Laparoscopic-assisted versus open pancreaticoduodenectomy: early favorable physical quality-of-life measures

Cost-effectiveness of open versus laparoscopic pancreatectomy: A nationwide, population-based study

BACKGROUND

Laparoscopic pancreatic resection is comparable to open pancreatic resection; however, cost-effectiveness analyses of laparoscopic pancreatic resection are scarce. The authors performed a population-based study investigating the cost-effectiveness of laparoscopic pancreatic resection versus open pancreatic resection.

METHODS

Data from 9,256 patients who received pancreaticoduodenectomy (66.8%) and distal pancreatectomy (33.2%) from 2016 to 2018 were retrieved from the Korean National Health Insurance Service. Events after pancreatectomy were categorized as no complication, complication, and death. Probabilities of each event and average cost during index admission and 1 year were utilized to calculate incremental cost-effectiveness ratio, the cost difference between two interventions divided by quality-adjusted life year. Quality-adjusted life year, a function of length and quality of life, was measured with utility values determined by researching literature.

RESULTS

Laparoscopic pancreatic resection was performed in 12.4% of pancreaticoduodenectomies and 53.4% of distal pancreatectomies. For pancreaticoduodenectomy, laparoscopic pancreatic resection was associated with an increase of 0.0022 quality-adjusted life years for index admission and 0.0023 quality-adjusted life years for 1 year compared with open pancreatic resection. The incremental cost was $321 for index admission and -$1,414 for 1 year, leading to an incremental cost-effectiveness ratio of $147,429 per quality-adjusted life year gained for index admission and -$614,965 per quality-adjusted life year gained for 1 year. For distal pancreatectomy, laparoscopic pancreatic resection improved 0.0131 quality-adjusted life years for index admission and 0.0285 quality-adjusted life years for index admission. The incremental cost was -$1,240 for index admission and -$5,875 for 1 year, leading to an incremental cost-effectiveness ratio of -$94,519 per quality-adjusted life year gained for index admission and -$206,351 for 1 year.

CONCLUSION

laparoscopic pancreatic resection was a cost-effective alternative to open pancreatic resection for pancreaticoduodenectomy and distal pancreatectomy, except for the higher cost of index admission for pancreaticoduodenectomy.

Laparoscopic Pancreaticoduodenectomy With Open Reconstruction: The Buddha's Middle Path

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is not universally adopted because of its steep learning curve. Its technical complexity discourages many surgeons. We believe that laparoscopic pancreaticoduodenectomy with open reconstruction (LPOR) has all the benefits of LPD without its drawbacks and combines the ease of open surgery with the benefits of minimal access surgery. We assessed the feasibility and safety of LPOR and compared it with open pancreaticoduodenectomy (OPD), with the objectives being perioperative and short-term clinical/oncologic outcomes.

METHODS

Retrospective review of prospectively maintained database; study period from January 2013 to December 2019. Till 2015, we did only OPD. In 2016, we started with LPD but soon switched to LPOR. The resection part was done laparoscopically and the reconstruction part was done through a 8-cm mini-laparotomy.

RESULTS

We did 19 OPDs and 15 LPORs. Demographic data of the 2 groups were comparable. The duration of surgery was significantly longer in the LPOR group (360 vs. 410 min; P=0.01), whereas the blood loss and hospital stay were longer in the OPD group (520 vs. 360 mL; P=0.03 and 13 vs. 11 d; P=0.08, respectively). Clinically significant complication rates, including delayed gastric emptying and postoperative pancreatic fistulas, were not different in either group. No patients in the LPOR group had wound-related/pulmonary complications. Lymph node yield was similar in both groups (20 vs. 22) and we had 100% R0 resections.

CONCLUSIONS

LPOR was better than OPD in terms of short-term outcomes and was not inferior to OPD in terms of complications/oncologic outcomes.

Feasibility, safety and oncological short-term outcome of laparoscopic pancreaticoduodenectomy for periampullary cancer: Findings from a large sample from Vietnam

Laparoscopic pancreaticoduodenectomy (LPD) is an alternative to open pancreaticoduodenectomy (OPD) for treatment of periampullary cancer in selected patients. However, this is a difficult procedure with a high complication rate. We conducted a prospective cohort study of 85 patients with suspected periampullary cancer who underwent LPD from February 2017 to January 2022 at University Medical Center at Ho Chi Minh City, Vietnam. Among these, 15 patients were excluded from the data analysis because of benign disease confirmed by postoperative pathological examination. Among 70 patients, the mean age was 58.9 ± 8.9 years old and 51.4% were female. The conversion rate to open surgery was 7.1% (n = 5). Among those underwent LPD, the mean operating time and estimated blood loss were 509 ± 94 minutes and 267 ± 102 mL, respectively. The median length of hospital stay was 8 days, interquartile range (IQR) 7-12 days. The percentage of cumulative morbidity, pancreatic fistula and major complication was 35.4%, 12.3%, and 13.8%, respectively. The median of comprehensive complication index (CCI) was 26.2 (IQR 20.9-29.6). Three patients required reoperation due to severe pancreatic fistula (n = 2) and necrotizing pancreatitis (n = 1). There was no death after ninety-day. The average number of harvested lymph nodes was 16.6 ± 5.1. The percentage of R0 resection was 100%. With properly selected patients, LPD can be a feasible, safe and effective approach with acceptable short-term outcomes.

Quality of life after pancreatic surgery

BACKGROUND

Pancreatic surgery is challenging owing to the anatomical characteristics of the pancreas. Increasing attention has been paid to changes in quality of life (QOL) after pancreatic surgery.

AIM

To summarize and analyze current research results on QOL after pancreatic surgery.

METHODS

A systematic search of the literature available on PubMed and EMBASE was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies were identified by screening the references of retrieved articles. Studies on patients' QOL after pancreatic surgery published after January 1, 2012, were included. These included prospective and retrospective studies on patients' QOL after several types of pancreatic surgeries. The results of these primary studies were summarized inductively.

RESULTS

A total of 45 articles were included in the study, of which 13 were related to pancreaticoduodenectomy (PD), seven to duodenum-preserving pancreatic head resection (DPPHR), nine to distal pancreatectomy (DP), two to central pancreatectomy (CP), and 14 to total pancreatectomy (TP). Some studies showed that 3-6 months were needed for QOL recovery after PD, whereas others showed that 6-12 months was more accurate. Although TP and PD had similar influences on QOL, patients needed longer to recover to preoperative or baseline levels after TP. The QOL was better after DPPHR than PD. However, the superiority of the QOL between patients who underwent CP and PD remains controversial. The decrease in exocrine and endocrine functions postoperatively was the main factor affecting the QOL. Minimally invasive surgery could improve patients' QOL in the early stages after PD and DP; however, the long-term effect remains unclear.

CONCLUSION

The procedure among PD, DP, CP, and TP with a superior postoperative QOL is controversial. The long-term benefits of minimally invasive versus open surgeries remain unclear. Further prospective trials are warranted.

Long-term quality of life is better after laparoscopic compared to open pancreatoduodenectomy

BACKGROUND

Three randomized controlled trials have reported improved functional recovery after Laparoscopic pancreatoduodenectomy (LPD), as compared to open pancreatoduodenectomy (OPD). Long-term results regarding quality of life (QoL) are lacking. The aim of this study was to compare long-term QoL of LPD versus OPD.

METHODS AND PATIENTS

A monocentric retrospective cross-sectional study was performed among patients < 75 years old who underwent LPD or OPD for a benign or premalignant pathology in a high-volume center (2011-2021). An electronic three-part questionnaire was sent to eligible patients, including two diseases specific QoL questionnaires (the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire for cancer (QLQ-C30) and a pancreatic cancer module (PAN26) and a body image questionnaire. Patient demographics and postoperative data were collected and compared between LPD and OPD.

