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Duclos C, Durin T, Marchese U, Sauvanet A, Laurent C, Ayav A, Turrini O, Sulpice L, Addeo P, Souche FR, Perinel J, Birnbaum DJ, Facy O, Gagnière J, Gaujoux S, Schwarz L, Regenet N, Iannelli A, Regimbeau JM, Piessen G, Lenne X, El Amrani M, Heyd B, Doussot A. Management and outcomes of hemorrhage after distal pancreatectomy: a multicenter study at high volume centers. HPB (Oxford) 2024; 26:234-240. [PMID: 37951805 DOI: 10.1016/j.hpb.2023.10.008] [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: 03/16/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Data on clinically relevant post-pancreatectomy hemorrhage (CR-PPH) are derived from series mostly focused on pancreatoduodenectomy, and data after distal pancreatectomy (DP) are scarce. METHODS All non-extended DP performed from 2014 to 2018 were included. CR-PPH encompassed grade B and C PPH. Risk factors, management, and outcomes of CR-PPH were evaluated. RESULTS Overall, 1188 patients were included, of which 561 (47.2 %) were operated on minimally invasively. Spleen-preserving DP was performed in 574 patients (48.4 %). Ninety-day mortality, severe morbidity and CR-POPF rates were 1.1 % (n = 13), 17.4 % (n = 196) and 15.5 % (n = 115), respectively. After a median interval of 8 days (range, 0-37), 65 patients (5.5 %) developed CR-PPH, including 28 grade B and 37 grade C. Reintervention was required in 57 patients (87.7 %). CR-PPH was associated with a significant increase of 90-day mortality, morbidity and hospital stay (p < 0.001). Upon multivariable analysis, prolonged operative time and co-existing POPF were independently associated with CR-PPH (p < 0.005) while a chronic use of antithrombotic agent trended towards an increase of CR-PPH (p = 0.081). As compared to CR-POPF, the failure-to-rescue rate in patients who developed CR-PPH was significantly higher (13.8 % vs. 1.3 %, p < 0.001). CONCLUSION CR-PPH after DP remains rare but significantly associated with an increased risk of 90-day mortality and failure-to-rescue.
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Affiliation(s)
- Côme Duclos
- Department of Digestive Surgical Oncology, Liver Transplantation Unit. CHU Besançon, Besançon, France
| | - Thibault Durin
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Lille, France
| | - Ugo Marchese
- Department of Digestive, Hepatobiliary and Pancreatic Surgery, Cochin Hospital, AP-HP, Paris, France
| | - Alain Sauvanet
- Department of HPB Surgery, Hôpital Beaujon, University of Paris, Clichy, France
| | - Christophe Laurent
- Department of Digestive Surgery, Centre Magellan - CHU Bordeaux, Bordeaux, France
| | - Ahmet Ayav
- Department of HPB Surgery, Nancy University Hospital, Nancy, France
| | - Olivier Turrini
- Institut Paoli Calmettes, Marseille University, Department of Oncological Surgery, Marseille, France
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive Surgery, University Hospital, Rennes 1 University, Rennes, France
| | - Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | | | - Julie Perinel
- Department of Digestive Surgery, Hopital Edouard Herriot, Lyon, France
| | - David J Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Olivier Facy
- Department of Digestive and Surgical Oncology, University Hospital, Dijon, France
| | - Johan Gagnière
- Department of Digestive and Hepatobiliary Surgery - Liver Transplantation, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Sébastien Gaujoux
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital and Université de Rouen Normandie, F-76100, Rouen, France
| | - Nicolas Regenet
- Department of Digestive Surgery, Nantes Hospital, Nantes, France
| | - Antonio Iannelli
- Digestive Surgery and Liver Transplantation Unit, University Hospital of Nice, Nice, France
| | - Jean M Regimbeau
- Department of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, CHU Lille, Claude Huriez University Hospital, F-59000, Lille, France
| | - Xavier Lenne
- Medical Information Department, Lille University Hospital, Lille, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Lille, France
| | - Bruno Heyd
- Department of Digestive Surgical Oncology, Liver Transplantation Unit. CHU Besançon, Besançon, France
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology, Liver Transplantation Unit. CHU Besançon, Besançon, France.
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Labadie KP, Melstrom LG, Lewis AG. Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience. J Surg Oncol 2023; 128:1347-1352. [PMID: 37781938 DOI: 10.1002/jso.27455] [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: 08/29/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023]
Abstract
Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.
