Gabriela Del Angel-Millán

Abdallah Al Farai, Gabriela Del Angel-Millán, Shady Salama, ZakaUllah Jan, Mariantonietta Alagia, Mohammed Al Hosni, Fatma Al Zadjali, Gianluca Cassese, Fabrizio Panaro. Ann Hepatobiliary Pancreat Surg 2026;30:276-83. https://doi.org/10.14701/ahbps.26-120

Background: Postoperative pancreatic fistula remains a frequent complication after distal pancreatectomy and represents the first cause for major morbidity and mortality. Multiple strategies have been proposed to mitigate the severity of pancreatic fistula, but their real benefits remain inconclusive. This study aimed to identify effective mitigation strategies for clinically relevant pancreatic fistula (CR-POPF) through a systematic review of randomized clinical trials. Methods: A systematic search of the Medline and Web of Science databases was conducted for studies published between 2006 and February 2025. Eligible studies included randomized clinical trials evaluating strategies to mitigate clinically relevant postoperative pancreatic fistula following distal pancreatectomy. Only studies in English and involving human subjects were included. Results: Twenty-seven studies were found eligible, comprising 4062 patients, treated with 22 different strategies classified in 8 categories: tissue coverage, sealants and glues, systemic corticoids, analogues of somatostatin, anastomosis of the stump, drain usage, closure of the stump and transpapillary stent. Only 6 studies demonstrated a significant reduction in CR-POPF, strategies applied include systemic corticoids, selective use of drains, polyglycolic acid mesh, reinforced staplers, and collagen enhanced thrombin sealant. Conclusions: Studies reporting successful strategies show considerable heterogeneity in both the included populations and the way the strategies were applied. A personalized approach based on the risk of developing fistula and specific pancreatic features may be beneficial and should be further explored in future randomized clinical trials.

Background: Liver resection of a caudate lobe is a challenging procedure in both open and minimally invasive approaches. The reason is mainly related to its anatomical position: segment 1 (S1) lies on the inferior vein cava, behind the main and the left portal veins, and below the hepatic veins. This meta-analysis aimed to assess the results of laparoscopic liver resection (LLR) versus open liver resection (OLR) for S1 resection. Methods: Available literature up to June 2024 was retrieved from the Medline and Embase databases. A systematic review with a meta-analysis was carried out to investigate the safety and efficacy of LLR for the S1 segment. Results: Six studies including 292 patients (LLR: n = 132; OLR: n = 160) were selected for the meta-analysis. The OLR cohort showed higher estimated blood loss (EBL) (MD: 140.1, 95% CI 49.3–130.8; p = 0.011) and longer length of hospital stay (MD: 3, 95% CI 1.8–4.2; p = 0.001). No differences in severe postoperative morbidity, overall morbidity, R1 resection rates, transfusion rates, operative time, and duration of Pringle maneuvers were shown. Conclusion: LLR for lesions located in S1 is safe and effective and may be associated with lower EBL and shorter length of stay than OLR. Further larger prospective studies are needed to confirm such results.

Robotic liver surgery is experiencing a period of great development, but some hurdles still need to be overcome. Parenchymal transection remains one of the most technically challenging steps. The lack of dedicated instruments and the flourishing of several techniques didn’t allow surgeons to reach a standard technique so far. The aim of the present paper is to provide an overview of the different robotic liver transection techniques described to date, highlighting the strengths and weaknesses of each one. We conducted an extensive search on PubMed, Scopus and Web of Science, inserting the following keywords: “robotic liver transection, robotic hepatic transection” and focusing particularly on technical reports and paper regarding new surgical methods. This search resulted in a total of 13 different surgical techniques. All the methods described can be classified into two categories the “hybrid techniques” and the “fully robotic techniques” which are based, respectively, on the combined use of laparoscopic and robotic instrumentation or exclusively robotic devices. Another fundamental difference is the division between “one-surgeon” and “two-surgeon techniques”, which depends on the level of expertise required of the assistant surgeon at the operating table. This is the first comprehensive review on this topic. Although the existing literature does not allow one technique to be established as superior to the others, the adoption of a standardized method of robotic hepatic transection is highly desirable to optimize surgical results and to allow better comparability of outcomes within the scientific community.

Background and Objectives: Resection of the caudate lobe of the liver is considered a highly challenging surgical procedure due to the deep anatomic location of this segment and the relationships with major vessels. There is no clear evidence about the safety and effectiveness of robotic resection of the caudate lobe. The aim of this systematic review was to report data about the safety, technical feasibility, and postoperative outcomes of robotic caudate lobectomy. Materials and Methods: A systematic review of the MEDLINE and SCOPUS databases was undertaken, including studies published until 19 December 2024. Results: A total of 5 studies including 110 patients were selected. Of these surgeries, 56.3% were performed for malignant tumors. Tumor size varied significantly between 0.9 and 7.7 cm in the largest diameter. The mean operative time was 184.5 min (range 70–522 min), and the estimated blood loss was 95.5 mL (range 10–1500 mL). The median hospital length of stay was 4.2 days (range 2–19 days) and no cases of conversion to open were reported. All the patients underwent R0 resection. In total, 24 out of 110 patients (21.8%) developed postoperative complications, with 1.8% of all patients developing a major complication (Clavien–Dindo classification ≥ III). No perioperative deaths were reported by the included studies. Conclusions: Few retrospective studies investigating the outcomes of robotic resection of the caudate lobe are currently available in the literature. From published data, it may be a safe and feasible alternative to open and laparoscopic caudate lobectomy in selected patients in referral HPB centers. Further studies with larger sample sizes are needed to confirm such preliminary findings.

Autops Case Rep, vol.14, e2024516, 2024