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Kumar A, Kaistha S, Gangavatiker R. Laparoscopic Pancreaticoduodenectomy With Open Reconstruction: The Buddha's Middle Path. Surg Laparosc Endosc Percutan Tech 2024:00129689-990000000-00255. [PMID: 39016282 DOI: 10.1097/sle.0000000000001311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/28/2021] [Indexed: 07/18/2024]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is not universally adopted because of its steep learning curve. Its technical complexity discourages many surgeons. We believe that laparoscopic pancreaticoduodenectomy with open reconstruction (LPOR) has all the benefits of LPD without its drawbacks and combines the ease of open surgery with the benefits of minimal access surgery. We assessed the feasibility and safety of LPOR and compared it with open pancreaticoduodenectomy (OPD), with the objectives being perioperative and short-term clinical/oncologic outcomes. METHODS Retrospective review of prospectively maintained database; study period from January 2013 to December 2019. Till 2015, we did only OPD. In 2016, we started with LPD but soon switched to LPOR. The resection part was done laparoscopically and the reconstruction part was done through a 8-cm mini-laparotomy. RESULTS We did 19 OPDs and 15 LPORs. Demographic data of the 2 groups were comparable. The duration of surgery was significantly longer in the LPOR group (360 vs. 410 min; P=0.01), whereas the blood loss and hospital stay were longer in the OPD group (520 vs. 360 mL; P=0.03 and 13 vs. 11 d; P=0.08, respectively). Clinically significant complication rates, including delayed gastric emptying and postoperative pancreatic fistulas, were not different in either group. No patients in the LPOR group had wound-related/pulmonary complications. Lymph node yield was similar in both groups (20 vs. 22) and we had 100% R0 resections. CONCLUSIONS LPOR was better than OPD in terms of short-term outcomes and was not inferior to OPD in terms of complications/oncologic outcomes.
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Affiliation(s)
- Ameet Kumar
- Department of GI Surgery, Command Hospital, Pune
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2
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Johansen KU, Augustinus S, Wellner UF, Andersson B, Beane JD, Björnsson B, Busch OR, Davis CH, Ghadimi M, Gleeson EM, de Graaf N, Koerkamp BG, Pitt HA, van Santvoort HC, Tingstedt B, Uhl W, Werner J, Williamsson C, Besselink MG, Keck T. International differences in the selection and outcome of minimally invasive and open distal pancreatectomy: A transatlantic analysis. Surgery 2024:S0039-6060(24)00451-3. [PMID: 39019733 DOI: 10.1016/j.surg.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 05/02/2024] [Accepted: 06/13/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The efficacy and safety of minimally invasive distal pancreatectomy have been confirmed by randomized trials, but current patient selection and outcome of minimally invasive distal pancreatectomy in large international cohorts is unknown. This study aimed to compare the use and outcome of minimally invasive distal pancreatectomy in North America, the Netherlands, Germany, and Sweden. METHODS All patients in the 4 Global Audits on Pancreatic Surgery Group (GAPASURG) registries who underwent minimally invasive distal pancreatectomy or open distal pancreatectomy during 2014-2020 were included. RESULTS Overall, 20,158 distal pancreatectomies were included, of which 7,316 (36%) were minimally invasive distal pancreatectomies. Use of minimally invasive distal pancreatectomy varied from 29% to 54% among registries, of which 13% to 35% were performed robotically. Both the use of minimally invasive distal pancreatectomy and robotic surgery were the highest in the Netherlands. Patients undergoing minimally invasive distal pancreatectomy tended to have a younger age (Germany and Sweden), female sex (North America, Germany), higher body mass index (North America, the Netherlands, Germany), lower comorbidity classification (North America, Germany, Sweden), lower performance status (Germany), and lower rate of pancreatic adenocarcinoma (all). The minimally invasive distal pancreatectomy group had fewer vascular resections (all) and lower rates of severe complications and mortality (North America, Germany). In the multivariable regression analysis, country was associated with severe complications but not with 30-day mortality. Minimally invasive distal pancreatectomy was associated with a lower risk of 30-day mortality compared with open distal pancreatectomy (odds ratio 1.633, 95% CI 1.159-2.300, P = .005). CONCLUSIONS Considerable disparities were seen in the use of minimally invasive distal pancreatectomy among 4 transatlantic registries of pancreatic surgery. Overall, minimally invasive distal pancreatectomy was associated with decreased mortality as compared with open distal pancreatectomy. Differences in patient selection among countries could imply that countries are in different stages of the learning curve.
