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Munir MM, Rashid Z, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Association between quality metric adherence and overall survival among patients undergoing resection of pancreatic ductal adenocarcinoma. Surgery 2024; 176:873-879. [PMID: 38890100 DOI: 10.1016/j.surg.2024.04.043] [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: 12/01/2023] [Revised: 03/16/2024] [Accepted: 04/29/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Process-based quality metrics are important for improving long-term outcomes after surgical resection. We sought to develop a practical surgical quality score for patients diagnosed with pancreatic ductal adenocarcinoma undergoing curative-intent resection. METHODS Patients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified using the National Cancer Database. Five surgical quality metrics were defined: minimally invasive approach, adequate lymphadenectomy, negative surgical margins, receipt of adjuvant therapy, and no prolonged hospitalization. Log-rank test and multivariable Cox regression analysis were used to determine the association of quality metrics with overall survival. RESULTS A total of 38,228 patients underwent curative-intent resection for pancreatic ductal adenocarcinoma. Median age at diagnosis was 68 years (interquartile range = 61-75), and roughly half the cohort was male (n = 19,562; 51.2%). Quality metrics were achieved on a varied basis: minimally invasive approach (n = 5,701; 14.9%), adequate lymphadenectomy (n = 27,122; 80.0%), negative surgical margin (n = 29,248; 76.5%), receipt of adjuvant therapy (n = 26,006; 68.0%), and absence of prolonged hospitalization (n = 26,470; 69.2%). An integer-based surgical quality score from 0 (no quality metrics) to 16 (all quality metrics) was calculated. Patients with higher scores had progressively better overall survival. Median overall survival differed substantially among the score categories (score = 0-4 points, 8.7 [8.0-9.6] months; 5-8 points, 17.5 [16.9-18.2] months; 9-12 points, 22.1 [21.6-22.8] months; and 13-16 points, 30.8 [30.2-31.3] months; P < .001). On multivariable analysis, risk-adjusted mortality hazards decreased in a stepwise manner with higher scores (0-4 points: reference; 5-8 points: multivariable adjusted hazard ratio = 0.60; 95% CI, 0.57-0.63; 9-12 points: adjusted hazard ratio = 0.49; 95% CI, 0.47-0.52; 13-16 points: and adjusted hazard ratio = 0.37; 95% CI, 0.34-0.40; all P < .001). CONCLUSION Adherence to quality metrics may be associated with improved overall survival. Efforts aimed at increasing compliance with quality metric measures may help optimize long-term outcomes among patients undergoing surgical resection for pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Jones LR, Zwart MJW, de Graaf N, Wei K, Qu L, Jiabin J, Ningzhen F, Wang SE, Kim H, Kauffmann EF, de Wilde RF, Molenaar IQ, Chao YJ, Moraldi L, Saint-Marc O, Nickel F, Peng CM, Kang CM, Machado M, Luyer MDP, Lips DJ, Bonsing BA, Hackert T, Shan YS, Groot Koerkamp B, Shyr YM, Shen B, Boggi U, Liu R, Jang JY, Besselink MG, Abu Hilal M. Learning curve stratified outcomes after robotic pancreatoduodenectomy: International multicenter experience. Surgery 2024:S0039-6060(24)00375-1. [PMID: 39164152 DOI: 10.1016/j.surg.2024.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 01/30/2024] [Accepted: 05/21/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Robotic pancreatoduodenectomy is increasingly being implemented worldwide, with good results reported from individual expert centers. However, it is unclear to what extent outcomes will continue to improve during the learning curve, as large international studies are lacking. METHODS An international retrospective multicenter case series, including consecutive patients after robotic pancreatoduodenectomy from 18 centers in 8 countries in Europe, Asia, and South America until December 31, 2019, was conducted. A cumulative sum analysis was performed to determine the inflection points for the feasibility (operative time and blood loss) and proficiency (postoperative pancreatic fistula grade B/C and major morbidity) learning curves. Outcomes were compared in 3 groups on the basis of the learning curve inflection points. RESULTS Overall, 2,186 patients after robotic pancreatoduodenectomy were included. The feasibility learning curve was reached after 30-45 robotic pancreatoduodenectomy procedures and the proficiency learning curve after 90 robotic pancreatoduodenectomy procedures. These inflection points created 3 phases, which were associated with major morbidity (24.7%, 23.4%, and 12.3%, P < .001) but not 30-day mortality (2.1%, 2.0%, and 1.5%, P = .670). Other outcomes mostly continued to improve, including median operative time 432, 390, and 300 minutes (P < .0001), conversion 6.0%, 4.7%, and 2.7% (P = .002), bile leakage 7.2%, 4.1%, and 2.4% (P < .001), postpancreatectomy hemorrhage 6.5%, 6.1%, and 1.8% (n = 21) but not R0 resection (pancreatic ductal adenocarcinoma only) 78.5%, 73.9%, and 82.8% (P = .35), and 90-day mortality rate 3.1%, 3.5%, and 2.1% (P = .191). Centers performing >20 robotic pancreatoduodenectomies annually had lower rates of conversion, reoperation, and shorter median operative time as compared with centers performing 10-20 robotic pancreatoduodenectomies annually. CONCLUSION This international multicenter study demonstrates that most outcomes of robotic pancreatoduodenectomy continued to improve during 3 learning curve phases without a negative effect on 90-day mortality. Randomized studies are needed in high-volume centers that have surpassed the first learning curves, to compare these outcomes with the open approach.
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Affiliation(s)
- Leia R Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Maurice J W Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Nine de Graaf
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Kongyuan Wei
- Department of Surgery, Chinese PLA General Hospital, Beijing, China
| | - Liu Qu
- Department of Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jin Jiabin
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Fu Ningzhen
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, Taiwan
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Emanuele F Kauffmann
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, the Netherlands
| | - Ying Jui Chao
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Luca Moraldi
- Department of Surgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Felix Nickel
- Department of Surgery, University Hospital of Heidelberg, Germany
| | - Cheng-Ming Peng
- Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chang Moo Kang
- Department of Surgery, Yonsei University Severance Hospital, Sinchon-dong, South Korea
| | - Marcel Machado
- Department of Surgery, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - Thilo Hackert
- Department of Surgery, University Hospital of Heidelberg, Germany
| | - Yan-Shen Shan
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital, Taiwan
| | - Baiyong Shen
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rong Liu
- Department of Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, University Hospital Southampton NHS, United Kingdom.
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McKay B, Brough D, Kilburn D, Cavallucci D. Safety and feasibility of instituting a robotic pancreas program in the Australian setting: a case series and narrative review. ANZ J Surg 2024; 94:1247-1253. [PMID: 38529778 DOI: 10.1111/ans.18998] [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: 05/09/2023] [Revised: 01/25/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Minimally invasive pancreatic resection has been gathering interest over the last decade due to the technical demands and high morbidity associated with these typically open procedures. We report our experience with robotic pancreatectomy within an Australian context. METHODS All patients undergoing robotic distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) at two Australian tertiary academic hospitals between May 2014 and December 2020 were included. RESULTS Sixty-two patients underwent robotic pancreatectomy during the study period. Thirty-four patients with a median age of 68 years (range 42-84) were in the PD group whilst the DP group included 28 patients with a median age of 60 years (range 18-78). Thirteen patients (46.4%) in the DP group had spleen-preserving procedures. There were 13 conversions (38.2%) in the PD group whilst 0 conversions occurred in the DP group. The Clavien-Dindo grade ≥III complication rate was 26.4% and 17.9% in the PD and DP groups, respectively. Two deaths (5.9%) occurred within 90-days in the PD group whilst none were observed in the DP group. The median length of hospital stay was 11.5 days (range 4-56) in the PD group and 6 days (range 2-22) in the DP group. CONCLUSION Robotic pancreatectomy outcomes at our institution are comparable with international literature demonstrating it is both safe and feasible to perform. With improved access to this platform, robotic pancreas surgery may prove to be the turning point for patients with regards to post-operative complications as more experience is obtained.
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Affiliation(s)
- Bartholomew McKay
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - David Brough
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Daniel Kilburn
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - David Cavallucci
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
- Department of Surgery, The Wesley Hospital, Brisbane, Queensland, Australia
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Bhatia V, Fernandez N, Long C, Sturm R, Farhat W, O’Kelly F. Advancements in Hypospadias Management: Trends, Techniques, Training, and Patient-Centric Outcomes. UROLOGY RESEARCH & PRACTICE 2024; 50:94-101. [PMID: 39115355 PMCID: PMC11232038 DOI: 10.5152/tud.2024.23219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/04/2024] [Indexed: 08/11/2024]
Abstract
Hypospadias has drawn increasing attention due to its prevalence, complex etiology, and significant impacts on psychological and sexual quality of life. This comprehensive review delves into the facets of hypospadias management, exploring pivotal themes that shape present understanding and practice. We demonstrate potential explanatory factors for its incidence through an analysis of geographic, genetic, and environmental influences. We then contextualize care by exploring historical and evolving surgical techniques, and highlight that advances in surgical approaches employ a spectrum of repair strategies. Innovation in surgical training, with a focus on simulation-based methodologies, offers a bridge between didactic learning and real-world application, which is particularly relevant due to the demonstrated effect of personal experience with hypospadias repair outcomes. Considering the importance of mentorship, case exposure, and hands-on practice, a holistic understanding of expertise cultivation at each training stage is essential. Lastly, patient-centric outcomes research must take center stage, particularly as the impact of our interventions on children with hypospadias will be judged by them as adults. Shifting from solely surgeon-reported outcomes to patient-reported outcomes is emphasized in the review, allowing for a more comprehensive assessment of the influence of surgical interventions across the lifespan. Integrating patients' perspectives refines surgical decision-making to align with expectations, ultimately enhancing overall satisfaction. Our multi-pronged exploration of advancements in hypospadias underscores the symbiotic relationship between evolving surgical techniques, training methodologies, personal experience, and patientreported outcomes. As the field progresses, these insights will collectively contribute to optimizing hypospadias care, advancing both medical practice and patient well-being.
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Affiliation(s)
- Vinaya Bhatia
- Department of Urology, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, WI, USA
| | - Nicolas Fernandez
- Department of Pediatric Urology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Christopher Long
- Department of Pediatric Urology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Renea Sturm
- Division of Pediatric Urology, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Walid Farhat
- Department of Urology, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, WI, USA
| | - Fardod O’Kelly
- Division of Pediatric Urology, Women and Children’s Hospital, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA
- Division of Pediatric Urology, Beacon Hospital, University College Dublin, Dublin, Ireland
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Delman AM, Whitrock JN, Turner KM, Donovan EC, Quillin RC, Shah SA, Patel SH, Ahmad SA, Wilson GC. Defining the operative time threshold for safety in patients undergoing robotic pancreaticoduodenectomy. HPB (Oxford) 2024; 26:323-332. [PMID: 38072726 DOI: 10.1016/j.hpb.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/12/2023] [Accepted: 11/28/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) is a safe and efficacious procedure in appropriately selected patients, though frequently with increased operative times compared to open pancreaticoduodenectomy (OPD). METHODS From 2014 to 2019, patients who underwent elective, low-risk, RPDs and OPDs in the NSQIP database were isolated. The operative time threshold (OTT) for safety in RPD patients was estimated by identifying the operative time at which complication rates for RPD patients exceeded the complication rate of the benchmark OPD control. RESULTS Of 6270 patients identified, 939 (15%) underwent RPD and 5331 (85%) underwent OPD. The incidence of major morbidity or mortality for the OPD cohort was 35.1%. The OTT was identified as 7.7 h. Patients whose RPDs were above the OTT experienced a higher incidence of major morbidity (42.5% vs. 35.0%, p < 0.01) and 30-day mortality (2.7% vs. 1.2%, p = 0.03) than the OPD cohort. Preoperative obstructive jaundice (OR: 1.47, [95% CI: 1.08-2.01]) and pancreatic duct size <3 mm (OR: 2.44, [95% CI: 1.47-4.06]) and 3-6 mm (OR: 2.15, [95% CI: 1.31-3.52]) were risk factors for prolonged RPDs on multivariable regression. CONCLUSION The operative time threshold for safety, identified at 7.7 h, should be used to improve patient selection for RPDs and as a competency-based quality benchmark.
