Robotic Left Hepatectomy with En Bloc Biliary Resection and Roux-en-Y Hepaticojejunostomy: A Technique of Portal Venous Tangential Vascular Reconstruction

BACKGROUND

Robotic technology is increasingly utilized in perihilar cholangiocarcinoma treatments, requiring expertise in minimally invasive liver surgeries and biliary reconstructions. These resections often involve vascular and multiple sectoral bile duct reconstructions. Minimally invasive vascular repairs are now emerging with promising outcomes, potentially altering criteria for selecting minimally invasive hepatobiliary tumor resections. In this multimedia article, we describe our technique of robotic portal venous tangential primary reconstruction with right sectoral bile duct unification ductoplasty for the treatment of perihilar cholangiocarcinoma using the robotic approach.

METHODS

The robotic technique was chosen in this operation with preoperative anticipation of needing vascular resection and reconstruction due to left portal vein tumor involvement. Additionally, a Roux-en-Y hepaticojejunostomy to the right anterior and posterior sectoral duct was planned for biliary reconstruction. Proximal and distal vascular control of the portal vein bifurcation was obtained by placing vascular bulldog clamps across the main and right portal veins. Once an R0 vascular margin was obtained on the left portal vein, portal bifurcation was tangentially repaired. Perfusion to the liver was then restored, and left hemihepatectomy with en bloc extrahepatic biliary resection was carried out, followed by Roux-en-Y hepaticojejunostomy reconstruction to the right anterior and posterior sectoral bile ducts, as a single anastomosis.

RESULTS

The operation was uneventful without vascular or biliary complications. Robotic unification ductoplasty circumvented the need for multiple anastomoses.

CONCLUSION

The robotic approach for left-sided perihilar cholangiocarcinoma resections, requiring precise biliovascular management, is safe, feasible, and efficient. This method demonstrates the potential of robotic techniques as an alternative to traditional open surgery.

The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma

Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.

Robotic Biliary Stricturoplasty and Roux-en-Y Hepaticojejunostomy After Hepatic Artery Infusion Pump Injury

BACKGROUND

Hepatic artery infusion pump (HAIP) with floxuridine/dexamethasone and systemic chemotherapy is an established treatment regimen, which had been reported about converting 47% of patients with stage 4 colorectal liver metastasis from unresectable to resectable.1,2 To this effect, HAIP chemotherapy contributes to prolonged survival of many patients, which otherwise may not have other treatment options. Biliary sclerosis, however, is a known complication of the HAIP treatment, which occurs in approximately 5.5% of patients receiving this modality as an adjuvant therapy after hepatectomy and in 2% of patients receiving HAIP treatment for unresectable disease.3 While biliary sclerosis diffusely affects the perihilar and intrahepatic biliary tree, a dominant stricture maybe found in select cases, which gives an opportunity for a local surgical treatment after failure of endoscopic stenting/dilations. While the use of minimally invasive approach to biliary surgery is gradually increasing,4 there have been no descriptions of its application in this scenario. In this video, we demonstrate the use of minimally invasive robotic technique for biliary stricturoplasty and Roux-en-Y (RY) hepaticojejunostomy to treat persistent right hepatic duct stricture after HAIP chemotherapy.

PATIENT

A 68-year-old woman with history of multifocal bilobar stage 4 colorectal liver metastasis presented to our office with obstructive jaundice and recurrent cholangitis that required nine endoscopic retrograde cholangiopancreatographies (ERCPs) and a placement of internal-external percutaneous transhepatic biliary drain (PTBD) by interventional radiology within the past 2 years. Her past surgical history was consistent with laparoscopic right hemicolectomy 3 years prior, followed by a left lateral sectorectomy with placement of an HAIP for adjuvant treatment. The patient had more than ten metastatic liver lesions within the right and left lobe, ranging from 2 to 3 cm in size at the time of HAIP placement. The patient had a histologically normal background liver parenchyma before the HAIP chemotherapy treatment. The patient did not have any history of alcohol use, diabetes mellitus, metabolic syndrome, nonalcoholic steatohepatitis, or other underlying intrinsic liver disorders, which are known to contribute to the development of hepatic fibrosis. Despite a radiologically disease-free status, the patient started to have episodes of acute cholangitis 1 year after the placement of HAIP that required multiple admissions to a local hospital. The HAIP was subsequently removed once the diagnosis of biliary sclerosis was made despite dose reductions and treatment with intrahepatic dexamethasone for almost 1 year. In addition to this finding, the known liver metastases have shown complete radiological resolution. Therefore further treatment with HAIP was deemed unnecessary, and pump removal was undertaken. Magnetic resonance imaging showed a dominant stricture at the junction of the right anterior and right posterior sectoral hepatic duct. The location of the dominant stricture was confirmed by an ERCP and cholangioscopy. Absence of neoplasia was confirmed with multiple cholangioscopic biopsies. Multiple endoscopic and percutaneous attempts with stent placement failed to dilate the area of stricture. Postprocedural cholangiographies showed a persistent significant narrowing, which led to multiple recurrent obstructive jaundice and severe cholangitis. While the use of surgical approach is rarely needed in the treatment of biliary sclerosis, a decision was made after extensive multidisciplinary discussions to perform a robotic stricturoplasty and RY hepaticojejunostomy with preservation of the native common bile duct.