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Affiliation(s)
- Kevin P Labadie
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Aaron G Lewis
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
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Kauffmann EF, Napoli N, Di Dato A, Salamone A, Ginesini M, Gianfaldoni C, Viti V, Amorese G, Cappelli C, Vistoli F, Boggi U. Practical implications of tumor proximity to landmark vessels in minimally invasive radical antegrade modular pancreatosplenectomy. Updates Surg 2023; 75:1533-1540. [PMID: 37458902 PMCID: PMC10435633 DOI: 10.1007/s13304-023-01584-7] [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] [Accepted: 07/05/2023] [Indexed: 08/18/2023]
Abstract
Careful preoperative planning is key in minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS). This retrospective study aims to show the practical implications of computed tomography distance between the right margin of the tumor and either the left margin of the spleno-mesenteric confluence (d-SMC) or the gastroduodenal artery (d-GDA). Between January 2011 and June 2022, 48 minimally invasive RAMPS were performed for either pancreatic cancer or malignant intraductal mucinous papillary neoplasms. Two procedures were converted to open surgery (4.3%). Mean tumor size was 31.1 ± 14.7 mm. Mean d-SMC was 21.5 ± 18.5 mm. Mean d-GDA was 41.2 ± 23.2 mm. A vein resection was performed in 10 patients (20.8%) and the pancreatic neck could not be divided by an endoscopic stapler in 19 operations (43.1%). In patients requiring a vein resection, mean d-SMC was 10 mm (1.5-15.5) compared to 18 mm (10-37) in those without vein resection (p = 0.01). The cut-off of d-SMC to perform a vein resection was 17 mm (AUC 0.75). Mean d-GDA was 26 mm (19-39) mm when an endoscopic stapler could not be used to divide the pancreas, and 46 mm (30-65) when the neck of the pancreas was stapled (p = 0.01). The cut-off of d-GDA to safely pass an endoscopic stapler behind the neck of the pancreas was 43 mm (AUC 0.75). Computed tomography d-SMC and d-GDA are key measurements when planning for MI-RAMPS.
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Affiliation(s)
- Emanuele Federico Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Virginia Viti
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carla Cappelli
- Diagnostic and Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
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Xu Q, Li P, Zhang H, Wang M, Liu Q, Liu W, Dai M. Identifying the preoperative factors predicting the surgical difficulty of robotic distal pancreatectomy. Surg Endosc 2023; 37:3823-3831. [PMID: 36690891 DOI: 10.1007/s00464-023-09865-3] [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: 01/24/2022] [Accepted: 01/04/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Few studies have evaluated the preoperative factors predicting the surgical difficulty of robotic distal pancreatectomy (RDP). This study aims to explore such factors and provide guidance on the selection of suitable patients to aid surgeons lacking extensive experience in RDP. METHODS A retrospective study was conducted on consecutive patients who underwent RDP to identify preoperative factors predicting surgical difficulty. High surgical difficulty was defined by both operation time and intraoperative estimated blood loss exceeding their median, or by conversion to laparotomy. RESULTS A total of 161 patients were ultimately enrolled, including 51 patients with high levels of surgical difficulty. Multivariate analysis revealed that male sex [OR (95% CI): 4.07 (1.77,9.40), p = 0.001], body mass index (BMI) ≥ 25 kg/m2 OR (95% CI): 2.27 (1.03,5.00), p = 0.042], tumors located at the neck of the pancreas [OR (95% CI): 4.15 (1.49,11.56), p = 0.006] and splenic artery type B [OR (95% CI): 3.28 (1.09,9.91), p = 0.035] were independent risk factors for surgical difficulty. Regarding postoperative complications, high surgical difficulty was associated with the risk of overall complications and pancreatic fistula (grade B/C) (49.0% vs. 22.7%, p < 0.001; 39.2% vs. 19.1%, p = 0.006). CONCLUSION Male sex, body mass index ≥ 25 kg/m2, tumor located at the neck of the pancreas and splenic artery type B are associated with a high RDP difficulty level. These factors can be used preoperatively to assess the difficulty level of surgery, to help surgeons choose patients suitable for them and ensure surgical safety.
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Affiliation(s)
- Qiang Xu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Pengyu Li
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Hanyu Zhang
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Mengyi Wang
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Qiaofei Liu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Wenjing Liu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China.