RESULTS

Among 948 patients who underwent PD (137 LPD, 811 OPD), 170 were eligible and 111 responded (58 LPD and 53 OPD). LPD versus OPD showed no difference in mean age (51 vs. 55 years, p = 0.199) and female gender (40% vs. 45%, p = 0.631), but LPD showed lower BMI (24 vs 26; p = 0.028) and higher preoperative pancreatitis (29% vs 13%; p = 0.041). The postoperative outcome showed similar Clavien-Dindo ≥ III morbidity (19% vs. 23%; p = 0.343) and length of stay (24 vs. 21 days, p = 0.963). After a similar median follow-up (3 vs. 3 years; p = 0.122), LPD vs OPD patients reported higher QoL (QLQ-C30: 49.6 vs 56.3; p = 0.07), better pancreas specific health status score (PAN20: 50.5 vs 55.5; p = 0.002), physical functioning (p = 0.002), and activities limitations (p = 0.02). Scar scores were better after LPD regarding esthetics (p = 0.001), satisfaction (p = 0.04), chronic pain at rest (p = 0.036), moving (p = 0.011) or in daily activities (p = 0.02). There was no difference in digestive symptoms (p = 0.995).

CONCLUSION

This monocentric study found improved long-term QoL in patients undergoing LPD, as compared to OPD, for benign and premalignant diseases. These results could be considered when choosing the surgical approach in these patients.

Evolution of laparoscopic pancreaticoduodenectomy at Westmead Hospital

BACKGROUND

Despite its proposed benefits, laparoscopic pancreaticoduodenectomy (LPD) has not been widely adopted due to its technical complexity and steep learning curve. The aim of this study was to report a single surgeon's experience in the stepwise implementation of LPD and evolution of technique over a nine-year period in a moderate-high volume unit.

METHODS

Carefully selected patients underwent LPD initially by hybrid approach (laparoscopic resection and open reconstruction), which evolved into a total LPD (laparoscopic resection and reconstruction). Data was prospectively collected to include patient characteristics, intraoperative data, evolution of technique and postoperative outcomes.

RESULTS

A total of 25 patients underwent hybrid LPD (HLPD) and 20 patients underwent total LPD (TLPD). There was no 90-day mortality. Three patients developed a postoperative pancreatic fistula (POPF), all of which occurred in patients undergoing HLPD. There was no POPF in 20 consecutive TLPD. There was no evidence of anastomotic strictures in the hepaticojejunostomy in patients undergoing TLPD at long term follow up.

CONCLUSION

A gradual and cautious progression from HLPD to TLPD is essential to ensure safe implementation into a unit. LPD should only be considered in carefully selected patients, with outcomes subjected to regular and rigorous independent audit.

Systematic review and meta-analysis of cost-effectiveness of minimally invasive versus open pancreatic resections

BACKGROUND

The systematic review is aimed to evaluate the cost-effectiveness of minimally invasive surgery (MIS) and open distal pancreatectomy and pancreaticoduodenectomy.

METHOD

The MEDLINE, CENTRAL, EMBASE, Centre for Reviews and Dissemination, and clinical trial registries were systematically searched using the PRISMA framework. Studies of adults aged ≥ 18 year comparing laparoscopic and/or robotic versus open DP and/or PD that reported cost of operation or index admission, and cost-effectiveness outcomes were included. The risk of bias of non-randomised studies was assessed using the Newcastle-Ottawa Scale, while the Cochrane Risk of Bias 2 (RoB2) tool was used for randomised studies. Standardised mean differences (SMDs) with 95% confidence intervals (CI) were calculated for continuous variables.

RESULTS

Twenty-two studies (152,651 patients) were included in the systematic review and 15 studies in the meta-analysis (3 RCTs; 3 case-controlled; 9 retrospective studies). Of these, 1845 patients underwent MIS (1686 laparoscopic and 159 robotic) and 150,806 patients open surgery. The cost of surgical procedure (SMD 0.89; 95% CI 0.35 to 1.43; I2 = 91%; P = 0.001), equipment (SMD 3.73; 95% CI 1.55 to 5.91; I2 = 98%; P = 0.0008), and operating room occupation (SMD 1.17, 95% CI 0.11 to 2.24; I2 = 95%; P = 0.03) was higher with MIS. However, overall index hospitalisation costs trended lower with MIS (SMD - 0.13; 95% CI - 0.35 to 0.06; I2 = 80%; P = 0.17). There was significant heterogeneity among the studies.

CONCLUSION

Minimally invasive major pancreatic surgery entailed higher intraoperative but similar overall index hospitalisation costs.

An assessment of perioperative outcomes for open, laparoscopic, and robot-assisted pancreaticoduodenectomy in New York State

BACKGROUND

Minimally invasive techniques for pancreaticoduodenectomy (PD) are increasing in practice, however, data remains limited regarding perioperative outcomes. Our study sought to compare patients undergoing open pancreaticoduodenectomy (OPD) with those undergoing laparoscopic (LPD) or robot-assisted pancreaticoduodenectomy (RPD).

METHODS

Patients who underwent PD during 2016-2018 were identified from the New York State Planning and Research Cooperative System database.

RESULTS

Of the 1954 patients identified, 1708 (87.4%) underwent OPD, 165 (8.4%) underwent LPD, and 81 (4.2%) underwent RPD. The majority of patients were White (63.8%), males (53.3%) with a mean age of 65.4 years. RPD patients had a lower median Charlson Comorbidity Index (2) than OPD (3) or LPD (3, p = 0.01) and had a lower 30-day rate of complications (35.8% vs. 48.3% vs. 43.6% respectively, p = 0.05). After propensity-score matching, however, there were no differences between the groups regarding overall complications, surgical site infections, anastomotic leaks, or mortality (p = NS for all). OPD demonstrated a longer length of stay (median 8 days) compared to LPD (7 days) or RPD (7 days, p < 0.01).

CONCLUSIONS

Patients undergoing LPD and RPD have a shorter length of hospital stay compared to OPD and there was no difference in overall morbidity or mortality when matched to similar patients.

Does CT scanning after pancreatoduodenectomy reduce readmission rates: an analysis of 900 resections at a high-volume center

BACKGROUND

Pancreatoduodenectomy (PD) remains associated with significant complication and readmission rates. Infection constitutes a significant proportion of morbidity. We aim to evaluate whether CT scans performed prior to discharge for suspected infection prevents readmission.

METHODS

A retrospective review of patients undergoing PD at a tertiary referral center from 2010 to 2018.

RESULTS

A total of 982 patients underwent PD: 74% had no clinical infection at the index admission. Of the non-infected patients, 59% exhibited leukocytosis, 27% underwent a CT scan, and 33.6% were readmitted. Of the non-infected patients, 148 (20.3%) experienced major complications, and this was the strongest predictor of readmission (OR: 10.5, [95% CI: 6.5-17], p = 0.0001). In the non-infected patients who had major complications, CT scanning was predictive of lower risk of readmission (OR: 0.38, [95% CI: 0.17-0.83], p = 0.015). Leukocytosis was also found to be predictive of lower risk of readmission (OR: 0.42, [95% CI: 0.18-0.98], p = 0.044). These findings did not hold true for those who had yet to experience major complications on their index admission.

CONCLUSION

CT scanning without evidence of infection was associated with reduction of readmission in the cohort with major complications and showed a trend towards preventing readmission in the overall cohort. Development of clinical algorithms to maximize the utility of this test is warranted.

Hybrid Laparoscopic Versus Open Pancreatoduodenectomy. A Meta-Analysis

INTRODUCTION

Hybrid laparoscopic techniques have been proposed as a good transition from open to complete minimally invasive approach especially in complex surgical procedures. This meta-analysis aimed to compare the outcomes of hybrid laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy.

