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Donisi G, Zerbi A. Exploring the landscape of minimally invasive pancreatic surgery: Progress, challenges, and future directions. World J Gastrointest Surg 2024; 16:3094-3103. [PMID: 39575294 PMCID: PMC11577386 DOI: 10.4240/wjgs.v16.i10.3094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 09/27/2024] Open
Abstract
Minimally invasive surgery (MI) has become the standard of care for many surgical procedures aimed at reducing the burden on patients. However, its adoption in pancreatic surgery (PS) has been limited by the pancreas's unique location and the complexity of the dissection and reconstruction phases. These factors continue to contribute to PS having one of the highest morbidity and mortality rates in general surgery. Despite a rough start, MIPS has gained widespread acceptance in clinical practice recently. Robust evidence supports MI distal pancreatectomy safety, even in oncological cases, indicating its potential superiority over open surgery. However, definitive evidence of MI pancreaticoduodenectomy (MIPD) feasibility and safety, particularly for malignant lesions, is still lacking. Nonetheless, reports from high-volume centers are emerging, suggesting outcomes comparable to those of the open approach. The robotic PS increasing adoption, facilitated by the wider availability of robotic platforms, may further facilitate the transition to MIPD by overcoming the technical constraints associated with laparoscopy and accelerating the learning curve. Although the MIPS implementation process cannot be stopped in this evolving world, ensuring patient safety through strict outcome monitoring is critical. Investing in younger surgeons with structured and recognized training programs can promote safe expansion.
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Affiliation(s)
- Greta Donisi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
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Kumar A, Kaistha S, Gangavatiker R. Laparoscopic Pancreaticoduodenectomy With Open Reconstruction: The Buddha's Middle Path. Surg Laparosc Endosc Percutan Tech 2024; 34:511-517. [PMID: 39016282 DOI: 10.1097/sle.0000000000001311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/28/2021] [Indexed: 07/18/2024]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is not universally adopted because of its steep learning curve. Its technical complexity discourages many surgeons. We believe that laparoscopic pancreaticoduodenectomy with open reconstruction (LPOR) has all the benefits of LPD without its drawbacks and combines the ease of open surgery with the benefits of minimal access surgery. We assessed the feasibility and safety of LPOR and compared it with open pancreaticoduodenectomy (OPD), with the objectives being perioperative and short-term clinical/oncologic outcomes. METHODS Retrospective review of prospectively maintained database; study period from January 2013 to December 2019. Till 2015, we did only OPD. In 2016, we started with LPD but soon switched to LPOR. The resection part was done laparoscopically and the reconstruction part was done through a 8-cm mini-laparotomy. RESULTS We did 19 OPDs and 15 LPORs. Demographic data of the 2 groups were comparable. The duration of surgery was significantly longer in the LPOR group (360 vs. 410 min; P =0.01), whereas the blood loss and hospital stay were longer in the OPD group (520 vs. 360 mL; P =0.03 and 13 vs. 11 d; P =0.08, respectively). Clinically significant complication rates, including delayed gastric emptying and postoperative pancreatic fistulas, were not different in either group. No patients in the LPOR group had wound-related/pulmonary complications. Lymph node yield was similar in both groups (20 vs. 22) and we had 100% R0 resections. CONCLUSIONS LPOR was better than OPD in terms of short-term outcomes and was not inferior to OPD in terms of complications/oncologic outcomes.
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Affiliation(s)
- Ameet Kumar
- Department of GI Surgery, Command Hospital, Pune
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Koh YX, Zhao Y, Tan IEH, Tan HL, Chua DW, Loh WL, Tan EK, Teo JY, Au MKH, Goh BKP. Evaluating the economic efficiency of open, laparoscopic, and robotic distal pancreatectomy: an updated systematic review and network meta-analysis. Surg Endosc 2024; 38:3035-3051. [PMID: 38777892 DOI: 10.1007/s00464-024-10889-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND This study compared the cost-effectiveness of open (ODP), laparoscopic (LDP), and robotic (RDP) distal pancreatectomy (DP). METHODS Studies reporting the costs of DP were included in a literature search until August 2023. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, mean difference (MD), odds ratio (OR), and 95% credible intervals (CrIs) were calculated for outcomes of interest. Cluster analysis was performed to examine the similarity and classification of DP approaches into homogeneous clusters. A decision model-based cost-utility analysis was conducted for the cost-effectiveness analysis of DP strategies. RESULTS Twenty-six studies with 29,164 patients were included in the analysis. Among the three groups, LDP had the lowest overall costs, while ODP had the highest overall costs (LDP vs. ODP: MD - 3521.36, 95% CrI - 6172.91 to - 1228.59). RDP had the highest procedural costs (ODP vs. RDP: MD - 4311.15, 95% CrI - 6005.40 to - 2599.16; LDP vs. RDP: MD - 3772.25, 95% CrI - 4989.50 to - 2535.16), but incurred the lowest hospitalization costs. Both LDP (MD - 3663.82, 95% CrI - 6906.52 to - 747.69) and RDP (MD - 6678.42, 95% CrI - 11,434.30 to - 2972.89) had significantly reduced hospitalization costs compared to ODP. LDP and RDP demonstrated a superior profile regarding costs-morbidity, costs-mortality, costs-efficacy, and costs-utility compared to ODP. Compared to ODP, LDP and RDP cost $3110 and $817 less per patient, resulting in 0.03 and 0.05 additional quality-adjusted life years (QALYs), respectively, with positive incremental net monetary benefit (NMB). RDP costs $2293 more than LDP with a negative incremental NMB but generates 0.02 additional QALYs with improved postoperative morbidity and spleen preservation. Probabilistic sensitivity analysis suggests that LDP and RDP are more cost-effective options compared to ODP at various willingness-to-pay thresholds. CONCLUSION LDP and RDP are more cost-effective than ODP, with LDP exhibiting better cost savings and RDP demonstrating superior surgical outcomes and improved QALYs.
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Affiliation(s)
- Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore.
- Duke-National University of Singapore Medical School, Singapore, Singapore.
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore.
| | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Darren Weiquan Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
| | - Wei-Liang Loh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Ek Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
- Finance, SingHealth Community Hospitals, Singapore, 168582, Singapore
- Finance, Regional Health System & Strategic Finance, Singapore Health Services, Singapore, 168582, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
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Wehrle CJ, Chang JH, Gross AR, Woo K, Naples R, Stackhouse KA, Dahdaleh F, Augustin T, Joyce D, Simon R, Walsh RM, Naffouje SA. Comparing oncologic and surgical outcomes of robotic and laparoscopic pancreatoduodenectomy in patients with pancreatic cancer: a propensity-matched analysis. Surg Endosc 2024; 38:2602-2610. [PMID: 38498210 PMCID: PMC11078803 DOI: 10.1007/s00464-024-10783-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/07/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Minimally invasive Pancreatoduodenectomy (MIPD), or the Whipple procedure, is increasingly utilized. No study has compared laparoscopic (LPD) and robotic (RPD) approaches, and the impact of the learning curve on oncologic, technical, and post-operative outcomes remains relatively understudied. METHODS The National Cancer Database was queried for patients undergoing LPD or RPD from 2010 to 2020 with a diagnosis of pancreatic cancer. Outcomes were compared between approaches using propensity-score matching (PSM); the impact of annual center-level volume of MIPD was also assessed by dividing volume into quartiles. RESULTS A total of 3,342 patients were included. Most (n = 2,716, 81.3%) underwent LPD versus RPD (n = 626, 18.7%). There was a high rate (20.2%, n = 719) of positive margins. Mean length-of-stay (LOS) was 10.4 ± 8.9 days. Thirty-day mortality was 2.8% (n = 92) and ninety-day mortality was 5.7% (n = 189). PSM matched 625 pairs of patients receiving LPD or RPD. After PSM, there was no differences between groups based on age, sex, race, CCI, T-stage, neoadjuvant chemo/radiotherapy, or type of PD. After PSM, there was a higher rate of conversion to open (HR = 0.68, 95%CI = 0.50-0.92)., but there was no difference in LOS (HR = 1.00, 95%CI = 0.92-1.11), 30-day readmission (HR = 1.08, 95% CI = 0.68-1.71), 30-day (HR = 0.78, 95% CI = 0.39-1.56) or 90-day mortality (HR = 0.70, 95% CI = 0.42-1.16), ability to receive adjuvant therapy (HR = 1.15, 95% CI = 0.92-1.44), nodal harvest (HR = 1.01, 95%CI = 0.94-1.09) or positive margins (HR = 1.19, 95% CI = 0.89-1.59). Centers in lower quartiles of annual volume of MIPD demonstrated reduced nodal harvest (p = 0.005) and a higher rate of conversion to open (p = 0.038). Higher-volume centers had a shorter LOS (p = 0.012), higher rate of initiation of adjuvant therapy (p = 0.042), and, most strikingly, a reduction in 90-day mortality (p = 0.033). CONCLUSION LPD and RPD have similar surgical and oncologic outcomes, with a lower rate of conversion to open in the robotic cohort. The robotic technique does not appear to eliminate the "learning curve", with higher volume centers demonstrating improved outcomes, especially seen at minimum annual volume of 5 cases.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Jenny H Chang
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Abby R Gross
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kimberly Woo
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Robert Naples
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kathryn A Stackhouse
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Samer A Naffouje
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Schleimer LE, Chabot JA, Kluger MD. Innovation in the Surgical Management of Pancreatic Cystic Neoplasms: Same Operations, Narrower Indications, and an Individualized Approach to Decision-Making. Gastrointest Endosc Clin N Am 2023; 33:655-677. [PMID: 37245941 DOI: 10.1016/j.giec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Historically, the management of pancreatic cystic neoplasms (PCN) has been operative. Early intervention for premalignant lesions, including intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN), offers an opportunity to prevent pancreatic cancer-with potential decrement to patients' short-term and long-term health. The operations performed have remained fundamentally the same, with most patients undergoing pancreatoduodenectomy or distal pancreatectomy using oncologic principles. The role of parenchymal-sparing resection and total pancreatectomy remains controversial. We review innovations in the surgical management of PCN, focusing on the evolution of evidence-based guidelines, short-term and long-term outcomes, and individualized risk-benefit assessment.
