Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial

Laparoscopic versus open pancreaticoduodenectomy outcomes in patients ≥ 75 years old: an NSQIP analysis of 4343 patients

BACKGROUND

The benefits of MIS in older adults are conflicting. This study evaluates demographics and early outcomes, for older patients (≥75) undergoing minimally invasive (MIS) versus open pancreaticoduodenectomy (PD).

METHOD

We categorized elderly patients who underwent PD from 2017 to 2021 NSQIP databases by surgical approach (open vs MIS). Baseline characteristics were examined with bivariate analysis, and multivariate logistic regression assessed the independent effect of minimally invasive surgery on 30-day serious complications and mortality.

RESULTS

Amongst 4137 patients, 150 (3.63 %) underwent MIS PD. Patients demographics were similar. Open cohorts were older (79.1 vs 78.4 years; p = 0.011) with greater tumor invasion (36.6 % vs. 27.0 %; p = 0.018). MIS had longer operations (133.1 vs 119.6 min; p < 0.001). Multivariate analysis demonstrated that MIS approach was associated with increased serious complications (OR 2.21; p < 0.001), but not mortality (OR 2.11; p = 0.173). Post hoc analysis excluding cases converted to open demonstrated no difference in serious complications (OR 1.94; p = 0.070) or mortality (OR 3.58; p = 0.094). PSM analysis estimated a 14.7 % higher rate of serious complications in MIS but similar mortality (p = 0.291).

CONCLUSIONS

MIS PD uptake in elderly patients remains limited, with early findings indicating longer operations and higher complications. Further research on patient selection differences, technique modifications, and center expertise is required.

Minimal Invasive Pancreatoduodenectomy: A Comprehensive Systematic Review and Metanalysis of Randomized Controlled Clinical Trials

BACKGROUND

The role of a minimally invasive approach (MI) in patients who underwent pancreatoduodenectomy (PD) remained unclear.

METHODS

A systematic search of randomized controlled trials was conducted. A random-effects meta-analysis was conducted, reporting risk ratio (RR) or mean difference (MD). The primary endpoints were the morbidity, mortality, and R1 rate. The secondary endpoints were clinically relevant postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), biliary fistula, reoperation, length of stay (LOS), time to functional recovery (TFR), and readmission.

RESULTS

The meta-analysis includes seven studies and 1428 patients: 618 (46.5%) in the OPD arm and 711 (53.5%) in minimally invasive pancreaticoduodenectomy (MIPD). The mortality rate was 2.9% for MIPD and 2.6% for OPD (RR 1.11 [range 0.53-2.29]). The major morbidity rate was 29.4% for MIPD and 25.6% for OPD (RR 1.11 [range 0.53-2.29]). The R1 rate was 6.2% for MIPD and 7% for OPD (RR 0.80 [0.54-1.20]). The operative time, comprehensive complication index score, POPF, PPH, DGE, biliary fistula, reoperation, readmission, LOS, TFR, and harvested lymph nodes were similar. Greater than 25% of heterogeneity was observed for major morbidity, operative time, POPF, LOS, TFR, and harvested lymph nodes. No publication bias was registered.

CONCLUSIONS

Minimally invasive pancreaticoduodenectomy was not superior to OPD and provided marginal advantages in short-term results. Further efforts should be addressed to clarify the impact of learning curve in MIPD results and the economic sustainability of MIPD, particularly robotic approach.

Diagnostic utility of ultrasonography in the management of postoperative fluid collections and abdominal indwelling catheters following pancreaticoduodenectomy: retrospective cohort study

INTRODUCTION

The management of postoperative fluid collections, which refers to the accumulation of fluid in the peritoneal cavity following pancreaticoduodenectomy, presents significant challenges. However, ultrasonography has emerged as a promising tool for diagnosing and guiding interventions for this condition. Ultrasonography offers several advantages, including accessibility, cost-effectiveness, and real-time imaging capabilities. It plays a crucial role in identifying ascitic fluid collections, characterizing their contents, and evaluating the severity of fluid collections. Moreover, ultrasound guidance enhances the safety and effectiveness of placing abdominal catheters. The aim of this study is to assess the diagnostic utility of ultrasonography in postoperative fluid collections following pancreaticoduodenectomy and evaluate the clinical efficacy of ultrasound-guided abdominal catheter placement.

METHODS

A total of 309 hospitalized patients underwent postoperative pancreaticoduodenectomy, with 171 patients undergoing laparoscopic pancreaticoduodenectomy (LPD) and 138 patients undergoing open pancreaticoduodenectomy (OPD), as assessed by ultrasonography. We examined the abdominal cavity for the presence of postoperative fluid collections and evaluated the site of postoperative fluid collections and the necessity for tube drainage. In cases where an abdominal indwelling catheter was required, we observed the location of postoperative fluid collections, performed echocardiography, and analyzed the characteristics of drainage fluid. We conducted a comparative analysis of short-term postoperative outcomes between LPD and OPD, encompassing hospitalization duration, fever duration, presence or localization of postoperative fluid collections, number of abdominal indwelling catheters used, location of abdominal drainage fluid collection, and time until postoperative catheter removal.

RESULTS

The LPD group demonstrated a significantly lower incidence of postoperative fluid collections compared to the OPD group, as determined by ultrasonography (39.2% vs. 59.3%, p = 0.001). Additionally, the LPD group had shorter hospital stays (16 [13, 21] vs. 21 [17, 28] days; p < 0.001), reduced duration of fever (1 [0, 3] vs. 3 [1, 5] days; p < 0.001), faster time to postoperative catheterization (7 [5, 10] vs. 8 [6, 13] days; p < 0.001), fewer required tubes (0 [0, 1] vs. 1 [0, 1]; p < 0.001), and shorter extubation time (7 [5, 9] vs. 9 [5, 12] h; p < 0.001) compared to the OPD group. There were correlations observed between the two groups regarding postoperative fluid collections, ultrasound sound transmission, separation of postoperative fluid collections, and traits of drainage fluid. However, there were no significant differences between the two groups in terms of postoperative fluid collections location (dissociative or restrictive), ultrasound sound transmission (excellent or poor), and separation of postoperative fluid collections (no separation, less separation, and more separation).

CONCLUSIONS

Postoperative fluid collections is a commonly encountered concurrent condition following pancreaticoduodenectomy. Ultrasonography allows for the observation of diverse characteristics related to postoperative fluid collections, including its precise localization, sound transmission properties, and the presence of internal separations. Moreover, it enables timely guidance for precise placement of drainage tubes.

Impact of a Quantitative Early Activity Program on Gastrointestinal Function Following Laparoscopic Pancreaticoduodenectomy: A Single-Center Retrospective Analysis

OBJECTIVE

The objective of this study is to assess the impact of a quantitative early activity program, integrated into the Enhanced Recovery After Surgery (ERAS) protocol on gastrointestinal function in patients undergoing laparoscopic pancreatoduodenectomy (LPD).

METHODS

Perioperative data from 203 patients who underwent LPD at the Department of Comprehensive Treatment of Pancreatic Cancer, Fudan University Shanghai Cancer Center, between January 2021 and December 2022 were analyzed retrospectively. The patients were categorized into 2 groups based on their nursing plans. Group A received the standard perioperative ERAS nursing plan, while group B followed the ERAS plan supplemented with a quantitative early activity program. We assessed postoperative outcomes including bowel sound recovery time, time to first anal exhaust, time to first mobilization, activity compliance 1-week postsurgery, and incidence of postoperative breakthrough pain.

RESULT

We compared several postoperative metrics between group A and group B. Specifically, the time to bowel sound recovery was 62.39±17.89 hours in group A versus 56.45±22.85 hours in group B. The time to first anal exhaust was 78.88±71.99 hours in group A compared with 63.62±24.73 hours in group B. The time to first mobilization was 56.98±18.66 hours in group A versus 49.85±20.48 hours in group B. In addition, activity compliance 1-week postsurgery and the incidence of postoperative breakthrough pain (1.55±2.01 times in group A vs. 0.94±1.16 times in group B) were also compared. All these differences were statistically significant ( P <0.05). Conversely, the incidence of postoperative complications and the length of hospital stay (11.20±5.69 d in group A vs. 12.47±6.67 d in group B) did not reveal any significant differences ( P >0.05).

CONCLUSION

The quantitative early activity program for LPD, based on the ERAS protocol, enhances the adherence to postoperative activity and decreases the incidence of breakthrough pain, thereby facilitating gastrointestinal function recovery in patients. This approach merits clinical adoption.

Long-Term Reoperation Rates Following Pancreatoduodenectomy for Pancreatic Adenocarcinoma

BackgroundShort-term outcomes after pancreatoduodenectomy (PD) are well-studied, but long-term reoperation rates and their indications remain poorly characterized.MethodsA single-center retrospective chart review was performed on patients who underwent PD for pancreatic adenocarcinoma between 1/2011 and 12/2021. Reoperations occurring >90 days after PD were dichotomized to being related or unrelated to the index PD or pancreatic adenocarcinoma. The Kaplan-Meier analysis estimated the incidence of long-term reoperation at 1 and 5 years postoperatively.ResultsSix-hundred twenty-eight patients were included. The 5-year incidence of any additional operation >90 days after PD was 30.0% (95% CI 23.2-36.2%), and the 5-year incidence of any long-term related reoperation was 21.2% (95% CI 15.0-26.8%). The most common indications for reoperations by 5-year incidence were cancer recurrence (12.8%, 95% CI 7.6-17.7%), incisional hernia (6.2%, 95% CI 2.6-9.7%), small bowel obstruction (1.3%, 95% CI 0.2-2.4%), and leak, fistula, or infection (1.0%, 95% CI 0.1-2.0%). Of the examined risk factors, only 90-day reoperation was found to be predictive of long-term related reoperations (P = 0.02). Additionally, the 5-year incidence of endoscopic or interventional radiology procedures was 20.2% (95% CI 14.5-25.4%). However, 40.9% (95% CI 33.6-47.3%) of patients required additional surgery or procedures of any kind between 90 days and 5 years after PD.DiscussionWithin 5 years of PD, one in three patients required additional surgery, and one in five had operations for related indications. Related reoperative indications included recurrence, hernia, PD-specific complications, and small bowel obstruction. However, the rates of each of these reoperations were relatively low.

Retrospective analysis of delta hemoglobin and bleeding-related risk factors in pancreaticoduodenectomy

BACKGROUND

Objective and accurate assessment of blood loss during pancreaticoduodenectomy (PD) is crucial for ensuring the safety and efficacy of the procedure. While the visual method remains the most common clinical metric, many scholars argue that it significantly differs from actual blood loss and is inherently subjective.

AIM

To assess blood loss in PD via delta hemoglobin (ΔHb) and compare it with the visual method to predict bleeding-related risk factors.

METHODS

In this retrospective analysis, 1722 patients who underwent PD from 2017 to 2022 at Shandong Provincial Hospital were divided into three groups: Open PD (OPD), laparoscopic PD (LPD), and conversion to OPD (CTOPD). Intraoperative ΔHb (IΔHb) was calculated via preoperative and 72-hour-postoperative hemoglobin concentrations, and its association with visually obtained estimated blood loss (EBL) was analyzed. Perioperative ΔHb (PΔHb) was calculated via preoperative and predischarge hemoglobin concentrations. We compared the differences in IΔHb and PΔHb among the three groups, and performed univariate and multivariate regression analyses of IΔHb and PΔHb.

RESULTS

The preoperative general information of patients showed no statistically significant difference among the three groups (P > 0.05). The IΔHb in the OPD, LPD, and CTOPD groups were 22.00 (12.00, 36.00), 21.00 (10.00, 33.00), and 33.00 (18.12, 52.24) g/L, respectively; And the PΔHb in the OPD, LPD, and CTOPD groups were 25.87 (13.51, 42.00), 25.00 (14.00, 45.00), and 37.48 (21.64, 59.65) g/L, respectively, values significantly differed (P < 0.05). IΔHb and EBL were significantly correlated (r = 0.337, P < 0.001). The results of univariate and multivariate regression analyses indicated that American Society of Anesthesiologists (ASA) classification IV [95% confidence interval (CI): 2.330-37.811, P = 0.049] and preoperative total bilirubin > 200 μmol/L (95%CI: 2.805-8.673, P < 0.001) were independent risk factors for IΔHb (P < 0.05), and ASA classification IV (95%CI: 45.934-105.485, P < 0.001), body mass index > 24 kg/m2 (95%CI: 1.285-9.890, P = 0.011), and preoperative total bilirubin > 200 μmol/L (95%CI: 6.948-16.797, P < 0.001) were independent risk factors for PΔHb (P < 0.05).

CONCLUSION

There is a correlation between IΔHb and EBL in PD, so we can assess the patients' intraoperative blood loss by the ΔHb method. ASA classification IV, body mass index > 24 kg/m², and preoperative total bilirubin > 200 μmol/L increased perioperative bleeding risk.

Complexity and Experience Grading to Guide Patient Selection for Minimally Invasive Pancreatoduodenectomy: An International Study Group for Pancreatic Surgery (ISGPS) Consensus

OBJECTIVE

To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD).

BACKGROUND

Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience.

METHODS

The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions.

RESULTS

The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification.

CONCLUSIONS

This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries.

Comparison of laparoscopic and open pancreaticoduodenectomy for distal cholangiocarcinoma and impact factors on textbook outcome

BACKGROUND

Distal cholangiocarcinoma (dCCA) is an aggressive malignancy with poor prognosis. This study aimed to compare the short-term and long-term outcomes and "textbook outcome (TO)" between laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for dCCA after the learning curve of surgeons.

METHODS

Clinical and follow-up data were included for dCCA patients treated with LPD or OPD at our center between January 2017 and December 2022. The propensity score matching (PSM) method was used to minimize bias between groups. Univariate and multivariate logistic regression analyses were used to determine independent prognostic factors for TO.

RESULTS

A total of 430 patients were enrolled in the study, 224 in the LPD group and 206 in the OPD group. After PSM, 184 patients were included in each group. There were no significant differences in operative duration, lymph nodes harvest, intraoperative transfusion, vascular resection, R0 resection, severe complications, readmission rate, 30-day mortality, TO, and long-term prognosis between the two groups before and after PSM (all P > 0.05). Compared with OPD, LPD had less estimated blood loss (160 vs. 250mL, P < 0.001) and shorter postoperative length of stay (13 vs. 16 days, P < 0.001). Multivariate analysis showed that texture of pancreas [hard vs. soft, Odds Ratio (OR) 2.016; 95% confidence interval (CI) 1.276-3.184; P = 0.003] and operation duration (> 360 min vs. ≤ 360 min, OR 0.595, 95% CI 0.375-0.944, P = 0.027) were independent prognostic factors for TO.

CONCLUSIONS

After learning curve, LPD is safe and feasible for the treatment of dCCA, with the advantages of less intraoperative blood loss and faster postoperative recovery.

Pancreatic ductal adenocarcinoma (PDAC): clinical progress in the last five years

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal malignancy with limited therapeutic options and poor overall survival. In recent years, advances in genomic profiling have revealed the complex molecular and cellular heterogeneity of PDAC, offering new avenues for therapeutic intervention.

AREAS COVERED

This review explores emerging therapeutic strategies targeting dysregulated molecular pathways, along with the tumor microenvironment, that have shown promise in overcoming drug resistance. Novel immunotherapy strategies, such as immune checkpoint inhibitors and CAR T-cell therapies, are currently being explored in an attempt to modulate PDAC immugnosuppressive microenvironment. Additionally, we highlight recent clinical trials over the last 5 years and innovative therapeutic strategies aiming to improve outcomes in PDAC.

EXPERT OPINION

Significant progress in genomic profiling, targeted therapies, and immunotherapy is shaping the treatment of PDAC. Despite challenges posed by its dense stroma and immune suppressive microenvironment, novel strategies such as IL 6 and CD137 inhibitors, CAR-T, and therapeutic cancer vaccines are promising. KRAS targeted therapies are expanding beyond G12C inhibitors, with novel drugs in development that will further improve treatment options. Additionally, tumor treating fields (TTF) are being investigated in locally advanced PDAC, with the PANOVA-3 trial potentially integrating this modality into future treatment strategies. Continued advancements in these areas will significantly enhance PDAC outcomes.

Oncological resection and perioperative outcomes of robotic, laparoscopic and open pancreatoduodenectomy for ampullary adenocarcinoma: a propensity score matched international multicenter cohort study

BACKGROUND

Ampullary adenocarcinoma (AAC) typically presents at an early stage due to biliary obstruction and therefore might be specifically suitable for minimally invasive pancreatoduodenectomy (MIPD). However, studies assessing MIPD specifically for AAC, including the robotic and laparoscopic approach, are limited. The aim of this study is to compare short- and long-term oncological resection and perioperative outcomes of robotic (RPD), laparoscopic (LPD) and open pancreatoduodenectomy (OPD) performed specifically for AAC.

METHODS

In this multicenter international cohort study, encompassing 35 centers from 11 countries, MIPD versus OPD and subgroup analyses of LPD versus RPD were undertaken. The primary outcomes regarded the oncological resection (R1 resection rate, lymph node yield) and 5-years overall survival. Secondary outcomes were perioperative outcomes (including intra-operative variables, surgical complications and hospital stay).

RESULTS

In total, patients with AAC who underwent OPD (1721) or MIPD (141) were included. After propensity-score matching, 134 patients per cohort were included. The MIPD group consisted of 53 RPDs and 71 LPDs (50 per group after PSM). There was no difference in overall survival between MIPD and OPD (61.6 % vs 56.2 %, P = 0.215). In the MIPD group, operative time was longer (439 vs 360 min, P < 0.001). Between RPD and LPD, overall survival was not significantly different (75.8 % vs 47.4 %, P = 0.098) and lymph node yield was higher in RPD (21 vs 18, P = 0.014).

CONCLUSION

In conclusion, patients with AAC seem to have comparable oncological resection and perioperative outcomes from MIPD compared to the traditional OPD. Both RPD as LPD appear to be safe alternatives for patients with AAC, which warrants confirmation by future randomized studies.

A comprehensive analysis of robotic assisted vs. laparoscopic distal pancreatectomy using propensity score matching

Using the propensity-matched methodology, this meta-analysis and comprehensive review aimed to compare robotic distal pancreatectomy with laparoscopic distal pancreatectomy in terms of perioperative and short-term oncologic outcomes. Within the scope of this investigation, complete and total adherence to the PRISMA guidelines for Systematic Reviews and Meta-Analyses was established. The search we conducted in PubMed, Google Scholar, and EMBASE was automated to find relevant papers that matched the tendency up to July 1, 2024. The length of time spent while operating, the rate of conversion, and the collection of lymph nodes were the primary factors that were considered. Other metrics that were taken into consideration were the approximate amount of blood loss, the length of time spent in the hospital, the need for transfusions, and the occurrence of major adverse events. In the end, there were 8 studies that involved 1649 patients. Of those patients, 758 had robotic assisted distal pancreatectomy, whereas 891 underwent laparoscopic distal pancreatectomy. In comparison to laparoscopic distal pancreatectomy, the robotic assisted technique did result in higher anticipated blood loss and conversion rates; however, it also required longer durations of operation due to its lengthier duration. In terms of lymph node retrieval, the duration of hospital stay, the need for blood transfusions, and the incidence of postoperative pancreatic fistula, there were no distinctions that could be considered statistically significant between the two techniques. A realistic and risk-free surgical alternative is a distal pancreatectomy that is performed with the aid of robotic technology. When compared to laparoscopic surgery, the outcomes of robot-assisted surgery were superior in terms of conversion rates to laparotomy and less anticipated intraoperative blood loss. However, the operation took longer to complete than laparoscopic surgery.

Effects of Pancreatic Fistula After Minimally Invasive and Open Pancreatoduodenectomy

Importance

Postoperative pancreatic fistulas (POPF) are the biggest contributor to surgical morbidity and mortality after pancreatoduodenectomy. The impact of POPF could be influenced by the surgical approach.

Objective

To assess the clinical impact of POPF in patients undergoing minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD).

Design, Setting, and Participants

This cohort study was conducted from 2007 to 2020 in 36 referral centers in Europe, South America, and Asia. Participants were patients with POPF (grade B/C as defined by the International Study Group of Pancreatic Surgery [ISGPS]) after MIPD and OPD (MIPD-POPF, OPD-POPF). Propensity score matching was performed in a 1:1 ratio based on the variables age (continuous), sex, body mass index (continuous), American Society of Anesthesiologists score (dichotomous), vascular involvement, neoadjuvant therapy, tumor size, malignancy, and POPF grade C. Data analysis was performed from July to October 2023.

Exposure

MIPD and OPD.

Main Outcomes and Measures

The primary outcome was the presence of a second clinically relevant (ISGPS grade B/C) complication (postpancreatic hemorrhage [PPH], delayed gastric emptying [DGE], bile leak, and chyle leak) besides POPF.

Results

Overall, 1130 patients with POPF were included (558 MIPD and 572 OPD), of whom 336 patients after MIPD were matched to 336 patients after OPD. The median (IQR) age was 65 (58-73) years; there were 703 males (62.2%) and 427 females (37.8%). Among patients who had MIPD-POPF, 129 patients (55%) experienced a second complication compared with 95 patients (36%) with OPD-POPF (P < .001). The rate of PPH was higher with MIPD-POPF (71 patients [21%] vs 22 patients [8.0%]; P < .001), without significant differences for DGE (65 patients [19%] vs 45 patients [16%]; P = .40), bile leak (43 patients [13%] vs 52 patients [19%]; P = .06), and chyle leak (1 patient [0.5%] vs 5 patients [1.9%]; P = .39). MIPD-POPF was associated with a longer hospital stay (median [IQR], 27 [18-38] days vs 22 [15-30] days; P < .001) and more reoperations (67 patients [21%] vs 21 patients [7%]; P < .001) but comparable in-hospital/30-day mortality (25 patients [7%] vs 7 patients [5%]; P = .31) with OPD-POPF, respectively.

Conclusions and Relevance

This study found that for patients after MIPD, the presence of POPF is more frequently associated with other clinically relevant complications compared with OPD. This underscores the importance of perioperative mitigation strategies for POPF and the resulting PPH in high-risk patients.

Comparison of short‑ and long‑term outcomes between laparoscopic and open pancreaticoduodenectomy in overweight patients: a propensity score‑matched study

BACKGROUND

Overweight is thought to affect the outcome of minimally invasive surgery. There is still a lack of controlled studies of laparoscopic pancreaticoduodenectomy (LPD) versus open pancreaticoduodenectomy (OPD) in overweight patients. This study was designed to compare short-term and long-term outcomes in overweight patients treated with LPD and OPD.

METHODS

Clinical and follow-up data on overweight patients who received LPD or OPD at Shandong Provincial Hospital from January 2015 to December 2022 were analyzed retrospectively. The bias between groups were balanced by 1:1 propensity score matching (PSM). Kaplan-Meier survival curves described long-term survival outcomes in overweight pancreatic ductal adenocarcinoma (PDAC) patients.

RESULTS

A total of 502 overweight patients were enrolled in the study. There were 276 patients in the LPD group and 226 in the OPD group. After matching, 196 patients were enrolled in each group. Compared with the OPD group, the LPD group had fewer estimated blood loss (EBL) (140 vs. 200 mL, P < 0.001), more lymph node dissection (14 vs. 12, P = 0.010), and shorter postoperative length of stay (LOS) (13 vs. 16 days, P < 0.001). There were no significant differences in severe complications, 90-day readmission and mortality rates (all P > 0.05). The subgroup analysis of obese patients also showed that the LPD group had fewer intraoperative EBL, more lymph node dissection, and shorter LOS. The survival analysis showed that overweight patients with PDAC who underwent LPD or OPD had similar overall survival (OS) (23.8 vs.25.7 months, P = 0.963) after PSM.

CONCLUSION

It is safe and feasible for overweight patients undergoing LPD to have less EBL, more lymph node harvesting, and a shorter LOS. There was no statistically significant difference in long-term survival outcomes among overweight PDAC patients between the two approaches.

Postoperative complications and surgical outcomes of robotic versus laparoscopic pancreaticoduodenectomy: a meta-analysis of propensity-score-matched studies

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is used more commonly, but high-level evidence is still scarce. This meta-analysis aimed to compare the short-term outcomes between RPD and laparoscopic pancreaticoduodenectomy (LPD) using data collected from propensity score-matched (PSM) studies.

MATERIALS AND METHODS

We searched PubMed, Cochrane Library, Embase, and Web of Science databases for PSM studies comparing RPD and LPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated.

RESULTS

Ten PSM studies were included, encompassing 8106 patients (RPD group: 3695 patients; LPD group: 4411 patients). Compared with LPD, RPD was associated with a lower conversion rate (RR, 0.56) and blood transfusion rate (RR, 0.49), as well as a higher number of harvested lymph nodes (MD, 2.15). There were no significant differences observed in 30-day readmission (RR, 1.02), 90-day mortality (RR, 1.01), overall morbidity (RR, 0.94), major complications (RR, 1.06), operative time (MD, -8.00 min), blood loss (MD, -19.37 mL), reoperation (RR, 0.95), bile leak (RR, 0.93), chylous leak (RR, 1.40), postoperative pancreatic fistula (RR, 1.06), delayed gastric emptying (RR, 0.92), wound infection (RR, 1.12), length of stay (MD, -0.32 days), and R0 resection (RR, 0.98) between the groups.

CONCLUSIONS

Although LPD and RPD had similar surgical outcomes, RPD had the perioperative advantage over LPD in decreasing conversion rates and blood transfusion rates and increasing the number of lymph nodes harvested. Further randomized controlled trials evaluating the potential advantages of RPD over LPD are warranted.

Laparoscopic pancreatoduodenectomy is safe for the treatment of pancreatic ductal adenocarcinoma treated by chemoradiotherapy compared with open pancreatoduodenectomy: A matched case-control study

BACKGROUND

Few studies compared laparoscopic and open pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy.

METHODS

Retrospective cohort of patients who underwent laparoscopic or open pancreatoduodenectomy for resectable or borderline resectable pancreatic ductal adenocarcinoma after chemoradiotherapy between 2012 and 2023 was analyzed. Open pancreatoduodenectomy patients could theoretically benefit from the laparoscopic approach. We used a 1:2 (laparoscopic-to-open pancreatoduodenectomy) propensity score matching analysis stratified on age, gender, and body mass index.

RESULTS

We included 128 patients (33 laparoscopic and 95 open pancreatoduodenectomy), and after propensity score matching, 33 laparoscopic pancreatoduodenectomy and 66 open pancreatoduodenectomy were compared. There was no difference in demographic data except for lower tobacco use in laparoscopic pancreatoduodenectomy group (9% vs 30%, P = .023) with similar clinical presentation. Laparoscopic pancreatoduodenectomy compared to open pancreatoduodenectomy showed a longer median operative duration (380 vs 255 minutes, P < .001), shorter median length of resected vein (15 vs 23 mm, P = .01), longer median venous clamping time (29 vs 15 minutes, P = .005), similar median blood loss (300 vs 300 mL, P = .223), similar rate of hard pancreas (97% vs 85%, P = .094), and a larger median size of Wirsung duct (5 vs 4 mm, P = .02). Postoperative outcomes showed similar 90-day mortality rates (3% vs 3%, P > .99), Clavien-Dindo III-IV complications (6% vs 14%, P = .158), median lengths of hospital stay (12 vs 13 days, P = .409), and readmission rates (9% vs 18%, P = .366). Pathologic data showed similar R0 resection rates (88% vs 82%, P = .568). With a similar rate of adjuvant chemotherapy (P = .324) and shorter median follow-up with laparoscopic pancreatoduodenectomy (18 vs 34 months, P = .004), 3-year overall (P = .768) and disease-free (P = .839) survival rates were similar.

CONCLUSION

In selected patients, laparoscopic pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy appears to be safe and feasible when performed in experienced centers.

Minimally invasive pancreaticoduodenectomy: A bibliometric method applied to the top one hundred cited articles

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) is considered one of the most complex procedures in general surgery. The number of articles on MIPD has been increasing annually. However, published reports often have complex research directions, and the focal points frequently change. Therefore, a comprehensive review and organization of the literature in this field is necessary.

AIM

To summarize current research, predict future hotspots and trends, and provide insights for MIPD development.

METHODS

To conduct the study, the Web of Science Core Collection was searched for relevant articles. The analysis focused on the top 100 articles in the field. Two widely used bibliometric tools, CiteSpace and VOSviewer, were used to examine various aspects, including research directions, authors, countries, institutions, journals, and keywords.

RESULTS

The top 100 articles were published between 2005 and 2022, with the majority originating from the United States (n = 51). Among the contributing institutions, Pancreas Center of the University of Chicago and the Health System of the University of Chicago had the highest number of publications (n = 17). In terms of individual authors, "Zeh HJ" and "Zureikat AH" led with 13 articles each. The high-frequency keywords in the literature encompassed three main areas: Surgical modality, perioperative outcomes, and the learning curve. These keywords were further categorized into seven primary clusters, with the largest being "laparoscopic pancreaticoduodenectomy".

