Minimally invasive surgery for pancreatic cancer

Association between quality metric adherence and overall survival among patients undergoing resection of pancreatic ductal adenocarcinoma

BACKGROUND

Process-based quality metrics are important for improving long-term outcomes after surgical resection. We sought to develop a practical surgical quality score for patients diagnosed with pancreatic ductal adenocarcinoma undergoing curative-intent resection.

METHODS

Patients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified using the National Cancer Database. Five surgical quality metrics were defined: minimally invasive approach, adequate lymphadenectomy, negative surgical margins, receipt of adjuvant therapy, and no prolonged hospitalization. Log-rank test and multivariable Cox regression analysis were used to determine the association of quality metrics with overall survival.

RESULTS

A total of 38,228 patients underwent curative-intent resection for pancreatic ductal adenocarcinoma. Median age at diagnosis was 68 years (interquartile range = 61-75), and roughly half the cohort was male (n = 19,562; 51.2%). Quality metrics were achieved on a varied basis: minimally invasive approach (n = 5,701; 14.9%), adequate lymphadenectomy (n = 27,122; 80.0%), negative surgical margin (n = 29,248; 76.5%), receipt of adjuvant therapy (n = 26,006; 68.0%), and absence of prolonged hospitalization (n = 26,470; 69.2%). An integer-based surgical quality score from 0 (no quality metrics) to 16 (all quality metrics) was calculated. Patients with higher scores had progressively better overall survival. Median overall survival differed substantially among the score categories (score = 0-4 points, 8.7 [8.0-9.6] months; 5-8 points, 17.5 [16.9-18.2] months; 9-12 points, 22.1 [21.6-22.8] months; and 13-16 points, 30.8 [30.2-31.3] months; P <  .001). On multivariable analysis, risk-adjusted mortality hazards decreased in a stepwise manner with higher scores (0-4 points: reference; 5-8 points: multivariable adjusted hazard ratio = 0.60; 95% CI, 0.57-0.63; 9-12 points: adjusted hazard ratio = 0.49; 95% CI, 0.47-0.52; 13-16 points: and adjusted hazard ratio = 0.37; 95% CI, 0.34-0.40; all P < .001).

CONCLUSION

Adherence to quality metrics may be associated with improved overall survival. Efforts aimed at increasing compliance with quality metric measures may help optimize long-term outcomes among patients undergoing surgical resection for pancreatic ductal adenocarcinoma.

Value of the surgical pancreatic duct anatomy and associated outcomes in pancreatic cancer

INTRODUCTION

Pancreatic cancer recurrence following surgery is a significant challenge, and personalized surgical care is crucial. Topographical variations in pancreatic duct anatomy are frequent but often underestimated. This study aimed to investigate the potential importance of these variations in outcomes and patient survival after Whipple's procedures.

METHODS

Data were collected from 105 patients with confirmed pancreatic head neoplasms who underwent surgery between 2008 and 2020. Radiological measurements of pancreatic duct location were performed, and statistical analysis was carried out using IBM SPSS.

RESULTS

Inferior pancreatic duct topography was associated with an increased rate of metastatic spread and tumour recurrence. Additionally, inferior duct topography was associated with reduced overall and recurrence-free survival. Posterior pancreatic duct topography was associated with decreased incidence of perineural sheet infiltration and improved overall survival.

DISCUSSION

These findings suggest that topographical diversity of pancreatic duct location can impact outcomes in Whipple's procedures. Intraoperative review of pancreatic duct location could help surgeons define areas of risk or safety and deliver a personalized surgical approach for patients with beneficial or deleterious anatomical profiles. This study provides valuable information to improve surgical management by identifying high-risk patients and delivering a personalized surgical approach with prognosis stratification.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

Human microbiota colonization and pancreatic ductal carcinoma

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease with a high mortality rate and a poor prognosis. The human microbiota has been confirmed to participate in oncogenesis and may influence the treatment response to both chemotherapy and immunotherapy. Evidence for the association of the microbiota with PDAC risk, tumorigenesis, treatment response, and survival period is rapidly emerging. The oral microbiota and gut microbiota have the potential to be used in early diagnosis and risk stratification. Intratumor microbiota-targeted intervention strategies may be used as adjuvants to current treatments to improve therapeutic efficacy and overall survival. Here, we summarize the effect and association of the oral, gut and intratumor microbiota on the oncogenesis, progression and treatment of PDAC, as well as the potential of the microbiota to serve as a biomarker for the diagnosis and prognosis of PDAC, as well as a therapeutic target.

Modified Frailty Index to Assess Risk in Elderly Patients Undergoing Distal Pancreatectomy: A Retrospective Single-Center Study

Background

To compare the postoperative course of elderly patients (≥70 years) submitted to minimally invasive (MIDP) versus open distal pancreatectomy (ODP) and to evaluate if the modified Frailty Index (mFI) predicts the surgical course of elderly patients submitted to DP.

Methods

Data of patients aged ≥70 who underwent DP at a single institution between March 2011 and December 2019 were retrospectively retrieved. A 2:1 propensity score matching (PSM) was used to correct for differences in baseline characteristics. Then, postoperative complications were compared between the two groups (MIDP vs. ODP). Additionally, the entire cohort of DP elderly patients was stratified according to the mFI into three groups: non-frail (mFI = 0), mildly frail (mFI = 1/2), or severely frail (mFI = 3) and then compared.

Results

A total of 204 patients were analyzed. After PSM, 40 MIDP and 80 ODP patients were identified. The complications considered stratified homogenously between the two groups, with no statistically significant differences. The severity of the postoperative course increased as mFI did among the three groups regarding any complication (p = 0.022), abdominal collection (p = 0.014), pulmonary complication (p = 0.001), postoperative confusion (p = 0.047), Clavien-Dindo severity ≥3 events (p = 0.036), and length of stay (p = 0.018).

Conclusions

Elderly patients can be safely submitted to MIDP. The mFI identifies frail elderly patients more prone to develop surgical and non-surgical complications after DP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06436-2.

Robotic Dual-Console Distal Pancreatectomy: Could it be Considered a Safe Approach and Surgical Teaching even in Pancreatic Surgery? A Retrospective Observational Study Cohort

Background

The study aims to assess the safety and feasibility of the robotic dual-console during a robotic distal pancreatectomy

Methods

The data of the consecutive patients submitted to RDP from 2012 to 2019 at the Verona University were retrieved from a prospectively maintained database. The patients submitted to RDP were divided into the dual-console platform group (DG) and compared to the standard robotic procedure group (SG).

Results

In the study period, 102 robotic distal pancreatectomies were performed, of whom 42 patients (41%) belonged to the DG and 60 patients (59%) to the SG. Higher operation time was recorded in the DG compared to the SG (410 vs. 265 min, p < 0.001). The overall conversion rate of the series was 7% (n 7 patients). All the conversions were observed in the SG (p = 0.021). No differences in morbidity or pancreatic fistula rate were recorded (p > 0.05). No mortality events in the 90th postoperative days were reported in this series.

Conclusions

The robotic dual-console approach for distal pancreatectomy is safe, feasible, and reproducible. The postoperative surgical outcomes are comparable to the standard RDP with the single-console da Vinci Surgical System®. This surgical technique can widely and safely improve the robotic surgical training program.

Robotic pancreatic surgery: minimally invasive approach to challenging operations

BACKGROUND

Pancreatic surgery is still associated with high perioperative morbidity and mortality. The purpose of this study was to present the short-term outcomes of robot-assisted pancreatic surgery, including pancreaticoduodenectomy (RAPD), distal pancreatectomy (RDP) with or without splenectomy, enucleation (REN), and atypical resection (RAR), for benign, borderline, and malignant lesions at a high-volume center.

METHODS

A single-center, prospective database was used to retrospectively analyze the early outcomes of robotic pancreatic procedures completed between 2014 and 2020. Out of 124 attempted operations, 3 patients received palliative robotic surgery (2.4%). Of the remaining 121, 14 (11.6%) were converted to open surgery. The robotic procedures included 107 patients: 56 underwent RAPD, 31 underwent RDP (28 with and 3 without splenectomy), 16 underwent REN, and 4 underwent RAR (2 central and 2 total pancreatectomies).

RESULTS

The preoperative baseline characteristics and comorbidities were consistent with those of a Western population. The overall incidence of complications was 43.9%, with the more severe (Clavien-Dindo III-IV) occurring after RAPD (19.6%). We collected 7 (13.1%) postoperative pancreatic fistulae after RAPD, 5 (16.1%) after RADP, and 2 (12.5%) after REN. The two central pancreatectomies developed a biochemical leak without sequelae. Three patients (2.8%) died within 90 days after surgery. Early refeeding was achieved in those who did not experience severe complications, while the median hospital stay was 8 days. The median number of harvested lymph nodes was 22, with non-R1 microscopic residual tumors found.

CONCLUSIONS

Robotic pancreatic surgery is a safe and oncologically adequate technique to manage benign and malignant diseases arising from the head, body, and tail of the pancreas.

Propensity score-matched comparison of the oncological feasibility and survival outcomes for pancreatic adenocarcinoma with robotic and open pancreatoduodenectomy

BACKGROUND

This study is to clarify the feasibility of and justification for robotic pancreaticoduodenectomy (RPD) in patients with pancreatic adenocarcinoma.

METHODS

A 1-to-1 propensity score-matched comparison of RPD and open pancreaticoduodenectomy (OPD) was performed based on six covariates commonly used to predict the survival outcome for pancreatic adenocarcinoma.

RESULTS

A total of 130 patients were enrolled, with 65 in each study group after propensity score matching. The median operating time was longer for RPD (8.3 h vs. 7.0 h, P = 0.002). However, RPD was associated with less blood loss, lower overall surgical complication rate, and lower incidence of delayed gastric emptying. The resection radicality was oncologically similar between these two groups, but the median lymph node yield was higher for RPD (18 vs. 16, P = 0.038). Before propensity score matching, the 5-year survival was better in RPD (27.0% vs. 17.6%, P = 0.006). After matching, there was still a trend towards improved overall survival in the RPD group; however, the difference in 5-year survival between RPD and OPD was not significant (24.5% vs. 19.7%, P = 0.088).

CONCLUSION

RPD is not only technically feasible with no increase in surgical risk but also oncologically justifiable without compromising survival outcome. However, unlike randomized control trials, the limitations in this propensity score-matched analysis only accounted for 6 observed covariates commonly used to predict the survival outcome in patients with pancreatic adenocarcinoma, and confounders not included in this study could also affect our results.

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP.

METHODS

A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology.

RESULTS

Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found.

CONCLUSIONS

The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

Robotic versus laparoscopic hepatectomy for malignancy: A systematic review and meta-analysis

The aim of this study was to compare the clinical safety and efficacy of robotic hepatectomy (RH) versus conventional laparoscopic hepatectomy (LH) for malignancy using meta-analysis. A systematic literature search was performed using PubMed, EMBASE, Medline and the Cochrane Library databases up to September 2020 for studies, which limited to comparative articles of RH or LH for malignant tumors. Stata14.0 was performed in the meta-analysis. Six studies with a total of 1093 patients (345 RH and 748 LH) were eligible for inclusion. Operative time, tumor size, open procedure rate and the proportion of right hepatectomy were found to be significantly different between RH and LH in the pooled analysis (P < 0.05). Compared to LH, RH was associated with longer operative time, larger tumor size, lower open procedure rate and more common use for right hepatectomy. On the other hand, there was no difference in the operative time, estimated blood loss (EBL), blood transfusion rate, hospital stay, R0 resection rate, complications, resection margin, left lateral sectionectomy and left hepatectomy (P > 0.05). For malignant tumors that require hepatectomy, robotic approaches have demonstrated similar safety and feasibility to laparoscopy, with lower open procedure rate, were suitable for larger tumor size, and have a high right hepatectomy utilization rate. These results still need to be confirmed by multicenter, high-quality randomized controlled studies.

Defining Common Features in High Impact and Highly Cited Journal Articles on Pancreatic Tumors: An Analysis of 1044 Studies over the Past Decade

INTRODUCTION

Surgical researchers seek to publish their findings in esteemed surgical journals to advance science and their careers. A detailed investigation of study and manuscript attributes in a specific research area, like pancreatic neoplasia, may yield informative insights for researchers looking to maximize research impact.

