Does robotic pancreaticoduodenectomy improve outcomes in patients with high risk morphometric features compared to the open approach

Open versus Robotic-Assisted Pancreaticoduodenectomy, Cost-effectiveness, and Long-term Oncologic Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Whipple pancreaticoduodenectomy (PD) is a complex gastrointestinal surgery that is performed increasingly via minimally invasive approach through robotic platforms. We sought to provide a comparative review of available data regarding robot-assisted versus open PD in terms of cost-effectiveness, overall survival, and other perioperative and long-term oncologic outcomes.

METHODS

Utilizing PRISMA criteria, PubMed, Scopus, and Web of Science databases were searched from 1980 to April 2024 using designated keywords. English-language studies comparing costs and oncologic outcomes of robotic versus open PDs were considered for inclusion. Reviews, abstracts, case reports, letters to the editor, and non-English articles were excluded.

RESULTS

A total of 1,733 studies were initially identified throughout the literature search. Following the removal of duplicates and title and abstract screening, 16 studies were included in the review. No statistically significant differences were detected in terms of short-term complications (95% CI; [0.805, 1.096], p=0.42), mortality (95% CI; [0.599,1.123], p=0.21), and readmission (95% CI; [0.959,1.211], p=0.20) among patients undergoing open versus robotic PD. Robotic PDs was associated with a slightly better overall survival (95% CI; [1.020, 1.233]) and higher costs (95% CI; [0.134,1.139], p=0.013). Mean length of stay (LOS) was higher in the open PD group (95% CI; [-0.353, 0.189], p < 0.001).

CONCLUSION

Robotic-assisted PD had a slightly shorter LOS and improved overall survival. There were no differences in short-term complications, mortality, or readmission. The use of cohort studies and residual potential selection bias necessitate randomized controlled trials to define the benefit of robotic PD.

Deconstructing the Operative Times of Robotic Pancreaticoduodenectomy

INTRODUCTION

Despite numerous benefits offered, robotic procedures take longer than "open" procedures. With the intent to reduce operative duration, we examined the degree each operative step contributes to operative duration in robotic pancreaticoduodenectomy.

MATERIALS AND METHODS

With IRB approval, we prospectively followed 88 patients to determine the duration of robotic pancreaticoduodenectomy, and the duration of 12 key steps. Each operative step was regressed against the operation date, from most distant to most recent operation date. Data are presented as median (mean ± SD) for illustrative purposes.

RESULTS

Patients were 73 (71 ± 10.2) years old; 53% were men. Total time patient spent in the operating room was 471 (488 ± 93.3) minutes. Total operative time was 399 (421 ± 90.7) minutes. Total console time was 293 (297 ± 68.0) minutes. The 3 longest portions of the operation were (1) mobilization of the specimen and specimen extraction; (2) construction of the duodenojejunostomy; and (3) closure.

CONCLUSION

A third of the operative time is spent off the console. Over half of the steps required more than 20 minutes each to complete. Since robotic operations are associated with shorter LOS and without increased complication rates relative to "open" operations, salutary benefit can be gained by decreasing operative times of robotic procedures. Operative duration is an important metric that needs to be addressed. We need to target the most time-consuming steps, and break them into smaller pieces, to reach optimal efficiency and provide the benefits of decreased operative duration to the patients, hospitals, and providers.

Learning Curves in Establishing a New Minimally Invasive Pancreas Program

INTRODUCTION

Robotic pancreaticoduodenectomy (rPD) is a complex operation with a reported learning curve of 80 cases. Two recent graduates of a formal robotic complex general surgical oncology training program have been performing rPD at our institution since 2016, which had no previous institutional experience with rPD.

OBJECTIVE

To evaluate the learning curve associated with developing a new robotic pancreaticoduodenectomy (rPD) program by fellowship trained surgeons with institutional support.

METHODS

Sixty patients undergoing rPD from 2016 to 2022 were reviewed for and compared with proficiency benchmarks set by the University of Pittsburg experience.

