Objective: To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively. Background: POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet. Methods: Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014–2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007–2016) to assess discrimination and calibration in an internal-external validation procedure. Results: Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11–1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32–1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78–0.88) and 0.73 (95% CI: 0.70–0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%–25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74–0.85). Conclusions: The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com. The 3 distinct risk groups allow for personalized treatment and benchmarking.

The attribute grammar technique used for design of structure editors is suggested as a foundation for building hierarchical incremental design editors for VLSI circuits.The usual definition of attribute grammars is extended: the cycles that occur in VLSI design make us come to terms with circuiar attributes (under conditions that guarantee their least fixpoint solution, namely that the functions be monotone and yield values over a lattice of bounded height). Many interesting VLSI design problems can be cast in attributes meeting this condition, for example, timing verification, logic simulation, power dissipation, and adherence to clocking disciplines, to name a few. .As an illustration of the formalism, attributes are presented which solve the All Bidirectional Edges problem that labels the direction of information flow in a circuit. The incremental evaluation algorithm of [Rep821 is extended to handle fixpoint computations of circular attributes by noting that when the dependency graph is broken into its strongly connected components, a directed acyclic graph results, The wors~:ease running time of the resulting incremental evaluation algorithm is bounded by O (kk tAFFECTEDSCCD, where h is the height of the largest attribute lattice, k the largest number of attributes in any one strongly connected component, and ]A.FFEC-TEDSCC 1 the number of strongly connected components affected by a single modification to the design tree.to IntroductionIt has been suggested that the programming process carl be improved by the use of str.uet~Lre editors, as a means to remove the possibility of syntactic and semantic errors and to allow the programmer to concentrate on the design of correct and efficient algorithms. A number of structure editors [TeR81] [JoF82] have been implemented using attribute grammara [Knu68a] which bind semantics to the syntax of the target programming language, and have been shown to be an efficient, natural method for the operations required by an interactive editor [Rep82]. Structure editors based on attribute grammars can exploit the strict hierarchy given by the grammatical structure of the programs.Hierarchies also arise in VLSI design: it is well known that hierarchical design techniques facilitate the design of complicated VLSI projects. Several systems have been developed that take advantage of this to provide the user the ability to abstract and hide details of circuit, design as wall as simptify the verification process. Some systems have even attempted to provide the user with feedback about the correctness of design [OHM84} [MEW781 The purpose of this paper is to suggest that the problem of designing correct VLSt circuits can be simplified through the use of a hierarchical incremental design editor based on attribute grammars. Such a system could interactively compute estimates for the speed and power dissipation of a circuit, check adherence to clocking disciplines [SeiS01 [Kar84], and recompute these at reasonable cost as the designer changes the circuit, uses new modules, subsystems or ...

Introduction: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. Materials and methods: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. Results: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. Conclusion: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy.