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Luo YC, Yang TY, Li W, Yu QJ, Xia X, Lin ZY, Chen RD, Cheng L. Perioperative and oncologic outcomes of robot-assisted versus open surgery for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. J Robot Surg 2024; 18:288. [PMID: 39039276 DOI: 10.1007/s11701-024-02046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 07/07/2024] [Indexed: 07/24/2024]
Abstract
This systematic review and meta-analysis aimed to compare perioperative and oncologic outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) treated with robotic-assisted surgery versus open laparotomy. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials (RCTs) and cohort studies up to June 15, 2024, were identified using PubMed, EMBASE, and Google Scholar. Additionally, reference lists of included studies, relevant review articles, and clinical guidelines were manually searched. The primary outcomes evaluated were length of stay, 90-day mortality, postoperative pancreatic fistula (POPF), and Post-pancreatectomy haemorrhage (PPH). Secondary outcomes included estimated blood loss, reoperation rate, lymph node yield, and operative time. The final analysis included 10 retrospective cohort studies involving 23,272 patients (2,179 robotic-assisted and 21,093 open surgery). There were no significant differences between the two procedures in terms of postoperative pancreatic fistula, Post-pancreatectomy haemorrhage, lymph node yield, and operative time. However, patients undergoing robotic-assisted surgery had shorter lengths of stay, lower 90-day mortality, and less estimated blood loss compared to those undergoing open surgery. The reoperation rate was higher for the robotic-assisted group. Robotic-assisted surgery for pancreatic ductal adenocarcinoma is safe and feasible. Compared to open surgery, it offers better perioperative and short-term oncologic outcomes, but with a higher risk of reoperation.
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Affiliation(s)
- Yu-Chuan Luo
- North Sichuan Medical College, Nanchong, China
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Ting-Yu Yang
- North Sichuan Medical College, Nanchong, China
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Wei Li
- North Sichuan Medical College, Nanchong, China
| | - Qian-Jun Yu
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Xin Xia
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Zhi-Yu Lin
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Ru-De Chen
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Long Cheng
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China.
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Zhun Hong Wong N, Wei Ting Yap D, Lei Ng S, Yu Ning Ng J, James JJ, Wei Chieh Kow A. Oncological outcomes in minimally invasive vs. open distal pancreatectomy: a systematic review and network meta-analysis. Front Surg 2024; 11:1369169. [PMID: 38933652 PMCID: PMC11203400 DOI: 10.3389/fsurg.2024.1369169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/08/2024] [Indexed: 06/28/2024] Open
Abstract
Background Advancements in surgical techniques have improved outcomes in patients undergoing pancreatic surgery. To date there have been no meta-analyses comparing robotic and laparoscopic approaches for distal pancreatectomies (DP) in patients with pancreatic adenocarcinoma (PDAC). This systematic review and network meta-analysis aims to explore the oncological outcomes of laparoscopic distal pancreatectomy (LDP), robotic distal pancreatectomy (RDP) and open distal pancreatectomy (ODP). Methods A systematic search was conducted for studies reporting laparoscopic, robotic or open surgery for DP. Frequentist network meta-analysis of oncological outcomes (overall survival, resection margins, tumor recurrence, examined lymph nodes, administration of adjuvant therapy) were performed. Results Fifteen studies totalling 9,301 patients were included in the network meta-analysis. 1,946, 605 and 6,750 patients underwent LDP, RDP and ODP respectively. LDP (HR: 0.761, 95% CI: 0.642-0.901, p = 0.002) and RDP (HR: 0.757, 95% CI: 0.617-0.928, p = 0.008) were associated with overall survival (OS) benefit when compared to ODP. LDP (HR: 1.00, 95% CI: 0.793-1.27, p = 0.968) was not associated with OS benefit when compared to RDP. There were no significant differences between LDP, RDP and ODP for resection margins, tumor recurrence, examined lymph nodes and administration of adjuvant therapy. Conclusion This study highlights the longer OS in both LDP and RDP when compared to ODP for patients with PDAC. Systematic Review Registration https://www.crd.york.ac.uk/, PROSPERO (CRD42022336417).
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Affiliation(s)
- Nicky Zhun Hong Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Dominic Wei Ting Yap
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sherryl Lei Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Junie Yu Ning Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Juanita Jaslin James
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Alfred Wei Chieh Kow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University Hospital Singapore, Singapore, Singapore
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Li Z, Zhuo Q, Li B, Liu M, Chen C, Shi Y, Xu W, Liu W, Ji S, Yu X, Xu X. Feasibility of laparoscopic versus open pancreatoduodenectomy following neoadjuvant chemotherapy for borderline resectable pancreatic cancer: a retrospective cohort study. World J Surg Oncol 2024; 22:1. [PMID: 38169384 PMCID: PMC10759588 DOI: 10.1186/s12957-023-03277-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/09/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND There is no evidence supporting the feasibility of laparoscopic pancreaticoduodenectomy (LPD) compared to open pancreatoduodenectomy (OPD) following neoadjuvant chemotherapy (NACT) for pancreatic ductal adenocarcinoma (PDAC). METHODS The clinical data of consecutive patients with borderline resectable PDAC who received NACT and underwent either LPD or OPD between January 2020 and December 2022 at Fudan University Shanghai Cancer Center was prospectively collected and retrospectively analyzed. RESULTS The analysis included 57 patients in the OPD group and 20 in the LPD group. Following NACT, the LPD group exhibited a higher median CA19-9 decrease rate compared to the OPD group (85.3% vs. 66.9%, P = 0.042). Furthermore, 3 anatomically borderline PDACs in the LPD group and 5 in the OPD group were downstaged into resectable status (30.0% vs. 12.3%, P = 0.069). According to RECIST criteria, 51 (66.2%) patients in the entire cohort were evaluated as having stable disease. The median operation time for the LPD group was longer than the OPD group (419 vs. 325 min, P < 0.001), while the venous resection rate was 35.0% vs. 43.9%, respectively (P = 0.489). There was no difference in the number of retrieved lymph nodes, with a median number of 18.5 in the LPD group and 22 in the OPD group, and the R1 margin rate (15.0% vs. 12.3%) was also comparable. The incidence of Clavien-Dindo complications (35.0% vs. 66.7%, P = 0.018) was lower in the LPD group compared to the OPD group. Multivariable regression analysis revealed that a tumor diameter > 3 cm before NACT (HR 2.185) and poor tumor differentiation (HR 1.805) were independent risk factors for recurrence-free survival, and a decrease rate of CA19-9 > 70% (OR 0.309) was a protective factor for early tumor recurrence and overall survival. CONCLUSIONS LPD for PDAC following NACT is feasible and oncologically equivalent to OPD. Effective control of CA19-9 levels is beneficial in reducing early tumor recurrence and improving overall survival.
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Affiliation(s)
- Zheng Li
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Qifeng Zhuo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Borui Li
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Mengqi Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Chen Chen
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Yihua Shi
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Wenyan Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Wensheng Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Shunrong Ji
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China.
| | - Xiaowu Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China.
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Wysocki M, Borys M, Gałązka K, Stranek M, Budzyński A. Splenectomy and tumor size are risk factors for serious perioperative morbidity of laparoscopic distal pancreatectomies. POLISH JOURNAL OF SURGERY 2023; 96:6-12. [PMID: 38348977 DOI: 10.5604/01.3001.0053.9292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
<b><br>Introduction:</b> The determinants influencing the risk for complications of laparoscopic distal pancreatectomies (LDP) are not yet fully defined, thus we aimed to determine risk factors for serious perioperative morbidity after LDP with spleen preservation, LDP and radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas (RAMPS).</br> <b><br>Material and methods:</b> Retrospective cohort study of consecutive patients that underwent LDP between January 2019 and December 2022. The study group included cases of serious perioperative morbidity (III-V grades in Clavien-Dindo classification) during a 30-day period after operation. The control group consisted of patients without serious perioperative morbidity. As many as 142 patients were included in the study.</br> <b><br>Results:</b> Serious perioperative morbidity was found in 33 (23.24%) operated patients, while mortality in 3 cases (2.11%). Serious perioperative morbidity after LDP with spleen preservation was found in 9/68 (13.2%) patients (27.3% of the perioperative morbidity group). Thirteen out of 51 patients, i.e. 25.5%, after LDP with splenectomy were included in the perioperative morbidity group (39.4%). Serious perioperative morbidity after RAMPS was found in 11/23 (47.8%) patients (33.3% of the perioperative morbidity group). In multivariate logistic regression, the need for splenectomy during pancreatectomy (OR 3.66, 95%CI 1.20-11.18) and tumor above 28 millimeters in size (OR 3.01, 95%CI 1.19-9.59) were independent risk factors for serious perioperative morbidity.</br> <b><br>Conclusions:</b> The need for splenectomy during laparoscopic distal pancreatectomy and tumor size above 28 millimeters were independent risk factors for serious perioperative morbidity after laparoscopic distal pancreatectomies.</br>.
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Affiliation(s)
- Michal Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Maciej Borys
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Krystyna Gałązka
- Department of Pathomorphology, Jagiellonian University Medical College, Cracow, Poland
| | - Maciej Stranek
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Andrzej Budzyński
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
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Ota M, Asakuma M, Taniguchi K, Ito Y, Komura K, Tanaka T, Yamakawa K, Ogura T, Nishioka D, Hirokawa F, Uchiyama K, Lee SW. Short-term Outcomes of Laparoscopic and Open Distal Pancreatectomy Using Propensity Score Analysis: A Real-world Retrospective Cohort Study. Ann Surg 2023; 278:e805-e811. [PMID: 36398656 DOI: 10.1097/sla.0000000000005758] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to compare the short-term outcomes between laparoscopic and open distal pancreatectomy for lesions of the distal pancreas from a real-world database. BACKGROUND Reports on the benefits of laparoscopic distal pancreatectomy include 2 randomized controlled trials; however, large-scale, real-world data are scarce. METHODS We analyzed the data of patients undergoing laparoscopic or open distal pancreatectomy for benign or malignant pancreatic tumors from April 2008 to May 2020 from a Japanese nationwide inpatient database. We performed propensity score analyses to compare the inhospital mortality, morbidity, readmission rate, reoperation rate, length of postoperative stay, and medical cost between the 2 groups. RESULTS From 5502 eligible patients, we created a pseudopopulation of patients undergoing laparoscopic and open distal pancreatectomy using inverse probability of treatment weighting. Laparoscopic distal pancreatectomy was associated with lower inhospital mortality during the period of admission (0.0% vs 0.7%, P <0.001) and within 30 days (0.0% vs 0.2%, P =0.001), incidence of reoperation during the period of admission (0.7% vs 1.7%, P =0.018), postpancreatectomy hemorrhage (0.4% vs 2.0%, P <0.001), ileus (1.1% vs 2.8%, P =0.007), and shorter postoperative length of stay (17 vs 20 d, P <0.001). CONCLUSIONS The propensity score analysis revealed that laparoscopic distal pancreatectomy was associated with better outcomes than open surgery in terms of inhospital mortality, reoperation rate, postoperative length of stay, and incidence of postoperative complications such as postpancreatectomy hemorrhage and ileus.
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Affiliation(s)
- Masato Ota
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Mitsuhiro Asakuma
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Kohei Taniguchi
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Yuri Ito
- Department of Medical Statistics, Research and Development Center, Osaka Medical and Pharmaceutical University
| | - Kazumasa Komura
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Tomohito Tanaka
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Kazuma Yamakawa
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Takeshi Ogura
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University
| | - Daisuke Nishioka
- Department of Medical Statistics, Research and Development Center, Osaka Medical and Pharmaceutical University
| | - Fumitoshi Hirokawa
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Sang-Woong Lee
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
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Comparison of oncologic outcomes between open and laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma using data from the KOTUS-BP national database: overcoming selection bias and the necessity of definite indications. HPB (Oxford) 2022; 24:1804-1812. [PMID: 35871134 DOI: 10.1016/j.hpb.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/09/2022] [Accepted: 01/18/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite the lack of high-level evidence, laparoscopic distal pancreatectomy (LDP) is frequently performed in patients with pancreatic ductal adenocarcinoma (PDAC) owing to advancements in surgical techniques. The aim of this study was to investigate the long-term oncologic outcomes of LDP in patients with PDAC via propensity score matching (PSM) analysis using data from a large-scale national database. METHODS A total of 1202 patients who were treated for PDAC via distal pancreatectomy across 16 hospitals were included in the Korean Tumor Registry System-Biliary Pancreas. The 5-year overall (5YOSR) and disease-free (5YDFSR) survival rates were compared between LDP and open DP (ODP). RESULTS ODP and LDP were performed in 846 and 356 patients, respectively. The ODP group included more aggressive surgeries with higher pathologic stage, R0 resection rate, and number of retrieved lymph nodes. After PSM, the 5YOSRs for ODP and LDP were 37.3% and 41.4% (p = 0.150), while the 5YDFSRs were 23.4% and 27.2% (p = 0.332), respectively. Prognostic factors for 5YOSR included R status, T stage, N stage, differentiation, and lymphovascular invasion. CONCLUSION LDP was performed in a selected group of patients with PDAC. Within this group, long-term oncologic outcomes were comparable to those observed following ODP.
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Radulova-Mauersberger O, Distler M, Riediger C, Weitz J, Welsch T, Kirchberg J. How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery. Langenbecks Arch Surg 2022; 407:3819-3831. [PMID: 36136152 DOI: 10.1007/s00423-022-02662-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 08/21/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects. METHODS All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity. RESULTS Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred. CONCLUSIONS The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.
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Affiliation(s)
- O Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - M Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - C Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - J Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany. .,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - T Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - J Kirchberg
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
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Holm MB, Verbeke CS. Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma. Curr Oncol 2022; 29:6551-6563. [PMID: 36135084 PMCID: PMC9498008 DOI: 10.3390/curroncol29090515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.
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Affiliation(s)
- Maia Blomhoff Holm
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
| | - Caroline Sophie Verbeke
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
- Correspondence: ; Tel.: +47-405-578-36
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9
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Esposito A, Ramera M, Casetti L, De Pastena M, Fontana M, Frigerio I, Giardino A, Girelli R, Landoni L, Malleo G, Marchegiani G, Paiella S, Pea A, Regi P, Scopelliti F, Tuveri M, Bassi C, Salvia R, Butturini G. 401 consecutive minimally invasive distal pancreatectomies: lessons learned from 20 years of experience. Surg Endosc 2022; 36:7025-7037. [PMID: 35102430 PMCID: PMC9402493 DOI: 10.1007/s00464-021-08997-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/31/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to discuss and report the trend, outcomes, and learning curve effect after minimally invasive distal pancreatectomy (MIDP) at two high-volume centres. METHODS Patients undergoing MIDP between January 1999 and December 2018 were retrospectively identified from prospectively maintained electronic databases. The entire cohort was divided into two groups constituting the "early" and "recent" phases. The learning curve effect was analyzed for laparoscopic (LDP) and robotic distal pancreatectomy (RDP). The follow-up was at least 2 years. RESULTS The study population included 401 consecutive patients (LDP n = 300, RDP n = 101). Twelve surgeons performed MIDP during the study period. Although patients were more carefully selected in the early phase, in terms of median age (49 vs. 55 years, p = 0.026), ASA class higher than 2 (3% vs. 9%, p = 0.018), previous abdominal surgery (10% vs. 34%, p < 0.001), and pancreatic adenocarcinoma (PDAC) (7% vs. 15%, p = 0.017), the recent phase had similar perioperative outcomes. The increase of experience in LDP was inversely associated with the operative time (240 vs 210 min, p < 0.001), morbidity rate (56.5% vs. 40.1%, p = 0.005), intra-abdominal collection (28.3% vs. 17.3%, p = 0.023), and length of stay (8 vs. 7 days, p = 0.009). Median survival in the PDAC subgroup was 53 months. CONCLUSION In the setting of high-volume centres, the surgical training of MIDP is associated with acceptable rates of morbidity. The learning curve can be largely achieved by several team members, improving outcomes over time. Whenever possible resection of PDAC guarantees adequate oncological results and survival.
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Affiliation(s)
- Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Marco Ramera
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Martina Fontana
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | | | | | | | - Luca Landoni
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Antonio Pea
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Paolo Regi
- Department of Surgery, Pederzoli Hospital, Peschiera, Italy
| | | | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy.
- Università di Verona, Verona, Italy.
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
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10
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Jiang Z, Pan L, Chen M, Zhang B, Sarun J, Fan S, Cai X. Risk factors and consequences of conversion in minimally invasive distal pancreatectomy. J Minim Access Surg 2022; 18:384-390. [PMID: 35708384 PMCID: PMC9306137 DOI: 10.4103/jmas.jmas_4_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Although recent studies have reported potential benefits of laparoscopic approach in distal pancreatectomy, reports of conversion during minimally invasive distal pancreatectomy (MIDP) were limited. Methods This was a retrospective study using data from Sir Run Run Shaw Hospital around May 2013 to December 2018. Outcomes of patients who had conversions during MIDP were compared with patients with successful MIDP and with patients undergoing open distal pancreatectomy (ODP). Results Two-hundred and eighty-three cases were included in this study: 225 (79.5%) had MIDP, 30 (10.6%) had conversions and 28 (9.9%) had outpatient department. The risk factors for conversion included large lesion size (heart rates [HR]: 5.632, 95% confidencevinterval [CI]: 1.036-1.450, P = 0.018) and pancreatic cancer (HR: 6.957, 95% CI: 1.359-8.022, P = 0.009). Compared with MIDP, those who required conversion were associated with longer operations (P = 0.003), higher blood loss (P < 0.001) and more severe of the complications (P < 0.001). However, no statistically significant differences were found between the conversion group and ODP. Conclusions Large lesion size and pancreatic cancer were reported to be independent risk factors for conversion during MIDP. As for post-operative outcomes, the outcomes of successfully MIDP were better than those for conversion. However, conversion did not lead to worsening outcomes when compared with ODP.
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Affiliation(s)
- Zhiyu Jiang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Long Pan
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mingyu Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bin Zhang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Juengpanich Sarun
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sandra Fan
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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11
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Kato T, Inoue Y, Oba A, Ono Y, Sato T, Ito H, Takahashi Y. Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos). Ann Surg Oncol 2022; 29:3505-3514. [PMID: 35157192 DOI: 10.1245/s10434-022-11382-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/16/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear. PATIENTS AND METHODS Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups. RESULTS The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification. CONCLUSIONS The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.
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Affiliation(s)
- Tomotaka Kato
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Atsushi Oba
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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12
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Lee SE, Han SS, Kang CM, Kwon W, Paik KY, Song KB, Yang JD, Chung JC, Jeong CY, Kim SW. Korean Surgical Practice Guideline for Pancreatic Cancer 2021: A summary of evidence-based surgical approaches. Ann Hepatobiliary Pancreat Surg 2022; 26:1-16. [PMID: 35220285 PMCID: PMC8901981 DOI: 10.14701/ahbps.22-009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related deaths in Korea. Despite the increasing incidence and high mortality rate of pancreatic cancer, there are no appropriate surgical practice guidelines for the current domestic medical situation. To enable standardization of management and facilitate improvements in surgical outcome, a total of 10 pancreatic surgical experts who are members of Korean Association of Hepato-Biliary-Pancreatic Surgery have developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. This is an English version of the Korean Surgical Practice Guideline for Pancreatic Cancer 2021. This guideline includes 13 surgical questions and 15 statements. Due to the lack of high-level evidence, strong recommendation is almost impossible. However, we believe that this guideline will help surgeons understand the current status of evidence and suggest what to investigate further to establish more solid recommendations in the future.
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Affiliation(s)
- Seung Eun Lee
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sung-Sik Han
- Department of Surgery, National Cancer Center, Goyang, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Yeol Paik
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Do Yang
- Department of Surgery, Jeonbuk National University Medical School, Jeonju, Korea
| | - Jun Chul Chung
- Department of Surgery, Soon Chun Hyang University School of Medicine, Cheonan, Korea
| | - Chi-Young Jeong
- Department of Surgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sun-Whe Kim
- Department of Surgery, National Cancer Center, Goyang, Korea
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13
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Aliakbarian M, Fard A, Sadeghi R, Saffari S, Hashemi Fard S. A meta-analysis of prognostic factors in patients with left-sided pancreatic cancer. Indian J Cancer 2022; 59:310-316. [DOI: 10.4103/ijc.ijc_1150_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Radulova-Mauersberger O, Weitz J, Riediger C. Vascular surgery in liver resection. Langenbecks Arch Surg 2021; 406:2217-2248. [PMID: 34519878 PMCID: PMC8578135 DOI: 10.1007/s00423-021-02310-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/18/2021] [Indexed: 01/04/2023]
Abstract
Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.
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Affiliation(s)
- Olga Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
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15
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Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based, multi-disciplinary diagnostic and therapeutic approaches. Pancreatology 2021; 21:1326-1341. [PMID: 34148794 DOI: 10.1016/j.pan.2021.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer. This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.
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16
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Nassour I, Paniccia A, Moser AJ, Zureikat AH. Minimally Invasive Techniques for Pancreatic Resection. Surg Oncol Clin N Am 2021; 30:747-758. [PMID: 34511194 DOI: 10.1016/j.soc.2021.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There is increasing interest in the role of minimally invasive surgery (MIS) for pancreatectomy. Prospective data indicate significant advantages for MIS when performed for left-sided pancreatic pathologies and may be deemed as the standard of care. However, there is reluctance in implementing this technique to pancreaticoduodenectomy because of the complexity of the operation and the mixed results from randomized trials. A detailed description of the technical aspects of robotic pancreaticoduodenectomy and distal pancreatectomy is presented in this article in addition to a summary of the most important prospective and cohort studies. We also provide insights into patient selection and the learning curve of MIS surgery for pancreatectomy.
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Affiliation(s)
- Ibrahim Nassour
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - A James Moser
- Harvard Medical School, Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 5150 Center Avenue, Suite 421, Pittsburgh, PA 15232, USA.
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17
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van Hilst J, Korrel M, Lof S, de Rooij T, Vissers F, Al-Sarireh B, Alseidi A, Bateman AC, Björnsson B, Boggi U, Bratlie SO, Busch O, Butturini G, Casadei R, Dijk F, Dokmak S, Edwin B, van Eijck C, Esposito A, Fabre JM, Falconi M, Ferrari G, Fuks D, Groot Koerkamp B, Hackert T, Keck T, Khatkov I, de Kleine R, Kokkola A, Kooby DA, Lips D, Luyer M, Marudanayagam R, Menon K, Molenaar Q, de Pastena M, Pietrabissa A, Rajak R, Rosso E, Sanchez Velazquez P, Saint Marc O, Shah M, Soonawalla Z, Tomazic A, Verbeke C, Verheij J, White S, Wilmink HW, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma (DIPLOMA): study protocol for a randomized controlled trial. Trials 2021; 22:608. [PMID: 34503548 PMCID: PMC8427847 DOI: 10.1186/s13063-021-05506-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
Background Recently, the first randomized trials comparing minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) for non-malignant and malignant disease showed a 2-day reduction in time to functional recovery after MIDP. However, for pancreatic ductal adenocarcinoma (PDAC), concerns have been raised regarding the oncologic safety (i.e., radical resection, lymph node retrieval, and survival) of MIDP, as compared to ODP. Therefore, a randomized controlled trial comparing MIDP and ODP in PDAC regarding oncological safety is warranted. We hypothesize that the microscopically radical resection (R0) rate is non-inferior for MIDP, as compared to ODP. Methods/design DIPLOMA is an international randomized controlled, patient- and pathologist-blinded, non-inferiority trial performed in 38 pancreatic centers in Europe and the USA. A total of 258 patients with an indication for elective distal pancreatectomy with splenectomy because of proven or highly suspected PDAC of the pancreatic body or tail will be randomly allocated to MIDP (laparoscopic or robot-assisted) or ODP in a 1:1 ratio. The primary outcome is the microscopically radical resection margin (R0, distance tumor to pancreatic transection and posterior margin ≥ 1 mm), which is assessed using a standardized histopathology assessment protocol. The sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected R0 rate in the open group of 58%, expected R0 resection rate in the minimally invasive group of 67%, and a non-inferiority margin of 7%. Secondary outcomes include time to functional recovery, operative outcomes (e.g., blood loss, operative time, and conversion to open surgery), other histopathology findings (e.g., lymph node retrieval, perineural- and lymphovascular invasion), postoperative outcomes (e.g., clinically relevant complications, hospital stay, and administration of adjuvant treatment), time and site of disease recurrence, survival, quality of life, and costs. Follow-up will be performed at the outpatient clinic after 6, 12, 18, 24, and 36 months postoperatively. Discussion The DIPLOMA trial is designed to investigate the non-inferiority of MIDP versus ODP regarding the microscopically radical resection rate of PDAC in an international setting. Trial registration ISRCTN registry ISRCTN44897265. Prospectively registered on 16 April 2018.
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Affiliation(s)
- Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Maarten Korrel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Sanne Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands.,Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Frederique Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olivier Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, Azienda Ospedaliero Universitaria Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Frederike Dijk
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Safi Dokmak
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France
| | - Bjorn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Casper van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | | | - Massimo Falconi
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Giovanni Ferrari
- Department of Surgery, Niguarda Ca'Granda Hospital, Milan, Italy
| | - David Fuks
- Department of Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Keck
- Department of Surgery, UKSH campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | - Ruben de Kleine
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Arto Kokkola
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - David A Kooby
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Krishna Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | | | - Rushda Rajak
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Edoardo Rosso
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | - Olivier Saint Marc
- Department of Surgery, Centre Hospitalier Regional D'Orleans, Orleans, France
| | - Mihir Shah
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Steven White
- Department of Surgery, The Freeman Hospital Newcastle Upon Tyne, Newcastle, UK
| | - Hanneke W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI) and Humanitas University, Pieve Emanuele, MI, Italy
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy. .,Department of General Surgery, Fondazione Poliambulanza Instituto Ospedaliero, Brescia, Italy.
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18
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Lequeu JB, Cottenet J, Facy O, Perrin T, Bernard A, Quantin C. Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients. HPB (Oxford) 2021; 23:1410-1417. [PMID: 33622649 DOI: 10.1016/j.hpb.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND FTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP. METHODS We analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year. RESULTS Some 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505-0.643], p < 0.001) and also for FTR (OR = 0.550, CI95% [0.486-0.630], p < 0.001). CONCLUSION Hospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.
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Affiliation(s)
- Jean-Baptiste Lequeu
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France.
| | - Jonathan Cottenet
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
| | - Olivier Facy
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Thomas Perrin
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Alain Bernard
- Dijon University Hospital, Department of Thoracic Surgery, Dijon F-21000, France
| | - Catherine Quantin
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
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19
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Sahakyan MA, Verbeke CS, Tholfsen T, Ignjatovic D, Kleive D, Buanes T, Lassen K, Røsok BI, Labori KJ, Edwin B. Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma. Ann Surg Oncol 2021; 29:366-375. [PMID: 34296358 PMCID: PMC8677636 DOI: 10.1245/s10434-021-10464-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023]
Abstract
Background Resection margin status is considered one of the few surgeon-controlled parameters affecting prognosis in pancreatic ductal adenocarcinoma (PDAC). While studies mostly focus on resection margins in pancreatoduodenectomy, little is known about their role in distal pancreatectomy (DP). This study aimed to investigate resection margins in DP for PDAC. Methods Patients who underwent DP for PDAC between October 2004 and February 2020 were included (n = 124). Resection margins and associated parameters were studied in two consecutive time periods during which different pathology examination protocols were used: non-standardized (period 1: 2004–2014) and standardized (period 2: 2015–2020). Microscopic margin involvement (R1) was defined as ≤1 mm clearance. Results Laparoscopic and open resections were performed in 117 (94.4%) and 7 (5.6%) patients, respectively. The R1 rate for the entire cohort was 73.4%, increasing from 60.4% in period 1 to 83.1% in period 2 (p = 0.005). A significantly higher R1 rate was observed for the posterior margin (35.8 vs. 70.4%, p < 0.001) and anterior pancreatic surface (based on a 0 mm clearance; 18.9 vs. 35.4%, p = 0.045). Pathology examination period, poorly differentiated PDAC, and vascular invasion were associated with R1 in the multivariable model. Extended DP, positive anterior pancreatic surface, lymph node ratio, perineural invasion, and adjuvant chemotherapy, but not R1, were significant prognostic factors for overall survival in the entire cohort. Conclusions Pathology examination is a key determinant of resection margin status following DP for PDAC. A high R1 rate is to be expected when pathology examination is meticulous and standardized. Involvement of the anterior pancreatic surface affects prognosis. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10464-6.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway. .,Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway. .,Department of Surgery N1, Yerevan State Medical University, Yerevan, Armenia.
| | - Caroline S Verbeke
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pathology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Tore Tholfsen
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Dejan Ignjatovic
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Trond Buanes
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristoffer Lassen
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Knut Jørgen Labori
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
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20
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Lee JM, Kim H, Kang JS, Byun Y, Choi YJ, Sohn HJ, Han Y, Kwon W, Jang JY. Comparison of perioperative short-term outcomes and oncologic long-term outcomes between open and laparoscopic distal pancreatectomy in patients with pancreatic ductal adenocarcinoma. Ann Surg Treat Res 2021; 100:320-328. [PMID: 34136428 PMCID: PMC8176202 DOI: 10.4174/astr.2021.100.6.320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/15/2021] [Accepted: 03/09/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose Laparoscopic distal pancreatectomy (LDP) is widely performed but its efficacy and safety are not established for malignant lesions. This study was aimed to compare outcomes of LDP and open distal pancreatectomy (ODP) in pancreatic ductal adenocarcinoma (PDAC). Methods Patients who underwent distal pancreatectomy for PDAC between 2009 and 2017 were enrolled. The preoperative clinical stage was evaluated and propensity score matching (PSM) was performed using age, sex, The American Joint Committee on Cancer 8th clinical T stage, and other organ involvement. Results In 186 patients enrolled, 35 (18.8%) received LDP. The ODP group showed larger tumor size and frequent involvement of other organs in preoperative images. However, after PSM, these differences were balanced. R0 resection (90.5% vs. 94.3%, P = 0.730), harvested lymph nodes (14.3 vs. 12.6, P = 0.380) and pathologic T stage (P = 0.474) were comparable between ODP and LDP groups, respectively. LDP demonstrated shorter operation time, less postoperative pain, and shorter hospitalization (14.4 days vs. 11.1 days, P = 0.026). In terms of long-term oncologic outcomes, median overall survival (32 months vs. 28 months, P = 0.724) and disease-free survival (18 months vs. 19 months, P = 0.926) were comparable. Conclusion LDP demonstrated better short-term outcomes and comparable long-term outcomes compared with ODP. LDP is a safe and feasible procedure for PDAC.
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Affiliation(s)
- Jung Min Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Jin Choi
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Ju Sohn
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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21
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Serra F, Bonaduce I, De Ruvo N, Cautero N, Gelmini R. Short-term and long term morbidity in robotic pancreatic surgery: a systematic review. Gland Surg 2021; 10:1767-1779. [PMID: 34164320 DOI: 10.21037/gs-21-64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Pancreatic cancer is one of the most aggressive and lethal tumours in Western society. Pancreatic surgery can be considered a challenge for open and laparoscopic surgeons, even if the accuracy of gland dissection, due to the close relationship between pancreas, the portal vein, and mesenteric vessels, besides the reconstructive phase (in pancreaticoduodenectomy), lead to significant difficulties for laparoscopic technique. Minimally invasive pancreatic surgery changed utterly with the development of robotic surgery. However, this review aims to make more clarity on the influence of robotic surgery on long-term morbidity. Methods A systematic literature search was performed in PubMed, Cochrane Library, and Scopus to identify and analyze studies published from November 2011 to September 2020 concerning robotic pancreatic surgery. The following terms were used to perform the search: "long term morbidity robotic pancreatic surgery". Results Eighteen articles included in the study were published between November 2011 and September 2020. The review included 2041 patients who underwent robotic pancreatic surgery, mainly for a malignant tumour. The two most common robotic surgical procedures adopted were the robotic distal pancreatectomy (RDP) and the robotic pancreaticoduodenectomy (RPD). In two studies, patients were divided into groups; on the one hand, those who underwent a robotic pancreaticoduodenectomy (RPD), on the other hand, those who underwent robotic distal pancreatectomy (RDP). The remaining items included surgical approach such as robotic middle pancreatectomy (RMP), robotic distal pancreatectomy and splenectomy, robotic-assisted laparoscopic pancreatic dissection (RALPD), robotic enucleation of pancreatic neuroendocrine tumours. Conclusions Comparison between robotic surgery and open surgery lead to evidence of different advantages of the robotic approach. A multidisciplinary team and a surgical centre at high volume are essential for better postoperative morbidity and mortality.
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Affiliation(s)
- Francesco Serra
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Modena, Italy
| | - Isabella Bonaduce
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Modena, Italy
| | - Nicola De Ruvo
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Modena, Italy
| | - Nicola Cautero
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Modena, Italy
| | - Roberta Gelmini
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Modena, Italy
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22
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Chen K, Pan Y, Huang CJ, Chen QL, Zhang RC, Zhang MZ, Wang GY, Wang XF, Mou YP, Yan JF. Laparoscopic versus open pancreatic resection for ductal adenocarcinoma: separate propensity score matching analyses of distal pancreatectomy and pancreaticoduodenectomy. BMC Cancer 2021; 21:382. [PMID: 33836678 PMCID: PMC8034161 DOI: 10.1186/s12885-021-08117-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 03/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a leading causes of cancer mortality worldwide. Currently, laparoscopic pancreatic resection (LPR) is extensively applied to treat benign and low-grade diseases related to the pancreas. The viability and safety of LPR for PDAC needs to be understood better. Laparoscopic distal pancreatectomy (LDP) and pancreaticoduodenectomy (LPD) are the two main surgical approaches for PDAC. We performed separate propensity score matching (PSM) analyses to assess the surgical and oncological outcomes of LPR for PDAC by comparing LDP with open distal pancreatectomy (ODP) as well as LPD with open pancreaticoduodenectomy (OPD). METHODS We assessed the data of patients who underwent distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) for PDAC between January 2004 and February 2020 at our hospital. A one-to-one PSM was applied to prevent selection bias by accounting for factors such as age, sex, body mass index, and tumour size. The DP group included 86 LDP patients and 86 ODP patients, whereas the PD group included 101 LPD patients and 101 OPD patients. Baseline characteristics, intraoperative effects, postoperative recovery, and survival outcomes were compared. RESULTS Compared to ODP, LDP was associated with shorter operative time, lesser blood loss, and similar overall morbidity. Of the 101 patients who underwent LPD, 10 patients (9.9%) required conversion to laparotomy. The short-term surgical advantage of LPD is not as apparent as that of LDP due to conversions. Compared with OPD, LPD was associated with longer operative time, lesser blood loss, and similar overall morbidity. For oncological and survival outcomes, there were no significant differences in tumour size, R0 resection rate, and tumour stage in both the DP and PD subgroups. However, laparoscopic procedures appear to have an advantage over open surgery in terms of retrieved lymph nodes (DP subgroup: 14.4 ± 5.2 vs. 11.7 ± 5.1, p = 0.03; PD subgroup 21.9 ± 6.6 vs. 18.9 ± 5.4, p = 0.07). These two groups did not show a significant difference in the pattern of recurrence and overall survival rate. CONCLUSIONS Laparoscopic DP and PD are feasible and oncologically safe procedures for PDAC, with similar postoperative outcomes and long-term survival among patients who underwent open surgery.
