Duodenopancreatectomy: open or minimally invasive approach?

Minimally Invasive Pancreaticoduodenectomy in Elderly versus Younger Patients: A Meta-Analysis

(1) Background: With ageing, the number of pancreaticoduodenectomies (PD) for benign or malignant disease is expected to increase in elderly patients. However, whether minimally invasive pancreaticoduodenectomy (MIPD) should be performed in the elderly is not clear yet and it is still debated. (2) Materials and Methods: A systematic review and meta-analysis was conducted including seven published articles comparing the technical and post-operative outcomes of MIPD in elderly versus younger patients up to December 2022. (3) Results: In total, 1378 patients were included in the meta-analysis. In term of overall and Clavien-Dindo I/II complication rates, post-operative pancreatic fistula (POPF) grade > A rates and biliary leakage, abdominal collection, post-operative bleeding and delayed gastric emptying rates, no differences emerged between the two groups. However, this study showed slightly higher intraoperative blood loss [MD 43.41, (95%CI 14.45, 72.38) p = 0.003], Clavien-Dindo ≥ III complication rates [OR 1.87, (95%CI 1.13, 3.11) p = 0.02] and mortality rates [OR 2.61, (95%CI 1.20, 5.68) p = 0.02] in the elderly compared with the younger group. Interestingly, as a minor endpoint, no differences in terms of the mean number of harvested lymphnode and of R0 resection rates were found. (4) Conclusion: MIPD seems to be relatively safe; however, there are slightly higher major morbidity, lung complication and mortality rates in elderly patients, who potentially represent the individuals that may benefit the most from the minimally invasive approach.

Short-term outcomes between robot-assisted and open pancreaticoduodenectomy in patients with high body mass index: A propensity score matched study

BACKGROUND

High body mass index was considered as a risk factor for minimally invasive surgery. The short-term outcomes of robot-assisted pancreaticoduodenectomy (RPD) remain controversial. This study aims to investigate the feasibility and advantage of RPD in patients with high body mass index compared to open pancreaticoduodenectomy (OPD).

METHODS

Clinical data of 304 patients who underwent pancreaticoduodenectomy from January 2016 to December 2019 in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine was collected. Patients with BMI >25 kg/m2 were included and divided into RPD and OPD group. After PSM at a 1:1 ratio, 75 patients of OPD and 75 patients of RPD were recorded and analyzed.

RESULTS

The RPD group showed advantages in the estimated blood loss (EBL) (323.3 mL vs. 480.7 mL, p = 0.010), the postoperative abdominal infection rate (24% vs. 44%, p = 0.010), the incidence of Clavien-Dindo III-V complications (14.7% vs. 28.0%, p = 0.042) over OPD group.

CONCLUSION

RPD shows advantages in less EBL, lower incidence rate of Clavien-Dindo III-V complications over OPD in overweight and obese patients. RPD was confirmed as a safe and feasible surgical approach for overweight or obsess patients.

Outcomes of laparoscopic pancreaticoduodenectomy using a modified technique：346 cases from a single center

PURPOSE

To study the outcomes of laparoscopic pancreaticoduodenectomy (LPD) using a modified technique.

METHODS

Our center used priority approach of uncinate process and artery in the pancreatectomy and duct to mucosa pancreaticojejunostomy with a single stitch in the pancreaticojejunostomy. Herein, we retrospectively reviewed 346 cases of LPD using modified techniques. Basic characteristics, preoperative outcomes, factors associated with unfavorable postoperative outcome, and mortality of patients undergoing LPD were collected and analyzed.

RESULTS

The average operative time was 259.31 (35-425) min. The mean duration of pancreaticojejunostomy anastomosis was 31.97 (16-90) min. The mean intraoperative blood loss was 101.76 (0-1200) ml by estimation. Postoperative complications included 14 cases (4.1%) of bile leakage, 9 cases (2.6%) of delayed gastric emptying, 26 cases (7.5%) of postoperative bleeding, 34 cases (9.9%) of organ space infection, 17 cases (4.9%) of pulmonary infection, and 50 cases (14.5%) of POPF. Three factors including postoperative bleeding (OR = 3.502; P = 0.033), positive lymph node (OR = 3.296; P < 0.001), and postoperative chemotherapy (OR = 0.241; P = 0.008) were significantly associated with death of LPD.

CONCLUSIONS

The modified technique for LPD presents safety and reliability. Postoperative bleeding and positive lymph node may be associated with worse overall survival, and postoperative chemotherapy may be associated with better overall survival.