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Affiliation(s)
- Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Jenna N Whitrock
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Eileen C Donovan
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Ralph C Quillin
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA; Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, USA; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, USA.
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Yu Y, Changyong E, Lin C, Wang L, Jiang T. Safety and learning curve analysis of robotic-assisted pancreaticoduodenectomy: experience of a single surgeon. J Robot Surg 2024; 18:92. [PMID: 38400999 DOI: 10.1007/s11701-024-01844-7] [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: 11/24/2023] [Accepted: 01/21/2024] [Indexed: 02/26/2024]
Abstract
Although prior studies have discussed learning curves (LC) of robotic-assisted pancreaticoduodenectomy (RPD), a recognized definition is lacking. This study analyzed the clinical outcomes of 85 consecutive RPD cases performed by a single surgeon to evaluate the safety and learning curve of RPD using the da Vinci Xi robotic system. There were 51 male and 34 female patients, with a median age of 64 (20-87) years. The average preoperative body weight and BMI were 64.15 ± 11.43 kg and 23.36 ± 3.33 kg/m2, respectively. The clinical outcomes of each patient were analyzed using the textbook outcome(TO), and the learning curve of the RPD was evaluated by calculating the TO rate of patients using the cumulative sum analysis method (CUSUM).The operation time (OT) was 288.92 ± 44.41 min, and the postoperative hospital stay was 10 (1-134) days. In total, 23.52% (20/85), 5.88% (5/85), 2.35% (2/85), and 5.9% (5/85) experienced grade IIIa, IIIb, IV, and V complications. A total of 46 patients achieved TO outcomes (TO group), while 39 did not (non-TO group). The smoking rate in the TO group was lower (P < 0.05) and the albumin level was higher (P < 0.05) than that in the non-TO group. The TO rate became positive after the 56th case, all patients were divided into a learning improvement group (56 cases) and a proficient group (29 cases). The total bilirubin level in the learning improvement group was lower (P < 0.05) and the bleeding volume was higher (P < 0.05).RPD is safe and effective for carefully selected patients. The learning curve was completed after 56 patients.
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Affiliation(s)
- Yang Yu
- Hapatobiliary and Pancreatic Surgery Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - E Changyong
- Hapatobiliary and Pancreatic Surgery Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Chao Lin
- Hapatobiliary and Pancreatic Surgery Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Lun Wang
- Hapatobiliary and Pancreatic Surgery Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Tao Jiang
- Hapatobiliary and Pancreatic Surgery Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China.
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Heckman JT, Martinez AE, Keim RL, Mazzaferro SE, Mir KS, Gorman MA, Shah US. Implementation of robotic pancreaticoduodenectomy at a community tertiary care hospital utilizing a comprehensive curriculum. Am J Surg 2024; 228:83-87. [PMID: 37620215 DOI: 10.1016/j.amjsurg.2023.08.013] [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: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We evaluated the outcomes of a robotic pancreaticoduodenectomy (RPD) program implemented at a community tertiary care hospital. METHODS A retrospective review of 65 RPD cases compared surgical outcomes and performance to benchmark data. RESULTS Postoperative complications occurred in 31% (20) of patients vs. ≤73% (variance -42), with grade IV complications in 3% (2) vs. ≤5% (variance -2). Postoperative pancreatic fistula type B frequency was 12% (8) vs. ≤15% (variance -3). One 90-day mortality occurred (1.5% vs. 1.6%). Failure to rescue rate was 7% vs. ≤9% (variance -2), and R1 resection rate was 2% vs. ≤39% (variance -37). There was a downward trend of operative time (rho = -0.600, P < 0.001), with a learning curve of 27 cases. Median hospital length of stay was 6 days vs. ≤15 days (variance -9). CONCLUSION Our comprehensive RPD training program resulted in improved operative performance and outcomes commensurate with benchmark thresholds.
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Affiliation(s)
- Jason T Heckman
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Ashley E Martinez
- Albany Medical College, 43 New Scotland Ave, Albany, NY, 12208, United States.
| | - Rebecca L Keim
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Sarah E Mazzaferro
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Kristin S Mir
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Michael A Gorman
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Ujas S Shah
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
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8
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de Graaf N, Zwart MJW, van Hilst J, van den Broek B, Bonsing BA, Busch OR, Coene PPLO, Daams F, van Dieren S, van Eijck CHJ, Festen S, de Hingh IHJT, Lips DJ, Luyer MDP, Mieog JSD, van Santvoort HC, van der Schelling GP, Stommel MWJ, de Wilde RF, Molenaar IQ, Groot Koerkamp B, Besselink MG. Early experience with robotic pancreatoduodenectomy versus open pancreatoduodenectomy: nationwide propensity-score-matched analysis. Br J Surg 2024; 111:znae043. [PMID: 38415878 PMCID: PMC10898866 DOI: 10.1093/bjs/znae043] [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: 09/25/2023] [Revised: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Although robotic pancreatoduodenectomy has shown promising outcomes in experienced high-volume centres, it is unclear whether implementation on a nationwide scale is safe and beneficial. The aim of this study was to compare the outcomes of the early experience with robotic pancreatoduodenectomy versus open pancreatoduodenectomy in the Netherlands. METHODS This was a nationwide retrospective cohort study of all consecutive patients who underwent robotic pancreatoduodenectomy or open pancreatoduodenectomy who were registered in the mandatory Dutch Pancreatic Cancer Audit (18 centres, 2014-2021), starting from the first robotic pancreatoduodenectomy procedure per centre. The main endpoints were major complications (Clavien-Dindo grade greater than or equal to III) and in-hospital/30-day mortality. Propensity-score matching (1 : 1) was used to minimize selection bias. RESULTS Overall, 701 patients who underwent robotic pancreatoduodenectomy and 4447 patients who underwent open pancreatoduodenectomy were included. Among the eight centres that performed robotic pancreatoduodenectomy, the median robotic pancreatoduodenectomy experience was 86 (range 48-149), with a 7.3% conversion rate. After matching (698 robotic pancreatoduodenectomy patients versus 698 open pancreatoduodenectomy control patients), no significant differences were found in major complications (40.3% versus 36.2% respectively; P = 0.186), in-hospital/30-day mortality (4.0% versus 3.1% respectively; P = 0.326), and postoperative pancreatic fistula grade B/C (24.9% versus 23.5% respectively; P = 0.578). Robotic pancreatoduodenectomy was associated with a longer operating time (359 min versus 301 min; P < 0.001), less intraoperative blood loss (200 ml versus 500 ml; P < 0.001), fewer wound infections (7.4% versus 12.2%; P = 0.008), and a shorter hospital stay (11 days versus 12 days; P < 0.001). Centres performing greater than or equal to 20 robotic pancreatoduodenectomies annually had a lower mortality rate (2.9% versus 7.3%; P = 0.009) and a lower conversion rate (6.3% versus 11.2%; P = 0.032). CONCLUSION This study indicates that robotic pancreatoduodenectomy was safely implemented nationwide, without significant differences in major morbidity and mortality compared with matched open pancreatoduodenectomy patients. Randomized trials should be carried out to verify these findings and confirm the observed benefits of robotic pancreatoduodenectomy versus open pancreatoduodenectomy.
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Affiliation(s)
- Nine de Graaf
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Maurice J W Zwart
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Bram van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Epidemiologist Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | | | | | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Martijn W J Stommel
- Deptartment of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
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9
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El-Sayed C, Yiu A, Burke J, Vaughan-Shaw P, Todd J, Lin P, Kasmani Z, Munsch C, Rooshenas L, Campbell M, Bach SP. Measures of performance and proficiency in robotic assisted surgery: a systematic review. J Robot Surg 2024; 18:16. [PMID: 38217749 DOI: 10.1007/s11701-023-01756-y] [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: 10/03/2023] [Accepted: 11/07/2023] [Indexed: 01/15/2024]
Abstract
Robotic assisted surgery (RAS) has seen a global rise in adoption. Despite this, there is not a standardised training curricula nor a standardised measure of performance. We performed a systematic review across the surgical specialties in RAS and evaluated tools used to assess surgeons' technical performance. Using the PRISMA 2020 guidelines, Pubmed, Embase and the Cochrane Library were searched systematically for full texts published on or after January 2020-January 2022. Observational studies and RCTs were included; review articles and systematic reviews were excluded. The papers' quality and bias score were assessed using the Newcastle Ottawa Score for the observational studies and Cochrane Risk Tool for the RCTs. The initial search yielded 1189 papers of which 72 fit the eligibility criteria. 27 unique performance metrics were identified. Global assessments were the most common tool of assessment (n = 13); the most used was GEARS (Global Evaluative Assessment of Robotic Skills). 11 metrics (42%) were objective tools of performance. Automated performance metrics (APMs) were the most widely used objective metrics whilst the remaining (n = 15, 58%) were subjective. The results demonstrate variation in tools used to assess technical performance in RAS. A large proportion of the metrics are subjective measures which increases the risk of bias amongst users. A standardised objective metric which measures all domains of technical performance from global to cognitive is required. The metric should be applicable to all RAS procedures and easily implementable. Automated performance metrics (APMs) have demonstrated promise in their wide use of accurate measures.
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Affiliation(s)
- Charlotte El-Sayed
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom.
| | - A Yiu
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - J Burke
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - P Vaughan-Shaw
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - J Todd
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - P Lin
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - Z Kasmani
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - C Munsch
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - L Rooshenas
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - M Campbell
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
| | - S P Bach
- RCS England/HEE Robotics Research Fellow, University of Birmingham, Birmingham, United Kingdom
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10
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Hays SB, Corvino G, Lorié BD, McMichael WV, Mehdi SA, Rieser C, Rojas AE, Hogg ME. Prince and princesses: The current status of robotic surgery in surgical oncology. J Surg Oncol 2024; 129:164-182. [PMID: 38031870 DOI: 10.1002/jso.27536] [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: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023]
Abstract
Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.