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Affiliation(s)
- Ke Chen
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Yu Pan
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Chao-Jie Huang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Qi-Long Chen
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Ren-Chao Zhang
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Miao-Zun Zhang
- Department of Hepatopancreatobiliary Surgery, Ningbo Medical Center, Lihuili Hospital, Ningbo, 315100, Zhejiang Province, China
| | - Guan-Yu Wang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Xian-Fa Wang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Yi-Ping Mou
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Jia-Fei Yan
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
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23
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Nishino H, Zimmitti G, Ohtsuka T, Abu Hilal M, Goh BKP, Kooby DA, Nakamura Y, Shrikhande SV, Yoon YS, Ban D, Nagakawa Y, Nakata K, Endo I, Tsuchida A, Nakamura M. Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:136-150. [PMID: 33527704 DOI: 10.1002/jhbp.903] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/23/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Giuseppe Zimmitti
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Mohammed Abu Hilal
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore City, Singapore
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | | | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, Seoul, Korea
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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24
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Ishido K, Hakamada K, Kimura N, Miura T, Wakiya T. Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2021; 5:7-23. [PMID: 33532676 PMCID: PMC7832965 DOI: 10.1002/ags3.12379] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is highly malignant. While cancers in other organs have shown clear improvements in 5-year survival, the 5-year survival rate of pancreatic cancer is approximately 10%. Early relapse and metastasis are not uncommon, making it difficult to achieve an acceptable prognosis even after complete surgical resection of the pancreas. Studies have been performed on various treatments to improve the prognosis of PDAC, and multidisciplinary approaches including non-surgical treatments have led to gradual improvement. In the present literature review, we have described the significance of anatomical and biological resectability criteria, the concept of R0 resection in surgical treatment, the feasibility of minimally invasive surgery, the remarkable development of perioperative chemotherapy, the effectiveness of conversion surgery for unresectable PDAC, and ongoing challenges in PDAC treatment. We also provide an essential update on these subjects by focusing on recent trends and topics.
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Affiliation(s)
- Keinosuke Ishido
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Kenichi Hakamada
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Norihisa Kimura
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Takuya Miura
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Taiichi Wakiya
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
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25
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Miyasaka Y, Ohtsuka T, Nakamura M. Minimally invasive surgery for pancreatic cancer. Surg Today 2020; 51:194-203. [PMID: 32857251 DOI: 10.1007/s00595-020-02120-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022]
Abstract
Pancreatic cancer is the most lethal malignancy of the digestive organs. Although pancreatic resection is essential to radically cure this refractory disease, the multi-organ resection involved, as well as sequelae such as glucose tolerance insufficiency and severe complications impose a heavy burden on these patients. Since the late twentieth century, minimally invasive surgery has become more popular for the surgical management of digestive disease and pancreatic cancer. Minimally invasive pancreatic resection (MIPR), including pancreaticoduodenectomy and distal pancreatectomy, is now a treatment option for pancreatic cancer. Some evidence suggests that MIPR for pancreatic cancer provides comparable oncological outcomes to open surgery, with some advantages in perioperative outcomes. However, as this evidence is retrospective, prospective investigations, including randomized controlled trials, are necessary. Because neoadjuvant therapy for resectable or borderline-resectable pancreatic cancer and conversion surgery for initially unresectable pancreatic cancer has become more common, the feasibility of MIPR after neoadjuvant therapy or as conversion surgery requires further assessment. It is expected that progress in surgical techniques and devices, as well as the standardization of surgical procedures and widespread educational programs will improve the outcomes of MIPR.
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Affiliation(s)
- Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Kagoshima, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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26
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Song KB, Hong S, Kim HJ, Park Y, Kwon J, Lee W, Jun E, Lee JH, Hwang DW, Kim SC. Predictive Factors Associated with Complications after Laparoscopic Distal Pancreatectomy. J Clin Med 2020; 9:jcm9092766. [PMID: 32858997 PMCID: PMC7563868 DOI: 10.3390/jcm9092766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 02/08/2023] Open
Abstract
Although laparoscopic distal pancreatectomy (LDP) has become more popular, the postoperative complication rate remains high. We sought to identify the risk factors for post-LDP complications. We examined 1227 patients who underwent LDP between March 2005 and December 2015 at a single large-volume center. We used logistic regression for the analysis. The overall (13.2%) and major (3.3%) complication rates were determined. Postoperative pancreatic fistula was the most frequent complication, and 58 patients (4.7%) had clinically significant (grade B) pancreatic fistulas. No 90-day mortality was recorded. Long operative time (≥200 min), large estimated blood loss (≥320 mL), LDP performed by an inexperienced surgeon (<50 cases), and concomitant splenectomy were identified as risk factors for overall complications using a logistic regression model. For major complications, male sex (p = 0.020), long operative time (p = 0.005), and LDP performed by an inexperienced surgeon (p = 0.026) were significant predictive factors. Using logistic regression analysis, surgery-related factors, including long operative time and LDP performed by an inexperienced surgeon, were correlated with overall and major complications of LDP. As LDP is a technically challenging procedure, surgery-related variables emerged as the main risk factors for postoperative complications. Appropriate patient selection and sufficient surgeon experience may be essential to reduce the complications of LDP.
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Affiliation(s)
- Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Sarang Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea;
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Jaewoo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
- Correspondence: ; Tel.: +82-2-3010-3936; Fax: +82-2-3010-6701
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27
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Watson MD, Baimas-George MR, Thompson KJ, Iannitti DA, Ocuin LM, Baker EH, Martinie JB, Vrochides D. Improved oncologic outcomes for minimally invasive left pancreatectomy: Propensity-score matched analysis of the National Cancer Database. J Surg Oncol 2020; 122:1383-1392. [PMID: 32772366 DOI: 10.1002/jso.26147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/17/2020] [Accepted: 07/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Minimally invasive (MIS) left pancreatectomy (LP) is increasingly used to treat pancreatic adenocarcinoma (PDAC). Despite improved short-term outcomes, no studies have demonstrated long-term benefits over open resection. METHODS The National Cancer Database was queried between 2010 and 2016 for patients with PDAC, grouped by surgical approach (MIS vs open). Demographics, comorbidities, clinical staging, and pathologic staging were used for propensity-score matching. Perioperative, short-term oncologic, and survival outcomes were compared. RESULTS After matching, both cohorts included 805 patients. There were no differences in baseline characteristics, staging, or preoperative therapy between cohorts. The MIS cohort had a shorter length of stay (6.8 ± 5.5 vs 8.5 ± 7.3 days; P < .0001) with the trend toward improved time to chemotherapy (53.9 ± 26.1 vs 57.9 ± 29.9 days; P = .0511) and margin-positive resection rate (15.3% vs 18.9%; P = .0605). Lymph node retrieval and receipt of chemotherapy were similar. The MIS cohort had higher median overall survival (28.0 vs 22.1 months; P = .0067). Subgroup analysis demonstrated the highest survival for robotic compared with laparoscopic and open LP (41.9 vs 26.6 vs 22.1 months; P < .0001). CONCLUSIONS This study demonstrates the safety of MIS LP and favorable long-term oncologic outcomes. The improved survival after MIS LP warrants further study with prospective, randomized trials.
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Affiliation(s)
- Michael D Watson
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Maria R Baimas-George
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kyle J Thompson
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A Iannitti
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee M Ocuin
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin H Baker
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B Martinie
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Nassour I, Winters SB, Hoehn R, Tohme S, Adam MA, Bartlett DL, Lee KK, Paniccia A, Zureikat AH. Long-term oncologic outcomes of robotic and open pancreatectomy in a national cohort of pancreatic adenocarcinoma. J Surg Oncol 2020; 122:234-242. [PMID: 32350882 DOI: 10.1002/jso.25958] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/25/2020] [Accepted: 04/13/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Robotic pancreatectomy is gaining momentum; however, limited data exist on the long-term survival of this approach for pancreatic ductal adenocarcinoma (PDAC). The objective of this study is to compare the long-term oncologic outcomes of robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP) to open surgery in patients with PDAC. STUDY DESIGN Robotic and open pancreatectomy for stages I-III PDAC were obtained from the 2010 to 2016 National Cancer Database. RESULTS We identified 17 831 pancreaticoduodenectomies and 2718 distal pancreatectomies of which 626 (4%) and 332 (12%) were robotic, respectively. There was no difference in median overall survival between RPD (22.0 months) and open pancreatoduodenectomy (21.8 months; logrank P = .755). The adjusted hazard ratio [HR] was 1.014 (95% confidence interval [CI]: 0.903-1.139). The median overall survival for RDP (35.3 months) was higher than open distal pancreatectomy (ODP) (24.9 months; logrank P = .001). The adjusted HR suggests a benefit to RDP compared to ODP (HR, 0.744; 95% CI: 0.632-0.868) CONCLUSION: In a national cohort of resected pancreatic adenocarcinoma, the robotic platform was associated with similar long-term survival for pancreaticoduodenectomy, but improved survival for distal pancreatectomy.
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Affiliation(s)
- Ibrahim Nassour
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sharon B Winters
- UPMC Network Cancer Registry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard Hoehn
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mohamed A Adam
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center propensity score matching study. Updates Surg 2020; 72:387-397. [PMID: 32266660 DOI: 10.1007/s13304-020-00742-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/04/2020] [Indexed: 12/17/2022]
Abstract
Laparoscopic distal pancreatectomy (LDP) for benign and low-grade malignant pancreatic diseases has been increasingly utilized. However, the use of LDP for pancreatic ductal adenocarcinoma (PDAC) remains controversial and has not been widely accepted. In this study, the outcomes of LDP versus conventional open distal pancreatectomy (ODP) for left-sided PDAC were examined. A retrospective review of patients who underwent LDP or ODP for left-sided PDAC between January 2010 and January 2019 was conducted. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors including age, sex, ASA grade, tumor size, and combined resection. Demographic data, their pathological and short-term clinical parameters, and long-term oncological outcomes were compared between the LDP and ODP groups. A total of 197 patients with PDAC were enrolled. There were 115 (58.4%) patients in the LDP group and 82 (41.6%) patients in the ODP group. After 1:1 PSM, 66 well-matched patients in each group were evaluated. The LDP group had lesser blood loss (195 vs. 210 mL, p < 0.01), shorter operative time (193.6 vs. 217.5 min; p = 0.02), and shorter hospital stay (12 vs. 15 days, p < 0.01), whereas the overall complication rates were comparable between groups (10.6% vs.16.7%, p = 0.31). There were no significant differences between the LDP and ODP groups regarding 3-year recurrence-free or overall survival rate (p = 0.89 and p = 0.33, respectively). LDP in the treatment of left-sided PDAC is a technically safe, feasible and favorable approach in short-term surgical outcomes. Moreover, patients undergoing LDP than ODP for PDAC had comparable oncological metrics and similar middle-term survival rate.