CONCLUSION

The most influential studies predominantly originate from the United States, and there is growing interest in robotic surgery. Despite MIPD's potential benefits, further research is required to address technical challenges and improve outcomes.

Multimodal treatment combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy and adjuvant therapy for pancreatic neck-body cancer: Case series

BACKGROUND

Pancreatic cancer involving the pancreas neck and body often invades the retroperitoneal vessels, making its radical resection challenging. Multimodal treatment strategies, including neoadjuvant therapy, surgery, and postoperative adjuvant therapy, are contributing to a paradigm shift in the treatment of pancreatic cancer. This strategy is also promising in the treatment of pancreatic neck-body cancer.

AIM

To evaluate the feasibility and effectiveness of a multimodal strategy for the treatment of borderline/locally advanced pancreatic neck-body cancer.

METHODS

From January 2019 to December 2021, we reviewed the demographic characteristics, neoadjuvant and adjuvant treatment data, intraoperative and postoperative variables, and follow-up outcomes of patients who underwent multimodal treatment for pancreatic neck-body cancer in a prospectively collected database of our hospital. This investigation was reported in line with the Preferred Reporting of Case Series in Surgery criteria.

RESULTS

A total of 11 patients with pancreatic neck-body cancer were included in this study, of whom 6 patients were borderline resectable and 5 were locally advanced. Through multidisciplinary team discussion, all patients received neoadjuvant therapy, of whom 8 (73%) patients achieved a partial response and 3 patients maintained stable disease. After multidisciplinary team reassessment, all patients underwent laparoscopic subtotal distal pancreatectomy and portal vein reconstruction and achieved R0 resection. Postoperatively, two patients (18%) developed ascites, and two patients (18%) developed pancreatic fistulae. The median length of stay of the patients was 11 days (range: 10-15 days). All patients received postoperative adjuvant therapy. During the follow-up, three patients experienced tumor recurrence, with a median disease-free survival time of 13.3 months and a median overall survival time of 20.5 months.

CONCLUSION

A multimodal treatment strategy combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy, and adjuvant therapy is safe and feasible in patients with pancreatic neck-body cancer.

Pretreatment red blood cell distribution width as a predictive marker for postoperative complications after laparoscopic pancreatoduodenectomy

BACKGROUND

Red blood cell distribution width (RDW) is associated with the development and progression of various diseases.

AIM

To explore the association between pretreatment RDW and short-term outcomes after laparoscopic pancreatoduodenectomy (LPD).

METHODS

A total of 804 consecutive patients who underwent LPD at our hospital between March 2017 and November 2021 were retrospectively analyzed. Correlations between pretreatment RDW and clinicopathological characteristics and short-term outcomes were investigated.

RESULTS

Patients with higher pretreatment RDW were older, had higher Eastern Cooperative Oncology Group scores and were associated with poorer short-term outcomes than those with normal RDW. High pretreatment RDW was an independent risk factor for postoperative complications (POCs) (hazard ratio = 2.973, 95% confidence interval: 2.032-4.350, P < 0.001) and severe POCs of grade IIIa or higher (hazard ratio = 3.138, 95% confidence interval: 2.042-4.824, P < 0.001) based on the Clavien-Dino classification system. Subgroup analysis showed that high pretreatment RDW was an independent risk factor for Clavien-Dino classification grade IIIb or higher POCs, a comprehensive complication index score ≥ 26.2, severe postoperative pancreatic fistula, severe bile leakage and severe hemorrhage. High pretreatment RDW was positively associated with the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio and was negatively associated with albumin and the prognostic nutritional index.

CONCLUSION

Pretreatment RDW was a special parameter for patients who underwent LPD. It was associated with malnutrition, severe inflammatory status and poorer short-term outcomes. RDW could be a surrogate marker for nutritional and inflammatory status in identifying patients who were at high risk of developing POCs after LPD.

Active-Targeted ICG for Surgical Navigation and Fluorescence-Guided Laparoscopic Photothermal Ablation in Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy, but there is limited improvement in its treatment. Near-infrared fluorescence (NIRF) imaging could potentially address the clinical challenges of PDAC. Indocyanine green (ICG) has been widely used in clinical practice; however, its short half-life and lack of active targeting greatly limit its application in pancreatic surgery. In this study, the active targeting peptide KTLLPTP (which actively recognizes PDAC cell surface overexpression Plectin-1) was modified to the ICG to create the novel contrast agent ICG-PTP, which actively targets PDAC cells. It was successfully applied to the NIRF imaging of the PDAC orthotopic mice model, achieving an improved tumor signal background ratio (T/N ratio) of 4.28, compared to 2.34 in the free ICG group. Next, Fluorescence-guided excision of subcutaneous/orthotopic PDAC using ICG-PTP was performed, accurately identifying the tumor margin and significantly facilitating resection efficiency. Finally, PDAC metastases were identified, and interventional photothermal ablation (iPTA) was performed under fluorescence laparoscope guidance. ICG-PTP exhibits good biosafety and clinical transitional potential. Thus, they can provide surgeons with efficient real-time tumor information and offer new treatment strategies for metastases. Accordingly, modification of probes for clinical use and adaptation studies of current equipment are the current focus.

Updating the paradigm of prophylactic abdominal drainage following pancreatoduodenectomy

BACKGROUND

Prophylactic abdominal drainage (PAD) is considered a routine procedure after pancreatoduodenectomy (PD) to prevent and detect severe complications at an early stage. However, the drainage itself may cause adverse consequences. Thus, the optimal strategy of PAD after PD remains controversial.

METHODS

The present paper summarizes the latest research on the strategies of PAD following PD, mainly focusing on 1) the selective placement of PAD, 2) the optimal drainage types, 3) the early removal of drainage (EDR), and 4) novel strategies for PAD management.

RESULTS

Accurate stratifications based on the potential risk factors of clinically relevant-postoperative pancreatic fistula (CR-POPF) facilitates the selective placement of PAD and the implementation of EDR, with postoperative outcomes superior or similar to routine PAD placement. Both active and passive drainage methods are feasible in most patients after PD, with similar prognostic outcomes. Novel predictive models with accurate, dynamic, and individualized performance further guide the management of PAD and afford a better prognosis.

CONCLUSIONS

Evidence-based risk stratification of CR-POPF aids in the management of PAD in patients undergoing PD. Novel dynamic and individualized PAD strategies might be the next hotspot in drain-relevant explorations.

Short-term surgical outcomes of open, laparoscopic, and robot-assisted pancreatoduodenectomy: A comparative, single-center, retrospective study

PURPOSE

Although laparoscopic pancreaticoduodenectomy (LPD) and robot-assisted pancreaticoduodenectomy (RPD) are gradually gaining popularity, their advantages over open pancreaticoduodenectomy (OPD) remain controversial. This study aimed to compare the short-term outcomes of OPD, LPD, and RPD to elucidate the advantages and disadvantages of each procedure.

METHODS

We retrospectively analyzed 16 LPD, 43 RPD, and 36 OPD procedures performed at a single center between April 2020 and May 2024. Clinical data, including operative time, estimated blood loss, postoperative complications, length of hospital stay, and hospitalization costs, were retrospectively collected and analyzed.

RESULTS

RPD demonstrated a significantly longer operative time (553 min) than OPD (446 min) and LPD (453 min) but a significantly lower estimated blood loss than OPD (150 mL vs. 400 mL, p < .001). Postoperative complication rates (Clavien-Dindo grade ≥3) were lower for RPD (24.4%) than those for OPD (50.0%) and LPD (68.8%). RPD also showed a significantly lower rate of clinically relevant postoperative pancreatic fistula (14.6% vs. 38.9% for OPD and 43.8% for LPD) and a shorter duration of hospitalization (11 vs. 28 days for OPD and 21 days for LPD, p < .001). Hospitalization costs were higher for RPD (20 109 USD) than for OPD (18 487 USD, p < .001), with LPD (20 496 USD) and RPD costs being similar.

CONCLUSIONS

RPD appears to offer advantages in terms of reduced blood loss and postoperative complications and shortened hospital stay despite longer operative times and higher hospitalization costs. Therefore, RPD may be a more beneficial approach than OPD or LPD in pancreatic surgery.

Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference

OBJECTIVE

To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

BACKGROUND

HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

METHODS

The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

RESULTS

Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

CONCLUSIONS

The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Impact of patient age on outcome of minimally invasive versus open pancreatoduodenectomy: a propensity score matched study

BACKGROUND

Pancreatoduodenectomy in elderly patients may be associated with increased postoperative mortality, but studies in minimally invasive pancreatoduodenectomy (MIPD) are scarce.

METHODS

International multicenter retrospective study including patients aged >60 years undergoing MIPD (robot-assisted and laparoscopic) and open pancreatoduodenectomy (OPD), were categorized by age: 60-69, 70-79, and 80+ years. In each category, propensity score matching (PSM) was performed (1:1 ratio) between MIPD and OPD. Primary outcome was 30-day/in-hospital mortality.

RESULTS

Among 3820 patients, we matched 1468 patients aged 60-69, 1154 patients aged 70-79, and 196 patients aged 80+ years. In patients aged 60-69 and 70-79 years, MIPD was associated with longer operative time, less blood loss and a longer length of stay. Major morbidity was higher after MIPD with similar 30-day/in-hospital mortality. The R0 resection rate was higher after MIPD. In patients aged 80+ years, besides a longer operative time in MIPD, outcomes were comparable between both groups.