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Robotic versus laparoscopic distal pancreatectomy on perioperative outcomes: a systematic review and meta-analysis. Updates Surg 2023; 75:7-21. [PMID: 36378464 PMCID: PMC9834369 DOI: 10.1007/s13304-022-01413-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Abstract
Robotic surgery has become a promising surgical method in minimally invasive pancreatic surgery due to its three-dimensional visualization, tremor filtration, motion scaling, and better ergonomics. Numerous studies have explored the benefits of RDP over LDP in terms of perioperative safety and feasibility, but no consensus has been achieved yet. This article aimed to evaluate the benefits and drawbacks of RDP and LDP for perioperative outcomes. By June 2022, all studies comparing RDP to LDP in the PubMed, the Embase, and the Cochrane Library database were systematically reviewed. According to the heterogeneity, fix or random-effects models were used for the meta-analysis of perioperative outcomes. Odds ratio (OR), weighted mean differences (WMD), and 95% confidence intervals (CI) were calculated. A sensitivity analysis was performed to explore potential sources of high heterogeneity and a trim and fill analysis was used to evaluate the impact of publication bias on the pooled results. Thirty-four studies met the inclusion criteria. RDP provides greater benefit than LDP for higher spleen preservation (OR 3.52 95% CI 2.62-4.73, p < 0.0001) and Kimura method (OR 1.93, 95% CI 1.42-2.62, p < 0.0001) in benign and low-grade malignant tumors. RDP is associated with lower conversion to laparotomy (OR 0.41, 95% CI 0.33-0.52, p < 0.00001), and shorter postoperative hospital stay (WMD - 0.57, 95% CI - 0.92 to - 0.21, p = 0.002), but it is more costly. In terms of postoperative complications, there was no difference between RDP and LDP except for 30-day mortality (RDP versus LDP, 0.1% versus 1.0%, p = 0.03). With the exception of its high cost, RDP appears to outperform LDP on perioperative outcomes and is technologically feasible and safe. High-quality prospective randomized controlled trials are advised for further confirmation as the quality of the evidence now is not high.
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Lv J, Guan X, Wei R, Yin Y, Liu E, Zhao Z, Chen H, Liu Z, Jiang Z, Wang X. Development of artificial blood loss and duration of excision score to evaluate surgical difficulty of total laparoscopic anterior resection in rectal cancer. Front Oncol 2023; 13:1067414. [PMID: 36959789 PMCID: PMC10028132 DOI: 10.3389/fonc.2023.1067414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/03/2023] [Indexed: 03/09/2023] Open
Abstract
Purpose Total laparoscopic anterior resection (tLAR) has been gradually applied in the treatment of rectal cancer (RC). This study aims to develop a scoring system to predict the surgical difficulty of tLAR. Methods RC patients treated with tLAR were collected. The blood loss and duration of excision (BLADE) scoring system was built to assess the surgical difficulty by using restricted cubic spline regression. Multivariate logistic regression was used to evaluate the effect of the BLADE score on postoperative complications. The random forest (RF) algorithm was used to establish a preoperative predictive model for the BLADE score. Results A total of 1,994 RC patients were randomly selected for the training set and the test set, and 325 RC patients were identified as the external validation set. The BLADE score, which was built based on the thresholds of blood loss (60 ml) and duration of surgical excision (165 min), was the most important risk factor for postoperative complications. The areas under the curve of the predictive RF model were 0.786 in the training set, 0.640 in the test set, and 0.665 in the external validation set. Conclusion This preoperative predictive model for the BLADE score presents clinical feasibility and reliability in identifying the candidates to receive tLAR and in making surgical plans for RC patients.
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Seo S, Uemura K, Sumiyoshi T, Kondo N, Okada K, Otsuka H, Murakami Y, Takahashi S. Optimal lymph-node dissection for pancreatic tail cancer. Surg Today 2022; 52:1307-1312. [PMID: 35182251 DOI: 10.1007/s00595-022-02463-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The optimal range of lymph-node dissection for pancreatic tail cancer remains unclear. We investigated the location and frequency of lymph-node metastases to identify the correct range of lymph-node dissection for pancreatic tail cancer. METHODS We analyzed clinical data retrospectively, on patients who underwent distal pancreatectomy for resectable left-sided pancreatic cancer, between February, 2006 and March, 2021. Eligible patients were divided into two groups according to the tumor location: those with pancreatic tail cancer (Pt group) and those with pancreatic body or body and tail cancer (non-Pt group). RESULTS Of the 96 patients analyzed, 61 (64%) were assigned to the Pt group and 35 (36%) were assigned to the non-Pt group. Metastases to stations 7, 8, 9, 10, 11, 14, and 18 were found in 0 (0%), 0 (0%), 0 (0%), 4 (7%), 18 (30%), 2 (4%), and 10 (17%) patients in the Pt group, and in 1 (3%), 4 (12%), 2 (6%), 1 (3%), 18 (51%), 3 (9%), and 6 (17%) patients in the non-Pt group, respectively. CONCLUSION Lymph-node dissection at stations 7, 8, and 9 might not be necessary in patients with resectable pancreatic cancer confined to the pancreatic tail.
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Affiliation(s)
- Shingo Seo
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kenichiro Uemura
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tatsuaki Sumiyoshi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Naru Kondo
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kenjiro Okada
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hiroyuki Otsuka
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yoshiaki Murakami
- Digestive Disease Center, Hiroshima Memorial Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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