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Armstrong M, Lu P, Wang J, El-Hayek K, Cleary S, Asbun H, Alseidi A, Tran Cao HS, Wei AC. Advancing minimally invasive hepato-pancreato-biliary surgery: barriers to adoption and equitable access. Surg Endosc 2024:10.1007/s00464-024-11078-1. [PMID: 39117957 DOI: 10.1007/s00464-024-11078-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/09/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption. METHODS A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results. RESULTS Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training. CONCLUSIONS This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.
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Affiliation(s)
- Misha Armstrong
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Pamela Lu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jane Wang
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Kevin El-Hayek
- Department of Surgery, MetroHealth System, Cleveland, OH, USA
| | - Sean Cleary
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Horacio Asbun
- Department of Surgery, Baptist Health Miami Cancer Institute, Miami, FL, USA
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alice C Wei
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-886A, New York, NY, 10065, USA.
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2
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Wang J, Lu P, Armstrong M, El-Hayek K, Cleary S, Asbun H, Alseidi A, Wei A, Tran Cao HS. Advancing minimally invasive hepato-pancreato-biliary surgery: ensuring safety with implementation. Surg Endosc 2024:10.1007/s00464-024-10957-x. [PMID: 38886227 DOI: 10.1007/s00464-024-10957-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Although minimally invasive hepato-pancreato-biliary (MIS HPB) surgery can be performed with good outcomes, there are currently no standardized requirements for centers or surgeons who wish to implement MIS HPB surgery. The aim of this study was to create a consensus statement regarding safe dissemination and implementation of MIS HPB surgical programs. METHODS Sixteen key questions regarding safety in MIS HPB surgery were generated after a focused literature search and iterative review by three field experts. Participants for the working group were then selected using sequential purposive sampling and snowball techniques. Review of the 16 questions took place over a single 2-h meeting. The senior author facilitated the session, and a modified nominal group technique was used. RESULTS Twenty three surgeons were in attendance. All participants agreed or strongly agreed that formal guidelines should exist for both institutions and individual surgeons interested in implementing MIS HPB surgery and that routine monitoring and reporting of institutional and surgeon technical outcomes should be performed. Regarding volume cutoffs, most participants (91%) agreed or strongly agreed that a minimum annual institutional volume cutoff for complex MIS HPB surgery, such as major hepatectomy or pancreaticoduodenectomy, should exist. A smaller proportion (74%) agreed or strongly agreed that a minimum annual surgeon volume requirement should exist. The majority of participants agreed or strongly agreed that surgeons were responsible for defining (100%) and enforcing (78%) guidelines to ensure the overall safety of MIS HPB programs. Finally, formal MIS HPB training, minimum case volume requirements, institutional support and infrastructure, and mandatory collection of outcomes data were all recognized as important aspects of safe implementation of MIS HPB surgery. CONCLUSIONS Safe implementation of MIS HPB surgery requires a thoughtful process that incorporates structured training, sufficient volume and expertise, a proper institutional ecosystem, and monitoring of outcomes.
