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Lippert T, Ross S, Pattilachan T, Christodoulou M, Gratsianskiy D, Rosemurgy A, Sucandy I. Initial clinical outcomes of robotic resection for perihilar cholangiocarcinoma: Is it safe and effective? J Surg Oncol 2024; 130:102-108. [PMID: 38739865 DOI: 10.1002/jso.27676] [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: 02/14/2024] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND AND OBJECTIVES We aimed to describe our outcomes of robotic resection for perihilar cholangiocarcinoma, the largest single institutional series in the Western hemisphere to date. METHODS Between 2016 and 2022, we prospectively followed all patients who underwent robotic resection for perihilar cholangiocarcinoma. RESULTS In total, 23 patients underwent robotic resection for perihilar cholangiocarcinoma, 18 receiving concomitant hepatectomy. The median age was 73 years. Operative time was 470 min with an estimated blood loss of 150 mL. No intraoperative conversions to open or other intraoperative complications occurred. Median length of stay was 5 days. Four postoperative complications occurred. Three readmissions occurred within 30 days with one 90-day mortality. R0 resection was achieved in 87% of patients and R1 in 13% of patients. At a median follow-up of 27 months, 15 patients were alive without evidence of disease, two patients with local recurrence at 1 year, and six were deceased. CONCLUSIONS Utilization of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with excellent perioperative outcomes. Further studies are needed to determine the long-term oncological outcomes.
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Affiliation(s)
- Trenton Lippert
- College of Medicine, University of South Florida Morsani, Tampa, Florida, USA
| | - Sharona Ross
- AdventHealth Digestive Health Institute, Tampa, Florida, USA
| | | | | | | | | | - Iswanto Sucandy
- AdventHealth Digestive Health Institute, Tampa, Florida, USA
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Christodoulou M, Pattilachan TM, Ross S, Shapera E, Sucandy I. ASO Author Reflections: Application of Robotic Technique for Treatment of Biliary Sclerosis from Hepatic Artery Infusion Pump Chemotherapy. Ann Surg Oncol 2024; 31:4456-4457. [PMID: 38689170 DOI: 10.1245/s10434-024-15368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 05/02/2024]
Affiliation(s)
| | | | - Sharona Ross
- Digestive Health Institute at AdventHealth Tampa, Tampa, FL, USA
| | - Emanuel Shapera
- Digestive Health Institute at AdventHealth Tampa, Tampa, FL, USA
| | - Iswanto Sucandy
- Digestive Health Institute at AdventHealth Tampa, Tampa, FL, USA.
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Sucandy I, Marques HP, Lippert T, Magistri P, Coelho JS, Ross SB, Chumbinho B, Di Sandro S, DiBenedetto F. Clinical Outcomes of Robotic Resection for Perihilar Cholangiocarcinoma: A First, Multicenter, Trans-Atlantic, Expert-Center, Collaborative Study. Ann Surg Oncol 2024; 31:81-89. [PMID: 37718337 DOI: 10.1245/s10434-023-14307-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Perihilar cholangiocarcinoma is a difficult cancer to treat with frequent vascular invasion, local recurrence, and poor survival. Due to the need for biliary anastomosis and potential vascular resection, the standard approach is an open operation. Suboptimal outcomes after laparoscopic resection had been sporadically reported by high-volume centers. In this first, Trans-Atlantic, multicenter study, we report our outcomes of robotic resection for perihilar cholangiocarcinoma. This is the largest study of its kind in the Western hemisphere. METHODS Between 2016 and 2023, we prospectively followed patients undergoing robotic resection for perihilar cholangiocarcinoma at three, high-volume, robotic, liver-surgery centers. RESULTS Thirty-eight patients underwent perihilar cholangiocarcinoma utilizing the robotic technique; Klatskin type-3 was the most common. The median age was 72 years, and 82% of the patients underwent preoperative biliary drainage. Median operative time was 481 minutes with a median estimated blood loss of 200 mL. The number of harvested lymph nodes was seven, and 11 (28%) patients yielded positive lymph nodes. Three patients required vascular reconstruction; 18% of patients had >1 biliary anastomosis. R0 resection margins were achieved in 82% of patients. Clavien-Dindo Grade ≥3 complications were seen in 16% of patients. The length of stay was 6 days. Five patients had an unplanned readmission within 30 days. One patient died within 30 days. With a median follow-up of 15 months, 68% of patients are alive without disease, 13% recurred, and 19% died. CONCLUSIONS Application of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with acceptable short-term clinical and oncological outcomes.