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Affiliation(s)
- Sarah B Hays
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Gaetano Corvino
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Benjamin D Lorié
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - William V McMichael
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Syed A Mehdi
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Caroline Rieser
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Aram E Rojas
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Melissa E Hogg
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois, USA
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11
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Zwart MJ, van den Broek B, de Graaf N, Suurmeijer JA, Augustinus S, te Riele WW, van Santvoort HC, Hagendoorn J, Borel Rinkes IH, van Dam JL, Takagi K, Tran KT, Schreinemakers J, van der Schelling G, Wijsman JH, de Wilde RF, Festen S, Daams F, Luyer MD, de Hingh IH, Mieog JS, Bonsing BA, Lips DJ, Abu Hilal M, Busch OR, Saint-Marc O, Zeh HJ, Zureikat AH, Hogg ME, Koerkamp BG, Molenaar IQ, Besselink MG. The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following a Multicenter Training Program: "Standing on the Shoulders of Giants". Ann Surg 2023; 278:e1232-e1241. [PMID: 37288547 PMCID: PMC10631507 DOI: 10.1097/sla.0000000000005928] [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] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework. BACKGROUND The long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program. METHODS Post hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned." RESULTS Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome. CONCLUSIONS The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.
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Affiliation(s)
- Maurice J.W. Zwart
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bram van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
| | - José A. Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Wouter W. te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H.M. Borel Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L. van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Khé T.C. Tran
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Jan H. Wijsman
- Department of Surgery, Amphia Medical Center, Breda, the Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Misha D. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S.D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J. Lips
- Department of Surgery, Twente Medical Spectrum, Enschede, the Netherlands
| | - Mohamed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Herbert J. Zeh
- Department of Surgery, University of Texas, Southwestern, Dallas, TX
| | - Amer H. Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa E. Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, IL
| | - Bas G. Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Isaac Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
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12
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McCarron FN, Vrochides D, Martinie JB. Current progress in robotic hepatobiliary and pancreatic surgery at a high-volume center. Ann Gastroenterol Surg 2023; 7:863-870. [PMID: 37927925 PMCID: PMC10623982 DOI: 10.1002/ags3.12737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/18/2023] [Accepted: 08/19/2023] [Indexed: 11/07/2023] Open
Abstract
There has been steady growth in the adoption of robotic HPB procedures world-wide over the past 20 years, but most of this increase has occurred only recently. Not surprisingly, the vast majority of robotics has been in the United States, with very few, select centers of adoption in Italy, South Korea, and Brazil, to name a few. We began our robotic HPB program in 2008, well before almost all other centers in the world, with the most notable exception of Giullianotti and colleagues. Our program began gradually, with smaller cases carefully selected to optimize the strengths of the original robotic platform and included complex biliary and pancreatic resections. We performed the first reported series of choledochojejunostomy for benign biliary strictures and first series of completion cholecystectomies. We began performing robotic distal pancreatectomies and longitudinal pancreaticojejunostomies, reporting our early experience for each of these procedures. Over time we progressed to robotic pancreaticoduodenectomies. Initially, these were performed with planned conversions until we were able to optimize efficiency. Now we have performed over 200 robotic whipples, reaching a 100% robotic completion rate by 2020. Finally, we have added robotic major hepatectomies, including resections for hilar cholangiocarcinoma to our repertoire. Since the program began, we have performed over 1600 robotic HPB cases. Outcomes from our program have shown superior lymph node harvest, lower DGE rates, shorter hospitalizations, and fewer rehab admissions with similar overall complications to open and laparoscopic procedures, signifying that over time a robotic HPB program is not only feasible but advantageous as well.
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Affiliation(s)
- Frances N. McCarron
- Department of Hepatobiliary and Pancreas SurgeryCarolinas Medical CenterCharlotteNorth CarolinaUSA
| | - Dionisios Vrochides
- Department of Hepatobiliary and Pancreas SurgeryCarolinas Medical CenterCharlotteNorth CarolinaUSA
| | - John B. Martinie
- Department of Hepatobiliary and Pancreas SurgeryCarolinas Medical CenterCharlotteNorth CarolinaUSA
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13
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Baeten IGT, Hoogendam JP, Schreuder HWR, Jürgenliemk-Schulz IM, Gerestein CG, Zweemer RP. Introducing a novice surgeon to an experienced robotic gynaecological oncology team: An observational cohort study on the impact of a structured curriculum on outcomes of cervical cancer surgery. Gynecol Oncol 2023; 178:153-160. [PMID: 37865051 DOI: 10.1016/j.ygyno.2023.10.008] [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: 05/26/2023] [Revised: 09/26/2023] [Accepted: 10/14/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE To evaluate the effect on patient outcomes when introducing a novice robotic surgeon, trained in accordance with a structured learning curriculum, to an experienced robotic surgery team treating cervical cancer patients. METHODS Patients with early-stage cervical cancer who were treated with primary robot-assisted surgery between 2007 and 2019 were retrospectively included. In addition to the 165 patients included in a former analysis, we included a further 61 consecutively treated patients and divided all 226 patients over three groups: early learning phase of 61 procedures without structured training (group 1), experienced phase of 104 procedures (group 2), and the 61 procedures during introduction of a novice with structured training (group 3). Risk-adjusted cumulative sum (RA-CUSUM) analysis was performed to assess the learning curve effect. Patient outcomes between the groups were compared. RESULTS Based on RA-CUSUM analysis, no learning curve effect was observed for group 3. Regarding surgical outcomes, mean operation time in group 3 was significantly shorter than group 1 (p < 0.001) and similar to group 2 (p = 0.96). Proportions of intraoperative and postoperative adverse events in group 3 were not significantly different from the experienced group (group 2). Regarding oncological outcomes, the 5-year disease-free survival, disease-specific survival, and overall survival in group 3 were not significantly different from the experienced group. CONCLUSIONS Introducing a novice robotic surgeon, who was trained in accordance with a structured learning curriculum, resulted in similar patient outcomes as by experienced surgeons suggesting novices can progress through a learning phase without compromising outcomes of cervical cancer patients.
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Affiliation(s)
- Ilse G T Baeten
- Department of Gynaecological Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Jacob P Hoogendam
- Department of Gynaecological Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Henk W R Schreuder
- Department of Gynaecological Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ina M Jürgenliemk-Schulz
- Department of Radiology and Nuclear Medicine, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Cornelis G Gerestein
- Department of Gynaecological Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ronald P Zweemer
- Department of Gynaecological Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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14
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Kong D, Zhang H, Zhao X, Meng Y, Chai W, Wang Z. Effect of laparoscopic pancreaticoduodenectomy on the incidence of surgical-site wound infection: A meta-analysis. Int Wound J 2023; 20:3682-3689. [PMID: 37277912 PMCID: PMC10588349 DOI: 10.1111/iwj.14259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/10/2023] [Accepted: 05/20/2023] [Indexed: 06/07/2023] Open
Abstract
A meta-analysis was conducted to assess the impact of robotic and laparoscopic pancreaticoduodenectomies on postoperative surgical site wound infections. A comprehensive computerised search of databases, such as PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang Data, was performed to identify studies comparing robotic pancreaticoduodenectomy (PD) with laparoscopicPD. Relevant studies were searched from the inception of the database construction until April 2023. The meta-analysis outcomes were analysed using odds ratios (OR) with corresponding 95% confidence intervals (CI). The RevMan 5.4 software was used for the meta-analysis. The findings of the meta-analysis showed that patients who underwent laparoscopic PD had a significantly lower incidence of surgical-site wound (16.52% vs. 18.92%, OR: 0.78, 95% CI: 0.68-0.90, P = .0005), superficial wound (3.65% vs. 7.57%, OR: 0.51, 95% CI: 0.39-0.68, P < .001), and deep wound infections (1.09% vs. 2.23%, OR: 0.53, 95% CI: 0.34-0.85, P = .008) than those who received robotic PD. However, because of variations in sample size between studies, some studies suffered from methodological quality deficiencies. Therefore, further validation of this result is needed in future studies with higher quality and larger sample sizes.
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Affiliation(s)
- De‐Shuai Kong
- Department of Biliary‐pancreatic Surgery ICangzhou Central HospitalCangzhouHebeiChina
| | - Heng‐Le Zhang
- Graduate School of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Xiu‐Lei Zhao
- Department of Biliary‐pancreatic Surgery ICangzhou Central HospitalCangzhouHebeiChina
| | - Yu Meng
- Department of Biliary‐pancreatic Surgery ICangzhou Central HospitalCangzhouHebeiChina
| | - Wei Chai
- Department of Biliary‐pancreatic Surgery ICangzhou Central HospitalCangzhouHebeiChina
| | - Zhen‐Yong Wang
- Department of Biliary‐pancreatic Surgery ICangzhou Central HospitalCangzhouHebeiChina
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15
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Park JY, Mirzaie S, Premji A, Seo Y, Mederos M, Hines J, Donahue T, Tomlinson J, King J, Girgis M. Learning Curves in Establishing a New Minimally Invasive Pancreas Program. Am Surg 2023; 89:4166-4170. [PMID: 37279455 DOI: 10.1177/00031348231177926] [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] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Robotic pancreaticoduodenectomy (rPD) is a complex operation with a reported learning curve of 80 cases. Two recent graduates of a formal robotic complex general surgical oncology training program have been performing rPD at our institution since 2016, which had no previous institutional experience with rPD. OBJECTIVE To evaluate the learning curve associated with developing a new robotic pancreaticoduodenectomy (rPD) program by fellowship trained surgeons with institutional support. METHODS Sixty patients undergoing rPD from 2016 to 2022 were reviewed for and compared with proficiency benchmarks set by the University of Pittsburg experience. RESULTS By 30 cases, operative time met the proficiency benchmark of 391 minutes. Additionally, the entire cohort had comparable rates of clinically relevant postoperative pancreatic fistula (6.7% vs 3%, P = .6), 30-day mortality (0% vs 3%, P = .18), major complications (Clavien >2; 23% vs 17%, P = .14), and length of stay (6 vs 7 days, P = .49) when compared to the benchmark. CONCLUSION Perioperative outcomes were comparable to proficiency benchmarks from initiation of the new rPD program, and operative time reached proficiency benchmark by 30 cases. This data suggests that graduates of formal rPD training programs can safely establish new minimally invasive pancreas programs at sites with no previous institutional rPD experience.
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Affiliation(s)
- Joon Y Park
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sarah Mirzaie
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Aly Premji
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Youngji Seo
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Michael Mederos
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Joe Hines
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Timothy Donahue
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - James Tomlinson
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jonathan King
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Mark Girgis
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
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16
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Perri G, van Hilst J, Li S, Besselink MG, Hogg ME, Marchegiani G. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. BJS Open 2023; 7:zrad081. [PMID: 37698977 PMCID: PMC10496870 DOI: 10.1093/bjsopen/zrad081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form. METHODS This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques. RESULTS Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models. CONCLUSION Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Shen Li
- Department of Surgical Oncology, University of Chicago, Chicago, Illinois, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Melissa E Hogg
- Department of HPB Surgery, NorthShore Health System, Evanston, Illinois, USA
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
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17
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Khachfe HH, Nassour I, Hammad AY, Hodges JC, AlMasri S, Liu H, deSilva A, Kraftician J, Lee KK, Pitt HA, Zureikat AH, Paniccia A. Robotic Pancreaticoduodenectomy: Increased Adoption and Improved Outcomes: Is Laparoscopy Still Justified? Ann Surg 2023; 278:e563-e569. [PMID: 36000753 PMCID: PMC11186698 DOI: 10.1097/sla.0000000000005687] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the rate of postoperative 30-day complications between laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD). BACKGROUND Previous studies suggest that minimally invasive pancreaticoduodenectomy (MI-PD)-either LPD or RPD-is noninferior to open pancreaticoduodenectomy in terms of operative outcomes. However, a direct comparison of the two minimally invasive approaches has not been rigorously performed. METHODS Patients who underwent MI-PD were abstracted from the 2014 to 2019 pancreas-targeted American College of Surgeons National Sample Quality Improvement Program (ACS NSQIP) dataset. Optimal outcome was defined as absence of postoperative mortality, serious complication, percutaneous drainage, reoperation, and prolonged length of stay (75th percentile, 11 days) with no readmission. Multivariable logistic regression models were used to compare optimal outcome of RPD and LPD. RESULTS A total of 1540 MI-PDs were identified between 2014 and 2019, of which 885 (57%) were RPD and 655 (43%) were LPD. The rate of RPD cases/year significantly increased from 2.4% to 8.4% ( P =0.008) from 2014 to 2019, while LPD remained unchanged. Similarly, the rate of optimal outcome for RPD increased during the study period from 48.2% to 57.8% ( P <0.001) but significantly decreased for LPD (53.5% to 44.9%, P <0.001). During 2018-2019, RPD outcomes surpassed LPD for any complication [odds ratio (OR)=0.58, P =0.004], serious complications (OR=0.61, P =0.011), and optimal outcome (OR=1.78, P =0.001). CONCLUSIONS RPD adoption increased compared with LPD and was associated with decreased overall complications, serious complications, and increased optimal outcome compared with LPD in 2018-2019.