CONCLUSION

This study found no evidence that increasing age worsens mortality of MIPD. MIPD was associated with longer operative time, higher rate of major morbidity, prolonged length of stay versus less blood loss and a higher R0 resection in patients aged 60-69 and 70-79 years. These differences continue in patients aged 80+ years, but became less evident.

Clinicopathologic features and surgery-related outcomes of duodenal adenocarcinoma: A multicenter retrospective study

BACKGROUND

The incidence of duodenal adenocarcinoma is increasing, with limited studies on this disease published. This multicenter retrospective study aimed to analyze the clinicopathologic features of duodenal adenocarcinoma and identify prognostic factors for postoperative survival.

METHODS

Demographic characteristics, clinicopathologic features, treatment outcomes, and survival of patients with duodenal adenocarcinoma undergoing surgical treatment at 16 Chinese medical centers from 2012 to 2023 were retrospectively analyzed.

RESULTS

Among the 2,189 patients with duodenal adenocarcinoma included, 50.07% had extra-ampullary duodenal adenocarcinoma and 49.93% had peri-ampullary duodenal adenocarcinoma. The 1-, 3-, and 5-year overall survival rates for patients who underwent radical surgery were 91.78%, 69.30%, and 55.86%, respectively. The median overall survival was 73 months (range, 64-84), and the median progression-free survival was 64 months (range, 52-76). No differences in survival were observed between the laparotomy and minimally invasive surgery groups (log-rank P = .562); furthermore, no significant between-group differences in operation time, lymph node dissection, postoperative complications, or in-hospital mortality were observed (P > .05). The minimally invasive surgery group experienced less intraoperative blood loss (250 mL vs 100 mL, P < .001), fewer intraoperative blood transfusions (24.97% vs 18.84%, P = .002), and shorter hospital stays (28 days vs 23 days, P < .001). Multivariate Cox regression analysis revealed that advanced age, advanced stage, longer operation time, intraoperative blood transfusion, and postoperative hemorrhage were independent risk factors for poor prognosis.

CONCLUSION

Radical surgery was associated with favorable overall survival among patients with duodenal adenocarcinoma, and no difference in survival was observed between patients with extra-ampullary duodenal adenocarcinoma and peri-ampullary duodenal adenocarcinoma. Minimally invasive surgery is a reliable alternative for duodenal adenocarcinoma treatment.

Learning curve stratified outcomes after robotic pancreatoduodenectomy: International multicenter experience

BACKGROUND

Robotic pancreatoduodenectomy is increasingly being implemented worldwide, with good results reported from individual expert centers. However, it is unclear to what extent outcomes will continue to improve during the learning curve, as large international studies are lacking.

METHODS

An international retrospective multicenter case series, including consecutive patients after robotic pancreatoduodenectomy from 18 centers in 8 countries in Europe, Asia, and South America until December 31, 2019, was conducted. A cumulative sum analysis was performed to determine the inflection points for the feasibility (operative time and blood loss) and proficiency (postoperative pancreatic fistula grade B/C and major morbidity) learning curves. Outcomes were compared in 3 groups on the basis of the learning curve inflection points.

RESULTS

Overall, 2,186 patients after robotic pancreatoduodenectomy were included. The feasibility learning curve was reached after 30-45 robotic pancreatoduodenectomy procedures and the proficiency learning curve after 90 robotic pancreatoduodenectomy procedures. These inflection points created 3 phases, which were associated with major morbidity (24.7%, 23.4%, and 12.3%, P < .001) but not 30-day mortality (2.1%, 2.0%, and 1.5%, P = .670). Other outcomes mostly continued to improve, including median operative time 432, 390, and 300 minutes (P < .0001), conversion 6.0%, 4.7%, and 2.7% (P = .002), bile leakage 7.2%, 4.1%, and 2.4% (P < .001), postpancreatectomy hemorrhage 6.5%, 6.1%, and 1.8% (n = 21) but not R0 resection (pancreatic ductal adenocarcinoma only) 78.5%, 73.9%, and 82.8% (P = .35), and 90-day mortality rate 3.1%, 3.5%, and 2.1% (P = .191). Centers performing >20 robotic pancreatoduodenectomies annually had lower rates of conversion, reoperation, and shorter median operative time as compared with centers performing 10-20 robotic pancreatoduodenectomies annually.

CONCLUSION

This international multicenter study demonstrates that most outcomes of robotic pancreatoduodenectomy continued to improve during 3 learning curve phases without a negative effect on 90-day mortality. Randomized studies are needed in high-volume centers that have surpassed the first learning curves, to compare these outcomes with the open approach.

Transatlantic differences in the use and outcome of minimally invasive pancreatoduodenectomy: an international multi-registry analysis

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) has emerged as an alternative to open pancreatoduodenectomy (OPD). However, the extent of variation in the use and outcomes of MIPD in relation to OPD among countries is unclear as international studies using registry data are lacking. This study aimed to investigate the use, patient selection, and outcomes of MIPD and OPD in four transatlantic audits for pancreatic surgery.

METHODS

A post hoc comparative analysis including consecutive patients after MIPD and OPD from four nationwide and multicenter pancreatic surgery audits from North America, Germany, the Netherlands, and Sweden (2014-2020). Patient factors related to MIPD were identified using multivariable logistic regression. Outcome analyses excluded the Swedish audit because < 100 MIPD were performed during the studied period.

RESULTS

Overall, 44,076 patients who underwent pancreatoduodenectomy were included (29,107 North America, 7586 Germany, 4970 the Netherlands, and 2413 Sweden), including 3328 MIPD procedures (8%). The use of MIPD varied widely among countries (absolute largest difference [ALD] 17%, p < 0.001): 7% North America, 4% Germany, 17% the Netherlands, and 0.1% Sweden. Over time, the use of MIPD increased in North America and the Netherlands (p < 0.001), mostly driven by robotic MIPD, but not in Germany (p = 0.297). Patient factors predicting the use of MIPD included country, later year of operation, better performance status, high POPF-risk score, no vascular resection, and non-malignant indication. Conversion rates were higher in laparoscopic MIPD (range 28-45%), compared to robotic MIPD (range 9-37%). In-hospital/30-day mortality differed among North America, Germany, and the Netherlands; MIPD (2%, 7%, 4%; ALD 5%, p < 0.001) and OPD (2%, 5%, 3%; ALD 3%, p < 0.001), similar to major morbidity; MIPD (25%, 42%, 38%, ALD 17%, p < 0.001) and OPD (25%, 31%, 30%, ALD 6%, p < 0.001), respectively.

CONCLUSIONS

Considerable differences were found in the use and outcome, including conversion and mortality rates, of MIPD and OPD among four transatlantic audits for pancreatic surgery. Our findings highlight the need for international collaboration to optimize treatment standards and patient outcome.

Network Meta-Analysis and Trial Sequential Analysis of Randomised Controlled Trials Comparing Robotic, Laparoscopic, and Open Pancreatoduodenectomy

Background

The use of minimally invasive (laparoscopic and robotic) pancreatoduodenectomy (PD) is being increasingly adopted despite the lack of hard evidence to support its utilisation. With recent randomised controlled trials (RCTs) comparing open pancreatoduodenectomy (OPD) with robotic or laparoscopic pancreatoduodenectomy (RPD or LPD), we undertook a network meta-analysis (NMA) comparing all 3 approaches to evaluate comparative outcomes.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane CENTRAL was conducted up to May 2024 and relevant RCTs were identified. A random-effects meta-analysis and trial sequential analysis (TSA) were conducted for primary outcomes, followed by a Bayesian NMA of length of stay (LOS), duration of surgery, intraoperative blood loss, and pancreas resection-related outcomes.

Results

Seven RCTs involving 1336 patients were included, 5 investigating LPD compared with OPD and 2 RPD to OPD. Pairwise meta-analysis indicated that LPD was associated with shorter hospital stay (mean difference [MD], -1.39; 95% confidence interval [CI], -2.33 to -0.45) and lower intraoperative blood loss compared with OPD (MD, -131; 95% CI, -146 to -117). However, LPD was associated with significantly longer operative duration (MD, 39.5; 95% CI, 34-45). TSA confirmed the robustness of the positive and negative findings on pairwise meta-analysis. In comparison, there were no significant differences between RPD and OPD in pairwise meta-analysis, which could not be confirmed by TSA. Network meta-analysis tended to favour LPD in most outcome parameters including LOS, duration of surgery, and pancreas resection-related outcomes.

Conclusions

The current RCT evidence suggests potential better outcomes in LPD in comparison with RPD and OPD. However, few studies demonstrated robust statistical significance in outcome measures, suggesting an underpowered evidence base and possible selection bias. Hence, with current equivocal data, there is a need for ongoing RCTs to validate the role of minimally invasive approaches in PD.

Minimally invasive pancreatoduodenectomy with combined venous vascular resection: A comparative analysis with open approach

Backgrounds/Aims

This study aimed to compare the minimally invasive pancreatoduodenectomy with venous vascular resection (MI-PDVR) and open pancreatoduodenectomy with venous vascular resection (O-PDVR) for periampullary cancer.

Methods

Data of 124 patients who underwent PDVR (45 MI-PDVR, 79 O-PDVR) between January 1, 2016, and December 31, 2023, was retrospectively reviewed.