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Affiliation(s)
| | - Hugo P Marques
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Trenton Lippert
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Joao Santos Coelho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | | | - Beatriz Chumbinho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio DiBenedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
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Sucandy I, Marques HP, Lippert T, Magistri P, Coelho JS, Ross SB, Chumbinho B, Di Sandro S, DiBenedetto F. ASO Author Reflections: Clinical Outcomes of Robotic Resection for Perihilar Cholangiocarcinoma: A First Multicenter, Trans-Atlantic, Expert-Center Collaborative Study. Ann Surg Oncol 2024; 31:154-155. [PMID: 37773564 DOI: 10.1245/s10434-023-14362-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 10/01/2023]
Affiliation(s)
| | - Hugo P Marques
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Trenton Lippert
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Joao Santos Coelho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | | | - Beatriz Chumbinho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio DiBenedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
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Sucandy I, Younos A, Lim-Dy A, Lippert T. ASO Author Reflections: Robotic Klatskin Type 3A Resection with Biliary Reconstruction: Can this Emerging Minimally Invasive Technique Become an Alternative Approach to Open Surgery for Perihilar Cholangiocarcinoma? Ann Surg Oncol 2023; 30:8012-8013. [PMID: 37725223 DOI: 10.1245/s10434-023-14298-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA.
| | - Ahmed Younos
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Allyson Lim-Dy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Trenton Lippert
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
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Magistri P, Pang NQ, Guidetti C, Caracciolo D, Odorizzi R, Catellani B, Guerrini GP, Di Sandro S, Di Benedetto F. Robotic approach for perihilar cholangiocarcinoma: from Bismuth 1 to vascular resection. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107002. [PMID: 37599146 DOI: 10.1016/j.ejso.2023.107002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/18/2023] [Accepted: 07/30/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Implementation of minimally invasive surgical approaches for perihilar cholangiocarcinoma (pCCA) has been relatively slow compared to other indications. This is due to the complexity of the disease and the need of advanced skills for the reconstructive phase. The robot may contribute to close the gap between open and minimally invasive surgery in patients with Klastkin tumors. STUDY DESIGN We report details of our experience with robotic approach in patients affected by pCCA. In particular selection criteria, ERAS management, technical tips and robotic setup are discussed. Finally, results from our cohort are reported. A video clip of a patient that underwent left hepatectomy with en-bloc caudatectomy and portal vein resection at the confluence with end-to-end reconstruction for a pCCA 3-b according to Bismuth-Corlette classification with full robotic approach is enclosed. RESULTS Fourteen patients underwent robotic resection of pCCA over the three-year interval with a median follow-up interval of 18.7 months. The pre-operative Bismuth-Corlette classification was 1 for two patients (14.2%) and 2 for one patient (7.1%), 3-a for three (21.4%) patients, 3-b for four (28.6%) patients and 4 for four (28.6%) patients. Median estimated blood loss was 150 ml (range 50-800 ml) and median operative time was 490 min (range 390-750 min). The median length of hospital stay after the index operation was 6 days (range 3-91). Final histology revealed a median of 19 (range 11-40) lymph nodes retrieved, with 92.9% R0 resections. 90-days mortality was nihil and 3-year survival exceeds 50%. CONCLUSION With adequate preparation, outcomes of robotic approach to pCCA can be safe and in line with the current international benchmark outcomes, as showed in this study, when performed in expert high volume centers for complex major hepatectomy and robotic HPB.
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Affiliation(s)
- Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Ning Qi Pang
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy; Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore
| | - Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Daniela Caracciolo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Odorizzi
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Barbara Catellani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy.
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Sucandy I, Kang RD, Adorno J, Goodwin S, Crespo K, Syblis C, Ross S, Rosemurgy A. Analysis of Clinical Outcomes After Robotic Hepatectomy Applying the Western-Model Southampton Laparoscopic Difficulty Scoring System. An Experience From a Tertiary US Hepatobiliary Center. Am Surg 2023; 89:3788-3793. [PMID: 37265440 DOI: 10.1177/00031348231173948] [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: 06/03/2023]
Abstract
BACKGROUND Identification of resections with high risk of intraoperative complications is critical in guiding case selection for minimally invasive liver surgery. Several Japanese and European difficulty scoring systems have been proposed for laparoscopic liver surgery. However, the applicability of these systems for robotic liver resections has not been fully investigated. This study considers the Southampton system and examines its validity when applied to robotic hepatectomies. METHODS We undertook a retrospective review of 372 patients who underwent robotic hepatectomies for various indications between 2013 and 2022. Of these patients, 63 operations were classified as low risk, 91 as moderate risk, 198 as high risk and 20 as extremely high risk based on Southampton criteria. Patient outcomes were compared by utilizing an ANOVA of repeated measures. Data are presented as median (mean ± SD). RESULTS The Southampton difficulty scoring system was a strong predictor of intraoperative variables including tumor size, operative duration, estimated blood loss (EBL), and incidence of major vs minor resection (all P < .0001). In contrast, the Southampton system was a weaker predictor of postoperative outcomes including 30-day mortality (P = .15), length of stay (P = .13), and readmissions within 30 days (P = .38). CONCLUSION The Southampton difficulty scoring system is a valid system for classifying robotic liver resections and is a strong predictor of intraoperative outcomes. However, the system was found to be a weaker predictor of postoperative outcomes. This finding may suggest the need for proposal of a new difficulty scoring system for robotic hepatectomies.
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Affiliation(s)
- Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Richard D Kang
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jeilianis Adorno
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
- University of South Florida, Tampa, FL, USA
| | - Sarah Goodwin
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Kaitlyn Crespo
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Cameron Syblis
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Sharona Ross
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
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Pure robotic major hepatectomy with biliary reconstruction for hepatobiliary malignancies: first European results. Surg Endosc 2023:10.1007/s00464-023-09863-5. [PMID: 36759354 DOI: 10.1007/s00464-023-09863-5] [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: 10/10/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Combined liver and bile duct resection with biliary reconstruction for hepatobiliary malignancies are defined as highly complex surgical procedures. The robotic platform may overcome some major limitations of conventional laparoscopic surgery for these complex cases but its precise role is however still to be defined. METHODS In our institution, patients requiring major hepatectomy with biliary reconstruction for malignancies were consecutively selected for minimally invasive robotic surgery from September 2020. All surgeries were undertaken using the da Vinci Xi Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA). Intra-operative technique and postoperative outcome were analyzed. RESULTS A total number of 10 patients (3 males and 7 females, median age 72 years) underwent robotic major hepatectomy and bile duct resection for hepatobiliary malignancies between September 2020 and March 2022. The indication for surgery was perihilar cholangiocarcinoma in 5 of 10 patients. Median operative time was 338 min and median blood loss was 110 mL. Postoperative length of stay was between 3 and 16 days (median: 9 days). There was no postoperative 90-day mortality. CONCLUSIONS A robotic approach for hepatobiliary malignancies requiring combined major hepatectomy and bile duct resection seems feasible and safe in experienced hands.