TECHNIQUE

The operation began with a laparoscopic adhesiolysis to allow for identification of HAIP tubing (which was later removed) and placement of robotic ports. A peripheral liver biopsy was obtained to evaluate the degree of hepatic parenchymal fibrosis. Porta hepatic area was carefully exposed without causing an inadvertent injury to the surrounding hollow organs. Biopsy of perihepatic soft tissues was taken as appropriate to rule out any extrahepatic disease. The common bile duct and common hepatic duct with ERCP stents within it were identified with the use of ultrasonography. Anterior wall of the common hepatic duct was then opened, exposing the two plastic stents. Cephalad extension of the choledochotomy was made toward the biliary bifurcation and the right hepatic duct. The distal common bile duct was preserved for future endoscopic access to the biliary tree. After lowering the right-sided hilar plate, dense fibrosis around the right hepatic duct was divided sharply with robotic scissors, achieving a mechanical release of the dominant stricture. An intraoperative cholangioscopy was performed to confirm adequate openings of the right hepatic duct secondary and tertiary radicles, as well as patency of the left hepatic duct. A 4-Fr Fogarty catheter was used to sweep the potential biliary debris from within the right and left hepatic lobe. Finally, a confirmatory choledochoscopy was performed to ensure patency and clearance of the right-sided intrahepatic biliary ducts and the left hepatic duct before fashioning the hepaticojejunostomy. A 40-cm antecolic roux limb was next prepared for the RY hepaticojejunostomy. A side-to-side double staple technique was utilized to create the jejunojejunostomy. The common enterotomy was closed in a running watertight fashion. Once the roux limb was transposed to the porta hepatic in a tension-free manner, a side-to-side hepaticojejunostomy was constructed in a running fashion by using absorbable barbed sutures. The index suture was placed at 9 o'clock location, and the posterior wall of the anastomosis was run toward 3 o'clock location. This stabilized the roux limb to the bile duct. The anterior wall of the anastomosis was next fashioned by using a running technique from both corners of the anastomosis toward the middle (12 o'clock), where both sutures were tied together. This completed a wide side-to-side hepaticojejunostomy anastomosis encompassing the upper common hepatic duct, biliary bifurcation, and the right hepatic duct. A closed suction drain was placed before closing.5 RESULTS: The operative time was approximately 4 hr with 60 ml of blood loss. The postoperative course was uneventful. The patient was discharged home on postoperative Day 5 after removal of the closed suction drain, confirming the absence of bile leak. The patient had developed periportal/periductal fibrosis, cholestasis, and moderate-severe parenchymal fibrosis (F3-F4) based on liver biopsy, often seen in patients treated with a long course of floxuridine HAIP chemotherapy. The patient is clinically doing well at 1 year outpatient follow-up without any evidence of recurrent cholangitis at the time of this manuscript preparation.

CONCLUSIONS

Robotic biliary stricturoplasty with RY hepaticojejunostomy for treatment of biliary sclerosis after HAIP chemotherapy is safe and feasible. Appropriate experience in minimally invasive hepatobiliary surgery is necessary to achieve this goal.

Learning Curve Analysis After 500 Robotic Hepatectomies

BACKGROUND

The robotic platform is growing in popularity for hepatobiliary resections. While the learning curve for basic competency has been reported, this is the first study to analyze the learning curve to achieve long-term mastery on a decade of experience with over 500 robotic hepatectomies.

METHODS

After Institutional Review Board (IRB) approval, 500 consecutive robotic hepatectomies from 2013-2023 were analyzed. Cumulative Sum Chart (CUSUM) analysis using operative duration was utilized to determine the learning curves.

RESULTS

500 patients were included in this study: 46% men 54% women, aged 63(61 ± 14.6) years, with BMI 28(29 ± 8.0) kg/m2, MELD 7(8 ± 3.0), ALBI -3(-3 ± 0.6) and Child-Pugh score 5(5 ± 0.7). Operative duration was 235(260.1 ± 131.9) minutes, EBL was 100(165 ± 208.1) mL, tumor size was 4(5 ± 3.5) cm, and 94% achieved R0 margins. Length of hospital stay was 3(4 ± 3.7) days with 4% of patient had major complications. 30-day readmission was 17% with 30-day mortality of 2%, and 90-day mortality of 3%. On CUSUM analysis, the learning curve for minor resection (n=215) was 75 cases, major resection (n=154) was 100 cases, and technically challenging minor resection (n=131) was 57 cases. As we gained experience, we had shorter operative duration, lower blood loss, higher R0 resections, and lower major postoperative complications.

CONCLUSIONS

The minimum number of robotic hepatectomies to overcome the learning curves for mastery of minor, major, and technically challenging minor resections was significant. This can help guide surgeons in their early experience to optimize patient safety and outcomes.

Is the robotic approach the future of distal pancreatectomy with splenectomy? A propensity score matched analysis

Our study provides a comparative analysis of the Laparo-Endoscopic Single Site (LESS) and robotic surgical approaches for distal pancreatectomy and splenectomy, examining their cosmetic advantages, patient outcomes, and operative efficiencies through propensity score matching (PSM). We prospectively followed 174 patients undergoing either the LESS or robotic procedure, matched by cell type, tumor size, age, sex, and BMI from 2012 to 2023. Propensity score matching (PSM) was utilized for data adjustment, with results presented as median (mean ± SD). Post-PSM analysis showed no significant differences in age or BMI between the two groups. LESS approach exhibited a shorter operative duration (180(180 ± 52.0) vs. 248(262 ± 78.5) minutes, p = 0.0002), but increased estimated blood loss (200(317 ± 394.4) vs. 100 (128 ± 107.2) mL, p = 0.04). Rates of intraoperative and postoperative complications, length of hospital stay, readmissions within 30 days, in-hospital mortalities, and costs were comparably similar between the two procedures. While the robotic approach led to lower blood loss, LESS was more time-efficient. Patient outcomes were similar in both methods, suggesting that the choice between these surgical techniques should balance cosmetic appeal with technical considerations.

Robotic Biliary Resection for Type I Choledochal Cyst With Dual Hepaticojejunostomy

The distal bile duct was isolated and transected with a frozen section examination confirming the absence of malignancy. Attention was then shifted to constructing a 60 cm Roux limb by first identifying and transecting the proximal jejunum 40 cm from the ligamentum of Treitz. A side-to-side stapled jejunojejunostomy anastomosis was completed. The Roux limb was transposed toward the porta hepatis through an antecolic approach.

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.

The Implications of Readmission on Cost and Patient Outcomes Following Distal Pancreatectomy and Splenectomy

BACKGROUND

Robotic platform usage for distal pancreatectomy and splenectomy has grown exponentially in recent years. This study aims to identify the impact of readmission following robotic distal pancreatectomy and splenectomy and to analyze the financial implications of these readmissions.

