Background: To date, no standardized protocols nor a quantitative assessment of the near-infrared fluorescence angiography with indocyanine green (NIR-ICG) are available. The aim of this study was to evaluate the timing of fluorescence as a reproducible parameter and its efficacy in predicting anastomotic leakage (AL) in colorectal surgery. Methods: A consecutive cohort of 108 patients undergoing minimally invasive elective procedures for colorectal cancer was prospectively enrolled. The difference between macro and microperfusion (ΔT) was obtained by calculating the timing of fluorescence at the level of iliac artery division and colonic wall, respectively. Results: Subjects with a ΔT ≥ 15.5± 0.5 s had a higher tendency to develop an AL (p < 0.01). The ΔT/heart rate interaction was found to predict AL with an odds ratio of 1.02 (p < 0.01); a cut-off threshold of 832 was identified (sensitivity 0.86, specificity 0.77). Perfusion parameters were also associated with a faster bowel motility resumption and a reduced length of hospital stay. Conclusions: The analysis of the timing of fluorescence provides a quantitative, easy evaluation of tissue perfusion. A ΔT/HR interaction ≥832 may be used as a real-time parameter to guide surgical decision making in colorectal surgery.

Background: The rising diffusion of vascular resections during complex pancreatectomy for malignancy, for both oncological and technical matters, brought with it the use of vascular shunts, either temporary or definitive, to prevent bowel congestion and liver ischemia. This study aimed to systematically review the literature on the technical feasibility of vascular shunts during advanced pancreatic surgery, analyzing intraoperative and postoperative outcomes. Methods: A systematic literature search was performed on PubMed, Scopus, Web of Science, and the Cochrane Library Central, according to PRISMA guidelines. Studies published before 2006 were excluded, considering the lack of a standardized definition of locally advanced pancreatic cancer. The main outcomes evaluated were the overall complication rate and shunt patency. Results: Among 789 papers retrieved from the database search, only five fulfilled the inclusion criteria and were included in the review, amounting to a total of 145 patients undergoing a shunt creation at the time of pancreatectomy. Pancreatic adenocarcinoma (PDAC) was found to be the most common diagnosis and pancreaticoduodenectomy was the main surgical procedure, accounting for 88% and 83% of the overall cohort, respectively. The distal splenorenal shunt was the most performed. Overall, 44 out of 145 patients (30%) experienced postoperative complications; the long-term patency of definitive shunts was 83% (110 out of 120 patients). Conclusions: An increasing number of patients with borderline resectable or locally advanced PDAC are becoming amenable to resection and shunt creation may facilitate vascular resection with clear margins, becoming a valid tool of modern pancreatic surgery.

Background: Despite the advantages of robotic-assisted liver resection (RALR), intraoperative blood loss (IBL) remains a main concern in hepatic surgery. The current multicenter study was designed to evaluate the determinants of significant intraoperative bleeding in RALR and the clinical impact of such bleeding. Methods: This study retrospectively analyzed 708 consecutive RALR performed in nine high-volume European centers between 2011 and 2023. All demographic, intraoperative, and postoperative data were extracted from a shared database. Patients were stratified into two groups based on the IBL value (< 500 mL vs. ≥ 500 mL). Variables that reached the level of p < 0.10 at univariable analysis were included in a multivariate logistic regression model. Results: The mean IBL was 224.7 mL, and 9.6% of patients experienced IBL ≥ 500 mL. Both cirrhosis (OR 3.00, 95% CI 1.63–5.52; p < 0.001) and higher TAMPA score (OR 1.09 per point, 95% CI 1.03–1.16; p = 0.004) independently predicted major bleeding. Patients with IBL ≥ 500 mL had longer operative times (372 vs. 239 min, p < 0.001), higher morbidity (72% vs. 46%, p < 0.001), and greater mortality (4.4% vs. 0.6%, p = 0.022). Conclusions: During RALR significant bleeding persists in 10% of cases. Cirrhosis and procedural complexity remain independent predictors. Early identification of the high-risk patient and tailored perioperative strategies are of paramount importance in reducing bleeding and improving overall outcomes following robotic hepatobiliary surgery.