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He YG, Huang W, Ren Q, Li J, Yang FX, Deng CL, Li LQ, Peng XH, Tang YC, Zheng L, Huang XB, Li YM. Comparison of Efficacy and Safety Between Laparoscopic and Open Radical Resection for Hilar Cholangiocarcinoma—A Propensity Score-Matching Analysis. Front Oncol 2022; 12:1004974. [PMID: 36226051 PMCID: PMC9549331 DOI: 10.3389/fonc.2022.1004974] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRadical resection remains the most effective treatment for hilar cholangiocarcinoma (HCCA). However, due to the complex anatomy of the hilar region, the tumor is prone to invade portal vein and hepatic arteries, making the surgical treatment of HCCA particularly difficult. Successful laparoscopic radical resection of HCCA(IIIA, IIIB) requires excellent surgical skills and rich experience. Furthermore, the safety and effectiveness of this operation are still controversial.AimTo retrospectively analyze and compare the efficacy and safety of laparoscopic and open surgery for patients with HCCA.MethodsClinical imaging and postoperative pathological data of 89 patients diagnosed with HCCA (IIIA, IIIB) and undergoing radical resection in our center from January 2018 to March 2022 were retrospectively analyzed. Among them, 6 patients (4 were lost to follow-up and 2 were pathologically confirmed to have other diseases after surgery) were ruled out, and clinical data was collected from the remaining 83 patients for statistical analysis. These patients were divided into an open surgery group (n=62) and a laparoscopic surgery group (n=21) according to the surgical methods used, and after 1:2 propensity score matching (PSM), 32 and 16 patients respectively in the open surgery group and laparoscopic surgery group were remained. The demographic data, Bismuth type, perioperative data, intraoperative data, postoperative complications, pathological findings, and long-term survivals were compared between these two groups.ResultsAfter 1:2 PSM, 32 patients in the open surgery group and 16 patients in the laparoscopic surgery group were included for further analysis. Baseline characteristics and pathological outcomes were comparable between the two groups. Statistically significant differences between the two groups were observed in intraoperative blood loss and operative time, as it were 400-800 mL vs 200-400 mL (P=0.012) and (407.97 ± 76.06) min vs (489.69 ± 79.17) min (P=0.001) in the open surgery group and laparoscopic surgery group, respectively. The R0 resection rate of the open group was 28 cases (87.5%), and the R0 resection rate of the laparoscopic group was 15 cases (93.75%). The two groups showed no significant difference in terms of surgical approach, intraoperative blood transfusion, incidence of postoperative complications, and short- and long-term efficacy (P>0.05).ConclusionsLaparoscopic radical resection of HCCA has comparable perioperative safety compared to open surgery group, as it has less bleeding and shorter operation time. Although it is a promising procedure with the improvement of surgical skills and further accumulation of experience, further investigations are warranted before its wider application.
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Affiliation(s)
- Yong-Gang He
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Wen Huang
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Qian Ren
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Jing Li
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Feng-Xia Yang
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Chang-Lin Deng
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Li-Qi Li
- Department of General Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xue-Hui Peng
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yi-Chen Tang
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Lu Zheng
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
- *Correspondence: Yu-Ming Li, ; Xiao-Bing Huang, ; Lu Zheng,
| | - Xiao-Bing Huang
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
- *Correspondence: Yu-Ming Li, ; Xiao-Bing Huang, ; Lu Zheng,
| | - Yu-Ming Li
- Department of Hepatobiliary, The Second Affiliated Hospital of Army Medical University, Chongqing, China
- *Correspondence: Yu-Ming Li, ; Xiao-Bing Huang, ; Lu Zheng,
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Bahra M, Ossami Saidy RR. Current status of robotic surgery for hepato-pancreato-biliary malignancies. Expert Rev Anticancer Ther 2022; 22:939-946. [PMID: 35863758 DOI: 10.1080/14737140.2022.2105211] [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: 11/04/2022]
Abstract
INTRODUCTION Robotic surgery is an emerging aspect of gastrointestinal surgery. Hepato-pancreato-biliary surgery is currently being explored for a broad spectrum of indications, entities, and postoperative outcomes. Noninferiority and financial aspects are the focus of studies. In this review, the impact on oncological therapies is assessed. AREAS COVERED An extensive literature review was conducted, and relevant studies and articles and reviews for robotic surgery in the field of hepato-pancreato-biliary surgery were examined. Special attention was given to the oncological aspects of robotic surgery and its possible impact on the therapy of malignant neoplasms. EXPERT OPINION Robotic-assisted surgery for oncological indications is promising, in part, an established technique that has already shown its advantages in the last decade, although high-quality studies are missing. Upcoming experience must consider the oncological benefit and putative new indications in a rapidly changing field of anti-neoplastic regimens. Also, robotic surgery may possess the ability to accelerate digitalization and AI-based augmentation in this context.