METHODS

We prospectively followed 137 patients after robotic distal pancreatectomy and splenectomy. Readmission was defined as rehospitalization within 30 days post-discharge. Total cost incorporated initial and readmission hospital costs, when applicable. Outcomes were analyzed using chi-square/Fisher's exact test and Student's t test. Data are presented as median (mean ± SD).

RESULTS

Of 137 patients, 20 (14%) were readmitted. Readmitted patients were 67 (66 ± 10.3) years old and had a BMI of 30 (30 ± 7.0) kg/m2; 9 (45%) had previous abdominal operations. Non-readmitted patients were 67 (62 ± 14.7) years old and had a BMI of 28 (28 ± 5.7) kg/m2; 37 (32%) had previous abdominal operations (P = NS, for all). Readmitted patients vs non-readmitted patients had operative durations of 327 (363 ± 179.1) vs 251 (293 ± 176.4) minutes (P = .10), estimated blood loss (EBL) of 90 (159 ± 214.6) vs 100 (244 ± 559.4) mL (P = .50), and tumor diameter of 3 (4 ± 2.0) vs 3 (4 ± 2.9) cm (P = 1.00). Initial length of stay (LOS) for readmitted patients vs patients who were not readmitted was 5 (5 ± 2.7) vs 4 (5 ± 3.0) days (P = 1.00); total hospital cost of those readmitted, including both admissions, was $29,095 (32,324 ± 20,227.38) vs $24,663 (25,075 ± 10,786.45) (P = .018) for those not readmitted.

DISCUSSION

Despite a similar perioperative course, readmissions were associated with increased costs. We propose thorough consideration before readmission and increased patient education initiatives will reduce readmissions after robotic distal pancreatectomy and splenectomy.

Comparison of IWATE, Institut Mutualiste Montsouris, and Southampton Laparoscopic Liver Resection Difficulty Scoring Systems for Predicting Intra and Postoperative Outcomes in Robotic Hepatectomy

BACKGROUND

IWATE, Institut Mutualiste Montsouris (IMM), and Southampton are established difficulty scoring systems (DSS) for laparoscopic hepatectomy, yet none specifically address robotic hepatectomy. Our study evaluates these 3 DSS for predicting perioperative outcomes in robotic hepatectomy.

METHODS

With IRB approval, we prospectively followed 359 consecutive patients undergoing robotic hepatectomies, assessing categorical metrics like conversions to open, intra/postoperative issues, Clavien-Dindo Score (≥III), 30 and 90-day mortality, and 30-day readmissions using Receiver Operating Characteristic (ROC) curves and Area Under the Curve (AUC) to determine efficacy in predicting their occurrence for each DSS. Continuous metrics such as operative duration, estimated blood loss (EBL), length of stay, and total cost were analyzed using Spearman's correlation and regression. Predictive strength was significant with an AUC or correlation ≥.700 and P-value ≤.05.

RESULTS

IMM had highest predictive accuracy for conversions to open (AUC = .705) and postoperative complications (AUC = .481). Southampton was most accurate in predicting Clavien Dindo ≥ III complications (AUC = .506). IWATE excelled in predicting 30-day mortality (AUC = .552), intraoperative issues (AUC = .798), In-hospital mortality (AUC = .450), 90-day mortality (AUC = .596), and readmissions (AUC = .572). Regression showed significant relationships between operative duration, EBL, and hospital cost with increasing scores for all DSS (P ≤ .05).

DISCUSSION

Statistical analysis of the 3 DSS indicates that each has specific strengths that can best predict intra- and/or postoperative outcomes. However, all showed inaccuracies and conflicting relationships with the variables, indicating lack of substantial hierarchy between DSS. Given these inconsistencies, a dedicated comprehensive DSS should be created for robotic hepatectomy.

A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS

BACKGROUND

The increasing use of robotic systems for anti-reflux operations prompted this study to evaluate and compare the efficacy of robotic and Laparo-Endoscopic Single-Site (LESS) approaches.

METHODS

From 2012, 228 robotic fundoplication and 518 LESS fundoplication patients were prospectively followed, analyzing perioperative metrics. Data are presented as median (mean ± SD); significance at p ≤ 0.05.

RESULTS

Patients undergoing a robotic vs. LESS fundoplication were 67 (64 ± 13.7) vs. 61 (59 ± 15.1) years-old with BMIs of 25 (25 ± 3.2) vs. 26 (25 ± 3.9) kg/m2 (p = 0.001 and 1.00, respectively). 72% of patients who underwent the robotic approach had a previous abdominal operation(s) vs 44% who underwent the LESS approach (p = 0.0001). 38% vs. 8% had a re-operative fundoplication (p = 0.0001), 59% vs. 45% had a type IV hiatal hernia (p = 0.0004). Operative duration was 160 (176 ± 76.7) vs. 130 (135 ± 50.5) min (p = 0.0001). There were 0 (robotic) vs. 5 (LESS) conversions to a different approach (p = 0.33). 5 Patients vs. 3 patients experienced postoperative complications (p = 0.06), and length of stay (LOS) was 1 (2 ± 2.6) vs. 1 (1 ± 3.2) days (p = 0.0001). Patient symptomatic dysphagia preoperatively for the robotic vs. LESS approach was scored as 2 (2.4 ± 1.9) vs. 1 (1.9 ± 1.6). Postoperatively, symptomatic dysphagia was scored as 1 (1.5 ± 1.6) vs. 1 (1.7 ± 1.7). The change in these scores was - 1 (- 1 ± 2.2) vs. 0 (- 0.5 ± 2.2) (p = 0.004).

CONCLUSION

Despite longer operative times and LOS in older patients, the robotic approach is efficient in undertaking very difficult operations, including patients with type IV or recurrent hiatal hernias. Furthermore, preoperative anti-reflux operations were more likely to be undertaken with the robotic approach than the LESS approach. The patient's postoperative symptomatic dysphagia improved relatively more than after the LESS approach. The vast majority of patients who underwent the LESS approach enjoyed improved cosmesis, thus, making LESS a stronger candidate for more routine operations. Despite patient selection bias, the robotic and LESS approaches to anti-reflux operations are safe, efficacious, and should be situationally utilized.