Robotic gastrointestinal surgery: learning curve, educational programs and outcomes

The use of the robotic platform for gastrointestinal surgery was introduced nearly 20 years ago. However, significant growth and advancement has occurred primarily in the last decade. This is due to several advantages over traditional laparoscopic surgery allowing for more complex dissections and reconstructions. Several randomized controlled trials and retrospective reviews have demonstrated equivalent oncologic outcomes compared to open surgery with improved short-term outcomes. Unfortunately, there are currently no universally accepted or implemented training programs for robotic surgery and robotic surgery experience varies greatly. Additionally, several limitations to the robotic platform exist resulting in a distinct learning curve associated with various procedures. Therefore, implementation of robotic surgery requires a multidisciplinary team approach with commitment and investment from clinical faculty, operating room staff and hospital administrators. Additionally, there is a need for wider distribution of educational modules to train more surgeons and reduce the associated learning curve. This article will focus on the implementation of the robotic platform for surgery of the pancreas, stomach, liver, colon and rectum with an emphasis on the associated learning curve, educational platforms to develop proficiency and perioperative outcomes.

Comparison of Perioperative and Oncological Outcomes of Hybrid and Totally Laparoscopic Pancreatoduodenectomy

BACKGROUND Laparoscopic pancreatoduodenectomy (LPD) is a complicated procedure accompanied with high morbidity. Hybrid LPD is usually used as an alternative/transitional approach. This study aimed to prove whether the hybrid procedure is a safe procedure during a surgeon's learning curve of LPD. MATERIAL AND METHODS There were 48 hybrid LPD patients and 62 TLPD patients selected from January 2016 to December 2018; their demographics, surgical outcomes, and oncological data were retrospectively collected. Patient follow-up for the study continued until February 2020. RESULTS Patient demographics and baseline parameters were well balanced between the 2 groups. Intraoperative conditions, overall operation time was shorter for TLPD compared to hybrid LPD (407.79 minutes versus 453.29 minutes, respectively; P=0.035) and blood loss was less in TLPD patients compared to hybrid LPD patients (100.00 mL versus 300.00 mL, respectively; P<0.001). There was no difference in transfusion rates between the 2 groups (hybrid LPD 16.7% versus TLPD 4.8%; P=0.084). Postoperative outcomes and intensive care unit (ICU) stay was longer in the hybrid LPD patient group (hybrid LPD 1-day versus TLPD 0-day, P=0.002) and postoperative hospital stay was similar between the 2 groups (P=0.503). Reoperation rates, in-hospital, 30-day mortality, and 90-day mortality rates were comparable between the 2 groups (P=0.276, 1.000, 1.000, 0.884, respectively). Surgical site infection, bile leak, Clavien-Dindo classification (CDC) ≥3, delayed gastric emptying, grade B/C postoperative pancreatic fistulae, and grade B/C post pancreatectomy hemorrhage were not different between the 2 groups (P=0.526, 0.463, 0.220, 0.089, 0.165, 0.757, respectively). The tumor size, margin status, lymph nodes harvested, and metastasis were similar in the 2 groups (P=0.767, 0.438, 0.414, 0.424, respectively). In addition, the median overall survival rates were comparable between the 2 groups (hybrid LPD 29.0 months versus TLPD 30.0 months, P=0.996) as were the progression-free survival rates (hybrid LPD 11.0 months versus TLPD 12.0 months, P=0.373) CONCLUSIONS Hybrid LPD was comparable to TLPD. Hybrid LPD could be performed safely when some surgeons first started LPD (during the operative learning curve), while for skilled surgeons, TLPD could be applied initially.

The impact of high body mass index on patients undergoing robotic pancreatectomy: A propensity matched analysis

BACKGROUND

Patients with high body mass index are associated with a higher risk of complications after open pancreatectomy. We aimed to investigate the perioperative outcome for patients with high body mass index after robotic pancreatectomy.

METHODS

This is a retrospective, propensity-score matched cohort analysis. From our prospectively maintained database, we identified consecutive patients with body mass index >25 who underwent robotic pancreatectomy between January 2016 and December 2018. Propensity score matching with open pancreatectomy was applied in 1:2 fashion based on age, gender, American Society of Anesthesiologists classification, surgery type, histology, neoadjuvant therapy, and body mass index during the same study period.

RESULTS

A total of 127 patients were included. The mean age for all patients was 61.7 ± 12.8 years and 65 (51.2%) were male. Median body mass index was 29.9 (interquartile range, 27.0-31.8) for both groups. Propensity score matching provided equally distributed general demographic and clinicopathological factors. Robotic pancreatectomy was associated with decreased blood loss (100 mL vs 300 mL, P < .001) and shorter hospital stay (7 vs 9 days, P = .019).

