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ABSTRACT: BACKGROUND: There are few reports of robot-assisted pancreatic surgery. Our purpose was to report our surgical and clinical experiences and outcomes of 47 cases of robot-assisted pancreatic resection to show that minimally invasive pancreatic surgery is both feasible and effective. METHODS: The medical records of 47 patients who underwent robot-assisted pancreatic resections for adenocarcinoma, cystic tumours or other pancreatic diseases at our institution by a single surgical team from March 2010 to December 2011 were retrospectively analysed. RESULTS: There were 32 females and 15 males with a mean age of 48.7 ± 15.4 years, of whom 13 patients had pathologically diagnosed malignancies, 25 had cystic tumours or chronic pancreatitis, three had solid pseudopapillary tumours of pancreas, and six had other lesions. Sixteen patients underwent pancreatoduodenectomy, 16 distal pancreatectomies (nine of which had spleen resections), 10 middle pancreatectomies, four Beger's procedure, and one had enucleation of a pancreatic lesion. The mean surgical time was 299.2 ± 133.5 (range 70-540) min and mean blood loss was 431.8 ± 309.0 (range 50-1100) ml. Nine patients required a blood transfusion (mean transfusion volume 597.2 ± 543.3 ml). There were no conversions to laparotomy. The mean hospital stay was 29.4 ± 9.1 (range 8-41) days. Pancreatic fistula occurred in 20 cases, anastomotic bleeding in three patients and anastomotic leakage in one patient. Two patients, one who received a PD and one who received a distal pancreatectomy, required a second surgery. All other complications were resolved with conservative management. Surgical margins were negative in all cases, with a postoperative histopathological diagnosis of malignancy. Eleven of the 13 patients with malignancies were alive and well without recurrence at the time of publication, while two patients died. CONCLUSIONS: Our series of 47 robot-assisted pancreatic resections adds further evidence that this technique is feasible and effective. Copyright © 2012 John Wiley & Sons, Ltd.
International Journal of Medical Robotics and Computer Assisted Surgery 12/2012; · 1.59 Impact Factor
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ABSTRACT: The only potentially curative option for patients with gallbladder cancer is radical resection. This is the first report that describes the successful application of a minimally invasive, robot-assisted radical resection, including lymphadenectomy, in five gallbladder cancer patients.
Medical records of patients who underwent radical resection of gallbladder cancer via the da Vinci robotic surgical system in the Hepato-Bilio-Pancreatic Surgical Department of the Shanghai Ruijin Hospital, China, between March 2010 and July 2011 were reviewed and analyzed.
Robot-assisted radical resection was successful in all five patients. The mean number of excised lymph nodes was 9 (range = 3-11), mean operative time was 200 min (range = 120-300 min), mean intraoperative blood loss was 210 ml (range = 50-400 ml), and mean length of hospital stay was 7.4 days (range = 7-8 days). All patients were discharged with no reported complications. Mean postoperative follow-up was 11 months (range = 1-17 months). One patient died due to tumor recurrence 10 months postsurgically, but there was no recurrence in the remaining four patients during the follow-up period.
Robot-assisted radical resection for gallbladder cancer is both feasible and safe. Compared to laparoscopic surgery, the robotic surgery system is better suited for subtle dissection in a narrow, deep space. This is advantageous for both the removal of lymph nodes near the pancreas and hepatoduodenal ligament and the skeletonization of the hepatoduodenal ligament, the hepatic artery, and the celiac axis. The long-term outcome and direct comparisons to laparotomy in a larger patient cohort are needed to provide more clinical data supporting the superiority of this approach.
Surgical Endoscopy 05/2012; 26(11):3245-50. · 4.01 Impact Factor
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ABSTRACT: The duodenum-preserving pancreatic head resection (DPPHR) has been accepted as a valid surgical alternative to more extensive standard resections for the treatment of benign and low malignant tumors at the head of the pancreas. In this article, a new minimally invasive operation, the robot-assisted laparoscopic technique, is introduced for this procedure.
From March 2010 to Dec 2010, four patients (three women and one man), with a mean age of 42.3 years (range: 21-62 years), underwent robot-assisted laparoscopic DPPHR at the Hepato-Bilio-Pancreatic Surgical Department of Rui Jin Hospital in Shanghai, China. The preoperative symptoms include two cases of repeated upper abdominal pain, one case with no obvious preoperative symptoms, and one case of repeated hypoglycemia. The da Vinci Surgical System was used to perform the main steps of the operation. All patients underwent a pancreaticogastrostomy for pancreaticoenteric reconstruction to the distal stump.
All four surgeries were successfully performed. There were no deaths. The mean operative time was 298.8 (270-335) min, average blood loss was 425 ml (range: 100-600 ml). The mean postoperative hospital stay was 26.8 days (range: 20-30 days). The one patient with an islet cell tumor has had normal blood glucose levels since the operation, and the other three patients have had no hyperglycemia. Three of the patients developed a pancreatic fistula that was cured by conservative treatment.