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30
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Ohtsuka T, Nagakawa Y, Toyama H, Takeda Y, Maeda A, Kumamoto Y, Nakamura Y, Hashida K, Honda G, Fukuzawa K, Toyoda E, Tanabe M, Gotohda N, Matsumoto I, Ryu T, Uyama I, Kojima T, Unno M, Ichikawa D, Inoue Y, Matsukawa H, Sudo T, Takaori K, Yamaue H, Eguchi S, Tahara M, Shinzeki M, Eguchi H, Kurata M, Morimoto M, Hayashi H, Marubashi S, Inomata M, Kimura K, Amaya K, Sho M, Yoshida R, Murata A, Yoshitomi H, Hakamada K, Yasunaga M, Abe N, Hioki M, Tsuchiya M, Misawa T, Seyama Y, Noshiro H, Sakamoto E, Hasegawa K, Kawabata Y, Uchida Y, Kameyama S, Ko S, Takao T, Kitahara K, Nakahira S, Baba H, Watanabe M, Yamamoto M, Nakamura M. A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 27:47-55. [PMID: 31665567 DOI: 10.1002/jhbp.695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system. METHODS Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836. RESULTS Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD. CONCLUSION LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.
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Affiliation(s)
- Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yutaka Takeda
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Yusuke Kumamoto
- Department of General, Pediatric and Hepato-Biliary-Pancreatic Surgery, Kitasato University Hospital, Sagamihara, Kanagawa, Japan
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kazuki Hashida
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kengo Fukuzawa
- Department of Surgery, Oita Red Cross Hospital, Oita, Japan
| | - Eiji Toyoda
- Department of Surgery, Otsu Red Cross Hospital, Otsu, Shiga, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naoto Gotohda
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Tomoki Ryu
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Ichiro Uyama
- Department of Surgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Toru Kojima
- Department of Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Kofu, Yamanashi, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroyoshi Matsukawa
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Takeshi Sudo
- Department of Surgery National Hospital Organization Kure Medical Center Chugoku Cancer Center, Kure, Hiroshima, Japan
| | - Kyoichi Takaori
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Munenori Tahara
- Department of Surgery, Hokkaido P.W.F.A.C Sapporo Kosei General Hospital, Sapporo, Hokkaido, Japan
| | - Makoto Shinzeki
- Department of Surgery, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masanao Kurata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mamoru Morimoto
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | | | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University, Fukushima, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Kenjiro Kimura
- Department of Surgical Oncology, Osaka City University School of Medicine, Osaka, Japan
| | - Koji Amaya
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Ryuichi Yoshida
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Akihiro Murata
- Department of Hepatobiliary Pancreatic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Masafumi Yasunaga
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Masayoshi Hioki
- Department of Gastroenterological Surgery, Fukuyama City Hospital, Fukuyama, Hiroshima, Japan
| | - Masaru Tsuchiya
- Division of General and Gastroenterological Surgery, Department of Surgery, Toho University School of Medicine, Omori, Tokyo, Japan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Yasuji Seyama
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Eiji Sakamoto
- Department of Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yoichiro Uchida
- Department of Gastroenterological Surgery and Oncology, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Shinichiro Kameyama
- Department of Surgery, Center for Gastroenterology, Urasoe General Hospital, Urasoe, Okinawa, Japan
| | - Saiho Ko
- Department of Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Takashi Takao
- Department of Surgery, Shin Koga Hospital, Kurume, Fukuoka, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga Medical Center Koseikan, Saga, Japan
| | - Shin Nakahira
- Department of Surgery, Sakai City Medical Center, Sakai, Osaka, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masahiko Watanabe
- Kitasato University Kitasato Institutional Hospital, Sagamihara, Kanagawa, Japan.,Japan Society for Endoscopic Surgery, Tokyo, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.,Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Japanese Society for Endoscopic and Robotic Pancreatic Surgery, Tokyo, Japan
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31
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Esposito A, Balduzzi A, De Pastena M, Fontana M, Casetti L, Ramera M, Bassi C, Salvia R. Minimally invasive surgery for pancreatic cancer. Expert Rev Anticancer Ther 2019; 19:947-958. [DOI: 10.1080/14737140.2019.1685878] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alberto Balduzzi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Martina Fontana
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marco Ramera
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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32
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Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA): A Pan-European Propensity Score Matched Study. Ann Surg 2019; 269:10-17. [PMID: 29099399 DOI: 10.1097/sla.0000000000002561] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to compare oncological outcomes after minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) in patients with pancreatic ductal adenocarcinoma (PDAC). BACKGROUND Cohort studies have suggested superior short-term outcomes of MIDP vs. ODP. Recent international surveys, however, revealed that surgeons have concerns about the oncological outcomes of MIDP for PDAC. METHODS This is a pan-European propensity score matched study including patients who underwent MIDP (laparoscopic or robot-assisted) or ODP for PDAC between January 1, 2007 and July 1, 2015. MIDP patients were matched to ODP patients in a 1:1 ratio. Main outcomes were radical (R0) resection, lymph node retrieval, and survival. RESULTS In total, 1212 patients were included from 34 centers in 11 countries. Of 356 (29%) MIDP patients, 340 could be matched. After matching, the MIDP conversion rate was 19% (n = 62). Median blood loss [200 mL (60-400) vs 300 mL (150-500), P = 0.001] and hospital stay [8 (6-12) vs 9 (7-14) days, P < 0.001] were lower after MIDP. Clavien-Dindo grade ≥3 complications (18% vs 21%, P = 0.431) and 90-day mortality (2% vs 3%, P > 0.99) were comparable for MIDP and ODP, respectively. R0 resection rate was higher (67% vs 58%, P = 0.019), whereas Gerota's fascia resection (31% vs 60%, P < 0.001) and lymph node retrieval [14 (8-22) vs 22 (14-31), P < 0.001] were lower after MIDP. Median overall survival was 28 [95% confidence interval (CI), 22-34] versus 31 (95% CI, 26-36) months (P = 0.929). CONCLUSIONS Comparable survival was seen after MIDP and ODP for PDAC, but the opposing differences in R0 resection rate, resection of Gerota's fascia, and lymph node retrieval strengthen the need for a randomized trial to confirm the oncological safety of MIDP.
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33
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Daniel FE, Tamim HM, Hosni MN, Mailhac AC, Khalife MJ, Jamali FR, Faraj W. Short-term surgical morbidity and mortality of distal pancreatectomy performed for benign versus malignant diseases: a NSQIP analysis. Surg Endosc 2019; 34:3927-3935. [PMID: 31598880 DOI: 10.1007/s00464-019-07163-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/24/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND/AIM Distal pancreatectomy (DP) accounts for 25% of all pancreatic resections. Complications following DP occur in around 40% of the cases. Our aim is to analyze short-term surgical outcomes of DP based on whether the indication for resection was benign or malignant pathology, as well as the effect of the surgical approach, open versus laparoscopic on morbidity and mortality. METHODS We studied all patients undergoing DP from the National Surgery Quality Improvement Program (NSQIP) targeted pancreatectomy participant use file from 2014 to 2016. The patients were divided into 2 groups, those who underwent DP for benign diseases (DP-B) and those who underwent DP for malignant diseases (DP-M). We performed multivariate logistic regression to evaluate the association between benign or malignant distal pancreatectomies and 30-day outcomes. We included clinically and/or statistically significant confounders into the models. We also conducted the same analysis in the subgroups of open and laparoscopic DP. RESULTS Three thousand five hundred and seventy-nine patients underwent distal pancreatectomy. The most common indication for surgery was malignant disease in 1894 (53%). Thirty-day mortality occurred in 0.4% of DP-B compared to 1.3% DP-M. On multivariate analysis, no significant difference was found in mortality or in the risk of pancreatic fistula between the 2 groups. Bleeding (p = 0.002) and composite morbidity (p = 0.01) were significantly higher in the DP-M group. Among composite morbidities, thromboembolism was significantly associated with DP-M (OR 2.1, p = 0.0004) only when performed with an open approach. CONCLUSION DP-M is associated with a significantly higher risk of post-operative bleeding, thromboembolism, and sepsis compared to DP-B but no significant increase in mortality. When further analyzing the impact of the operative approach on morbidity, there was an increased rate of post-operative thromboembolic in the DP-M group when the surgery was performed in an open manner and this increased risk was no longer statistically significant if the DP-M was performed using a minimally invasive approach.