RESULTS

By 30 cases, operative time met the proficiency benchmark of 391 minutes. Additionally, the entire cohort had comparable rates of clinically relevant postoperative pancreatic fistula (6.7% vs 3%, P = .6), 30-day mortality (0% vs 3%, P = .18), major complications (Clavien >2; 23% vs 17%, P = .14), and length of stay (6 vs 7 days, P = .49) when compared to the benchmark.

CONCLUSION

Perioperative outcomes were comparable to proficiency benchmarks from initiation of the new rPD program, and operative time reached proficiency benchmark by 30 cases. This data suggests that graduates of formal rPD training programs can safely establish new minimally invasive pancreas programs at sites with no previous institutional rPD experience.

The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis

BACKGROUND

Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity between these tumors. Therefore, this study aimed to evaluate the role of MIPD compared to open pancreatoduodenectomy (OPD) in patients with non-pancreatic periampullary cancer (NPPC).

METHODS

A systematic review of Pubmed, Embase, and Cochrane databases was performed by two independent reviewers to identify studies comparing MIPD and OPD for NPPC (ampullary, distal cholangio, and duodenal adenocarcinoma) (01/2015-12/2021). Individual patient data were required from all identified studies. Primary outcomes were (90-day) mortality, and major morbidity (Clavien-Dindo 3a-5). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood-loss, length of hospital stay (LOS), and overall survival (OS).

RESULTS

Overall, 16 studies with 1949 patients were included, combining 928 patients with ampullary, 526 with distal cholangio, and 461 with duodenal cancer. In total, 902 (46.3%) patients underwent MIPD, and 1047 (53.7%) patients underwent OPD. The rates of 90-day mortality, major morbidity, POPF, DGE, PPH, blood-loss, and length of hospital stay did not differ between MIPD and OPD. Operation time was 67 min longer in the MIPD group (P = 0.009). A decrease in DFS for ampullary (HR 2.27, P = 0.019) and distal cholangio (HR 1.84, P = 0.025) cancer, as well as a decrease in OS for distal cholangio (HR 1.71, P = 0.045) and duodenal cancer (HR 4.59, P < 0.001) was found in the MIPD group.

CONCLUSIONS

This individual patient data meta-analysis of MIPD versus OPD in patients with NPPC suggests that MIPD is not inferior in terms of short-term morbidity and mortality. Several major limitations in long-term data highlight a research gap that should be studied in prospective maintained international registries or randomized studies for ampullary, distal cholangio, and duodenum cancer separately.

PROTOCOL REGISTRATION

PROSPERO (CRD42021277495) on the 25th of October 2021.

Surgical methods influence on the risk of anastomotic fistula after pancreaticoduodenectomy: a systematic review and network meta-analysis

BACKGROUND

Pancreaticoduodenectomy is the first choice surgical intervention for the radical treatment of pancreatic tumors. However, an anastomotic fistula is a common complication after pancreaticoduodenectomy with a high mortality rate. With the development of minimally invasive surgery, open pancreaticoduodenectomy (OPD), laparoscopic pancreaticoduodenectomy (LPD), and robotic pancreaticoduodenectomy (RPD) are gaining interest. But the impact of these surgical methods on the risk of anastomosis has not been confirmed. Therefore, we aimed to integrate relevant clinical studies and explore the effects of these three surgical methods on the occurrence of anastomotic fistula after pancreaticoduodenectomy.

METHODS

A systematic literature search was conducted for studies reporting the RPD, LPD, and OPD. Network meta-analysis of postoperative anastomotic fistula (Pancreatic fistula, biliary leakage, gastrointestinal fistula) was performed.

RESULTS

Sixty-five studies including 10,026 patients were included in the network meta-analysis. The rank of risk probability of pancreatic fistula for RPD (0.00) was better than LPD (0.37) and OPD (0.62). Thus, the analysis suggests the rank of risk of the postoperative pancreatic fistula for RPD, LPD, and OPD. The rank of risk probability for biliary leakage was similar for RPD (0.15) and LPD (0.15), and both were better than OPD (0.68).