METHODS

A systematic literature research was performed according to PRISMA guidelines. A broad search strategy with terms "laparoscopy" and "pancreatoduodenectomy" was used. Included studies were analyzed by quantitative meta-analysis using the metafor package for R software.

RESULTS

Of 655 identified articles, 627 were excluded and 28 articles fully assessed, including 14 comparative studies, 8 case series and 6 case reports. Extracted data included intraoperative variables and postoperative outcome parameters. The predefined inclusion criteria were met by 14 comparative studies, and 371 patients were pooled in the meta-analysis. Hybrid laparoscopic pacreatoduodenectomy was associated with significantly longer operative time (I² 0%, p = 0,01, Mean HPD 494,6 min, Mean OPD 421,6 min, WMD 67 min, 95% CI 14-120 min). For all other postoperative outcome parameters, no statistically significant differences were found. A nonsignificant reduction in intraoperative transfusion rate (I² 20%, p = 0,2, proportion HPD 2%, proportion OPD 1,6%, OR 0,44, 95% CI 0,16-1,27) and blood loss (I² 95%, p = 0,1, Mean HPD 397,2 ml, Mean OPD 1017,8 ml, MD - 601 ml, 95% CI - 1311-108) was observed for hybrid pancreatoduodenectomy in comparison to open surgery.

CONCLUSIONS

This meta-analysis demonstrates significantly increased operation time for hybrid laparoscopic compared to open pancreatoduodenectomy. Intraoperative variables as well as postoperative parameters and major morbidity were comparable for both techniques. Overall results of this meta-analysis demonstrated the hybrid technique as a safe procedure in high-volume centers offering aspects of a safe transition to fully laparoscopic pancreatoduodenectomy.

Minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma (DIPLOMA): study protocol for a randomized controlled trial

Background

Recently, the first randomized trials comparing minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) for non-malignant and malignant disease showed a 2-day reduction in time to functional recovery after MIDP. However, for pancreatic ductal adenocarcinoma (PDAC), concerns have been raised regarding the oncologic safety (i.e., radical resection, lymph node retrieval, and survival) of MIDP, as compared to ODP. Therefore, a randomized controlled trial comparing MIDP and ODP in PDAC regarding oncological safety is warranted. We hypothesize that the microscopically radical resection (R0) rate is non-inferior for MIDP, as compared to ODP.

Methods/design

DIPLOMA is an international randomized controlled, patient- and pathologist-blinded, non-inferiority trial performed in 38 pancreatic centers in Europe and the USA. A total of 258 patients with an indication for elective distal pancreatectomy with splenectomy because of proven or highly suspected PDAC of the pancreatic body or tail will be randomly allocated to MIDP (laparoscopic or robot-assisted) or ODP in a 1:1 ratio. The primary outcome is the microscopically radical resection margin (R0, distance tumor to pancreatic transection and posterior margin ≥ 1 mm), which is assessed using a standardized histopathology assessment protocol. The sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected R0 rate in the open group of 58%, expected R0 resection rate in the minimally invasive group of 67%, and a non-inferiority margin of 7%. Secondary outcomes include time to functional recovery, operative outcomes (e.g., blood loss, operative time, and conversion to open surgery), other histopathology findings (e.g., lymph node retrieval, perineural- and lymphovascular invasion), postoperative outcomes (e.g., clinically relevant complications, hospital stay, and administration of adjuvant treatment), time and site of disease recurrence, survival, quality of life, and costs. Follow-up will be performed at the outpatient clinic after 6, 12, 18, 24, and 36 months postoperatively.

Discussion

The DIPLOMA trial is designed to investigate the non-inferiority of MIDP versus ODP regarding the microscopically radical resection rate of PDAC in an international setting.

Trial registration

ISRCTN registry ISRCTN44897265. Prospectively registered on 16 April 2018.

Long- and short-term survival following laparoscopic and open pancreaticoduodenectomy for patients with periampullary tumors in Vietnam

Background

Laparoscopic pancreaticoduodenectomy (LPD) is a less invasive alternative to the traditional open pancreaticoduodenectomy (OPD) approach used to treat periampullary tumors. However, previous studies examining the advantages of this surgery over OPD have produced mixed results. Here, a retrospective observational approach was used to compare the short- and long-term outcomes of patients with periampullary tumors who underwent LPD or OPD at a single institution in Vietnam.

Materials and methods

Data were obtained from hospital medical records collected over five years from patients that underwent OPD or LPD. Information on demographics, medical status, tumor characteristics, operative variables, complications, and mortality was examined. Survival curves were constructed and the stepwise multivariate Cox proportional hazard model was used to identify the factors associated with the risk of death following surgery.

Results

Eighty-four patients aged 26–80 years were included. Twenty-two patients underwent LPD and 62 received OPD. The operative time for the LPD group was significantly longer than that for the OPD group, and the LPD group was less likely to require a blood transfusion during surgery. While the short- and long-term survival rates did not differ for the procedures, the factors associated with the risk of death following surgery were tumors at the N1 stage and an age >65 years.

Conclusion

Both LPD and OPD procedures for treating periampullary tumors exhibited comparable safety profiles, with similar short-term outcomes and long-term survival rates observed. Future studies with a larger sample size should be conducted to further examine the treatment outcomes following these surgical approaches.

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The OPD group was significantly more likely to require blood transfusion as compared to the LPD group (p=0.04).

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The operative time for the LPD group was significantly longer than that for the OPD group (p < 0.01).

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Factors associated with the risk of death following surgery were tumors at the N1 stage and age group > 65 years.

Does minimally invasive pancreaticoduodenectomy increase the chance of a textbook oncologic outcome?

BACKGROUND

Textbook oncologic outcome has been described in an effort to improve upon traditional outcomes defining care after pancreaticoduodenectomy for adenocarcinoma. We sought to examine whether minimally invasive pancreaticoduodenectomy increased the likelihood of an optimal textbook oncologic outcome.

METHODS

Patients undergoing open pancreaticoduodenectomy or minimally invasive pancreaticoduodenectomy between 2010 and 2015 were identified in the National Cancer Database. Textbook oncologic outcome was defined as R0 resection with American Joint Committee on Cancer compliant lymphadenectomy, no prolonged duration of stay, no 30-day readmission/mortality, and receipt of adjuvant chemotherapy. Propensity score matching was employed to evaluate adjusted rates of textbook oncologic outcome, in addition to overall survival.

RESULTS

Among 12,854 patients who underwent pancreaticoduodenectomy, 48.3% were female, and the median patient age was 66 years; 87.5% underwent open pancreaticoduodenectomy, and 12.5% underwent whether minimally invasive pancreaticoduodenectomy. After propensity score matching, there were no noted differences in the likelihood of R0 resection, adequate lymphadenectomy, nonprolonged duration of stay, no readmission, no 30-day mortality, adjuvant chemotherapy, or textbook oncologic outcome among open pancreaticoduodenectomy versus minimally invasive pancreaticoduodenectomy (P > .05). Textbook oncologic outcome was associated with an improved median overall survival (negative textbook oncologic outcome: 21.3 months vs positive textbook oncologic outcome: 27.6 months, P < .001).

CONCLUSION

Although textbook oncologic outcome was associated with a survival advantage, it was only achieved in 1 in 4 patients undergoing pancreaticoduodenectomy for adenocarcinoma. Achievement of textbook oncologic outcome was equivalent among patients who underwent minimally invasive pancreaticoduodenectomy compared with open pancreaticoduodenectomy after propensity score matching.

Evaluation of Postoperative Quality of Life After Pancreatic Surgery and Determination of Influencing Risk Factors

OBJECTIVES

The postoperative quality of life (QoL) after pancreatic surgery is frequently impaired. The aim of this study was to evaluate the QoL after pancreatic surgery and its influencing risk factors. Furthermore, an age-adjusted comparison with the normal population of Germany was performed.

METHODS

A total of 94 patients were surveyed. The Short Form-36 questionnaire was sent to all patients undergoing pancreatic surgery between 2013 and 2017. All pathologies and types of pancreatic resections were included. Statistical analyses were performed, and an analysis by the Robert Koch-Institute to determine the health-related age-adjusted QoL in Germany served as control group.

RESULTS

Response rate was 29%. Median time of survey was 28 months. As compared with a normative population, QoL after pancreaticoduodenectomy was significantly impaired. Distal pancreatic resection showed no significant differences. Univariate and Lasso analyses showed that the following factors had a negative impact: coronary artery disease, chronic pancreatitis, and open access. Postoperative enzyme supplementation seemed to have a positive impact.

CONCLUSIONS

Pancreatic surgery leads to long-lasting negative effect on QoL. Distal pancreatic resections and laparoscopic access seemed to be the best tolerated. Complications seems to have less impact, whereas maintaining exocrine and endocrine function seems to have a positive effect.

Laparoscopic hybrid pancreaticoduodenectomy: Initial single center experience

Backgrounds/Aims

Pancreaticoduodenectomy (PD) is the gold standard for the treatment of periampullary tumors. Many specialized centers have adopted the totally laparoscopic or hybrid laparoscopic PD (LPD). However, this procedure has not yet been standardized and serious debate is taking place towards its safety and feasibility. Herein, we report our recent experience whit hybrid-LPD.

Methods

During 2019 in our department 56 PD were performed and 21 (37.5%) underwent hybrid-LPD. We have retrospectively reviewed the short-term outcomes of these patients.

Results

Main indication was pancreatic adenocarcinoma (71,4%). The median operative time and intraoperative blood loss were respectively 425 min (range, 226 to 576) and 317 ml (range 60 to 800 ml). Conversion to an open procedure was required in 4 patients (19%): 2 with suspected vein involvement, 1 for mesenteric panniculitis and 1 for biliary injury. The post-operative complication rate was 42.8% (9/21). Regarding post-operative pancreatic fistula, three patients (14.2%) had grade B and 1 grade C (4.7%). Median length of hospital stay was 14 days (range 9-23) and 90- days mortality was 4.7%. The mean number of harvested lymph nodes was 17.7 (range 12 to 26). The rate of margins R0 was 80%; R1 ＞0<1 mm was 10.5% and R1 0 mm was 9.5%.

Conclusions

Hydrid-LPD is safe and feasible. Careful patient selection and increasing experience can reduce the risk of post-operative complications.

The comparation of short-term outcome between laparoscopic and open pancreaticoduodenectomy: a propensity score matching analysis

Pancreaticoduodenectomy (PD) is one of the most complex and delicate operations in abdominal surgery. With the development of laparoscopic techniques, more and more pancreatic experts have become skilled in laparoscopic pancreaticoduodenectomy (LPD). However, the short-term efficacy of LPD compared to open pancreaticoduodenectomy (OPD) remains unclear. Here, we performed a propensity score matching study aiming to compare the short outcomes of patients who underwent LPD or OPD after the learning curve and established a risk model of pancreatic fistula. The data of 346 patients who had OPD or LPD from July 2015 to January 2020 were retrieved. After a 1:1 matching, 224 patients remained. The operation time was significantly longer (P = 0.001) but the amount of bleeding was significantly lower (P = 0.001) in the LPD group than in the OPD group. Patients in LPD group had fewer blood transfusions (P = 0.002) than those in OPD group. More lymph nodes (P < 0.001) were dissected in LPD group. The rate of grade B/C pancreatic fistula was significantly higher in the LPD group than in the OPD group (16.1% vs. 6.3%, P = 0.002). By multi variate Logistic regression analysis, we identified pancreatic tumor, malignancy and low body mass index were risk factors of Grade B/C pancreatic fistula after PD operation. Then, we developed a Grade B/C pancreatic fistula nomogram with the risk factors. The C-index of the nomogram was 0.836 (95% CI 0.762-0.910). In conclusion, LPD could be technically feasible, get less trauma and achieve similar short-term outcome as compared with OPD.

Practice Patterns and Perioperative Outcomes of Laparoscopic Pancreaticoduodenectomy in China: A Retrospective Multicenter Analysis of 1029 Patients

OBJECTIVE

The aim of the study was to analyze the outcomes of patients who have undergone laparoscopic pancreaticoduodenectomy (LPD) in China.

SUMMARY BACKGROUND DATA

LPD is being increasingly used worldwide, but an extensive, detailed, systematic, multicenter analysis of the procedure has not been performed.

METHODS

We retrospectively reviewed 1029 consecutive patients who had undergone LPD between January 2010 and August 2016 in China. Univariate and multivariate analyses of patient demographics, changes in outcome over time, technical learning curves, and the relationship between hospital or surgeon volume and patient outcomes were performed.

RESULTS

Among the 1029 patients, 61 (5.93%) required conversion to laparotomy. The median operation time (OT) was 441.34 minutes, and the major complications occurred in 511 patients (49.66%). There were 21 deaths (2.43%) within 30 days, and a total of 61 (5.93%) within 90 days. Discounting the effects of the early learning phase, critical parameters improved significantly with surgeons' experience with the procedure. Univariate and multivariate analyses revealed that the pancreatic anastomosis technique, preoperative biliary drainage method, and total bilirubin were linked to several outcome measures, including OT, estimated intraoperative blood loss, and mortality. Multicenter analyses of the learning curve revealed 3 phases, with proficiency thresholds at 40 and 104 cases. Higher hospital, department, and surgeon volume, as well as surgeon experience with minimally invasive surgery, were associated with a lower risk of surgical failure.

CONCLUSIONS

LPD is technically safe and feasible, with acceptable rates of morbidity and mortality. Nonetheless, long learning curves, low-volume hospitals, and surgical inexperience are associated with higher rates of complications and mortality.

Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation

OBJECTIVE

The aim of the study was to validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort.

BACKGROUND

MIPD may be associated with an increased risk of postoperative pancreatic fistula (POPF). The a-FRS could allow for risk-adjusted comparisons in research and improve preventive strategies for high-risk patients. The a-FRS, however, has not yet been validated specifically for laparoscopic, robot-assisted, and hybrid MIPD.

METHODS

A validation study was performed in a pan-European cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. The primary outcome was POPF (International Study Group on Pancreatic Surgery grade B/C). Model performance was assessed using the area under the receiver operating curve (AUC; discrimination) and calibration plots. Validation included univariable screening for clinical variables that could improve performance.

RESULTS

Overall, 202 of 952 patients (21%) developed POPF after MIPD. Before adjustment, the original a-FRS performed moderately (AUC 0.68) and calibration was inadequate with systematic underestimation of the POPF risk. Single-row pancreatojejunostomy (odds ratio 4.6, 95 confidence interval [CI] 2.8-7.6) and male sex (odds ratio 1.9, 95 CI 1.4-2.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of body mass index, pancreatic texture, duct size, and male sex, showed good discrimination (AUC 0.75, 95 CI 0.71-0.79) and adequate calibration. Performance was adequate for laparoscopic, robot-assisted, and hybrid MIPD and open pancreatoduodenectomy.

CONCLUSIONS

The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and open pancreatoduodenectomy. The increased risk of POPF in laparoscopic MIPD was associated with single-row pancreatojejunostomy, which should therefore be discouraged.

Short-term outcomes after minimally invasive versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis

BACKGROUND

To date, the evidence on the safety and benefits of minimally invasive pancreatoduodenectomy (MIPD) in elderly patients is still controversy. This study aim to compare the risk and benefit between MIPD and open pancreatoduodenectomy (OPD) in elderly patients.

METHODS

From 2016 to 2020, we retrospective enrolled 26 patients underwent MIPD and other 119 patients underwent OPD. We firstly compared the baseline characteristics, 90-day mortality and short-term surgical outcomes of MIPD and OPD. Propensity score matching was applied for old age patient (≥ 65-year-old vs. < 65-year-old) for detail safety and feasibility analysis.

RESULTS

Patients received MIPD is significantly older, had poor performance status, less lymph node harvest, longer operation time, less postoperative hospital stay (POHS) and earlier drain removal. After 1:2 propensity score matching analysis, elderly patients in MIPD group had significantly poor performance status (P = 0.042) compared to OPD group. Patients receiving MIPD had significantly shorter POHS (18 vs. 25 days, P = 0.028), earlier drain removal (16 vs. 21 days, P = 0.012) and smaller delay gastric empty rate (5.9 vs. 32.4% P = 0.036). There was no 90-day mortality (0% vs. 11.8%, P = 0.186) and pulmonary complications (0% vs. 17.6%, P = 0.075) in MIPD group, and the major complication rate is comparable to OPD group (17.6% vs. 29.4%, P = 0.290).

CONCLUSION

For elderly patients, MIPD is a feasible and safe option even in patients with inferior preoperative performance status. MIPD might also provide potential advantage for elderly patients in minimizing pulmonary complication and overall mortality over OPD.

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.

Totally laparoscopic versus open pancreaticoduodenectomy: A propensity score matching analysis of short-term outcomes

INTRODUCTION

Laparoscopic pancreaticoduodenectomy (LPD) is a demanding operation that has not yet gained popularity. Safety, feasibility, and clinical advantages of LPD in comparison with open pancreaticoduodenectomy (OPD) have not been clearly demonstrated. The aim of this study was to compare the short term outcomes of LPD with those of OPD.

MATERIAL AND METHODS

Data from a prospectively collected database of patients who underwent pancreaticoduodenectomy at our institution between January 2013 and March 2020 were retrieved and analyzed, comparing the short-term postoperative outcomes of LPD and OPD, using a propensity score matching analysis.

RESULTS

In the study period, 177 patients undergoing pancreaticoduodenectomy were selected, 52 of these were LPD. In the LPD group, the conversion rate to OPD was 3.8%. After matching, a total of 50 LPD and 50 OPD were compared. LPD was associated with a shorter length of stay (14 vs 20 days, p = 0.011), decreased blood loss (255 vs 350 ml, p = 0.022), but longer median operative time (590 vs 382.5 min; p < 0.001). No significant difference was found between LPD and OPD in terms of overall complications (56% vs 62%, p = 0.542), severe complications (26% vs 22%, p = 0.640), and postoperative mortality (4% vs 6%, p = 0.646). The groups had similar reoperation rate, pancreatic-specific complications, and readmission rate.

CONCLUSIONS

In comparison with the open approach, LPD seems associated to with improved short-term outcomes in terms of hospital stay and blood loss, but with a longer operative time. No difference in morbidity and mortality rate were found in our series.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Robotic Whipple for pancreatic ductal and ampullary adenocarcinoma: 10 years experience of a US single-center

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.

Outcomes After Minimally-invasive Versus Open Pancreatoduodenectomy: A Pan-European Propensity Score Matched Study

OBJECTIVE

To assess short-term outcomes after minimally invasive (laparoscopic, robot-assisted, and hybrid) pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) among European centers.

BACKGROUND

Current evidence on MIPD is based on national registries or single expert centers. International, matched studies comparing outcomes for MIPD and OPD are lacking.

METHODS

Retrospective propensity score matched study comparing MIPD in 14 centers (7 countries) performing ≥10 MIPDs annually (2012-2017) versus OPD in 53 German/Dutch surgical registry centers performing ≥10 OPDs annually (2014-2017). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3).

RESULTS

Of 4220 patients, 729/730 MIPDs (412 laparoscopic, 184 robot-assisted, and 130 hybrid) were matched to 729 OPDs. Median annual case-volume was 19 MIPDs (interquartile range, IQR 13-22), including the first MIPDs performed in 10/14 centers, and 31 OPDs (IQR 21-38). Major morbidity (28% vs 30%, P = 0.526), mortality (4.0% vs 3.3%, P = 0.576), percutaneous drainage (12% vs 12%, P = 0.809), reoperation (11% vs 13%, P = 0.329), and hospital stay (mean 17 vs 17 days, P > 0.99) were comparable between MIPD and OPD. Grade-B/C postoperative pancreatic fistula (POPF) (23% vs 13%, P < 0.001) occurred more frequently after MIPD. Single-row pancreatojejunostomy was associated with POPF in MIPD (odds ratio, OR 2.95, P < 0.001), but not in OPD. Laparoscopic, robot-assisted, and hybrid MIPD had comparable major morbidity (27% vs 27% vs 35%), POPF (24% vs 19% vs 25%), and mortality (2.9% vs 5.2% vs 5.4%), with a fewer conversions in robot-assisted- versus laparoscopic MIPD (5% vs 26%, P < 0.001).

CONCLUSIONS

In the early experience of 14 European centers performing ≥10 MIPDs annually, no differences were found in major morbidity, mortality, and hospital stay between MIPD and OPD. The high rates of POPF and conversion, and the lack of superior outcomes (ie, hospital stay, morbidity) could indicate that more experience and higher annual MIPD volumes are needed.

Lessons Learned from the Introduction of Laparoscopic Pancreaticoduodenectomy

Introduction: Minimally invasive techniques have been suggested to achieve enhanced recovery and improved outcome after pancreaticoduodenectomy (PD). This study describes our experience and a stepwise technical implementation of the laparoscopic pancreaticoduodenectomy (LPD) during early introduction in 2016. Methods: A team of three hepatopancreaticobiliary surgeons with extensive experience in open pancreaticoduodenectomy (OPD) and with advanced laparoscopic skills started a proctor-guided program with LPD. The first 20 carefully selected cases were prospectively reviewed and compared with a matched OPD cohort. Results: In 20 months, 20 minimally invasive PDs were performed. Reviewing the first 10 LPD cases, 7 patients (70%) had anastomosis-related complications, versus 16% in OPD (P = .001). After consulting an international LPD expert, the team switched to a hybrid technique consisting of LPD followed by open reconstruction through midline minilaparotomy (LPD-OR). In the following 10 cases of LPD-OR, no anastomosis-related complications did occur (P = .342 OPD versus LPD-OR). Conclusion: Safe introduction of new techniques in minimally invasive major abdominal surgery is imperative. Based on our single-center experience, LPD-OR may be safer in the earliest phase of the learning curve of minimally invasive PD, as part of a stepwise implementation toward the fully laparoscopic technique.

Pancreatic head cancer: Open or minimally invasive pancreaticoduodenectomy?

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.

Outcomes of a Multicenter Training Program in Laparoscopic Pancreatoduodenectomy (LAELAPS-2)

OBJECTIVE

The aim of the study was to assess feasibility and outcomes of a multicenter training program in laparoscopic pancreatoduodenectomy (LPD).

BACKGROUND

Whereas expert centers have reported promising outcomes of LPD, nationwide analyses have raised concerns on its safety, especially during the learning curve. Multicenter, structured LPD training programs reporting outcomes including the first procedures are lacking. No LPD had been performed in the Netherlands before this study.

METHODS

During 2014-2016, 8 surgeons from 4 high-volume centers completed the Longitudinal Assessment and Realization of Laparoscopic Pancreatic Surgery (LAELAPS-2) training program in LPD, including detailed technique description, video training, and proctoring. In all centers, LPD was performed by 2 surgeons with extensive experience in pancreatic and laparoscopic surgery. Outcomes of all LPDs were prospectively collected.

RESULTS

In total, 114 patients underwent LPD. Median pancreatic duct diameter was 3 mm [interquartile range (IQR = 2-4)] and pancreatic texture was soft in 74% of patients. The conversion rate was 11% (n = 12), median blood loss 350 mL (IQR = 200-700), and operative time 375 minutes (IQR = 320-431). Grade B/C postoperative pancreatic fistula occurred in 34% of patients, requiring catheter drainage in 22% and re-operation in 2%. A Clavien-Dindo grade ≥ III complication occurred in 43% of patients. Median length of hospital stay was 15 days (IQR = 9-25). Overall, 30-day and 90-day mortality were both 3.5%. Outcomes were similar for the first and second part of procedures.

CONCLUSIONS

This LPD training program was feasible and ensured acceptable outcomes during the learning curve in all centers. Future studies should determine whether such a training program is applicable in other settings and assess the added value of LPD.

Laparoscopic surgery in pancreatic diseases: Pushing the boundaries

BACKGROUND

Laparoscopic surgery has expanded exponentially in the last two decades but, somehow it is limited in pancreatic surgery by virtue of the pancreas being a friable, retroperitoneal organ with difficult access and adjacent major vessels risking torrential bleed. It is thought to be unforgiving if not handled well. However, improvements in technology and surgeon's expertise have pushed the boundaries of minimal access surgery (MAS) to include pancreas in its domain. We present our series of laparoscopic pancreatic surgery (LPS) with an aim to look at the feasibility and outcomes.

METHODS

This is a retrospective review of all LPS done at the Gastrointestinal Surgery (GIS) centre of a tertiary care Armed Forces Hospital over a period of 3 years.

RESULTS

A total of 24 LPS were done during this period. The median age of the patients was 46 years (range; 13-81). There were 14 male and 10 female patients. Nine patients had at least one co-morbidity. Three patients underwent laparoscopic lateral pancreaticojejunostomy, 4 distal pancreatectomy, 4 laparoscopic Whipples pancreaticoduodenectomy, 6 laparoscopic pancreatic necrosectomy, 6 laparoscopic cystogastrostomy and 1 roux en y cystojejunostomy.

CONCLUSION

LPS can be performed for almost all open pancreatic surgeries and can be done with reasonable outcomes. However, it has a steep learning curve and therefore, a hybrid approach leading to a totally laparoscopic approach may be the way forward.

Minimally invasive pancreatoduodenectomy is associated with lower morbidity compared to open pancreatoduodenectomy: An updated meta-analysis of randomized controlled trials and high-quality nonrandomized studies

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) is being increasingly performed as an alternative to open pancreatoduodenectomy (OPD) in selected patients. Our study aimed to present a meta-analysis of the high-quality studies conducted that compared MIPD to OPD performed for pancreatic head and periampullary diseases.

METHODS

A systematic review of the available literature was performed to identify those studies conducted that compared MIPD to OPD. Here, all randomized controlled trials identified were included, while the selection of high-quality, nonrandomized comparative studies were based on a validated tool (i.e., Methodological Index for Nonrandomized Studies). Intraoperative outcomes, postoperative recovery, oncologic clearance, and postoperative complications were also evaluated.

RESULTS

Sixteen studies matched the selection criteria, including a total of 3168 patients (32.1% MIPD, 67.9% OPD). The pooled data showed that MIPD was associated with a longer operative time (weighted mean difference [WMD] = 80.89 minutes, 95% confidence interval [CI]: 39.74-122.05, P < .01), less blood loss (WMD = -227.62 mL, 95% CI: -305.48 to -149.75, P < .01), shorter hospital stay (WMD = -4.68 days, 95% CI: -5.52 to -3.84, P < .01), and an increase in retrieved lymph nodes (WMD = 1.85, 95% CI: 1.33-2.37, P < .01). Furthermore, the overall morbidity was significantly lower in the MIPD group (OR = 0.67, 95% CI: 0.54-0.82, P < .01), as were total postoperative pancreatic fistula (POPF) (OR = 0.79, 95% CI: 0.63-0.99, P = .04), delayed gastric emptying (DGE) (OR = 0.71, 95% CI: 0.52-0.96, P = .02), and wound infection (OR = 0.56, 95% CI: 0.39-0.79, P < .01). However, there were no statistically significant differences observed in major complications, clinically significant POPFs, reoperation rate, and mortality.

CONCLUSION

Our study suggests that MIPD is a safe alternative to OPD, as it is associated with less blood loss and better postoperative recovery in terms of the overall postoperative complications as well as POPF, DGE, and wound infection. Methodologic high-quality comparative studies are required for further evaluation.

The Yonsei experience of 104 laparoscopic pancreaticoduodenectomies: a propensity score-matched analysis with open pancreaticoduodenectomy

BACKGROUND

With continued technical advances in surgical instruments and growing expertise, several surgeons have performed laparoscopic pylorus preserving pancreaticoduodenectomy (L-PPPD) safely with good results, and the laparoscopic approach is being performed more frequently. We performed over 100 cases of L-PPPD and compared their outcomes to those of open PPPD (O-PPPD) using the large sample size. The aim of the present study was to evaluate the safety and feasibility of L-PPPD compared with O-PPPD.

METHODS

From September 2012 to June 2017, PPPD was performed for 217 patients at Yonsei University Severance Hospital by a single surgeon. Patients were divided into two groups: those who underwent O-PPPD (n = 113) and those who underwent L-PPPD (n = 104). We performed a 1:1 propensity score-matched (PSM) analysis and retrospectively analyzed the demographic and surgical outcomes. We also reviewed all previous studies of more than 100 cases.

RESULTS

The L-PPPD group had lesser intraoperative blood loss than the O-PPPD group (548.1 ml vs. 244.7 ml; p < 0.001). Both groups showed similar rates of negative resection margins (99.1% vs. 96.2%; p = 0.196). Overall complication rates did not differ significantly between O-PPPD and L-PPPD (39.8% vs. 35.6%; p = 0.519). The clinically relevant postoperative pancreatic fistula (POPF) rates in the O-PPPD and L-PPPD groups were 18.8% and 13.5%, respectively (p = 0.311). There was no difference in 30- and 90-day mortality rates between the two groups (p = 0.479). Similar results were obtained after PSM analysis.

CONCLUSIONS

L-PPPD can be a good alternative option for well-selected patients with periampullary lesions requiring PPPD.

Laparoscopic pancreatoduodenectomy with open or laparoscopic reconstruction during the learning curve: a multicenter propensity score matched study

BACKGROUND

Laparoscopic pancreatoduodenectomy with open reconstruction (LPD-OR) has been suggested to lower the rate of postoperative pancreatic fistula reported after laparoscopic pancreatoduodenectomy with laparoscopic reconstruction (LPD). Propensity score matched studies are, lacking.

METHODS

This is a multicenter prospective cohort study including patients from 7 Dutch centers between 2014-2018. Patients undergoing LPD-OR were matched LPD patients in a 1:1 ratio based on propensity scores. Main outcomes were postoperative pancreatic fistulas (POPF) grade B/C and Clavien-Dindo grade ≥3 complications.

RESULTS

A total of 172 patients were included, involving the first procedure for all centers. All 56 patients after LPD-OR could be matched to a patient undergoing LPD. With LPD-OR, the unplanned conversion rate was 21% vs. 9% with LPD (P < 0.001). Median blood loss (300 vs. 400 mL, P = 0.85), operative time (401 vs. 378 min, P = 0.62) and hospital stay (10 vs. 12 days, P = 0.31) were comparable for LPD-OR vs. LPD, as were Clavien-Dindo grade ≥3 complications (38% vs. 52%, P = 0.13), POPF grade B/C (23% vs. 21%, P = 0.82), and 90-day mortality (4% vs. 4%, P > 0.99).

CONCLUSION

In this propensity matched cohort performed early in the learning curve, no benefit was found for LPD-OR, as compared to LPD.

Laparoscopic pancreaticoduodenectomy: are the best times coming?

Background

The introduction of laparoscopic technology has greatly promoted the development of surgery, and the trend of minimally invasive surgery is becoming more and more obvious. However, there is no consensus as to whether laparoscopic pancreaticoduodenectomy (LPD) should be performed routinely.

Main body

We summarized the development of laparoscopic pancreaticoduodenectomy (LPD) in recent years by comparing with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD) and evaluated its feasibility, perioperative, and long-term outcomes including operation time, length of hospital stay, estimated blood loss, and overall survival. Then, several relevant issues and challenges were discussed in depth.

Conclusion

The perioperative and long-term outcomes of LPD are no worse and even better in length of hospital stay and estimated blood loss than OPD and RPD except for a few reports. Though with strict control of indications, standardized training, and learning, ensuring safety and reducing cost are still and will always the keys to the healthy development of LPD; the best times for it are coming.

Total laparoscopic versus robot-assisted laparoscopic pancreaticoduodenectomy

In this study, the clinical effectiveness of the robot-assisted laparoscopic pancreatico-duodenectomy (RPD) and Total laparoscopic pancreaticoduodenectomy LPD were retrospectively reviewed. From December 2013 to September 2017, 20 patients underwent robot-assisted laparoscopic pancreaticoduodenectomy and 80 patients underwent Total laparoscopic pancreaticoduodenectomy. The clinical data of the RPDs and the first 20 LPDs were reviewed retrospectively. There is no difference in operative time, estimated blood loss, length of stay, and rates of complications and mortality between the LPD and RPD group. The next 10 cases in the RPD group had shorter operative times (p = 0.03) than the first 10 cases. The estimated blood loss and length of stay were also lower in the next 10 cases; however, these results did not reach statistical significance. Our results show that LPD and RPD are technically safe and feasible. Comparable results were demonstrated between the two groups, while the robotic system seemed to shorten the learning curve of minimally invasive pancreaticoduodenectomy (PD).

Laparoscopic pancreaticoduodenectomy with segmental resection of superior mesenteric vein-splenic vein-portal vein confluence in pancreatic head cancer: can it be a standard procedure?

The feasibility of laparoscopic pancreaticoduodenectomy (LPD) in the treatment of pancreatic cancer is still disputed. However, advances in surgical technique and accumulating experience have led to the use of LPD with combined vascular resection and reconstruction as a safe and feasible procedure, especially in pancreatic cancer with major vascular involvement. A 64-year-old woman presented with obstructive jaundice secondary to pancreatic head cancer. Contrast abdominopelvic computed tomography revealed a pancreatic head tumor measuring approximately 22 mm in diameter that was abutting the first jejunal branch of the superior mesenteric vein at an angle of <180°. The patient underwent LPD, which failed to resect the pancreatic head tumor invading the superior mesenteric vein. Consequently, segmental resection of the confluence of the superior mesenteric vein, splenic vein, and portal vein (SMV/SV/PV) was completely performed in laparoscopic approach without complication. The patient recovered without any event and was discharged on postoperative day 9. LPD combined with vascular resection and reconstruction is feasible in cases involving major blood vessels. Further surgical expertise and education are required before LPD can be used as a standard procedure.

Multicenter outcomes of robotic reconstruction during the early learning curve for minimally-invasive pancreaticoduodenectomy

BACKGROUND

Perceived excess morbidity during the early learning curve of minimally-invasive pancreaticoduodenectomy (MIPD) has limited widespread adoption. It was hypothesized that robot-assisted reconstruction (RA) after MIPD allows anastomotic outcomes equivalent to open pancreaticoduodenectomy (PD).

METHODS

Intent to treat analysis of centrally audited data accrued during early adoption of RA-MIPD at five centers.

RESULTS

CUSUM analysis of operating times at each center identified 92 RA-MIPD during the early learning curve. Mean age was 65 ± 12 years with body mass index 25.8 ± 5.0. Surgical indications included malignant (60%) and premalignant (38%) lesions. Median operating time was 504 min (interquartile range 133) with 242 ml median estimated blood loss (IQR 398) and twelve (13%) conversions to open PD. Major complication rate (Clavien-Dindo III/IV) was 24% with 2 (2.2%) deaths and ten (10.9%) reoperations. Nine (9.9%) clinically significant pancreatic fistulae were observed (4 grade B; 5 grade C). Margin negative resection rate for malignancy was 90% (75% for PDA) with mean harvest of 16 ± 8 lymph nodes.

CONCLUSIONS

These multicenter data during the early learning curve for RA-MIPD do not demonstrate excess anastomotic morbidity compared to open. Further studies are required to determine whether surgeon proficiency and evolving technique improve anastomotic outcomes compared to open.

Minimally invasive surgical approach versus open procedure for pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging abdominal procedures. Safety and feasibility remain controversial when comparing MIPD with open pancreaticoduodenectomy (OPD). The aim of this systematic review and meta-analysis was to evaluate the feasibility and safety of MIPD versus OPD.

METHODS

A systematic review of the literature was performed to identify studies comparing MIPD and OPD. Postoperative complications, intraoperative outcomes and oncologic data, and postoperative recovery were compared.

RESULTS

There were 27 studies that matched the selection criteria. Totally 1306 cases of MIPD and 5603 cases of OPD were included. MIPD was associated with a reduction in postoperative hemorrhage (odds ratio [OR] 1.60; 95% confidence interval [CI] 1.03-2.49; P = .04) and wound infection (OR 0.44, 95% CI 0.30-0.66, P < .0001). MIPD was also associated with less estimated blood loss (mean difference [MD] -300.14 mL, 95% CI -400.11 to -200.17 mL, P < .00001), a lower transfusion rate (OR 0.46, 95% CI 0.35-0.61; P < .00001) and a shorter length of hospital stay (MD -2.95 d, 95% CI -3.91 to -2.00 d, P < .00001) than OPD. Meanwhile, the MIPD group had a higher R0 resection rate (OR 1.45, 95% CI 1.18-1.78, P = .0003) and more lymph nodes harvested (MD 1.34, 95% CI 0.14-2.53, P = .03). However, the minimally invasive approach proved to have much longer operative time (MD 71.00 minutes; 95% CI 27.01-115.00 minutes; P = .002) than OPD. Finally, there were no significant differences between the 2 procedures in postoperative pancreatic fistula (P = .30), delayed gastric emptying (P = .07), bile leakage (P = .98), mortality (P = .88), tumor size (P = .15), vascular resection (P = .68), or reoperation rate (P = .11).

CONCLUSIONS

Our results suggest that MIPD is currently safe, feasible, and worthwhile. Future large-volume, well-designed randomized controlled trials (RCT) with extensive follow-up are awaited to further clarify this role.

Minimally invasive pancreaticoduodenectomy for periampullary disease: a comprehensive review of literature and meta-analysis of outcomes compared with open surgery

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear.

METHODS

Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis.

RESULTS

One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes.

CONCLUSION

Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.

Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours

BACKGROUND

Laparoscopic resection as an alternative to open pancreatoduodenectomy may yield short-term benefits, but has not been investigated in a randomized trial. The aim of this study was to compare laparoscopic and open pancreatoduodenectomy for short-term outcomes in a randomized trial.

METHODS

Patients with periampullary cancers were randomized to either laparoscopic or open pancreatoduodenectomy. The outcomes evaluated were hospital stay (primary outcome), and blood loss, radicality of surgery, duration of operation and complication rate (secondary outcomes).