The robotic surgical system is technically fully capable of performing the complex DPPHR procedure with an acceptable range of surgical complications. It breaks through the bottleneck of the traditional laparoscopic technology and expands the range of its applications. However, this new technology is still at an exploratory stage, and the long-term effect remains to be validated by additional clinical data.
World Journal of Surgery 03/2012; 36(5):1136-41. · 2.36 Impact Factor
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ABSTRACT: Our purpose was to assess the clinicopathological features and surgical outcomes of combined hepatocellular-cholangiocarcinoma (HCC-CC) in an Asian center.
Between 1998 and 2009, 27 patients were diagnosed with combined HCC-CC at our hospital. Their medical records were reviewed and clinicopathological data retrospectively analyzed.
The 27 patients included 24 (88.9%) males and 3 (11.1%) females with a mean age of 58.26 ± 11.18 years. Cirrhosis was present in 10 patients (37.0%), and 12 patients had hepatitis C or hepatitis B virus infection. Serum alpha fetoprotein was >20 ng/ml in 7 of the 19 patients in whom it was measured (36.8%). Twenty-five patients underwent hepatic resections and 2 received liver transplantations. Five (18.5%) patients had separate HCC and CC within the same liver (type I), 21 (77.8%) had tumors with mixed components (type II), and 1 patient had a type III tumor (3.7%). Of 22 patients with immunohistochemical data, 19 (86.4%) were cytokeratin (CK) 7-positive, 20 (90.9%) were CK19-positive, and 4 (18.2%) were CK20-positive. Mean follow-up was 25.8 months. The 1- and 2-year survival rates were 72.5 and 49.4%, respectively. The 1- and 2-year disease-free survival rates were 54.2 and 41.3%, respectively. Symptoms at the time of diagnosis, and regional lymph node metastases, were associated with higher mortality and recurrence.
Lymph node metastasis and positive resection margins are important factors affecting HCC-CC surgical outcomes.
Journal of hepato-biliary-pancreatic sciences. 07/2011; 19(4):361-9.
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ABSTRACT: To analyze the influence of pancreatic fistula in middle segmental pancreatic resection and summarize the experience in dealing with the stump.
The data of 40 cases undergoing middle pancreatectomy were reviewed retrospectively to analyze the curative effect and pancreatic fistula between April 2003 and December 2009. Of these, 36 patients with benign cases outcomes were compared with 2 separate control groups, 44 pancreaticoduodenectomy (PD) and 26 extended distal pancreatectomy (EDP).
The mean operating time of group MSP was 222 min, which was significantly shorter than that of group PD. The mean blood loss of group MSP was 316 ml, which was less than that of others. Otherwise, the postoperative nutritional status and blood sugar control in group MSP was superior to the other 2 groups. Through long-term follow-up, the patients in group MSP retained endocrine and exocrine function better. Only 1 patient developed new-onset diabetes mellitus after operation, and no patient required enzyme substitution. No lesion recurred. The rate of pancreatic fistula was highest (42%), but didn't result in the significant deference of overall discharge time with group PD and EDP. The pancreatic fistula level and the mean postoperative time in hospital didn't differ significantly from the other 2 groups.
Middle segmental pancreatectomy is a safe and feasible technique that is indicated for selected patients with benign or low malignant lesion in the neck and body of the pancreas. Though the rate of pancreatic fistula is higher, the risk of which is reduced by the marked curative effect. It is very important to deal with the stump reasonably.
Zhonghua wai ke za zhi [Chinese journal of surgery] 08/2010; 48(16):1201-5.
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ABSTRACT: To retrospectively evaluate the imaging features of pancreatic intraductal papillary mucinous neoplasms (IPMNs) in multi-detector row computed tomography (MDCT).
A total of 20 patients with pathologically-confirmed intraductal papillary mucinous neoplasms (IPMNs) were included in this study. Axial MDCT images combined with CT angiography (CTA) and multiplanar volume reformations (MPVR) or curved reformations (CR) were preoperatively acquired. Two radiologists (Tan L and Wang DB) reviewed all the images in consensus using an interactive picture archiving and communication system. The disputes in readings were resolved through consultation with a third experienced radiologist (Chen KM). Finally, the findings and diagnoses were compared with the pathologic results.