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Affiliation(s)
- Marcus Bahra
- Krankenhaus Waldfriede, Akademisches Lehrkrankenhaus der Charité, Zentrum für Onkologische Oberbauchchirurgie und Robotik, Argentinische Allee 40, 14163 Berlin
| | - Ramin Raul Ossami Saidy
- Krankenhaus Waldfriede, Akademisches Lehrkrankenhaus der Charité, Zentrum für Onkologische Oberbauchchirurgie und Robotik, Argentinische Allee 40, 14163 Berlin
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Shapera EA, Ross S, Syblis C, Crespo K, Rosemurgy A, Sucandy I. Analysis of Oncological Outcomes After Robotic Liver Resection for Intrahepatic Cholangiocarcinoma. Am Surg 2022:31348221093933. [PMID: 35512632 DOI: 10.1177/00031348221093933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concerns regarding minimally invasive liver resection of intrahepatic cholangiocarcinoma (IHCC) include inadequate resection margins and inferior long-term overall survival (OS) when compared to an "open" approach. Limited data exists to address these issues. We aimed to compare perioperative variables, tumor distance to margin, and long-term outcomes after IHCC resection based on surgical approach (robotic vs open) in our hepatobiliary center to address these concerns. METHODS With IRB approval, 34 patients who underwent robotic or open hepatectomy for IHCC were prospectively followed. Patients were stratified by tumor distance to resection margin (≤1 mm, 1.1-9.9 mm, ≥10 mm) for illustrative purposes and by approach (robotic vs open). Where appropriate, regression analysis and cox model of proportional hazards were utilized. Survival was stratified by margin distance and approach utilizing Kaplan-Meier curves. Data are presented as median (mean ± SD). RESULTS Patients undergoing robotic vs open hepatectomy had similar demographics. Patients undergoing the robotic approach had significantly lower estimated blood loss (EBL). Tumor distance to margin between the two approaches were similar (P = .428). Median OS between the two approaches was similar in patients of any margin distance.In the subgroup analysis by margin distance, the robotic approach yielded less EBL for patients in the 1.1-9.9 mm and ≥10 mm margin groups, and a shorter ICU length of stay for patients with ≥10 mm margin. DISCUSSION Similar margins were attained via either approach, translating into oncological non-inferiority of robotic IHCC resection. Robotic approach for the treatment of IHCC should be considered an alternative to an open approach.
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Affiliation(s)
- Emanuel A Shapera
- Center for Advanced Minimally Invasive Liver Surgery, Digestive Health Institute, 4422AdventHealth Tampaa, Tampa, FL, USA
| | - Sharona Ross
- Center for Advanced Minimally Invasive Liver Surgery, Digestive Health Institute, 4422AdventHealth Tampaa, Tampa, FL, USA
| | - Cameron Syblis
- Center for Advanced Minimally Invasive Liver Surgery, Digestive Health Institute, 4422AdventHealth Tampaa, Tampa, FL, USA
| | - Kaitlyn Crespo
- Center for Advanced Minimally Invasive Liver Surgery, Digestive Health Institute, 4422AdventHealth Tampaa, Tampa, FL, USA
| | - Alexander Rosemurgy
- Center for Advanced Minimally Invasive Liver Surgery, Digestive Health Institute, 4422AdventHealth Tampaa, Tampa, FL, USA
| | - Iswanto Sucandy
- Center for Advanced Minimally Invasive Liver Surgery, Digestive Health Institute, 4422AdventHealth Tampaa, Tampa, FL, USA
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Shapera E, Ross SB, Chudzinski A, Massarotti H, Syblis CC, Crespo K, Rosemurgy AS, Sucandy I. Simultaneous Resection of Colorectal Carcinoma and Hepatic Metastases is Safe and Effective: Examining the Role of the Robotic Approach. Am Surg 2022:31348221093533. [PMID: 35487498 DOI: 10.1177/00031348221093533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUNDS AND OBJECTIVES Up to 50% of patients with colorectal carcinoma (CRC) present with liver metastases (CLM) throughout their course. Complete resection of both sites provides the only chance for cure. Either a staged or simultaneous resection is feasible. The latter avoids delays in adjuvant systemic chemotherapy but may increase technical complexity and perioperative complications. We aim to evaluate our initial outcomes of simultaneous CRC and CLM resections with a focus on the robotic technique. METHOD With institutional review board approval, we followed 26 consecutive patients who underwent simultaneous/concomitant liver and colorectal resection. Major liver resection is defined as resection of ≥3 contiguous Couinaud segments. Data are presented as median (mean ± SD). RESULTS Patients were 64 (63 ± 14.0) years old. Body mass index was 29 (29 ± 5.7) kg/m2. 54% of patients had prior abdominal operation(s). A majority of patients were >ASA class III (73%), underwent major liver resection (62%) with robotic approach (77%). In the robotic cohort, there were no unplanned conversions to open. Estimated blood loss was 150 (210 ± 181.8) ml. Total operative duration was 446 (463 ± 93.6) minutes. Negative margins (R0) were obtained in all patients. Postoperative complication of Clavien-Dindo≥3 occurred in three patients, including one requiring reoperation with end ileostomy for anastomotic leak. Length of stay was 5 (6 ± 3.5) days. Three patients were readmitted within 30 days after discharge, none for reoperation. There was no 90-day mortality. CONCLUSION Our cohort of concomitant CRC and CLM resection demonstrates safety and efficacy via both the open and robotic approach.