CONCLUSION

Robotic pancreatectomy is associated with decreased blood loss and shorter length of hospital stay in overweight patients. Robotic approach may help alleviate morbidity in overweight patients undergoing pancreatectomy.

Stepwise implementation of laparoscopic pancreatic surgery. Case series of a single centre's experience

BACKGROUND

Laparoscopic pancreatic surgery still represents a challenge for surgeons. However, in recent decades the experience is expanding. Recent systematic reviews and meta-analyses confirm that laparoscopic pancreatic resection (LPR) is safe, feasible and worthwhile. This study analyses the first 100 consecutive LPRs in our centre.

METHODS

A retrospective analysis was conducted of the first 100 LPRs in a single supra-regional Belgian centre, performed between January 2012 and January 2019. Pre-, peri- and postoperative data were retrieved from a prospectively maintained database. All procedures were performed laparoscopically by two attending surgeons, specialized in minimally invasive and hepatopancreatobiliary surgery.

RESULTS

Of 100 procedures, 62 laparoscopic pancreatoduodenectomies (LPD) and 36 laparoscopic distal pancreatectomies (LDP) were performed, along with 1 enucleation and 1 central pancreatectomy. Indication was malignancy in 70%. Conversion rate was 24,2% in LPD and 11% in LDP. Median operative time was 330 min (IQR 300-360) in LPD and 150 min (IQR 142.5-210) in LDP. Median blood loss was 200 mL (IQR 100-487.5) in LPD and 150 mL (IQR 50-500) in LDP, transfusion rate was 22.6% and 8.3% respectively. Median length of stay (LOS) was 13 days (IQR 10-19.25) in LPD and 9 days (IQR 9-14) in LDP. R0 resection rate was 88.6% (62/70). Major complication rate (Clavien-Dindo grade III-IV) was 12%. Thirty-day mortality was 0%, 90-day mortality was 2%.

CONCLUSION

Our results confirm that LPR is a feasible and safe alternative to open pancreatic surgery. Safe implementation with a clear strategy is fundamental to gain experience and overcome the learning curve of this technically demanding procedures.

Is total laparoscopic pancreaticoduodenectomy superior to open procedure? A meta-analysis

BACKGROUND

Laparoscopy has been widely used in general surgical procedures, but total laparoscopic pancreaticoduodenectomy (TLPD) is still a complex and challenging surgery that is only performed in a small number of patients at a few large academic medical centers. Although the safety and feasibility of TLPD have been established, few studies have compared it with open pancreaticoduodenectomy (OPD) with regard to perioperative and oncological outcomes. Therefore, we carried out a meta-analysis to evaluate whether TLPD is superior to OPD.

AIM

To compare the treatment outcomes of TLPD and OPD in order to assess the safety and feasibility of TLPD.

METHODS

We conducted a systematic search of studies comparing TLPD with OPD that were published in the PubMed, EMBASE, and Cochrane Library databases through December 31, 2018. The studies comparing TLPD and OPD with at least one of the outcomes we were interested in and with more than 10 cases in each group were included in this analysis. The Newcastle-Ottawa scale was used to assess the quality of the nonrandomized controlled trials and the Jadad scale was used to assess the randomized controlled trials. Intraoperative data, postoperative complications, and oncologic outcomes were evaluated. The meta-analysis was performed using Review Manager Software version 5.3. Random or fixed-effects meta-analyses were undertaken to measure the pooled estimates.