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Affiliation(s)
- Fady E Daniel
- Department of Internal Medicine, Gastroenterology and Hepatology Division, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani M Tamim
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohammad N Hosni
- Department of Internal Medicine, Gastroenterology and Hepatology Division, American University of Beirut Medical Center, Beirut, Lebanon
| | - Aurelie C Mailhac
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohammad J Khalife
- Department of Surgery, American University of Beirut Medical Center, Cairo Street, Hamra 72020, Beirut, Lebanon
| | - Faek R Jamali
- Department of Surgery, American University of Beirut Medical Center, Cairo Street, Hamra 72020, Beirut, Lebanon.
| | - Walid Faraj
- Department of Surgery, American University of Beirut Medical Center, Cairo Street, Hamra 72020, Beirut, Lebanon.
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34
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Maggino L, Malleo G, Salvia R, Bassi C, Vollmer CM. Defining the practice of distal pancreatectomy around the world. HPB (Oxford) 2019; 21:1277-1287. [PMID: 30910318 DOI: 10.1016/j.hpb.2019.02.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Best management practices for distal pancreatectomy (DP) have not been conclusively defined. The aim of this study was to analyze the practice of DP worldwide and to compare surgeons' behavior with the best available evidence. METHODS A survey assessing management approaches for DP was distributed worldwide, in eight native-language translations. Regions were clustered: North-America, South/Central America, Asia/Australia, and Europe/Africa/Middle East. RESULTS Overall, 721/797 (91%) responding surgeons (median age = 48; years of experience = 14) indicated their region, representing six continents and 68 nations. Use of minimally-invasive (MI) techniques is diverse-highest in North-America (p < 0.001). Laparoscopy is the most common MI approach, while robotic techniques are rarely performed outside North-America. The preferred means of pancreatic remnant closure is via stapler - more commonly applied in North-America than in Europe/Africa/Middle East. Management techniques for the remnant and other fistula mitigation strategies display significant regional variability. The use of drains is also diverse, with the biggest disparity between North-American and Asian/Australian surgeons (selective and routine drainers, respectively). CONCLUSION There is wide heterogeneity in practices for DP worldwide, which is influenced by the surgeon's region of practice. Variability in practice reflects the lack of solid evidence on the benefit of any given strategy, underlining areas for improvement.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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35
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Søreide K, Nymo LS, Kleive D, Olsen F, Lassen K. Variation in use of open and laparoscopic distal pancreatectomy and associated outcome metrics in a universal health care system. Pancreatology 2019; 19:880-887. [PMID: 31395453 DOI: 10.1016/j.pan.2019.07.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/16/2019] [Accepted: 07/31/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Universal health care (UHC) should ensure equal access to and use of surgery, but few studies have explored variation in UHC systems. The objective was to describe practice of distal pancreatectomy in Norway covered exclusively by an UHC. METHODS Data on all patients undergoing distal pancreatectomy from the Norwegian Patient Register over a 5-year period. Age- and gender-adjusted population-based resection rates (adj. per million/yr) for distal pancreatectomy were analysed across 4 regions and outcomes related to splenic salvage rate, hospital stay, reoperation, readmissions and 90-day mortality risk between regions. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). RESULTS Regional difference exist in terms of absolute numbers, with the majority of procedures done in one region (n = 331; 59.7%). Regional variation persisted for age- and gender-adjusted population-rates, with highest rate at 23.8/million/yr and lowest rate at 13.5/mill/yr (for a 176% relative difference; or an absolute difference of +10.3 resections/million/yr). Overall, a lapDP instead of an open DP was 3.5 times more likely in SouthEast compared to all other regions combined (lapDP rate: 83% vrs 24%, respectively; OR 15.4, 95% c.i. 10.1-23.5; P < 0.001). The splenic salvage rate was lower in SouthEast (19.9%) compared to all other regions (average 26.5%; highest in Central-region at 37.0%; P = 0.010 for trend). Controlled for other factors in multivariate regression, 'region' of surgery remained significantly associated with laparoscopic access. CONCLUSION Despite a universal health care system, considerable variation exists in resection rates, use of laparoscopy and splenic salvage rates across regions.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway; Institute of Clinical Medicine, the Arctic University of Norway, Tromsø, Norway
| | - Dyre Kleive
- Department of Hepatobiliary and Pancreatic surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Frank Olsen
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Tromsø, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, the Arctic University of Norway, Tromsø, Norway; Department of Hepatobiliary and Pancreatic surgery, Oslo University Hospital, Oslo, Norway
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Søreide K, Olsen F, Nymo LS, Kleive D, Lassen K. A nationwide cohort study of resection rates and short-term outcomes in open and laparoscopic distal pancreatectomy. HPB (Oxford) 2019; 21:669-678. [PMID: 30391219 DOI: 10.1016/j.hpb.2018.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/10/2018] [Accepted: 10/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Distal pancreatectomy (DP) is increasingly done by laparoscopy but data from routine practise are scarce. We describe practise in a national cohort. METHODS Data from the Norwegian Patient Register of all patients undergoing DP from 2012 to 2016. National resection rates were analysed. Short-term outcomes include length of stay, reoperation, readmissions and 90-day mortality. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). RESULTS Of 554 procedures, 327 (59%) were laparoscopic. Median age was 66 years (iqr 55-72) and 52% were women. Resection rates increased during the period for all DP (from 1.76 to 2.39 per 100.000/yr), and significantly for laparoscopic DP (adjusted R-square 0.858; P = 0.015). Elderly patients had more resection (r2 = 0.11; P = 0.019). Splenectomy (n = 427; 77%) was less likely with laparoscopy (laparoscopy 72% vs open 84%, respectively; OR 0.64, 95% c.i. 0.42-0.97; P = 0.035). Multivisceral resections occurred more often in open DP (5.3% vs 1.2% for laparoscopy, OR 4.51, 1.44-14.2; P = 0.008). Reoperation occurred in 34 (6%), readmission in 109 (20%), and mortality in 8 (1.4%). Hospital stay was shorter for laparoscopic DP. CONCLUSION Use of DP increases in the population, particularly in the elderly, with use of laparoscopic access and an association with a reduced hospital stay.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Frank Olsen
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Tromsø, Norway
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Dyre Kleive
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway; Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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van Hilst J, Korrel M, de Rooij T, Lof S, Busch OR, Groot Koerkamp B, Kooby DA, van Dieren S, Abu Hilal M, Besselink MG. Oncologic outcomes of minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Eur J Surg Oncol 2019; 45:719-727. [DOI: 10.1016/j.ejso.2018.12.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/03/2018] [Accepted: 12/07/2018] [Indexed: 12/16/2022] Open
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The current surgical treatment of pancreatic neuroendocrine neoplasms in China: a national wide cross-sectional study. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Wang ZZ, Zhao GD, Zhao ZM, Gao YX, Xu Y, Yin ZZ, Liu Q, Lau WY, Liu R. An end-to-end pancreatic anastomosis in robotic central pancreatectomy. World J Surg Oncol 2019; 17:67. [PMID: 30981283 PMCID: PMC6462313 DOI: 10.1186/s12957-019-1609-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/26/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Suturing the proximal pancreatic stump and performing pancreaticoenterostomy for the distal pancreatic stump following central pancreatectomy is a conventional procedure. This reconstruction after resection of the pathological pancreatic lesion brings changes in anatomy and physiology. In this study, an innovative one-stage robotic end-to-end pancreatic anastomosis was reported to replace the conventional pancreaticoenterostomy following central pancreatectomy. MATERIALS AND METHODS The clinical data of 11 consecutive patients who underwent robotic central pancreatectomy with end-to-end pancreatic anastomosis between August 2017 and December 2017 were analyzed retrospectively. RESULTS All operations were completed successfully without any conversion to open surgery. Nine patients had benign tumors, one had a mass-forming chronic pancreatitis, and one had an isolated pancreatic metastasis from a renal cancer. The mean gap left after central pancreatectomy was 4.3 ± 1.0 cm. The median operative time was 121 (range, 105 to 199) min. The median blood loss was 50 (range, 20 to 100) ml. Seven (63.6%) patients developed complications which included Clavien-Dindo Grade I complications in five patients, a Grade II complication in one patient, and a Grade IIIa complication in one patient. Seven patients developed a Grade B postoperative pancreatic fistula, and two patients a biochemical leak. There was no Grade C or worse pancreatic fistula. Magnetic resonance cholangiopancreatography at postoperative 6 months showed no stricture in any of the main pancreatic ducts. Three patients had an asymptomatic and small pancreatic pseudocyst. CONCLUSION Robotic central pancreatectomy with end-to-end pancreatic anastomosis was safe and feasible. It restores the normal anatomy of the pancreas. With its good short-and long-term outcomes, it could be an alternative reconstructive method to pancreaticoenterostomy following central pancreatectomy.