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Affiliation(s)
- Hussein H. Khachfe
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Florida, Gainesville, FL
| | - Abdulrahman Y. Hammad
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Samer AlMasri
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Hao Liu
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anissa deSilva
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jasmine Kraftician
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth K. Lee
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Amer H. Zureikat
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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18
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Harley F, Fong E, Yao HH, Hashim H, O'Connell HE. What credentials are required for robotic-assisted surgery in reconstructive and functional urology? BJUI COMPASS 2023; 4:493-500. [PMID: 37636202 PMCID: PMC10447218 DOI: 10.1002/bco2.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/25/2023] [Accepted: 03/05/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction The increasing popularity of robotic assisted surgery (RAS) as it is implemented in to sub specialities poses many challenges to ensuring standards in quality and safety. The area of Reconstructive and Functional Urology (RFU) has a wide range and largely complex heterogeneous procedures. In recent years RFU has started to incorporate RAS as the primary method to undertake these procedures due to improved vision, dexterity, and access to deep cavities. To ensure patient safety majority of institutions maintain minimal requirements to operate using RAS however across specialities and institutions these greatly vary. Methods A narrative review of all the relevant papers known to the author was conducted. Results Specific challenges facing RFU is the inability to rely on case numbers as a surrogate means to measure competency as well the ongoing consideration of how to differentiate between surgeons with robotic training and those with the clinical experience specific to RFU. Conclusion This review explores current models of training and credentialling and assess how it can be adapted to suggest a standardised guideline for RFU to ensure the highest standards of patient care.
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Affiliation(s)
- Frances Harley
- Department of SurgeryUniversity of MelbourneMelbourneVictoriaAustralia
| | - Eva Fong
- Department of UrologyUrology InstituteAucklandNew Zealand
| | - Henry Han‐I Yao
- Department of SurgeryUniversity of MelbourneMelbourneVictoriaAustralia
| | - Hashim Hashim
- Bristol Urological InstituteSouthmead Hospital, North Bristol NHS TrustBristolUK
| | - Helen E. O'Connell
- Department of SurgeryUniversity of MelbourneMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
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19
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Yim NH, Burns HR, Davis MJ, Selber JC. Robotic Plastic Surgery Education: Developing a Robotic Surgery Training Program Specific to Plastic Surgery Trainees. Semin Plast Surg 2023; 37:157-167. [PMID: 38444955 PMCID: PMC10911909 DOI: 10.1055/s-0043-1771026] [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: 03/07/2024]
Abstract
Over the past two decades, the surgical community has increasingly embraced robotic-assisted surgery (RAS) due to its potential to enhance accuracy and decrease surgical morbidity. Plastic surgery as a field has been historically slow to incorporate RAS, with lack of adequate training posing as one of the most commonly cited barriers. To date, robot technology has been utilized for various reconstructive procedures including flap elevation and inset, pedicle dissection, and microvascular anastomosis. As RAS continues to integrate within plastic surgery procedures, the need for a structured RAS curriculum designed for plastic surgery trainees is rising. This article delineates the essential components of a plastic surgery-specific RAS curriculum and outlines current training models and assessment tools utilized across surgical subspecialties to date.
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Affiliation(s)
- Nicholas H. Yim
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Heather R. Burns
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Matthew J. Davis
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, Corewell Health, Grand Rapids, Michigan
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20
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Huang XT, Wang XY, Xie JZ, Cai JP, Chen W, Chen LH, Yin XY. Learning curves of resection and reconstruction procedures in robotic-assisted pancreatoduodenectomy by a single surgeon: a retrospective cohort study of 160 consecutive cases. Gastroenterol Rep (Oxf) 2023; 11:goad042. [PMID: 37502197 PMCID: PMC10371495 DOI: 10.1093/gastro/goad042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/04/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023] Open
Abstract
Background Robotic-assisted pancreatoduodenectomy (RPD) has been routinely performed in a few of centers worldwide. This study aimed to evaluate the perioperative outcomes and the learning curves of resection and reconstruction procedures in RPD by one single surgeon. Methods Consecutive patients undergoing RPD by a single surgeon at the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between July 2016 and October 2022 were included. The perioperative outcomes and learning curves were retrospectively analysed by using cumulative sum (CUSUM) analyses. Results One-hundred and sixty patients were included. According to the CUSUM curve, the times of resection and reconstruction procedures were shortened significantly after 30 cases (median, 284 vs 195 min; P < 0.001) and 45 cases (median, 138 vs 120 min; P < 0.001), respectively. The estimated intraoperative blood loss (median, 100 vs 50 mL; P < 0.001) and the incidence of clinically relevant post-operative pancreatic fistula (29.2% vs 12.5%; P = 0.035) decreased significantly after 20 and 120 cases, respectively. There were no significant differences in the total number of lymph nodes examined, post-operative major complications, or post-operative length-of-stay between the two groups. Conclusions Optimization of the resection procedure and the acquisition of visual feedback facilitated the performance of RPD. RPD was a safe and feasible procedure in the selected patients.
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Affiliation(s)
| | | | | | - Jian-Peng Cai
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wei Chen
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Liu-Hua Chen
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiao-Yu Yin
- Corresponding author. Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, Guangzhou, Guangdong 510080, P. R. China.
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21
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Sobel J, Hayden SR, Wardi G. The Knowledge Gap: Mentorship in Emergency Medicine Residency. Ann Emerg Med 2023; 82:47-54. [PMID: 36841659 PMCID: PMC10293097 DOI: 10.1016/j.annemergmed.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 01/14/2023] [Accepted: 01/24/2023] [Indexed: 02/26/2023]
Abstract
STUDY OBJECTIVE Studies of mentorship in emergency medicine show that mentored residents are twice as likely to describe their career preparation as excellent as compared to nonmentored peers. There has been significant interest in the mentor-mentee relationship in medicine; however, there is minimal guidance and published literature specific to emergency medicine residents. METHODS In this narrative review, we described the emergency medicine mentor-mentee relationship, discussed alternatives to the traditional dyadic model, and highlighted current barriers to effective mentorship. We conducted a structured literature review to identify relevant published articles regarding the mentoring of emergency medicine residents. Additional studies from general mentoring literature were included based on relevancy. RESULTS We identified 39 studies in emergency medicine literature based on our search criteria. Additional studies from general medicine literature were included based on relevancy to this review. Based on the limited available literature, we recommend maximizing the resident mentoring relationship by developing formal mentoring programs, supporting the advancement of women and underrepresented minority mentors, and moving toward team mentoring, including peer, near-peer, and collaborative mentorship. The development of a mentoring network is a logical strategy for residents to work with a diverse group of individuals to maximize benefits in multiple areas. CONCLUSION Alternative approaches to the traditional and hierarchal dyadic mentoring style (eg, team mentoring) are effective methods that residencies may promote to increase effective mentoring. Future efforts in mentoring emergency medicine residents emphasize these strategies, which are increasingly beneficial given the constraints and use of technology highlighted by the COVID-19 pandemic.
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Affiliation(s)
- Julia Sobel
- Department of Emergency Medicine, UC San Diego Health, San Diego, CA.
| | - Stephen R Hayden
- Department of Emergency Medicine, UC San Diego Health, San Diego, CA; Department of Emergency Medicine, UHS SoCal MEC - Temecula Valley Hospital, Temecula, CA
| | - Gabriel Wardi
- Department of Emergency Medicine, UC San Diego Health, San Diego, CA; Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego Health, La Jolla, CA
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22
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Irfan A, Cochrun S, He K, Okorji L, Parmar AD. Towards identifying a learning curve for robotic abdominal wall reconstruction: a cumulative sum analysis. Hernia 2023; 27:671-676. [PMID: 37160504 DOI: 10.1007/s10029-023-02794-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/15/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Over the past decade, an increase has been seen in robotics used for hernia repair, specifically robotic abdominal wall reconstruction (rAWR). However, the learning curve for rAWR can be steep and presently, little is understood regarding the optimal case volume required to achieve proficiency. The aim of our study was to review skill acquisition and describe the learning curve for rAWR. METHODS A retrospective, single-surgeon case series of consecutive patients who underwent rAWR from 2018 to 2022. The primary outcome was operative time, obtained from console time identified through the MyIntutive application. A one-sided cumulative sum analysis (CUSUM) curve for the total operative time was derived based on the mean operative time of chronological procedures (207 min). RESULTS 185 patients underwent rAWR between 2018 and 2022. These patients were more likely to be female, Caucasian, and have undergone two previous hernia repairs. ASA complexity increased over time with ASA 3 being predominant from 2020 onwards. The median hernia length was 15.0 cm and the median width was 7 cm. Average operative time was 207.8 min and decreased over time. The CUSUM analysis identified four phases of skill acquisition with the following case volumes: Initial Learning Curve (0-20), Stabilization Phase (21-55), Second Learning Curve (56-70), 4) Skill Proficiency (> 70). CONCLUSION In the early learning curve of rAWR, operative time decreased consistently after 70 cases, with an initial inflection after 20 cases. We identified varying stages of skill acquisition that are likely typical of a surgeon as they would progress through the learning curve of advanced robotic surgery. Future studies are needed to confirm the optimal case volume for determining the skill level for the performance of rAWR.
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Affiliation(s)
- A Irfan
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
| | - S Cochrun
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
| | - K He
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
| | - L Okorji
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
| | - Abhishek D Parmar
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA.