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Affiliation(s)
- Jane Wang
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Pamela Lu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Misha Armstrong
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York City, NY, USA
| | - Kevin El-Hayek
- Department of Surgery, The MetroHealth System, Cleveland, OH, USA
| | - Sean Cleary
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Horacio Asbun
- Department of Surgery, Baptist Health Miami Cancer Institute, Miami, FL, USA
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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The Impact of Patient Age ≥80 Years on Postoperative Outcomes and Treatment Costs Following Pancreatic Surgery. J Clin Med 2021; 10:jcm10040696. [PMID: 33578965 PMCID: PMC7916670 DOI: 10.3390/jcm10040696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 01/08/2023] Open
Abstract
As life expectancy is increasing, elderly patients are evaluated more frequently for resection of benign or malignant pancreatic lesions. However, the impact of age on postoperative morbidity, mortality, and treatment costs in octogenarian patients (≥80 years) undergoing major pancreatic surgery needs further investigation. The clinicopathological data of patients who underwent pancreatic surgery between January 2015 and March 2019 in a major hepatopancreatobiliary center in Switzerland were assessed. Postoperative outcomes and hospital costs of octogenarians and younger patients were compared in univariate and multivariate regression analysis. During the study period, 346 patients underwent pancreatic resection. Pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, and other procedures were performed in 54%, 20%, 13%, and 13% of patients, respectively. The major postoperative morbidity rate and postoperative mortality rate were 25% and 3.5%, respectively. A total of 39 patients (11%) were ≥80 years old, and 307 patients were <80 years old. The majority of octogenarians suffered from ductal adenocarcinoma, whereas among younger patients, other indications for a pancreatic resection were predominant (ductal adenocarcinoma 64% vs. 41%, p = 0.006). Age ≥80 was associated with more frequent postoperative medical (pulmonary, cardiovascular) and surgical (high-grade pancreatic fistula, postoperative hemorrhage) complications. Postoperative mortality was significantly higher in octogenarians (15.4% vs. 2%, p < 0.0001). This finding may be explained by the higher rate of type C pancreatic fistula (13% vs. 5%), resulting more frequently in postoperative hemorrhage (18% vs. 5%, p = 0.002) among patients ≥80 years old. In the multivariate logistic regression analysis, patient age ≥80 years predicted postoperative mortality independently of the tumor entity and surgical technique (p = 0.013, OR 6.71, 95% CI [1.5–30.3]). Increased major postoperative morbidity was responsible for lower cost recovery in octogenarians (94% vs. 102%, p = 0.046). In conclusion, patient age ≥80 years is associated with increased postoperative medical and surgical morbidity after major pancreatic surgery leading to lower cost recovery and a lower chance for successful resuscitation in patients requiring revisional surgery for postoperative hemorrhage and/or pancreatic fistula. In octogenarian patients suffering from pancreatic tumors, careful selection, and thorough prehabilitation is crucial to achieve the best postoperative and long-term oncologic outcomes.
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Sahakyan MA, Røsok BI, Tholfsen T, Kleive D, Waage A, Ignjatovic D, Buanes T, Labori KJ, Edwin B. Implementation and training with laparoscopic distal pancreatectomy: 23-year experience from a high-volume center. Surg Endosc 2021; 36:468-479. [PMID: 33534075 PMCID: PMC8741682 DOI: 10.1007/s00464-021-08306-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/09/2021] [Indexed: 02/05/2023]
Abstract
Background Distal pancreatectomy is the most common procedure in minimally-invasive pancreatic surgery. Data in the literature suggest that the learning curve flattens after performing up to 30 procedures. However, the exact number remains unclear. Methods The implementation and training with laparoscopic distal pancreatectomy (LDP) in a high-volume center were studied between 1997 and 2020. Perioperative outcomes and factors related to conversion were assessed. The individual experiences of four different surgeons (pioneer and adopters) performing LDP on a regular basis were examined. Results Six hundred forty LDPs were done accounting for 95% of all distal pancreatectomies performed throughout the study period. Conversion was needed in 14 (2.2%) patients due to intraoperative bleeding or tumor adherence to the major vasculature. Overall morbidity and mortality rates were 35 and 0.6%, respectively. Intra- and postoperative outcomes did not change for any of the surgeons within their first 40 cases. Operative time significantly decreased after the first 80 cases for the pioneer surgeon and did not change afterwards although the proportion of ductal adenocarcinoma increased. Tumor size increased after the first 80 cases for the first adopter without affecting the operative time. Conclusions In this nearly unselected cohort, no significant changes in surgical outcomes were observed throughout the first 40 LDPs for different surgeons. The exact number of procedures required to overcome the learning curve is difficult to determine as it seems to depend on patient selection policy and specifics of surgical training at the corresponding center. Supplementary Information The online version of this article (10.1007/s00464-021-08306-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway. .,Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. .,Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Tore Tholfsen
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Anne Waage
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Trond Buanes
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Abstract
Minimally invasive pancreatic surgery lags behind the development of other fields of application of minimally invasive surgery. After a very slow development over the last two decades minimally invasive pancreatic surgery has currently gained wider acceptance especially in centers. This is due if nothing else, to the increasing availability of robotic assistance systems, which provide maneuverable instruments as well as a 3‑dimensional and enlarged view. Meanwhile, the technical feasibility for even complex pancreatic resections has been shown. This gives rise to the question whether laparoscopic or robotic techniques can generate equal or better results (evidence) with respect to perioperative morbidity, survival after oncological resection and the quality of life. As with all innovative techniques, which are implemented in surgery, the transferability to a wider audience, teaching methods and cost-effectiveness have to be evaluated. This article presents the current scientific evidence for laparoscopic and robotic pancreatic head and left-sided pancreatic surgery.