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Affiliation(s)
- Zi-Zheng Wang
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Guo-Dong Zhao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhi-Ming Zhao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yuan-Xing Gao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yong Xu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhu-Zeng Yin
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Qu Liu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
| | - Rong Liu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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The current surgical treatment of pancreatic cancer in China: a national wide cross-sectional study. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Yang DJ, Xiong JJ, Lu HM, Wei Y, Zhang L, Lu S, Hu WM. The oncological safety in minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. Sci Rep 2019; 9:1159. [PMID: 30718559 PMCID: PMC6362067 DOI: 10.1038/s41598-018-37617-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 12/11/2018] [Indexed: 02/08/2023] Open
Abstract
The safety of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) regarding oncological outcomes of pancreatic ductal adenocarcinoma (PDAC) remains inconclusive. Therefore, the aim of this study was to examine the oncological safety of MIDP and ODP for PDAC. Major databases including PubMed, Embase, Science Citation Index Expanded, and the Cochrane Library were searched for studies comparing outcomes in patients undergoing MIDP and ODP for PDAC from January 1994 to August 2018. In total, 11 retrospective comparative studies with 4829 patients (MIDP: 1076, ODP: 3753) were included. The primary outcome was long-term survival, including 3-year overall survival (OS) and 5-year OS. The 3-year OS (hazard ratio (HR): 1.03, 95% confidence interval (CI): 0.89, 1.21; P = 0.66) and 5-year OS (HR: 0.91, 95% CI: 0.65, 1.28; P = 0.59) showed no significant differences between the two groups. Furthermore, the positive surgical margin rate (weighted mean difference (WMD): 0.71, 95% CI: 0.56, 0.89, P = 0.003) was lower in the MIDP group. However, patients in the MIDP group had less intraoperative blood loss (WMD: -250.03, 95% CI: -359.68, -140.39; P < 0.00001), a shorter hospital stay (WMD: -2.76, 95% CI: -3.73, -1.78; P < 0.00001) and lower morbidity (OR: 0.57, 95% CI: 0.46, 0.71; P < 0.00001) and mortality (OR: 0.50, 95% CI: 0.31, 0.81, P = 0.005) than patients in the ODP group. The limited evidence suggested that MIDP might be safer with regard to oncological outcomes in PDAC patients. Therefore, future high-quality studies are needed to examine the oncological safety of MIDP.
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Affiliation(s)
- Du-Jiang Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Jun-Jie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Hui-Min Lu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yi Wei
- Department of Transportation Center, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Ling Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Shan Lu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Wei-Ming Hu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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Deguelte S, de Mestier L, Hentic O, Cros J, Lebtahi R, Hammel P, Kianmanesh R. Sporadic pancreatic neuroendocrine tumor: Surgery of the primary tumor. J Visc Surg 2018; 155:483-492. [PMID: 30448206 DOI: 10.1016/j.jviscsurg.2018.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The management of patients with sporadic pancreatic neuroendocrine tumors (PNET) is multi-disciplinary and often, multimodal. Surgery has a large part in treatment because it is the only potentially curative therapeutic modality if resection can be complete. The update reviews the operative indications and the different surgical techniques available (including parenchymal-sparing surgery) to treat the primary lesion according to patient status, preoperative work-up and whether the tumor is functioning or not. The place of observation for "small" non-functional sporadic PNET is also discussed.
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Affiliation(s)
- S Deguelte
- Service de chirurgie generale, digestive et endocrinienne, hôpital Robert-Debré, université de Reims Champagne-Ardenne, 51100 Reims, France
| | - L de Mestier
- Service de gastroenterologie-pancréatologie, hôpital Beaujon, université Denis Diderot, AP-HP Clichy, 92110 Paris 7, France
| | - O Hentic
- Service de gastroenterologie-pancréatologie, hôpital Beaujon, université Denis Diderot, AP-HP Clichy, 92110 Paris 7, France
| | - J Cros
- Service d'anatomie pathologique, hôpital Beaujon, université Denis Diderot, AP-HP, Clichy, 92110 Paris 7, France
| | - R Lebtahi
- Service of médecine nucléaire, hôpital Beaujon, université Denis Diderot, AP-HP, Clichy, 92110 Paris 7, France
| | - P Hammel
- Service de gastroenterologie-pancréatologie, hôpital Beaujon, université Denis Diderot, AP-HP Clichy, 92110 Paris 7, France
| | - R Kianmanesh
- Service de chirurgie generale, digestive et endocrinienne, hôpital Robert-Debré, université de Reims Champagne-Ardenne, 51100 Reims, France.
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Sahakyan MA, Kleive D, Kazaryan AM, Aghayan DL, Ignjatovic D, Labori KJ, Røsok BI, Edwin B. Extended laparoscopic distal pancreatectomy for adenocarcinoma in the body and tail of the pancreas: a single-center experience. Langenbecks Arch Surg 2018; 403:941-948. [DOI: 10.1007/s00423-018-1730-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/06/2018] [Indexed: 12/11/2022]
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Siech M, Strauss P, Huschitt S, Bartsch DK, Wittel U, Keck T. The Indications for Laparoscopic Pancreatectomy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:263-268. [PMID: 28468714 DOI: 10.3238/arztebl.2017.0263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 10/12/2016] [Accepted: 12/14/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopic pancreatectomy is not yet established as a routine procedure everywhere in Germany or in other countries. Few data are available on its short- and long-term outcomes. METHODS From 2008 onward, a working group initiated by 10 centers and currently comprising 34 centers has gathered data on all cases of laparoscopic pancreatectomy. Procedures in which laparoscopy was converted to open surgery are also included. RESULTS The registry now contains 550 data sets representing 267 cases of benign disease, 244 malignancies, and 39 borderline tumors. The most common procedure was laparoscopic left pancreatectomy, followed by resection of the head of the pancreas and tumor enucleation. The most common intraoperative complication was hemorrhage, with a frequency of 3%. The rate of conversion to open surgery was 35%; if minilaparotomies are excluded, the conversion rate was only 16%. 39% of patients developed a pancreatic fistula after surgery (usually grade A or B, with 1.5% grade C) and 3% underwent reoperation because of postoperative hemorrhage. The procedure-related mortality was 1.3%. 91% of the patients reported only very mild postoperative pain. 6.7% newly developed diabetes mellitus after the procedure. CONCLUSION The patient cohort in the registry consists of persons who were selected to undergo laparoscopic pancreatectomy by the participating hospital teams, and the data are thus inherently affected by selection bias. The operative procedures that they underwent reflect the current practice of laparoscopic pancreatectomy in Germany. The complication rates are similar to those of open surgery. Selection bias can be avoided only by a randomized trial.
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Affiliation(s)
- Marco Siech
- Department of Surgery I, Ostalb Klinikum Aalen; Department of General and Visceral Surgery, Medical Center-University of Freiburg; Department of Visceral, Thoracic and Vascular Surgery University of Marburg; Department of Surgery, University Medical Center-UKSH, Lübeck
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Surgical outcomes of laparoscopic distal pancreatectomy in elderly and octogenarian patients: a single-center, comparative study. Surg Endosc 2018; 33:2142-2151. [DOI: 10.1007/s00464-018-6489-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/11/2018] [Indexed: 12/23/2022]
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Chen K, Pan Y, Zhang B, Maher H, Cai XJ. Laparoscopic versus open pancreatectomy for pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Int J Surg 2018; 53:243-256. [DOI: 10.1016/j.ijsu.2017.12.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/16/2017] [Accepted: 12/30/2017] [Indexed: 12/11/2022]
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Abstract
Some major procedures and an assessment of their impact in the field
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Affiliation(s)
- Thomas Hanna
- Department of HPB and Liver Transplant Surgery, The Royal Free NHS Trust , London
| | - Charles Imber
- Department of HPB and Liver Transplant Surgery, The Royal Free NHS Trust , London
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Stiles ZE, Dickson PV, Deneve JL, Glazer ES, Dong L, Wan JY, Behrman SW. The impact of unplanned conversion to an open procedure during minimally invasive pancreatectomy. J Surg Res 2018; 227:168-177. [PMID: 29804849 DOI: 10.1016/j.jss.2018.02.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 11/28/2017] [Accepted: 02/14/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Minimally invasive pancreatic resection (MIPR) is being increasingly utilized. Outcomes for patients experiencing unplanned conversion to an open procedure during MIPR have been incompletely assessed. We sought to determine the short-term outcomes and factors associated with unplanned conversion during MIPR. METHODS A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy-targeted data set was conducted. Successful MIPR was compared with unplanned conversion. Propensity matching was used to separately compare unplanned conversion during MIPR with planned open pancreatectomy. RESULTS Unplanned conversion occurred in 24.6% of 350 attempted minimally invasive pancreatoduodenectomy (MIPD) and 19.6% of 1174 attempted minimally invasive distal pancreatectomy (MIDP). Conversion was associated with greater overall morbidity and 30-day mortality compared with successful MIPR for both MIPD and MIDP. After matching, unplanned conversion resulted in outcomes equivalent or inferior to open pancreatectomy. Factors significantly associated with unplanned conversion during MIPD included intermediate gland texture, vascular resection, hypertension, disseminated cancer, and chronic steroid use. For MIDP, male sex, hard gland texture, vascular resection, smoking, and recent weight loss were independently associated with conversion. A robotic approach was inversely associated with conversion for MIPD and MIDP. CONCLUSIONS Unplanned conversion during MIPR is associated with greater morbidity and 30-day mortality. Conversion resulted in outcomes that, at best, mimicked those of open pancreatectomy. Several risk factors including the need for vascular resection are associated with unplanned conversion and should be acknowledged when planning an operative approach.
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Affiliation(s)
- Zachary E Stiles
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jeremiah L Deneve
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Evan S Glazer
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Lei Dong
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jim Y Wan
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Stephen W Behrman
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.
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