Hospital readmissions after robotic hepatectomy for neoplastic disease: Analysis of risk factors, survival, and economical impact. A logistical regression and propensity score matched study

BACKGROUND

As the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden.

METHODS

The study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis.

RESULTS

Among 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p ​= ​0.01), increased Child-Pugh score (p ​< ​0.01), and R1 margin status (p ​= ​0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p ​= ​0.045). Readmissions didn't significantly impact five-year survival (p ​= ​0.42) but increased fixed indirect hospital costs (p ​< ​0.01).

CONCLUSIONS

Readmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.

Weighing the outcomes: the role of BMI in complex robotic esophageal and hepatobiliary operations

BACKGROUND

The correlation between body mass index (BMI) and surgical outcomes has emerged as a critical consideration in complex abdominal operations. While elevated BMI is often associated with increased perioperative risk, its specific effects on the outcomes of robotic surgeries remain inadequately explored. This study assesses the impact of BMI on perioperative variables of complex esophageal and hepatopancreaticobiliary (HPB) robotic operations.

METHODS

Following IRB approval, we prospectively followed 607 patients undergoing pancreaticoduodenectomy, trans-hiatal esophagectomy (THE), major liver resection or distal pancreatectomy with splenectomy, all performed robotically. Perioperative data retrieved included operative duration, estimated blood loss (EBL), intraoperative and postoperative complications, conversions to an 'open' operation and length of stay (LOS). Z scores were assigned to each variable to standardize operations, and the variables were then regressed against BMI. For illustrative purposes, data are presented as median(mean ± standard deviation).

RESULTS

Between 2012 and 2020, surgeries included 71 THE, 122 distal pancreatectomies with splenectomies, 129 major hepatectomies and 285 pancreaticoduodenectomies. Median age was 67(65 ± 12.5) years old, and BMI was 27(28 ± 5.5) kg/m2. Operative duration for all operations was 349(355 ± 124.5) min and had a positive correlation with increasing BMI (p = 0.004), specifically for robotic THE and robotic pancreaticoduodenectomy, with both operative durations having positive correlation with increasing BMI (p = 0.02 and p = 0.05). No significant correlation with BMI was found for EBL, intraoperative or postoperative complications, conversion to 'open' surgery, or LOS.

CONCLUSION

Elevated BMI is associated with longer operative durations in select robotic surgeries, such as trans-hiatal esophagectomy and pancreaticoduodenectomy, and highlights the need for strategic planning in these patients.

Epidural versus general anesthesia for laparo-endoscopic single-site cholecystectomy: a randomized controlled trial

INTRODUCTION

This study compares outcomes after LESS cholecystectomy utilizing epidural versus general anesthesia.

METHODS

Patients undergoing LESS Cholecystectomy were randomized into receiving epidural or general anesthesia by protocol. Patients used a Visual Analog Scale to rate pain from 0 (no pain) to 10 (severe pain). Data presented as median (mean ± standard deviation).

RESULTS

75 patients underwent LESS cholecystectomy with general anesthesia [32 patients (22% men) after five patients withdrew consent] or epidural anesthesia [23 patients (22% men) after 15 patients withdrew consent]. Respectively, they were of age 38 years (41 ± 15.1) and 47 years (48 ± 13.9), BMI 29 (28 ± 4.9) kg/m2 and 28 (28 ± 3.8) kg/m2, and ASA 2 (2 ± 0.5) and 2 (2 ± 0.3) (p > 0.05 for all). LOS for patients receiving general vs. epidural anesthesia was 72 min (122 ± 104.4) vs. 95 min (113 ± 77.5) (p = 0.25). On POD 0, patients receiving general anesthesia rated pain as 4 (4 ± 2.9) vs. 0 (1 ± 2.2) for epidural anesthesia (p = 0.02). On POD 1, they rated pain as 6 (5 ± 2.3) vs. 6 (6 ± 2.9) (p = 0.68). On POD 6, patients rated pain as 3 (3 ± 2.7) vs. 4 (3 ± 2.2) (p = 1.00). For patient satisfaction with incisional scars for those receiving general vs. epidural anesthesia, patients rated their scars to be 10 (8 ± 3.6) vs. 10 (9 ± 1.2) (p = 0.21). Total costs for the hospital using general vs. epidural anesthesia were found $6,909 (7,167 ± 2,083.8) vs. $6,225 (5,848 ± 1530.1) (p = 0.014), respectively. Patients self-assessed satisfaction on a scale of 1 (worst) to 5 (best) as a 5 (5 ± 0).

CONCLUSIONS

Patients undergoing LESS cholecystectomy with general vs. epidural anesthesia had similar demographics, LOS, and pain scores. Patients that received epidural anesthesia reported less pain and incurred less cost. Utilization of epidural anesthesia in lieu of general anesthesia for LESS cholecystectomy is safe, reduces pain, and offers potential cost savings.

Effect of insurance status on perioperative outcomes after robotic pancreaticoduodenectomy: a propensity-score matched analysis

The influence of Medicaid or being uninsured is prevailingly thought to negatively impact a patient's socioeconomic and postoperative course, yet little has been published to support this claim specifically in reference to robotic pancreaticoduodenectomy. This study was undertaken to determine impact of health insurance type on perioperative outcomes in patients undergoing robotic pancreaticoduodenectomy. Following IRB approval, we prospectively followed 364 patients who underwent robotic pancreaticoduodenectomy. Patients were stratified by insurance status (i.e., Private, Medicare, and Medicaid/Uninsured); 100 patients were 2:2:1 propensity-score matched by age, BMI, ASA class, pathology, 8th edition AJCC staging, and tumor size. Perioperative variables were compared utilizing contingency testing and ANOVA. Statistical significance was accepted at a p-value ≤ 0.05 and data are presented as median (mean ± SD). The 100 patients undergoing propensity-score matching were 64 (65 ± 9.1) years old with a BMI of 27 (27 ± 4.9) kg/m2 and ASA class of 3 (3 ± 0.5). Operative duration was 421 (428 ± 105.9) minutes and estimated blood loss was 200 (385 ± 795.0) mL. There were 4 in-hospital deaths and 8 readmissions within 30 days of discharge. Total hospital cost was $32,064 (38,014 ± 22,205.94). After matching, no differences were found in pre-, intra-, and short-term postoperative variables among patients with different insurances, including hospital cost and time to initiate adjuvant treatment, which was 8 (9 ± 7.9) weeks for patients with malignant disease. In our hepatopancreaticobiliary program, health insurance status did not impact perioperative outcomes or hospital costs. These findings highlight that financial coverage does not influence quality of perioperative care, reinforcing the equity of robotic surgery.