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23
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Cienfuegos JA, Hurtado-Pardo L, Breeze CE, Guillen F, Valenti V, Zozaya G, Martí P, Benito A, Pardo F, Hernández Lizoáin JL, Rotellar F. Predictors of postoperative complications and readmissions in laparoscopic pancreas resection: Results of a cohort 105 consecutive cases. A retrospective study. Cir Esp 2023; 101:333-340. [PMID: 35500758 DOI: 10.1016/j.cireng.2022.04.015] [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: 11/04/2021] [Accepted: 04/14/2022] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Laparoscopic resection of the pancreas (LRP) has been implemented to a varying degree because it is technically demanding and requires a long learning curve. In the present study we analyze the risk factors for complications and hospital readmissions in a single center study of 105 consecutive LRPs. METHODS We conducted a retrospective study using a prospective database. Data were collected on age, gender, BMI, ASA score, type of surgery, histologic type, operative time, hospital stay, postoperative complications, degree of severity and hospital readmission. RESULTS The cohort included 105 patients, 63 females and 42 males with a median age and BMI of 58 (53-70) and 25.5 (22,2-27.9) respectively. Eighteen (17%) central pancreatectomies, 5 (4.8%) enucleations, 81 (77.6%) distal pancreatectomies and one total pancreatectomy were performed. Fifty-six patients (53.3%) experienced some type of complication, of which 13 (12.3%) were severe (Clavien-Dindo > IIIb) and 11 (10.5%) patients were readmitted in the first 30 days after surgery. In the univariate analysis, age, male gender, ASA score, central pancreatectomy and operative time were significantly associated with the development of complications (P <0.05). In the multivariate analysis, male gender (OR 7.97; 95% CI 1.08-58.88)), severe complications (OR 59.40; 95% CI, 7.69-458.99), and the development of intrabdominal collections (OR 8.97; 95% CI, 1.28-63.02)) were associated with hospital readmission. CONCLUSIONS Age, male gender, ASA score, operative time and central pancreatectomy are associated with a higher incidence of complications. Male gender, severe complications and intraabdominal collections are associated with more hospital readmissions.
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Affiliation(s)
- Javier A Cienfuegos
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.
| | - Luis Hurtado-Pardo
- Department of General Surgery, University and Polytechnic La Fe Hospital, Valencia, Spain
| | - Charles E Breeze
- UCL Cancer Institute, University College London, London WC1E 6BT, UK
| | - Francisco Guillen
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain; Department Preventive Medicine, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Víctor Valenti
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain; CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Spain
| | - Gabriel Zozaya
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Pablo Martí
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Alberto Benito
- Department of Radiology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Fernando Pardo
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - José Luis Hernández Lizoáin
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Fernando Rotellar
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
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24
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Giuliani T, Perri G, Kang R, Marchegiani G. Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge. Cancers (Basel) 2023; 15:cancers15092499. [PMID: 37173964 PMCID: PMC10177600 DOI: 10.3390/cancers15092499] [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: 04/07/2023] [Revised: 04/23/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.
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Affiliation(s)
| | | | - Ravinder Kang
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Giovanni Marchegiani
- Verona University Hospital, 37134 Verona, Italy
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, 35122 Padua, Italy
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25
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Napoli N, Cacace C, Kauffmann EF, Jones L, Ginesini M, Gianfaldoni C, Salamone A, Asta F, Ripolli A, Di Dato A, Busch OR, Cappelle ML, Chao YJ, de Wilde RF, Hackert T, Jang JY, Koerkamp BG, Kwon W, Lips D, Luyer MDP, Nickel F, Saint-Marc O, Shan YS, Shen B, Vistoli F, Besselink MG, Hilal MA, Boggi U. The PD-ROBOSCORE: A difficulty score for robotic pancreatoduodenectomy. Surgery 2023; 173:1438-1446. [PMID: 36973127 DOI: 10.1016/j.surg.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Difficulty scoring systems are important for the safe, stepwise implementation of new procedures. We designed a retrospective observational study for building a difficulty score for robotic pancreatoduodenectomy. METHODS The difficulty score (PD-ROBOSCORE) aims at predicting severe postoperative complications after robotic pancreatoduodenectomy. The PD-ROBOSCORE was developed in a training cohort of 198 robotic pancreatoduodenectomies and was validated in an international multicenter cohort of 686 robotic pancreatoduodenectomies. Finally, all centers tested the model during the early learning curve (n = 300). Growing difficulty levels (low, intermediate, high) were defined using cut-off values set at the 33rd and 66th percentile (NCT04662346). RESULTS Factors included in the final multivariate model were a body mass index of ≥25 kg/m2 for males and ≥30 kg/m2 for females (odds ratio:2.39; P < .0001), borderline resectable tumor (odd ratio:1.98; P < .0001), uncinate process tumor (odds ratio:1.69; P < .0001), pancreatic duct size <4 mm (odds ratio:1.59; P < .0001), American Society of Anesthesiologists class ≥3 (odds ratio:1.59; P < .0001), and hepatic artery originating from the superior mesenteric artery (odds ratio:1.43; P < .0001). In the training cohort, the absolute score value (odds ratio = 1.13; P = .0089) and difficulty groups (odds ratio = 2.35; P = .041) predicted severe postoperative complications. In the multicenter validation cohort, the absolute score value predicted severe postoperative complications (odds ratio = 1.16, P < .001), whereas the difficulty groups did not (odds ratio = 1.94, P = .082). In the learning curve cohort, both absolute score value (odds ratio:1.078, P = .04) and difficulty groups (odds ratio: 2.25, P = .017) predicted severe postoperative complications. Across all cohorts, a PD-ROBOSCORE of ≥12.51 doubled the risk of severe postoperative complications. The PD-ROBOSCORE score also predicted operative time, estimated blood loss, and vein resection. The PD-ROBOSCORE predicted postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, and postoperative mortality in the learning curve cohort. CONCLUSION The PD-ROBOSCORE predicts severe postoperative complications after robotic pancreatoduodenectomy. The score is readily available via www.pancreascalculator.com.
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Affiliation(s)
- Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Concetta Cacace
- Division of General and Transplant Surgery, University of Pisa, Italy
| | | | - Leia Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Italy
| | | | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Fabio Asta
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Allegra Ripolli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Marie L Cappelle
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Ying Jui Chao
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Jin-Young Jang
- Department of Hepatobiliary and Pancreatic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Wooil Kwon
- Department of Hepatobiliary and Pancreatic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional D'Orleans, Orléans, France
| | - Yan-Shen Shan
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy.
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Impact of educational video on performance in robotic simulation training (TAKUMI-1): a randomized controlled trial. J Robot Surg 2023:10.1007/s11701-023-01556-4. [PMID: 36905486 PMCID: PMC10374749 DOI: 10.1007/s11701-023-01556-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/01/2023] [Indexed: 03/12/2023]
Abstract
The use of virtual reality for simulations plays an important role in the initial training for robotic surgery. This randomized controlled trial aimed to investigate the impact of educational video on the performance of robotic simulation. Participants were randomized into the intervention (video) group that received an educational video and robotic simulation training or the control group that received only simulation training. The da Vinci® Skills Simulator was used for the basic course, including nine drills. The primary endpoint was the overall score of nine drills in cycles 1-10. Secondary endpoints included overall, efficiency, and penalty scores in each cycle, as well as the learning curves evaluated by the cumulative sum (CUSUM) analysis. Between September 2021 and May 2022, 20 participants were assigned to the video (n = 10) and control (n = 10) groups. The video group had significantly higher overall scores than the control group (90.8 vs. 72.4, P < 0.001). Significantly higher overall scores and lower penalty scores were confirmed, mainly in cycles 1-5. CUSUM analysis revealed a shorter learning curve in the video group. The present study demonstrated that educational video training can be effective in improving the performance of robotic simulation training and shortening the learning curve.
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The influence of procedural volume on short-term outcomes for robotic pancreatoduodenectomy-a cohort study and a learning curve analysis. Surg Endosc 2023:10.1007/s00464-023-09941-8. [PMID: 36890417 DOI: 10.1007/s00464-023-09941-8] [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: 10/13/2022] [Accepted: 02/11/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND An increasing number of robotic pancreatoduodenectomies (RPD) are reported, however, questions remain on the number of procedures needed for gaining technical proficiency in RPD. Therefore, we aimed to assess the influence of procedure volume on short-term RPD outcomes and assess the learning curve effect. METHODS A retrospective review of consecutive RPD cases was undertaken. Non-adjusted cumulative sum (CUSUM) analysis was performed to identify the procedure volume threshold, following which before-threshold and after-threshold outcomes were compared. RESULTS Since May 2017, 60 patients had undergone an RPD at our institution. The median operative time was 360 min (IQR 302.25-442 min). CUSUM analysis of operative time identified 21 cases as proficiency threshold, indicated by curve inflexion. Median operative time was significantly shorter after the threshold of 21 cases (470 vs 320 min, p < 0.001). No significant difference was found between before- and after-threshold groups in major Clavien-Dindo complications (23.8 vs 25.6%, p = 0.876). CONCLUSIONS A decrease in operative time after 21 RPD cases suggests a threshold of technical proficiency potentially associated with an initial adjustment to new instrumentation, port placement and standardisation of operative step sequence. RPD can be safely performed by surgeons with prior laparoscopic surgery experience.
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Alterio RE, Nagaraj MB, Scott DJ, Tellez J, Radi I, Baker HB, Zeh HJ, Polanco PM. Developing a Robotic Surgery Curriculum: Selection of Virtual Reality Drills for Content Alignment. J Surg Res 2023; 283:726-732. [PMID: 36463811 DOI: 10.1016/j.jss.2022.11.019] [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: 02/27/2022] [Revised: 09/27/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Despite the importance of simulation-based training for robotic surgery, there is no consensus about its training curricula. Recently, a virtual reality (VR) platform (SimNow, Intuitive, Inc) was introduced with 33 VR drills but without evidence of their validity. As part of our creating a new robotic VR curriculum, we assessed the drills' validity through content mapping and the alignment between learning goals and drill content. METHODS Three robotically trained surgeons content-mapped all 33 drills for how well the drills incorporated 15 surgery skills and also rated the drills' difficulty, usefulness, relevance, and uniqueness. Drills were added to the new curriculum based on consensus about ratings and historic learner data. The drills were grouped according to similar skill sets and arranged in order of complexity. RESULTS The 33 drills were judged to have 12/15 surgery skills as primary goals and 13/15 as secondary goals. Twenty of the 33 drills were selected for inclusion in the new curriculum; these had 11/15 skills as primary goals and 11/15 as secondary goals. However, skills regarding energy sources, atraumatic handling, blunt dissection, fine dissection, and running suturing were poorly represented in the drills. Three previously validated inanimate drills were added to the curriculum to address lacking skill domains. CONCLUSIONS We identified 20 of the 33 SimNow drills as a foundation for a robotic surgery curriculum based on content-oriented evidence. We added 3 other drills to address identified gaps in drill content.