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Affiliation(s)
- Karin U Johansen
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Ulrich F Wellner
- DGAV StuDoQ|Pancreas Registry and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joal D Beane
- Department of Surgery, The Ohio State University, Columbus, USA
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | | | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre Göttingen, Germany
| | | | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | - Bobby Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Waldemar Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital Bochum, Klinik der Ruhr-Universität, Bochum
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität, München
| | - Caroline Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas Registry and Clinic of Surgery, UKSH Campus Lübeck, Germany.
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3
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Yu YD, Halazun KJ, Chandwani R, Samstein B. Minimally invasive tools are necessary for the modern practice of liver surgery. J Minim Access Surg 2024:01413045-990000000-00059. [PMID: 38958005 DOI: 10.4103/jmas.jmas_377_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/15/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Minimally invasive liver resection (MILR) is performed for other gastrointestinal applications. At our centre, all liver resections are systematically performed using a minimally invasive approach. This study aimed to describe our experience in minimising open surgery and emphasised the importance of minimally invasive surgery. PATIENTS AND METHODS We retrospectively reviewed 260 patients who underwent liver surgery and compared the surgical outcomes between the open and MILR groups. RESULTS A total of 154 patients (68%) underwent MILR. The proportion of patients who underwent prior abdominal surgery and resection was higher in the open surgery group. However, the proportion of patients with liver cirrhosis was similar between the two groups. The MILR group was superior in terms of operative time, blood loss, Pringle manoeuvre rate and mean hospital stay. In addition, major complication and bile leak rates were lower in the MILR group. No significant differences in the tumour size, number of lesions or underlying liver pathology were observed between the two groups. CONCLUSION Acceptable outcomes can be achieved even when the minimally invasive approach is considered the primary option for all patients who require liver resection. Minimally invasive tools are necessary for the modern practice of liver surgery; therefore, laparoscopic or robotic surgery should be included in the armamentarium of liver surgeons.
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Affiliation(s)
- Young-Dong Yu
- Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgery, Weill Cornell Medical College, New York, NY, USA
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University College of Medicine, Seoul, Korea
| | - Karim J Halazun
- Department of Surgery, Division Hepatobiliary and Pancreatic Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Rohit Chandwani
- Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Benjamin Samstein
- Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgery, Weill Cornell Medical College, New York, NY, USA
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4
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Kakati RT, Naffouje S, Spanheimer PM, Dahdaleh FS. Role of minimally invasive surgery in the management of localized pancreatic ductal adenocarcinoma: a review. J Robot Surg 2024; 18:85. [PMID: 38386224 DOI: 10.1007/s11701-024-01825-w] [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: 10/15/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal malignancy with a minority of patients eligible for curative-intent surgical intervention. Pancreatic resections are technically demanding operations associated with considerable morbidity and mortality. Minimally invasive pancreatic resections (MIPRs), which include laparoscopic and robotic approaches, may enhance postoperative outcomes by lessening physiological impact of open surgery. A limited number of randomized-controlled trials as well as numerous retrospective reports have focused on MIPR outcomes and role in management of a variety of tumors, including PDAC. Today, MIPRs are generally considered acceptable alternatives to open surgery as a trend towards improved short-term metrics is observed. However, several questions remain regarding the oncological adequacy of MIPR's as long-term experience is less extensive compared to open techniques. This review aims to summarize existing evidence on MIPRs with a focus on PDAC.
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Affiliation(s)
- Rasha T Kakati
- Department of Surgical Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Samer Naffouje
- Department of Surgical Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Philip M Spanheimer
- Department of Surgical Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Fadi S Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA.
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5
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Korrel M, van Hilst J, Bosscha K, Busch ORC, Daams F, van Dam R, van Eijck CHJ, Festen S, Groot Koerkamp B, van der Harst E, Lips DJ, Luyer MD, de Meijer VE, Mieog JSD, Molenaar IQ, Patijn GA, van Santvoort HC, van der Schelling GP, Stommel MWJ, Besselink MG. Nationwide use and Outcome of Minimally Invasive Distal Pancreatectomy in IDEAL Stage IV following a Training Program and Randomized Trial. Ann Surg 2024; 279:323-330. [PMID: 37139822 DOI: 10.1097/sla.0000000000005900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To assess the nationwide long-term uptake and outcomes of minimally invasive distal pancreatectomy (MIDP) after a nationwide training program and randomized trial. BACKGROUND Two randomized trials demonstrated the superiority of MIDP over open distal pancreatectomy (ODP) in terms of functional recovery and hospital stay. Data on implementation of MIDP on a nationwide level are lacking. METHODS Nationwide audit-based study including consecutive patients after MIDP and ODP in 16 centers in the Dutch Pancreatic Cancer Audit (2014 to 2021). The cohort was divided into three periods: early implementation, during the LEOPARD randomized trial, and late implementation. Primary endpoints were MIDP implementation rate and textbook outcome. RESULTS Overall, 1496 patients were included with 848 MIDP (56.5%) and 648 ODP (43.5%). From the early to the late implementation period, the use of MIDP increased from 48.6% to 63.0% and of robotic MIDP from 5.5% to 29.7% ( P <0.001). The overall use of MIDP (45% to 75%) and robotic MIDP (1% to 84%) varied widely between centers ( P <0.001). In the late implementation period, 5/16 centers performed >75% of procedures as MIDP. After MIDP, in-hospital mortality and textbook outcome remained stable over time. In the late implementation period, ODP was more often performed in ASA score III-IV (24.9% vs. 35.7%, P =0.001), pancreatic cancer (24.2% vs. 45.9%, P <0.001), vascular involvement (4.6% vs. 21.9%, P <0.001), and multivisceral involvement (10.5% vs. 25.3%, P <0.001). After MIDP, shorter hospital stay (median 7 vs. 8 d, P <0.001) and less blood loss (median 150 vs. 500 mL, P <0.001), but more grade B/C postoperative pancreatic fistula (24.4% vs. 17.2%, P =0.008) occurred as compared to ODP. CONCLUSION A sustained nationwide implementation of MIDP after a successful training program and randomized trial was obtained with satisfactory outcomes. Future studies should assess the considerable variation in the use of MIDP between centers and, especially, robotic MIDP.
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Affiliation(s)
- Maarten Korrel
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
| | - Jony van Hilst
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Department of Surgery, OLVG Oost, Amsterdam
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch
| | - Olivier R C Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
| | - Freek Daams
- Cancer Center Amsterdam
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery, Amsterdam
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht
| | | | | | | | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht
| | | | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
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6
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Abu Hilal M, van Ramshorst TM, Boggi U, Dokmak S, Edwin B, Keck T, Khatkov I, Ahmad J, Al Saati H, Alseidi A, Azagra JS, Björnsson B, Can FM, D’Hondt M, Efanov M, Espin Alvarez F, Esposito A, Ferrari G, Groot Koerkamp B, Gumbs AA, Hogg ME, Huscher CG, Ielpo B, Ivanecz A, Jang JY, Liu R, Luyer MD, Menon K, Nakamura M, Piardi T, Saint-Marc O, White S, Yoon YS, Zerbi A, Bassi C, Berrevoet F, Chan C, Coimbra FJ, Conlon KC, Cook A, Dervenis C, Falconi M, Ferrari C, Frigerio I, Fusai GK, De Oliveira ML, Pinna AD, Primrose JN, Sauvanet A, Serrablo A, Smadi S, Badran A, Baychorov M, Bannone E, van Bodegraven EA, Emmen AM, Giani A, de Graaf N, van Hilst J, Jones LR, Levi Sandri GB, Pulvirenti A, Ramera M, Rashidian N, Sahakyan MA, Uijterwijk BA, Zampedri P, Zwart MJ, Alfieri S, Berti S, Butturini G, Di Benedetto F, Ettorre GM, Giuliante F, Jovine E, Memeo R, Portolani N, Ruzzenente A, Salvia R, Siriwardena AK, Besselink MG, Asbun HJ. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS). Ann Surg 2024; 279:45-57. [PMID: 37450702 PMCID: PMC10727198 DOI: 10.1097/sla.0000000000006006] [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: 07/18/2023]
Abstract
OBJECTIVE To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. SUMMARY BACKGROUND DATA Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. METHODS Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee. RESULTS Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. CONCLUSIONS The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies.
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Affiliation(s)
- Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Tess M.E. van Ramshorst
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Safi Dokmak
- Department of HPB surgery and liver transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Clichy, France
| | - Bjørn Edwin
- The Intervention Centre, Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital and Institute of Medicine, Oslo University, Oslo, Norway
| | - Tobias Keck
- Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Jawad Ahmad
- Department of Surgery, University Hospitals Coventry and Warwickshire, West Midlands, UK
| | - Hani Al Saati
- Department of Surgery, Salmanyia Medical Complex, Manama, Bahrain
| | - Adnan Alseidi
- Department of Surgery, University of California - San Francisco, San Francisco, California
| | - Juan S. Azagra
- Department of General & Minimally Invasive Surgery (Laparoscopy & Robotic), Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Fatih M. Can
- Department of General Surgery, Bayindir Sogutozu Hospital, Ankara, Turkey
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Mikhail Efanov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Francisco Espin Alvarez
- Department of Hepato-Pancreato-Biliary Surgery, Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Alessandro Esposito
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Giovanni Ferrari
- Division of Minimally invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Andrew A. Gumbs
- Department of Visceral Surgery, Centre Hospitalier Intercommunal de Poissy/Saint-Germain-en-Laye, Poissy, France
| | - Melissa E. Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, Illinois
| | - Cristiano G.S. Huscher
- Department of Oncologic Surgery, Casa di Cura Cobellis, Vallo Della Lucania, Salerno, Italy
| | - Benedetto Ielpo
- Hepato-Biliary and Pancreatic Surgery Unit, Hospital del Mar, Barcelona, Spain
| | - Arpad Ivanecz
- Department of Abdominal and General Surgery, University Medical Center Maribor, Maribor, Slovenia
| | - Jin-Young Jang
- Departments of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Misha D.P. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Krishna Menon
- Institute of Liver Studies, King’s College Hospital, London, UK
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tullio Piardi
- Department of Hepatobiliary, Pancreatic, and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional Orleans, Orleans, France
| | - Steve White
- Department of HPB and Liver Transplant Surgery, The Freeman Hospital, Newcastle, United Kingdom
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy and IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Carlos Chan
- Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Felipe J. Coimbra
- Department of Abdominal Surgery, AC Camargo Cancer Center, São Paulo, Brazil
| | - Kevin C.P. Conlon
- Department of Surgery, St. Vincent’s University Hospital Dublin, Ireland
| | - Andrew Cook
- Southampton Clinical Trials Unit, University Hospital Southampton, Southampton, UK
| | | | - Massimo Falconi
- Pancreas Translational & Clinical Research Center, San Raffaele IRCCS, Università Vita-Salute, Milan, Italy
| | - Clarissa Ferrari
- Unit of Statistics, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Isabella Frigerio
- Department of HPB Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | | | - Michelle L. De Oliveira
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Antonio D. Pinna
- Department of Abdominal and Transplant Surgery, Cleveland Clinic Florida, Weston, Florida
| | - John N. Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Alain Sauvanet
- Department of HPB Surgery and Liver Transplantation, Hospital of Beaujon, Paris, France
| | - Alejandro Serrablo
- HPB Surgical Division, Miguel Servet University Hospital, Zaragoza, Spain
| | - Sameer Smadi
- Department of Surgery, King Hussein Medical Center, Amman, Jordan
| | - Ali Badran
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Magomet Baychorov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Elisa Bannone
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Eduard A. van Bodegraven
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Anouk M.L.H. Emmen
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Alessandro Giani
- Division of Minimally invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nine de Graaf
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Jony van Hilst
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Leia R. Jones
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Giovanni B. Levi Sandri
- Division of General Surgery and Liver Transplantation, S. Camillo Forlanini Hospital, Rome, Italy
| | - Alessandra Pulvirenti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marco Ramera
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Niki Rashidian
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Mushegh A. Sahakyan
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of Surgery N1, Yerevan State Medical University, Yerevan, Armenia
| | - Bas A. Uijterwijk
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Pietro Zampedri
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Maurice J.W. Zwart
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Sergio Alfieri
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefano Berti
- Department of General Surgery, “Sant’Andrea” Hospital La Spezia, La Spezia, Italy
| | - Giovanni Butturini