RESULTS

A total of 4790 articles were initially identified for our study. After screening, 4762 articles were excluded and 28 studies representing 39771 patients (3543 undergoing TLPD and 36228 undergoing OPD) were eventually included. Patients who underwent TLPD had less intraoperative blood loss [weighted mean difference (WMD) = -260.08 mL, 95% confidence interval (CI): (-336.02, -184.14) mL, P < 0.00001], a lower blood transfusion rate [odds ratio (OR) = 0.51, 95%CI: 0.36-0.72, P = 0.0001], a lower perioperative overall morbidity (OR = 0.82, 95%CI: 0.73-0.92, P = 0.0008), a lower wound infection rate (OR = 0.48, 95%CI: 0.34-0.67, P < 0.0001), a lower pneumonia rate (OR = 0.72, 95%CI: 0.60-0.85, P = 0.0002), a shorter duration of intensive care unit (ICU) stay [WMD = -0.28 d, 95%CI (-2.88, -1.29) d, P < 0.00001] and a shorter length of hospital stay [WMD = -3.05 d, 95%CI (-3.93, -2.17), P < 0.00001], a lower rate of discharge to a new facility (OR = 0.55, 95%CI: 0.39-0.78, P = 0.0008), and a lower 30-d readmission rate (OR = 0.81, 95%CI: 0.68-0.95, P = 0.10) than those who underwent OPD. In addition, the TLPD group had a higher R0 rate (OR = 1.28, 95%CI: 1.13-1.44, P = 0.0001) and more lymph nodes harvested (WMD = 1.32, 95%CI: 0.57-2.06, P = 0.0005) than the OPD group. However, the patients who underwent TLPD experienced a significantly longer operative time (WMD = 77.92 min, 95%CI: 40.89-114.95, P < 0.0001) and had a smaller tumor size than those who underwent OPD [WMD = -0.32 cm, 95%CI: (-0.58, -0.07) cm, P = 0.01]. There were no significant differences between the two groups in the major morbidity, postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, bile leak, gastroenteric anastomosis fistula, intra-abdominal abscess, bowel obstruction, fluid collection, reoperation, ICU admission, or 30-d and 90-d mortality rates. For malignant tumors, the 1-, 2-, 3-, 4- and 5-year overall survival rates were not significantly different between the two groups.

CONCLUSION

This meta-analysis indicates that TLPD is safe and feasible, and may be a desirable alternative to OPD, although a longer operative time is needed and only smaller tumors can be treated.

Minimally Invasive Approaches to Pancreatic Cancer

In pancreatic cancer, resection combined with neoadjuvant and/or adjuvant therapy remains the only chance for cure and/or prolonged survival. A minimally invasive approach to pancreatic cancer has gained increased acceptance and popularity. The aim of minimally invasive surgery of the pancreas includes limiting trauma, decreasing length of hospitalization, lessening cost, decreasing blood loss, and allowing for a more meticulous oncologic dissection. New advances and routine use in practice have helped progress the field making the minimally invasive approach more feasible. In this article, the minimally invasive surgical approaches to proximal, central, and distal pancreatic cancer are described and literature reviewed.

Laparoscopic pancreaticoduodenectomy: patients' interest should be the goal of health care

Pancreatic ductal adenocarcinoma is the fourth deadliest malignancy in developed countries and is predicted to become the second one within the 2030. The present work focuses on the state of the art of laparoscopic pancreaticoduodenectomy, including results of recent randomized trials, and discusses technical challenge and patients' interest of this technique.

A novel technique of pancreaticojejunostomy for laparoscopic pancreaticoduodenectomy

BACKGROUND

Pancreaticojejunostomy (PJ) reconstruction is the Achilles' heel of laparoscopic pancreaticoduodenectomy (LPD). However, only a few studies have focused on the performance of this difficult procedure laparoscopically.

METHODS

We present a safe and feasible technique of duct-to-mucosa pancreaticojejunostomy for LPD, named Bing's anastomosis. Our study included 238 cases of LPDs that underwent Bing's anastomosis. Data on the demographic characteristics, operative outcomes (total operative time, PJ duration, and estimated blood loss), and postoperative results (length of hospital stay, recovery of bowel function, and rates of postoperative morbidity and mortality) of the cases were prospectively collected and retrospectively analyzed.

RESULTS

Only one patient (0.4%) in our series required conversion to open surgery as a result of uncontrolled bleeding from the superior mesenteric artery. The average operative time was 358 min (220 min to 495 min). The mean duration for PJ was 23 min (19 min to 33 min). The mean estimated blood loss was 112 ml (50 ml to 800 ml). The overall incidence of pancreatic fistula was 21.4% and included 42 cases (17.6%) of biochemical leak, eight cases (3.4%) of Grade B, and one case (0.4%) of Grade C pancreatic fistulas. The 90-day mortality was 0.4%.

CONCLUSIONS

Bing's anastomosis is a safe, reliable, and rapid PJ technique for LPD that is associated with favorable outcomes and a low risk of pancreatic fistula. However, its safety and feasibility should be verified by performing prospective randomized controlled trials at different institutions.

Low conversion rate during minimally invasive major hepatectomy: Ten-year experience at a high-volume center

BACKGROUND

Minimally invasive approaches for major hepatectomy have been marred by significant rates of conversion and associated morbidity. This study aimed to determine risk factors for conversion as well as postoperative morbidity in patients undergoing minimally invasive right-sided hepatectomy (MIRH).

METHODS

Data for patients undergoing MIRH between 2008 and 2017 at Emory University were reviewed. Risk factors for conversion were determined using multivariate regression analysis. Outcomes of conversion patients were compared with those who underwent successful MIRH or elective open surgery.