The effects of smoking history on robotic transhiatal esophagectomy patient outcomes

Esophageal resection for the treatment of esophageal cancer generally entails high rates of morbidity and mortality. Patients with a smoking history have increased post-operative complications following esophagectomy. This study was undertaken to determine how smoking or a history of smoking can affect perioperative outcomes and morbidity following robotic transhiatal esophagectomy. 75 patients were prospectively followed and divided; 44 patients actively smoking or with a history of significant smoking were classified as 'smokers', while the other 31 patients were classified as 'non-smokers'. Significance was determined at a p-value of ≤ 0.05 and data are presented as median (mean ± SD). 'Smokers' averaged 70(70 ± 7.8) years, 89% male, with 82% undergoing neoadjuvant therapy. 'Nonsmokers' averaged 68(69 ± 7.8) years, 74% male, and 74% receiving neoadjuvant therapy. BMI and ASA class showed no significant difference between the cohorts. 'Smokers' had an operative time of 341(343 ± 91.0) minutes and a blood loss of 150(191 ± 140.0) mL; 'nonsmokers' had 291(298 ± 65.9) minutes and 100(140 ± 120.9) mL, respectively (p = 0.02 for operative time). Tumor size and AJCC staging were similar for both cohorts. No significant differences were noted in postoperative complications, Clavien-Dindo score ≥ III, in-hospital mortality, length of stay, or 30-day readmissions. Survival rates were comparable. Hospital costs for 'smokers' were $33,131(41,091 ± 23,465.17) and $34,896 (62,154 ± 65,839.53) for 'nonsmokers' (p = 0.05). Profit/loss was $-23,155 (- 15,137 ± 35,819.29) for smokers and $-23,720 (- 16,716 ± 50,864.64) for nonsmokers. Current or past 'smokers' had longer operative times and lower costs following robotic transhiatal esophagectomy, with no significant difference in postoperative complications or survival compared to 'non-smokers'.

The weight of BMI in impacting postoperative and oncologic outcomes in pancreaticoduodenectomy is attenuated by a robotic approach

This study was undertaken to observe the effect of body mass index (BMI) on perioperative outcomes and survival when comparing robotic vs 'open' pancreaticoduodenectomy. With IRB approval, we prospectively followed 505 consecutive patients who underwent either robotic or 'open' pancreaticoduodenectomy from 2012 to 2021. For illustrative purposes, patients were separated based on the Center for Disease Control and Prevention BMI table but regression analysis was utilized to identify significant relationships involving BMI. Data are presented as median (mean ± SD). Significance was determined at p ≤ 0.05. 205 and 300 patients underwent 'open' and robotic pancreaticoduodenectomy, respectively. Neither sex nor age correlated with BMI in patients undergoing 'open' nor robotic operation. Operative duration correlated with increasing BMI in each operational approach, which was statistically significant for those receiving the 'open' operation (p = 0.02). There were statistically significantly fewer lymph nodes harvested with rising BMI in patients that had an 'open' operation (p = 0.01), but no such difference was found in patients undergoing the robotic approach. Length of stay (LOS) and in-hospital mortality were statistically significantly associated with rising BMI when an 'open' operation was undertaken (p = 0.02 and p = 0.0002, respectively) but not when the robotic platform was utilized. Patients with higher BMI had significantly longer operative duration, smaller lymph node harvest, greater LOS, and increased in-hospital mortality rate when undergoing 'open' pancreaticoduodenectomy, but not robotic pancreaticoduodenectomy. Thus, the robotic platform may attenuate the increased technical and oncologic difficulties associated with a greater BMI in patients undergoing pancreaticoduodenectomy.

Cost comparison between medicare and private insurance for robotic transhiatal esophagectomy

Esophageal cancer is a significant health concern, with the robotic platform being increasingly adopted for transhiatal esophagectomy (THE). While literature exists regarding the cost of robotic THE and its benefits, there is limited data analyzing cost and concurrent hospital reimbursement based on payor or provider. This study aimed to compare hospital reimbursement after robotic THE for patients with Medicare versus private insurance. With IRB approval, a prospective study of 85 patients from 2012 to 2022 who underwent robotic THE was conducted. Private insurance was defined as coverage excluding Medicare, Medicaid, or self-pay. Statistical analyses involved Student's t test, Chi-square test, and Fisher's exact test, with p ≤ 0.05 considered statistically significant. Data are presented as median (mean ± standard deviation). Among the 85 patients, 64 had Medicare, and 21 had private insurance. Medicare patients exhibited more frequent history of prior abdominal or thoracic surgeries (41% vs 10%, p < 0.01). Both groups showed no differences in factors like sex, body mass index, ASA classification, operative duration, estimated blood loss, conversions to 'open', tumor size, and major postoperative complications (Clavien-Dindo ≥ III). Similarly, metrics such as hospital stay duration, in-hospital mortality, 30-day readmission, and various financial components including total and variable costs, hospital reimbursement, and net margin were consistent across both. Despite Medicare patients being older and often having a broader operative history, hospital costs and reimbursements did not differ from patients with private insurance post-robotic THE. The robotic platform appears to mitigate potential disparities in hospitalization costs and hospital reimbursement for THE between Medicare and private insurance.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience

BACKGROUND

Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes.

METHODS

This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD).

RESULTS

From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3 ± 0.5; the MELD score was 9 ± 4.1; the Child-Pugh score was 6 ± 1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272 min, and the average blood loss amounted to 79 mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4 days, with a readmission rate of 15% within 30 days. During an average follow-up period of 33 months, one patient had to undergo a revision at 18 months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities.