The pathological study revealed 12 malignant IPMNs and eight benign IPMNs. The diameters of the cystic lesions and main pancreatic ducts (MPDs) were significantly larger in malignant IPMNs compared with those of the benign IPMNs (P < 0.05). The combined-type IPMNs had a higher rate of malignancy than the other two types of IPMNs (P < 0.05). Tumors with mural nodules and thick septa had a significantly higher incidence of malignancy than tumors without these features (P < 0.05). Communication of side-branch IPMNs with the MPD was present in nine cases at pathologic examination. Seven of them were identified from CTA and MPVR or CR images. From comparison with the pathological diagnosis, the sensitivity, specificity, and accuracy of MDCT in characterizing the malignancy of IPMN of the pancreas were determined to be 100%, 87.5% and 95%, respectively.
MDCT with CTA and MPVR or CR techniques can elucidate the imaging features of IPMNs and help predict the malignancy of these tumors.
World Journal of Gastroenterology 09/2009; 15(32):4037-43. · 2.47 Impact Factor
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ABSTRACT: To retrospectively analyze the imaging features of solid-pseudopapillary tumors (SPTs) of the pancreas on multi-detector row computed tomography (MDCT) and define the imaging findings suggestive of malignant potential.
A total of 24 consecutive cases with surgically and pathologically confirmed SPTs of the pancreas underwent preoperative abdominal MDCT studies in our hospital. All axial CT images, CT angiographic images, and coronally and sagittally reformed images were obtained. The images were retrospectively reviewed at interactive picture archiving and communication system workstations.
Of the 24 cases of SPTs, 11 cases (45.8%) occurred in the pancreatic head and seven (29.1%) in the tail. Eighteen were pathologically diagnosed as benign and six as malignant. MDCT diagnosis of SPTs was well correlated with the surgical and pathological results (Kappa = 0.6, P < 0.05). The size of SPTs ranged from 3 to 15 cm (mean, 5.8 cm). When the size of the tumor was greater than 6 cm (including 6 cm), the possibilities of vascular (8 vs 1) and capsular invasion (9 vs 0) increased significantly (P < 0.05). Two pathologically benign cases with vascular invasion and disrupted capsule on MDCT presented with local recurrence and hepatic metastases during follow-up about 1 year after the resection of the primary tumors.
Vascular and capsular invasion with superimposed spread into the adjacent pancreatic parenchyma and nearby structures in SPTs of the pancreas can be accurately revealed by MDCT preoperatively. These imaging findings are predictive of the malignant potential associated with the aggressive behavior of the tumor, even in the pathologically benign cases.
World Journal of Gastroenterology 03/2009; 15(7):829-35. · 2.47 Impact Factor
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ABSTRACT: In the early period of orthotopic liver transplantation (OLT), initial poor graft function (IPGF) is one of the complications which leads to primary graft non-function (PGNF) in serious cases. This study set out to establish the clinical risk factors resulting in IPGF after OLT.
Eighty cases of OLT were analyzed. The IPGF group consisted of patients with alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) above 1500 IU/L within 72 hours after OLT, while those in the non-IPGF group had values below 1500 IU/L. Recipient-associated factors before OLT analyzed were age, sex, primary liver disease and Child-Pugh classification; factors analyzed within the peri-operative period were non-heart beating time (NHBT), cold ischemia time (CIT), rewarming ischemic time (RWIT), liver biopsy at the end of cold ischemia; and factors analyzed within 72 hours after OLT were ALT and/or AST values. A logistic regression model was applied to filter the possible factors resulting in IPGF.
Donor NHBT, CIT and RWIT were significantly longer in the IPGF group than in the non-IPGF group; in the logistic regression model, NHBT was the risk factor leading to IPGF (P<0.05), while CIT and RWIT were possible risk factors. In one case in the IPGF group, PGNF appeared with moderate hepatic steatosis.
Longer NHBT is an important risk factor leading to IPGF, while serious steatosis in the donor liver, CIT and RWIT are potential risk factors.
Hepatobiliary & pancreatic diseases international: HBPD INT 05/2007; 6(2):141-6. · 1.08 Impact Factor
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ABSTRACT: To observe induction of heat shock reaction by pretreatment of Doxorubicin (DXR) in long-term cold preservation-reperfusion injury of the rat liver.
The rats were administered intravenously by DXR at a dose of 1 mg/kg body weight in DXR group and by saline in control group. After 48 hours, the rat liver was perfused by using cold University of Wisconsin (UW) solutions and was preserved in UW solution at 4 degrees C for 48 hours. Recipient liver was perfused for 1 and 3 hours after orthotopic liver transplantation. Tumor necrosis factor-alpha (TNF-alpha) mRNA, cytokine-induced neutrophil chemoattractant (CINC) mRNA, macrophage inflammatory protein (MIP-2) mRNA was measured by RT-PCR and heat shock protein 72 (HSP72), nuclear factor-kappaB (NF-kappaB) by Western blot. The serum levels of TNF-alpha, CINC, MIP-2 by ELISA and AST were measured. The survival rate of 7 days was observed.