CONCLUSIONS

This network meta-analysis provided ranking for three different types of pancreaticoduodenectomy. The RPD and LPD can effectively improve the quality of surgery and are safe as well as feasible for OPD.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I² = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I² = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I²= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I² = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I² = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Meta-analysis of robotic versus open pancreaticoduodenectomy in all patients and pancreatic cancer patients

Purposes

To compare perioperative outcomes of robotic pancreaticoduodenectomy (RPD) to open pancreaticoduodenectomy (OPD) using evidence from cohort studies.

Methods

Outcomes of interest include operative time, blood loss, R0 resection rate, lymph nodes harvested, overall complication rate, pancreatic fistula rate, delayed gastric emptying rate and 90-day mortality.

Results

6 prospective studies and 15 retrospective studies were included. Five of these studies were limited to patients with pancreatic cancer. Operative time was significantly longer in RPD (WMD: 64.60 min; 95% CI: 26.89 to 102.21; p = 0.001). Estimated blood loss was lower in RPD (WMD: −185.44 ml; 95% CI: −239.66 to −131.21; p < 0.001). Overall complication rates (OR: 0.66; 95% CI: 0.44 to 0.97; p < 0.001) and pancreatic fistula rate (OR: 0.67; 95% CI: 0.55 to 0.82; p < 0.001) were both lower in RPD. Length of hospital stay was longer in OPD (WMD: −1.90; 95% CI: −2.47 to −1.33). 90-day mortality was lower in RPD [odds ratio (OR): 0.77; 95% CI: 0.45 to 0.95; p = 0.025].

Conclusion

At current level of evidence, RPD is a safer alternative than OPD with regard to post-operative outcomes and blood loss. However, in terms of oncological outcomes RPD show no advantage over OPD, and the cost of RPD was higher. In general, RPD is now considered a reliable technology, but high-quality randomized controlled trial (RCT) studies are still needed to support this conclusion.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery

OBJECTIVE

To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery.

BACKGROUND

IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia.

METHODS

A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination.

RESULTS

Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117.

CONCLUSIONS

Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

Minimally Invasive Pancreatoduodenectomy: Contemporary Practice, Evidence, and Knowledge Gaps

Minimally invasive pancreatoduodenectomy has gained popularity throughout the last decade. For laparoscopic pancreatoduodenectomy, some high-level evidence exists, but with conflicting results. There are currently no published randomized controlled trials comparing robotic and open pancreatoduodenectomy. Comparative long-term data for patients with pancreatic ductal adenocarcinoma is lacking to date. Based on the existing evidence, current observed benefits of minimally invasive pancreatoduodenectomy over open pancreatoduodenectomy seem scarce, but retrospective data indicate the safety of these procedures in selected patients. As familiarity with the robotic platform increases, studies have shown an expansion in indications, also including patients with vascular involvement and even indicating favorable results in patients with obesity and high-risk morphometric features. Several ongoing randomized controlled trials aim to investigate potential differences in short- and long-term outcomes between minimally invasive and open pancreatoduodenectomy. Their results are much awaited.

Robotic versus open pancreaticoduodenectomy, comparing therapeutic indexes; a systematic review

BACKGROUND

Pancreaticoduodenectomy (PD) is a challenging procedure with peri-operative complications. Robotic surgery offers improved dexterity, visibility, and accessibility. Recently, many centres have reported improved clinical outcomes for robotic PD. We reviewed the safety and efficacy of robotic PD in comparison to open PD using 'Therapeutic Index' (TI).

METHODS

A systematic review of the literature was conducted in various databases. Articles published between January 2010 and March 2021 reporting totally-robotic and open PD were included, according to the PRISMA and AMSTAR-2 guidelines. The Cochrane tool was used for risk of bias assessment. We compared 30-day mortality rates (MR₃₀), lymphadenectomy rates (LR), R0 resection rates (R₀RR) and therapeutic index (TI). STATA 16.1 was used for statistical analysis.

RESULTS

The four studies that met inclusion criteria included 5090 PDs, out of which 617 were totally-robotic (RPD) and 4473 were open (OPD). Variance ratio tests demonstrated a)Higher TI for RPD versus OPD (1807.42 vs 1723.37, p = 0.86), b)Significantly smaller MR₃₀ (2.50 vs 19.00, p = 0.0004), c)Significantly lower R₀RR (130.50 vs 939.25, p = 0.00) and d)No significant difference in LR between RPD and OPD (35.63 vs 38.25, p = 0.81). Meta-regression analysis showed a significantly higher TI coefficient of RPD than OPD (0.66 vs -0.40, p = 0.08, α = 0.1).

CONCLUSION

Our study suggests that robotic PD is safe and not inferior to open PD and our analysis RPD demonstrated a higher therapeutic index than OPD. Randomised controlled trials are required to establish the efficacy of robotic PD. Also, standardisation of reporting mortality, survival and oncological outcomes is needed for the effective calculation of TI.

Determining Hospital Volume Threshold for Safety of Minimally Invasive Pancreaticoduodenectomy: A Contemporary Cutpoint Analysis

BACKGROUND

Guidelines recommend limiting minimally invasive pancreaticoduodenectomy (MIPD) to high-volume centers. However, the definition of high-volume care remains unclear. We aimed to objectively define a minimum number of MIPD performed annually per hospital associated with improved outcomes in a contemporary patient cohort.

PATIENTS AND METHODS

Resectable pancreatic adenocarcinoma patients undergoing MIPD were included from the National Cancer Database (2010-2017). Multivariable modeling with restricted cubic splines was employed to identify an MIPD annual hospital volume threshold associated with lower 90-day mortality. Outcomes were compared between patients treated at low-volume (≤ model-identified cutoff) and high-volume (> cutoff) centers.

RESULTS

Among 3079 patients, 141 (5%) died within 90 days. Median hospital volume was 6 (range 1-73) cases/year. After adjustment, increasing hospital volume was associated with decreasing 90-day mortality for up to 19 (95% CI 16-25) cases/year, indicating a threshold of 20 cases/year. Most cases (82%) were done at low-volume (< 20 cases/year) centers. With adjustment, MIPD at low-volume centers was associated with increased 90-day mortality (OR 2.7; p = 0.002). Length of stay, positive surgical margins, 30-day readmission, and overall survival were similar. On analysis of the most recent two years (n = 1031), patients at low-volume centers (78.2%) were younger and had less advanced tumors but had longer length of stay (8 versus 7 days; p < 0.001) and increased 90-day mortality (7% versus 2%; p = 0.009).

CONCLUSIONS

The cutpoint analysis identified a threshold of at least 20 MIPD cases/year associated with lower postoperative mortality. This threshold should inform national guidelines and institution-level protocols aimed at facilitating the safe implementation of this complex procedure.

The current status and future directions of robotic pancreatectomy

Robotic surgery has emerged as an alternative to laparoscopic surgery and it has also been applied to pancreatectomy. With the increase in the number of robotic pancreatectomies, several studies comparing robotic pancreatectomy and conventional open or laparoscopic pancreatectomy have been published. However, the use of robotic pancreatectomy remains controversial. In this review, we aimed to provide a comprehensive overview of the current status of robotic pancreatectomy. Various aspects of robotic pancreatectomy and conventional open or laparoscopic pancreatectomy are compared, including the benefits, limitations, oncological efficacy, learning curves, and costs. Both robotic pancreatoduodenectomy and distal pancreatectomy have favorable or comparable outcomes to conventional procedures, and robotic pancreatectomy has the potential to be an alternative to open or laparoscopic procedures. However, there are still several disadvantages to robotic platforms, such as prolonged operative duration and the high cost of the procedure. These disadvantages will be improved by developing instruments, overcoming the learning curve, and increasing the number of robotic pancreatectomies. In addition, robotic pancreatectomy is still in the introductory period in most centers and should only be used in accordance with strict indications.

500 Minimally Invasive Robotic Pancreatoduodenectomies: One Decade of Optimizing Performance

OBJECTIVES

This study aims to present the outcomes of our decade-long experience of robotic pancreatoduodenectomy and provide insights into successful program implementation.

BACKGROUND

Despite significant improvement in mortality over the past 30 years, morbidity following open pancreatoduodenectomy remains high. We implemented a minimally invasive pancreatic surgery program based on the robotic platform as one potential method of improving outcomes for this operation.

METHODS

A retrospective review of a prospectively maintained institutional database was performed to identify patients who underwent robotic pancreatoduodenectomy (RPD) between 2008 and 2017 at the University of Pittsburgh.

RESULTS

In total, 500 consecutive RPDs were included. Operative time, conversion to open, blood loss, and clinically relevant postoperative pancreatic fistula improved early in the experience and have remained low despite increasing complexity of case selection as reflected by increasing number of patients with pancreatic cancer, vascular resections, and higher Charlson Comorbidity scores (all P<0.05). Operating room time plateaued after 240 cases at a median time of 391 minutes (interquartile rang 340-477). Major complications (Clavien >2) occurred in less than 24%, clinically relevant postoperative pancreatic fistula in 7.8%, 30- and 90-day mortality were 1.4% and 3.1% respectively, and median length of stay was 8 days. Outcomes were not impacted by integration of trainees or expansion of selection criteria.

CONCLUSIONS

Structured implementation of robotic pancreatoduodenectomy can be associated with excellent outcomes. In the largest series of RPD, we establish benchmarks for the surgical community to consider when adopting this approach.

Robotic pancreaticoduodenectomy provides better histopathological outcomes as compared to its open counterpart: a meta-analysis

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p < 0.00001]. EBL was significantly decreased in robotic PD [MD (95%CI) = - 191.35 (- 238.12, - 144.59); p < 0.00001]. Number of lymph nodes harvested was significantly higher in robotic PD [MD (95%CI) = 2.88 (1.12, 4.65); p = 0.001]. This meta-analysis found that robotic PD provides better histopathological outcomes as compared to open PD at the cost of longer operating time. Furthermore, robotic PD did not have any detrimental impact on clinical outcomes, with lower wound infection rates.

Long-term survival after minimally invasive resection versus open pancreaticoduodenectomy for periampullary cancers: a systematic review, meta-analysis and meta-regression

BACKGROUND

It remains unclear whether minimally invasive pancreaticoduodenectomy (MIPD) and open pancreaticoduodenectomy (OPD) influences long-term survival in periampullary cancers. This review aims evaluate long-term survival between MIPD and OPD for periampullary cancers.

METHODS

A systematic review was performed to identify studies comparing long-term survival after MIPD and OPD. The I₂ test was used to test for statistical heterogeneity and publication bias using Egger test. Random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year survival, and disease-specific 5-year and 3-year survival. Meta-regression was performed for the 5-year and 3-year survival outcomes with adjustment for study (region, design, case matching), hospital (centre volume), patient (ASA grade, gender, age), and tumor (stage, neoadjuvant therapy, subtype (i.e. ampullary, distal bile duct, duodenal, pancreatic)). Sensitivity analyses performed on studies including pancreatic ductal adenocarcinoma (PDAC) only.

RESULTS

The review identified 31 relevant studies. Among all 58,622 patients, 8716 (14.9%) underwent MIPD and 49,875 (85.1%) underwent OPD. Pooled analysis revealed similar 5-year overall survival after MIPD compared with OPD (HR: 0.78, 95% CI 0.50-1.22, p = 0.2). Meta-regression indicated case matching, and ASA Grade II and III as confounding covariates. The statistical heterogeneity was limited (I₂ = 12, χ² = 0.26) and the funnel plot was symmetrical both according to visual and statistical testing (Egger test = 0.32). Sensitivity subset analyses for PDAC demonstrated similar 5-year overall survival after MIPD compared with OPD (HR 0.69, 95% CI: 0.32-1.50, p = 0.3).

CONCLUSION

Long-term survival after MIPD is non-inferior to OPD. Thus, MIPD can be recommended as a standard surgical approach for periampullary cancers.

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.

Does center or surgeon volume influence adoption of minimally invasive versus open pancreatoduodenectomy? A systematic review and meta-regression

BACKGROUND

There has been increasing uptake of minimally invasive pancreatoduodenectomy during the past decade, but it remains a highly specialized procedure as benefits over open pancreatoduodenectomy remain contentious. This study aimed to evaluate current evidence on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy in terms of impact of center volume on outcomes.

METHODS

A systematic review of articles on comparative cohort and registry studies on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy published until 31st December 2019 were identified, and meta-analyses were performed. Primary endpoints were International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula and 30-day mortality.

RESULTS

After screening 7,390 studies, 43 comparative cohort studies (8,755 patients) with moderate methodological quality and 3 original registry studies (43,735 patients) were included. For the cohort studies, the median annual hospital minimally invasive pancreatoduodenectomy volume was 10. No significant differences were found in grade B/C postoperative pancreatic fistula (odds ratio: 0.98, 95% confidence interval: 0.78-1.23) or 30-day mortality (odds ratio: 1.14, 95% confidence interval: 0.65-2.01) between minimally invasive pancreatoduodenectomy when compared with open. No publication biases were present and meta-regression identified no confounding for grade B/C postoperative pancreatic fistula, center volume or 30-day mortality. Minimally invasive pancreatoduodenectomy was only strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection, shorter length of stay, and significantly higher rates of R0 margin resections.

CONCLUSION

Minimally invasive pancreatoduodenectomy remains noninferior to open pancreatoduodenectomy for grade B/C postoperative pancreatic fistula but is strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection. Minimally invasive pancreatoduodenectomy can be adopted safely with good outcomes irrespective of annual center resection volume.

Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers

The objective of the study is to compare the safety and efficacy of robot-assisted pancreaticoduodenectomy (PD) with open PD. The PubMed, EMBASE and Cochrane Library databases were searched for the literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio (RR) and weighted mean difference (WMD) and their 95% confidence intervals (CIs) were calculated using fixed-effect or random effect models. 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) (WMD = - 175.65, 95% CI (- 251.85, - 99.44), P < 0.00001), wound infection rate (RR = 0.60, 95% CI (0.44, 0.81), P = 0.001), reoperation rate (RR = 0.61, 95% CI (0.41, 0.91), P = 0.02), hospital day (WMD = - 2.95, 95% CI (- 5.33, - 0.56), P = 0.02), intraoperative blood transfusion (RR = 0.56, 95% CI (0.42, 0.76), P = 0.0001), overall complications (RR = 0.78, 95% CI (0.64, 0.95), P = 0.01), and clinical postoperative pancreatic fistula (POPF) (RR = 0.54, 95% CI (0.41, 0.70), P < 0.0001). In terms of lymph node clearance (WMD = 0.48, 95% CI (- 2.05, 3.02), P = 0.71), R0 rate (RR = 1.05, 95% CI (1.00, 1.11), P = 0.05), postoperative pancreatic fistula (RR = 1, 95% CI (0.85, 1.19), P = 0.97), bile leakage (RR = 0.99, 95% CI (0.54, 1.83), P = 0.98), delayed gastric emptying (DGE) (RR = 0.79, 95% CI (0.60, 1.03), P = 0.08), 90-day mortality (RR = 0.82, 95% CI (0.62, 1.10), P = 0.19), and severe complications (RR = 0.98, 95% CI (0.71, 1.36), P = 0.91), and there were no significant differences between the two groups. Robotic surgery was inferior to open surgery in terms of operational time (WMD = 80.85, 95% CI (16.09, 145.61), P = 0.01). RPD is not inferior to OPD, and it is even more advantageous for EBL, wound infection rate, reoperation rate, hospital stay, intraoperative transfusion, overall complications and clinical POPF. However, these findings need to be further verified by high-quality randomized controlled trials.

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017

BACKGROUND

Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD).

MATERIALS AND METHODS

We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality.

RESULTS

Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission.

CONCLUSIONS

Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

Hybrid pancreatoduodenectomy in laparoscopic and robotic surgery: a single-center experience in China

BACKGROUND

Minimally invasive surgery is beneficial for pancreatic surgery, and the indication has been expanded to pancreatoduodenectomy (PD). The aim of this study was to share our experiences with hybrid PD in laparoscopic and robotic surgery.