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Affiliation(s)
- Lauren E Schleimer
- Department of Surgery, Columbia University Irving Medical Center, 177 Fort Washington Avenue, 8 Garden South, New York, NY 10032, USA. https://twitter.com/lschleim
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 819, New York, NY 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 823, New York, NY 10032, USA.
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Sattari SA, Sattari AR, Makary MA, Hu C, He J. Laparoscopic Versus Open Pancreatoduodenectomy in Patients With Periampullary Tumors: A Systematic Review and Meta-analysis. Ann Surg 2023; 277:742-755. [PMID: 36519444 DOI: 10.1097/sla.0000000000005785] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of randomized controlled trials compared laparoscopic pancreatoduodenectomy (LPD) versus open pancreatoduodenectomy (OPD) in patients with periampullary tumors. BACKGROUND LPD has gained attention; however, its safety and efficacy versus OPD remain debatable. METHODS We searched PubMed and Embase. Primary outcomes were the length of hospital stay (LOS) (day), Clavien-Dindo grade ≥III complications, and 90-day mortality. Secondary outcomes were blood loss (milliliter), blood transfusion, duration of operation (minute), readmission, reoperation, comprehensive complication index score, bile leak, gastrojejunostomy or duodenojejunostomy leak, postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, surgical site infection, intra-abdominal infection, number of harvested lymph nodes, and R0 resection. Pooled odds ratio (OR) or mean difference (MD) of data was calculated using the random-effect model. The grading of recommendations, assessment, development and evaluation approach was used for grading the level of evidence. RESULTS Four randomized controlled trials yielding 818 patients were included, of which 411 and 407 patients underwent LPD and OPD, respectively. The meta-analysis concluded that 2 approaches were similar, except in the LPD group, the LOS tended to be shorter [MD=-2.54 (-5.17, 0.09), P =0.06], LOS in ICU was shorter [MD=-1 (-1.8, -0.2), P =0.01], duration of operation was longer [MD=75.16 (23.29, 127.03), P =0.005], blood loss was lower [MD=-115.40 (-152.13, -78.68), P <0.00001], blood transfusion was lower [OR=0.66 (0.47, 0.92), P =0.01], and surgical site infection was lower [OR=0.35 (0.12, 0.96), P =0.04]. The overall certainty of the evidence was moderate. CONCLUSIONS Within the hands of highly skilled surgeons in high-volume centers, LPD is feasible and as safe and efficient as OPD.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Yong TL, Malik H, Gold G. How to do a laparoscopic pancreaticoduodenectomy. ANZ J Surg 2023; 93:1024-1026. [PMID: 36825669 DOI: 10.1111/ans.18352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 02/25/2023]
Abstract
This paper describes our technique of laparoscopic pancreaticoduodenectomy and our experience in performing this procedure.
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Affiliation(s)
- Tuck Leong Yong
- Department of Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Hassan Malik
- Department of Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Grace Gold
- Department of Surgery, Northern Health, Melbourne, Victoria, Australia
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8
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Olakowski M, Jabłońska B, Mrowiec S. A chronicle of the pancreatoduodenectomy technique development - from the surgeon's hand to the robotic arm. Acta Chir Belg 2023; 123:94-101. [PMID: 36250406 DOI: 10.1080/00015458.2022.2135251] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) remains one of the most challenging abdominal surgical procedures. METHODS A review of the literature regarding the history of PD, starting from the pioneers, Walter Kausch and Alan Whipple, through the great surgeons of the last century, up to the present day. RESULTS The greatest development of the PD technique took place at the end of the twentieth century. Over the last 40 years, there have been huge technological advances in medicine, which have resulted in the introduction of laparoscopic and robotic techniques for abdominal surgery. However, it turns out that PD is still performed as it used to be "by the surgeon's hand" via laparotomy rather than using the most modern robot or laparoscope and is currently recommended by experts for treatment of pancreatic head cancer (PHC). This is mainly caused by not many data comparing these three PD methods. Moreover, increasingly the results achieved by surgeons advanced in minimally invasive pancreatic resections are comparable to or even better than those achieved by the open method in reference centres. Robot-assisted PD appears to be gaining an advantage over laparoscopic technique in the efficacy of PHC treatment. The obstacles most inhibiting the use of surgical robotics are the high cost of the device and procedure, and the long learning curve. A bright future lies ahead for both methods, with the robotic technique in the forefront. CONCLUSIONS Despite significant advances in access and surgical technique, PD remains a challenging surgical procedure requiring a big surgeon's experience.
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Affiliation(s)
- Marek Olakowski
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
| | - Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
| | - Sławomir Mrowiec
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
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Olakowski M, Grudzińska E. Pancreatic head cancer - Current surgery techniques. Asian J Surg 2023; 46:73-81. [PMID: 35680512 DOI: 10.1016/j.asjsur.2022.05.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/30/2022] [Accepted: 05/20/2022] [Indexed: 12/24/2022] Open
Abstract
Pancreatic head cancer is a highly fatal disease. For now, surgery offers the only potential long-term cure albeit with a high risk of complications. However, the progress of surgical technique during the past decade has resulted in 5-year survival approaching 30% after resection and adjuvant chemotherapy. This paper presents current data on the recommended extent of lymphadenectomy, the resection margin, on the definition of resectable and borderline resectable tumors and mesopancreas. Surgical techniques proposed to improve PD are presented: the artery first approach, the uncinate process first, the mesopancreas first approach, the triangle operation, periarterial divestment, and multiorgan resection.
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Affiliation(s)
- Marek Olakowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland.
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Zhang P, Gong S, Wu N, Zhang C, Zhang Y, Zhang X, Ren Z. Effect of total laparoscopic versus open pancreaticoduodenectomy on short-term and oncological outcomes: a single-institution comparative study. Langenbecks Arch Surg 2022; 407:2789-2799. [DOI: 10.1007/s00423-022-02478-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
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11
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van Hilst J, Korrel M, Lof S, de Rooij T, Vissers F, Al-Sarireh B, Alseidi A, Bateman AC, Björnsson B, Boggi U, Bratlie SO, Busch O, Butturini G, Casadei R, Dijk F, Dokmak S, Edwin B, van Eijck C, Esposito A, Fabre JM, Falconi M, Ferrari G, Fuks D, Groot Koerkamp B, Hackert T, Keck T, Khatkov I, de Kleine R, Kokkola A, Kooby DA, Lips D, Luyer M, Marudanayagam R, Menon K, Molenaar Q, de Pastena M, Pietrabissa A, Rajak R, Rosso E, Sanchez Velazquez P, Saint Marc O, Shah M, Soonawalla Z, Tomazic A, Verbeke C, Verheij J, White S, Wilmink HW, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma (DIPLOMA): study protocol for a randomized controlled trial. Trials 2021; 22:608. [PMID: 34503548 PMCID: PMC8427847 DOI: 10.1186/s13063-021-05506-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Recently, the first randomized trials comparing minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) for non-malignant and malignant disease showed a 2-day reduction in time to functional recovery after MIDP. However, for pancreatic ductal adenocarcinoma (PDAC), concerns have been raised regarding the oncologic safety (i.e., radical resection, lymph node retrieval, and survival) of MIDP, as compared to ODP. Therefore, a randomized controlled trial comparing MIDP and ODP in PDAC regarding oncological safety is warranted. We hypothesize that the microscopically radical resection (R0) rate is non-inferior for MIDP, as compared to ODP. METHODS/DESIGN DIPLOMA is an international randomized controlled, patient- and pathologist-blinded, non-inferiority trial performed in 38 pancreatic centers in Europe and the USA. A total of 258 patients with an indication for elective distal pancreatectomy with splenectomy because of proven or highly suspected PDAC of the pancreatic body or tail will be randomly allocated to MIDP (laparoscopic or robot-assisted) or ODP in a 1:1 ratio. The primary outcome is the microscopically radical resection margin (R0, distance tumor to pancreatic transection and posterior margin ≥ 1 mm), which is assessed using a standardized histopathology assessment protocol. The sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected R0 rate in the open group of 58%, expected R0 resection rate in the minimally invasive group of 67%, and a non-inferiority margin of 7%. Secondary outcomes include time to functional recovery, operative outcomes (e.g., blood loss, operative time, and conversion to open surgery), other histopathology findings (e.g., lymph node retrieval, perineural- and lymphovascular invasion), postoperative outcomes (e.g., clinically relevant complications, hospital stay, and administration of adjuvant treatment), time and site of disease recurrence, survival, quality of life, and costs. Follow-up will be performed at the outpatient clinic after 6, 12, 18, 24, and 36 months postoperatively. DISCUSSION The DIPLOMA trial is designed to investigate the non-inferiority of MIDP versus ODP regarding the microscopically radical resection rate of PDAC in an international setting. TRIAL REGISTRATION ISRCTN registry ISRCTN44897265 . Prospectively registered on 16 April 2018.
