Only advances that occurred from 2011–2014 that either strengthen the previous 2011 guidelines [1;2] or lead to changes or additional guidelines are reviewed here. Advances and modifications in the treatment of advanced metastatic disease is only briefly dealt with here as it is covered in a separate chapter, similar to the 2011 guideline format [3]. The format used here is the same as used in the 2011 guidelines with page references to the appropriate section inserted [1;2] and this document is meant as a supplement to these guidelines and does not reiterate all of the points made in the previous guidelines, only changes, supporting findings or modifications of the 2011 guidelines are thus covered here.

As in the previous F-p-NET guidelines [1], the F-p-NETs will be considered in three groups: the more frequent gastrinomas and insulinomas considered independently and all the rare functional p-NETs (RFTs) considered together and as a separate category (Annex 1 and Table 1).

Table 1

Functional Pancreatic endocrine tumors [F-p-NET] syndromes

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ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic Neuroendocrine Tumors and Non-Functional Pancreatic Neuroendocrine Tumors.

OBJECTIVES To compare perioperative outcomes of laparoscopic left-sided pancreatectomy (LLP) with traditional open left-sided pancreatectomy (OLP) in a multicenter experience. SUMMARY AND BACKGROUND DATA LLP is being performed more commonly with limited data comparing results with outcomes from OLP. METHODS Data from 8 centers were combined for all cases performed between 2002-2006. OLP and LLP cohorts were matched by age, American Society of Anesthesiologists, resected pancreas length, tumor size, and diagnosis. Multivariate analysis was performed using binary logistic regression. RESULTS Six hundred sixty-seven LPs were performed, with 159 (24%) attempted laparoscopically. Indications were solid lesion in 307 (46%), cystic in 295 (44%), and pancreatitis in 65 (10%) cases. Positive margins occurred in 51 (8%) cases, 335 (50%) had complications, and significant leaks occurred in 108 (16%). Conversion to OLP occurred in 20 (13%) of the LLPs. In the matched comparison, 200 OLPs were compared with 142 LLPs. There were no differences in positive margin rates (8% vs. 7%, P = 0.8), operative times (216 vs. 230 minutes, P = 0.3), or leak rates (18% vs. 11%, P = 0.1). LLP patients had lower average blood loss (357 vs. 588 mL, P < 0.01), fewer complications (40% vs. 57%, P < 0.01), and shorter hospital stays (5.9 vs. 9.0 days, P < 0.01). By MVA, LLP was an independent factor for shorter hospital stay (P < 0.01, odds ratio 0.33, 95% confidence interval 0.19-0.56). CONCLUSIONS In selected patients, LLP is associated with less morbidity and shorter LOS than OLP. Pancreatic fistula rates are similar for OLP and LLP. LLP is appropriate for selected patients with left-sided pancreatic pathology.

Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches.

Perioperative outcomes of laparoscopic versus open splenectomy: a meta-analysis with an emphasis on complications.

Laparoscopic colorectal resection has become popular. The recently developed da Vinci Surgical System promises to facilitate endoscopic surgery and overcome its disadvantages. This study therefore aimed to compare the short-term results between robotic tumor-specific mesorectal excision (R-TSME) using the da Vinci Surgical System and conventional laparoscopic tumor-specific mesorectal excision (L-TSME) in rectal cancer patients. Between April 2006 and February 2007, 36 patients were randomly assigned to receive R-TSME or L-TSME. During the study, 18 patients underwent robotic low anterior resection using the da Vinci Surgical System, and 18 patients had conventional laparoscopic low anterior resection. Patient characteristics, perioperative clinical results, complications, and pathologic details were compared between the two groups. The patient characteristics were not significantly different between the two groups. The mean operating time, hemoglobin change, and conversion rate were not significantly different between the groups. Complications were treated conservatively and did not require surgical intervention in the R-TSME group. The average length of stay was 6.9 ± 1.3 days in the R-TSME group and 8.7 ± 1.3 days in the L-TSME group (p < 0.001). The specimen quality of the R-TSME group was acceptable. Tumor-specific mesorectal excision was performed safely and effectively using the da Vinci Surgical System and the perioperative outcomes were acceptable.

Robotic tumor-specific mesorectal excison of rectal cancer: short-term outcome of a pilot randomized trial

Purpose
There is growing enthusiasm for robotic-assisted laparoscopic operations across many surgical specialities, including colorectal surgery, often not supported by robust clinical or cost-effectiveness data. A proper assessment of this new technology is required, prior to widespread recommendation or implementation.

An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer.