The expression of TNF-alpha mRNA, CINC mRNA and MIP-2 mRNA was stronger in control group than in DXR group. HSP72 was expressed in SA group but not in control group and oppositely NF-kappaB was expressed in control group but not in DXR group. Serum AST, TNF-alpha, CINC and MIP-2 concentrations were significantly lower in DXR group than in control group (P < 0.05). The survival rate of 7 days was significantly higher in DXR group than in control group (50% vs. 0%, P < 0.05).
These data suggested that long-term cold ischemia-reperfusion injury was attenuated in liver graft with pretreatment of DXR. The induction of HSP72 may offer protection to hepatocytes by restraining the activation of NF-kappaB and inflammation.
Zhonghua wai ke za zhi [Chinese journal of surgery] 03/2006; 44(5):310-3.
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ABSTRACT: To study the roles of granzyme B and perforin in diagnosing acute rejection after liver transplantation, and the relationship between their activity index (AI) and Banff's histological grading criteria.
Liver biopsies were processed as for routine surgical specimens and labeled with granzyme B and perforin monoclonal antibodies. The number of positive cells/mm(2) was determined as activity index (AI) by IPP image analysis software. Histologic findings were used as the "gold standard" in diagnosing acute rejection.
Of 41 liver biopsy samples studied, acute rejection was noted in 21 cases, the remaining 20 cases showed no evidence of rejection. The AI of granzyme B and perforin in the acute rejection group was significantly higher than that in the non-acute rejection group (< 0.001). In the acute rejection group, the AI in moderate to severe acute rejection was higher than that in mild to indeterminate acute rejection (< 0.001). Compared with the "golden" histologic criteria, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of granzyme B in diagnosing acute rejection were 90.0%, 95.2%, 94.7%, 90.9% and 92.7% respectively. The values of these parameters for perforin were also above 80%.
Granzyme B and perforin are key markers of activated immune cells in acute rejection and highly expressed during acute liver rejection episodes. As ancillary investigations, these parameters demonstrated high sensitivity and specificity in diagnosing acute rejection in allograft post-transplant liver biopsies.
Zhonghua bing li xue za zhi Chinese journal of pathology 04/2005; 34(4):198-201.
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ABSTRACT: To investigate the expression of perforin and granzyme B in rejection response following liver transplantation, and evaluate their roles to be used as predictive markers of rejection.
The expression of perforin and granzyme B in liver biopsies obtained from liver allograft recipients was determined by immunohistochemistry. Biopsies were classified into two groups-no evidence of rejection and rejection-according to Histopathologic criteria. The relationship between the perforin/granzume B expression and acute rejection was analyzed.
From 19 patients, thirty-five liver biopsies were obtained after liver transplantation. Among them, nineteen samples were diagnosed as rejection response. The frequencies of perforin and granzyme B expression in rejection group were 100% (19/19) and 94.7% (18/19), respectively. While those in no rejection group were 25.0% (4/16) and 12.5 (2/16), respectively. In most rejected samples, perforin and granzyme B were expressed simultaneously. Only three samples showed perforin expression alone, while no samples demonstrated granzyme B expression alone. There was a close relationship between perforin/granzyme B expression and liver allograft rejection.
Perforin and granzyme B expression seemed to be related to the development of acute rejection following liver transplantation, and might be served as sensitive and reliable markers in diagnosing acute rejection in early stage.
Zhonghua gan zang bing za zhi = Zhonghua ganzangbing zazhi = Chinese journal of hepatology 07/2004; 12(6):325-7.
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ABSTRACT: To observe the protective effect of heat shock protein 72 (HSP 72) induced by pretreatment of doxorubicin (DXR) on long-term cold preservation injury of rat livers.
Sprague-Dawley rats were administered intravenously DXR at a dose of 1 mg/kg body mass in DXR group and saline in control group. After 48 h, the rat liver was perfused with cold Linger's and University of Wisconsin (UW) solutions and then was preserved in UW solution at 4 degrees for 24, 36 and 48 h. AST, ALT, LDH and hyaluronic acid in preservative solution were determined. Routine HE, immunohistochemical staining for HSP 72 and electron microscopic examination of hepatic tissues were performed.
After 24, 36 and 48 h, the levels of AST, ALT and hyaluronic acid in preservative solution were significantly higher in control group than in DXR group (P<0.05), while LDH level was not significantly different between the 2 groups (P>0.05). Hepatic tissues in DXR group were morphologically normal and significantly injured in control group. HSP 72 was expressed in hepatocytes and sinusoidal endothelial cells in DXR group but not in control group.
Pretreatment of DXR may extend the time of rat liver cold preservation and keep liver alive. The expression of HSP 72 in liver can prevent hepatocytes and sinusoidal endothelial cells from long-term cold preservation injury.
World Journal of Gastroenterology 05/2004; 10(9):1375-8. · 2.47 Impact Factor