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Partelli S, Ricci C, Rancoita PMV, Montorsi R, Andreasi V, Ingaldi C, Arru G, Pecorelli N, Crippa S, Alberici L, Di Serio C, Casadei R, Falconi M. Preoperative predictive factors of laparoscopic distal pancreatectomy difficulty. HPB (Oxford) 2020; 22:1766-1774. [PMID: 32340858 DOI: 10.1016/j.hpb.2020.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is a challenging operation due to technical complexity and tumor-related factors. Aim of this study was to identify preoperative risk factors affecting LDP difficulty. METHODS Consecutive patients who underwent LDP between 2015 and 2018 at San Raffaele Hospital and Policlinico S.Orsola-Malpighi Hospital were enrolled retrospectively. Three variables were used to define surgical difficulty: conversion to open, duration of surgery >3rd quartile and intraoperative blood loss >3rd quartile. The presence of ≥1 of these 3 variables was considered as another measure of difficulty. RESULTS Overall, 191 patients were included. Conversion to open was required in 25 patients (13%). At multiple regression analysis, tumor proximity to major vessels was the only independent predictor of conversion from laparoscopic to open (p < 0.001). No variables independently predicted an excessive duration of surgery. Male gender (p = 0.033) and increasing parenchymal thickness at resection line (p = 0.018) were independent predictors of excessive blood loss. Increasing parenchymal thickness at resection line (p = 0.014) and tumor proximity to major vessels (p = 0.002) were significant risk factors for the presence of ≥1 outcome of surgical difficulty. CONCLUSION Male gender, increasing parenchymal thickness at resection line and tumor proximity to major vessels represent preoperative risk factors of LDP difficulty.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Paola M V Rancoita
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Roberto Montorsi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Carlo Ingaldi
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Giaime Arru
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Laura Alberici
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Clelia Di Serio
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy.
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7
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Gumbs AA, Croner R, Chouillard E. Is robotic pancreatic surgery finally ready for prime-time? Hepatobiliary Surg Nutr 2020; 9:650-653. [PMID: 33163516 DOI: 10.21037/hbsn.2019.12.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Andrew A Gumbs
- Centre Hospitalier Intercommunal de Poissy/Saint-Germain-En-Laye, Poissy, France
| | - Roland Croner
- Department of General-, Visceral-, Vascular- and Transplantation Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Elie Chouillard
- Centre Hospitalier Intercommunal de Poissy/Saint-Germain-En-Laye, Poissy, France
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The experience of the minimally invasive (MI) fellowship-trained (FT) hepatic-pancreatic and biliary (HPB) surgeon: could the outcome of MI pancreatoduodenectomy for peri-ampullary tumors be better than open? Surg Endosc 2020; 35:5256-5267. [PMID: 33146810 DOI: 10.1007/s00464-020-08118-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques. METHOD We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery. RESULTS From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03). CONCLUSION FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.