OBJECTIVES

We analyzed publications related to pancreatic surgery primarily focused on pancreatic and periampullary tumors in order to identify elements associated with acceptance into high impact journals and a high likelihood of future citations.

METHODS

A comprehensive review of nine surgical journals was performed between 2010-19. Journals were grouped based on impact factor into high (>3), medium (1-3) and low (<1) impact categories. Each publication was annotated to identify study topic, methodology and statistical approach. Findings were compared according to journal impact and number of citations to identify predictors of success across these two domains.

RESULTS

A total of 1,044 out of 21,536 (4.8%) articles published in the index journals were related to pancreatic tumors. The most common focus of study was perioperative outcomes and complications (46.7%). There was significantly more number of authors, participating institutions, countries, and randomized clinical trials in higher impact journals as well as high-cited articles (p<0.05). Though advanced statistical analysis was used more commonly in high-impact journals (p<0.05), it did not translate to higher citations (p>0.05).

CONCLUSION

Pancreatic neoplasia continues to be extensively studied in surgical literature. Specific elements of study methodology and design were identified as potentially key attributes to acceptance in high impact journals and citation success.

Robotic vs open distal pancreatectomy: A multi-institutional matched comparison analysis

BACKGROUND

Pancreatic surgery is still a challenge even in high-volume centers. Clinically relevant postoperative pancreatic fistula (CR-POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study, we compared robotic distal pancreatectomy (RDP) to open distal pancreatectomy (ODP) in terms of CR-POPF development and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

We collected data from five high-volume centers for pancreatic surgery and performed a matched comparison analysis to compare short and long-term outcomes after ODP or RDP. Patients were matched with a 2:1 ratio according to age, ASA (American Society of Anesthesiologists) score, body mass index (BMI), final pathology, and TNM (Tumour, Node, Metastasis) staging system VIII ed.

RESULTS

Two hundred and forty-six patients who underwent 82 RDPs and 164 ODPs were included. No differences were found in the incidence of CR-POPF. In the PDAC group, median DFS and OS were 10.8 months and 14.8 months in the ODP group and 10.4 months and 15 months in the RDP group, respectively.

CONCLUSIONS

Robotic distal pancreatectomy is a safe surgical strategy for PDAC and incidence of CR-POPF is equivalent between RDP and ODP. RDP should be considered equivalent to ODP in terms of oncological efficacy when performed in high-volume and proficient centers.

Robotic spleen-preserving distal pancreatectomy: the Verona experience

BACKGROUND

The minimally invasive approach in spleen-preserving distal pancreatectomy has currently been emphasized in benign and pre-malignant pancreatic diseases. The study aims to demonstrate the safety and feasibility of our technique of robotic spleen-preserving distal pancreatectomy (RSPDP) by a stepwise approach.

METHODS

The data of consecutive patients presented for RSPDP from 2014 to 2019 at Verona University were retrieved from a prospectively maintained database. The patients were divided into two groups based on the surgical procedure performed, such as Kimura's (KG) or Warshaw's (WG) technique, and then compared.

RESULTS

In the study period, 32 patients underwent RSPDP. Twenty-three patients presented for the Kimura procedure (72%), while nine patients underwent the Warshaw procedure (28%). A higher body mass index was found in the KG (26 ± 4 vs. 22 ± 3, p = 0.037). Regarding the pathological data, the WG group differed in the tumor dimension, and the lymph nodes harvested (30 ± 2 vs. 17 ± 10, 9 ± 5 vs. 3 ± 4, p = 0.0028, and p = 0.005, respectively). Notably, no conversions and mortality were recorded. The overall morbidity was 25% ( eight patients) with no difference between the groups (p = 0.820). The mean length of stay was 8 days, and was similar between the groups (p = 0.350).

CONCLUSIONS

The present study suggests that RSPDP is a valid option for the treatment of benign or pre-malignant pancreatic diseases of the distal pancreas, with comparable morbidity with the standard treatment and no mortality. Further research is needed to standardize the technique and to assess the immunological, surgical, and financial benefits of the procedure.