RESULTS

Of 268 patients, 64 who met the eligibility criteria were randomized, 32 to each group. The median duration of postoperative hospital stay was longer for open pancreaticoduodenectomy than for laparoscopy (13 (range 6-30) versus 7 (5-52) days respectively; P = 0·001). Duration of operation was longer in the laparoscopy group. Blood loss was significantly greater in the open group (mean(s.d.) 401(46) versus 250(22) ml; P < 0·001). Number of nodes retrieved and R0 rate were similar in the two groups. There was no difference between the open and laparoscopic groups in delayed gastric emptying (7 of 32 versus 5 of 32), pancreatic fistula (6 of 32 versus 5 of 32) or postpancreatectomy haemorrhage (4 of 32 versus 3 of 32). Overall complications (defined according to the Clavien-Dindo classification) were similar (10 of 32 versus 8 of 32). There was one death in each group.

CONCLUSION

Laparoscopy offered a shorter hospital stay than open pancreatoduodenectomy in this randomized trial. Registration number: NCT02081131( http://www.clinicaltrials.gov).

Minimally Invasive Versus Open Pancreatoduodenectomy: Systematic Review and Meta-analysis of Comparative Cohort and Registry Studies

OBJECTIVE

This study aimed to appraise and to evaluate the current evidence on minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy only in comparative cohort and registry studies.

BACKGROUND

Outcomes after MIPD seem promising, but most data come from single-center, noncomparative series.

METHODS

Comparative cohort and registry studies on MIPD versus open pancreatoduodenectomy published before August 23, 2015 were identified systematically and meta-analyses were performed. Primary endpoints were mortality and International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula (POPF).

RESULTS

After screening 2293 studies, 19 comparative cohort studies (1833 patients) with moderate methodological quality and 2 original registry studies (19,996 patients) were included. For cohort studies, the median annual hospital MIPD volume was 14. Selection bias was present for cancer diagnosis. No differences were found in mortality [odds ratio (OR) = 1.1, 95% confidence interval (CI) = 0.6-1.9] or POPF [(OR) = 1.0, 95% CI = 0.8 to 1.3]. Publication bias was present for POPF. MIPD was associated with prolonged operative times [weighted mean difference (WMD) = 74 minutes, 95% CI = 29-118], but lower intraoperative blood loss (WMD = -385 mL, 95% CI = -616 to -154), less delayed gastric emptying (OR = 0.6, 95% = CI 0.5-0.8), and shorter hospital stay (WMD = -3 days, 95% CI = -5 to -2). For registry studies, the median annual hospital MIPD volume was 2.5. Mortality after MIPD was increased in low-volume hospitals (7.5% vs 3.4%; P = 0.003).

CONCLUSIONS

Outcomes after MIPD seem promising in comparative cohort studies, despite the presence of bias, whereas registry studies report higher mortality in low-volume centers. The introduction of MIPD should be closely monitored and probably done only within structured training programs in high-volume centers.

A systemic review and an updated meta-analysis: minimally invasive vs open pancreaticoduodenectomy

The feasible of minimally invasive pancreaticoduodenectomy (MIPD) remains controversial when compared with open pancreaticoduodenectomy (OPD). We conducted a systemic review and meta-analysis to summarise the available evidence to compare MIPD vs OPD. We systemically searched PubMed, EMBASE and Web of Science for studies published through February 2016. The primary endpoint was postoperative pancreatic fistula (POPF, grade B/C). A total of 27 studies involving 14,231 patients (2,377 MIPD and 11,854 OPD) were included. MIPD was associated with longer operative times (P < 0.01) and increased mortality (P < 0.01), but decreased estimated blood loss (P < 0.01), decreased delayed gastric emptying (P < 0.01), increased R0 resection rate (P < 0.01), decreased wound infection (P = 0.03) and shorter hospital stays (P < 0.01). There were no significant differences in BMI (P = 0.43), tumor size (P = 0.17), lymph nodes harvest (P = 0.57), POPF (P = 0.84), reoperation (P = 0.25) and 5-year survival rates (P = 0.82) for MIPD compared with OPD. Although there was an increased operative cost (P < 0.01) for MIPD compared with OPD, the postoperative cost was less (P < 0.01) with the similar total costs (P = 0.28). MIPD can be a reasonable alternative to OPD with the potential advantage of being minimally invasive. However, MIPD should be performed in high-volume centers and more randomized-controlled trials are needed to evaluate the appropriate indications of MIPD.

A Propensity Score-Matched Analysis of Robotic vs Open Pancreatoduodenectomy on Incidence of Pancreatic Fistula

Importance

The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD).

Objective

To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD.

Design, Setting, and Participants

Data were accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center-in a standardized fashion-by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement.

Interventions

Use of RPD or OPD.

Main Outcomes and Measures

The major outcome of interest was CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy.

Results

The overall cohort was 51.5% male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score-matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95% CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95% CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95% CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs ≥5 mm: 2 mm, OR, 2.1 [95% CI, 1.4-3.1]; P < .001; ≤1 mm, OR, 1.8 [95% CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs ≤400 mL: 401-700 mL, OR, 1.5 [95% CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95% CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95% CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95% CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6% vs 11.2%; P = .23). This relationship held for both grade B (6.6% vs 9.2%; P = .52) and grade C (0% vs 2.0%; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7% vs 66.4%; P = .21), severe complications (Accordion grade ≥3, 23.05% vs 23.7%; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4% vs 21.7%; P > .99), and 90-day mortality (3.3% vs 1.3%; P = .38).

Conclusions and Relevance

To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.

Minimally invasive pancreatic resections: cost and value perspectives

BACKGROUND

The number of minimally invasive pancreatic resections (MIPR) performed for benign or malignant disease, have increased in recent years. However, there is limited information regarding cost/value implications.

METHODS

An international conference evaluating MIPR was held during the 12th Bi-Annual International Hepato-Pancreato-Biliary Association (IHPBA) World Congress in Sao Paulo, Brazil, on April 20th, 2016. This manuscript summarizes the presentations that reviewed current topics in cost and value as they pertain to MIPR.

RESULTS

Compared to the open approach, MIPR's are associated with higher operative costs but lower postoperative costs. However, measurements of patient value (defined as improvement in both quantity and quality of life) and financial value (using incremental cost-effectiveness ratio) are required to determine the true value at societal level.

CONCLUSION

Challenges remain as to how the potential benefits, both to the patient and the healthcare system as a whole, are measured. Research comparing MIPR versus other techniques for pancreatectomy will require appropriate and valid measurement tools, some of which are yet to be refined. Nonetheless, the experience to date would support the continued development of MIPR by experienced surgeons in high-volume pancreatic centers, married with appropriate review and recalibration.

Minimally invasive pancreatoduodenectomy

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) is increasingly performed with several institutional series and comparative studies reported. The aim was to conduct an assessment of the best-evidence and expert opinion on the current status and future challenges of MIPD.

METHODS

A systematic review of the literature was performed and best-evidence presented at a State-of-the-Art conference on Minimally Invasive Pancreatic Resection. Expert panel discussion and audience response activity was used to assess perceived value and future direction.

RESULTS

From 582 studies, 26 comparative trials of MIPD and open pancreatoduodenectomy (OPD) were assessed for perioperative outcomes. There were no randomized controlled trials and all available comparative studies were determined of low quality. Several observational and case-matched studies demonstrate longer operative times, but less estimated blood loss and shorter length of hospital stay for MIPD. Registry-based studies demonstrate increased mortality rates after MIPD in low-volume centers. Oncologic assessment demonstrates comparable outcomes of MIPD. Expert opinion supports ongoing evaluation of MIPD.

CONCLUSION

MIPD appears to provide similar perioperative and oncologic outcomes in selected patients, when performed at experienced, high-volume centers. Its overall role in pancreatoduodenectomy needs to be better defined. Improved training opportunities, registry participation and prospective evaluation are needed.