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9
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Nota CL, Molenaar IQ, Te Riele WW, van Santvoort HC, Hagendoorn J, Borel Rinkes IHM. Stepwise implementation of robotic surgery in a high volume HPB practice in the Netherlands. HPB (Oxford) 2020; 22:1596-1603. [PMID: 32093965 DOI: 10.1016/j.hpb.2020.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Aims of this study were to describe the stepwise implementation and expansion of robotic HPB surgery in a high volume HPB unit in the Netherlands and to analyze clinical outcomes of all robotic liver resections and robotic pancreatoduodenectomies performed within this program. METHODS After proctoring by expert international surgeons, HPB surgeons were introduced to robotic liver resection and robotic pancreatoduodenectomy in a stepwise fashion. Data from two prospective databases containing all consecutive patients who underwent robotic liver resection or robotic pancreatoduodenectomy between August 1st, 2015 and March 1st, 2019 were analyzed post hoc. RESULTS In total, 77 consecutive robotic liver resections and 68 consecutive robotic pancreatoduodenectomies were performed. Five surgeons were consecutively introduced to robotic HPB surgery. Mean operative time for robotic liver resection was 160 ± 78 min. Mean operative time for robotic pancreatoduodenectomy was 420 ± 67 min. Operative times remained stable over time and were not affected by the introduction of new surgeons. CONCLUSION Stepwise implementation and expansion of robotic HPB surgery within one unit over a three-and-half year period is feasible and associated with good clinical outcomes. Despite introducing new surgeons to the technique, operative times, an indicator of the learning process, remained stable over time.
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Affiliation(s)
- Carolijn L Nota
- Dept. of Surgery, Regional Academic Cancer Center Utrecht (RAKU), UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, G.04.228, the Netherlands
| | - I Q Molenaar
- Dept. of Surgery, Regional Academic Cancer Center Utrecht (RAKU), UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, G.04.228, the Netherlands
| | - Wouter W Te Riele
- Dept. of Surgery, Regional Academic Cancer Center Utrecht (RAKU), UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, G.04.228, the Netherlands
| | - Hjalmar C van Santvoort
- Dept. of Surgery, Regional Academic Cancer Center Utrecht (RAKU), UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, G.04.228, the Netherlands
| | - Jeroen Hagendoorn
- Dept. of Surgery, Regional Academic Cancer Center Utrecht (RAKU), UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, G.04.228, the Netherlands
| | - Inne H M Borel Rinkes
- Dept. of Surgery, Regional Academic Cancer Center Utrecht (RAKU), UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, G.04.228, the Netherlands.
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10
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Goh BK, Low TY, Koh YX, Lee SY, Teo JY, Kam JH, Jeyaraj PR, Cheow PC, Chow PK, Ooi LL, Chung AY, Chan CY. Changing trends and outcomes associated with the adoption of minimally invasive pancreatic surgeries: A single institution experience with 150 consecutive procedures in Southeast Asia. J Minim Access Surg 2020; 16:404-410. [PMID: 31571669 PMCID: PMC7597893 DOI: 10.4103/jmas.jmas_127_19] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Minimally invasive pancreatic surgeries (MIPS) are increasingly adopted worldwide. However, it remains uncertain if these reported experiences are reproducible throughout the world today. This study examines the safety and evolution of MIPS at a single institution in Southeast Asia. METHODS This is a retrospective review of 150 consecutive patients who underwent MIPS between 2006 and 2018 of which 135 cases (90%) were performed since 2012. To determine the evolution of MIPS, the study population was stratified into 3 equal groups of 50 patients. Comparison was also made between pancreatoduodenectomies (PD), distal pancreatectomies (DP) and other pancreatic surgeries. RESULTS One hundred and fifty patients underwent MIPS (103 laparoscopic, 45 robotic and 2 hand-assisted). Forty-three patients underwent PD, 93 DP and 14 other MIPS. There were 21 (14.0%) open conversions. There was an exponential increase in caseload over the study period. Comparison across the 3 time periods demonstrated that patients were significantly more likely to have a higher American Society of Anesthesiologists score, older, undergo PD and a longer operation time. The conversion rate decreased from 28% to 0% and increased again to 14% across the 3 time periods. Comparison between the various types of MIPS demonstrated that patients who underwent PD were significantly older, more likely to have symptomatic tumours, had longer surgery time, increased blood loss, increased frequency of extended pancreatectomies, increased frequency of hybrid procedures, longer post-operative stay, increased post-operative morbidity rate and increased post-operative major morbidity rate. CONCLUSION The case volume of MIPS increased rapidly at our institution over the study period. Furthermore, although the indications for MIPS expanded to include more complex procedures in higher risk patients, there was no change in key perioperative outcomes.