Results

MI-PDVR is significantly better than O-PDVR in terms of perioperative outcomes (median operation time [452.69 minutes vs. 543.91 minutes; p = 0.004], estimated blood loss [410.44 mL vs. 747.59 mL; p < 0.01], intraoperative transfusion rate [2 cases vs. 18 cases; p = 0.01], and hospital stay [18.16 days vs. 23.91 days; p = 0.008]). The complications until the discharge day showed no significant difference between the two groups (Clavien-Dindo < 3, 84.4% vs. 82.3%; Clavien-Dindo ≥ 3, 15.6% vs. 17.7%; p = 0.809). In terms of long-term oncological outcomes, there was no statistical difference in overall survival (OS, 51.55 months [95% CI: 35.95-67.14] vs. median 49.92 months [95% CI: 40.97-58.87]; p = 0.340) and disease-free survival (DFS, median 35.06 months [95% CI: 21.47-48.65] vs. median 38.77 months [95% CI: 29.80-47.75]; p = 0.585), between the two groups. Long-term oncological outcomes for subgroup analysis focusing on pancreatic ductal adenocarcinoma also showed no statistical differences in OS (40.86 months [95% CI: 34.45-47.27] vs. 48.48 months [95% CI: 38.16-58.59]; p = 0.270) and DFS (24.42 months [95% CI: 17.03-31.85] vs. 34.35 months, [95% CI: 25.44-43.27]; p = 0.740).

Conclusions

MI-PDVR can provide better perioperative outcomes than O-PDVR, and has similar oncological impact.

Impact of overweight on patients undergoing laparoscopic pancreaticoduodenectomy: analysis of surgical outcomes in a high-volume center

BACKGROUND

The feasibility and safety of laparoscopic pancreaticoduodenectomy (LPD) in overweight patients is still controversial. This study was designed to analyze the impact of overweight on surgical outcomes in patients undergoing LPD.

METHODS

Data from patients who underwent LPD between January 2018 and July 2022 were analyzed retrospectively. A 1:1 propensity score-matching (PSM) analysis was performed to minimize bias between groups.

RESULTS

A total of 432 patients were enrolled, with a normal weight group (n = 241) and an overweight group (n = 191). After matching, 144 patients were enrolled in each group. The results showed that the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) and delayed gastric emptying (DGE) was significantly higher in the overweight group compared to the normal weight group (P = 0.036). However, there were no significant differences in perioperative mortality (1.4% vs. 2.1%, P = 0.652) and long-term survival outcomes between malignancy patients with different body mass index (BMI) before and after PSM (all P > 0.05).

CONCLUSIONS

It is safe and feasible for overweight patients to undergo LPD with mortality and long-term survival outcomes comparable to the normal weight group. High-quality prospective randomized controlled trials are still needed.

Exploring the landscape of minimally invasive pancreatic surgery: Progress, challenges, and future directions

Minimally invasive surgery (MI) has become the standard of care for many surgical procedures aimed at reducing the burden on patients. However, its adoption in pancreatic surgery (PS) has been limited by the pancreas's unique location and the complexity of the dissection and reconstruction phases. These factors continue to contribute to PS having one of the highest morbidity and mortality rates in general surgery. Despite a rough start, MIPS has gained widespread acceptance in clinical practice recently. Robust evidence supports MI distal pancreatectomy safety, even in oncological cases, indicating its potential superiority over open surgery. However, definitive evidence of MI pancreaticoduodenectomy (MIPD) feasibility and safety, particularly for malignant lesions, is still lacking. Nonetheless, reports from high-volume centers are emerging, suggesting outcomes comparable to those of the open approach. The robotic PS increasing adoption, facilitated by the wider availability of robotic platforms, may further facilitate the transition to MIPD by overcoming the technical constraints associated with laparoscopy and accelerating the learning curve. Although the MIPS implementation process cannot be stopped in this evolving world, ensuring patient safety through strict outcome monitoring is critical. Investing in younger surgeons with structured and recognized training programs can promote safe expansion.

Impact of an enhanced anti-infection prophylaxis strategy for pancreatoduodenectomy: a single centre analysis

INTRODUCTION : Surgical site infection (SSI) after pancreatoduodenectomy (PD) is a significant concern. Targeted antibiotic prophylaxis (pAP) has been tested to mitigate antibiotic resistance patterns, especially after preoperative bile duct stenting. The aim of this study was to investigate the effect of enhanced anti-infective prophylaxis (EAP) on the incidence of superficial and intraabdominal SSI.

METHODS

All patients who underwent PD at a single centre between May 2018 and May 2021 were retrospectively analysed. A control cohort of patients who received pAP with intravenous cefuroxime and metronidazole and routine intraoperative abdominal lavage according to the surgeons' preferences. Since March 2020, pAP has been changed to piperacillin/tazobactam according to local resistance patterns and combined with routine intraoperative extended abdominal lavage (EIPL). Preoperative selective decontamination of the digestive tract (SDD) has been applied routinely since Jan 2019.

RESULTS

In total, 163 patients were included. The standard (n = 100) and EAP (n = 63) groups did not significantly differ with regard to pertinent patient and operative characteristics. In the EAP group, the rates of SSI (14% vs. 37%, p = 0.002, total rate: 28%) and urinary tract infection (24% vs. 8%, p = 0.011, total rate 18%) were significantly lower. Other septic complications were not significantly different. In addition, the risk of developing gastrointestinal bleeding and delayed gastric emptying was significantly lower in the EAP group. Multivariate analysis showed that an age > 67 years was a significant risk factor for SSI.

CONCLUSION

The results indicate that enhanced anti-infective prophylaxis may significantly decrease the incidence of SSI in patients after PD.

Consensus, debate, and prospective on pancreatic cancer treatments

Pancreatic cancer remains one of the most aggressive solid tumors. As a systemic disease, despite the improvement of multi-modality treatment strategies, the prognosis of pancreatic cancer was not improved dramatically. For resectable or borderline resectable patients, the surgical strategy centered on improving R0 resection rate is consensus; however, the role of neoadjuvant therapy in resectable patients and the optimal neoadjuvant therapy of chemotherapy with or without radiotherapy in borderline resectable patients were debated. Postoperative adjuvant chemotherapy of gemcitabine/capecitabine or mFOLFIRINOX is recommended regardless of the margin status. Chemotherapy as the first-line treatment strategy for advanced or metastatic patients included FOLFIRINOX, gemcitabine/nab-paclitaxel, or NALIRIFOX regimens whereas 5-FU plus liposomal irinotecan was the only standard of care second-line therapy. Immunotherapy is an innovative therapy although anti-PD-1 antibody is currently the only agent approved by for MSI-H, dMMR, or TMB-high solid tumors, which represent a very small subset of pancreatic cancers. Combination strategies to increase the immunogenicity and to overcome the immunosuppressive tumor microenvironment may sensitize pancreatic cancer to immunotherapy. Targeted therapies represented by PARP and KRAS inhibitors are also under investigation, showing benefits in improving progression-free survival and objective response rate. This review discusses the current treatment modalities and highlights innovative therapies for pancreatic cancer.

Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE.

DATA SOURCES

Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles.

RESULTS

In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE.

CONCLUSIONS

Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.

Minimally Invasive Pancreas Surgery: Is There a Benefit?

Minimally invasive procedures minimize trauma to the human body while maintaining satisfactory therapeutic results. Minimally invasive pancreas surgery (MIPS) was introduced in 1994, but questions regarding its efficacy compared to an open approach were widespread. MIPS is associated with several perioperative advantages while maintaining oncological standards when performed by surgeons with a robust training regimen and frequent practice. Future research should focus on addressing learning curve discrepancies while identifying factors associated with shortening the time needed to attain technical proficiency.

Preoperative systemic inflammatory response index as a prognostic marker for distal cholangiocarcinoma after pancreatoduodenectomy

BACKGROUND

The relationship between preoperative inflammation status and tumorigenesis as well as tumor progression is widely acknowledged.

AIM

To assess the prognostic significance of preoperative inflammatory biomarkers in patients with distal cholangiocarcinoma (dCCA) who underwent pancreatoduodenectomy (PD).

METHODS

This single-center study included 216 patients with dCCA after PD between January 1, 2011, and December 31, 2022. The individuals were categorized into two sets based on their systemic inflammatory response index (SIRI) levels: A low SIRI group (SIRI < 1.5, n = 123) and a high SIRI group (SIRI ≥ 1.5, n = 93). Inflammatory biomarkers were evaluated for predictive accuracy using receiver operating characteristic curves. Both univariate and multivariate Cox proportional hazards analyses were performed to estimate SIRI for overall survival (OS) and recurrence-free survival (RFS).

RESULTS

The study included a total of 216 patients, with 58.3% being male and a mean age of 65.6 ± 9.6 years. 123 patients were in the low SIRI group and 93 were in the high SIRI group after PD for dCCA. SIRI had an area under the curve value of 0.674 for diagnosing dCCA, showing better performance than other inflammatory biomarkers. Multivariate analysis indicated that having a SIRI greater than 1.5 independently increased the risk of dCCA following PD, leading to lower OS [hazard ratios (HR) = 1.868, P = 0.006] and RFS (HR = 0.949, P < 0.001). Additionally, survival analysis indicated a significantly better prognosis for patients in the low SIRI group (P < 0.001).

CONCLUSION

It is determined that a high SIRI before surgery is a significant risk factor for dCCA after PD.

Artisential®-assisted pancreatoduodenectomy: a comparative analysis with Robot(Da Vinci®)-assisted pancreatoduodenectomy

BACKGROUND

Robot-assisted pancreaticoduodenectomy (R-PD) helps further improve the safety and efficacy of minimally invasive pancreaticoduodenectomy. However, it faces challenges such as high costs and limitations in availability at different centers, making it difficult for patients to access. In this study, we evaluate the initial experience of Artisential®-assisted PD (A-PD) and compare its perioperative outcomes with R-PD, discussing the clinical applicability of A-PD.

METHODS

This study reviewed cases of R-PD and A-PD conducted between 2022 and 2023. A total of 34 patients underwent R-PD, while 26 patients underwent A-PD. Statistical analysis was conducted based on factors related to the patient's surgical procedure and postoperative prognostic indicators.