RESULTS

Unplanned conversion occurred in 7 (6.25%) of 112 patients undergoing MIRH. Primary reason for conversion was difficult dissection secondary to inflammation and severe adhesions. No preoperative clinical factor was identified that predicted conversions. Converted cases had higher EBL and pRBC transfusion compared to non-converted cases however morbidity was similar to those undergoing primary open surgery.

CONCLUSION

Difficult dissection and adhesions remained the only clinically applicable parameter leading to unplanned conversions. While these did offset benefits of a successful minimally invasive approach, it did not increase risk of postoperative complications compared with planned open surgery.

Expanding laparoscopic pancreaticoduodenectomy to pancreatic-head and periampullary malignancy: major findings based on systematic review and meta-analysis

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) remains to be established as a safe and effective alternative to open pancreaticoduodenectomy (OPD) for pancreatic-head and periampullary malignancy. The purpose of this meta-analysis was to compare LPD with OPD for these malignancies regarding short-term surgical and long-term survival outcomes.

METHODS

A literature search was conducted before March 2018 to identify comparative studies in regard to outcomes of both LPD and OPD for the treatment of pancreatic-head and periampullary malignancies. Morbidity, postoperative pancreatic fistula (POPF), mortality, operative time, estimated blood loss, hospitalization, retrieved lymph nodes, and survival outcomes were compared.

RESULTS

Among eleven identified studies, 1196 underwent LPD, and 8247 were operated through OPD. The pooled data showed that LPD was associated with less morbidity (OR = 0.57, 95%CI: 0.41~ 0.78, P < 0.01), less blood loss (WMD = - 372.96 ml, 95% CI, - 507.83~ - 238.09 ml, P < 0.01), shorter hospital stays (WMD = - 197.49 ml, 95% CI, - 304.62~ - 90.37 ml, P < 0.01), and comparable POPF (OR = 0.85, 95%CI: 0.59~ 1.24, P = 0.40), and overall survival (HR = 1.03, 95%CI: 0.93~ 1.14, P = 0.54) compared to OPD. Operative time was longer in LPD (WMD = 87.68 min; 95%CI: 27.05~ 148.32, P < 0.01), whereas R0 rate tended to be higher in LPD (OR = 1.17; 95%CI: 1.00~ 1.37, P = 0.05) and there tended to be more retrieved lymph nodes in LPD (WMD = 1.15, 95%CI: -0.16~ 2.47, P = 0.08), but these differences failed to reach statistical significance.

CONCLUSIONS

LPD can be performed as safe and effective as OPD for pancreatic-head and periampullary malignancy with respect to both surgical and oncological outcomes. LPD is associated with less intraoperative blood loss and postoperative morbidity and may serve as a promising alternative to OPD in selected individuals in the future.

Perioperative and Long-term Oncological Results of Minimally Invasive Pancreatoduodenectomy as Hybrid Technique - A Matched Pair Analysis of 120 Cases

Background Laparoscopic pancreatoduodenectomy is a highly challenging procedure. The aim of this study was to analyse post-operative morbidity and mortality as well as long term overall survival in patients undergoing hybrid LPD, as compared to open pancreaticoduodenecomy (OPD) in a single surgeon series.

Methods Patients undergoing pancreatoduodenectomy (PD) in the period from 2000 to 2015 were identified from a prospectively maintained database. All LPD procedures were performed by one specialised pancreatic surgeon (TK). Patients were matched 1 : 1 for age, sex, BMI, ASA, histological diagnosis, pancreatic texture and portal venous resection (PVR). All LPD procedures were performed as hybrid LPD – combining laparoscopic resection and open reconstruction via mini laparotomy.

Results A total of 549 patients were identified, including 489 patients in the OPD group and 60 patients in the LPD group. 60 patients were identified who underwent LPD between 2010 and 2015 versus 60 OPD patients operated in the same period. Median overall operation time was shorter in the LPD group than with OPD patients (LPD 352 vs. OPD 397 min; p = 0.002). Overall transfusion units were lower in the LPD group (LPD range 0 – 4 vs. OPD range 0 – 11; p = 0.032). Intensive care unit stay (LPD 1 vs. OPD 6 d; p = 0.008) and overall hospital stay (OHS: LPD 14 vs. OPD 18 d; p = 0.012) were shorter in the LPD groups than in the OPD group. As regards postoperative complications, LPD was associated with reduced rates of clinically relevant grade B/C postoperative pancreatic fistula (LPD 15 vs. OPD 36%; p = 0.036) and grade B/C delayed gastric emptying (LPD 8 vs. OPD 20%; p = 0.049). A total of 56 patients were diagnosed with malignant disease. The number of harvested lymph nodes and R0-resection rates were equal for LPD and OPD patients. LPD patients showed a trend to improved median overall survival (LPD mean 56 months vs. OPD mean 48 months; p = 0.056).