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Affiliation(s)
| | - Sharona B Ross
- Digestive Health Institute, 4422AdventHealth Tampa, Tampa, FL, USA
| | - Allen Chudzinski
- Digestive Health Institute, 4422AdventHealth Tampa, Tampa, FL, USA
| | - Haane Massarotti
- Digestive Health Institute, 4422AdventHealth Tampa, Tampa, FL, USA
| | - Cameron C Syblis
- Digestive Health Institute, 4422AdventHealth Tampa, Tampa, FL, USA
| | - Kaitlyn Crespo
- Digestive Health Institute, 4422AdventHealth Tampa, Tampa, FL, USA
| | | | - Iswanto Sucandy
- Digestive Health Institute, 4422AdventHealth Tampa, Tampa, FL, USA
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Analysis of surgical approach and tumor distance to margin after liver resection for colorectal liver metastasis. J Robot Surg 2022; 16:1427-1439. [PMID: 35199291 DOI: 10.1007/s11701-022-01387-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/06/2022] [Indexed: 02/07/2023]
Abstract
This study was undertaken to compare tumor distance to margin after robotic vs. open hepatectomy for colorectal liver metastases (CLM) and to determine the relationship between perioperative variables, surgical approach and tumor distance to margin with overall survival. With IRB approval, we followed 56 patients who underwent a robotic or open hepatectomy for treatment of CLM. The relationships between the tumor distance to margin, operative approach, perioperative variables and survival was determined. The robotic approach yielded greater margins than the open approach (p = 0.04). The robotic vs. open approach had an operative duration of 375 vs. 269 min (p = 0.05), ICU length of stay (LOS) of 0 vs. 1 day (p = 0.01), and hospital LOS of 4 vs. 7 days (p = 0.04). Patients with a tumor distance to margin of ≤ 1 mm and 1.1-9.9 mm had an estimated median survival of 49 months and 24 months, respectively. Estimated median survival for patients with tumor distance to margin of ≥ 10 mm has not been reached but is > 84 months. The use of the robotic approach is associated with greater tumor distance to margin and shorter hospital LOS, but with longer operations. The robotic approach does not compromise oncological margins during resection for CLM.
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14
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Robotic Surgery for Biliary Tract Cancer. Cancers (Basel) 2022; 14:cancers14041046. [PMID: 35205792 PMCID: PMC8869869 DOI: 10.3390/cancers14041046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 12/26/2022] Open
Abstract
Biliary tract cancer consists of cholangiocarcinoma (CC) and gallbladder cancer (GBC). When resectable, surgery provides the best chance at long-term survival. Unfortunately, surgery for these tumors is associated with long operative times, high morbidities, and prolonged hospital stays. Minimally invasive surgery has been shown to impact selected outcomes, including length of stay, in other diseases, and robotic surgery may offer additional advantages compared to laparoscopic surgery in treating bile duct cancers. This is a systematic review of robotic surgery for biliary tract cancer. Predetermined selection criteria were used to appraise the literature. The PRISMA guidelines were followed. In total, 20 unique articles with a total of 259 patients with biliary tract cancer undergoing robotic surgery met the inclusion criteria. For CC and GBC, respectively, the weighted average operative time was 401 and 277 min, the estimated blood loss was 348 and 260 mL, the conversion rate to open was 7 and 3.5%, the all-cause morbidity was 52 and 9.7%, the major morbidity was 12 and 4.4%, the perioperative mortality was 1.4 and 0%, the length of stay was 15 and 4.8 days, the positive margin rate was 27 and 9%, and the number of lymph nodes retrieved was 4.2 and 8. Robotic surgery for biliary tract cancer appears non-inferior to open surgery when compared to the published contemporary data. However, the current literature on the topic is of low quality, and future prospective/randomized studies are needed.