RESULTS

There were no significant differences observed between the two groups in terms of surgical factors. There were also no differences in the occurrence of postoperative complications. However, there was a significant difference in the length of hospital stay, with the Artisential® group having an average of 11.50 ± 5.54 days and the Robot group having 15.06 ± 5.34 days (p = 0.001).

CONCLUSIONS

R-PD and A-PD showed no differences in procedures or outcomes. Using a multi-articulated device is beneficial where robot use is challenging.

Drainage and irrigation on demand may decrease severe septic complications and mortality in pancreatic resections

PURPOSE

The necessity of routine drain placement in pancreatic resections is controversial. Some randomized controlled trials have shown that the omission of drainage is safe for some patients, whereas reintervention rates and mortality rates are substantial for others. The present study aimed to assess fistula-associated outcomes in the setting of routine drain placement and drain irrigation on demand.

METHODS

Between 01/2017 and 12/2022, perioperative and outcome data from patients who underwent consecutive pancreatoduodenectomies (PD, n = 253) or distal pancreatectomies (DP, n = 72) were prospectively collected in the electronic StuDoQ database and analysed. All patients underwent intraoperative drain placement. Drains were removed starting at postoperative day 2 in PD or at day 5 in DP after testing for amylase concentration. In case of high amylase levels or macroscopically suspicious pancreatic fistulas, drain irrigation was started. Nondrained fluid collections underwent percutaneous radiologic or transluminal endoscopic evacuation.

RESULTS

Clinically relevant pancreatic fistulas were detected in 53 of 325 patients (POPF grade B 16.3%, grade C 1.2%). 43.3% of those had drain irrigation. Additional interventional or endoscopic drainage was necessary in 14 and 5 patients, respectively (overall 5.8%), and were observed in 4.0% of patients with PD and in 12.5% with DP (p = 0.009). Delayed fistula-associated postpancreatectomy haemorrhage (PPH) was present in 1.2% (4/325) of patients. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). The 30-day and in-hospital mortality rates were both 1.5% (5/325), and the rate of fistula-associated mortality was 0.6% (2/325). The overall 90-day mortality rate was 4.5%.

CONCLUSIONS

In pancreatectomies, a standardized drainage protocol including on-demand drain irrigation results in very low fistula-associated morbidity and mortality and an infrequent need for interventional or surgical reintervention as compared to previously published drainage studies.

Effects of Minimally Invasive Versus Open Pancreatoduodenectomy on Short-Term Surgical Outcomes and Postoperative Nutritional and Immunological Statuses: A Single-Institution Propensity Score-Matched Study

Objective

To evaluate the feasibility and clinical impact of minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) on postoperative nutritional and immunological indices.

Background

The surgical advantages of MIPD over OPD are controversial, and the postoperative nutritional and immunological statuses are unknown.

Methods

In total, 306 patients who underwent MIPD (n = 120) or OPD (n = 186) for periampullary tumors from April 2016 to February 2024 were analyzed. Surgical outcomes and postoperative nutritional and immunological indices (albumin, prognostic nutritional index [PNI], neutrophil-to-lymphocyte ratio [NLR], and platelet-to-lymphocyte ratio [PLR]) were examined by 1:1 propensity score matching (PSM) with well-matched background characteristics.

Results

PSM resulted in 2 balanced groups of 99 patients each. Compared with OPD, MIPD was significantly associated with less estimated blood loss (P < 0.0001), fewer intraoperative blood transfusions (P = 0.001), longer operative time, shorter postoperative hospital stay (P < 0.0001), fewer postoperative complications (P = 0.001) (especially clinically relevant postoperative pancreatic fistula [P = 0.018]), and a higher rate of textbook outcome achievement (70.7% vs 48.5%, P = 0.001). The number of dissected lymph nodes and the R0 resection rate did not differ between the 2 groups. In elective cases with textbook outcome achievement, the change rates of albumin, PNI, NLR, and PLR from before to after surgery were equivalent in both groups.

Conclusions

MIPD has several surgical advantages (excluding a prolonged operative time), and it enhances the achievement of textbook outcomes over OPD. However, the postoperative nutritional and immunological statuses are equivalent for both procedures.

Laparoscopic Versus Open Pancreatoduodenectomy for Periampullary Tumors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

Laparoscopic pancreatoduodenectomy (LPD) has emerged as an alternative to open technique in treating periampullary tumors. However, the safety and efficacy of LPD compared to open pancreatoduodenectomy (OPD) remain unclear. Thus, we conducted an updated meta-analysis to evaluate the efficacy and safety of LPD versus OPD in patients with periampullary tumors, with a particular focus on the pancreatic ductal adenocarcinoma patient subgroup.

METHODS

According to PRISMA guidelines, we searched PubMed, Embase, and Cochrane Library in December 2023 for randomized controlled trials (RCTs) that directly compare LPD versus OPD in patients with periampullary tumors. Endpoints and sensitive analysis were conducted for short-term endpoints. All statistical analysis was performed using R software version 4.3.1 with a random-effects model.

RESULTS

Five RCTs yielding 1018 patients with periampullary tumors were included, of whom 511 (50.2%) were randomized to the LPD group. Total follow-up time was 90 days. LPD was associated with a longer operation time (MD 66.75; 95% CI 26.59 to 106.92; p = 0.001; I2 = 87%; Fig. 1A), lower intraoperative blood loss (MD - 124.05; 95% CI - 178.56 to - 69.53; p < 0.001; I2 = 86%; Fig. 1B), and shorter length of stay (MD - 1.37; 95% IC - 2.31 to - 0.43; p = 0.004; I2 = 14%; Fig. 1C) as compared with OPD. In terms of 90-day mortality rates and number of lymph nodes yield, no significant differences were found between both groups.

CONCLUSION

Our meta-analysis of RCTs suggests that LPD is an effective and safe alternative for patients with periampullary tumors, with lower intraoperative blood loss and shorter length of stay.

Performance of nutritional and inflammatory markers in patients with pancreatic cancer

BACKGROUND

Systemic inflammation and nutrition play pivotal roles in cancer progression and can increase the risk of delayed recovery after surgical procedures.

AIM

To assess the significance of inflammatory and nutritional indicators for the prognosis and postoperative recovery of patients with pancreatic cancer (PC).

METHODS

Patients who were diagnosed with PC and underwent surgical resection at our hospital between January 1, 2019, and July 31, 2023, were enrolled in this retrospective observational cohort study. All the data were collected from the electronic medical record system. Seven biomarkers - the albumin-to-globulin ratio, prognostic nutritional index (PNI), systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), nutritional risk index (NRI), and geriatric NRI were assessed.

RESULTS

A total of 446 patients with PC met the inclusion criteria and were subsequently enrolled. Patients with early postoperative discharge tended to have higher PNI values and lower SII, NLR, and PLR values (all P < 0.05). Through multivariable logistic regression analysis, the SII value emerged as an independent risk factor influencing early recovery after surgery. Additionally, both univariable and multivariable Cox regression analyses revealed that the PNI value was the strongest prognostic marker for overall survival (OS; P = 0.028) and recurrence-free survival (RFS; P < 0.001). The optimal cutoff PNI value was established at 47.30 using X-tile software. Patients in the PNI-high group had longer OS (P < 0.001) and RFS (P = 0.0028) times than those in the PNI-low group.

CONCLUSION

Preoperative systemic inflammatory-nutritional biomarkers may be capable of predicting short-term recovery after surgery as well as long-term patient outcomes.

Causes and predictors of unplanned reoperations within 30 days post laparoscopic pancreaticoduodenectomy: a comprehensive analysis

Objective

To delineate the risk factors and causes of unplanned reoperations within 30 days following laparoscopic pancreaticoduodenectomy (LPD).

Methods

A retrospective study reviewed 311 LPD patients at Ningbo Medical Center Li Huili Hospital from 2017 to 2024. Demographic and clinical parameters were analyzed using univariate and multivariate analyses, with P < 0.05 indicating statistical significance.

Results

Out of 311 patients, 23 (7.4%) required unplanned reoperations within 30 days post-LPD, primarily due to postoperative bleeding (82.6%). Other causes included anastomotic leakage, abdominal infection, and afferent loop obstruction. The reoperation intervals varied, with the majority occurring within 0 to 14 days post-surgery. Univariate analysis identified significant risk factors: diabetes, liver cirrhosis, elevated CRP on POD-3 and POD-7, pre-operative serum prealbumin < 0.15 g/L, prolonged operation time, intraoperative bleeding > 120 ml, vascular reconstruction, soft pancreatic texture, and a main pancreatic duct diameter ≤3 mm (all P < 0.05). Multivariate analysis confirmed independent risk factors: pre-operative serum prealbumin < 0.15 g/L (OR = 3.519, 95% CI 1.167-10.613), CRP on POD-7 (OR = 1.013, 95% CI 1.001-1.026), vascular reconstruction (OR = 9.897, 95% CI 2.405-40.733), soft pancreatic texture (OR = 5.243, 95% CI 1.628-16.885), and a main pancreatic duct diameter ≤3 mm (OR = 3.462, 95% CI 1.049-11.423), all associated with unplanned reoperation within 30 days post-LPD (all P < 0.05).

Conclusion

Postoperative bleeding is the primary cause of unplanned reoperations after LPD. Independent risk factors, confirmed by multivariate analysis, include low pre-operative serum prealbumin, elevated CRP on POD-7, vascular reconstruction, soft pancreatic texture, and a main pancreatic duct diameter of ≤3 mm. Comprehensive peri-operative management focusing on these risk factors can reduce the likelihood of unplanned reoperations and improve patient outcomes.

Meta-analysis of postoperative incision infection risk factors in colorectal cancer surgery

Objective

To evaluate the risk factors for postoperative incision infection in colorectal cancer, this meta-analysis aimed to identify key variables impacting infection incidence following colorectal cancer surgery.