Conclusion Hybrid LPD is a safe procedure associated with a reduction in clinically relevant postoperative complications and allows faster recovery. Long term oncological outcome of hybrid LPD for malignant disease is equal to that with the standard open approach.

Minimally Invasive Pancreaticoduodenectomy: What is the Best "Choice"? A Systematic Review and Network Meta-analysis of Non-randomized Comparative Studies

BACKGROUND

Many mini-invasive pancreaticoduodenectomy (MIPD) techniques have been reported, but their advantages with respect to an open technique (OPD) and with respect to each other are unclear.

METHOD

A systematic literature search of studies comparing different types of MIPD was carried out: laparoscopic-assisted (LAPD), totally robotic (TRPD), totally laparoscopic (TLPD) or totally laparoscopic-robotic assisted (TLPD-RA) to OPD. The primary endpoint was postoperative mortality. The secondary endpoints were intraoperative, postoperative and oncological outcomes. A network meta-analysis was designed to generate direct, indirect and mixed estimate effects, between different approaches, for each variable. The effects were reported as pairwise comparisons and hierarchical ranking as to each approach could be the best or the worst for each outcome, expressed by the surface under the cumulative ranking curve.

RESULTS

Twenty studies were identified, involving 2759 patients: 1813 OPDs, 81 LAPDs, 505 TRPDs, 224 TLPDs and 136 TLPD-RAs. No differences regarding postoperative mortality were found in pairwise comparison. The LAPD technique had a high probability of being the worst approach, while TRPD had a high probability of being one of the best. Regarding the secondary endpoints, OPD was the best regarding operative time and postoperative bleeding, but the worst regarding blood loss and wound infection. The TRPD or TLPD-RA techniques seemed to be the best for delayed gastric emptying, length of hospital stay, harvested lymph nodes and postoperative morbidity. The TLPD technique was often the worst approach, especially for overall and major complications, postoperative bleeding and biliary leak.

CONCLUSION

The safest MIPDs are those involving a robotic system which seems to have a promising role in ameliorating the outcomes of OPD, especially when compared to a laparoscopic approach.

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.

Totally laparoscopic or robot-assisted pancreaticoduodenectomy versus open surgery for periampullary neoplasms: separate systematic reviews and meta-analyses

OBJECTIVE

To compare perioperative and oncologic outcomes of pure (totally) laparoscopic pancreaticoduodenectomy (TLPD) or robot-assisted pancreaticoduodenectomy (RAPD) with those of conventional open pancreaticoduodenectomy (OPD).

METHODS

A systematic literature search was performed using PubMed, EMBASE, and Cochrane library databases. Studies comparing TLPD with OPD and RAPD with OPD were included; only original studies reporting more than 10 cases for each technique were included. Studies were combined using a random-effects model to report heterogeneous data, or a fixed-effects model was applied.

RESULTS

TLPD involved longer operative time (weighted mean difference [WMD]: 116.85 min; 95% confidence interval [CI] 54.53-179.17) and significantly shorter postoperative hospital stay (WMD: -3.68 days; 95% CI -4.65 to -2.71). Overall morbidity and postoperative pancreatic fistula were not significantly different between TLPD and OPD. RAPD was associated with a longer operative time, less intraoperative blood loss, and shorter hospital stay. Oncologic outcomes were not significantly different among the procedure types.

CONCLUSIONS

Compared to OPD, TLPD and RAPD were feasible and oncologically safe procedures. However, there are no prospective studies, and the majority of the studies on TLPD and RAPD have remained in the early training phase. In addition to randomized controlled trials or prospective studies, new data from the late training phase of learning experiences should also be analyzed.

Minimally invasive hepatopancreatobiliary surgery in North America: an ACS-NSQIP analysis of predictors of conversion for laparoscopic and robotic pancreatectomy and hepatectomy

BACKGROUND

Procedural conversion rates represent an important aspect of the feasibility of minimally invasive surgical (MIS) approaches. This study aimed to outline the rates and predictors of procedural completion/conversion for MIS hepatectomy and pancreatectomy.

METHODS

All 2014 ACS-NSQIP laparoscopic and robotic hepatectomy and pancreatectomy procedures were identified and grouped into pure, open assist, or unplanned conversion to open. Risk adjusted multinomial logistic regression models were generated with completion (Pure) set as the primary outcome.