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Affiliation(s)
- Rodrigo E Alterio
- Department of Surgery, University of Texas Southwestern, Dallas, Texas
| | - Madhuri B Nagaraj
- Department of Surgery, University of Texas Southwestern, Dallas, Texas
| | - Daniel J Scott
- Department of Surgery, University of Texas Southwestern, Dallas, Texas; Simulation Center, University of Texas Southwestern, Dallas, Texas
| | - Juan Tellez
- Department of Surgery, University of Texas Southwestern, Dallas, Texas
| | - Imad Radi
- Department of Surgery, University of Texas Southwestern, Dallas, Texas
| | - Hayley B Baker
- Department of Surgery, University of Texas Southwestern, Dallas, Texas
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, Texas
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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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Gall TMH, Malhotra G, Elliott JA, Conneely JB, Fong Y, Jiao LR. The Atlantic divide: contrasting surgical robotics training in the USA, UK and Ireland. J Robot Surg 2023; 17:117-123. [PMID: 35366194 PMCID: PMC9939491 DOI: 10.1007/s11701-022-01399-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/11/2022] [Indexed: 11/29/2022]
Abstract
The uptake of robotic surgery is rapidly increasing worldwide across surgical specialties. However, there is currently a much higher use of robotic surgery in the United States of America (USA) compared to the United Kingdom (UK) and Ireland. Reduced exposure to robotic surgery in training may lead to longer learning curves and worse patient outcomes. We aimed to identify whether any difference exists in exposure to robotic surgery during general surgical training between trainees in the USA, UK and Ireland. Over a 15-week period from September 2021, a survey was distributed through the professional networks of the research team. Participants were USA, UK or Irish trainees who were part of a formal general surgical training curriculum. 116 survey responses were received. US trainees (n = 34) had all had robotic simulator experience, compared to only 37.93% of UK (n = 58) and 75.00% of Irish (n = 24) trainees (p < 0.00001). 91.18% of US trainees had performed 15 or more cases as the console surgeon, compared to only 3.44% of UK and 16.67% of Irish trainees (p < 0.00001). Fifty UK trainees (86.21%) and 22 Irish trainees (91.67%) compared to 12 US trainees (35.29%) do not think they have had adequate robotics training (p < 0.00001). Surgical trainees in the USA have had significantly more exposure to training in robotic surgery than their UK and Irish counterparts.
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Affiliation(s)
- Tamara M. H. Gall
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, UK ,Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gautam Malhotra
- Department of Surgery, City of Hope Medical Center, 1500 East Duarte Road, Duarte, CA 91010 USA
| | - Jessie A. Elliott
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John B. Conneely
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Yuman Fong
- Department of Surgery, City of Hope Medical Center, 1500 East Duarte Road, Duarte, CA 91010 USA
| | - Long R. Jiao
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, UK ,Department of Academic Surgery, The Royal Marsden Hospital, London, UK
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Rahimi AO, Ho K, Chang M, Gasper D, Ashouri Y, Dearmon-Moore D, Hsu CH, Ghaderi I. A systematic review of robotic surgery curricula using a contemporary educational framework. Surg Endosc 2022; 37:2833-2841. [PMID: 36481821 DOI: 10.1007/s00464-022-09788-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND There has been a rising trend in robotic surgery. Thus, there is demand for a robotic surgery curriculum (RSC) for training surgical trainees and practicing surgeons. There are limited data available about current curricular designs and the extent to which they have incorporated educational frameworks. Our aim was to study the existing robotic surgery curricula using Kern's 6-step approach in curriculum development. METHODS A systematic review was conducted using PubMed, PubMed Central, Cochrane, Embase, and Scopus (we searched studies from 2001 to 2021). PRISMA Guidelines was used to guide the search. Curriculum designed for general surgery and its subspecialties were included. Urology and gynecology were excluded. The articles were reviewed by five reviewers. RESULTS Our review yielded 71 articles, including 39 curricula at 9 different settings. Using Kern's framework, we demonstrated that the majority of robotic surgery curricula contained all the elements of Kern's curricular design. However, there were significant deficiencies in important aspects of these curricula i.e., implementation, the quality of assessment tools for measurement of performance and evaluation of the educational value of these interventions. Most institutions used commercial virtual reality simulators (VRS) as the main component of their RSC and 23% of curricula only used VRS. CONCLUSIONS Although majority of these studies contained all the elements of Kern's framework, there are critical deficiencies in the components of existing curricula. Future curricula should be designed using established educational frameworks to improve the quality of robotic surgery training.
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Zwart MJW, Nota CLM, de Rooij T, van Hilst J, Te Riele WW, van Santvoort HC, Hagendoorn J, Borei Rinkes IHM, van Dam JL, Latenstein AEJ, Takagi K, Tran KTC, Schreinemakers J, van der Schelling GP, Wijsman JH, Festen S, Daams F, Luyer MD, de Hingh IHJT, Mieog JSD, Bonsing BA, Lips DJ, Hilal MA, Busch OR, Saint-Marc O, Zehl HJ, Zureikat AH, Hogg ME, Molenaar IQ, Besselink MG, Koerkamp BG. Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3). Ann Surg 2022; 276:e886-e895. [PMID: 33534227 DOI: 10.1097/sla.0000000000004783] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation. BACKGROUND Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking. METHODS A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit. RESULTS Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%. CONCLUSIONS This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.
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Affiliation(s)
- Maurice J W Zwart
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Carolijn L M Nota
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H M Borei Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Khé T C Tran
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Jan H Wijsman
- Department of Surgery, Amphia Ziekenhuis, Breda, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional Orleans, Orleans, France
| | - Herbert J Zehl
- Department of Surgery, University of Texas, Southwestern, Dallas, Texas
| | - Amer H Zureikat
- Department of Surgery, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, Illinois
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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Xu YC, Yang F, Fu DL. Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review. World J Gastroenterol 2022; 28:2057-2075. [PMID: 35664036 PMCID: PMC9134138 DOI: 10.3748/wjg.v28.i19.2057] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.
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Affiliation(s)
- Ye-Cheng Xu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai 200040, China
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Moris D, Rushing C, McCracken E, Shah KN, Zani S, Perez A, Allen PJ, Niedzwiecki D, Fish LJ, Blazer DG. Quality of Life Associated with Open vs Minimally Invasive Pancreaticoduodenectomy: A Prospective Pilot Study. J Am Coll Surg 2022; 234:632-644. [PMID: 35290283 PMCID: PMC10166568 DOI: 10.1097/xcs.0000000000000102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies. STUDY DESIGN From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted. RESULTS Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being. CONCLUSIONS Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christel Rushing
- Duke Cancer Institute-Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Emily McCracken
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin N. Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Alexander Perez
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter J. Allen
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Donna Niedzwiecki
- Duke Cancer Institute-Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Laura J. Fish
- Duke Family Medicine and Community Health, Duke University, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Dan G. Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Glatz T, Brinkmann S, Thaher O, Driouch J, Bausch D. Robotische Pankreaschirurgie – Lernkurve und Etablierung. Zentralbl Chir 2022; 147:188-195. [DOI: 10.1055/a-1750-9779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ZusammenfassungMinimalinvasive Resektionstechniken zur Behandlung verschiedener Pathologien des Pankreas sind potenziell vorteilhaft für die behandelten Patienten in Bezug auf Rekonvaleszenzzeit und
postoperative Morbidität, stellen jedoch eine besondere technische Herausforderung für den behandelnden Chirurgen dar. Der Einzug der robotischen Technik in die Viszeralchirurgie bietet eine
prinzipielle Möglichkeit zur weitreichenden Verbreitung minimalinvasiver Verfahren in der Pankreaschirurgie.Ziel dieser Arbeit war es, die Entwicklungsmöglichkeiten der robotischen Pankreaschirurgie in Deutschland zu überprüfen. Datengrundlage sind die Qualitätsberichte der Krankenhäuser der
Jahre 2015–2019 kombiniert mit einer selektiven Literaturrecherche.Die Anzahl der vorliegenden Qualitätsberichte reduzierte sich von 2015 bis 2019 von 1635 auf 1594. Im Median führten 96 Kliniken 11–20, 56 Kliniken 21–50 und 15 Kliniken mehr als 50
Pankreaskopfresektionen jährlich durch. Bei den Linksresektionen waren es 35 Kliniken mit 11–20, 14 Kliniken mit 21–50 und 2 Kliniken mit mehr als 50 Eingriffen. Unter Berücksichtigung aller
Kliniken, die 5 oder mehr Linksresektionen pro Jahr durchführen, wurden an nur 29 Kliniken minimalinvasive Verfahren eingesetzt. Der Anteil an laparoskopischen Linksresektionen über 50%
wurde an nur 7 Kliniken beschrieben.Nach Datenlage in der Literatur divergieren die Lernkurven für die robotische Pankreaslinks- und Pankreaskopfresektion. Während die Lernkurve für die robotische Pankreaslinksresektion nach
etwa 20 Eingriffen durchlaufen ist, hat die Lernkurve für die robotische Pankreaskopfresektion mehrere Plateaus, die etwa nach 30, 100 und 250 Eingriffen erreicht werden.Aufgrund der dezentralen Struktur der Pankreaschirurgie in Deutschland scheint ein flächendeckendes Angebot robotischer Verfahren aktuell in weiter Ferne. Insbesondere die Etablierung der
robotischen Pankreaskopfresektion wird zunächst Zentren mit entsprechend hoher Fallzahl vorbehalten bleiben.
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Affiliation(s)
- Torben Glatz
- Chirurgische Klinik, Marien Hospital Herne – Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | - Sebastian Brinkmann
- Chirurgische Klinik, Marien Hospital Herne – Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | - Omar Thaher
- Chirurgische Klinik, Marien Hospital Herne – Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | - Jamal Driouch
- Chirurgische Klinik, Marien Hospital Herne – Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | - Dirk Bausch
- Chirurgische Klinik, Marien Hospital Herne – Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
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Hand F, Gall T, Jiao LR. Comment on: Learning Curve From 450 Cases of Robot-Assisted Pancreaticoduodenectomy in a High-Volume Pancreatic Center. ANNALS OF SURGERY OPEN 2022; 3:e137. [PMID: 37600108 PMCID: PMC10431312 DOI: 10.1097/as9.0000000000000137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022] Open
Affiliation(s)
- Fiona Hand
- From the Department of Academic Surgery, The Royal Marsden Hospital, Imperial College London, London SW3 6JJ
| | - Tamara Gall
- From the Department of Academic Surgery, The Royal Marsden Hospital, Imperial College London, London SW3 6JJ
| | - Long R Jiao
- From the Department of Academic Surgery, The Royal Marsden Hospital, Imperial College London, London SW3 6JJ
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Factors affecting the learning curve in robotic colorectal surgery. J Robot Surg 2022; 16:1249-1256. [DOI: 10.1007/s11701-022-01373-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 01/18/2023]
Abstract
AbstractLearning related to robotic colorectal surgery can be measured by surgical process (such as time or adequacy of resection) or patient outcome (such as morbidity or quality of life). Time based metrics are the most commonly used variables to assess the learning curve because of ease of analysis. With analysis of the learning curve, there are factors which need to be considered because they may have a direct impact on operative times or may be surrogate markers of clinical effectiveness (unrelated to times). Variables which may impact on operation time include surgery case mix, hybrid technique, laparoscopic and open colorectal surgery experience, robotic surgical simulator training, technology, operating room team, and case complexity. Multidimensional analysis can address multiple indicators of surgical performance and include variables such as conversion rate, complications, oncological outcome and functional outcome. Analysis of patient outcome and/or global assessment of robotic skills may be the most reliable methods to assess the learning curve.