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Affiliation(s)
- Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Maarten Korrel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Sanne Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Frederique Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olivier Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, Azienda Ospedaliero Universitaria Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Frederike Dijk
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Safi Dokmak
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France
| | - Bjorn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Casper van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | | | - Massimo Falconi
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Giovanni Ferrari
- Department of Surgery, Niguarda Ca'Granda Hospital, Milan, Italy
| | - David Fuks
- Department of Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Keck
- Department of Surgery, UKSH campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | - Ruben de Kleine
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Arto Kokkola
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - David A Kooby
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Krishna Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | | | - Rushda Rajak
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Edoardo Rosso
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | - Olivier Saint Marc
- Department of Surgery, Centre Hospitalier Regional D'Orleans, Orleans, France
| | - Mihir Shah
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Steven White
- Department of Surgery, The Freeman Hospital Newcastle Upon Tyne, Newcastle, UK
| | - Hanneke W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI) and Humanitas University, Pieve Emanuele, MI, Italy
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
- Department of General Surgery, Fondazione Poliambulanza Instituto Ospedaliero, Brescia, Italy.
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12
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Khachfe HH, Habib JR, Chahrour MA, Nassour I. Robotic pancreaticoduodenectomy: Where do we stand? Artif Intell Gastrointest Endosc 2021; 2:103-109. [DOI: 10.37126/aige.v2.i4.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/24/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is a complex operation accompanied by significant morbidity rates. Due to this complexity, the transition to minimally invasive PD has lagged behind other abdominal surgical operations. The safety, feasibility, favorable post-operative outcomes of robotic PD have been suggested by multiple studies. Compared to open surgery and other minimally invasive techniques such as laparoscopy, robotic PD offers satisfactory outcomes, with a non-inferior risk of adverse events. Trends of robotic PD have been on rise with centers substantially increasing the number the operation performed. Although promising, findings on robotic PD need to be corroborated in prospective trials.
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Affiliation(s)
- Hussein H Khachfe
- Surgery Department, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, United States
| | - Joseph R Habib
- Surgery Department, Johns Hopkins University, Balitmore, MD 21287, United States
| | - Mohamad A Chahrour
- Surgery Department, Henry Ford Health System, Detroit, MI 48202, United States
| | - Ibrahim Nassour
- Surgery Department, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, United States
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13
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Khachfe HH, Habib JR, Harthi SA, Suhool A, Hallal AH, Jamali FR. Robotic pancreas surgery: an overview of history and update on technique, outcomes, and financials. J Robot Surg 2021; 16:483-494. [PMID: 34357526 DOI: 10.1007/s11701-021-01289-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/31/2021] [Indexed: 02/06/2023]
Abstract
The use robotics in surgery is gaining momentum. This approach holds substantial promise in pancreas surgery. Robotic surgery for pancreatic lesions and malignancies has become well accepted and is expanding to more and more center annually. The number of centers using robotics in pancreatic surgery is rapidly increasing. The most studied robotic pancreas surgeries are pancreaticoduodenectomy and distal pancreatectomy. Most studies are in their early phases, but they report that robotic pancreas surgery is safe feasible. Robotic pancreas surgery offers several advantages over open and laparoscopic techniques. Data regarding costs of robotics versus conventional techniques is still lacking. Robotic pancreas surgery is still in its early stages. It holds promise to become the new surgical standard for pancreatic resections in the future, however, more research is still needed to establish its safety, cost effectiveness and efficacy in providing the best outcomes.
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Affiliation(s)
- Hussein H Khachfe
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Division of GI Surgical Oncology, Department of Surgery, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, PA, USA.
| | - Joseph R Habib
- Division of General Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Salem Al Harthi
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Amal Suhool
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Ali H Hallal
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Faek R Jamali
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
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14
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van Hilst J, de Graaf N, Abu Hilal M, Besselink MG. The Landmark Series: Minimally Invasive Pancreatic Resection. Ann Surg Oncol 2021; 28:1447-1456. [PMID: 33341916 PMCID: PMC7892688 DOI: 10.1245/s10434-020-09335-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic resections are among the most technically demanding procedures, including a high risk of potentially life-threatening complications and outcomes strongly correlated to hospital volume and individual surgeon experience. Minimally invasive pancreatic resections (MIPRs) have become a part of standard surgical practice worldwide over the last decade; however, in comparison with other surgical procedures, the implementation of minimally invasive approaches into clinical practice has been rather slow. OBJECTIVE The aim of this study was to highlight and summarize the available randomized controlled trials (RCTs) evaluating the role of minimally invasive approaches in pancreatic surgery. METHODS A WHO trial registry and Pubmed database literature search was performed to identify all RCTs comparing MIPRs (robot-assisted and/or laparoscopic distal pancreatectomy [DP] or pancreatoduodenectomy [PD]) with open pancreatic resections (OPRs). RESULTS Overall, five RCTs on MIPR versus OPR have been published and seven RCTs are currently recruiting. For DP, the results of two RCTs were in favor of minimally invasive distal pancreatectomy (MIDP) in terms of shorter hospital stay and less intraoperative blood loss, with comparable morbidity and mortality. Regarding PD, two RCTs showed similar advantages for MIPD. However, concerns were raised after the early termination of the third multicenter RCT on MIPD versus open PD due to higher complication-related mortality in the laparoscopic group and no clear other demonstrable advantages. No RCTs on robot-assisted pancreatic procedures are available as yet. CONCLUSION At the current level of evidence, MIDP is thought to be safe and feasible, although oncological safety should be further evaluated. Based on the results of the RCTs conducted for PD, MIPD cannot be proclaimed as the superior alternative to open PD, although promising outcomes have been demonstrated by experienced centers. Future studies should provide answers to the role of robotic approaches in pancreatic surgery and aim to identity the subgroups of patients or indications with the greatest benefit of MIPRs.
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Affiliation(s)
- Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Nine de Graaf
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.
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15
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Miyasaka Y, Ohtsuka T, Nakamura M. Minimally invasive surgery for pancreatic cancer. Surg Today 2020; 51:194-203. [PMID: 32857251 DOI: 10.1007/s00595-020-02120-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022]
Abstract
Pancreatic cancer is the most lethal malignancy of the digestive organs. Although pancreatic resection is essential to radically cure this refractory disease, the multi-organ resection involved, as well as sequelae such as glucose tolerance insufficiency and severe complications impose a heavy burden on these patients. Since the late twentieth century, minimally invasive surgery has become more popular for the surgical management of digestive disease and pancreatic cancer. Minimally invasive pancreatic resection (MIPR), including pancreaticoduodenectomy and distal pancreatectomy, is now a treatment option for pancreatic cancer. Some evidence suggests that MIPR for pancreatic cancer provides comparable oncological outcomes to open surgery, with some advantages in perioperative outcomes. However, as this evidence is retrospective, prospective investigations, including randomized controlled trials, are necessary. Because neoadjuvant therapy for resectable or borderline-resectable pancreatic cancer and conversion surgery for initially unresectable pancreatic cancer has become more common, the feasibility of MIPR after neoadjuvant therapy or as conversion surgery requires further assessment. It is expected that progress in surgical techniques and devices, as well as the standardization of surgical procedures and widespread educational programs will improve the outcomes of MIPR.
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Affiliation(s)
- Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Kagoshima, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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16
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Choi M, Hwang HK, Lee WJ, Kang CM. Total laparoscopic pancreaticoduodenectomy in patients with periampullary tumors: a learning curve analysis. Surg Endosc 2020; 35:2636-2644. [DOI: 10.1007/s00464-020-07684-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/27/2020] [Indexed: 12/15/2022]
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17
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Minimally invasive pancreatic surgery: An upward spiral. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2020. [DOI: 10.1016/j.lers.2020.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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18
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Haney CM, Karadza E, Limen EF, de Santibanes M, Kinny-Köster B, Müller PC, Bintintan VV, Kulu Y, Hackert T, Müller-Stich BP, Nickel F. Training and learning curves in minimally invasive pancreatic surgery: from simulation to mastery. JOURNAL OF PANCREATOLOGY 2020; 3:101-110. [DOI: 10.1097/jp9.0000000000000050] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background:
Minimally invasive pancreatic surgery (MIPS) has developed over the last 3 decades and is nowadays experiencing an increased interest from the surgical community. With increasing awareness of both the public and the surgical community on patient safety, optimization of training has gained importance. For implementation of MIPS we propose 3 training phases. The first phase focuses on developing basic skills and procedure specific skills with the help of simulation, biotissue drills, video libraries, live case observations, and training courses. The second phase consists of index procedures, fellowships, and proctoring programs to ensure patient safety during the first procedures. During the third phase the surgeons aim is to safely implement the procedure into standard practice while minimizing learning curve related excess morbidity and mortality. Case selection, skills assessment, feedback, and mentoring are important methods to optimize this phase. The residual learning curve can reach up to 100 cases depending on the surgeons’ previous experience, selection of cases, and definition of the parameters used to assess the learning curve. Adequate training and high procedural volume are key to implementing MIPS safely.