METHODS

Sixty-four patients underwent hybrid PD in which specimen resection and gastrojejunostomy were performed through the laparoscopic route and pancreatojejunostomy and hepaticojejunostomy were performed via a robotic approach by the same surgeon at a single institution between July 2016 and June 2019. The primary endpoint was complications; secondary endpoints were operative time (OT), the length of hospital stay, and blood loss. The data for the patients were retrospectively obtained from electrical medical records.

RESULTS

All patients underwent surgery with the hybrid procedure. The mean OTs and estimated blood loss (EBL) were 309.7 ± 77.6 min (range 17-620 min), 160 ± 31.7 mL (range 50-800 mL). The mean number of lymph nodes retrieved was 7.3 ± 6.7 (range 0-37), and that among 45 malignant cases was 8.42 ± 6.7 (range 1-37). The average length of postoperative stay in the hospital was 11.14 ± 7.03 days (range 6-47 days). Clinically relevant postoperative pancreatic fistulas (POPFs) occurred in 39 (60.9%) cases, and most were biochemical leak POPF (29 cases, 45.3%); only 10 (15.6%) cases were grade B/C (8 cases were Grade B and 2 cases were Grade C treated with digital subtraction angiography). Bile leakage occurred in 2 (3.1%) patients. One (1.5%) patient had a gastric fistula, and 3 (4.7%) developed postoperative delayed gastric emptying categorized as International Study Group of Pancreatic Surgery (ISGPS) Grade A. Three (4.7%) patients were readmitted for postoperative bleeding, and 2 (3.1%) died within 30 days.

CONCLUSION

Hybrid PD with laparoscopic and robot surgery is safe and feasible. OT can be reduced by switching from the laparoscopic approach to the robotic procedure at the appropriate timepoint.

Robotic-assisted versus open pancreaticoduodenectomy for patients with benign and malignant periampullary disease: a systematic review and meta-analysis of short-term outcomes

BACKGROUND

Although several non-randomized studies comparing robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) recently demonstrated that the two operative techniques could be equivalent in terms of safety outcomes and short-term oncologic efficacy, no definitive answer has arrived yet to the question as to whether robotic assistance can contribute to reducing the high rate of postoperative morbidity.

METHODS

Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases. Prospective and retrospective studies comparing RPD and OPD as surgical treatment for periampullary benign and malignant lesions were included in the systematic review and meta-analysis with no limits of language or year of publication.

RESULTS

18 non-randomized studies were included for quantitative synthesis with 13,639 patients allocated to RPD (n = 1593) or OPD (n = 12,046). RPD and OPD showed equivalent results in terms of mortality (3.3% vs 2.8%; P = 0.84), morbidity (64.4% vs 68.1%; P = 0.12), pancreatic fistula (17.9% vs 15.9%; P = 0.81), delayed gastric emptying (16.8% vs 16.1%; P = 0.98), hemorrhage (11% vs 14.6%; P = 0.43), and bile leak (5.1% vs 3.5%; P = 0.35). Estimated intra-operative blood loss was significantly lower in the RPD group (352.1 ± 174.1 vs 588.4 ± 219.4; P = 0.0003), whereas operative time was significantly longer for RPD compared to OPD (461.1 ± 84 vs 384.2 ± 73.8; P = 0.0004). RPD and OPD showed equivalent results in terms of retrieved lymph nodes (19.1 ± 9.9 vs 17.3 ± 9.9; P = 0.22) and positive margin status (13.3% vs 16.1%; P = 0.32).

CONCLUSIONS

RPD is safe and feasible as surgical treatment for malignant or benign disease of the pancreatic head and the periampullary region. Equivalency in terms of surgical radicality including R0 curative resection and number of harvested lymph nodes between the two groups confirmed the reliability of RPD from an oncologic point of view.

Comparison Between Robotic and Laparoscopic or Open Anastomoses: A Systematic Review and Meta-Analysis

INTRODUCTION

Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.

METHODS

A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.

RESULTS

We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).

CONCLUSION

Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.