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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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Niemann B, Kenney C, Marsh JW, Schmidt C, Boone BA. Implementing a robotic hepatopancreatobiliary program for new faculty: safety, feasibility and lessons learned. J Robot Surg 2024; 18:253. [PMID: 38878073 DOI: 10.1007/s11701-024-02011-8] [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: 04/15/2024] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
Robotic surgery is increasingly utilized in hepatopancreatobiliary (HPB) surgery, but the learning curve is a substantial obstacle hindering implementation. Comprehensive robotic training can help to surmount this obstacle; however, despite the expansion of robotic training into residency and fellowship programs, limited data are available about how this translates into successful incorporation in faculty practice. All operations performed during the first three years of practice of a surgical oncologist at a tertiary care academic institution were retrospectively reviewed. The surgeon underwent comprehensive robotic training during residency and fellowship. 137 HPB operations were performed during the initial three years of practice. Over 80% were performed robotically each year across a spectrum of HPB procedures with a 6% conversion rate. Median operative time, a metric for operative proficiency and evaluation for a learning curve, was similar throughout the study period for each major operation and below several reported optimized operative time benchmarks. The major complications, defined as a Clavien-Dindo of 3 or more, were similar across the experience and comparable to published series. Comprehensive robotic training in residency and fellowship as well as a dedicated, well-trained operative team allows for early attainment of optimized outcomes in a new HPB robotic practice.
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Affiliation(s)
- Britney Niemann
- Division of Surgical Oncology, Department of Surgery, West Virginia University, One Medical Center Drive, PO Box 9238 HSCS, Morgantown, WV, 26506, USA
| | - Christopher Kenney
- Division of Surgical Oncology, Department of Surgery, West Virginia University, One Medical Center Drive, PO Box 9238 HSCS, Morgantown, WV, 26506, USA
| | - J Wallis Marsh
- Division of Surgical Oncology, Department of Surgery, West Virginia University, One Medical Center Drive, PO Box 9238 HSCS, Morgantown, WV, 26506, USA
| | - Carl Schmidt
- Division of Surgical Oncology, Department of Surgery, West Virginia University, One Medical Center Drive, PO Box 9238 HSCS, Morgantown, WV, 26506, USA
| | - Brian A Boone
- Division of Surgical Oncology, Department of Surgery, West Virginia University, One Medical Center Drive, PO Box 9238 HSCS, Morgantown, WV, 26506, USA.
- Cancer Cell Biology, West Virginia University, Morgantown, WV, USA.
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV, USA.
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Niemann B, Kenney C, Wallis Marsh J, Schmidt C, Boone BA. Implementing a Robotic Hepatopancreatobiliary Program for New Faculty: Safety, Feasibility and Lessons Learned. RESEARCH SQUARE 2024:rs.3.rs-4271384. [PMID: 38746355 PMCID: PMC11092865 DOI: 10.21203/rs.3.rs-4271384/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background Robotic surgery is increasingly utilized in hepatopancreatobiliary (HPB) surgery, but the learning curve is a substantial obstacle hindering implementation. Comprehensive robotic training can help to surmount this obstacle; however, despite the expansion of robotic training into residency and fellowship programs, limited data is available about how this translates into successful incorporation in faculty practice. Methods All operations performed during the first three years of practice of a complex general surgical oncology-trained surgical oncologist at a tertiary care academic institution were retrospectively reviewed. The surgeon underwent comprehensive robotic training during residency and fellowship. Results 137 HPB operations were performed during the initial three years of practice. Over 80% were performed robotically each year across a spectrum of HPB procedures with a 6% conversion rate. Median operative time, the optimal metric for operative proficiency and evaluation for a learning curve, was similar throughout the study period for each major operation and below several reported optimized operative times. Major complications were similar across the experience and comparable to published series. Conclusion Comprehensive robotic training in residency and fellowship as well as a dedicated, well-trained operative team allows for early attainment of optimized outcomes in a new HPB robotic practice.
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Affiliation(s)
- Britney Niemann
- Division of Surgical Oncology, Department of Surgery, West Virginia University
| | - Christopher Kenney
- Division of Surgical Oncology, Department of Surgery, West Virginia University
| | - J Wallis Marsh
- Division of Surgical Oncology, Department of Surgery, West Virginia University
| | - Carl Schmidt
- Division of Surgical Oncology, Department of Surgery, West Virginia University
| | - Brian A Boone
- Division of Surgical Oncology, Department of Surgery, West Virginia University
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DeLaura I, Sharib J, Creasy JM, Berchuck SI, Blazer DG, Lidsky ME, Shah KN, Zani S. Defining the learning curve for robotic pancreaticoduodenectomy for a single surgeon following experience with laparoscopic pancreaticoduodenectomy. J Robot Surg 2024; 18:126. [PMID: 38492057 DOI: 10.1007/s11701-023-01746-0] [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: 09/21/2023] [Accepted: 12/02/2023] [Indexed: 03/18/2024]
Abstract
Robotic pancreaticoduodenectomy (RPD) has a learning curve of approximately 30-250 cases to reach proficiency. The learning curve for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study describes the RPD learning curve for a single surgeon following experience with LPD. LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and learning curve were defined with respect to operative time using CUSUM analysis. Seventeen LPD and 69 RPD were analyzed LPD had an inverted learning curve possibly accounting for proficiency attained during the surgeon's fellowship and acquisition of new skills coinciding with more complex patient selection. The learning curve for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 479 min, p < 0.005), less EBL (250 vs 500, p < 0.02), and similar R0 resection. RPD also had improved LOS (7 vs 10 days, p < 0.007), and lower rates of surgical site infection (10% vs 47%, p < 0.002), DGE (19% vs 47%, p < 0.03), and readmission (13% vs 41%, p < 0.02). Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between LPD and RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.
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Affiliation(s)
- Isabel DeLaura
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Jeremy Sharib
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - John M Creasy
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Samuel I Berchuck
- Department of Statistical Science, Duke University, Durham, NC, 27710, USA
| | - Dan G Blazer
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Kevin N Shah
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Sabino Zani
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA.
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Chen H, Weng Y, Zhao S, Wang W, Ji Y, Peng C, Deng X, Shen B. Robotic versus open pancreatoduodenectomy in patients with pancreatic duct adenocarcinoma after the learning curve: a propensity score-matched analysis. Surg Endosc 2024; 38:821-829. [PMID: 38066192 DOI: 10.1007/s00464-023-10530-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: 04/13/2023] [Accepted: 10/12/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Studies have demonstrated that the learning curve plays an important role in robotic pancreatoduodenectomy (RPD). Although improved short-term outcomes of RPD after the learning curve have been reported compared to open pancreatoduodenectomy (OPD), there is a lack of long-term survival analyses. METHODS Patients who underwent curative intended RPD and OPD for pancreatic duct adenocarcinoma (PDAC) between January 2017 and June 2020 were retrospectively reviewed. A 1:2 propensity score matching (PSM) analysis was performed to balance the baseline characteristics between the RPD and OPD groups. RESULTS Of the 548 patients (108 RPD and 440 OPD), 103 RPD patients were matched with 206 OPD patients after PSM. There were 194 (62.8%) men and 115 (37.2%) women, with a median age of 64 (58-69) years. The median overall survival (OS) in the RPD group was 33.2 months compared with 25.7 months in the OPD group (p = 0.058, log-rank). The median disease-free survival (DFS) following RPD was longer than the OPD (18.5 vs. 14.0 months, p = 0.011, log-rank). The RPD group has a lower incidence of local recurrence compared the OPD group (36.9% vs. 51.2%, p = 0.071). Multivariate Cox analysis demonstrated that RPD was independently associated with improved OS (HR 0.70, 95% CI 0.52-0.94, p = 0.019) and DFS (HR 0.66, 95% CI 0.50-0.88, p = 0.005). CONCLUSION After the learning curve, RPD had improved oncologic outcomes in PDAC patients compared to OPD. Future prospective randomized clinical trials will be required to validate these findings.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Shulin Zhao
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yuchen Ji
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Chenghong Peng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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Tang Y, Peng X, He Y, Li J, Zheng L, Huang X. A novel laparoscopic pancreaticoduodenal training model: optimization of the learning curve and simplification of postoperative complications. Int J Surg 2024; 110:758-765. [PMID: 37988408 PMCID: PMC10871600 DOI: 10.1097/js9.0000000000000918] [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: 07/12/2023] [Accepted: 11/05/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE Laparoscopic pancreaticoduodenectomy requires a long learning curve. A preoperative training system was established to optimize the surgeons' learning curve and reduce the incidence rate of complications at the beginning of the curve. METHODS The laparoscopic pancreaticojejunostomy model, and choledochojejunostomy and gastrojejunostomy training systems were developed, and corresponding evaluation systems were also defined. Surgeons B and C performed laparoscopic pancreaticoduodenectomy after completing training session. Surgical outcomes, postoperative complications and their learning curves were analyzed. RESULTS Patients operated by surgeons B and C experienced shorter operative durations following training session than those in nontrained group (called A) ( P <0.001). B and C began entering the inflection point at the 26th and 20th case in learning curve, respectively. The incidence of postoperative pancreatic fistula in group B was 3.3%, significantly lower than 13.1% in group A ( P =0.047). Patients in group B showed significantly lower incidence of biliary-enteric anastomosis leakage (0% vs. 8.2%, P =0.029) and Clavien-Dindo classification greater than or equal to 3 (3.3% vs. 14.8%, P =0.027) compared with those in group A. The incidence of surgical site infection in groups B (3.3%, P =0.004) and C (4.9%, P =0.012) was significantly lower than that in group A (19.7%). Moreover, the length of postoperative hospital stay was significantly shorter in groups B (12.5±5.9 days, P =0.002) and C (13.7±6.5 days, P =0.002) compared with group A (16.7±8.5 days). CONCLUSIONS The laparoscopic pancreaticojejunostomy training model and evaluation system can shorten the operative duration, lower the risk of postoperative complications, and shorten the length of hospital stay.