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Affiliation(s)
- Caelán M. Haney
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Emir Karadza
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Eldridge F. Limen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin de Santibanes
- Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Benedict Kinny-Köster
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Vasile V. Bintintan
- Department of Surgery, University Hospital Cluj Napoca, Cluj Napoca, Romania
| | - Yakub Kulu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat-Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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19
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Laparoscopic Versus Open Pancreaticoduodenectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2020; 271:54-66. [PMID: 30973388 DOI: 10.1097/sla.0000000000003309] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to open pancreaticoduodenectomy (OPD) using evidence from randomized controlled trials (RCTs). BACKGROUND LPD is used more commonly, but this surge is mostly based on observational data. METHODS We searched CENTRAL, Medline and Web of Science for RCTs comparing minimally invasive to OPD for adults with benign or malignant disease requiring elective pancreaticoduodenectomy. Main outcomes were 90-day mortality, Clavien-Dindo ≥3 complications, and length of hospital stay (LOS). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), bile leak, blood loss, reoperation, readmission, oncologic outcomes (R0-resection, lymph nodes harvested), and operative times. Data were pooled as odds ratio (OR) or mean difference (MD) with a random-effects model. Risk of bias was assessed using the Cochrane Tool and the GRADE approach (Prospero registration ID: CRD42019120363). RESULTS Three RCTs with a total of 224 patients were included. Meta-analysis showed there were no significant differences regarding 90-day mortality, Clavien-Dindo ≥3 complications, LOS, POPF, DGE, PPH, bile leak, reoperation, readmission, or oncologic outcomes between LPD and OPD. Operative times were significantly longer for LPD {MD [95% confidence interval (CI)] 95.44 minutes (24.06-166.81 minutes)}, whereas blood loss was lower for LPD [MD (CI) -150.99 mL (-168.54 to -133.44 mL)]. Certainty of evidence was moderate to very low. CONCLUSIONS At current level of evidence, LPD shows no advantage over OPD. Limitations include high risk of bias and moderate to very low certainty of evidence. Further studies should focus on patient safety during LPD learning curves and the potential role of robotic surgery.
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20
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Singh Y, Cawich SO, Mohammed S, Kuruvilla T, Naraynsingh V. Totally Laparoscopic Whipple's Operation: Initial Report from the Caribbean. Cureus 2020; 12:e7401. [PMID: 32337127 PMCID: PMC7182051 DOI: 10.7759/cureus.7401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Oncologic surgery in the Caribbean has evolved over the past decade, with increasing reports of advanced minimally invasive operations being performed. However, the minimally invasive approach has not been used for peri-ampullary lesions. This is because a laparoscopic Whipple's operation is a technically demanding and time-consuming operation. We report the first case of a totally laparoscopic Whipple's operation to be performed in the Caribbean.
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Affiliation(s)
- Yardesh Singh
- Surgery, University of the West Indies, St. Augustine, TTO
| | | | | | | | - Vijay Naraynsingh
- Surgery, Medical Associates Hospital, St. Joseph, TTO.,Clinical Surgical Sciences, University of the West Indies, St. Augustine, TTO
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21
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Song KB, Kim SC, Lee W, Hwang DW, Lee JH, Kwon J, Park Y, Lee SJ, Park G. Laparoscopic pancreaticoduodenectomy for periampullary tumors: lessons learned from 500 consecutive patients in a single center. Surg Endosc 2020; 34:1343-1352. [DOI: 10.1007/s00464-019-06913-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 06/11/2019] [Indexed: 12/22/2022]
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22
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Vandeputte M, D'Hondt M, Willems E, De Meyere C, Parmentier I, Vansteenkiste F. Stepwise implementation of laparoscopic pancreatic surgery. Case series of a single centre's experience. Int J Surg 2019; 72:137-143. [PMID: 31704423 DOI: 10.1016/j.ijsu.2019.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/27/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic pancreatic surgery still represents a challenge for surgeons. However, in recent decades the experience is expanding. Recent systematic reviews and meta-analyses confirm that laparoscopic pancreatic resection (LPR) is safe, feasible and worthwhile. This study analyses the first 100 consecutive LPRs in our centre. METHODS A retrospective analysis was conducted of the first 100 LPRs in a single supra-regional Belgian centre, performed between January 2012 and January 2019. Pre-, peri- and postoperative data were retrieved from a prospectively maintained database. All procedures were performed laparoscopically by two attending surgeons, specialized in minimally invasive and hepatopancreatobiliary surgery. RESULTS Of 100 procedures, 62 laparoscopic pancreatoduodenectomies (LPD) and 36 laparoscopic distal pancreatectomies (LDP) were performed, along with 1 enucleation and 1 central pancreatectomy. Indication was malignancy in 70%. Conversion rate was 24,2% in LPD and 11% in LDP. Median operative time was 330 min (IQR 300-360) in LPD and 150 min (IQR 142.5-210) in LDP. Median blood loss was 200 mL (IQR 100-487.5) in LPD and 150 mL (IQR 50-500) in LDP, transfusion rate was 22.6% and 8.3% respectively. Median length of stay (LOS) was 13 days (IQR 10-19.25) in LPD and 9 days (IQR 9-14) in LDP. R0 resection rate was 88.6% (62/70). Major complication rate (Clavien-Dindo grade III-IV) was 12%. Thirty-day mortality was 0%, 90-day mortality was 2%. CONCLUSION Our results confirm that LPR is a feasible and safe alternative to open pancreatic surgery. Safe implementation with a clear strategy is fundamental to gain experience and overcome the learning curve of this technically demanding procedures.
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Affiliation(s)
- Mathieu Vandeputte
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, Kortrijk, Belgium
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, Kortrijk, Belgium.
| | - Edward Willems
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, Kortrijk, Belgium
| | - Celine De Meyere
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, Kortrijk, Belgium
| | - Isabelle Parmentier
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, Kortrijk, Belgium
| | - Franky Vansteenkiste
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, Kortrijk, Belgium
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23
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Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial. Ann Surg 2019; 268:731-739. [PMID: 30138162 DOI: 10.1097/sla.0000000000002893] [Citation(s) in RCA: 262] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare perioperative outcomes of pancreatoduodenectomy (PD) performed through the laparoscopic route or by open surgery. SUMMARY BACKGROUND DATA Laparoscopic PD is being progressively performed in selected patients. METHODS An open-label single-center RCT was conducted between February 2013 and September 2017. The primary endpoint was the length of hospital stay (LOS). Secondary endpoints were operative time, transfusion requirements, specific pancreatic complications (pancreatic or biliary fistula, pancreatic hemorrhage, and delayed gastric emptying), Clavien-Dindo grade ≥ 3 complications, comprehensive complication index (CCI) score, poor quality outcome (PQO), and the quality of pathologic resection. Analyses were performed on an intention to treat basis. RESULTS Of 86 patients assessed for PD, 66 were randomized (34 laparoscopic approach, 32 open surgery). Conversion to an open procedure was needed in 8 (23.5%) patients. Laparoscopic versus open PD was associated with a significantly shorter LOS (median 13.5 vs. 17 d; P = 0.024) and longer median operative time (486 vs. 365 min; P = 0.0001). The laparoscopic approach was associated with significantly better outcomes regarding Clavien-Dindo grade ≥ 3 complications (5 vs. 11 patients; P = 0.04), CCI score (20.6 vs. 29.6; P = 0.038), and PQO (10 vs. 14 patients; P = 0.041). No significant differences in transfusion requirements, pancreas-specific complications, the number of lymph nodes retrieved, and resection margins between the two approaches were found. CONCLUSIONS Laparoscopic PD versus open surgery is associated with a shorter LOS and a more favorable postoperative course while maintaining oncological standards of a curative-intent surgical resection. TRIAL REGISTRY ISRCTN93168938.
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24
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Chen K, Pan Y, Liu XL, Jiang GY, Wu D, Maher H, Cai XJ. Minimally invasive pancreaticoduodenectomy for periampullary disease: a comprehensive review of literature and meta-analysis of outcomes compared with open surgery. BMC Gastroenterol 2017; 17:120. [PMID: 29169337 PMCID: PMC5701376 DOI: 10.1186/s12876-017-0691-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 11/17/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear. METHODS Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis. RESULTS One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes. CONCLUSION Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.
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Affiliation(s)
- Ke Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, China
| | - Yu Pan
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, China
| | - Xiao-Long Liu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, China
| | - Guang-Yi Jiang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, China
| | - Di Wu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, China
| | - Hendi Maher
- School of Medicine, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang Province, 310058, China
| | - Xiu-Jun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, 310016, China.
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Abstract
BACKGROUND Robotic assistance enhances surgical dexterity and could facilitate wider adoption of laparoscopy for pancreatic resections (PR). METHODS Data were prospectively entered into a database and analyzed retrospectively to assess feasibility and safety of robotic-assisted PR (RAPR). Additionally, robotic-assisted pancreaticoduodenectomy (RAPD) was compared to a contemporary group of open pancreaticoduodenectomies (OPD). RESULTS Between October 2008 and October 2014, 200 consecutive patients underwent RAPR. Three procedures were converted to open surgery (1.5 %), despite 14 patients required associated vascular procedures. RAPD was performed in 83 patients (41.5 %), distal pancreatectomy in 83 (41.5 %), total pancreatectomy in 17 (8.5 %), tumor enucleation in 12 (6 %), and central pancreatectomy in 5 (2.5 %). Thirty-day and 90-day mortality rates were 0.5 and 1 %, respectively. Both deaths occurred after RAPD with vein resection. Complications occurred in 63.0 % of the patients (≥Clavien-Dindo grade IIIb in 4 %). Median comprehensive complication index was 20.9 (0-26.2). Incidence of grade B/C pancreatic fistula was 28.0 %. Reoperation was required in 14 patients (7.0 %). The risk of reoperation decreased after post-operative day 20 (OR 0.072) (p = 0.0015). When compared to OPD, RAPD was associated with longer mean operative time (527.2 ± 166.1 vs. 425.3 ± 92.7; <0.0001) but had an equivalent safety profile. The median number of examined lymph nodes (37; 28.8-45.3 vs. 36; 28-52.8) and the rate of margin positivity in patients diagnosed with pancreatic cancer were also similar (12.5 vs. 45.5 %). CONCLUSIONS RAPR, including RAPD, are safely feasible in selected patients. The results of RAPD in pancreatic cancer are encouraging but deserve further investigation.
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Cesaretti M, Bifulco L, Costi R, Zarzavadjian Le Bian A. Pancreatic resection in the era of laparoscopy: State of Art. A systematic review. Int J Surg 2017; 44:309-316. [PMID: 28689866 DOI: 10.1016/j.ijsu.2017.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/22/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature. DATA SOURCE A systematic review of literature was performed regarding laparoscopic pancreatic resection. RESULTS Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported. CONCLUSIONS Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.
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Affiliation(s)
- Manuela Cesaretti
- Service de Chirurgie Hépatique, Pancréatique et Biliaire, Transplantation Hépatique, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot-VII, Clichy, 92110, France; Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Lelio Bifulco
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Renato Costi
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, 43100, Italy
| | - Alban Zarzavadjian Le Bian
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Laboratoire d'Ethique Médicale et de Médecine Légale, Université Paris Descartes - V, Paris, 75006, France.
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Wexner T, Rosales-Velderrain A, Wexner SD, Rosenthal RJ. Does implementing a general surgery residency program and resident involvement affect patient outcomes and increase care-associated charges? Am J Surg 2017; 214:147-151. [DOI: 10.1016/j.amjsurg.2016.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 09/25/2016] [Accepted: 11/14/2016] [Indexed: 12/21/2022]
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Dapri G, Bascombe NA, Gerard L, Samaniego Ballart C, Gimenez Viñas C, Saussez S. Completely Intracorporeal Handsewn Laparoscopic Anastomoses During Whipple Procedure. Ann Surg Oncol 2017; 24:2785-2786. [PMID: 28653162 DOI: 10.1245/s10434-017-5944-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Whipple procedure has been described since 1935,1 using classic open surgery. With the advent of minimally invasive surgery (MIS), it has been described to be feasible using the latest technology.2 , 3 In this video the authors report a full laparoscopic Whipple procedure, realizing the three anastomoses by intracorporeal handsewn method. VIDEO A 70-year-old man who presented with adenocarcinoma of the ampulla of Vater, infiltrating the pancreatic parenchyma underwent to a laparoscopic Whipple. Preoperative work-up shows a T3N1M0 tumor. RESULTS No perioperative complications were registered. The pancreatico-jejunostomy was created in end-to-side fashion using two PDS 3/0 running sutures (Fig. 1), the hepatico-jejunostomy in end-to-side method using two PDS 4/0 running sutures (Fig. 2), and the gastro-jejunostomy in end-to-side method using two PDS 1 running sutures (Fig. 3). Total operative time was 8 h 20 min. Time for the dissection was 6 h 20 min, time for the specimen's extraction was 20 min, and time for the three laparoscopic intracorporeal handsewn anastomoses was 1 h 40 min. Operative bleeding was 350 cc. Patient was discharged on postoperative day 9. Pathologic report confirmed the moderately differentiated adenocarcinoma of the ampulla of Vater, with perinervous infiltration and lymphovascular emboli, free margins, 2 metastatic lymphnodes on 23 isolated; 8 edition UICC stade: pT3bN1. CONCLUSIONS Laparoscopic Whipple remains an advanced procedure to be performed by laparoscopy as well as by open surgery. All the advantages of MIS, such as reduced abdominal trauma, less postoperative pain, shorter hospital stay, improved patient's comfort, and enhanced cosmesis are offered using using laparoscopy.
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Affiliation(s)
- Giovanni Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium. .,Laboratory of Anatomy, Faculty of Medicine and Pharmacy, University of Mons, Mons, Belgium.
| | - Nigel Antonio Bascombe
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Leonardo Gerard
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Carla Samaniego Ballart
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Carlos Gimenez Viñas
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sven Saussez
- Laboratory of Anatomy, Faculty of Medicine and Pharmacy, University of Mons, Mons, Belgium
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Minimally invasive pancreatic cancer surgery: What is the current evidence? Med Oncol 2017; 34:125. [PMID: 28573639 PMCID: PMC5486522 DOI: 10.1007/s12032-017-0984-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 05/24/2017] [Indexed: 12/20/2022]
Abstract
Surgery remains the only option to cure pancreatic cancer. Although the use of laparoscopy in oncology is rapidly growing worldwide, its efficacy in pancreatic surgery remains controversial. A number of studies have compared outcomes of minimally invasive and open pancreatic resections. However, they are mostly non-randomized trials including relatively small groups of patients. In addition, most of these studies were conducted in high-volume pancreatic centres. It seems that despite longer operative time, laparoscopy may be beneficial in terms of morbidity, blood loss and hospital stay. Thus far, very little is known about the long-term outcomes of laparoscopic surgery for pancreatic cancer. Our aim was to review current evidence for the use of minimally invasive techniques in patients with pancreatic malignancy.
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Conrad C, Basso V, Passot G, Zorzi D, Li L, Chen HC, Fuks D, Gayet B. Comparable long-term oncologic outcomes of laparoscopic versus open pancreaticoduodenectomy for adenocarcinoma: a propensity score weighting analysis. Surg Endosc 2017; 31:3970-3978. [PMID: 28205031 DOI: 10.1007/s00464-017-5430-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/20/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND To date, no study has reported long-term oncologic outcome for patients undergoing laparoscopic pancreaticoduodenectomy (LPD) compared to open surgery (OPD). The aim of this study is assess long-term oncologic outcomes for patients with adenocarcinoma undergoing LPD versus OPD using propensity score weighting modeling to minimize selection bias. PATIENTS AND METHODS All patients undergoing PD at Institut Mutualiste Montsouris between January 2000 and April 2010 were included. Propensity scores were calculated using multivariate logistic regression, relating preoperative covariates to surgical approach. Logistic regression was performed, and Cox proportional hazards models for postoperative outcomes were constructed, with and without adjustment for propensity scores weights. RESULTS Among 87 patients who underwent PD, 40 underwent LPD and 25 OPD for confirmed adenocarcinoma. Preoperative covariates across both groups were comparable. The median follow-up time was 34.5 months. During follow-up, metastasis was identified in 16 (40%) LPD and 7 (28%) OPD patients. After propensity score adjustment, the median overall survival (OS) was 35.5 versus 29.6 months, respectively. The 1-, 3-, and 5-year OS rates were 80.5, 49.2, 39.7% and 77.8, 46.4, 30% in the LP and OPD groups (P = 0.41, 0.42, 0.25), respectively. The median recurrence-free survival (RFS) was 21.5 versus 13.7 months (LPD vs. OPD), and the 1-, 3-, and 5-year RFS rates were 70.9, 33.3, 21.9% and 62.3, 37.9, 25.7% in the LP and OPD groups (P = 0.27, 0.37, 0.39), respectively. CONCLUSIONS Due to the early adoption of LPD, this study is the first to report on long-term oncologic safety of LPD: LPD is non-inferior to OPD with respect to long-term outcomes for patients with adenocarcinoma.
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Affiliation(s)
- Claudius Conrad
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, USA.
- Department of Digestive Diseases, L'Institute Mutualiste Montsouris, Paris, France.
| | - Valeria Basso
- Department of Digestive Diseases, L'Institute Mutualiste Montsouris, Paris, France
| | - Guillaume Passot
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, USA
| | - Daria Zorzi
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, USA
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hsiang-Chun Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Fuks
- Department of Digestive Diseases, L'Institute Mutualiste Montsouris, Paris, France
| | - Brice Gayet
- Department of Digestive Diseases, L'Institute Mutualiste Montsouris, Paris, France
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Wang M, Cai Y, Li Y, Peng B. Robotic Pancreaticoduodenectomy: Single-Surgeon Initial Experience. Indian J Surg 2016; 80:42-47. [PMID: 29581684 DOI: 10.1007/s12262-016-1555-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 10/07/2016] [Indexed: 02/05/2023] Open
Abstract
Minimally invasive surgery has gained increasing acceptance over the last few years, which has expanded to pancreaticoduodenectomy. Laparoscopic pancreaticoduodenectomy has been determined to be a feasible, safe, and effective procedure in an experienced surgeon's hands, but the adaptations to the clumsy instruments are needed. The improved dexterity of the Da Vinci robotic system provides a good opportunity to perform this challenging procedure in the minimally invasive context. The aim of this study was to share our preliminary experience of totally robotic pancreaticoduodenectomy. From April 2015 to August 2015, four patients were selected to undergo totally robotic pancreaticoduodenectomy in the Department of Pancreatic Surgery, West China Hospital, Sichuan University, China. The demographic characteristics, perioperative details, and pathological results were retrospectively reviewed. One female and two male patients underwent totally robotic pancreaticoduodenectomy, while another male patient underwent robotic total pancreatectomy due to the severe atrophy of pancreatic body and tail. The mean age of the four patients was 56.8 years. The average operation time and intraoperative blood loss were 563 min and 228 mL, respectively. No one needed blood transfusion, conversion to open pancreaticoduodenectomy, or postoperative analgesia. The postoperative courses of these patients were uneventful. The mean postoperative hospital stay was 10 days. No one required to be readmitted, and there was no death within 30 days following the surgery. Final pathologic examinations revealed one malignant pancreatic ductal adenocarcinoma, and three benign lesions. Based on this initial study, robotic pancreaticoduodenectomy is safe and feasible, with acceptable oncological outcomes for highly selected patients in experienced surgeons' hands. However, concerns such as long-term outcomes, cost-effectiveness analysis, and learning curve analysis should be fully demonstrated before the popularization of this challenging procedure.
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Affiliation(s)
- Mingjun Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, Sichuan 610041 China
| | - Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, Sichuan 610041 China
| | - Yongbin Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, Sichuan 610041 China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, Sichuan 610041 China
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Wang M, Cai H, Meng L, Cai Y, Wang X, Li Y, Peng B. Minimally invasive pancreaticoduodenectomy: A comprehensive review. Int J Surg 2016; 35:139-146. [PMID: 27664556 DOI: 10.1016/j.ijsu.2016.09.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/02/2016] [Accepted: 09/11/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND While an increasing number of open procedures are now routinely performed laparoscopically or robotically, minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging operations in abdomen. The aim of this study is to evaluate the current status and development of MIPD. METHODS Embase, Medline, and PubMed databases were searched to identify studies up to and including Feb 2016 using the keywords "laparoscopic", or "laparoscopy", or "hand-assisted", or "minimally invasive", or "robotic", or "da vinci" combined with "pancreaticoduodenectomy", or "duodenopancreatectomy", "Whipple", or "pancreatic resection". Articles written in English with more than 10 cases were included for review. RESULTS Thirty-two articles representing 2209 patients were included for review. The weighted average operative time and intraoperative blood loss was 427.3 min and 289.4 mL respectively. A total of 375 patients required conversion to open pancreaticoduodenectomy (OPD), with an overall conversion rate of 17.8%. The postoperative severe complications (the Clavien-Dindo Classification ≥ III) occurred in 3.8%-33.0% patients, with an overall severe morbidity of 14.3%. Particularly, the overall incidence of clinically significant postoperative pancreatic fistula (POPF) was 8.0%. There were 26 perioperative death cases in total, with an overall postoperative mortality rate of 2.3%. The weighted average number of collected lymph nodes was 17.9, and R0 resection ranged from 60.0% to 100.0%. Comparisons between MIPD and OPD showed that MIPD increased operative time, decreased intraoperative blood loss and shortened the length of hospital stay, but the overall morbidity and mortality were comparable. CONCLUSIONS MIPD is technically feasible and safe in highly selected patients and can offer acceptable oncological outcomes. But concerns such as long-term outcomes, cost-effectiveness analysis, and learning curve analysis should be fully demonstrated before the popularization of this challenging procedure.
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Affiliation(s)
- Mingjun Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - He Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Lingwei Meng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Yongbin Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China.
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Ramera M, Damoli I, Giardino A, Bassi C, Butturini G. Robotic pancreatectomies. ROBOTIC SURGERY : RESEARCH AND REVIEWS 2016; 3:29-36. [PMID: 30697553 PMCID: PMC6193431 DOI: 10.2147/rsrr.s81560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pancreatic surgery represents one of the most challenging fields in general surgery. Its complexity is related to the severity of the disease and the technical skills required for surgical approach. Given this, most pancreatic resections are performed through classic open surgery. Minimally invasive approaches are gradually gaining widespread popularity also in this specific setting, as for distal resections and enucleations. The robotic platform, due to its 3-dimensional vision and articulated movements, represents the natural progress of laparoscopic surgery overcoming the technical defaults and opening up the possibility to perform major pancreatic resections as pancreaticoduodenectomies. This review focuses on the impact of robotic platform in pancreatic surgery in terms of surgical and oncological outcome.
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Affiliation(s)
- Marco Ramera
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust
| | - Isacco Damoli
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust
| | - Alessandro Giardino
- Hepato-Pancreato-Biliary Unit, Casa di Cura Pederzoli, Peschiera del Garda, Verona, Italy,
| | - Claudio Bassi
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust
| | - Giovanni Butturini
- Hepato-Pancreato-Biliary Unit, Casa di Cura Pederzoli, Peschiera del Garda, Verona, Italy,
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Li Y, Li F, Liu H, Wang L. Using the Root of the Mesentery to Guide a Novel Operative Approach for Laparoscopic Insulinoma Resection. J Laparoendosc Adv Surg Tech A 2016; 26:557-9. [PMID: 27171819 DOI: 10.1089/lap.2015.0605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Insulinoma is a functioning endocrine neoplasm appearing primarily in the tail and body of the pancreas, although it is also rarely found in the uncinate process. The sole treatment for insulinoma is surgical resection. However, for insulinoma in the uncinate process, traditional laparoscopic surgery is controversial owing to the fact that it is a complex operation and carries a high surgical risk. Herein, we report a novel approach to complete the exposure of uncinate process and tumor resections starting from the root of the mesentery.
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Affiliation(s)
- Yang Li
- General Department, QiLu Hospital of Shandong University , Jinan, China
| | - Feng Li
- General Department, QiLu Hospital of Shandong University , Jinan, China
| | - Han Liu
- General Department, QiLu Hospital of Shandong University , Jinan, China
| | - Lei Wang
- General Department, QiLu Hospital of Shandong University , Jinan, China
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Justin V, Fingerhut A, Khatkov I, Uranues S. Laparoscopic pancreatic resection-a review. Transl Gastroenterol Hepatol 2016; 1:36. [PMID: 28138603 DOI: 10.21037/tgh.2016.04.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/11/2016] [Indexed: 12/12/2022] Open
Abstract
Contrary to many other gastrointestinal operations, minimal access approaches in pancreatic surgery have gained ground slowly. Laparoscopic distal pancreatectomy has gained wide acceptance. It is associated with reduced blood loss and shorter duration of stay (DOS) while oncologic results and morbidity are similar to open surgery. In recent years the number of laparoscopic pancreatoduodenectomies has also increased. While oncological outcome seems comparable to the open approach, operative times are longer while DOS and blood loss are reduced. One added advantage of the laparoscopic approach to pancreatic cancer seems to be that adjuvant treatment can start earlier. Minimal access total pancreatectomy, only reported in small numbers (mostly robot assisted), has also been shown to be feasible and safe. Enucleation (EN) of small pancreatic lesions is the most common tissue sparing resection. Although no reconstruction is necessary, the risk of pancreatic fistula is high, related to excision margins equal or smaller than 2 mm to the main pancreatic duct. Compared to the open approach, laparoscopic EN has shown comparable results in terms of morbidity, pancreatic function and fistula rate, with shorter operation times and faster recovery. Experience in robot assisted pancreatic surgery is increasing. However reports are still small in numbers, lacking randomization and mostly limited to dedicated centers. The learning curve for minimal access pancreatic surgery is steep. Low patient volume leads to longer DOS, higher costs and negatively impacts outcome.
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Affiliation(s)
| | - Abe Fingerhut
- Section for Surgical Research, Medical University of Graz, Graz, Austria
| | - Igor Khatkov
- Moscow Clinical Scientific Center, Moscow, Russia
| | - Selman Uranues
- Section for Surgical Research, Medical University of Graz, Graz, Austria
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Liao CH, Wu YT, Liu YY, Wang SY, Kang SC, Yeh CN, Yeh TS. Systemic Review of the Feasibility and Advantage of Minimally Invasive Pancreaticoduodenectomy. World J Surg 2016; 40:1218-25. [PMID: 26830906 DOI: 10.1007/s00268-016-3433-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy (MIPD), which includes laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is a complex procedure that needs to be performed by experienced surgeons. However, the safety and oncologic performance have not yet been conclusively determined. METHODS A systematic literature search was performed using the Embase, Medline, and PubMed databases to identify all studies published up to March 2015. Articles written in English containing the keywords: "pancreaticoduodenectomy" or "Whipple operation" combined with "laparoscopy," "laparoscopic," "robotic," "da vinci," or "minimally invasive surgery" were selected. Furthermore, to increase the power of evidence, articles describing more than ten MIPDs were selected for this review. RESULTS Twenty-six articles matched the review criteria. A total of 780 LPDs and 248 RPDs were included in the current review. The overall conversion rate to open surgery was 9.1 %. The weighted average operative time was 422.6 min, and the weighted average blood loss was 321.1 mL. The weighted average number of harvested lymph nodes was 17.1, and the rate of microscopically positive tumor margins was 8.4 %. The cumulative morbidity was 35.9 %, and a pancreatic fistula was reported in 17.0 % of cases. The average length of hospital stay was 12.4 days, and the mortality rate was 2.2 %. CONCLUSIONS In conclusion, after reviewing one-thousand cases in the current literature, we conclude that MIPD offers a good perioperative, postoperative, and oncologic outcome. MIPD is feasible and safe in well-selected patients.
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Affiliation(s)
- Chien-Hung Liao
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Tung Wu
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Yin Liu
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan, Taiwan
| | - Shang-Yu Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ching Kang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan, Taiwan
| | - Ta-Sen Yeh
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan, Taiwan.
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Kwon W, Jang JY, Kim JH, Chang YR, Jung W, Kang MJ, Kim SW. An Analysis of Complications, Quality of Life, and Nutritional Index After Laparoscopic Distal Pancreatectomy with Regard to Spleen Preservation. J Laparoendosc Adv Surg Tech A 2016; 26:335-42. [DOI: 10.1089/lap.2015.0171] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Ye Rim Chang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Woohyun Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Mee Joo Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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de Rooij T, Klompmaker S, Abu Hilal M, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nat Rev Gastroenterol Hepatol 2016; 13:227-38. [PMID: 26882881 DOI: 10.1038/nrgastro.2016.17] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Laparoscopic surgery for benign and malignant pancreatic lesions has slowly been gaining acceptance over the past decade and is being introduced in many centres. Some studies suggest that this approach is equivalent to or better than open surgery, but randomized data are needed to assess outcomes. In this Review, we aim to provide a comprehensive overview of the state of the art in laparoscopic pancreatic surgery by aggregating high-quality published evidence. Various aspects, including the benefits, limitations, oncological efficacy, learning curve and latest innovations, are discussed. The focus is on laparoscopic Whipple procedure and laparoscopic distal pancreatectomy for both benign and malignant disease, but robot-assisted surgery is also addressed. Surgical and oncological outcomes are discussed as well as quality of life parameters and the cost efficiency of laparoscopic pancreatic surgery. We have also included decision-aid algorithms based on the literature and our own expertise; these algorithms can assist in the decision to perform a laparoscopic or open procedure.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905, USA
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Tee MC, Croome KP, Shubert CR, Farnell MB, Truty MJ, Que FG, Reid-Lombardo KM, Smoot RL, Nagorney DM, Kendrick ML. Laparoscopic pancreatoduodenectomy does not completely mitigate increased perioperative risks in elderly patients. HPB (Oxford) 2015; 17:909-18. [PMID: 26294338 PMCID: PMC4571759 DOI: 10.1111/hpb.12456] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/06/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Elderly patients undergoing open pancreatoduodenectomy (OPD) are at increased risk for surgical morbidity and mortality. Whether totally laparoscopic pancreatoduodenectomy (TLPD) mitigates these risks has not been evaluated. METHODS A retrospective review of outcomes in patients submitted to pancreatoduodenectomy during 2007-2014 was conducted (n = 860). Outcomes in elderly patients (aged ≥70 years) were compared with those in non-elderly patients with respect to risk-adjusted postoperative morbidity and mortality. Differences in outcomes between patients submitted to OPD and TLPD, respectively, were evaluated in the elderly subgroup. RESULTS In elderly patients, the incidences of cardiac events (odds ratio [OR] 3.21, P < 0.001), respiratory events (OR 1.68, P = 0.04), delayed gastric emptying (DGE) (OR 1.73, P = 0.003), increased length of stay (LoS, 1 additional day) (P < 0.001), discharge disposition other than home (OR 8.14, P < 0.001) and blood transfusion (OR 1.48, P = 0.05) were greater than in non-elderly patients. Morbidity and mortality did not differ between the OPD and TLPD subgroups of elderly patients. In elderly patients, OPD was associated with increased DGE (OR 1.80, P = 0.03), LoS (1 additional day; P < 0.001) and blood transfusion (OR 2.89, P < 0.001) compared with TLPD. CONCLUSIONS Elderly patients undergoing TLPD experience rates of mortality, morbidity and cardiorespiratory events similar to those in patients submitted to OPD. In elderly patients, TLPD offers benefits by decreasing DGE, LoS and blood transfusion requirements.
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Affiliation(s)
- May C Tee
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - Kristopher P Croome
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - Christopher R Shubert
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - Michael B Farnell
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - Mark J Truty
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - Florencia G Que
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - KMarie Reid-Lombardo
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - Rory L Smoot
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - David M Nagorney
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
| | - Michael L Kendrick
- Division of Subspecialty General Surgery, Department of Surgery, Mayo ClinicRochester, MN, USA
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Stafford AT, Walsh RM. Robotic surgery of the pancreas: The current state of the art. J Surg Oncol 2015. [PMID: 26220683 DOI: 10.1002/jso.23952] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pancreatic surgery is one of the most technically challenging and complex types of surgery. Most pancreatic surgery is performed with the open technique, yet minimally invasive surgery has become the standard of care for many other intra-abdominal operations. The unique qualities of the robotic platform have made this approach to pancreatic surgery safe and feasible with at least equivalent if not better results than the open platform in terms of surgical and oncological outcomes.
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Affiliation(s)
- Anthony T Stafford
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
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Adam MA, Choudhury K, Goffredo P, Reed SD, Blazer D, Roman SA, Sosa JA. Minimally Invasive Distal Pancreatectomy for Cancer: Short-Term Oncologic Outcomes in 1733 Patients. World J Surg 2015; 39:2564-72. [DOI: 10.1007/s00268-015-3138-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Damoli I, Butturini G, Ramera M, Paiella S, Marchegiani G, Bassi C. Minimally invasive pancreatic surgery - a review. Wideochir Inne Tech Maloinwazyjne 2015; 10:141-149. [PMID: 26240612 PMCID: PMC4520856 DOI: 10.5114/wiitm.2015.52705] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 06/12/2015] [Accepted: 06/14/2015] [Indexed: 01/01/2023] Open
Abstract
During the past 20 years the application of a minimally invasive approach to pancreatic surgery has progressively increased. Distal pancreatectomy is the most frequently performed procedure, because of the absence of a reconstructive phase. However, middle pancreatectomy and pancreatoduodenectomy have been demonstrated to be safe and feasible as well. Laparoscopic distal pancreatectomy is recognized as the gold standard treatment for small tumors of the pancreatic body-tail, with several advantages over the traditional open approach in terms of patient recovery. The surgical treatment of lesions of the pancreatic head via a minimally invasive approach is still limited to a few highly experienced surgeons, due to the very challenging resection and complex anastomoses. Middle pancreatectomy and enucleation are indicated for small and benign tumors and offer the maximum preservation of the parenchyma. The introduction of a robotic platform more than ten years ago increased the interest of many surgeons in minimally invasive treatment of pancreatic diseases. This new technology overcomes all the limitations of laparoscopic surgery, but actual benefits for the patients are still under investigation. The increased costs associated with robotic surgery are under debate too. This article presents the state of the art of minimally invasive pancreatic surgery.
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Affiliation(s)
- Isacco Damoli
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust, Verona, Italy
| | - Giovanni Butturini
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust, Verona, Italy
| | - Marco Ramera
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust, Verona, Italy
| | - Claudio Bassi
- General Surgery Unit B, The Pancreas Institute, Verona University Hospital Trust, Verona, Italy
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Berti S, Ferrarese A, Feleppa C, Francone E, Martino V, Bianchi C, Falco E. Laparoscopic perspectives for distal biliary obstruction. Int J Surg 2015; 21 Suppl 1:S64-7. [PMID: 26118614 DOI: 10.1016/j.ijsu.2015.04.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 03/24/2015] [Accepted: 04/10/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions. METHODS We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected. RESULTS In the six-years period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred. CONCLUSIONS Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life.
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Affiliation(s)
| | - Alessia Ferrarese
- University of Turin, Department of Oncology, School of Medicine, "San Luigi Gonzaga" Teaching Hospital, Section of General Surgery, Orbassano, Turin, Italy.
| | | | | | - Valter Martino
- University of Turin, Department of Oncology, School of Medicine, "San Luigi Gonzaga" Teaching Hospital, Section of General Surgery, Orbassano, Turin, Italy
| | | | - Emilio Falco
- Department of Surgery, POLL-ASL 5, La Spezia, Italy
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Tee MC, Kendrick ML, Farnell MB. Laparoscopic Pancreaticoduodenectomy: Is It an Effective Procedure for Pancreatic Ductal Adenocarcinoma? Adv Surg 2015; 49:143-56. [PMID: 26299496 DOI: 10.1016/j.yasu.2015.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- May C Tee
- Section of Hepato-Pancreatic-Biliary Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michael L Kendrick
- Section of Hepato-Pancreatic-Biliary Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michael B Farnell
- Section of Hepato-Pancreatic-Biliary Surgery, Division of Subspecialty General Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Kawaguchi Y, Fuks D, Nomi T, Levard H, Gayet B. Laparoscopic distal pancreatectomy employing radical en bloc procedure for adenocarcinoma: Technical details and outcomes. Surgery 2015; 157:1106-12. [DOI: 10.1016/j.surg.2014.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 01/14/2023]
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Wang M, Zhang H, Wu Z, Zhang Z, Peng B. Laparoscopic pancreaticoduodenectomy: single-surgeon experience. Surg Endosc 2015; 29:3783-94. [PMID: 25783837 DOI: 10.1007/s00464-015-4154-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/06/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Innovations in surgical strategies and technologies have facilitated laparoscopic pancreaticoduodenectomy (LPD). However, data regarding the short-term and long-term results of LPD are sparse, and this procedure is the primary focus of the current study. METHODS Between October 2010 and October 2013, a total of 31 consecutive patients received LPD, including hand-assisted laparoscopic pancreaticoduodenectomy, total laparoscopic pancreaticoduodenectomy, and laparoscopic pylorus-preserving pancreaticoduodenectomy. Data regarding short-term surgical outcomes and long-term oncological results were collected prospectively. RESULTS The median operative time was 515.0 min (interquartile range 465.0-585.0 min). The median intraoperative estimated blood loss was 260.0 mL (interquartile range 150.0-430.0 mL). Conversion to open pancreaticoduodenectomy was required in three patients (9.7%) due to intraoperative pneumoperitoneum intolerance (n = 1, 3.2%) and tumor adherence to the superior mesenteric vein (n = 2, 6.5%). No significant differences between the surgical approaches were observed in regard to intraoperative and postoperative data. Postoperative severe complications (Clavien ≥ III) were detected in three (9.7%) patients, including one grade C pancreatic fistula, one grade B postoperative bleeding event, and one afferent loop obstruction. There were no deaths within 30 days following LPD. The final pathological results revealed duodenal adenocarcinoma in 14 (45.2%) patients, ampullary adenocarcinoma in four (12.9%) patients, distal common bile duct cancer in six (19.4%) patients, pancreatic ductal adenocarcinoma in five (16.1%) patients, gastrointestinal stroma tumor in one (3.2%) patient, and chronic pancreatitis in one (3.2%) patient. All patients suffering from tumors underwent R0 resection (n = 30, 100.0%), with the optimal number of collected lymph nodes (median: 13, interquartile range 11-19). At the most recent follow-up, 20 patients were still alive, and the 1-, and 3-year overall survival for patients with duodenal adenocarcinoma were 100.0 and 71.4%, respectively. CONCLUSIONS According to this study, LPD is feasible and technically safe for highly selected patients and can offer acceptable oncological outcomes and long-term survival.
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Affiliation(s)
- Mingjun Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Hua Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Zhong Wu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Zhaoda Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.
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Abstract
Pancreatic resection is a complex procedure that involves exposure of the retroperitoneal gland, dissection around major vascular structures, and management of an intricate organ, all of which results in a procedure associated with a high morbidity. The application of minimally invasive techniques to pancreatic resection have been studied only relatively recently. This analysis of the current concepts in minimally invasive pancreatic surgery focuses on a select look at currently published series or reviews from centers and groups that have the most experience with this procedure. We aim to present a comprehensive review gained from the experiences of those who are on the leading edge of the learning curve, with an emphasis on describing the similarities and differences between the minimally invasive and open pancreatic procedure. Minimally invasive distal pancreatectomy appears to be on the verge of widespread acceptance and shows clear benefits over its open counterpart. Minimally invasive proximal (right-sided) pancreatectomy, on the other hand, appears to be limited to select centers that have been able to demonstrate promising results despite its challenges. Additionally, minimally invasive central pancreatectomy and enucleation appear feasible as experience is gained in laparoscopic and robotic pancreatic resection.
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Affiliation(s)
- John A Stauffer
- Mayo College of Medicine, Department of General Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Mayo College of Medicine, Department of General Surgery, Mayo Clinic, Jacksonville, FL.
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Joyce D, Morris-Stiff G, Falk GA, El-Hayek K, Chalikonda S, Walsh RM. Robotic surgery of the pancreas. World J Gastroenterol 2014; 20:14726-14732. [PMID: 25356035 PMCID: PMC4209538 DOI: 10.3748/wjg.v20.i40.14726] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 04/11/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery is one of the most challenging and complex fields in general surgery. While minimally invasive surgery has become the standard of care for many intra-abdominal pathologies the overwhelming majority of pancreatic surgery is performed in an open fashion. This is attributed to the retroperitoneal location of the pancreas, its intimate relationship to major vasculature and the complexity of reconstruction in the case of pancreatoduodenectomy. Herein, we describe the application of robotic technology to minimally invasive pancreatic surgery. The unique capabilities of the robotic platform have made the minimally invasive approach feasible and safe with equivalent if not better outcomes (e.g., decreased length of stay, less surgical site infections) to conventional open surgery. However, it is unclear whether the robotic approach is truly superior to traditional laparoscopy; this is a key point given the substantial costs associated with procuring and maintaining robotic capabilities.
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Wang Y, Bergman S, Piedimonte S, Vanounou T. Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach. Can J Surg 2014; 57:263-70. [PMID: 25078932 DOI: 10.1503/cjs.026713] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Minimally invasive pancreatic surgery has evolved rapidly, but total laparoscopic pancreaticoduodenectomy has not been widely adopted owing to its technical complexity. Hybrid laparoscopy-assisted pancreaticoduodenectomy (HLAPD) combines the relative ease of open surgery with the benefits of a minimally invasive approach. This study evaluates the safety and effectiveness of the hybrid approach compared with open surgery. METHODS We retrospectively analyzed data of consecutive patients undergoing either hybrid or open pancreaticoduodenectomy (OPD) at our institution between September 2009 and December 2013. Demographic, operative and oncologic data were collected to compare outcomes between HLAPD and OPD. RESULTS Our analysis included 33 patients (HLAPD: n = 13; OPD: n = 20). There were no differences in patient demographics, comorbidities or surgical indications. The HLAPD group had significantly lower intraoperative blood loss (450 mL v. 1000 mL, p = 0.023) and shorter length of hospital stay (8 v. 12 d, p = 0.025) than the OPD group. Duration of surgery did not differ significantly between the groups. There were no differences in postoperative analgesic requirements, Clavien grade I/II or grade III/IV complications or 90-day mortality. Oncologic outcomes showed no significant differences in tumour size, R1 resection rate or number of lymph nodes harvested. CONCLUSION In select patients, HLAPD is a safe and effective procedure with comparable outcomes to conventional open surgery. Wider adoption of the hybrid approach will allow a greater number of patients to benefit from a less invasive procedure while facilitating the transition toward purely minimally invasive pancreaticoduodenectomy.
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Affiliation(s)
- Yifan Wang
- The Division of General Surgery, Jewish General Hospital, Montréal, Que
| | - Simon Bergman
- The Division of General Surgery, Jewish General Hospital, Montréal, Que
| | | | - Tsafrir Vanounou
- The Division of General Surgery, Jewish General Hospital, Montréal, Que
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Boggi U, Amorese G, Vistoli F, Caniglia F, De Lio N, Perrone V, Barbarello L, Belluomini M, Signori S, Mosca F. Laparoscopic pancreaticoduodenectomy: a systematic literature review. Surg Endosc 2014; 29:9-23. [PMID: 25125092 DOI: 10.1007/s00464-014-3670-z] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 05/31/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is gaining momentum, but there is still uncertainty regarding its safety, reproducibility, and oncologic appropriateness. This review assesses the current status of LPD. METHODS Our literature review was conducted in Pubmed. Articles written in English containing five or more LPD were selected. RESULTS Twenty-five articles matched the review criteria. Out of a total of 746 LPD, 341 were reported between 1997 and 2011 and 405 (54.2 %) between 2012 and June 1, 2013. Pure laparoscopy (PL) was used in 386 patients (51.7 %), robotic assistance (RA) in 234 (31.3 %), laparoscopic assistance (LA) in 121 (16.2 %), and hand assistance in 5 (0.6 %). PL was associated with shorter operative time, reduced blood loss, and lower rate of pancreatic fistula (vs LA and RA). LA was associated with shorter operative time (vs RA), but with higher blood loss and increased incidence of pancreatic fistula (vs PL and RA). Conversion to open surgery was required in 64 LPD (9.1 %). Operative time averaged 464.3 min (338-710) and estimated blood 320.7 mL (74-642). Cumulative morbidity was 41.2 %, and pancreatic fistula was reported in 22.3 % of patients (4.5-52.3 %). Mean length of hospital stay was 13.6 days (7-23), showing geographic variability (21.9 days in Europe, 13.0 days in Asia, and 9.4 days in the US). Operative mortality was 1.9 %, including one intraoperative death. No difference was noted in conversion rate, incidence of pancreatic fistula, morbidity, and mortality when comparing results from larger (≥30 LPD) and smaller (≤29 LPD) series. Pathology demonstrated ductal adenocarcinoma in 30.6 % of the specimens, other malignant tumors in 51.7 %, and benign tumor/disease in 17.5 %. The mean number of lymph nodes examined was 14.4 (7-32), and the rate of microscopically positive tumor margin was 4.4 %. CONCLUSIONS In selected patients, operated on by expert laparoscopic pancreatic surgeons, LPD is feasible and safe.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124, Pisa, Italy,
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