RESULTS

1667 (laparoscopic = 1360, robotic = 307) resections were captured. After risk adjustment, robotic DP was associated with similar open assist (relative risk ratio -1.9%, P = 0.602), but lower unplanned conversion (-8.2%, P = 0.004) and open assist + unplanned conversion (-10.1%, P = 0.015) compared to laparoscopic DP; while robotic PD was associated with lower open assist (-22.2%, P < 0.001), unplanned conversions (-15%, P = 0.006) and open assist + unplanned conversions (-37.2, P < 0.001) compared to laparoscopic PD. The robotic and laparoscopic approaches to hepatectomy were not associated with differences in pure MIS completion rates (P = NS) after risk adjustment.

CONCLUSIONS

The robotic approach to pancreatectomy was associated with higher rates of pure MIS completion compared to laparoscopy, whereas no difference in MIS completion rates was noted for robotic versus laparoscopic hepatectomy.

Standardizing terminology for minimally invasive pancreatic resection

BACKGROUND

There is a growing body of literature pertaining to minimally invasive pancreatic resection (MIPR). Heterogeneity in MIPR terminology, leads to confusion and inconsistency. The Organizing Committee of the State of the Art Conference on MIPR collaborated to standardize MIPR terminology.

METHODS

After formal literature review for "minimally invasive pancreatic surgery" term, key terminology elements were identified. A questionnaire was created assessing the type of resection, the approach, completion, and conversion. Delphi process was used to identify the level of agreement among the experts.

RESULTS

A systematic terminology template was developed based on combining the approach and resection taking into account the completion. For a solitary approach the term should combine "approach + resection" (e.g. "laparoscopic pancreatoduodenectomy); for combined approaches the term must combine "first approach + resection" with "second approach + reconstruction" (e.g. "laparoscopic central pancreatectomy" with "open pancreaticojejunostomy") and where conversion has resulted the recommended term is "first approach" + "converted to" + "second approach" + "resection" (e.g. "robot-assisted" "converted to open" "pancreatoduodenectomy") CONCLUSIONS: The guidelines presented are geared towards standardizing terminology for MIPR, establishing a basis for comparative analyses and registries and allow incorporating future surgical and technological advances in MIPR.

Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference

BACKGROUND

Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients.

METHODS

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey.

RESULTS

LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case-control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe.

CONCLUSIONS

LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.

Long-sleeve-working-port assisted laparoscopic pancreaticoduodenectomy-A new technique in laparoscopic surgery

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The new technique of using a long-sleeve-working-port in laparoscopic surgery can facilitate complicated operations like laparoscopic pancreaticoduodenectomy.

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This technique offers both advantages of minimally invasive surgery and the use of ordinary instruments for open surgery through the working port.

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This working port is cheap and easy to use.

Introduction

Advances in technology and instruments have made laparoscopic pancreaticoduodenectomy (LPD) feasible. Unfortunately, this operation is technically very challenging and it is not widely accepted by laparoscopic surgeons.

Presentation of case

A 59-year-old woman underwent LPD using a newly invented long-sleeve-working-port (LSWP) for a mucinous cystadenoma of the head of pancreas. This case report describes this port and its use on this patient.

Discussion

LSWP is a new invention to facilitate difficult laparoscopic operations. Through this LSWP, ordinary instruments used in open surgery can be used to overcome the limitation encountered in conventional laparoscopic surgery.

Conculsion

LSWP made complex laparoscopic surgery less complex.

Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches

INTRODUCTION

Laparoscopic and robotic surgery of the pancreas has only recently emerged as viable treatment options for benign and malignant disease. This review seeks to evaluate the current body of evidence on these approaches to pancreaticoduodenectomy and distal pancreatectomy.

METHODS

A systematic review of large published series was performed utilizing the PubMed search engine.

RESULTS

Based on these reports, both the laparoscopic and robotic techniques for these complex procedures appear to be safe and effective, if performed by high volume experienced pancreatic surgeons. The advantages of each approach are highlighted, emphasizing the data available on the learning curve and potential dissemination.

CONCLUSIONS

Both minimally invasive approaches to pancreatic resection are safe and feasible.

Robotic pancreatectomies

Pancreatic surgery represents one of the most challenging fields in general surgery. Its complexity is related to the severity of the disease and the technical skills required for surgical approach. Given this, most pancreatic resections are performed through classic open surgery. Minimally invasive approaches are gradually gaining widespread popularity also in this specific setting, as for distal resections and enucleations. The robotic platform, due to its 3-dimensional vision and articulated movements, represents the natural progress of laparoscopic surgery overcoming the technical defaults and opening up the possibility to perform major pancreatic resections as pancreaticoduodenectomies. This review focuses on the impact of robotic platform in pancreatic surgery in terms of surgical and oncological outcome.