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Jin J, Shi Y, Chen M, Qian J, Qin K, Wang Z, Chen W, Jin W, Lu F, Li Z, Wu Z, Jian L, Han B, Liang X, Sun C, Wu Z, Mou Y, Yin X, Huang H, Chen H, Gemenetzis G, Deng X, Peng C, Shen B. Robotic versus Open Pancreatoduodenectomy for Pancreatic and Periampullary Tumors (PORTAL): a study protocol for a multicenter phase III non-inferiority randomized controlled trial. Trials 2021; 22:954. [PMID: 34961558 PMCID: PMC8711152 DOI: 10.1186/s13063-021-05939-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 12/15/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is a complex and challenging procedure that requires meticulous tissue dissection and proficient suturing skills. Minimally invasive surgery with the utilization of robotic platforms has demonstrated advantages in perioperative patient outcomes in retrospective studies. The development of robotic pancreatoduodenectomy (RPD) in specific has progressed significantly, since first reported in 2003, and high-volume centers in pancreatic surgery are reporting large patient series with improved pain management and reduced length of stay. However, prospective studies to assess objectively the feasibility and safety of RPD compared to open pancreatoduodenectomy (OPD) are currently lacking. METHODS/DESIGN The PORTAL trial is a multicenter randomized controlled, patient-blinded, parallel-group, phase III non-inferiority trial performed in seven high-volume centers for pancreatic and robotic surgery in China (> 20 RPD and > 100 OPD annually in each participating center). The trial is designed to enroll and randomly assign 244 patients with an indication for elective pancreatoduodenectomy for malignant periampullary and pancreatic lesions, as well as premalignant and symptomatic benign periampullary and pancreatic disease. The primary outcome is time to functional recovery postoperatively, measured in days. Secondary outcomes include postoperative morbidity and mortality, as well as perioperative costs. A sub-cohort of 128 patients with pancreatic adenocarcinoma (PDAC) will also be compared to assess the percentage of patients who undergo postoperative adjuvant chemotherapy within 8 weeks, in each arm. Secondary outcomes in this cohort will include patterns of disease recurrence, recurrence-free survival, and overall survival. DISCUSSION The PORTAL trial is designed to assess the feasibility and safety of RPD compared to OPD, in terms of functional recovery as described previously. Additionally, this trial will explore whether RPD allows increased access to postoperative adjuvant chemotherapy, in a sub-cohort of patients with PDAC. TRIAL REGISTRATION ClinicalTrials.gov NCT04400357 . Registered on May 22, 2020.
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Affiliation(s)
- Jiabin Jin
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yusheng Shi
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengmin Chen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfeng Qian
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kai Qin
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhen Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Wei Chen
- Department of Pancreaticobiliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Weiwei Jin
- Department of Gastroenterology and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, China
| | - Fengchun Lu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Zheyong Li
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zehua Wu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Li Jian
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Han
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiao Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chuandong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Yiping Mou
- Department of Gastroenterology and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, China
| | - Xiaoyu Yin
- Department of Pancreaticobiliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Hao Chen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Georgios Gemenetzis
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of Hepatopancreatobiliary and Transplant Surgery, Royal Infirmary Edinburgh, Edinburgh, UK.
- Department of Pancreatobiliary Surgery, Glasgow Royal Infirmary, Glasgow, UK.
| | - Xiaxing Deng
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Chenghong Peng
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Al Abbas AI, Wang C, Hamad AB, Knab LM, Rice MK, Moser AJ, Zeh HJ, Zureikat AH, Hogg ME. Mentorship and formal robotic proficiency skills curriculum improve subsequent generations' learning curve for the robotic distal pancreatectomy. HPB (Oxford) 2021; 23:1849-1855. [PMID: 34059420 DOI: 10.1016/j.hpb.2021.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy is the accepted standard of care. The robotic distal (RDP) learning curve is 20-40 surgeries with operating time (ORT) as the most significant factor. This study evaluates how formal mentorship and a robotic skills curriculum impact the learning curve for subsequent generation surgeons. METHODS Consecutive RDP from 2008 to 2017 were evaluated. First Generation was two surgeons who started program without training or mentorship. Second Generation was the two surgeons who joined the program with mentorship. Third Generation was fellows who benefited from both formal training and mentorship. Multivariable models (MVA) were performed for ORT, clinically relevant pancreatic fistula (CR-POPF), and major complications (Clavien≥3). RESULTS A total of 296 RDP were performed of which 187 did not include other procedures: First Generation (n = 71), Second Generation (n = 50), and Third Generation (n = 66). ORT decreased by generation (p < 0.001) without any differences in CR-POPF or Clavien≥3. On MVA, earlier generation (p = 0.019), pre-operative albumin (p = 0.001) and pancreatic adenocarcinoma (p = 0.019) were predictive of ORT. Increased BMI (p = 0.049) and neoadjuvant therapy (p = 0.046) were predictive of CR-POPF. Fellow participation at the console increased over time. CONCLUSION Formal mentorship and a skills curriculum decreased the learning curve and complications were largely dependent on patient factors.
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Affiliation(s)
- Amr I Al Abbas
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Chi Wang
- Northshore University Healthsystem, Evanston, IL, USA
| | - Ahmad B Hamad
- Ohio State University Medical Center, Columbus, OH, USA
| | - L Mark Knab
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - MaryJoe K Rice
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - A James Moser
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bartella I, Fransen LFC, Gutschow CA, Bruns CJ, van Berge Henegouwen ML, Chaudry MA, Cheong E, Cuesta MA, Van Daele E, Gisbertz SS, van Hillegersberg R, Hölscher A, Mercer S, Moorthy K, Nafteux P, Nilsson M, Pattyn P, Piessen G, Räsanen J, Rosman C, Ruurda JP, Schneider PM, Sgromo B, Nieuwenhuijzen GA, Luyer MDP, Schröder W. Technique of open and minimally invasive intrathoracic reconstruction following esophagectomy-an expert consensus based on a modified Delphi process. Dis Esophagus 2021; 34:6102597. [PMID: 33846718 DOI: 10.1093/dote/doaa127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/11/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In recent years, minimally invasive Ivor Lewis (IL) esophagectomy with high intrathoracic anastomosis has emerged as surgical standard of care for esophageal cancer in expert centers. Alongside this process, many divergent technical aspects of this procedure have been devised in different centers. This study aims at achieving international consensus on the surgical steps of IL reconstruction using Delphi methodology. METHODS The expert panel consisted of specialized esophageal surgeons from 8 European countries. During a two-round Delphi process, a detailed analysis and consensus on key steps of intrathoracic gastric tube reconstruction (IL esophagectomy) was performed. RESULTS Response rates in Delphi rounds 1 and 2 were 100% (22 of 22 experts) and 83.3% (20 of 24 experts), respectively. Three essential technical areas of intrathoracic gastric tube reconstruction were identified: first, vascularization of the gastric conduit, second, gastric mobilization, tube formation and pull-up, and third, anastomotic technique. In addition, 3 main techniques for minimally invasive intrathoracic anastomosis are currently practiced: (i) end-to-side circular stapled, (ii) end-to-side double stapling, and (iii) side-to-side linear stapled technique. The step-by-step procedural analysis unveiled common approaches but also different expert practice. CONCLUSION This precise technical description may serve as a clinical guideline for intrathoracic reconstruction after esophagectomy. In addition, the results may aid to harmonize the technical evolution of this complex surgical procedure and thereby facilitate surgical training.
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Affiliation(s)
- Isabel Bartella
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Laura F C Fransen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Christian A Gutschow
- Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christiane J Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Mark L van Berge Henegouwen
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M Asif Chaudry
- Department of Surgery, The Royal Marsden Hospital, London, UK
| | - Edward Cheong
- Department of Upper GI Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Miguel A Cuesta
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Elke Van Daele
- Department of GI Surgery, University Hospital Ghent, Ghent, Belgium
| | - Suzanne S Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Arnulf Hölscher
- Center for Esophageal and Gastric Cancer Surgery, Markushospital Frankfurt, Frankfurt am Main, Germany
| | - Stuart Mercer
- Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Krishna Moorthy
- Department of Surgery and Cancer, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Magnus Nilsson
- Department of Upper Abdominal Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Piet Pattyn
- Department of GI Surgery, University Hospital Ghent, Ghent, Belgium
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Lille University Hospital, Lille, France
| | - Jari Räsanen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paul M Schneider
- Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Bruno Sgromo
- Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Wolfgang Schröder
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
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Ikoma N, Lee JE, Katz MHG. ASO Author Reflections: Accelerating the Learning Curve of Robotic Pancreatectomy and Gastrectomy Through a Composite Robotic Foregut Surgical Oncology Program. Ann Surg Oncol 2021; 29:286-287. [PMID: 34595667 DOI: 10.1245/s10434-021-10826-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Ryoo DY, Eskander MF, Hamad A, Li Y, Cloyd J, Manilchuk A, Tsung A, Pawlik TM, Dillhoff M, Schmidt C, Ejaz A. Mitigation of the Robotic Pancreaticoduodenectomy Learning Curve through comprehensive training. HPB (Oxford) 2021; 23:1550-1556. [PMID: 33903049 DOI: 10.1016/j.hpb.2021.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/05/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is an associated lag in achieving competency for robotic pancreaticoduodenectomy (PD), resulting in a learning curve. We hypothesize that the reported learning curve can be mitigated through a comprehensive graduated training protocol. METHODS All patients (n = 237) who underwent an open (n = 197, 83.1%) or robotic (n = 40, 16.9%) PD between 2015-2019 were identified at The Ohio State University. The learning curve for operative time and surgical failure (defined as conversion to open, blood transfusion, or Clavien-Dindo complication grade ≥3) was analyzed using a risk adjusted cumulative summation technique. RESULTS After 10 cases, operative time plateaued to a mean of 468.3 ± 96.3 minutes for robotic PD versus a mean of 332.5 ± 103.9 minutes for open PD (P < 0.001). There was no further apparent learning curve over time relative to rates of operative time or surgical failure. After propensity score-matching, patients undergoing robotic PD had a similar incidence of major complications, grade B/C postoperative pancreatic fistula, and delayed gastric emptying versus patients undergoing open PD (all P > 0.05). CONCLUSION Completion of a comprehensive procedure-specific robotic training protocol for PD mitigated the learning curve for this operative approach by shifting the curve into the training/simulation phase rather than the live operating phase. These data hold important implications for the future training and accreditation of surgeons embarking on robotic PD.
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Affiliation(s)
- Da Y Ryoo
- The Ohio State University, Columbus, OH, USA
| | | | - Ahmad Hamad
- The Ohio State University, Columbus, OH, USA
| | - Yaming Li
- The Ohio State University, Columbus, OH, USA
| | | | | | - Allan Tsung
- The Ohio State University, Columbus, OH, USA
| | | | | | | | - Aslam Ejaz
- The Ohio State University, Columbus, OH, USA.