Methods

Utilizing a meta-analytical approach, studies published from January 2015 to December 2022 were systematically collected and analyzed through the assessment of factors like body mass index, diabetes, albumin levels, malnutrition, and surgical duration.

Results

The meta-analysis of eleven high-quality studies revealed that elevated BMI, diabetes, low albumin levels, malnutrition, and extended surgical duration were associated with increased infection risk, while laparoscopic procedures showed potential for risk reduction.

Conclusions

This study underscores the significance of preoperative risk assessment and management in mitigating postoperative incision infections in colorectal cancer patients. The findings present actionable insights for clinicians to enhance patient prognoses and overall quality of life.

Early postoperative fever as a predictor of pancreatic fistula after pancreaticoduodenectomy: a single-center retrospective observational study

BACKGROUND

The connection between early postoperative fever and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy remains unclear. This study aimed to investigate this association and assess the predictive value of early postoperative fever for CR-POPF.

METHODS

This retrospective observational study included adult patients who underwent pancreaticoduodenectomy at a tertiary teaching hospital between 2007 and 2019. Patients were categorized into those with early postoperative fever (≥ 38 °C in the first 48 h after surgery) and those without early postoperative fever groups. Weighted logistic regression analysis using stabilized inverse probability of treatment weighting (sIPTW) and multivariable logistic analysis were performed. The c-statistics of the receiver operating characteristic curves were calculated to evaluate the impact on the predictive power of adding early postoperative fever to previously identified predictors of CR-POPF.

RESULTS

Of the 1997 patients analyzed, 909 (45.1%) developed early postoperative fever. The overall incidence of CR-POPF among all the patients was 14.3%, with an incidence of 19.5% in the early postoperative fever group and 9.9% in the group without early postoperative fever. Early postoperative fever was significantly associated with a higher risk of CR-POPF after sIPTW (adjusted odds ratio [OR], 1.73; 95% confidence interval [CI], 1.34-2.22; P < 0.001) and multivariable logistic regression analysis (adjusted OR, 1.88; 95% CI, 1.42-2.49; P < 0.001). The c-statistics for the models with and without early postoperative fever were 0.76 (95% CI, 0.73-0.79) and 0.75 (95% CI, 0.72-0.78), respectively, showing a significant difference between the two (difference, 0.02; 95% CI, 0.00-0.03; DeLong's test, P = 0.005).

CONCLUSIONS

Early postoperative fever is a significant but not highly discriminative predictor of CR-POPF after pancreaticoduodenectomy. However, its widespread occurrence limits its applicability as a predictive marker.

Prevention of postpancreatectomy hemorrhage after laparoscopic pancreaticoduodenectomy by wrapping ligamentum teres hepatis surrounding hepatic portal artery

Postpancreatectomy hemorrhage (PPH) is an important risk factor for postoperative complications after laparoscopic pancreaticoduodenectomy (LPD). Recent studies have reported that the use of ligamentum teres hepatis (LTH) in LPD may reduce the risk of PPH. Therefore, this study aims to investigate whether wrapping the hepatic hilar artery with the LTH can reduce PPH after LPD. We reviewed the data of 131 patients who underwent LPD in our team from April 2018 to December 2023. The patients were divided into Groups A (60 patients) and B (71 patients) according to whether the hepatic portal artery was wrapped or not. The perioperative data of the two groups were compared to evaluate the effect of LTH wrapping the hepatic hilar artery on LPD. The platelet count of Group A was (225.25 ± 87.61) × 10^9/L, and that of Group B was (289.38 ± 127.35) × 10^9/L, with a statistically significant difference (p < 0.001). The operation time of group A [300.00 (270.00, 364.00)] minutes was shorter than that of group B [330.00 (300.00, 360.00)] minutes, p = 0.037. In addition, A set of postoperative hospital stay [12.00 (10.00, 15.00)] days shorter than group B [15.00 (12.00, 19.50)] days, p < 0.001. No PPH occurred in Group A, while 8 patients in Group B had PPH (7 cases of gastroduodenal artery hemorrhage and 1 case of proper hepatic artery hemorrhage), p = 0.019. The new technique of wrapping the hepatic hilar artery through the LTH can effectively reduce the occurrence of PPH after LPD.

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 Right Hemicolectomy With Gastrocolic Trunk Resection for Advanced Transverse Colon Cancer

Locally advanced right-sided colon cancer sometimes requires advanced procedures in addition to normal complete mesocolic excision. We describe laparoscopic right hemicolectomy with gastrocolic trunk (GCT) resection. A 48-year-old woman was diagnosed with right transverse colon cancer and severe lymph node metastasis. Bulky lymph nodes were in contact with the superior mesenteric vein (SMV) that invaded the root of the GCT. Curative laparoscopic right hemicolectomy with GCT resection was performed. GCT resection was performed using both cranial and caudal approaches. First, we ligated the distal side of the GCT from the cranial side and dissected the mesocolonic root from the pancreas. Then, we moved to the caudal view. The root of the GCT was ligated, and the resected GCT was mobilized from the pancreatic head while carefully coagulating the anterior superior pancreaticoduodenal veins (ASPDVs) using an ultrasonically activated device (USAD). The patient's postoperative course was favorable. Approaching the GCT from both the cranial and caudal sides, considering the limited handling axis of laparoscopy, is useful for performing this procedure safely. The cranial approach is important for creating a cranial safety zone before transitioning to the caudal approach. The pitfall is that the ASPDVs should not be managed in this step because the head of the USAD will contact the pancreatic head owing to the handling axis. ASPDVs should be managed using the caudal approach with a cranial safety zone. Although rarely performed, this procedure is sometimes essential for the treatment of advanced right-sided colon cancer.

Learning curve of robotic pancreatoduodenectomy by a single surgeon with extensive laparoscopic pancreatoduodenectomy experience

With the development of robotic systems, robotic pancreatoduodenectomies (RPDs) have been increasingly performed. However, the number of cases required by surgeons with extensive laparoscopic pancreatoduodenectomy (LPD) experience to overcome the learning curve of RPD remains unclear. Therefore, we aimed to analyze and explore the impact of different phases of the learning curve of RPD on perioperative outcomes. Clinical data were prospectively collected and retrospectively analyzed for 100 consecutive patients who underwent RPD performed by a single surgeon. This surgeon had previous experience with LPD, having performed 127 LPDs with low morbidity. The learning curve for RPD was analyzed using the cumulative sum (CUSUM) method based on operation time, and perioperative outcomes were compared between the learning and proficiency phases. Between April 2020 and November 2022, one hundred patients (56 men, 44 women) were included in this study. Based on the CUSUM curve of operation time, the learning curve for RPD was divided into two phases: phase I was the learning phase (cases 1-33) and phase II was the proficiency phase (cases 34-100). The operation time during the proficiency phase was significantly shorter than that during the learning phase. In the learning phase of RPD, no significant increases were observed in estimated blood loss, conversion to laparotomy, severe complications, postoperative pancreatic hemorrhage, clinical pancreatic fistula, or other perioperative complications compared to the proficiency phases of either RPD or LPD. A surgeon with extensive prior experience in LPD can safely surmount the RPD learning curve without increasing morbidity in the learning phase. The proficiency was significantly improved after accumulating experience of 33 RPD cases.

Laparoscopic Pancreatoduodenectomy: Twenty years later, where are we?

In its 20th anniversary, laparoscopic pancreatoduodenectomy, while feasible and safe in the hands of experienced surgeons, has not seen the anticipated popularity observed in other digestive surgery procedures. The primary hurdle remains the absence of a clear advantage over traditional open surgery, paired with the procedures complexity and a consequent steep learning curve. In regions with limited pancreatic surgery services, conducting this procedure without adequate training can have serious repercussions. Given the advent of robotic platforms and the anticipation of prospective and randomized studies on this new technology, it is imperative to engage in comprehensive discussions, endorsed by surgical societies, on the value, application, and implementation strategies for various minimally invasive pancreatoduodenectomy techniques. Such dialogue is crucial for advancing the field and ensuring optimal patient outcomes.

Perioperative textbook outcomes of minimally invasive pancreatoduodenectomy: a multicenter retrospective cohort analysis in a Korean minimally invasive pancreatic surgery registry

BACKGROUND

The aim of this study is to investigate the perioperative composite textbook outcomes of pancreatic surgery after minimally invasive pancreatoduodenectomy (MIPD).

MATERIALS AND METHODS

The cohort study was conducted across 10 institutions and included 1552 patients who underwent MIPD registered with the Korean Study Group on Minimally Invasive Pancreatic Surgery between May 2007 and April 2020. We analyzed perioperative textbook outcomes of pancreatic surgery after MIPD. Subgroup analyses were performed to assess outcomes based on the hospital volume of MIPD.

RESULTS

Among all patients, 21.8% underwent robotic pancreatoduodenectomy. High-volume centers (performing >20 MIPD/year) performed 88.1% of the procedures. The incidence of clinically relevant postoperative pancreatic fistula was 11.5%. Severe complications (Clavien-Dindo grade ≥IIIa) occurred in 15.1% of the cases. The 90-day mortality rate was 0.8%. The mean hospital stay was 13.7 days. Textbook outcomes of pancreatic surgery success were achieved in 60.4% of patients, with higher rates observed in high-volume centers than in low-volume centers (62.2% vs. 44.7%, P <0.001). High-volume centers exhibited significantly lower conversion rates (5.4% vs. 12.5%, P =0.001), lower 90-day mortality (0.5% vs. 2.7%, P =0.001), and lower 90-day readmission rates (4.5% vs. 9.6%, P =0.006) than those low-volume centers.

CONCLUSION

MIPD could be performed safely with permissible perioperative outcomes, including textbook outcomes of pancreatic surgery, particularly in experienced centers. The findings of this study provided valuable insights for guiding surgical treatment decisions in periampullary disease.