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Affiliation(s)
- Brian K. Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
- Address for correspondence: Prof. Brian K. Goh, Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore. E-mail:
| | - Tze Yi Low
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Ser Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Juinn Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Prema Raj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Pierce K. Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - London L. Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Alexander Y. Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
| | - Chung Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia, Singapore
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11
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Kovid N, Han HS, Yoon YS, Cho JY. Advanced laparoscopic HPB surgery: Experience in Seoul National University Bundang Hospital. Ann Gastroenterol Surg 2020; 4:224-228. [PMID: 32490336 PMCID: PMC7240149 DOI: 10.1002/ags3.12323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/04/2020] [Accepted: 02/17/2020] [Indexed: 12/16/2022] Open
Abstract
The worldwide trend in surgery has moved from open surgery to minimally invasive surgery. Likewise, the application of minimally invasive surgery in the hepato-pancreato-biliary (HBP) field is also rapidly expanding. The field of HBP surgery can be divided into liver, pancreas and biliary fields. Minimally invasive liver surgery is recently developed. However, laparoscopic liver resection in difficult areas is challenging. However, with the accumulation of experiences, laparoscopic liver resection for difficult areas is performed more than before. With more propagation, more and more liver resection will be performed by laparoscopic approach. In minimally surgery for the pancreas, distal pancreatectomy has become a well-recommended procedure in benign and borderline malignancy. There have been several systemic reviews that show advantages of laparoscopic distal pancreatectomy. The reports on laparoscopic pancreaticoduodenectomy (PD) are slowly increasing in spite of technical difficulty, with several systemic reviews showing advantages of the procedure. However, more PD will be performed as robotic-assisted procedures in the future. The laparoscopic surgery for biliary tract malignancy is still in early stages. The laparoscopic surgery for gallbladder cancer has been contraindicated, although there have been encouraging reports from expert centers. The laparoscopic surgery for Klatskin tumor is still an experimental procedure. Robotic-assisted procedures for the surgery of cholangiocarcinoma will be the future. Robotic-assisted surgery for the HBP field is still not well-developed. However, with the necessity of more precise manipulation like intracorporeal suturing, robotic-assisted surgery will be used more often in the field of HBP surgery.
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Affiliation(s)
| | - Ho-Seong Han
- Seoul National University Bundang Hospital Gyeonggi-do Korea
| | - Yoo-Seok Yoon
- Seoul National University Bundang Hospital Gyeonggi-do Korea
| | - Jai Young Cho
- Seoul National University Bundang Hospital Gyeonggi-do Korea
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12
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Goh BKP, Zeng G, Low TY, Chua DW, Koh YX, Lim KI. Changing trends and outcomes associated with the adoption of minimally-invasive pancreato-biliary surgery: Contemporary experience of a 'self-taught' early adopter in Southeast Asia. J Minim Access Surg 2020; 16:341-347. [PMID: 31929225 PMCID: PMC7597885 DOI: 10.4103/jmas.jmas_94_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Minimally-invasive pancreato-biliary surgery (MIPBS) is increasingly reported worldwide. This study examines the changing trends, safety and outcomes associated with the adoption of MIPBS based on a contemporary experience of an early adopter in Southeast Asia. Methods: Retrospective review of 114 consecutive patients who underwent MIPBS by a single surgeon over 86 months from 2011. The study population was stratified into three equal groups of 38 patients. Comparison was also performed between minimally-invasive pancreato surgery (MIPS) and minimally-invasive biliary surgery (MIBS). Results: There were 70 MIPS and 44 MIBS. Sixty-three cases (55.3%) were performed using robotic assistance and fourteen (12.3%) were hybrid procedures with open reconstruction. Forty-four (38.6%) procedures were performed for malignancy. There were 8 (7.0%) open conversions and median operation time was 335 (range, 60–930) min. There were nine extended