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Dolan D, White A, Lee DN, Mazzola E, Polhemus E, Kucukak S, Wee JO, Swanson SJ. Short and Long-term Outcomes Among High-Volume vs Low-Volume Esophagectomy Surgeons at a High-Volume Center. Semin Thorac Cardiovasc Surg 2021; 34:1340-1350. [PMID: 34560249 DOI: 10.1053/j.semtcvs.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/13/2021] [Indexed: 11/11/2022]
Abstract
To determine associations between surgeon volume and esophagectomy outcomes at a high-volume institution. All esophagectomies for esophageal cancer at our institution from August 2005 to August 2019 were reviewed. Cases were divided by surgeon into low, <7 cases/year, vs high volume, ≥7 cases/year, based on Leapfrog Group recommendations. Surgeons remained 'high-volume' after one year of ≥7 cases. Demographics, comorbidities, course of care, and long-term outcomes were compared. In total, 1029 cases were evaluated; 120 performed by low-volume surgeons vs 909 by high-volume surgeons. Never-smokers, atrial fibrillation, and clinical Stage IVa patients were associated with high-volume surgeons. Other demographics were similar. Low-volume surgeons did more open cases, 45.8% vs 14.5%, P < 0.01. Low-volume surgeons had more complications than high-volume surgeons (71.7% vs 57.6%, P < 0.01), specifically Grade II and III (59.2% vs 46.8%, P = 0.01, and 44.2% vs 27.0%, P <0.01). No differences were seen in anastomotic leak rate, 90-day mortality, recurrences, 5-year overall survival (46.7% low-volume vs 49.3% high-volume, P = 0.64), or 5-year disease-free survival (35.7% low-volume vs 42.2% high-volume, P = 0.27). In multivariable logistic regression for Grade III or higher complications, high-volume surgeons had an odds ratio of 0.56 (95% confidence interval 0.36-0.87) for complications. Our study found higher rates of open esophagectomies and complications in low-volume esophagectomy surgeons compared to high-volume surgeons at the same, high-volume institution. However, low-volume surgeons were not associated with worse survival outcomes compared to high-volume surgeons. Low-volume esophagectomy surgeons may benefit from mentoring and support to improve perioperative outcomes; these efforts are underway at our institution.
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Affiliation(s)
- Daniel Dolan
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts.
| | - Abby White
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Daniel N Lee
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Emanuele Mazzola
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Emily Polhemus
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Suden Kucukak
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Jon O Wee
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
| | - Scott J Swanson
- Brigham and Women's Hospital, Division of Thoracic Surgery, Boston, Massachusetts
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The standardized technique and surgical video of robotic pancreaticoduodenectomy at the Chinese PLA General Hospital. Updates Surg 2021; 74:245-254. [PMID: 34368928 DOI: 10.1007/s13304-021-01149-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
The technical complexity of robotic pancreaticoduodenectomy (RPD) and lack of technical surgical standardization have slowed its widespread application. RPD is only routinely performed in a few highly specialized centers. This study describes in detail the standard steps and core techniques of an experienced robotic center in China. We took advantage of our single experience to provide a step-by-step technique and surgical video of our RPD standardized procedure. We divided RPD into 18 key steps. Demographics and perioperative outcomes of consecutive 20 patients who underwent the RPD standardized procedure were analyzed. For the 20 consecutive patients, the mean operative time was 253.6 min, and the median estimated blood loss was 210.0 mL. One patient required conversion to laparotomy due to the need for PV reconstruction. One patient had grade 3 complication. The median postoperative hospital stay was 11.0 days. No 90-day mortality was observed. By simplifying and optimizing the surgical techniques, the RPD procedure can be standardized and modeled to improve feasibility and repeatability.
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45
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Ahmad SB, Rice M, Chang C, Zureikat AH, Zeh HJ, Hogg ME. dV-Trainer vs. da Vinci Simulator: Comparison of Virtual Reality Platforms for Robotic Surgery. J Surg Res 2021; 267:695-704. [PMID: 34348185 DOI: 10.1016/j.jss.2021.06.036] [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: 01/31/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND A virtual reality (VR) curriculum performed on the da Vinci Simulation System (DVSS) was previously shown to be effective in training fellows. The dV-Trainer is a separate platform with similar features to the da Vinci console, but its efficacy and utility versus the DVSS simulator are not well known. MATERIALS AND METHODS A mastery-based VR curriculum was completed by surgical fellows on the DVSS (2014-2016) and on the dV-Trainer (2016-2018) at a large academic center. Pre-test/post-test scores were used to evaluate performance between the two groups. Data was collected prospectively. RESULTS Forty-six fellows enrolled in the curriculum: surgical oncology (n=31), hepatobiliary (n=5), head/neck (n=4), endocrine (n=2), cardiothoracic (n=2), gynecology (n=1) and transplant surgery (n=1). Twenty-four used the DVSS and twenty-two used the dV-Trainer. Compared to the DVSS, the dV-Trainer was associated with lower scores on 2 of 3 VR modules in the pre-test (P=0.027, P<0.001, respectively) and post-test (P=0.021, P<0.001, respectively). Fellows in the dV-Trainer era scored lower on inanimate drills as well. Average VR curriculum score was lower on the dV-Trainer (71.3% vs 83.34%, P<0.001). dV-Trainer users spent more time completing the pre-test and post-test; however, overall simulator time to complete the curriculum was not significantly different (297 vs 231 minutes, P=0.142). Both groups showed improvement in scores after completion of the VR curriculum. CONCLUSIONS The dV-Trainer simulator allows for more usability outside the operating room to complete VR modules; however, the DVSS simulator group outperformed the dV-Trainer group on the post-test.
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Affiliation(s)
- Sarwat B Ahmad
- University of Pittsburgh Medical Center, , Pittsburgh, PA,.
| | - MaryJoe Rice
- University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX
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Vining CC, Skowron KB, Hogg ME. Robotic gastrointestinal surgery: learning curve, educational programs and outcomes. Updates Surg 2021; 73:799-814. [PMID: 33484423 DOI: 10.1007/s13304-021-00973-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/06/2021] [Indexed: 02/07/2023]
Abstract
The use of the robotic platform for gastrointestinal surgery was introduced nearly 20 years ago. However, significant growth and advancement has occurred primarily in the last decade. This is due to several advantages over traditional laparoscopic surgery allowing for more complex dissections and reconstructions. Several randomized controlled trials and retrospective reviews have demonstrated equivalent oncologic outcomes compared to open surgery with improved short-term outcomes. Unfortunately, there are currently no universally accepted or implemented training programs for robotic surgery and robotic surgery experience varies greatly. Additionally, several limitations to the robotic platform exist resulting in a distinct learning curve associated with various procedures. Therefore, implementation of robotic surgery requires a multidisciplinary team approach with commitment and investment from clinical faculty, operating room staff and hospital administrators. Additionally, there is a need for wider distribution of educational modules to train more surgeons and reduce the associated learning curve. This article will focus on the implementation of the robotic platform for surgery of the pancreas, stomach, liver, colon and rectum with an emphasis on the associated learning curve, educational platforms to develop proficiency and perioperative outcomes.
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Affiliation(s)
- Charles C Vining
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Kinga B Skowron
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Walgreens Building, Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA.
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Abstract
Current evidence shows that robotic pancreatoduodenectomy (RPD) is feasible with a safety profile equivalent to either open pancreatoduodenectomy (OPD) or laparoscopic pancreatoduodenectomy (LPD). However, major intraoperative bleeding can occur and emergency conversion to OPD may be required. RPD reduces the risk of emergency conversion when compared to LPD. The learning curve of RPD ranges from 20 to 40 procedures, but proficiency is reached only after 250 operations. Once proficiency is achieved, the results of RPD may be superior to those of OPD. As for now, RPD is at least equivalent to OPD and LPD with respect to incidence and severity of POPF, incidence and severity of post-operative complications, and post-operative mortality. A minimal annual number of 20 procedures per center is recommended. In pancreatic cancer (versus OPD), RPD is associated with similar rates of R0 resections, but higher number of examined lymph nodes, lower blood loss, and lower need of blood transfusions. Multivariable analysis shows that RPD could improve patient survival. Data from selected centers show that vein resection and reconstruction is feasible during RPD, but at the price of high conversion rates and frequent use of small tangential resections. The true Achilles heel of RPD is higher operative costs that limit wider implementation of the procedure and accumulation of a large experience at most single centers. In conclusion, when proficiency is achieved, RPD may be superior to OPD with respect to CR-POPF and oncologic outcomes. Achievement of proficiency requires commitment, dedication, and truly high volumes.
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48
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Casciani F, Bassi C, Vollmer CM. Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula. Surgery 2021; 170:889-909. [PMID: 33892952 DOI: 10.1016/j.surg.2021.02.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/25/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula. METHODS A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon. RESULTS Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula. CONCLUSION A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.
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Affiliation(s)
- Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, University of Verona, Italy. https://twitter.com/F_Casciani
| | - Claudio Bassi
- Department of Surgery, University of Verona, Italy. https://twitter.com/pennsurgery
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Thornblade LW, Fong Y. Simulation-Based Training in Robotic Surgery: Contemporary and Future Methods. J Laparoendosc Adv Surg Tech A 2021; 31:556-560. [PMID: 33835885 DOI: 10.1089/lap.2021.0082] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
While robotic surgery has grown in popularity and scope over the past decade, there is a persistent need for simulation-based training as surgeons adapt from the working at the bedside to the immersive and multisensory tasks at the console. From dry laboratory to virtual reality (VR) environments, simulation can be used to train surgeons in basic tasks, complex operative steps, and coordination of whole operations with members of the entire operating room (OR) staff. By integrating simulation into mentored training programs, surgeons can reduce the number of cases required to master a complex operation. Future VR based simulation will become essential to the adaptation of the surgical workforce to new technologies and adoption of emerging robotic platforms. Ultimately, robotic simulation will set standards for credentialing of new surgeons.
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Affiliation(s)
- Lucas W Thornblade
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
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50
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Ahmad SB, Rice M, Chang C, Hamad A, Kingham TP, He J, Pimiento JM, Zureikat AH, Zeh HJ, Hogg ME. Will It Play in Peoria? A Pilot Study of a Robotic Skills Curriculum for Surgical Oncology Fellows. Ann Surg Oncol 2021; 28:6273-6282. [PMID: 33791900 DOI: 10.1245/s10434-021-09913-z] [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: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION To implement a mastery-based robotic surgery curriculum using virtual reality (VR) and inanimate reality (IR) drills at multiple Complex General Surgical Oncology (CGSO) fellowships. PATIENTS AND METHODS A prospective study of curriculum feasibility and efficacy was conducted at four CGSO fellowship sites. All sites had simulators, and kits were provided to perform 19 biotissue drills. Fellows from three non-UPMC sites (n = 15) in 2016-2018 were compared with fellows from University of Pittsburgh (UPMC; n = 15) where the curriculum was validated in 2014-2018. RESULTS All fellows completed the pre- and post-test. There was no difference in pre-test scores between UPMC and non-UPMC sites. Only 7 of 15 non-UPMC fellows completed the VR curriculum (47% compliance) compared with all 15 UPMC fellows completing the VR curriculum (100% compliance). UPMC had higher curriculum times (217 versus 93 mins) and % mastery (86% versus 55%). Time spent on curriculum was associated with % mastery (p = 0.01). Both groups showed improvement between pre- and post-test. Post-test VR scores trended higher for UPMC (221 versus 180). Between the non-UPMC sites, there was a difference in compliance (p = 0.03) and % mastery (p = 0.03). Zero non-UPMC fellows performed the biotissue drills, while five contemporary UPMC fellows completed 253 biotissue drills. Approximately 140 UPMC faculty and 300 staff hours were spent on the pilot. CONCLUSIONS A proficiency curriculum can result in improved robotic console skills. However, multiple barriers to implementation potentially exist, including availability of simulators, availability of a training robot, on-site support staff, and universal buy-in from fellows, faculty, and leadership.
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Affiliation(s)
- Sarwat B Ahmad
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - MaryJoe Rice
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cecilia Chang
- North Shore University Health System, Chicago, IL, USA
| | - Ahmad Hamad
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Jin He
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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