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Shapera E, Sucandy I, Syblis C, Crespo K, Ja'Karri T, Ross S, Rosemurgy A. Cost analysis of robotic versus open hepatectomy: Is the robotic platform more expensive? J Robot Surg 2022; 16:1409-1417. [PMID: 35152343 DOI: 10.1007/s11701-022-01375-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/21/2022] [Indexed: 11/27/2022]
Abstract
The robotic platform is perceived to be more expensive when compared to laparoscopic and open operations. We aimed to compare the perioperative costs of robotic vs. open hepatectomy for the treatment of liver tumors at our facility. We followed 370 patients undergoing robotic and open hepatectomy for benign and malignant liver tumors. Demographic, perioperative, cost and payment data were collected and analyzed. For illustrative purposes, the data were presented as median (mean ± SD). Two hundred sixty-seven robotic and 104 open hepatectomies were analyzed. There were no significant differences in perioperative variables between the two cohorts. The robotic group had a significantly lower estimated blood loss (EBL) (135 [208 ± 244.8] vs 300 [427 ± 502.5] ml, p < 0.0001), smaller lesion size (4 [5 ± 3.6] vs 5[6 ± 4.9] cm, p = 0.0052), shorter length of stay (LOS) (4 [4 ± 3.4] vs 6[8 ± 5.7] days, p < 0.0001) and decreased 90-day mortality (3 vs 7 p = 0.0028). There were no significant differences between the two groups any cost variable. The open group received significantly higher reimbursement ($29,297 [62,962 ± 75,377.96] vs $19,102 [38,975 ± 39,362.11], p < 0.001) and profit ($5005 [30,981 ± 79,541.09] vs $- 6682 [6146 ± 40,949.65], p < 0.001). Robotic hepatectomy is associated with lower EBL, shorter LOS and less mortality. There was no greater cost associated with the robotic platform despite a reduced reimbursement and profit.
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Affiliation(s)
- Emanuel Shapera
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA.
| | - Cameron Syblis
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Kaitlyn Crespo
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Thomas Ja'Karri
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Sharona Ross
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
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16
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Spiegelberg J, Iken T, Diener MK, Fichtner-Feigl S. Robotic-Assisted Surgery for Primary Hepatobiliary Tumors-Possibilities and Limitations. Cancers (Basel) 2022; 14:cancers14020265. [PMID: 35053429 PMCID: PMC8773643 DOI: 10.3390/cancers14020265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/26/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Primary liver malignancies are some of the most common and fatal tumors today. Robotic-assisted liver surgery is becoming increasingly interesting for both patients and surgeons alike. Up to date, prospective comparative studies around the topic are scarce. This leads us to an ever existing controversy about the efficacy, safety, and economic benefits of robotic surgery as an extension of traditional minimally invasive surgery over open liver surgery. However, there is evidence that robotic-assisted surgery is, after passing the learning curve, equivalent in terms of feasibility and safety, and in some cases superior to traditional laparoscopic hepatic resection. With this work, we want to provide an overview of the latest and most significant reviews and meta-analyses focusing on robotic hepatectomy in primary liver malignancies. We outline the technical aspects of robotic-assisted surgery and place them into the context of technical, surgical, and oncological outcomes compared with laparoscopic and open resection. When chosen per case individually, any hepatic resection can be performed robotically to overcome limitations of laparoscopic surgery by an experienced team. In this paper, we propose that prospective studies are needed to prove efficacy for robotic-assisted resection in liver malignancy. Abstract Hepatocellular and cholangiocellular carcinoma are fatal primary hepatic tumors demanding extensive liver resection. Liver surgery is technically challenging due to the complex liver anatomy, with an intensive and variant vascular and biliary system. Therefore, major hepatectomies in particular are often performed by open resection and minor hepatectomies are often performed minimally invasively. More centers have adopted robotic-assisted surgery, intending to improve the laparoscopic surgical limits, as it offers some technical benefits such as seven degrees of freedom and 3D visualization. The da Vinci® Surgical System has dominated the surgical robot market since 2000 and has shown surgical feasibility, but there is still much controversy about its economic benefits and real benefits for the patient over the gold standard. The currently available retrospective case studies are difficult to compare, and larger, prospective studies and randomized trials are still urgently missing. Therefore, here we summarize the technical, surgical, and economic outcomes of robotic versus open and laparoscopic hepatectomies for primary liver tumors found in the latest literature reviews and meta-analyses. We conclude that complex robotic liver resections (RLR) are safe and feasible after the steep learning curve of the surgical team has plateaued. The financial burden is lower in high volume centers and is expected to decrease soon as new surgical systems will enter the market.
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