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Affiliation(s)
| | | | | | | | - Lu Zheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xiaobing Huang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing, China
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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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Which one is better? Laparoscopic versus robotic reconstruction in the remnant soft pancreas with a small pancreatic duct following pancreaticoduodenectomy: a multicenter study with propensity score matching analysis. Surg Endosc 2022; 37:4028-4039. [PMID: 36097095 DOI: 10.1007/s00464-022-09602-2] [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: 03/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Evidence of the advantages of robotic pancreaticoduodenectomy (RPD) over laparoscopic pancreaticoduodenectomy (LPD) is limited. Thus, this study aimed to compare the surgical outcomes of laparoscopic reconstruction L-recon) versus robotic reconstruction (R-recon) in patients with soft pancreas and small pancreatic duct. METHOD Among 429 patients treated with minimally invasive pancreaticoduodenectomy (MIPD) between October 2012 and June 2020 by three surgeons at three institutions, 201 patients with a soft pancreas and a small pancreatic duct (< 3 mm) were included in this study. RESULTS Sixty pairs of patients who underwent L-recon and R-recon were selected after propensity score matching. The perioperative outcomes were comparable between the reconstruction approaches, with comparable clinically relevant postoperative pancreatic fistula (CR-POPF) rates (15.0% [L-recon] vs. 13.3% [R-recon]). The sub-analysis according to the type of MIPD procedure also showed comparable outcomes, but only a significant difference in postoperative hospital stay was identified. During the learning curve analysis using the cumulative summation by operation time (CUSUMOT), two surgeons who performed both L-recon and R-recon procedures reached their first peak in the CUSUMOT graph earlier for the R-recon group than for the L-recon group (i.e., 20th L-recon case and third R-recon case of surgeon A and 43rd L-recon case and seventh R-recon case of surgeon B). Surgeon C, who only performed R-recon, demonstrated the first peak in the 22nd case. The multivariate regression analysis for risk factors of CR-POPF showed that the MIPD procedure type, as well as other factors, did not have any significant effect. CONCLUSION Postoperative pancreatic fistula rates and the overall perioperative outcomes of L-recon and R-recon were comparable in patients with soft-textured pancreas and small pancreatic duct treated by experienced surgeons.
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Sun H, Sun C, Zhang B, Ma K, Wu Z, Visser BC, Han B. Establishment and Application of a Novel Difficulty Scoring System for da Vinci Robotic Pancreatoduodenectomy. Front Surg 2022; 9:916014. [PMID: 35722537 PMCID: PMC9200290 DOI: 10.3389/fsurg.2022.916014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRobotic pancreatoduodenectomy (RPD) technology is developing rapidly, but there is still a lack of a specific and objective difficulty evaluation system in the field of application and training of RPD surgery.MethodsThe clinical data of patients who underwent RPD in our hospital from November 2014 to October 2020 were analyzed retrospectively. Univariate and multivariate logistic regression analyses were used to determine the predictors of operation difficulty and convert into a scoring system.ResultsA total of 72 patients were enrolled in the group. According to the operation time (25%), intraoperative blood loss (25%), conversion to laparotomy, and major complications, the difficulty of operation was divided into low difficulty (0–2 points) and high difficulty (3–4 points). The multivariate logistic regression model included the thickness of mesenteric tissue (P1) (P = 0.035), the thickness of the abdominal wall (B1) (P = 0.017), and the preoperative albumin (P = 0.032), and the nomogram was established. AUC = 0.773 (0.645–0.901).ConclusionsThe RPD difficulty evaluation system based on the specific anatomical relationship between da Vinci’s laparoscopic robotic arm and tissues/organs in the operation area can be used as a predictive tool to evaluate the surgical difficulty of patients before operation and guide clinical practice.
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Affiliation(s)
- Hongfa Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuandong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bingyuan Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kai Ma
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zehua Wu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Brendan C. Visser
- Hepatobiliary & Pancreatic Surgery, Stanford University School of Medicine, Stanford, CA, United States
- Correspondence: Bing Han Brendan C. Visser
| | - Bing Han
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
- Correspondence: Bing Han Brendan C. Visser
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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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P. Goh B, Yang E, Chong Y, Wang Z, Koh YX, Lim KI. Minimally-invasive versus open pancreatoduodenectomies with vascular resection: A 1:1 propensity-matched comparison study. J Minim Access Surg 2022; 18:420-425. [PMID: 35708385 PMCID: PMC9306132 DOI: 10.4103/jmas.jmas_201_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Minimally invasive pancreatic pancreatoduodenectomy (MIPD) is increasingly adopted worldwide and its potential advantages include reduced hospital stay and decrease pain. However, evidence supporting the role of MIPD for tumours requiring vascular reconstruction remains limited and requires further evaluation. This study aims to investigate the safety and efficacy of MIPD with vascular resection (MIPDV) by performing a 1:1 propensity-score matched (PSM) comparison with open pancreatoduodenectomy with vascular resection (OPDV) based on a single surgeon's experience. Methods: This is a retrospective review of 41 patients who underwent PDV between 2011 and 2020 by a single surgeon. After PSM, the comparison was made between 13 MIPDV and 13 OPDV. Results: Thirty-six patients underwent venous reconstruction (VR) only and 5 underwent arterial reconstruction of which 4 had concomitant VR. The types of VR included 22 wedge resections with primary repair, 8 segmental resections with primary anastomosis and 11 requiring interposition grafts. Post-operative pancreatic fistula (POPF) occurred in 3 (7.3%) patients. Major complications (>Grade 2) occurred in 16 (39%) patients, of which 7 were due to delayed gastric emptying requiring nasojejunal tube placement. There was 1 (2.4%) 30-day mortality (OPDV). Of the 13 MIPDV, there were 3 (23.1%) open conversions. PSM comparison demonstrated that MIPDV was associated with longer median operative time (720 min vs. 485 min (P = 0.018). There was no statistically significant difference in other key perioperative outcomes such as intra-operative blood loss, overall morbidity, major morbidity rate, POPF and length of stay. Conclusion: Our initial experience with the adoption MIPDV has demonstrated it to be safe with comparable outcomes to OPDV despite the longer operation time.
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Timmermann L, Hillebrandt KH, Felsenstein M, Schmelzle M, Pratschke J, Malinka T. Challenges of single-stage pancreatoduodenectomy: how to address pancreatogastrostomies with robotic-assisted surgery. Surg Endosc 2021; 36:6361-6367. [PMID: 34888711 PMCID: PMC9402518 DOI: 10.1007/s00464-021-08925-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/21/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Establishing a sufficient pancreatico-enteric anastomosis remains one of the most important challenges in open single stage pancreatoduodenectomy as they are associated with persisting morbidity and mortality. Applicability on a robotic-assisted approach, however, even increases the requirements. With this analysis we introduce a dorsal-incision-only invagination type pancreatogastrostomy (dioPG) to the field of robotic assistance having been previously proven feasible in the field of open pancreatoduodenectomy and compare initial results to the open approach by means of morbidity and mortality. METHODS An overall of 142 consecutive patients undergoing reconstruction via the novel dioPG, 38 of them in a robotic-assisted and 104 in an open approach, was identified and further reviewed for perioperative parameters, complications and mortality. RESULTS We observed a comparable R0-resection rate (p = 0.448), overall complication rate (p = 0.52) and 30-day mortality (p = 0.71) in both groups. Rates of common complications, such as postoperative pancreatic fistula (p = 0.332), postoperative pancreatic hemorrhage (p = 0.242), insufficiency of pancreatogastrostomy (p = 0.103), insufficiency of hepaticojejunostomy (p = 0.445) and the re-operation rate (p = 0.103) were comparable. The procedure time for the open approach was significantly shorter compared to the robotic-assisted approach (p = 0.024). DISCUSSION The provided anastomosis appeared applicable to a robotic-assisted setting resulting in comparable complication and mortality rates when compared to an open approach. Nevertheless, also in the field of robotic assistance establishing a predictable pancreatico-enteric anastomosis remains the most challenging aspect of modern single-stage pancreatoduodenectomy and requires expertise and experience.
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Affiliation(s)
- Lea Timmermann
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Karl Herbert Hillebrandt
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Matthäus Felsenstein
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany. .,Department of Surgery, Charité Campus Mitte and Charité Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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13
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Kim HS, Kim H, Han Y, Lee M, Kang YH, Sohn HJ, Kang JS, Kwon W, Jang JY. ROBOT-assisted pancreatoduodenectomy in 300 consecutive cases: Annual trend analysis and propensity score-matched comparison of perioperative and long-term oncologic outcomes with the open method. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:301-310. [PMID: 34689430 DOI: 10.1002/jhbp.1065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND/PURPOSE We previously reported perioperative and oncologic outcomes of robot-assisted pancreatoduodenectomy (RAPD); however, the follow-up period in RAPD was relatively short, and disease-matched survival analyses were lacking. Therefore, this study investigated time trends of perioperative and long-term disease-matched outcomes of RAPD. METHODS Annual clinicopathologic outcomes of 328 patients with RAPD between 2015 and 2020 were analyzed and compared with 929 patients with open PD using the propensity score-matched (PSM) analysis based on postoperative pancreatic fistula (POPF) risk and oncologic variables in malignant patients. RESULTS Robot-assisted pancreatoduodenectomy cases increased from 10 (6.3%) in 2015 to 116 (50.2% of total PD) in 2020, with malignancy proportion increasing from 50.0% to 80.2%. POPF risk-based PSM analysis showed that compared with open PD, RAPD had younger patients (63.7 vs 65.6 years, P = .018), longer operation time (339.1 vs 290.0 min, P < .001); however, estimated blood loss (P = .275), complications (17.1% vs 18.3%, P = .702), and clinically relevant POPF (9.8% vs 11.1%, P = .584) were similar with shorter postoperative hospital stay (10.8 vs 15.6 days, P < .001). In disease and stage-matched malignant patients, R0 resection (93.9% vs 91.2%, P = .376), total retrieved lymph node (18.2 vs 19.9, P = .058), and 5-year survival rate (57.3% vs 60.6%, P = .406) were similar between RAPD and open PD, also in pancreatic cancer patients (31.6% vs 26.3%, P = .068). CONCLUSIONS Robot-assisted pancreatoduodenectomy demonstrated similar perioperative outcomes with earlier recovery and equivalent long-term survival with open PD. RAPD is safe and feasible for periampullary lesions, including pancreatic cancers, and its role will expand in the era of minimally invasive surgery.
