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Background Robotic surgery may improve surgical performance during minimally invasive pancreatoduodenectomy as compared to 3D- and 2D-laparoscopy but comparative studies are lacking. This study assessed the impact of robotic surgery versus 3D- and 2D-laparoscopy on surgical performance and operative time using a standardized biotissue model for pancreatico- and hepatico-jejunostomy using pooled data from two randomized controlled crossover trials (RCTs). Methods Pooled analysis of data from two RCTs with 60 participants (36 surgeons, 24 residents) from 11 countries (December 2017–July 2019) was conducted. Each included participant completed two pancreatico- and two hepatico-jejunostomies in biotissue using 3D-robotic surgery, 3D-laparoscopy, or 2D-laparoscopy. Primary outcomes were the objective structured assessment of technical skills (OSATS: 12–60) rating, scored by observers blinded for 3D/2D and the operative time required to complete both anastomoses. Sensitivity analysis excluded participants with excess experience compared to others. Results A total of 220 anastomoses were completed (robotic 80, 3D-laparoscopy 70, 2D­laparoscopy 70). Participants in the robotic group had less surgical experience [median 1 (0–2) versus 6 years (4–12), p < 0.001], as compared to the laparoscopic group. Robotic surgery resulted in higher OSATS ratings (50, 43, 39 points, p = .021 and p < .001) and shorter operative time (56.5, 65.0, 81.5 min, p = .055 and p < .001), as compared to 3D- and 2D­laparoscopy, respectively, which remained in the sensitivity analysis. Conclusion In a pooled analysis of two RCTs in a biotissue model, robotic surgery resulted in better surgical performance scores and shorter operative time for biotissue pancreatic and biliary anastomoses, as compared to 3D- and 2D-laparoscopy.

Additional file 1. Questionnaire used in this study.

Aim To compare postoperative outcome in elderly undergoing either open or minimally invasive esophagectomy. Background & Methods Randomized controlled trials have shown improved short term outcome in patients undergoing minimally invasive compared with open esophagectomy. However, all of them have excluded patients aged 75 years or older. Evidence regarding this patient group, therefore, remains scarce. A propensity score matched retrospective cohort study was performed in a Dutch nationwide cohort from the period of april 2011 to april 2016 of patients aged ≥75 years diagnosed with local and locally advanced esophageal cancer who underwent either minimally invasive or open esophagectomy. Primary outcomes consisted of anastomotic leakage and perioperative mortality. Secondary outcomes were the rate of other complications, reintervention and hospital/ICU readmission. Results After matching, 322 patients were included, 161 in the open esophagectomy and 161 in the minimally invasive esophagectomy group. In the minimally invasive group, a significantly higher incidence occurend of Clavien-Dindo ≥3 complications (RR 1.63, CI-95% 1.24—2.13), anastomotic leaks (RR 1.60, CI-95% 1.12—2.29) and reinterventions (RR 1.70, CI-95% 1.19—2.42). There were no significant differences regarding perioperative mortality, other complications and readmission rate. Conclusion Elderly patients diagnosed with locally advanced esophageal cancer should undergo minimally invasive esophagectomy in favor of open esophagectomy. Keywords Elderly, minimally invasive esophagectomy, open esophagectomy, esophageal cancer, clinical outcome, perioperative mortality.

Background Lymph node dissection (LND) is part of standard operating procedure in resectable esophageal cancer patients regardless of lymph node status. The aim of this case vignette survey was to acquire expert opinions on current practice of LND, and to determine potential consequences of non-invasive lymph node staging on the extent of LND and postoperative morbidity. Methods An online survey including 5 short clinical cases (case vignettes) was sent to 272 esophageal surgeons worldwide. Extent of standard LND, potential changes in LND based on accurate lymph node staging and consequences for postoperative morbidity were evaluated. Results 86 esophageal surgeons (median experience in esophageal surgery of 15 years) participated in the survey (response rate 32%). Standard LND varied considerably between experts, for example pulmonary ligament, splenic artery, aortopulmonary window and paratracheal lymph nodes are routinely dissected in less than 60%. The omission of (parts of) LND is expected to decrease the number of chyle leakages, pneumonias laryngeal nerve pareses and reduce operating time. In order to guide surgical treatment decisions, a diagnostic test for lymph node staging after neoadjuvant therapy requires a minimum sensitivity of 92% and specificity of 90%. Conclusion This expert case vignette survey study shows that there is no consensus on the extent of standard LND. Esophageal surgeons seem more willing to extend LND rather than omit LND, based on accurate lymph node staging. The majority of surgeons expect that less extensive LND can reduce post-operative morbidity.

Supplemental material, UEG879007 Supplemental Material for Predicting lymph node metastases with endoscopic resection in cT2N0M0 oesophageal cancer: A systematic review and meta-analysis by Ali Al-Kaabi, Rachel S van der Post, Jonathan Huising, Camiel Rosman, Iris D Nagtegaal and Peter D Siersema in United European Gastroenterology Journal

Contains fulltext : 49444.pdf ( ) (Open Access) BACKGROUND: The initial treatment of acute necrotizing pancreatitis is conservative. Intervention is indicated in patients with (suspected) infected necrotizing pancreatitis. In the Netherlands, the standard intervention is necrosectomy by laparotomy followed by continuous postoperative lavage (CPL). In recent years several minimally invasive strategies have been introduced. So far, these strategies have never been compared in a randomised controlled trial. The PANTER study (PAncreatitis, Necrosectomy versus sTEp up appRoach) was conceived to yield the evidence needed for a considered policy decision. METHODS/DESIGN: 88 patients with (suspected) infected necrotizing pancreatitis will be randomly allocated to either group A) minimally invasive 'step-up approach' starting with drainage followed, if necessary, by videoscopic assisted retroperitoneal debridement (VARD) or group B) maximal necrosectomy by laparotomy. Both procedures are followed by CPL. Patients will be recruited from 20 hospitals, including all Dutch university medical centres, over a 3-year period. The primary endpoint is the proportion of patients suffering from postoperative major morbidity and mortality. Secondary endpoints are complications, new onset sepsis, length of hospital and intensive care stay, quality of life and total (direct and indirect) costs. To demonstrate that the 'step-up approach' can reduce the major morbidity and mortality rate from 45 to 16%, with 80% power at 5% alpha, a total sample size of 88 patients was calculated. DISCUSSION: The PANTER-study is a randomised controlled trial that will provide evidence on the merits of a minimally invasive 'step-up approach' in patients with (suspected) infected necrotizing pancreatitis.

Appendix 1. PRISMA 2009 checklist. Appendix 2. The electronic sea. (DOCX 108 kb)

Appendix 1. PRISMA 2009 checklist. Appendix 2. The electronic sea. (DOCX 108 kb)