Early experience with robotic pancreatic surgery in a Canadian institution

BACKGROUND

Pancreatic resections have traditionally been associated with substantial morbidity and mortality. The robotic platform is believed to improve technical aspects of the procedure while offering minimally invasive benefits. We sought to determine the safety and feasibility of the first robotic pancreaticoduodenectomies performed at our institution.

METHODS

We retrospectively reviewed data on all patients who underwent robotic-assisted pancreaticoduodenectomy (RAPD) between July 2010 and June 2014 and compared them to outcomes of patients undergoing hybrid laparoscopic pancreaticoduodenectomies (HLAPD) during the same time period.

RESULTS

Fifteen patients were scheduled for RAPD; 2 were converted to an open approach and 1 to a mini-laparotomy during the laparoscopic portion of the procedure. Patients who had RAPD (n = 12) had a median duration of surgery of 596.6 (range 509-799) minutes, estimated blood loss of 275 (range 50-1000) mL and median length of stay of 7.5 (range 5-57) days. Mean total opioid use up to postoperative day 7 was 142.599 ± 68.2 versus 176.9 ± 112.7 mg equivalents of intravenous morphine for RAPD and HLAPD, respectively. There was no significant difference between RAPD and HLAPD in any parameters, highlighting the safety and feasibility of a step-wise minimally invasive learning platform. Most patients in the RAPD group had malignant pathology (88.2%). Oncologic outcomes were maintained with no significant difference in ability to resect lymph nodes or achieve negative margins. There were 4 (28.5%) Clavien I-II complications and 3 (29.4%) Clavien III- IV complications, 2 of which required readmission. There were no reported deaths at 90 days. Complication, pancreatic leak and mortality rates did not differ significantly from our laparoscopic experience.

CONCLUSION

Outcomes of RAPD and HLAPD were comparable at our centre, even during the early stages of our learning curve. These results also highlight the safety, feasibility and patient benefits of a step-wise transition from open to hybrid to fully robotic pancreaticoduodenectomies in a high-volume academic centre.

Robotic surgery of the pancreas: The current state of the art

Pancreatic surgery is one of the most technically challenging and complex types of surgery. Most pancreatic surgery is performed with the open technique, yet minimally invasive surgery has become the standard of care for many other intra-abdominal operations. The unique qualities of the robotic platform have made this approach to pancreatic surgery safe and feasible with at least equivalent if not better results than the open platform in terms of surgical and oncological outcomes.

Research gaps in pancreatic cancer research and comparative effectiveness research methodologies

Despite advances in cancer care, pancreatic adenocarcinoma remains one of the most lethal tumors. Most patients with pancreatic cancer are diagnosed with late stage disease, and approximately 6 % of patients are alive 5 years after diagnosis. Of the 10-20 % of patients who are candidates for resection and multi-modality therapy, most will succumb to the disease with 5-year survival rates only reaching approximately 25 % (Lim et al. in Annals of surgery 237(1):74-85, 2003 [1]; Trede et al. in Annals of surgery 211(4):447-458, 1990 [2]; Crist et al. in Annals of surgery 206(3):358-365, 1987 [3]). Clearly, there is a need to improve the management of this disease. To identify gaps in research and formulate strategies to address these issues, we designed a framework to encompass the scope of research for pancreatic cancer. In this chapter, we will examine each topic heading within this framework for gaps in knowledge and present research strategies focusing on diverse comparative effectiveness research (CER) methodologies to address the identified gaps.

Robotic surgery of the pancreas

Pancreatic surgery is one of the most challenging and complex fields in general surgery. While minimally invasive surgery has become the standard of care for many intra-abdominal pathologies the overwhelming majority of pancreatic surgery is performed in an open fashion. This is attributed to the retroperitoneal location of the pancreas, its intimate relationship to major vasculature and the complexity of reconstruction in the case of pancreatoduodenectomy. Herein, we describe the application of robotic technology to minimally invasive pancreatic surgery. The unique capabilities of the robotic platform have made the minimally invasive approach feasible and safe with equivalent if not better outcomes (e.g., decreased length of stay, less surgical site infections) to conventional open surgery. However, it is unclear whether the robotic approach is truly superior to traditional laparoscopy; this is a key point given the substantial costs associated with procuring and maintaining robotic capabilities.