CONCLUSIONS

Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

New generation evaluations: video-based surgical assessments : A technology update

BACKGROUND

Surgical skill training, assessment, and feedback are the backbone of surgical training. High-quality skills require expert supervision and evaluation throughout a resource-intensive multi-year training process. As technological barriers to internet access and the ability to save and upload surgical videos continue to improve, video-based assessment technology is emerging as a tool that could reshape surgical training for the next generation of surgeons. Video-based assessment platforms have the potential to allow surgeons from across the globe to upload their surgical videos online and receive high-quality, standardized, and unbiased feedback. They combine visual recordings of a surgeon's operative technique, with standardized grading tools that have the potential to significantly impact surgical training and technical skill acquisition across the world.

METHOD

The platforms included in this review are in various stages of development after a thorough discussion with national experts on the SAGES TAVAC (Technology and Value Assessments) Committee. For each VBA program, a description of its platform was given and a literature review was obtained using a PubMed search performed from inception until December 2021.

RESULTS

The study reviewed all video-based assessment programs currently available in the market, identified their strengths and weaknesses, and how they can be optimized in future.

CONCLUSION

The technological platforms will play a key role in the training and technical skill acquisition of the next generation of surgeons and can have an immense impact on patient care across the world. There is immense potential for all these platforms to grow and become incorporated within the framework of an effective surgical training program.

Collaborative Platforms and Matchmaking Algorithms for Research and Education, Establishment, and Optimization of Consortia

Matchmaking has a great position in the rational allocation of resources in several fields, ranging from market operation to people's daily lives. Matchmakers have evolved through artificial intelligence technologies and are being introduced in numerous aspects of industry, research, and academia in solving decision issues, research innovation design, and building robust and efficient networks. The goal of this report is to describe the collaborative platforms and matchmaking algorithms for research and education, as well as the establishment and optimization of consortia.

Musculoskeletal tuberculosis with multifocal muscle abscesses in a healthy young adult

Musculoskeletal tuberculosis represents 1% of total tuberculosis cases. It affects young adults from endemic countries or immunocompromised patients, and may lead to severe functional impairment. We report a case of a 27-year-old male from an endemic country presenting with a 4-month history of fever, a major pectoralis abscess, and low back pain. A lumbar spine MRI revealed osteolytic lesions in multiple vertebral bodies along with a large iliopsoas abscess. Both abscesses were drained and the diagnosis was established by positive polymerase chain reaction assay for tuberculosis. The patient was initiated on anti-tuberculous treatment for 9 months. Musculoskeletal tuberculosis is rarely found in Western countries. If left intreated, it can lead to severe complications which may require surgical intervention.

Local control and short-term outcomes after VATS segmentectomy vs lobectomy for pT1c pN0 NSCLC (2–3 cm)

Objective

Pulmonary segmentectomy has shown comparable oncological results to lobectomy for non-small cell lung cancers (NSCLC) of less than 2 cm. However, controversy remains for tumors of larger size. The aim of this study was to compare short-term outcomes and local control in pT1c pN0 NSCLC that were intentionally treated by VATS segmentectomy or lobectomy.

Methods

Multicenter retrospective study from January 2014 to October 2021 of 162 consecutive patients undergoing complete (R0) anatomical resections for pT1c pN0 NSCLC. Two groups, VATS lobectomy (VL) or VATS segmentectomy (VS) were defined according to the extension of the resection. Patients’ characteristics, postoperative outcomes and survival were compared.

Results

In total, 162 patients underwent VL (n=81) or VS (n=81). Except for age (median of 68 vs 71 years, p=0.034) and past medical history of cancer (32% vs 48%, p=0.038), there was no difference between VL and VS in terms of demographics and comorbidities (table1). Segmentectomies were performed in upper lobes in 68% and single segments represented 46% of all cases. Conversion thoracotomy rate was 5% in both groups. Morbidity were similar in both groups (34% vs 30%, p=0.5). The median time for chest tube removal (3 vs 2 days, p=0.002) and median LOS (6 vs 5 days, p=0.039) were in favor of the VS group. Significantly larger tumor (25 mm vs 23.5 mm p=0.001) and an increased number of lymph nodes removal (median 14 vs 10, p&lt;0.001) were found in the VL group. During the follow-up (median: 31 months), no statistical difference was found for local and distant recurrence in VL groups (12.3%) and VS group (6.2%) (p=0.414). Overall survival was comparable in-between both groups (p=0.166).

Conclusion

Despite a short follow-up, our preliminary data shows that local control is comparable for VATS lobectomy and VATS segmentectomy. Further prospective randomized trials are needed to corroborate these results.

Mapping the coordination and cooperation mechanisms of risk communication on feed/food safety in the EU

The mapping of the EU coordination and cooperation mechanisms of risk communication in the field of food safety (i.e. encompassing all matters pertaining to the feed and food chain) was conducted for the European Food Safety Authority (EFSA), following a mandate by the European Commission, to inform the General Plan for Risk Communication that the Commission will set out. This study focuses on communication activities in 'peacetime' situations (i.e. non-crisis) on the published outputs of risk assessment and risk management. This is a specific part of the risk communication process defined in the General Food Law. Data were collected through an online survey of competent authority organisations involved in risk communication at national and regional levels in the EU-27 Member States and Norway; and interviews with selected organisations at Member State, EU and international levels. Based on these data, this report provides an overview of the current information flow of risk communication, in terms of whether and how organisations at all levels receive, produce, and disseminate risk communication material. The existing flows in each country are described and mapped in flow charts. Flows are also presented for each of the EU/international organisations involved in risk communication on food safety. A number of relevant networks are identified that actively engage in sharing/exchanges of risk communication material on food safety, including networks managed by EFSA. This project also highlighted certain challenges in current risk communication systems, and recommendations are made to address them. At national level, these are: an increase in resources dedicated to coordinating communication on EU food safety issues, to improve capacity to undertake this task; strengthen the cooperation and coordination between authorities involved in risk communication activities to ensure a more proactive approach. In addition, recommendations are provided to enhance further collaboration of communication activities at all levels (between Member States and with EFSA; between EU Agencies), so that the coordination of risk communication at EU level follows a partnership approach.

