Catalin Copaescu

Background Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and “de novo” GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure’s metabolic and GERD-related outcomes. Patients and method Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients’ evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed. Results Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m². The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ’s position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and “de novo” severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett’s esophagus and no complication were recorded in any of the patients. Conclusion Concurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.

Introduction: Pancreaticoduodenectomy, commonly known as the Whipple procedure, is a complex surgical technique employed for the treatment of various pancreatic and periampullary pathologies. Minimally invasive PD was created in an attempt to enhance the outcomes of the traditional, open technique. However, the reconstruction phase has been recognized as a substantial barrier to widespread adoption of the laparoscopic technique. Several research appraisals and case studies recommend the robotic technique as a facilitator during the reconstruction steps. We propose a hybrid approach to combine the versatility of laparoscopy and the visual and motor advantages of the DaVinci Xi in order to maximize the precision of the reconstruction. Our suggestion is based on the experience that our institution has had with the standardization of different surgical procedures and protocols.Methods: This article is focused on the outcomes of robotic assisted PD in our institution. Eleven patients underwent robotic assisted laparoscopic PD between 1st January, 2020 and 7th March, 2023 (N=11). There were two approaches involved: hybrid PD type A (N=6) and hybrid PD type B (N=5). Of the eleven patients who underwent hybrid PD, most of them were men (81.8%) and mean age was 61.9 years-old (range 45 to 75 years). The mean operative duration was 618 minutes (range 480 to 780 minutes). Mean blood loss was 159 mL (range 50 to 350 mL). Ten operations were performed for malignancy and one for neuroendocrine duodenal tumour; the mean number of lymph nodes retrieved was 16.2 (range 11 to 24 nodes) and all the specimens were reported by pathology as R0. Mean hospital stay was 18 days (range 8 to 40 days). Reoperations were necessary in five patients (N=5), all from the type A group, and mortality occurred in one (N=1) patient. There were no conversions to open surgery during the index procedures as well as no clinically relevant postoperative pancreatic fistulae. Thirty-day mortality was nil, with 1 mortality at 90-days due to massive pulmonary embolism.Conclusions: The hybrid approach facilitates the advantages of both laparoscopic and robotic approaches. While laparoscopy is safer in manipulating the bowel and allows the Roux en Y reconstruction and gastro-pancreatic anastomosis, the robotic assistance enables the surgeon to perform delicate anastomosis with a high accuracy. The learning curve's most important element is standardization and careful patient selection along with a stepwise approach.

Introduction: There are very few reported cases of robotic surgery for median arcuate ligament syndrome. This clinical condition develops when the root of the celiac trunk is compressed by the median arcuate ligament of the diaphragm. The symptoms that typically accompany this syndrome are: discomfort and pain in the upper abdominal region, particularly after eating, and weight loss. During the diagnostic process, it is important to rule out other potential causes and demonstrate compression using any imaging technique available. Transecting the median arcuate ligament is the primary focus of the surgical treatment. We report a case of robotic MAL release, focusing on the particular aspects of the surgical technique. A literature review was also performed on the topic of robotic approach for MALS. Clinical case: A 25-year-old woman presented with sudden onset severe upper abdominal pain after physical activity and eating. She was then diagnosed with median arcuate ligament syndrome by imagistic means with computer tomography, doppler ultrasound, and angiographic computed tomography. After conservative management and careful planning, we performed robotic division of median arcuate ligament. The patient was discharged from the hospital without any complaint on the second day after surgery. Subsequent imaging studies revealed no residual celiac axis stenosis. Conclusion: The robotic approach is a safe and feasible treatment modality for median arcuate ligament syndrome.

Robotic assisted surgery (RAS) was perceived as the rising star of the minimally invasive surgery (MIS) since its early stages but, its penetration into the general use of surgery was very slow at the beginning. Over the first two decades of its existence, RAS struggled to be accepted as a valid alternative for standard MIS. Despite the promoted benefits offered by the computerassisted telemanipulation, the main limitations were related to the financial burden of the technology, while the real advantages over "classic" laparoscopy were modest. While medical institutions were not happy to support a wider use of RAS, a question related to the surgical expertise and indirectly to the better patients outcomes was raised. Is RAS improving the skills of an average surgeon to be as good as the MIS experts and reaching a higher level for her/his surgical outcomes? As the answer is very complex, and it is related to so many factors, the debate was always marked by many controverses and no conclusions. Often, during those times, an enthusiastic surgeon attracted by robotic technology, happened to be invited to get trained more for laparoscopic skills, rather than encouraged to spending resources for inconsistent benefits for the patients. Moreover, one could often hear during the surgical conferences arrogant quotes such as â??a fool with a tool is still a foolâ? (Grady Booch).

Porto-mesenteric vein thrombosis (PVMT) is a rare but life-threatening complication after laparoscopic sleeve gastrectomy (LSG). Laparoscopic sleeve gastrectomy (LSG) is considered the most common procedure for efficiently realizing weight loss and treating obesity-related co-morbidities. This study aimed to shed light on this relatively rare complication by presenting a series of patients who developed PMVT after LSG in light of the need to change the specific protocol of thromboprophylaxis in bariatric patients. We proposed to answer two questions: whether we should perform a thrombophilia workup as a standard practice and whether we should extend chemoprophylaxis to more than 3 weeks among all bariatric patients. This study also aimed to investigate the possible risk factors and eventually present our updated protocol for PMVT management and prophylaxis.

Aim: Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) parameters may be used to predict prognosis of pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumors (pNET). The aim of this study was to investigate the association between several perfusion parameters on CEH-EUS performed before treatment and survival outcome in patients with PDAC or pNET.Material and methods: Thirty patients with PDAC or pNET who underwent CEH-EUS and EUS-guided fine needle aspiration (EUS-FNA) were included. Quantitative analysis of tumor vascularity was performed using time-intensity curve (TIC) analysis-derived parameters, obtained from processing CEH-EUS recordings with a commercially available software (VueBox). Cox proportional hazards models were used to determine associations with survival outcome.Results: Median overall survival (OS) for PDAC patients was 9.61 months (95% CI: 0.1-38.7) while the median OS for pNET patients was 15.81 months (95% CI: 5.8-24.75. In a multivariate model for OS, a lower peak enhancement (HR=1.76, p=0.02) and a lower wash-in area under the curve (HR=1.06, p=0.001) were associated with worse survival outcome for patients with PDAC.Conclusions: CEH-EUS parameters may be used as a surrogate to predict PDAC aggressiveness and survival before treatment. After validation by large-scale studies, CEH-EUS perfusion parameters have the potential to be used in pretreatment risk stratification of patients with PDAC and in evidence-based clinical decision support.