Introduction: The versatile open modular design of the newly introduced robotic platform Hugo^TM RAS is expected to allow its rapid spread in general surgery. However, the system is not yet approved for use in oesophageal and HPB-surgery and is not licensed worldwide. The aim of this work was to review the current spectrum of general surgical procedures that may be feasibly and safely performed with Hugo. Methods: We retrospectively reviewed our own series and performed a systematic review of all the published reports of general surgical procedures performed with this system in the literature. Results: Seventy patients underwent general surgery with Hugo at our institution, and another 99 patients were reported in the literature. The most common procedures were colorectal (n = 55); cholecystectomy (n = 44); repair of groin, ventral and hiatal hernias (n = 34); upper GI (n = 28); adrenalectomy (n = 6); and spleen cyst deroofing (n = 2). No device-related complications were reported. Arm collisions and technical problems were rare. The docking and console times improved in all series. The port positions and robotic arm configurations varied among authors and depended on the surgical indication, patient characteristics and surgeon’s preference. Conclusions: A wide spectrum of general surgical procedures has been safely and effectively performed with the Hugo RAS, even by robotically inexperienced teams with a limited choice of instruments. Technical improvements to the system and the introduction of robotic energy devices may help Hugo evolve to a vital alternative to established robotic systems.

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers. Developing biomarkers for early detection and chemotherapeutic response prediction is crucial to improve the dismal prognosis of PDAC patients. However, molecular cancer signatures based on transcriptome analysis do not reflect intratumoral heterogeneity. To explore a more accurate stratification of PDAC phenotypes in an easily accessible matrix, plasma metabolome analysis using MxP^® Global Profiling and MxP^® Lipidomics was performed in 361 PDAC patients. We identified three metabolic PDAC subtypes associated with distinct complex lipid patterns. Subtype 1 was associated with reduced ceramide levels and a strong enrichment of triacylglycerols. Subtype 2 demonstrated increased abundance of ceramides, sphingomyelin and other complex sphingolipids, whereas subtype 3 showed decreased levels of sphingolipid metabolites in plasma. Pathway enrichment analysis revealed that sphingolipid-related pathways differ most among subtypes. Weighted correlation network analysis (WGCNA) implied PDAC subtypes differed in their metabolic programs. Interestingly, a reduced expression among related pathway genes in tumor tissue was associated with the lowest survival rate. However, our metabolic PDAC subtypes did not show any correlation to the described molecular PDAC subtypes. Our findings pave the way for further studies investigating sphingolipids metabolisms in PDAC.

The recently introduced Hugo RAS robotic platform has mostly been used for well standardized urologic and gynaecologic procedures. Experience with this new system in general surgery and especially in major colorectal surgery is very limited. This is a retrospective series of the first 25 consecutive non-selected colorectal surgeries performed at a single German center. The lessons learned from our initial experience are presented along with a systematic review of the currently available literature on this topic. Ten sigmoid and seven rectal resections, four right and one left hemicolectomies, two Hartmann’s reversals and an abdominoperineal resection were performed in 14 women and 11 men at the median age of 66 years for 12 benign findings and 13 malignancies. All procedures were performed using four robotic ports and a single 12 mm assistant port. Median docking, console and total operative times were 12, 170 and 270 min. Median blood loss was < 100 ml, and median stay was 8 days. The literature review identified five case series with a total of 23 colorectal procedures: 9 right and 1 left hemicolectomies, 5 ileocaecal, and 4 rectal and 4 sigmoid resections. Results corresponded to ours despite variations in setup used by different authors. A wide spectrum of major colorectal surgery can be safely and effectively performed with the Hugo RAS, even in a cohort of non-selected patients. Ongoing software and hardware upgrade, introduction of robotic energy devices and increasing surgical experience are expected to facilitate procedures and reduce duration of surgery.

Background: Acinar cell carcinomas (ACC) belong to the exocrine pancreatic malignancies. Due to their rarity, there is no consensus regarding treatment strategies for resectable ACC.Methods: This is a retrospective multicentric study of radically resected pure pancreatic ACC. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Further endpoints were oncologic outcomes related to tumor stage and therapeutic protocols. Results: 59 patients (44 men) with a median age of 64 years were included. The median tumor size was 45.0 mm. 61.0% were pT3 (n = 36), nodal positivity rate was 37.3% (n = 22), and synchronous distant metastases were present in 10.1% of the patients (n = 6). 5-Years OS was 60.9% and median DFS 30 months. 24 out of 31 recurred systemically (n = 18 only systemic, n = 6 local and systemic). Regarding TNM-staging, only the N2-stage negatively influenced OS and DFS (p = 0.004, p = 0.001). Adjuvant treatment protocols (performed in 62.7%) did neither improve OS (p = 0.542) nor DFS (p = 0.159). In 9 cases, radical resection was achieved following neoadjuvant therapy.Discussion: Radical surgery is currently the mainstay for resectable ACC, even for limited metastatic disease. Novel (neo)adjuvant treatment strategies are needed, since current systemic therapies do not result in a clear survival benefit in the perioperative setting.

Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade “A” was reported for 98 (61.3%), grade “B” for 41 (25.6%) and grade “C” for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, “abscesses with invasive therapy” (p < 0.001), “other surgical complications” (p < 0.001), prolonged “stays in ICU” (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance.