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Duan P, Sun L, Kou K, Li XR, Zhang P. Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2024; 23:449-457. [PMID: 37980179 DOI: 10.1016/j.hbpd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 10/31/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. DATA SOURCES Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. RESULTS In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. CONCLUSIONS Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.
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Affiliation(s)
- Peng Duan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Lu Sun
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Kai Kou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Xin-Rui Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China.
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Al Abbas AI, Namazi B, Radi I, Alterio R, Abreu AA, Rail B, Polanco PM, Zeh HJ, Hogg ME, Zureikat AH, Sankaranarayanan G. The development of a deep learning model for automated segmentation of the robotic pancreaticojejunostomy. Surg Endosc 2024:10.1007/s00464-024-10725-x. [PMID: 38488870 DOI: 10.1007/s00464-024-10725-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 01/28/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Minimally invasive surgery provides an unprecedented opportunity to review video for assessing surgical performance. Surgical video analysis is time-consuming and expensive. Deep learning provides an alternative for analysis. Robotic pancreaticoduodenectomy (RPD) is a complex and morbid operation. Surgeon technical performance of pancreaticojejunostomy (PJ) has been associated with postoperative pancreatic fistula. In this work, we aimed to utilize deep learning to automatically segment PJ RPD videos. METHODS This was a retrospective review of prospectively collected videos from 2011 to 2022 that were in libraries at tertiary referral centers, including 111 PJ videos. Each frame of a robotic PJ video was categorized based on 6 tasks. A 3D convolutional neural network was trained for frame-level visual feature extraction and classification. All the videos were manually annotated for the start and end of each task. RESULTS Of the 100 videos assessed, 60 videos were used for the training the model, 10 for hyperparameter optimization, and 30 for the testing of performance. All the frames were extracted (6 frames/second) and annotated. The accuracy and mean per-class F1 scores were 88.01% and 85.34% for tasks. CONCLUSION The deep learning model performed well for automated segmentation of PJ videos. Future work will focus on skills assessment and outcome prediction.
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Affiliation(s)
- Amr I Al Abbas
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | - Babak Namazi
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | - Imad Radi
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | - Rodrigo Alterio
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | - Andres A Abreu
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | - Benjamin Rail
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | - Patricio M Polanco
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA
| | | | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ganesh Sankaranarayanan
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA.
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3
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Boone BA. Employing Advanced Technology to Reduce Postoperative Pancreatic Fistula. ANNALS OF SURGERY OPEN 2024; 5:e373. [PMID: 38883937 PMCID: PMC11175965 DOI: 10.1097/as9.0000000000000373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/08/2023] [Indexed: 06/18/2024] Open
Affiliation(s)
- Brian A Boone
- From the Department of Surgery, West Virginia University, Morgantown, WV
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV
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Kakati RT, Naffouje S, Spanheimer PM, Dahdaleh FS. Role of minimally invasive surgery in the management of localized pancreatic ductal adenocarcinoma: a review. J Robot Surg 2024; 18:85. [PMID: 38386224 DOI: 10.1007/s11701-024-01825-w] [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: 10/15/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal malignancy with a minority of patients eligible for curative-intent surgical intervention. Pancreatic resections are technically demanding operations associated with considerable morbidity and mortality. Minimally invasive pancreatic resections (MIPRs), which include laparoscopic and robotic approaches, may enhance postoperative outcomes by lessening physiological impact of open surgery. A limited number of randomized-controlled trials as well as numerous retrospective reports have focused on MIPR outcomes and role in management of a variety of tumors, including PDAC. Today, MIPRs are generally considered acceptable alternatives to open surgery as a trend towards improved short-term metrics is observed. However, several questions remain regarding the oncological adequacy of MIPR's as long-term experience is less extensive compared to open techniques. This review aims to summarize existing evidence on MIPRs with a focus on PDAC.
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Affiliation(s)
- Rasha T Kakati
- Department of Surgical Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Samer Naffouje
- Department of Surgical Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Philip M Spanheimer
- Department of Surgical Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Fadi S Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA.
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5
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Pryor AD, Lendvay T, Jones A, Ibáñez B, Pugh C. An American Board of Surgery Pilot of Video Assessment of Surgeon Technical Performance in Surgery. Ann Surg 2023; 277:591-595. [PMID: 36645875 DOI: 10.1097/sla.0000000000005804] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The American Board of Surgery (ABS) sought to investigate the suitability of video-based assessment (VBA) as an adjunct to certification for assessing technical skills. BACKGROUND Board certification is based on the successful completion of a residency program coupled with knowledge and reasoning assessments. VBA is a new modality for evaluating operative skills that have been shown to correlate with patient outcomes after surgery. METHODS Diplomates of the ABS were initially assessed for background knowledge and interest in VBA. Surgeons were then solicited to participate in the pilot. Three commercially available VBA platforms were identified and used for the pilot assessment. All participants served as reviewers and reviewees for videos. After the interaction, participants were surveyed regarding their experiences and recommendations to the ABS. RESULTS To the initial survey, 4853/25,715 diplomates responded. The majority were neither familiar with VBA, nor the tools used for operative assessments. Two hundred seventy-four surgeons actively engaged in the subsequent pilot. One hundred sixty-nine surgeons completed the postpilot survey. Most participants found the process straightforward. Of the participants, 74% felt that the feedback would help their surgical practice. The majority (81%) remain interested in VBA for continuing medical education credits. Using VBA in continuous certification could improve surgeon skills felt by 70%. Two-thirds of participants felt VBA could help identify and remediate underperforming surgeons. Identified barriers to VBA included limitations for open surgery, privacy issues, and technical concerns. CONCLUSIONS VBA is promising as an adjunct to the current board certification process and should be further considered by the ABS.
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Affiliation(s)
- Aurora D Pryor
- Department of Surgery, Hofstra University/Northwell Health, Long Island, NY
| | - Thomas Lendvay
- Department of Urology, University of Washington, Seattle, WA
| | | | | | - Carla Pugh
- Department of Surgery, Stanford University, Palo Alto, CA
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Mederos MA, Starr S, Park JY, King JC, Tomlinson JS, Hines OJ, Donahue TR, Girgis MD. Robotic versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis. HPB (Oxford) 2023; 25:301-310. [PMID: 36529625 DOI: 10.1016/j.hpb.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/24/2022] [Accepted: 11/29/2022] [Indexed: 03/05/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is complex procedure with high morbidity in the elderly. This retrospective study aimed to compare post-operative outcomes in patients ≥75 years of age who underwent robot-assisted (RA)PD and open PD. METHODS We analyzed 2502 patients ≥75 years of age who underwent PD from 2015 to 2018 in the National Surgical Quality Improvement Program (NSQIP) database. RAPD and open PD patients were propensity score matched 1:5 to assess the 30-day outcomes of interest: postoperative complications, length of stay, discharge destination, and readmissions. RESULTS Of 725 matched patients, 110 underwent RAPD, 615 OPD, and 12 were converted to an open operation. Post-operative outcomes were largely similar between cohorts. RAPD was associated a shorter length of stay (median 8 days, interquartile range [IQR] 6 to 11) than OPD (median 8 days, IQR 7 to 13) (p = 0.003). However, RAPD was associated with more readmissions (28.1% vs. 17.7%; p = 0.02). CONCLUSIONS RAPD in patients ≥75 years of age appears to be safe and has a similar complication profile to open PD. Randomized or well-designed prospective matched studies are needed to confirm these findings.
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Affiliation(s)
- Michael A Mederos
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA.
| | - Savannah Starr
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Joon Y Park
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA
| | - Jonathan C King
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - James S Tomlinson
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Surgical Oncology, Los Angeles, CA, USA
| | - O J Hines
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - Timothy R Donahue
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - Mark D Girgis
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Surgical Oncology, Los Angeles, CA, USA
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7
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Takagi K, Umeda Y, Yoshida R, Fuji T, Yasui K, Kimura J, Hata N, Yagi T, Fujiwara T. Surgical Techniques of Gastrojejunostomy in Robotic Pancreatoduodenectomy: Robot-Sewn versus Stapled Gastrojejunostomy Anastomosis. J Clin Med 2023; 12:jcm12020732. [PMID: 36675661 PMCID: PMC9863298 DOI: 10.3390/jcm12020732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/18/2023] Open
Abstract
Background: Delayed gastric emptying (DGE) is a major complication of pancreatoduodenectomy (PD). Several efforts have been made to decrease the incidence of DGE. However, the optimal anastomotic method for gastro/duodenojejunostomy (GJ) remains debatable. Moreover, few studies have reported the impact of GJ surgical techniques on outcomes following robotic pancreatoduodenectomy (RPD). This study aimed to investigate the surgical outcomes of robot-sewn and stapled GJ anastomoses in RPD. Methods: Forty patients who underwent RPD at the Okayama University Hospital between September 2020 and October 2022 were included. The outcomes between robot-sewn and stapled anastomoses were compared. Results: The mean [standard deviation (SD)] operative and GJ time were 428 (63.5) and 34.0 (15.0) minutes, respectively. Postoperative outcomes included an overall incidence of DGE of 15.0%, and the mean postoperative hospital stays were 11.6 (5.3) days in length. The stapled group (n = 21) had significantly shorter GJ time than the robot-sewn group (n = 19) (22.7 min versus 46.5 min, p < 0.001). Moreover, stapled GJ cases were significantly associated with a lower incidence of DGE (0% versus 21%, p = 0.01). Although not significant, the stapled group tended to have shorter postoperative hospital stays (9.9 days versus 13.5 days, p = 0.08). Conclusions: Our findings suggest that stapled GJ anastomosis might decrease anastomotic GJ time and incidence of DGE after RPD. Surgeons should select a suitable method for GJ anastomosis based on their experiences with RPD.
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Teres ligamentum wrap covering the pancreaticojejunostomy following pancreatoduodenectomy is associated with a lower rate of postoperative pancreas fistula: a prospective cohort study. HPB (Oxford) 2023; 25:116-123. [PMID: 36280427 DOI: 10.1016/j.hpb.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/26/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreas fistula (POPF) is a common complication after pancreatoduodenectomy (PD). A Teres Ligamentum (TL)-wrap covering the pancreaticojejunostomy (PJ) is suggested as a potential solution to reduce POPF. The aim of this study was to compare POPF incidence (grade B/C) in patients with or without a TL-wrap. METHODS A prospective cohort study was performed between January 2019-December 2021. All consecutive patients were included. Patient, tumor and surgical characteristics and postoperative complications were compared in both open and robot-assisted surgery. RESULTS A total of 118 consecutive patients were included. The first 57 patients were treated without and the following 61 patients with a TL-wrap. There were no statistically significant differences between both groups regarding patient, pre-operative treatment and surgical characteristics. The occurrence of POPF was strongly reduced in the TL-wrap group compared to patients without a TL-wrap (3.3% vs 28.1%, P < 0.001). Also mean length of hospital stay was reduced (11.5 vs 18.8 days, P = 0.030). CONCLUSION The use of a TL-wrap covering the PJ as addition to the modified Blumgart anastomosis technique is associated with a significantly reduced POPF rate and a reduced length of hospital stay. A TL-wrap is a simple addition to a PJ that may be considered to improve postoperative outcome. This association must be studied more definitively in a randomized controlled trial.
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Risk factors for delayed gastric emptying in pancreaticoduodenectomy. Sci Rep 2022; 12:22270. [PMID: 36564517 PMCID: PMC9789159 DOI: 10.1038/s41598-022-26814-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022] Open
Abstract
The study of robotic pancreaticouodenectomy (RPD) focusing on delayed gastric emptying (DGE) is seldom reported. This study explored the incidence of DGE in RPD with extracorporeal hand-sewn gastrojejunostomy involving downward positioning of the stomach. Patients with periampullary lesions undergoing RPD or open pancreaticouodenectomy (OPD) were included for comparison. A variety of clinical factors were evaluated for the risk of developing DGE. There were 409 (68.2%) RPD and 191 (31.8%) OPD in this study. DGE occurred in 7.7% of patients after pancreaticoduodenectomy, with 4.4% in RPD and 14.7% in OPD, p < 0.001. Nausea/vomiting (12.6% vs. 6.3%) and jaundice (9.9% vs. 5.2%) were significant preoperative risk factors for DGE, while malignancy (8.7% vs. 2.2%) and lymph node involvement (9.8% vs. 5.6%) were significant pathological risk factors. Intraoperative blood loss > 200 c.c. was the other factor related to DGE (11.2% vs. 4.4% in those with blood loss ≤ 200 c.c.). None of the postoperative complications was significantly associated with DGE. Hospital stay was significantly longer in the group with DGE (median, 37 vs. 20 days in the group without DGE). After multivariate analysis by binary logistic regression, compared with OPD, RPD was the only independent factor associated with a lower incidence of DGE. RPD with extracorporeal hand-sewn antecolic, antiperistaltic, and inframesocolic gastrojejunostomy via a small umbilical wound involving careful downward positioning of the stomach was associated with a low incidence of DGE and presented as the most powerful independent predictor of this condition.
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Jiang P, Li X, Wang S, Liu Y. Prognostic Significance of PNI in Patients With Pancreatic Head Cancer Undergoing Laparoscopic Pancreaticoduodenectomy. Front Surg 2022; 9:897033. [PMID: 35722527 PMCID: PMC9198448 DOI: 10.3389/fsurg.2022.897033] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background Recently, several prognosis indicators based on inflammatory and nutritional factors, such as the neutrophil-to-lymphocyte ratio (NLR), plated-to-lymphocyte (PLR), lymphocyte-to-monocyte (LMR) and prognosis nutritional index (PNI), have been proposed as prognosis factors for several cancers. However, few studies have looked into PNI. The goal of this research was to see if preoperative PNI had any predictive value in patients with pancreatic head cancer who were having a laparoscopic pancreaticoduodenectomy. Methods From February 11, 2018 to May 31, 2019, two hundred and fifty-one pancreatic head carcinoma patients were retrospectively enrolled. The receiver operator characteristic (ROC) curve was used to determine the cut-off value. Patients were divided into two groups: PNI > 45.1 (high PNI group) and PNI < 45.1 (low PNI group), and clinic-pathological data was compared between the two groups. The link between PNI and NLR, PLR, and LMR, and their effect on overall survival. In addition, the factors of postoperative survival were analyzed univariate and multivariate. Results PNI, NLR, PLR and LMR cut-off values were 45.1, 3.7,287.2 and 3.6, respectively. Between the two groups of patients, the low PNI group exhibited considerably higher PLR and lower LMR. PNI had a negative correlation with PLR and NLR (r = −0.329, p < 0.001 and r = 0.170, p = 0.014), but a positive correlation with LMR (r = 0.476, p < 0.001). The high PNI group had a considerably greater survival rate than the low PNI group (median survival days, 217 vs. 468, log-rank = 45.92, p < 0.001). PNI < 45.1(HR: 0.357, 95 percent CI, 0.263–0.485, p < 0.001) and LMR <3.6(HR: 0.705, 95 percent CI, 0.528–0.942, p < 0.018) were revealed to be possible predictive variable in univariate analysis. Only PNI <45.1 was found to be an independent predictive factor in multivariate analysis (HR: 0.359, 95%CI,: 0.256–0.502, p < 0.001). Conclusions Our findings shoe that PNI is linked to a variety of systemic inflammatory response and can be used to predict survival in individuals with pancreatic head cancer.
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The impact of gastrojejunostomy orientation on delayed gastric emptying after pancreaticoduodenectomy: a single center comparative analysis. HPB (Oxford) 2022; 24:654-663. [PMID: 34654621 DOI: 10.1016/j.hpb.2021.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/14/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) represents the most frequent complication after pancreaticoduodenectomy (PD). Aim of this study was to evaluate the impact of gastrojejunostomy (GJ)orientation on DGE incidence after PD. METHODS One-hundred and twenty-one consecutive PDs were included in the analysis and divided in the horizontal (H-GJ group) and vertical GJ anastomosis groups (V-GJ group). Postoperative data and the value of the flow angle between the efferent jejunal limb and the stomach of the GJ anastomosis at the upper gastrointestinal series were registered. RESULTS Seventy-five patients (62%)underwent H-GJ, while 46 patients (38%)underwent V-GJ. The incidence of DGE was significantly lower in the V-GJ group as compared to the H-GJ group (23.9%vs45.3%; p = 0.02). V-GJ was also associated to a less severe DGE manifestation (p = 0.006). The flow angle was significantly lower in case of V-GJ as compared to H-GJ (24.5°vs37°; p = 0.002). At the multivariate analysis, ASA score≥3 (p = 0.02), H-GJ (p = 0.03), flow angle>30°(p = 0.004) and Clavien-Dindo≥3 (p = 0.03) were recognized as independent prognostic factors for DGE. These same factors were independent prognostic features also for a more severe DGE manifestation. CONCLUSION VGJ and the more acute flow angle appear to be associated to a lower incidence rate and severity of DGE. This modified technique should be considered by surgeons in order to reduce postoperative DGE occurrence.
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12
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Kuemmerli C, Tschuor C, Kasai M, Alseidi AA, Balzano G, Bouwense S, Braga M, Coolsen M, Daniel SK, Dervenis C, Falconi M, Hwang DW, Kagedan DJ, Kim SC, Lavu H, Liang T, Nussbaum D, Partelli S, Passeri MJ, Pecorelli N, Pillai SA, Pillarisetty VG, Pucci MJ, Su W, Sutcliffe RP, Tingstedt B, van der Kolk M, Vrochides D, Wei A, Williamsson C, Yeo CJ, Zani S, Zouros E, Abu Hilal M. Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis. Br J Surg 2022; 109:256-266. [PMID: 35037019 DOI: 10.1093/bjs/znab436] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy. METHODS The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission. RESULTS Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate. CONCLUSION ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.
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Affiliation(s)
- Christoph Kuemmerli
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Clarunis-University Centre for Gastrointestinal and Liver Diseases Basle, Basle, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Adnan A Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marco Braga
- Department of Surgery, Monza Hospital, University of Milano Bicocca, Monza, Italy
| | - Mariëlle Coolsen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sara K Daniel
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Christos Dervenis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Daniel Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Michael J Passeri
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Sastha Ahanatha Pillai
- Department of Surgery, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, India
| | - Venu G Pillarisetty
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wei Su
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Robert P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Efstratios Zouros
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Mohammed Abu Hilal
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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13
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Arango NP, Prakash LR, Chiang YJ, Dewhurst WL, Bruno ML, Ikoma N, Kim MP, Lee JE, Katz MHG, Tzeng CWD. Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying. J Gastrointest Surg 2021; 25:2221-2230. [PMID: 33236322 DOI: 10.1007/s11605-020-04877-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD) that impairs recovery and quality of life. The purpose of this study was to assess the impact risk-stratified pancreatectomy clinical pathways (RSPCPs) had on delayed gastric emptying (DGE) and identify factors associated with DGE in a contemporary period. METHODS A single-institution, prospective database was queried for consecutive PDs during July 2011-November 2019. Using international definitions, DGE rates were compared between periods before and after RSPCPs were implemented in 2016, classifying patients according to their postoperative pancreatic fistula (POPF) risk. Risk factors were analyzed to identify modifiable targets. RESULTS Among 724 elective PDs, 552 (76%) were for adenocarcinoma and 172 (24%) for other diagnoses. Of the 197 (27%) patients with DGE, 119 (16%) had type A, 41 (6%) type B, and 38 (5%) type C. In the overall cohort, DGE rates were higher with pylorus-preserving vs. classic hand-sewn reconstruction (odds ratio [OR] - 1.84; p < 0.001), postoperative abscess (OR - 2.54; p = 0.003), and non-white patients (p = 0.007), but lower after implementation of RSPCPs (OR - 0.34, p < 0.001). In the 374 patients treated with RSPCPs, only 17% (n = 65/374) developed DGE. Patients with protocol-compliant NGT removal ≤ 48 h were less likely to experience DGE (OR - 1.46, p = 0.042). CONCLUSION Our data suggest that implementation of preoperatively assigned RSPCPs as a care bundle was the most important factor in decreasing DGE. These gains were accentuated in patients who underwent early nasogastric tube removal and had a classic hand-sewn gastro-jejunostomy reconstruction. Application of these modifiable factors is generalizable with low implementation barriers.
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Affiliation(s)
- Natalia Paez Arango
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA.
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14
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Mascagni P, Rodríguez-Luna MR, Urade T, Felli E, Pessaux P, Mutter D, Marescaux J, Costamagna G, Dallemagne B, Padoy N. Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures. J Am Coll Surg 2021; 233:497-505. [PMID: 34325017 DOI: 10.1016/j.jamcollsurg.2021.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The critical view of safety (CVS) is poorly adopted in surgical practices although it is ubiquitously recommended to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aims to investigate whether performing a short intraoperative time out can improve CVS implementation. STUDY DESIGN In this before versus after study, surgeons performing LCs at an academic center were invited to use a 5-second long time out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LCs performed in the year before versus the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by two independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared. RESULTS 343 of the 381 LCs performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9 vs. 44.1% before vs. after the 5-second rule, respectively; P<0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2 vs. 15.7%; P=0.04), the median [IQR] time to clip the cystic duct or artery (00:17:26 [00:11:48, 00:28:35] vs. 00:23:12 [00:14:29, 00:31:45] duration; P=0.007), and the rate of postoperative CVS reporting (1.3 vs. 28.8%; P<0.001). Postoperative morbidity was comparable (1.8 vs. 2.3%; P=0.68). CONCLUSION Performing a short intraoperative time out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.
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Affiliation(s)
- Pietro Mascagni
- ICube, University of Strasbourg, CNRS, IHU Strasbourg, France; Gastrointestinal Endoscopic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | | | - Takeshi Urade
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Emanuele Felli
- Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Patrick Pessaux
- Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Didier Mutter
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Jacques Marescaux
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France
| | - Guido Costamagna
- Gastrointestinal Endoscopic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Center for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica S. Cuore, Rome, Italy
| | - Bernard Dallemagne
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France; IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France; Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Nicolas Padoy
- ICube, University of Strasbourg, CNRS, IHU Strasbourg, France; IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
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15
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Jopling JK, Visser BC. Mastering the thousand tiny details: Routine use of video to optimize performance in sport and in surgery. ANZ J Surg 2021; 91:1981-1986. [PMID: 34309995 DOI: 10.1111/ans.17076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/20/2021] [Accepted: 07/06/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Jeffrey K Jopling
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Brendan C Visser
- Department of Surgery, Stanford University, Stanford, California, USA
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16
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Miyazawa M, Kawai M, Hirono S, Okada KI, Kitahata Y, Kobayashi R, Ueno M, Hayami S, Miyamoto A, Yamaue H. Previous upper abdominal surgery is a risk factor for nasogastric tube reinsertion after pancreaticoduodenectomy. Surgery 2021; 170:1223-1230. [PMID: 33958204 DOI: 10.1016/j.surg.2021.03.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/28/2021] [Accepted: 03/30/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy without subsequent nasogastric tube management has not been widely adopted due to delayed gastric emptying, the specific and frequent morbidity associated with this surgical procedure. We assessed the feasibility of pancreaticoduodenectomy without use of nasogastric tubes and the risk factors for subsequent nasogastric tube reinsertion. METHODS We retrospectively reviewed 465 patients who underwent pancreaticoduodenectomy at a single institution between 2010 and 2019. Primary endpoint was the rate of nasogastric tube reinsertion. Logistic regression analysis was used to determine independent risk factors of nasogastric tube reinsertion and delayed gastric emptying. RESULTS The rate of nasogastric tube reinsertion was 10.1% (47/465). The rate of delayed gastric emptying was 9.5% (44/465). Logistic regression analysis identified 4 independent risk factors for nasogastric tube reinsertion: male sex (odds ratio = 4.42; 95% confidence interval 1.50-13.0, P = .007), comorbidity of cardiac ischemia (odds ratio = 3.04; 95% confidence interval 1.05-8.79, P = .041), preoperative cholangitis or cholecystitis (odds ratio = 2.21; 95% confidence interval 1.02-4.76, P = .044), and previous upper abdominal surgery (odds ratio = 8.34; 95% confidence interval 3.07-22.7, P < .001). Independent risk factors for delayed gastric emptying were male sex (odds ratio = 3.20; 95% confidence interval 1.11-9.21, P = .031), comorbidity of cardiac ischemia (odds ratio = 3.81; 95% confidence interval 1.34-10.8, P = .012), concomitant organ resection (odds ratio = 3.99; 95% confidence interval 1.10-14.4, P = .035), and previous upper abdominal surgery (odds ratio = 7.21; 95% confidence interval 2.68-19.4, P < .001). CONCLUSION Pancreaticoduodenectomy without use of nasogastric tubes is feasible, but patients with previous upper abdominal surgery require careful postoperative nasogastric tube management.
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Affiliation(s)
- Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ryohei Kobayashi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masaki Ueno
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinya Hayami
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Atsushi Miyamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
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17
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Liu X, Chen Q, Fu Y, Lu Z, Chen J, Guo F, Li Q, Wu J, Gao W, Jiang K, Dai C, Miao Y, Wei J. Early Nasojejunal Nutrition Versus Early Oral Feeding in Patients After Pancreaticoduodenectomy: A Randomized Controlled Trial. Front Oncol 2021; 11:656332. [PMID: 33996579 PMCID: PMC8118637 DOI: 10.3389/fonc.2021.656332] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Objective The aim of this study was to test the hypothesis that early oral feeding (EOF) is superior to early nasojejunal nutrition (ENN) after pylorus-preserving pancreaticoduodenectomy (PPPD) in terms of delayed gastric emptying (DGE). Background DGE is a common complication after PPPD. Although EOF after PPPD is recommended by several international guidelines, there is no randomized trial to support this recommendation. Methods From September 2016 to December 2017, a total of 120 patients undergoing PPPD were randomized into the ENN, EOF, or saline groups at a 1:1:1 ratio (40 patients in each group). The primary endpoint was the rate of clinically relevant DGE. Secondary endpoints included overall morbidity, postoperative pancreatic fistula, post-pancreatectomy hemorrhage, abdominal infection, length of hospital stay, reoperation rate, and in-hospital mortality. Results The baseline characteristics and operative parameters were comparable between the groups. The incidence of clinically relevant DGE varied significantly among the three groups (ENN, 17.5%; EOF, 10.0%; saline, 32.5%; p =0.038). The saline group had a higher clinically relevant DGE rate than the EOF group (p = 0.014). The saline group also had greater overall morbidities than the ENN and EOF groups (p = 0.041 and p = 0.006, respectively). There were no significant differences in other surgical complication rates or postoperative hospital stay. No mortality was observed in any of the groups. Conclusions Nutritional support methods were not related to DGE after PPPD. EOF was feasible and safe after PPPD, and additional ENN should not be routinely administered to patients after PPPD. Clinical Trial Registration ClinicalTrials.gov, identifier NCT03150615.
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Affiliation(s)
- Xinchun Liu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of General Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiuyang Chen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Fu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianmin Chen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Guo
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qiang Li
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wentao Gao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Cuncai Dai
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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18
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Chen K, Pan Y, Huang CJ, Chen QL, Zhang RC, Zhang MZ, Wang GY, Wang XF, Mou YP, Yan JF. Laparoscopic versus open pancreatic resection for ductal adenocarcinoma: separate propensity score matching analyses of distal pancreatectomy and pancreaticoduodenectomy. BMC Cancer 2021; 21:382. [PMID: 33836678 PMCID: PMC8034161 DOI: 10.1186/s12885-021-08117-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 03/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a leading causes of cancer mortality worldwide. Currently, laparoscopic pancreatic resection (LPR) is extensively applied to treat benign and low-grade diseases related to the pancreas. The viability and safety of LPR for PDAC needs to be understood better. Laparoscopic distal pancreatectomy (LDP) and pancreaticoduodenectomy (LPD) are the two main surgical approaches for PDAC. We performed separate propensity score matching (PSM) analyses to assess the surgical and oncological outcomes of LPR for PDAC by comparing LDP with open distal pancreatectomy (ODP) as well as LPD with open pancreaticoduodenectomy (OPD). METHODS We assessed the data of patients who underwent distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) for PDAC between January 2004 and February 2020 at our hospital. A one-to-one PSM was applied to prevent selection bias by accounting for factors such as age, sex, body mass index, and tumour size. The DP group included 86 LDP patients and 86 ODP patients, whereas the PD group included 101 LPD patients and 101 OPD patients. Baseline characteristics, intraoperative effects, postoperative recovery, and survival outcomes were compared. RESULTS Compared to ODP, LDP was associated with shorter operative time, lesser blood loss, and similar overall morbidity. Of the 101 patients who underwent LPD, 10 patients (9.9%) required conversion to laparotomy. The short-term surgical advantage of LPD is not as apparent as that of LDP due to conversions. Compared with OPD, LPD was associated with longer operative time, lesser blood loss, and similar overall morbidity. For oncological and survival outcomes, there were no significant differences in tumour size, R0 resection rate, and tumour stage in both the DP and PD subgroups. However, laparoscopic procedures appear to have an advantage over open surgery in terms of retrieved lymph nodes (DP subgroup: 14.4 ± 5.2 vs. 11.7 ± 5.1, p = 0.03; PD subgroup 21.9 ± 6.6 vs. 18.9 ± 5.4, p = 0.07). These two groups did not show a significant difference in the pattern of recurrence and overall survival rate. CONCLUSIONS Laparoscopic DP and PD are feasible and oncologically safe procedures for PDAC, with similar postoperative outcomes and long-term survival among patients who underwent open surgery.
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Affiliation(s)
- Ke Chen
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Yu Pan
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Chao-Jie Huang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Qi-Long Chen
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Ren-Chao Zhang
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Miao-Zun Zhang
- Department of Hepatopancreatobiliary Surgery, Ningbo Medical Center, Lihuili Hospital, Ningbo, 315100, Zhejiang Province, China
| | - Guan-Yu Wang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Xian-Fa Wang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Yi-Ping Mou
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Jia-Fei Yan
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
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19
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Sun YL, Gou JJ, Zhang KM, Li WQ, Ma XX, Zhou L, Zhu RT, Li J. Complete resection of the gastric antrum decreased incidence and severity of delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2021; 20:182-189. [PMID: 33342660 DOI: 10.1016/j.hbpd.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 10/30/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is the main complication after pancreaticoduodenectomy (PD), but the mechanism is still unclear. The aim of this study was to elucidate the role of complete resection of the gastric antrum in decreasing incidence and severity of DGE after PD. METHODS Sprague-Dawley rats were divided into three groups: expanded resection (ER group), complete resection (CR group), and incomplete resection (IR group) of the gastric antrum. The tension (g) of remnant stomach contraction was observed. We analyzed the histological morphology of the gastric wall by different excisional methods after distal gastrectomy. Moreover, patients underwent PD at our department between January 2012 and May 2016 were included in the study. These cases were divided into IR group and CR group of the gastric antrum, and the clinical data were retrospectively analyzed. RESULTS The ex vivo remnant stomachs of CR group exhibited much greater contraction tension than others (P < 0.05). The contraction tension of the remnant stomach increased with increasing acetylcholine concentration, while remained stable at the concentration of 10 × 10-5 mol/L. Furthermore, 174 consecutive patients were included and retrospectively analyzed in the study. The incidence of DGE was significantly lower (3.5% vs. 21.3%, P < 0.01) in CR group than in IR group. In addition, hematoxylin-eosin staining analyses of the gastric wall confirmed that the number of transected circular smooth muscle bundles were higher in IR group than in CR group (8.24 ± 0.65 vs. 3.76 ± 0.70, P < 0.05). CONCLUSIONS The complete resection of the gastric antrum is associated with decreased incidence and severity of DGE after PD. Gastric electrophysiological and physiopathological disorders caused by damage to gastric smooth muscles might be the mechanism underlying DGE.
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Affiliation(s)
- Yu-Ling Sun
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China.
| | - Jian-Jun Gou
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Kai-Ming Zhang
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Wen-Qi Li
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Xiu-Xian Ma
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Lin Zhou
- Department of Digestive, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Rong-Tao Zhu
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Jian Li
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
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20
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Takagi K, Umeda Y, Yoshida R, Yagi T, Fujiwara T, Zureikat AH, Hogg ME, Koerkamp BG. Surgical training model and safe implementation of robotic pancreatoduodenectomy in Japan: a technical note. World J Surg Oncol 2021; 19:55. [PMID: 33608019 PMCID: PMC7896387 DOI: 10.1186/s12957-021-02167-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/09/2021] [Indexed: 01/15/2023] Open
Abstract
Background Growing evidence for the advantages of robotic pancreatoduodenectomy (RPD) has been demonstrated internationally. However, there has been no structured training program for RPD in Japan. Herein, we present the surgical training model of RPD and a standardized protocol for surgical technique. Methods The surgical training model and surgical technique were standardized in order to implement RPD safely, based on the Dutch training system collaborated with the University of Pittsburgh Medical Center. Results The surgical training model included various trainings such as basic robotic training, simulation training, biotissue training, and a surgical video review. Furthermore, a standardized protocol on the surgical technique was established to understand the tips, tricks, and pitfalls of RPD. Conclusions Safe implementation of RPD can be achieved through the completion of a structured training program and learning surgical technique. A nationwide structured training system should be developed to implement the program safely in Japan. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02167-9.
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Affiliation(s)
- Kosei Takagi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan. .,Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Yuzo Umeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Ryuichi Yoshida
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takahito Yagi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, North Shore Hospital, Chicago, IL, USA
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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21
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Video review reveals technical factors predictive of biliary stricture and cholangitis after robotic pancreaticoduodenectomy. HPB (Oxford) 2021; 23:144-153. [PMID: 32646806 DOI: 10.1016/j.hpb.2020.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/13/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholangitis due to anastomotic stricture of the hepaticojejunostomy (HJ) following pancreaticoduodenectomy (PD), while uncommon, adversely affects postoperative quality-of-life. While prior studies have identified patient-related risk factors for these biliary complications, technical risk factors have not been systematically examined. Video review of surgical procedures has helped define technical details predictive of postoperative complications in bariatric and hepato-pancreato-biliary (HPB) surgery. Similarly, the present study utilized video review to identify technical factors associated with cholangitis and anastomotic biliary stricture following robotic PD. METHODS This was an observational study. A blinded experienced HPB surgeon reviewed videos of post-learning-curve HJs performed during robotic PD and extracted 20 technical variables. Other demographic and clinical variables were collected from a prospectively maintained database. RESULTS 241 robotic PD videos were reviewed. 29 (12.0%) developed cholangitis and/or biliary stricture, with a median time-to-event of 189 (IQR 78-365) days. Several clinical and technical factors were independently predictive of cholangitis and/or biliary stricture: preoperative radiotherapy, small duct size (<10 mm diameter), increased distance of the HJ (>10 mm) from the hilar plate, and continuous suturing technique. CONCLUSION Post-hoc video review of HJ is a powerful method to predict biliary complications. Moreover, altering specific technical factors might enable surgeons to improve postoperative outcomes.
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22
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de Groot EM, Möller T, Kingma BF, Grimminger PP, Becker T, van Hillegersberg R, Egberts JH, Ruurda JP. Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy. Dis Esophagus 2020; 33:6006405. [PMID: 33241304 DOI: 10.1093/dote/doaa055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/18/2020] [Accepted: 05/23/2020] [Indexed: 02/07/2023]
Abstract
The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1-3) started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1-10) and ended at 20% (cases 51-60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.
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Affiliation(s)
- Eline M de Groot
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thorben Möller
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter P Grimminger
- Department for General, Visceral-, Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Thomas Becker
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany
| | | | - Jan-Hendrik Egberts
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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23
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Zeh HJ, Wong SL, Heslin MJ. Warm and Welcoming: Is It What We Say or How We Say It? Ann Surg Oncol 2020; 27:3581-3582. [PMID: 32699929 DOI: 10.1245/s10434-020-08908-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Herbert J Zeh
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sandra L Wong
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Martin J Heslin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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24
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SAGES Video-Based Assessment (VBA) program: a vision for life-long learning for surgeons. Surg Endosc 2020; 34:3285-3288. [DOI: 10.1007/s00464-020-07628-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/04/2020] [Indexed: 12/22/2022]
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25
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Baimas-George M, Watson M, Murphy KJ, Iannitti D, Baker E, Ocuin L, Vrochides D, Martinie JB. Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study. Surg Endosc 2020; 34:3644-3649. [PMID: 32328825 DOI: 10.1007/s00464-020-07564-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma. METHODS A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann-Whitney U test, log rank tests, and Kaplan-Meier methods. RESULTS Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5; p = 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%; p = 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9; p = 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0 months; p = 0.1105) and longer time to recurrence (402 vs. 284 days; p = 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence. CONCLUSIONS While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.
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Affiliation(s)
- Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA.
- Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28203, USA.
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26
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Abstract
OBJECTIVE Compare oncologic outcomes after open and robotic pancreatic resections for pancreatic adenocarcinoma (PDAC). SUMMARY OF BACKGROUND DATA Receipt of adjuvant chemotherapy improves survival after resected PDAC. Complications after pancreatectomy have been shown to prohibit the administration of adjuvant chemotherapy and survival. We examined the effect of surgical approach on receipt of adjuvant chemotherapy, complications, and overall survival after pancreatectomy. METHODS A single-institution retrospective review of all patients with PDAC who underwent robotic or open pancreatectomy from 2011 to 2016 with 24-month follow-up. RESULTS Four hundred fifty-six patients underwent resection: 226 robotic and 230 open. No significant difference was identified in major complications or receipt of adjuvant chemotherapy between robotic and open pancreatectomy, nor was approach an independent predictor of these outcomes. Robotic pancreatectomy patients had a shorter length of stay than patients who underwent open pancreatectomy (7 days vs 9 days; P < 0.001). Additionally, wound infection rate (32.3% vs 12.4%, P < 0.0001) and transfusion (39.6% vs 12.4%, P < 0.0001) was improved in robotic pancreatectomy group with no differences in perioperative mortality. Improved median overall survival approached statistical significance for the robotic cohort (25.6 months vs 23.9 months; P = 0.055); however, on multivariable analysis the robotic approach predicted overall survival, (hazard ratio 0.77, P = 0.041). Robotic approach was an independent predictor of decreased blood loss and less transfusions than the open approach. CONCLUSIONS Robotic pancreatectomy was not inferior compared to open pancreatectomy in a high-volume experienced center for oncologic outcomes and due to decreased blood loss and transfusion may have improved survival.
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27
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Liu R, Wakabayashi G, Palanivelu C, Tsung A, Yang K, Goh BKP, Chong CCN, Kang CM, Peng C, Kakiashvili E, Han HS, Kim HJ, He J, Lee JH, Takaori K, Marino MV, Wang SN, Guo T, Hackert T, Huang TS, Anusak Y, Fong Y, Nagakawa Y, Shyr YM, Wu YM, Zhao Y. International consensus statement on robotic pancreatic surgery. Hepatobiliary Surg Nutr 2019; 8:345-360. [PMID: 31489304 DOI: 10.21037/hbsn.2019.07.08] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.
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Affiliation(s)
- Rong Liu
- Department of Hepatopancreatobiliary Surgical Oncology, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Ageo, Japan
| | - Chinnusamy Palanivelu
- Division of Gastrointestinal Surgery and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, India
| | - Allan Tsung
- Division of Surgical Oncology, Gastrointestinal Disease Specific Research Group, The Ohio State University Wexner Medical Center Department of Surgery, Columbus, OH, USA
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Charing Ching-Ning Chong
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Chang Moo Kang
- Division of HBP Surgery, Yonsei University College of Medicine, Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chenghong Peng
- Pancreatic Disease Centre, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Eli Kakiashvili
- Department of General Surgery, Galilee Medical Center, Nahariya, Israel
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hong-Jin Kim
- Department of Surgery, Yeungnam University Hospital, Daegu, Korea
| | - Jin He
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jae Hoon Lee
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Asan Medical Center, Seoul, Korea
| | - Kyoichi Takaori
- Department of Surgery, Kyoto University Hospital, Shogoin, Sakyo-Ku, Kyoto, Japan
| | - Marco Vito Marino
- Department of General Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Shen-Nien Wang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung
| | - Tiankang Guo
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou 730030, China
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ting-Shuo Huang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung
| | - Yiengpruksawan Anusak
- Minimally Invasive Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuman Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei
| | - Yao-Ming Wu
- Department of Surgery, National Taiwan University Hospital, Taipei
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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28
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Al Abbas AI, Jung JP, Rice MK, Zureikat AH, Zeh HJ, Hogg ME. Methodology for Developing an Educational and Research Video Library in Minimally Invasive Surgery. JOURNAL OF SURGICAL EDUCATION 2019; 76:745-755. [PMID: 30792160 DOI: 10.1016/j.jsurg.2018.10.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/28/2018] [Accepted: 10/11/2018] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Explore the methods used and costs necessary for the creation and maintenance of a surgical video library with an emphasis on its applications in surgical education and scholarship. DESIGN A methodology paper highlighting how to develop and utilize a surgical video library for trainee operative preparation, development of research projects, and surgeon credentialing. SETTING The study was conducted at the University of Pittsburgh Medical Center, a tertiary care medical center. PARTICIPANTS Not applicable. RESULTS The video library includes all recorded robotic operations performed by the Division of Surgical Oncology at the University of Pittsburgh from 2010 to 2018. It includes 929 videos of which 110 selected videos are uploaded for trainee review online to prepare for upcoming operations. These procedures are broken into steps to create intraoperative time metrics for trainee integration. Fellows operated from console in 85% of robotic cases and all 30 fellows could obtain robotic privileges based on case logs. To date 102 short scholarly videos have been created: 7 for manuscripts, 13 as video submissions, 27 in book chapters, and 55 for presentations. Three papers have been published using video review to determine clinical outcomes with four more under evaluation. The cost of the program is <$10,000 annually. CONCLUSIONS Video libraries can be efficiently created utilizing intraoperative recorders for minimally invasive surgery. Breaking surgeries into distinct steps can aid in deliberate integration and answer clinical questions. Overall video libraries are cost effective tools for trainee education, research, and ultimately surgeon credentialing.
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Affiliation(s)
| | - Jae P Jung
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Melissa E Hogg
- Northshore University Health System, Evanston, Illinois.
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