patient was treated with robotic distal splenopanceatectomy (video).

RESULTS

The operative time was 5 h with an estimated blood loss of 250 mL. No blood transfusion was necessary. The postoperative period was uneventful, and she was discharged on postoperative day 8. The histological finding revealed a solid pseudopapillary tumor of the pancreas pT2pN0 (0/14 lymph nodes removed). There was no evidence of clinical, biological, and radiological pancreatic fistula, and a control CT scan on postoperative day 8 did not show any abdominal fluid collection. The patient's 1 month follow-up was normal.

DISCUSSION

The robotic distal splenopancreatectomy is a procedure that offers some technical and oncological advantages over the already described minimally invasive techniques for distal pancreatic tumors.5,6 These advantages are mainly due to the stability of the operative field, to the 3D and magnified vision, and to the articulated robotic arms.7-9 The 3D representation and the stability of the operative field facilitate the performance of operative steps, as the creation of the retropancreatic tunnel and vascular identification. Moreover, the robotic articulated arms permit a superior handling of vascular structures, allowing a fine dissection that is extremely useful during lymphadenectomy. Articulated instruments easily achieve the correct rotation axis, thus minimizing peri-pancreatic tissue retraction and manipulation of the pancreatic gland. This smooth and no-touch technique in theory minimizes the risk of pancreatic capsule rupture as well as tumor cell dissemination, respecting oncological surgical standards. However, robotic surgery needs an adequate learning curve, especially concerning the installation and the lack of force feedback.

CONCLUSION

The robotic distal pancreatectomy is a possible minimally invasive technique for patients with solid pseudopapillary pancreatic tumors. It presents some advantages over the laparoscopic approach. Nevertheless its oncological indications are yet to be defined.10.

Robotic distal splenopancreatectomy: bridging the gap between pancreatic and minimal access surgery

INTRODUCTION

Almost 10 years have passed since computer-aided, most commonly known as robotic surgery, has emerged gaining slowly but steadily its place within minimally invasive surgical procedures. Nevertheless, pancreatic surgeons only recently have started incorporating it into current practice.

METHODS

In this 'how I do it' article, we describe our method for robotic distal splenopancreatectomy, focusing on its technical advantages, as well as its drawbacks. Furthermore, we describe some pitfalls commonly encountered during the procedure and we propose ways to avoid them.

CONCLUSION

Pancreatic robotic-assisted surgery is offering many practical advantages over the "classic" laparoscopic approach. Even though a difficult procedure to master, it may have the potential to establish the concept of minimally invasive surgery in areas where it is nonexistent as in pancreatic surgery.