How to change organisational culture: Action research in a South African public sector primary care facility

Background

Organisational culture is a key factor in both patient and staff experience of the healthcare services. Patient satisfaction, staff engagement and performance are related to this experience. The department of health in the Western Cape espouses a values-based culture characterised by caring, competence, accountability, integrity, responsiveness and respect. However, transformation of the existing culture is required to achieve this vision.

Aim

To explore how to transform the organisational culture in line with the desired values.

Setting

Retreat Community Health Centre, Cape Town, South Africa.

Methods

Participatory action research with the leadership engaged with action and reflection over a period of 18 months. Change in the organisational culture was measured at baseline and after 18 months by means of a cultural values assessment (CVA) survey. The three key leaders at the health centre also completed a 360-degree leadership values assessment (LVA) and had 6 months of coaching.

Results

Cultural entropy was reduced from 33 to 13% indicating significant transformation of organisational culture. The key driver of this transformation was change in the leadership style and functioning. Retreat health centre shifted from a culture that emphasised hierarchy, authority, command and control to one that established a greater sense of cohesion, shared vision, open communication, appreciation, respect, fairness and accountability.

Conclusion

Transformation of organisational culture was possible through a participatory process that focused on the leadership style, communication and building relationships by means of CVA and feedback, 360-degree LVA, feedback and coaching and action learning in a co-operative inquiry group.

Household cleaning activities as noningestion exposure determinants of urinary trihalomethanes

Previous epidemiological studies linking drinking water total trihalomethanes (THM) with pregnancy disorders or bladder cancer have not accounted for specific household cleaning activities that could enhance THM exposures. We examined the relation between household cleaning activities (washing dishes/clothes, mopping, toilet cleaning, and washing windows/surfaces) and urinary THM concentrations accounting for water sources, uses, and demographics. A cross-sectional study (n = 326) was conducted during the summer in Nicosia, Cyprus, linking household addresses to the geocoded public water pipe network, individual household tap water, and urinary THM measurements. Household tap water THM concentrations ranged between 3-129 μg L(-1), while the median (Q1, Q3) creatinine-adjusted urinary THM concentration in females (669 ng g(-1) (353, 1377)) was significantly (p < 0.001) higher than that in males (399 ng g(-1), (256, 681)). Exposure assessment, based on THM exposure equivalency units, showed that hand dishwashing, mopping, and toilet cleaning significantly (p < 0.001) increased urinary THM levels. The effect of dishwashing by females ≥36 y of age remained significant, even after adjusting for potential confounders. No significant (p > 0.05) association was observed between ingestion-based THM exposure equivalency units and urinary THM. Noningestion routes of THM exposures during performance of routine household cleaning activities were shown for the first time to exert a major influence on urinary THM levels. It is warranted that future pregnancy-birth cohorts include monitoring of noningestion household THM exposures in their study design.

Multiresponsive polymer conetworks capable of responding to changes in pH, temperature, and magnetic field: synthesis, characterization, and evaluation of their ability for controlled uptake and release of solutes

This study deals with the preparation of novel multiresponsive (magnetoresponsive, thermoresponsive and pH-responsive) nanocomposite conetworks consisting of oleic acid-coated magnetite nanoparticles (OA·Fe(3)O(4)), hydrophilic/thermoresponsive hexa(ethylene glycol) methyl ether methacrylate (HEGMA), hydrophobic/metal binding 2-(acetoacetoxy)ethyl methacrylate (AEMA), and pH-responsive/thermoresponsive N-diethylaminoethyl methacrylate (DEAEMA) and 2-(dimethylamino)ethyl methacrylate (DMAEMA) moieties. Conventional free radical copolymerization was employed for the synthesis of random conetworks in the absence and presence of preformed OA·Fe(3)O(4). Further, in characterization of these materials in regards to their swelling behavior in organic and aqueous solvents, thermal/thermoresponsive properties, and composition, assessment of their magnetic characteristics disclosed tunable superparamagnetic behavior. These systems were also evaluated toward their ability to adsorb and release a solute (benzoic acid) in a controlled manner upon varying the pH.

[Clostridium difficile: a serious outpatient infection?]

Secondary to severe hospital outbreaks due to hypervirulent strains of Clostridium difficile, several surveillance systems in North-America and Europe observed an increase in infections due to this micro-organism, also in the outpatient setting. The case reported in the present article illustrates the fulminant presentation that a C. difficile colitis can show in a previously healthy person without prior contact with healthcare facilities. It introduces a review of some recent publications on the current changes in the epidemiology, clinical presentation, diagnosis and treatment of this disease.

Robotic control in hand-assisted laparoscopic nephrectomy in humans - a pilot study

Computer-assisted surgical devices, including laparoscopic surgical robotic arms, can be used in urologic surgery to minimize trauma. In this study, we explored the feasibility and applicability of using a robotic arm, AESOP (Computer Motion Inc, Goleta, CA), as a substitute for surgical assistants during hand-assisted laparoscopic nephrectomies in humans. Four patients (3 men and 1 woman, mean age 66 years) underwent robotic-assisted laparoscopic nephrectomy. The hand-assisted laparoscopic nephrectomy was completed successfully in all patients. The average operative time, estimated blood loss, and time to hospital discharge was 252.5 minutes, 0.57 ml, and 4.5 days, respectively. Postoperative satisfactory function was confirmed through laboratory tests, imaging exams and biochemical tests. No complications were reported for any of the patients. Parameters, such as the operative time, are expected to be further reduced when more experience with the use of the robot has been acquired. In conclusion, robotic-assisted laparoscopic nephrectomy is feasible and safe, and can be performed without complications. The potential long-term cost effectiveness of using robotic surgical assistants in laparoscopic surgery highlights the economic impact of this research and warrants further investigation.

Herpes simplex virus type 1 in peptic ulcer disease: An inverse association with Helicobacter pylori

AIM: To assess the frequency of herpes simplex virus type I in upper gastrointestinal tract ulcers and normal mucosa with the modern and better assays and also with a larger number of well characterized patients and controls and its relationship to Helicobacter pylori(H pylori).