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Affiliation(s)
- Hyeong Seok Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Hyung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Ju Sohn
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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14
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Felsenstein M, Hillebrandt KH, Timmermann L, Feist M, Benzing C, Schmelzle M, Pratschke J, Malinka T. Robot-assisted pancreatic surgery-optimized operating procedures: set-up, port placement, surgical steps. J Robot Surg 2021; 16:807-814. [PMID: 34476723 PMCID: PMC9314296 DOI: 10.1007/s11701-021-01297-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/19/2021] [Indexed: 01/09/2023]
Abstract
Even in most complex surgical settings, recent advances in minimal-invasive technologies have made the application of robotic-assisted devices more viable. Due to ever increasing experience and expertise, many large international centers now offer robotic-assisted pancreatic surgery as a preferred alternative. In general however, pancreatic operations are still associated with high morbidity and mortality, while robotic-assisted techniques still require significant learning curves. As a prospective post-marketing trial, we have established optimized operating procedures at our clinic. This manuscript intends to publicize our standardized methodology, including pre-operative preparation, surgical set-up as well as the surgeons’ step-by-step actions when using pancreatic-assisted robotic surgery. This manuscript is based on our institutional experience as a high-volume pancreas operating center. We introduce novel concepts that should standardize, facilitate and economize the surgical steps in all types of robotic-assisted pancreatic surgery. The “One Fits All” principle enables single port placement irrespective of the pancreatic procedure, while the “Reversed 6-to-6 Approach” offers an optimized manual for pancreatic surgeons using the robotic console. Novel and standardized surgical concepts could guide new centers to establish a robust, efficient and safe robotic-assisted pancreatic surgery program.
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Affiliation(s)
- Matthäus Felsenstein
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany.,Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Karl H Hillebrandt
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany.,Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Lea Timmermann
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Mathilde Feist
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany.,Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Christian Benzing
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum I Campus Charité Mitte, Augustenburger Platz 1, 13353, Berlin, Germany.
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15
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Shirali AS, Pieterman CRC, Lewis MA, Hyde SM, Makawita S, Dasari A, Thosani N, Ikoma N, McCutcheon IE, Waguespack SG, Perrier ND. It's not a mystery, it's in the history: Multidisciplinary management of multiple endocrine neoplasia type 1. CA Cancer J Clin 2021; 71:369-380. [PMID: 34061974 DOI: 10.3322/caac.21673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/12/2021] [Accepted: 03/30/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Aditya S Shirali
- Department of Surgical Oncology, Section of Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carolina R C Pieterman
- Department of Surgical Oncology, Section of Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark A Lewis
- Department of Medicine, Intermountain Healthcare, Murray, Utah
| | - Samuel M Hyde
- Department of Obstetrics and Gynecology-Cancer Genetics, Northwestern Memorial Hospital, Chicago, Illinois
| | - Shalini Makawita
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Arvind Dasari
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology, and Nutrition, McGovern Medical School, UTHealth, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nancy D Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Tang YC, Liu QQ, He YG, Li J, Huang XB. Laparoscopic pancreaticoduodenectomy: a retrospective study of 200 cases and the optimization of the single-center learning curve. Transl Cancer Res 2021; 10:3436-3447. [PMID: 35116648 PMCID: PMC8798474 DOI: 10.21037/tcr-21-518] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/21/2021] [Indexed: 11/15/2022]
Abstract
Background Laparoscopic pancreaticoduodenectomy (LPD) is widely used in several centers. This study analyzed the postoperative complications rate curve, possible cause, and solution of LPD and open pancreaticoduodenectomy (OPD). Methods Between January 2015 and December 2019, the study included 213 and 204 patients undergoing OPD and LPD, respectively. Postoperative outcomes, complications, and complication risk, along with operation time were analyzed, and the learning curve was determined. Results The OPD group (378.7±8.98 min) had shorter operation time than the LPD group (402.5±7.12 min) (P=0.037). Blood loss was significantly lower in the LPD group (389.9±19.05 mL) than in the OPD group (530.1±33.55 mL) (P<0.001). The incidence of biliary-enteric anastomosis leakage was higher in the LPD group (2.9%) than in the OPD group (0.5%) (P=0.0495). The LPD group showed lower lung infection (7.4% vs. 17.4%, P=0.037), incision infection (1% vs. 8.5%, P<0.001), and anal exhaust time (3.35±0.07 vs. 4.05±0.07 days, P<0.001) than the OPD group. The biliary-enteric anastomosis leakage was strongly correlated with the pancreatic fistula (B/C) (R=0.6410), intraperitoneal infection (R=0.6126) and Clavien-Dindo Classification ≥3 (R=0.7403). According to the cumulative sum (CUSUM) curve, pancreatic fistula had a negative K value in 44 cases, biliary-enteric anastomosis leakage had a negative K value in 46 cases, and Clavien-Dindo Classification ≥3 had a negative K value in 40 cases. The learning curve for LPD has an inflection point in 86 cases. Conclusions LPD is safe and effective for patients with pancreatic cancer, and has a long learning curve and improved postoperative complications in 50 cases. This study’s results will help in reducing the complication rates of the first 50 consecutive cases of LPD.
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Affiliation(s)
- Yi-Chen Tang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Qin-Qin Liu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yong-Gang He
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Jing Li
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xiao-Bing Huang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing, China
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17
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Park SE, Choi HJ, You YK, Hong TH. Effectiveness and stability of robot-assisted anastomosis in minimally invasive pancreaticoduodenectomy. Ann Surg Treat Res 2021; 100:329-337. [PMID: 34136429 PMCID: PMC8176201 DOI: 10.4174/astr.2021.100.6.329] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/11/2021] [Accepted: 03/09/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose Reconstruction using robotic assistance in pancreaticoduodenectomy (PD) was expected to be an effective means to overcome the limitations of laparoscopic surgery. To our knowledge, few comparative reports exist on the outcomes of totally laparoscopic PD (TLPD) and robot-assisted laparoscopic PD (RLPD). This retrospective study aimed to analyze the surgical results of TLPD and RLPD in a high-volume pancreatic center. Methods We analyzed the surgical results of consecutive patients who underwent a minimally invasive PD for malignant or benign periampullary lesions between January 2016 and May 2020. Forty-three TLPD patients and 49 RLPD patients were enrolled. Results There were no significant differences in the demographic characteristics between the 2 groups except for tumor size, which was significantly larger in the RLPD group than in the TLPD group (mean, 3.1 cm vs. 2.5 cm; P = 0.035). The RLPD group had shorter whole operative times (mean, 400.4 minutes vs. 352.2 minutes; P = 0.003) and shorter anastomosis times than the TLPD group (mean, 94.5 minutes vs. 54.9 minutes; P < 0.001). There was no significant difference between the 2 groups in the rate of pancreatic fistulas, morbidity, and mortality. However, a significantly lower wound infection rate was found in the RLPD group relative to the TLPD group (0% vs. 9.3%, P = 0.038). Conclusion RLPD showed the advantage of reducing the operation time compared to TLPD as well as technical feasibility and safety.
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Affiliation(s)
- Sung Eun Park
- Division of Hepato-biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Joong Choi
- Division of Hepato-biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Division of Hepato-biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Division of Hepato-biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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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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19
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Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample. Surg Oncol 2021; 38:101577. [PMID: 33887674 DOI: 10.1016/j.suronc.2021.101577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. METHODS The current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. RESULTS The patients' preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). CONCLUSION The novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.
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Tyutyunnik P, Klompmaker S, Lombardo C, Lapshyn H, Menonna F, Napoli N, Wellner U, Izrailov R, Baychorov M, Besselink MG, Abu Hilal M, Fingerhut A, Boggi U, Keck T, Khatkov I. Learning curve of three European centers in laparoscopic, hybrid laparoscopic, and robotic pancreatoduodenectomy. Surg Endosc 2021; 36:1515-1526. [PMID: 33825015 DOI: 10.1007/s00464-021-08439-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 03/05/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION There are limited numbers of high-volume centers performing minimally invasive pancreatoduodenectomy (MIPD) routinely. Several approaches to MIPD have been described. Aim of this analysis was to show the learning curve of three different approaches to MIPD. Focus was on determining the number of cases necessary to obtain proficient level in MIPD. PATIENTS AND METHODS Retrospective study wherein outcomes of 300 consecutive patients at three centers-at each center the initial 100 consecutive patients undergoing MIPD for malignant and benign tumors of the head of the pancreas and perimpullary area, performed by three experienced surgeons were collected and analyzed. RESULTS Overall, 300 patients after MIPD were included: the three different cohorts (laparoscopic n = 100, hybrid n = 100, robotic n = 100). CUSUM analysis of operating time in each center demonstrated that the plateau for laparoscopic PD was n = 61, for hybrid PDes was n = 32 and for robotic PD was n = 68. Median operative time for laparoscopic, hybrid, and robotic approaches was 395 min, 404 min, 510 min, respectively. Intraoperative blood loss for laparoscopic PD, hybrid PD, and robotic PD was 250 ml, 250 ml, and 413 ml, respectively. Delayed gastric emptying occurred 12% in laparoscopic cohort, 10% in hybrid, and 53% in robotic cohort. Major complications (Clavien-Dindo III/IV) rate for laparoscopic PD, hybrid PD, and robotic PD was 32%, 37%, and 22% with 5% death in each cohorts, respectively. CONCLUSION This analysis of the learning curve of three European centers found a shorter learning curve with hybrid PD as compared to laparoscopic and robotic PD. In implementation of a MIPD program, a stepwise approach might be beneficial.
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Affiliation(s)
- Pavel Tyutyunnik
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123. .,Chair of Faculty Surgery No.2, FSBEI HE A.I. Yevdokimov MSMSU MOH, Moscow, Russia.
| | - Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Carlo Lombardo
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | | | - Francesca Menonna
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | - Niccolò Napoli
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | - Ulrich Wellner
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Roman Izrailov
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123.,Chair of Faculty Surgery No.2, FSBEI HE A.I. Yevdokimov MSMSU MOH, Moscow, Russia
| | - Magomet Baychorov
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123
| | - Mark G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Moh'd Abu Hilal
- Chair of the Department of Surgery, Head of Hepatobiliary Pancreatic and Minimally Invasive Surgery, Poliambulanza Foundation Hospital, Via Bissolati, Brescia, Italy
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.,Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ugo Boggi
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123.,Chair of Faculty Surgery No.2, FSBEI HE A.I. Yevdokimov MSMSU MOH, Moscow, Russia
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21
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Brandi ML, Agarwal SK, Perrier ND, Lines KE, Valk GD, Thakker RV. Multiple Endocrine Neoplasia Type 1: Latest Insights. Endocr Rev 2021; 42:133-170. [PMID: 33249439 PMCID: PMC7958143 DOI: 10.1210/endrev/bnaa031] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Indexed: 02/06/2023]
Abstract
Multiple endocrine neoplasia type 1 (MEN1), a rare tumor syndrome that is inherited in an autosomal dominant pattern, is continuing to raise great interest for endocrinology, gastroenterology, surgery, radiology, genetics, and molecular biology specialists. There have been 2 major clinical practice guidance papers published in the past 2 decades, with the most recent published 8 years ago. Since then, several new insights on the basic biology and clinical features of MEN1 have appeared in the literature, and those data are discussed in this review. The genetic and molecular interactions of the MEN1-encoded protein menin with transcription factors and chromatin-modifying proteins in cell signaling pathways mediated by transforming growth factor β/bone morphogenetic protein, a few nuclear receptors, Wnt/β-catenin, and Hedgehog, and preclinical studies in mouse models have facilitated the understanding of the pathogenesis of MEN1-associated tumors and potential pharmacological interventions. The advancements in genetic diagnosis have offered a chance to recognize MEN1-related conditions in germline MEN1 mutation-negative patients. There is rapidly accumulating knowledge about clinical presentation in children, adolescents, and pregnancy that is translatable into the management of these very fragile patients. The discoveries about the genetic and molecular signatures of sporadic neuroendocrine tumors support the development of clinical trials with novel targeted therapies, along with advancements in diagnostic tools and surgical approaches. Finally, quality of life studies in patients affected by MEN1 and related conditions represent an effort necessary to develop a pharmacoeconomic interpretation of the problem. Because advances are being made both broadly and in focused areas, this timely review presents and discusses those studies collectively.
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Affiliation(s)
| | | | - Nancy D Perrier
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Gerlof D Valk
- University Medical Center Utrecht, CX Utrecht, the Netherlands
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Wu J, Xiang Y, You G, Liu Z, Lin R, Yao X, Yang Y. An essential technique for modern hepato-pancreato-biliary surgery: minimally invasive biliary reconstruction. Expert Rev Gastroenterol Hepatol 2021; 15:243-254. [PMID: 33356656 DOI: 10.1080/17474124.2021.1847081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Minimally invasive reconstruction of the biliary tract is complex and involves multiple steps. The procedure is challenging and has been an essential technique in modern hepato-pancreato-biliary surgery in recent years. Additionally, the quality of the reconstruction directly affects long-and short-term complications and affects the prognosis and quality of life. Various minimally invasive reconstruction methods have been developed to improve the reconstruction effect; however, the optimal method remains controversial. Areas covered: In this study, were viewed published studies of minimally invasive biliary reconstruction within the last 5 years and discussed the current status and main complications of minimally invasive biliary reconstruction. More importantly, we introduced the current reconstruction strategies and technical details of minimally invasive biliary reconstruction, which may be potentially helpful for surgeons to choose reconstruction methods and improve reconstruction quality. Expert opinion: Although several improved and modified methods for biliary reconstruction have been developed recently, no single approach is optimal or adaptable to all situations. Patient-specific selection of appropriate technical strategies according to different situations combined with sophisticated and skilled minimally invasive techniques effectively improves the quality of anastomosis and reduces complications.
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Affiliation(s)
- Jiacheng Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , Changchun, China
| | - Yien Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , Changchun, China
| | - Guangqiang You
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Zefeng Liu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Ruixin Lin
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Xiaoxiao Yao
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
| | - Yongsheng Yang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , Changchun, China
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23
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Rosemurgy A, Ross S, Bourdeau T, Jacob K, Thomas J, Przetocki V, Luberice K, Sucandy I. Cost Analysis of Pancreaticoduodenectomy at a High-Volume Robotic Hepatopancreaticobiliary Surgery Program. J Am Coll Surg 2021; 232:461-469. [PMID: 33581292 DOI: 10.1016/j.jamcollsurg.2020.12.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND The robotic approach to pancreaticoduodenectomy is thought by many to be associated with increased financial burden for hospitals. We undertook this study to analyze and compare the cost of "open" pancreaticoduodenectomy with that associated with the application of the robotic surgical system to pancreaticoduodenectomy in our hepatobiliary program. STUDY DESIGN With IRB approval, all patients undergoing pancreaticoduodenectomy at our institution, from August 2012 to November 2019, were prospectively followed. Cost, including total, variable, fixed-direct, fixed-indirect, and profitability for robotic and "open" pancreaticoduodenectomy were analyzed and compared. Data are presented as median (mean ± SD). RESULTS There were 386 patients who underwent pancreaticoduodenectomy; 205 patients underwent robotic pancreaticoduodenectomy and 181 underwent "open" pancreaticoduodenectomy. Costs are presented as mean ± SD. Overall, the cost of care for robotic pancreaticoduodenectomy was $31,389 ($36,611 ± $20,545.40) vs $23,132 ($31,323 ± $28,885.50) for "open" pancreaticoduodenectomy (p = 0.04); total variable cost was $20,355 ($22,747 ± $11,127.60) vs $11,680 ($16,032 ± $14,817.20) (p = 0.01), total fixed direct cost was $1,999 ($2,330 ± $1,363.10) vs $2,073 ($2,983 ± $3,209.00) (p = 0.01), and total indirect cost was $7,217 ($9,354 ± $6,802.40) vs $6,802 ($9,505 ± $9,307.20) (p = 0.86), for robotic vs "open" pancreaticoduodenectomy, respectively. Since 2016, profitability was achieved in 29% of patients undergoing robotic pancreaticoduodenectomy. CONCLUSIONS Robotic pancreaticoduodenectomy had lower estimated blood loss and shorter length of stay. Cost of care for robotic pancreaticoduodenectomy was greater across all categories, except for total indirect cost, than "open" pancreaticoduodenectomy. For our institution, profitability was accomplished in less than one-third of patients undergoing robotic pancreaticoduodenectomy. The role of the robotic platform for pancreaticoduodenectomy needs to be discussed among all stakeholders.
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Timmermann L, Biebl M, Schmelzle M, Bahra M, Malinka T, Pratschke J. Implementation of Robotic Assistance in Pancreatic Surgery: Experiences from the First 101 Consecutive Cases. J Clin Med 2021; 10:jcm10020229. [PMID: 33440608 PMCID: PMC7826591 DOI: 10.3390/jcm10020229] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 12/13/2022] Open
Abstract
Robotic assisted minimally invasive surgery has been implemented to overcome typical limitations of conventional laparoscopy such as lack of angulation, especially during creation of biliary and pancreatic anastomoses. With this retrospective analysis, we provide our experience with the first 101 consecutive robotic pancreatic resection performed at our center. Distal pancreatectomies (RDP, N = 44), total pancreatectomies (RTP, N = 3) and pancreaticoduodenectomies (RPD, N = 54) were included. Malignancy was found in 45.5% (RDP), 66.7% (RTP) and 61% (RPD). Procedure times decreased from the first to the second half of the cohort for RDP (218 min vs. 128 min, p = 0.02) and RPD (378 min vs. 271 min, p < 0.001). Overall complication rate was 63%, 33% and 66% for RPD, RPT and RDP, respectively. Reintervention and reoperation rates were 41% and 17% (RPD), 33% and 0% (RTP) and 50% and 11.4% (RPD), respectively. The thirty-day mortality rate was 5.6% for RPD and nil for RTP and RDP. Overall complication rate remained stable throughout the study period. In this series, implementation of robotic pancreas surgery was safe and feasible. Final evaluation of the anastomoses through the median retrieval incision compensated for the lack of haptic feedback during reconstruction and allowed for secure minimally invasive resection and reconstruction.
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Goh BK, Low TY, Teo JY, Lee SY, Chan CY, Chow PK, Chung AY, Ooi LPJ. Adoption of Robotic Liver, Pancreatic and Biliary Surgery in Singapore: A Single Institution Experience with Its First 100 Consecutive Cases. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020; 49:742-748. [DOI: 10.47102/annals-acadmedsg.202036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Introduction: Presently, robotic hepatopancreatobiliary surgery (RHPBS) is increasingly adopted worldwide. This study reports our experience with the first 100 consecutive cases of RHPBS in Singapore. Methods: Retrospective review of a single-institution prospective database of the first 100 consecutive RHPBS performed over 6 years from February 2013 to February 2019. Eighty-six cases were performed by a single surgeon. Results: The 100 consecutive cases included 24 isolated liver resections, 48 pancreatic surgeries (including 2 bile duct resections) and 28 biliary surgeries (including 8 with concomitant liver resections). They included 10 major hepatectomies, 15 pancreaticoduodenectomies, 6 radical resections for gallbladder carcinoma and 8 hepaticojejunostomies. The median operation time was 383 minutes, with interquartile range (IQR) of 258 minutes and there were 2 open conversions. The median blood loss was 200ml (IQR 350ml) and 15 patients required intra-operative blood transfusion. There were no post-operative 90-day nor in-hospital mortalities but 5 patients experienced major (> grade 3a) morbidities. The median post-operative stay was 6 days (IQR 5 days) and there were 12 post-operative 30-day readmissions. Comparison between the first 50 and the subsequent 50 patients demonstrated a significant reduction in blood loss, significantly lower proportion of malignant indications, and a decreasing frequency in liver resections performed. Conclusion: Our experience with the first 100 consecutive cases of RHPBS confirms its feasibility and safety when performed by experienced laparoscopic hepatopancreatobiliary surgeons. It can be performed for even highly complicated major hepatopancreatobiliary surgery with a low open conversion rate. Keywords: Biliary surgery, hepaticojejunostomy, liver resection, pancreas, pancreaticoduodenectomy
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Affiliation(s)
| | | | | | | | | | | | | | - LPJ Ooi
- Singapore General Hospital, Singapore
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26
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Schmidt CR, Harris BR, Musgrove KA, Rao P, Marsh JW, Thomay AA, Hogg ME, Zeh HJ, Zureikat AH, Boone BA. Formal robotic training diminishes the learning curve for robotic pancreatoduodenectomy: Implications for new programs in complex robotic surgery. J Surg Oncol 2020; 123:375-380. [PMID: 33135785 DOI: 10.1002/jso.26284] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/19/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The learning curve associated with robotic pancreatoduodenectomy (RPD) is a hurdle for new programs to achieve optimal results. Since early analysis, robotic training has recently expanded, and the RPD approach has been refined. The purpose of this study is to examine RPD outcomes for surgeons who implemented a new program after receiving formal RPD training to determine if such training reduces the learning curve. METHODS Outcomes for consecutive patients undergoing RPD at a single tertiary institution were compared to optimal RPD benchmarks from a previously reported learning curve analysis. Two surgical oncologists with formal RPD training performed all operations with one surgeon as bedside assistant and the other at the console. RESULTS Forty consecutive RPD operations were evaluated. Mean operative time was 354 ± 54 min, and blood loss was 300 ml. Length of stay was 7 days. Three patients (7.5%) underwent conversion to open. Pancreatic fistula affected five patients (12.5%). Operative time was stable over the study and lower than the reported benchmark. These RPD operative outcomes were similar to reported surgeon outcomes after the learning curve. CONCLUSION This study suggests formal robotic training facilitates safe and efficient adoption of RPD for new programs, reducing or eliminating the learning curve.
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Affiliation(s)
- Carl R Schmidt
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Britney R Harris
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Kelsey A Musgrove
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Pavan Rao
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - J Wallis Marsh
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Alan A Thomay
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Melissa E Hogg
- Department of Surgery, Northshore University Health System, Chicago, Illinois, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian A Boone
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
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External Retraction Technique for Robotic Pancreatoduodenectomy. J Am Coll Surg 2020; 231:e8-e10. [PMID: 32805403 PMCID: PMC10074441 DOI: 10.1016/j.jamcollsurg.2020.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/17/2020] [Accepted: 06/20/2020] [Indexed: 01/29/2023]
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Robotic and open pancreaticoduodenectomy: results from Taipei Veterans General Hospital in Taiwan. Updates Surg 2020; 73:939-946. [PMID: 33068270 DOI: 10.1007/s13304-020-00899-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
This study is to clarify the feasibility and justification of robotic pancreaticoduodenectomy (RPD) by comparing the outcomes between RPD and open pancreaticoduodenectomy (OPD) groups. All perioperative data and outcomes were prospectively collected. There were 304 (63.9%) RPD and 172 (36.1%) OPD. The median operation time was longer in RPD group than OPD (7.5 vs 7.0 h). The blood loss was much lower in RPD group, with a median of 130 vs. 400 c.c. in OPD group. Based on Clavien-Dindo classification, grade 0 (no complication) was 51.8% in RPD group, higher than 43.2% in OPD. Delayed gastric emptying was only 3.5% in RPD group, much lower than 13.6% in OPD. Wound infection rate was also lower in RPD group, 3.2% vs. 7.7% in OPD. The postoperative hospital stay was shorter in RPD group, with a median of 20 days, vs. 24 days in OPD. There was no significant difference regarding the lymph node yield, surgical mortality, postoperative pancreatic fistula, postpancreatectomy hemorrhage, chyle leakage and bile leakage between RPD and OPD groups. For pancreatic head adenocarcinoma, the survival outcome was better in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8% respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD. RPD is not only feasible but also justified without increasing the surgical risks and compromising the survival outcomes. Moreover, RPD might provide benefits of less blood loss, less delayed gastric emptying, lower wound infection rate and shorter length of postoperative stay, as compared with OPD.
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Affiliation(s)
- Bor-Uei Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
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Kim H, Park SY, Park Y, Kwon J, Lee W, Song KB, Hwang DW, Kim SC, Lee JH. Assessment of learning curve and oncologic feasibility of robotic pancreaticoduodenectomy: A propensity score-based comparison with open approach. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 29:649-658. [PMID: 33058484 DOI: 10.1002/jhbp.837] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Though robotic pancreaticoduodenectomy(R-PD) is gradually adopted, learning curve and its feasibility is still controversial. We analyzed our first 70 R-PD cases, comparing surgical outcomes and feasibility to those of open pancreaticoduodenectomy (O-PD). METHODS Medical records of 70 patients of R-PD and 269 patients of O-PD between 2015 and 2019 were retrospectively analyzed. Cumulative sum analysis was used to determine learning curve. Surgical outcomes were compared between early(1-35) and late cases(36-70). Additional analyses with O-PD using propensity score-matching were done. RESULTS Learning curve of R-PD completed after 30 cases. Shorter operative time, lower estimated blood loss, and shorter length of stay were noted in later cases. Complication rate tended to decrease over time. In comparison with O-PD after matching, R-PD showed longer operation time(414.5 minutes vs 244.7 minutes; P < .001), with no differences in estimated blood loss, or length of stay. While overall complication rate was higher in R-PD(45.5% vs 21.8%; P = .010), no statistically significant difference was observed in major complication rates(23.6% vs 10.9%; P = .084). R0 rate was equivalent. CONCLUSION Surgical performance of R-PD improved over time. Learning curve of R-PD completed after 30 cases. R-PD is a promising modality, based on comparison of perioperative and oncologic feasibilities to those of O-PD.
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Affiliation(s)
- Hyeyeon Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatics, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Jaewoo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
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30
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Goh BK, Low TY, Koh YX, Lee SY, Teo JY, Kam JH, Jeyaraj PR, Cheow PC, Chow PK, Ooi LL, Chung AY, Chan CY. Changing trends and outcomes associated with the adoption of minimally invasive pancreatic surgeries: A single institution experience with 150 consecutive procedures in Southeast Asia. J Minim Access Surg 2020; 16:404-410. [PMID: 31571669 PMCID: PMC7597893 DOI: 10.4103/jmas.jmas_127_19] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Minimally invasive pancreatic surgeries (MIPS) are increasingly adopted worldwide. However, it remains uncertain if these reported experiences are reproducible throughout the world today. This study examines the safety and evolution of MIPS at a single institution in Southeast Asia. METHODS This is a retrospective review of 150 consecutive patients who underwent MIPS between 2006 and 2018 of which 135 cases (90%) were performed since 2012. To determine the evolution of MIPS, the study population was stratified into 3 equal groups of 50 patients. Comparison was also made between pancreatoduodenectomies (PD), distal pancreatectomies (DP) and other pancreatic surgeries. RESULTS One hundred and fifty patients underwent MIPS (103 laparoscopic, 45 robotic and 2 hand-assisted). Forty-three patients underwent PD, 93 DP and 14 other MIPS. There were 21 (14.0%) open conversions. There was an exponential increase in caseload over the study period. Comparison across the 3 time periods demonstrated that patients were significantly more likely to have a higher American Society of Anesthesiologists score, older, undergo PD and a longer operation time. The conversion rate decreased from 28% to 0% and increased again to 14% across the 3 time periods. Comparison between the various types of MIPS demonstrated that patients who underwent PD were significantly older, more likely to have symptomatic tumours, had longer surgery time, increased blood loss, increased frequency of extended pancreatectomies, increased frequency of hybrid procedures, longer post-operative stay, increased post-operative morbidity rate and increased post-operative major morbidity rate. CONCLUSION The case volume of MIPS increased rapidly at our institution over the study period. Furthermore, although the indications for MIPS expanded to include more complex procedures in higher risk patients, there was no change in key perioperative outcomes.
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Affiliation(s)
- Brian K. Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
- Address for correspondence: Prof. Brian K. Goh, Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore. E-mail:
| | - Tze Yi Low
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Ser Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Juinn Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Prema Raj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Pierce K. Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - London L. Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Alexander Y. Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Chung Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
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Franke F, Moeller T, Mehdorn AS, Beckmann JH, Becker T, Egberts JH. Ivor-Lewis oesophagectomy: A standardized operative technique in 11 steps. Int J Med Robot 2020; 17:1-10. [PMID: 32979300 DOI: 10.1002/rcs.2175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/02/2020] [Accepted: 09/22/2020] [Indexed: 01/23/2023]
Abstract
SYNOPSIS Standardization of robotic oesophagectomy can benefit both patients and surgeons by decreasing complications, shortening the learning curve and improving surgical training. BACKGROUND Thoraco-abdominal oesophagectomy with lymphadenectomy is the cornerstone of curative therapy for oesophageal carcinoma. To reduce post-operative morbidity, minimally invasive technology has become increasingly established. Conventional thoraco-laparoscopic procedures, however, are limited by their technical feasibility. These limitations can be overcome using robot-assisted technology. METHODS Robotic Ivor-Lewis oesophageal resection has gradually been implemented in our clinic from 2013. We have performed over 250 robot-assisted minimally invasive oesophagectomies and more than 2000 robotic procedures overall. This experience allowed us to establish a standardized operative technique. RESULTS We identified 11 operative steps as key elements for oesophageal resection, which should help implementation of this technique and allow surgeons to approach this complex procedure with greater confidence. CONCLUSION Standardization is fundamental to the establishment of a new surgical technique and is a key element in the learning curve of Ivor-Lewis oesophageal resection. Standardization can lead to better reproducibility of results, and thus to improved quality.
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Affiliation(s)
- Frederike Franke
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Thorben Moeller
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anne-Sophie Mehdorn
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jan Henrik Beckmann
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Thomas Becker
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jan-Hendrik Egberts
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
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Cloyd JM, Poultsides GA. The Landmark Series: Pancreatic Neuroendocrine Tumors. Ann Surg Oncol 2020; 28:1039-1049. [PMID: 32948965 DOI: 10.1245/s10434-020-09133-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 08/29/2020] [Indexed: 12/23/2022]
Abstract
Pancreatic neuroendocrine tumors (PNETs) comprise a heterogeneous group of neoplasms arising from pancreatic islet cells that remain relatively rare but are increasing in incidence worldwide. While significant advances have been made in recent years with regard to systemic therapies for patients with advanced disease, surgical resection remains the standard of care for most patients with localized tumors. Although formal pancreatectomy with regional lymphadenectomy is the standard approach for most PNETs, pancreas-preserving approaches without formal lymphadenectomy are acceptable for smaller tumors at low risk for lymph node metastases. Furthermore, observation of small, asymptomatic, low-grade PNETs is a safe, initial strategy and is generally recommended for tumors < 1 cm in size. In this Landmark Series review, we highlight the critical studies that have defined the surgical management of PNETs.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Wu J, Zhang G, Yao X, Xiang Y, Lin R, Yang Y, Zhang X. Achilles'heel of laparoscopic pancreatectomy: reconstruction of the remnant pancreas. Expert Rev Gastroenterol Hepatol 2020; 14:527-537. [PMID: 32567383 DOI: 10.1080/17474124.2020.1775582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Laparoscopic pancreatic reconstruction is a challenging procedure and is considered the Achilles' heel of laparoscopic pancreatectomy. Multiple techniques of laparoscopic pancreatic reconstruction have been reported, but the optimal technique remains unclear. AREAS COVERED This paper provides a brief introduction to the developmental status and major related complications of laparoscopic pancreatic reconstruction. We reviewed all published literature on the technology of laparoscopic pancreatic reconstruction within the last 5 years and herein discuss the advantages and disadvantages of different reconstruction methods. We also discuss several details of different reconstruction techniques in terms of their significance to the operation and complications. EXPERT OPINION No individual method of laparoscopic pancreatic reconstruction is considered optimal for all conditions. The reconstruction strategy should be based on the surgeon's proficiency with laparoscopic technology and the patient's individual risk factors. Personalized methods of pancreatic reconstruction may more effectively reduce morbidity and mortality.
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Affiliation(s)
- Jiacheng Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Guofeng Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xiaoxiao Yao
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yien Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Ruixin Lin
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yongsheng Yang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xuewen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
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Goh BKP, Teo RY. Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its
Adoption in Singapore. ANNALS ACADEMY OF MEDICINE SINGAPORE 2020. [DOI: 10.47102/annals-acadmedsg.202063] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite the potential clinical advantages offered by laparoscopic pancreatic surgery (LPS), the main obstacle to its widespread adoption is the technically demanding nature of the procedure and its steep learning curve. LPS and robotic pancreatic surgery (RPS) have been proven to result in superior short-term perioperative outcomes and equivalent long-term oncological outcomes compared to the conventional open approach, with the caveat that they are performed by expert surgeons who have been trained to perform such procedures. The primary challenge faced by most pancreatic surgeons is the steep learning curve associated with these complex procedures and the need to undergo surgical training, especially with regards to laparoscopic and robotic pancreaticoduodenectomy. Current evidence suggests that RPS may help to shorten the lengthy learning curve required for LPS. More robust evidence—in the form of large randomised controlled trials—is needed to determine whether LPS and RPS can be safely adopted universally.
Ann Acad Med Singapore 2020;49:377–83
Key words: Laparoscopic pancreatectomy, Laparoscopic pancreaticoduodenectomy, Minimally invasive pancreatic surgery, Robotic pancreatectomy, Robotic pancreaticoduodenectomy
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Valle V, Fernandes E, Mangano A, Aguiluz G, Bustos R, Bianco F, Giulianotti PC. Robotic Whipple for pancreatic ductal and ampullary adenocarcinoma: 10 years experience of a US single-center. Int J Med Robot 2020; 16:1-7. [PMID: 32510823 DOI: 10.1002/rcs.2135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND There is currently ample consensus about the safety and feasibility of robotic pancreaticoduodenectomy (RPD). However, few studies are available on the long-term oncological outcomes of this procedure. We present a long-term survival analysis (up to 10 years) of our series of RPD carried out for ductal and ampullary adenocarcinoma. METHODS A retrospective analysis of a prospectively collected approved database was carried out including 39 patients who underwent RPD for pancreatic ductal and ampullary adenocarcinomas. RESULTS The 5-year overall survival for ductal and ampullary carcinoma was 41% with an estimated median and mean survival of 27 and 52 months. The ampullary group had significantly longer 5-year survival (68%) than the ductal group (30%). CONCLUSION Our data show, within the limitations of their retrospective nature, that robotic pancreaticoduodenectomy provides similar short- and long-term survival outcomes compared to open technique in the treatment of pancreatic ductal and ampullary adenocarcinoma.
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Affiliation(s)
- Valentina Valle
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Eduardo Fernandes
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gabriela Aguiluz
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Roberto Bustos
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Francesco Bianco
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Perioperative and oncologic outcome of robot-assisted minimally invasive (hybrid laparoscopic and robotic) pancreatoduodenectomy: based on pancreatic fistula risk score and cancer/staging matched comparison with open pancreatoduodenectomy. Surg Endosc 2020; 35:1675-1681. [PMID: 32277354 DOI: 10.1007/s00464-020-07551-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 04/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Robotic surgery is a novel approach that scores over conventional minimally invasive approaches, even in pancreatic surgery. We investigated clinical outcomes of robot-assisted minimally invasive (hybrid laparoscopic and robotic) pancreatoduodenectomy (RA-MIPD). METHODS Total 150 patients who underwent RA-MIPD between 2015 and 2018 were compared with 710 patients who underwent open pancreatoduodenectomy (PD) during the same period. Demographics and surgical outcomes were analyzed, and propensity score-matched (PSM) analysis was performed to evaluate complications including clinically relevant postoperative pancreatic fistula (CR-POPF) and oncologic outcomes in patients with malignancy. RESULTS PSM analysis was performed based on the pancreatic fistula risk. Patients undergoing RA-MIPD were younger (RA-MIPD vs. open PD: 61.2 vs. 65.5 years, P < 0.001); however, no significant intergroup difference was observed in sex (P = 0.091) and body mass index (P = 0.281). Operation time was longer in the RA-MIPD group (361.2 vs. 305.7 min, P < 0.001); however, estimated blood loss did not significantly differ (515.6 vs. 478.0 mL, P = 0.318). Overall complication (24.7% vs. 30.9%, P = 0.178) and CR-POPF rates (6.7% vs. 6.9%, P > 0.999) were similar. The RA-MIPD group showed lower pain scores and shorter length of postoperative hospitalization (11.5 vs. 17.2 days, P < 0.001). After PSM analysis for cancer and staging among patients with malignancies, no significant intergroup difference was observed in the R0 resection rate (96.7% vs. 93.3%, P = 0.527), tumor size (2.59 vs. 2.60 cm, P = 0.954), total number of retrieved lymph nodes (17.0 vs. 16.6, P = 0.793), and 2-year survival rates (84.4% vs. 77.8%, P = 0.898). CONCLUSIONS Compared with open PD, RA-MIPD is associated with better or at least similar early perioperative and equivalent midterm survival outcomes. RA-MIPD is safe and feasible and enables early postoperative recovery. RA-MIPD is expected to play a key role in near future.
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Diaz A, Schoenbrunner A, Dillhoff M, Cloyd JM, Ejaz A, Tsung A, Shirley LA, Harzman AE, Cochran A, Pawlik TM. Complex hepato-pancreato-biliary caseload during general surgery residency training: are we adequately training the next generation? HPB (Oxford) 2020; 22:603-610. [PMID: 31551139 DOI: 10.1016/j.hpb.2019.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Information on procedure volume of graduating chief residents (GCRs) for hepato-pancreato-biliary(HPB) surgical procedures may inform assessments of resident training. This study sought to characterize trends in operative volumes over a 19-year period to define the degree to which general surgery residents gain exposure to HPB procedures during training. METHODS The ACGME was queried for all HPB operations performed by GCR between 2000-2018. Total procedures as well as means and fold change was calculated and reported for each year. RESULTS Between 2000-2018, the number of general surgery residency programs varied between 240 and 254. A total of 411,383 HPB procedures (36.2% liver, 42.8% pancreas, 21% complex biliary) were performed by 22,229 GCR. Each year of the study, GCR had similar mean number total procedures:liver 7.4, pancreas 8.7, and complex biliary 4.4. For liver procedures there was no difference in the fold change over time, however for pancreas there was an increase in the fold change from 2.25 to 3.25. CONCLUSION Most GCRs are graduating with a low number of HPB procedures and trends suggesting a decrease in the mean number of procedures per GCR and an increasing variability among residents.
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Affiliation(s)
- Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH, USA
| | - Mary Dillhoff
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Jordan M Cloyd
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Aslam Ejaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Allan Tsung
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Lawrence A Shirley
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Alan E Harzman
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Amalia Cochran
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Timothy M Pawlik
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA.
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Müller-Debus CF, Thomaschewski M, Zimmermann M, Wellner UF, Bausch D, Keck T. Robot-Assisted Pancreatic Surgery: A Structured Approach to Standardization of a Program and of the Operation. Visc Med 2020; 36:104-112. [PMID: 32355667 DOI: 10.1159/000506909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/28/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction The use of robots in minimal invasive surgery has become increasingly common in recent years. Robot-assisted pancreatoduodenectomy preponderates against a laparoscopic procedure especially due to the greater flexibility of instruments and therefore a better handling and a better angulation. Furthermore, there are benefits of enlarged 3-D visibility, software-based tremor control, and reduced physical exertion of the surgeon. Methods and Results This review delivers a point-by-point approach to the setup of a robot-assisted pancreatic program and a detailed approach to robot-assisted pancreatoduodenectomy. Results In our standardized standard operating procedure approach we use 5 trocars, i.e., 4 robotic trocars and 1 assist trocar. We prefer the position of the robot ports in a straight horizontal line with a distance of 20 cm from the operational field. The operation is dissected into 11 standardized procedural steps as follows: (1) access to the pancreas and visualization, (2) extended Kocher manoeuvre, (3) lower rim and mesentericoportal axis, (4) upper rim and hepatoduodenal ligament, (5) dissection of the pancreatic neck, (6) mesenteric root and pars IV duodeni, (7) mesopancreas, (8) pancreatic anastomosis reconstruction, (9) bilioenteric anastomosis, (10) dudenojejunal anastomosis, and (11) drainage and closure. The setup of the pancreas program and the structured approach to complex pancreatic resections are elucidated. Summary This review describes the approach to robot-assisted pancreatic surgery in a high-volume pancreas center on a structural and procedural level to support the establishment of such programs at other locations.
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Affiliation(s)
| | - Michael Thomaschewski
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Markus Zimmermann
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
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Yang SJ, Hwang HK, Kang CM, Lee WJ. Revisiting the potential advantage of robotic surgical system in spleen-preserving distal pancreatectomy over conventional laparoscopic approach. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:188. [PMID: 32309335 PMCID: PMC7154491 DOI: 10.21037/atm.2020.01.80] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background This study aimed to compare success rate of spleen preservation between robotic and laparoscopic distal pancreatectomy (DP). Methods Between November 2007 and March 2018, forty-one patients underwent the conventional laparoscopic DP (Lap group) and the other 37 patients underwent robotic DP (Robot group). The perioperative clinicopathologic variables were compared. Results The robotic procedure was chosen by younger patients compared to conventional laparoscopic surgery (42.9±14.0 vs. 51.3±14.6 years, P=0.016). The mean operation time was longer (313 vs. 246 min, P=0.000), but the mean tumor size was smaller in Robot group (2.7±1.2 vs. 4.2±3.3 cm, P=0.018). The overall spleen-preserving rate was higher in the Robot group (91.9% vs. 68.3%, P=0.012). However, with accumulating laparoscopic experiences (after 16th case), the statistical differences in spleen preservation rate between the Robot and Lap groups had diminished (P=0.428). Conclusions The present results suggest a robot can be helpful to save the spleen during DP for benign and borderline malignancy. However, a surgeon highly experienced in the laparoscopic approach can also produce a high success rate of spleen preservation, similar to that shown with the robotic approach.
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Affiliation(s)
- Seok Jeong Yang
- Department of Surgery, Yonsei University College of Medicine, Yongin Severance Hospital, Gyeonggi, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Department of Surgery, Yonsei University College of Medicine, Yongin Severance Hospital, Gyeonggi, Korea
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Feng M, Cao Z, Sun Z, Zhang T, Zhao Y. Pancreatic head cancer: Open or minimally invasive pancreaticoduodenectomy? Chin J Cancer Res 2020; 31:862-877. [PMID: 31949389 PMCID: PMC6955167 DOI: 10.21147/j.issn.1000-9604.2019.06.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons. Pancreaticoduodenectomy (PD) continues to be the operative standard of care and potentially curative procedure for pancreatic head cancer. Despite the rapid development of minimally invasive techniques, whether the efficacy of minimally invasive pancreaticoduodenectomy (MIPD) is noninferior or superior to open pancreaticoduodenectomy (OPD) remains unclear. In this review, we summarized the history of OPD and MIPD and the latest staging and classification information for pancreatic head cancer as well as the proposed recommendations for MIPD indications for patients with pancreatic head cancer. By reviewing the MIPD- vs. OPD-related literature, we found that MIPD shows noninferiority or superiority to OPD in terms of safety, feasibility, enhanced recovery after surgery (ERAS) and several short-term and long-term outcomes. In addition, we analyzed and summarized the different MIPD outcomes in the USA, Europe and China. Certain debates over MIPD have continued, however, selection bias, the large number of low-volume centers, the steep MIPD learning curve, high conversion rate and administration of neoadjuvant therapy may limit the application of MIPD for pancreatic head cancer.
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Affiliation(s)
- Mengyu Feng
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Zhe Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Zhiwei Sun
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.,Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Learning Curve From 450 Cases of Robot-Assisted Pancreaticoduocectomy in a High-Volume Pancreatic Center: Optimization of Operative Procedure and a Retrospective Study. Ann Surg 2019; 274:e1277-e1283. [PMID: 31651533 DOI: 10.1097/sla.0000000000003664] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We aimed to describe our experience and the learning curve of 450 cases of robot-assisted pancreaticoduodenectomy (RPD) and optimize the surgical process so that our findings can be useful for surgeons starting to perform RPD. SUMMARY BACKGROUND DATA Robotic surgical systems were first introduced 20 years ago. Pancreaticoduodenectomy (PD) is a challenging surgery because of its technical difficulty. RPD may overcome some of these difficulties. METHODS The medical records of 450 patients who underwent RPD between May 2010 and December 2018 at the Shanghai Ruijin Hospital were retrospectively analyzed. Operative times and estimated blood loss (EBL) were analyzed and the learning curve was determined. A cumulative sum (CUSUM) analysis was used to identify the inflexion points. Other postoperative outcomes, postoperative complications, and long-term follow-up were also analyzed. RESULTS Operative time improved gradually over time from 405.4 ± 112.9 minutes (case 1-50) to 273.6 ± 70 minutes (case 301-350) (P < 0.001). EBL improved from 410 ± 563.5 mL (case 1-50) to 149.0 ± 103.3 mL (case 351-400) (P < 0.001). According to the CUSUM curve, there were 3 phases in the RPD learning curve. The inflexion points were around cases 100 and 250. The incidence of pancreatic leak in the last 350 cases was significantly lower than that in the first 100 cases (30.0% vs 15.1%, P = 0.003). CONCLUSIONS RPD is safe and feasible for selected patients. Operative and oncologic outcomes were much improved after experience of 250 cases. Our optimization of the surgical process may have also contributed to this. Future prospective and randomized studies are needed to confirm our results.
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Shyr BU, Shyr BS, Chen SC, Chang IW, Shyr YM, Wang SE. Operative results and patient satisfaction after robotic pancreaticoduodenectomy. Asian J Surg 2019; 43:519-525. [PMID: 31606357 DOI: 10.1016/j.asjsur.2019.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/20/2019] [Accepted: 08/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/OBJECTIVE There are no reports available on patient satisfaction and quality-of-life after robotic pancreaticoduodenectomy (RPD). This study aimed to evaluate not only surgical outcomes but also patient satisfaction after RPD. METHODS Prospectively collected data for RPD were analyzed for surgical outcomes. Questionnaires were sent to patients to assess patient satisfaction regarding RPD. RESULTS The study included 105 patients who underwent RPD, with 44 (41.9%) patients presenting with associated surgical complications. There were no significant differences between the without and with complication groups in median console time (390 min. Vs. 373 min.), blood loss (100 mL vs. 100 mL), and harvested lymph node number (14 vs. 15). There was no surgical mortality in this study. Major complications ≥ Clavien-Dindo III occurred in 7.6% of the total 105 RPD patients. The most common complication was chyle leakage (18.1%), followed by postoperative pancreatic fistula (5.7%), intra-abdominal abscess (4.8%), delayed gastric emptying (3.8%), and post pancreatectomy hemorrhage (3.8%). Almost all of the patients responded to this RPD-related survey with "fair" to "excellent" grades for all items, except 1 (<1%) poor grade for operation service and 2 (1.9%) "not good" grades for diet tolerance. CONCLUSIONS RPD is a feasible procedure with acceptable surgical outcomes. This patient survey with high patient satisfaction rates indicates that RPD provides acceptable satisfaction results, and the robotic approach for a major operation such as RPD has probably a higher priority than cost concerns. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction.
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Affiliation(s)
- Bor-Uei Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - I-Wen Chang
- Department of Nursing, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan.
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Low TY, Koh YX, Goh BK. First experience with robotic pancreatoduodenectomy in Singapore. Singapore Med J 2019; 61:598-604. [PMID: 31535153 DOI: 10.11622/smedj.2019119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Recent studies reported that laparoscopic pancreatoduodenectomy (LPD) is associated with superior perioperative outcomes compared to the open approach. However, concerns have been raised about the safety of LPD, especially during the learning phase. Robotic pancreatoduodenectomy (RPD) has been reported to be associated with a shorter learning curve compared to LPD. We herein present our initial experience with RPD. METHODS A retrospective review of a single-institution prospective robotic hepatopancreaticobiliary (HPB) surgery database of 70 patients identified seven consecutive RPDs performed by a single surgeon in 2016-2017. These were matched at a 1:2 ratio with 14 open pancreatoduodenectomies (OPDs) selected from 77 consecutive pancreatoduodenectomies performed by the same surgeon between 2011 and 2017. RESULTS Seven patients underwent RPD, of which five were hybrid procedures with open reconstruction. There were no open conversions. Median operative time was 710.0 (range 560.0-930.0) minutes. Two major morbidities (> Grade 2) occurred: one gastrojejunostomy bleed requiring endoscopic haemostasis and one delayed gastric emptying requiring feeding tube placement. There were no pancreatic fistulas, reoperations or 90-day/in-hospital mortalities in the RPD group. Comparison between RPD and OPD demonstrated that RPD was associated with a significantly longer operative time. Compared to open surgery, there was no significant difference in estimated blood loss, blood transfusion, postoperative stay, pancreatic fistula rates, morbidity and mortality rates, R0 resection rates, and lymph node harvest rates. CONCLUSION Our initial experience demonstrates that RPD is feasible and safe in selected patients. It can be safely adopted without any compromise in patient outcomes compared to the open approach.
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Affiliation(s)
- Tze-Yi Low
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian Kp Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
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Abstract
PURPOSE OF REVIEW Pancreatic neuroendocrine tumors (pNETs) are a rare, heterogeneous group of pancreatic neoplasms with a wide range of malignant potential. They may manifest as noninfiltrative, slow-growing tumors, locally invasive masses, or even swiftly metastasizing cancers. RECENT FINDINGS In recent years, because of the increasing amount of scientific literature available for pNETs, the classification, prognostic stratification criteria, and available consensus guidelines for diagnosis and therapy have been revised and updated. SUMMARY The vast majority of new pNET diagnoses consist of incidentally discovered lesions on cross-sectional imaging. The biologic behavior of pNETs is defined by the grade and stage of the tumor. Surgery is the only curative treatment and it, therefore, represents the first therapeutic choice for any localized pNET; however, recent evidence suggests that patients with small (<2 cm), nonfunctioning G1 tumors can be safely observed.An aggressive surgical approach towards liver metastases is recommended in selected cases, as well as liver-directed therapies for disease control. In the presence of unresectable progressive disease, somatostatin analogs, targeted therapies such as everolimus, peptide receptor radionuclide therapy, and systemic chemotherapy are all useful tools for prolonging survival.
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Lee CR, Rho SY, Han SH, Moon Y, Hwang SY, Kim YJ, Kang CM. Comparison of Training Efficacy Between Custom-Made Skills Simulator (CMSS) and da Vinci Skills Simulators: A Randomized Control Study. World J Surg 2019; 43:2699-2709. [DOI: 10.1007/s00268-019-05108-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Liu R, Wakabayashi G, Palanivelu C, Tsung A, Yang K, Goh BKP, Chong CCN, Kang CM, Peng C, Kakiashvili E, Han HS, Kim HJ, He J, Lee JH, Takaori K, Marino MV, Wang SN, Guo T, Hackert T, Huang TS, Anusak Y, Fong Y, Nagakawa Y, Shyr YM, Wu YM, Zhao Y. International consensus statement on robotic pancreatic surgery. Hepatobiliary Surg Nutr 2019; 8:345-360. [PMID: 31489304 DOI: 10.21037/hbsn.2019.07.08] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.
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Affiliation(s)
- Rong Liu
- Department of Hepatopancreatobiliary Surgical Oncology, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Ageo, Japan
| | - Chinnusamy Palanivelu
- Division of Gastrointestinal Surgery and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, India
| | - Allan Tsung
- Division of Surgical Oncology, Gastrointestinal Disease Specific Research Group, The Ohio State University Wexner Medical Center Department of Surgery, Columbus, OH, USA
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Charing Ching-Ning Chong
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Chang Moo Kang
- Division of HBP Surgery, Yonsei University College of Medicine, Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chenghong Peng
- Pancreatic Disease Centre, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Eli Kakiashvili
- Department of General Surgery, Galilee Medical Center, Nahariya, Israel
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hong-Jin Kim
- Department of Surgery, Yeungnam University Hospital, Daegu, Korea
| | - Jin He
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jae Hoon Lee
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Asan Medical Center, Seoul, Korea
| | - Kyoichi Takaori
- Department of Surgery, Kyoto University Hospital, Shogoin, Sakyo-Ku, Kyoto, Japan
| | - Marco Vito Marino
- Department of General Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Shen-Nien Wang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung
| | - Tiankang Guo
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou 730030, China
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ting-Shuo Huang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Keelung
| | - Yiengpruksawan Anusak
- Minimally Invasive Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuman Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei
| | - Yao-Ming Wu
- Department of Surgery, National Taiwan University Hospital, Taipei
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Rosemurgy A, Ross S, Bourdeau T, Craigg D, Spence J, Alvior J, Sucandy I. Robotic Pancreaticoduodenectomy Is the Future: Here and Now. J Am Coll Surg 2019; 228:613-624. [DOI: 10.1016/j.jamcollsurg.2018.12.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 11/29/2022]
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Goh BKP, Low TY, Kam JH, Lee SY, Chan CY. Initial experience with laparoscopic and robotic surgery for the treatment of periampullary tumours: single institution experience with the first 30 consecutive cases. ANZ J Surg 2019; 89:E137-E141. [PMID: 30805992 DOI: 10.1111/ans.15033] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/24/2018] [Accepted: 11/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Concerns have been raised about the safety of minimally invasive surgery (MIS) for pancreatoduodenectomy (PD) during the early learning phase. In this study, we present our initial experience with MIS for periampullary tumours. METHODS Retrospective review of the first 30 consecutive patients who underwent laparoscopic (LS)/robotic surgery (RS) for periampullary tumours between 2014 and 2017. RESULTS Twenty-seven patients underwent PD, including three total pancreatectomies (TPs) and three underwent palliative bypasses. Twenty underwent LS, of which 18 were hybrid PDs, including two TPs and two bypasses. Ten patients underwent RS, of which nine were PDs, including one TP and one bypass. Five of 10 RSs were totally MIS procedures. There were four PDs with venous resection, of which three were by RS. There were four (13.3%) open conversions all in the LS cohort. There were five (16.7%) major (>grade 2) morbidities, including three pancreatic fistulas (two grade B and one grade C). There was no 30-day and one (3.3%) 90-day mortality. Comparison between RS and LS demonstrated that RS had a higher likelihood of being completed via totally MIS (five (50%) versus 0, P = 0.002), tended to have a shorter post-operative stay (eight (range 6-36) versus 14.5 (range 6-62) days, P = 0.058) but tended to be associated with a longer operation time (670 (range 500-930) versus 577 (range 235-715) min, P = 0.056). CONCLUSION Our initial experience demonstrated that both LS and RS can be safely adopted for the treatment of periampullary tumours. The learning curve for RS seemed to be shorter than LS as we could transition more quickly from hybrid PDs to totally MIS safely.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Tze-Yi Low
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Juinn-Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
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van der Vliet WJ, Haenen SM, Solis-Velasco M, Dejong CHC, Neumann UP, Moser AJ, van Dam RM. Systematic review of team performance in minimally invasive abdominal surgery. BJS Open 2019; 3:252-259. [PMID: 31183440 PMCID: PMC6551413 DOI: 10.1002/bjs5.50133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/26/2018] [Indexed: 11/17/2022] Open
Abstract
Background Adverse events in the operating theatre related to non‐technical skills and teamwork are still an issue. The influence of minimally invasive techniques on team performance and subsequent impact on patient safety remains unclear. The aim of this review was to assess the methodology used to objectify and rate team performance in minimally invasive abdominal surgery. Methods A systematic literature search was conducted according to the PRISMA guidelines. Studies on assessment of surgical team performance or non‐technical skills of the surgical team in the setting of minimally invasive abdominal surgery were included. Study aim, methodology, results and conclusion were extracted for qualitative synthesis. Results Sixteen studies involving 677 surgical procedures were included. All studies consisted of observational case series that used heterogeneous methodologies to assess team performance and were of low methodological quality. The most commonly used team performance objectification tools were ‘construct’‐ and ‘incident’‐based tools. Evidence of validity for the assessed outcome was spread widely across objectification tools, ranging from low to high. Diverse and poorly defined outcomes were reported. Conclusion Team demands for minimally invasive approaches to abdominal procedures remain unclear. The current literature consists of studies with heterogeneous methodology and poorly defined outcomes.
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Affiliation(s)
- W J van der Vliet
- Department of Hepatobiliary and Pancreatic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - S M Haenen
- Department of Hepatobiliary and Pancreatic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M Solis-Velasco
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, Massachusetts, USA
| | - C H C Dejong
- Department of Hepatobiliary and Pancreatic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - U P Neumann
- Department of Hepatobiliary and Pancreatic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | - A J Moser
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, Massachusetts, USA
| | - R M van Dam
- Department of Hepatobiliary and Pancreatic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
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Strobel O, Büchler MW. Laparoscopic pancreatoduodenectomy: safety concerns and no benefits. Lancet Gastroenterol Hepatol 2019; 4:186-187. [PMID: 30685488 DOI: 10.1016/s2468-1253(19)30006-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
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