pancreatectomies including seven involving vascular reconstructions. Major morbidity (>Grade 2) occurred in 20 (17.5%) patients including 6 (5.3%) reoperations and there was no mortality. Comparison across the three groups demonstrated that with increasing experience, there was a significant trend in a higher proportion of higher ASA score patients, increasing frequency of procedures requiring anastomosis and increasing the use of robotic assistance without significant difference in key perioperative outcomes such as open conversion rate, morbidity and hospital stay. Comparison between MIPS and MIBS demonstrated that MIPS was associated with significantly longer operation time, increased blood loss, increased transfusion rate, longer hospital stay, increased readmission rate and increased morbidity. Conclusion: MIPBS can be safely adopted today with a low open conversion rate.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke-NUS Medical School, Singapore
| | - Gerald Zeng
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Tze-Yi Low
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Darren W Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Kai-Inn Lim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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13
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Nagakawa Y, Nakamura Y, Honda G, Gotoh Y, Ohtsuka T, Ban D, Nakata K, Sahara Y, Velasquez VVDM, Takaori K, Misawa T, Kuroki T, Kawai M, Morikawa T, Yamaue H, Tanabe M, Mou Y, Lee WJ, Shrikhande SV, Conrad C, Han HS, Tang CN, Palanivelu C, Kooby DA, Asbun HJ, Wakabayashi G, Tsuchida A, Takada T, Yamamoto M, Nakamura M. Learning curve and surgical factors influencing the surgical outcomes during the initial experience with laparoscopic pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:498-507. [DOI: 10.1002/jhbp.586] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery; Tokyo Medical University; Tokyo Japan
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery; Nippon Medical School; Tokyo Japan
| | - Goro Honda
- Department of Surgery; Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital; Tokyo Japan
| | - Yoshitaka Gotoh
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery; Graduate School of Medicine; Tokyo Medical and Dental University; Tokyo Japan
| | - Kohei Nakata
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Yatsuka Sahara
- Department of Gastrointestinal and Pediatric Surgery; Tokyo Medical University; Tokyo Japan
| | | | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation; Department of Surgery; Kyoto University; Kyoto Japan
| | - Takeyuki Misawa
- Department of Surgery; The Jikei University School of Medicine; Tokyo Japan
| | - Tamotsu Kuroki
- Department of Surgery; National Hospital Nagasaki Medical Center; Nagasaki Japan
| | - Manabu Kawai
- Second Department of Surgery; School of Medicine; Wakayama Medical University; Wakayama Japan
| | | | - Hiroki Yamaue
- Second Department of Surgery; School of Medicine; Wakayama Medical University; Wakayama Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery; Graduate School of Medicine; Tokyo Medical and Dental University; Tokyo Japan
| | - Yiping Mou
- Department of Gastrointestinal and Pancreatic Surgery; Zhejiang Provincial People's Hospital; People's Hospital of Hangzhou Medical College; Zhejiang China
| | - Woo-Jung Lee
- Department of Hepatobiliary and Pancreatic Surgery; Yonsei University College of Medicine; Seoul South Korea
| | - Shailesh V. Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology; Tata Memorial Hospital; Mumbai India
| | - Claudius Conrad
- Department of Surgical Oncology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Ho-Seong Han
- Department of Surgery; Seoul National University Bundang Hospital; Seoul National University College of Medicine; Seoul South Korea
| | - Chung Ngai Tang
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Chai Wan Hong Kong SAR China
| | - Chinnusamy Palanivelu
- Division of Gastrointestinal Surgery and Minimal Access Surgery; GEM Hospital and Research Centre; Coimbatore India
| | - David A. Kooby
- Division of Surgical Oncology; Department of Surgery; Emory University School of Medicine; Atlanta GA USA
| | | | - Go Wakabayashi
- Department of Surgery; Ageo Central General Hospital; Ageo Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery; Tokyo Medical University; Tokyo Japan
| | - Tadahiro Takada
- Department of Surgery; Teikyo University School of Medicine; Tokyo Japan
| | - Masakazu Yamamoto
- Department of Surgery; Institute of Gastroenterology; Tokyo Women's Medical University; Tokyo Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
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