METHODS: Biopsy specimens from 90 patients (34 with gastric ulcer of the prepyloric area and 56 with duodenal ulcer) were evaluated. Biopsies from 50 patients with endoscopically healthy mucosa were considered as the control group. The method used to identify herpes simplex virus-1 (HSV-1) was polymerase chain reaction. H pylori was detected by the CLO-test and by histological method.

RESULTS: Herpes simplex virus-1 was detected in 28 of 90 patients with peptic ulcer (31%) [11 of 34 patients with gastric ulcer (32.4%) and 17 of 56 with duodenal ulcer (30.4%)] exclusively close to the ulcerous lesion. All control group samples were negative for HSV-1. The likelihood of H pylori negativity among peptic ulcer patients was significantly higher in HSV-1 positive cases than in HSV-1 negative cases (P = 0.009). Gastric ulcer patients with HSV-1 positivity were strongly associated with an increased possibility of Helicobacter pylori negativity compared to duodenal ulcer patients (P = 0.010).

CONCLUSION: HSV-1 is frequent in upper gastro-intestinal tract ulcers but not in normal gastric and duodenal mucosa. There is an inverse association between HSV-1 and H pylori infection.

[Hemilithotomy position for intramedullary nailing of the femur and compartment syndrome of the healthy leg]

The well leg compartment Syndrome following long procedures in the dorsal lithotomy or hemi-lithotomy position is a rare complication. Its diagnosis is usually late and the neurological deficit are often permanent. We report two cases of femoral nailing complicated by Compartment Syndrome of the contralateral leg. We review the published literature on 40 cases which suggests a clear relationship between these positions, the duration of the intervention and the degree of leg elevation. Given the potentially severe sequel, prevention is a must and a high degree of suspicion is the key to an early diagnosis. A modified hemi-lithotomy position is proposed. That avoids extreme elevation of the leg and diminishes the hip and knee flexion required while allowing adequate fluoroscopy.

Adenocarcinoma in the anal canal after ileal pouch-anal anastomosis for ulcerative colitis using a double stapling technique: report of a case

A case of adenocarcinoma, developed in the anal canal after ileal pouch-anal anastomosis for ulcerative colitis using a double stapling technique, is reported. In this case a T3N0 cecal cancer was found unexpectedly in the colectomy specimen. Two years later, this patient presented with an outlet obstruction of the pouch because of development of an adenocarcinoma of the anal canal. This was treated with an abdominoperineal excision of the pouch and anorectum.

Concurrent conventionally factionated radiotherapy and weekly docetaxel in the treatment of stage IIIb non-small-cell lung carcinoma

Docetaxel has shown remarkable radiosensitizing in vitro properties. In a previous phase I/II dose escalation study in non-small-cell lung cancer (NSCLC) we observed a high response rate after concomitant boost radiotherapy and weekly docetaxel. The maximum tolerated dose was 30 mg m(-2) week(-1). In the present phase II study we evaluated whether weekly docetaxel and conventionally fractionated radiotherapy could be better tolerated and equally effective in the treatment of locally advanced NSCLC. Thirty-five patients with T3, T4/N2, T3/M0-staged disease were recruited. Docetaxel (30 mg m(-2)) was given as a 30 min infusion once a week. Asthenia and radiation-induced oesophagitis were the main side-effects of the regimen enforcing 2-week treatment delay in 6/35 (17%) patients and minor delay (3-7 days) in another 11/35 (31%) patients. Neutrophil, platelet and haemoglobin toxicity was minimal, but pronounced lymphocytopenia was observed. Complete response (CR) of the chest disease was observed in 12/35 (34%) patients and partial response in 16/35 (46%). Although not statistically significant (P=0.19), a higher CR rate (8/18; 44%) was observed in patients who accomplished their therapy within the scheduled treatment time (44-47 days) as compared to patients that interrupted their treatment for several days due to treatment-related toxicity (CR 4/17; 23%). The overall survival and the local progression-free survival at 1 year was 48% and 60% respectively. We conclude that docetaxel combination with radiotherapy is a promising approach for the management of locally advanced NSCLC that results in high CR rate. Further trials with docetaxel-based radiochemotherapy should integrate accelerated radiotherapy together with cytoprotection.

Matrix metalloproteinases and processing of pro-TNF-alpha

Tumor necrosis factor-alpha (TNF-alpha) is released from a cell membrane-anchored precursor by proteolytic cleavage. We have shown that broad spectrum synthetic inhibitors of matrix metalloproteinases (MMPs) prevent the processing of the TNF precursor but do not inhibit the release of other cytokines. Purified MMPs, stromelysin, matrilysin, collagenase, and the gelatinases can all cleave a recombinant pro-TNF substrate to yield mature TNF. MMP inhibitors prevent the rise in blood levels of TNF after endotoxin administration in rats and are effective in animal models of inflammatory disease such as adjuvant arthritis. Drugs that inhibit MMP action and TNF release show great promise for the treatment of autoimmune inflammatory diseases.

Processing of tumour necrosis factor-alpha precursor by metalloproteinases

Tumour necrosis factor-alpha (TNF-alpha) is a potent pro-inflammatory and immunomodulatory cytokine implicated in inflammatory conditions such as rheumatoid arthritis, Crohn's disease, multiple sclerosis and the cachexia associated with cancer or human immunodeficiency virus infection. TNF-alpha is initially expressed as a 233-amino-acid membrane-anchored precursor which is proteolytically processed to yield the mature, 157-amino-acid cytokine. The processing enzyme(s) which cleave TNF-alpha are unknown. Here we show that the release of mature TNF-alpha from leukocytes cultured in vitro is specifically prevented by synthetic hydroxamic acid-based metalloproteinase inhibitors, which also prevent the release of TNF-alpha into the circulation of endotoxin challenged rats. A recombinant, truncated TNF-alpha precursor is cleaved to biologically active, mature TNF-alpha by several matrix metalloproteinase enzymes. These results indicate that processing of the TNF-alpha precursor is dependent on at least one matrix metalloproteinase-like enzyme, inhibition of which represents a novel therapeutic mechanism for interfering with TNF-alpha production.