In the last few years, robotics has been applied in clinical practice for a variety of laparoscopic procedures. This study reports our preliminary experience using robotics in the field of general surgery to evaluate the advantages and limitations of robot-assisted laparoscopy. Thirty-two consecutive patients were scheduled to undergo robot-assisted laparoscopic surgery in our units from March 2002 to July 2003. The indications were cholecystectomy, 20 patients; right adrenalectomy, two points; bilateral varicocelectomy, two points; Heller’s cardiomyotomy, two points; Nissen’s fundoplication, two points; total splenectomy, one point; right colectomy, one point; left colectomy, 1 point; and bilateral inguinal hernia repair, one point. In all cases, we used the da Vinci surgical system, with the surgeon at the robotic work station and an assistant by the operating table. Twenty-nine of 32 procedures (90.6%) were completed robotically, whereas three were converted to laparoscopic surgery. Conversion to laparoscopy was due in two patients to minor bleeding that could not be managed robotically and to robot malfunction in the third patient. There were no deaths. Median hospital stay was 2.2 days (range, 2–8). The main advantages of robot-assisted laparoscopic surgery are the availability of three-dimensional vision and easier instrument manipulation than can be obtain with standard laparoscopy. The learning curve to master the robot was ≥ 10 robotic procedures. The main limitations are the large diameter of the instruments (8 mm) and the limited number of robotic arms (maximum, three). We consider these technical shortcomings to be the cause for our conversions, because it is difficult to manage bleeding episodes with only two operating instruments. The benefit to the patient must be evaluated carefully and proven before this technology can become widely accepted in general surgery.

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Advantages and limits of robot-assisted laparoscopic surgery: preliminary experience.

Some reports have suggested that laparoscopic splenectomy (LS) can be successfully performed in adults. However, several aspects of this procedure remain as yet undefined; therefore, several attempts have been made to modify the standard technique to try to optimize the procedure. Herein we analyze our experience with 105 laparoscopic splenectomies. From 1993 to 2000, 105 patients underwent LS at our hospital. Twelve of these patients also underwent a concomitant cholecystectomy. There were 66 women and 39 men whose ages ranged between 4 and 78 years (median, 27.7). All patients underwent an elective laparoscopic splenectomy. Seventy five patients had thrombocytopenia (ITP), 14 had hereditary spherocytosis, eight were affected by β-thalassemia, two had splenic cysts, two had lymphoma, (two had myeloid chronic leukemia, one patient presented with a splenic abscess and one had incurred an iatrogenic spleen lesion during adrenalectomy. The first patients in this series were positioned in dorsal decubitus; however, as the team’s experience increased, the right lateral decubitus became the position of choice because it provides better exposure of the splenic hilum. This procedure requires the use of only four trocars. Mean operating time was 95 min (range, 35-320). Hospital stay ranged from 2 to 21 days (median, 4.5). There was only one conversion to open surgery. One patient died in the postoperative period due to the evolution of a preexisting malignant disease. We recorded nine complication-four subphrenic abscesses, two cases of pleuritis, two episodes of postoperative bleeding, and one intestinal infarction 16 days after surgery. Only two patients needed redo surgery. We believe that the laparoscopic approach is a valid alternative to open splenectomy, but mastery of some of the technical details of this procedure could greatly help avoid its complications. On the basis of our experience, it seems that the lateral approach should be considered the position of choice because it provides exposure and easier dissection of the splenic hilar structures. We also found that a 30° scope and an ultrasonic dissector allowed for perfect vision and optimal hemostasis during the procedure. At the end of procedure, the spleen should be fragmented and then extracted using an extraction bag.

Technical standardization of laparoscopic splenectomy: experience with 105 cases.

Background
In the past decade, laparoscopy has shown its efficacy also for advanced surgery. In this report, the authors retrospectively review their experience with the distal pancreas.

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Distal pancreas surgery: outcome for 19 cases managed with a laparoscopic approach.

We describe a laparoscopic hemisplenectomy that was performed to treat a 21-year-old patient with a large splenic pseudocyst located in the upper splenic pole. The diagnosis was made by computed tomography and ultrasound, and surgery was performed with ultrasound scalpel, clips, and fibrin glue. Surgery lasted 70 min and did not require blood transfusions. The patient was discharged on postoperative day 3, and at 28-month follow-up there were no sequelae or recurrences. The laparoscopic approach is a valid alternative to laparotomy because the integrated magnified view enables the surgical team to perform surgery in a much shorter time and with greater hemostatic accuracy than the traditional technique.

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Laparoscopic partial splenectomy for a splenic pseudocyst.

Background
We report our experience with laparoscopic adrenalectomy (LA) for malignant pathologies that in some cases required a multiorgan resection.

Anna Settembre

Papers

Advantages and limits of robot-assisted laparoscopic surgery: preliminary experience.

Technical standardization of laparoscopic splenectomy: experience with 105 cases.

Distal pancreas surgery: outcome for 19 cases managed with a laparoscopic approach.

Laparoscopic partial splenectomy for a splenic pseudocyst.

Laparoscopic adrenalectomy for malignant neoplasm: our experience in 15 cases.