- Department of HPB Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe M. Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Forlanini Hospital, Rome, Italy
| | - Felice Giuliante
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elio Jovine
- Alma Mater Studiorum, University of Bologna, AOU Sant’Orsola Malpighi, IRCCS at Maggiore Hospital, Bologna, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, Miulli Hospital, Bari, Italy
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Italy
| | - Andrea Ruzzenente
- Department of Surgery, General and Hepatobiliary Surgery, University Hospital G.B. Rossi, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Ajith K. Siriwardena
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, UK
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Horacio J. Asbun
- Hepato-Biliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
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7
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van Ramshorst TME, van Hilst J, Bannone E, Pulvirenti A, Asbun HJ, Boggi U, Busch OR, Dokmak S, Edwin B, Hogg M, Jang JY, Keck T, Khatkov I, Kohan G, Kokudo N, Kooby DA, Nakamura M, Primrose JN, Siriwardena AK, Toso C, Vollmer CM, Zeh HJ, Besselink MG, Abu Hilal M. International survey on opinions and use of robot-assisted and laparoscopic minimally invasive pancreatic surgery: 5-year follow up. HPB (Oxford) 2024; 26:63-72. [PMID: 37739876 DOI: 10.1016/j.hpb.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Evidence on the value of minimally invasive pancreatic surgery (MIPS) has been increasing but it is unclear how this has influenced the view of pancreatic surgeons on MIPS. METHODS An anonymous survey was sent to members of eight international Hepato-Pancreato-Biliary Associations. Outcomes were compared with the 2016 international survey. RESULTS Overall, 315 surgeons from 47 countries participated. The median volume of pancreatic resections per center was 70 (IQR 40-120). Most surgeons considered minimally invasive distal pancreatectomy (MIDP) superior to open (ODP) (94.6%) and open pancreatoduodenectomy (OPD) superior to minimally invasive (MIPD) (67.9%). Since 2016, there has been an increase in the number of surgeons performing both MIDP (79%-85.7%, p = 0.024) and MIPD (29%-45.7%, p < 0.001), and an increase in the use of the robot-assisted approach for both MIDP (16%-45.6%, p < 0.001) and MIPD (23%-47.9%, p < 0.001). The use of laparoscopy remained stable for MIDP (91% vs. 88.1%, p = 0.245) and decreased for MIPD (51%-36.8%, p = 0.024). CONCLUSION This survey showed considerable changes of MIPS since 2016 with most surgeons considering MIDP superior to ODP and an increased use of robot-assisted MIPS. Surgeons prefer OPD and therefore the value of MIPD remains to be determined in randomized trials.
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Affiliation(s)
- Tess M E van Ramshorst
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Jony van Hilst
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Elisa Bannone
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Alessandra Pulvirenti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Ugo Boggi
- Department of Surgery, University Hospital of Pisa, Pisa, Italy
| | - Olivier R Busch
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, APHP Beaujon Hospital - University of Paris Cité, Clichy, France
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Also Institute of Medicine, University of Oslo, Norway
| | - Melissa Hogg
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Gustavo Kohan
- Department of Surgery, Hospital Cosme Argerich, University of Buenos Aires, Buenos Aires, Argentina
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - David A Kooby
- Department of Surgery, Winship Cancer Institute, Emory University Hospital, Atlanta, GA, USA
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Christian Toso
- Division of Abdominal Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Charles M Vollmer
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Herbert J Zeh
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
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8
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Dincer HA, Cennet Ö, Dogrul AB. Comparison of Educational and Academic Quality of Laparoscopic Distal Pancreatectomy Videos on WebSurg ® and YouTube ® Platforms. Surg Innov 2023; 30:728-738. [PMID: 37867402 DOI: 10.1177/15533506231208583] [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: 10/24/2023]
Abstract
BACKGROUND The aim of this study was to compare the educational and academic quality of laparoscopic distal pancreatectomy (LDP) videos on YouTube® and WebSurg® platforms. MATERIAL AND METHODS YouTube and WebSurg platforms were searched with the keyword "laparoscopic distal pancreatectomy". According to the exclusion criteria, 12 videos were found on WebSurg. To ensure a 1:1 ratio, the first 12 videos that met the criteria on YouTube were also analyzed. Journal of American Medical Association (JAMA) benchmark criteria were used to evaluate the reliability of the videos. The non-educational quality of the videos was calculated using the Global Quality Score (GQS), the educational and academic quality of videos was calculated using Laparoscopic Distal Pancreatectomy-specific score (LDP-SS) and Laparoscopic Surgery Video Educational Guidelines scoring system (LAP-VEGaS). RESULTS The mean JAMA score was 1.58 on YouTube and 2.83 on WebSurg (P < .001). The median GQS was 2 on YouTube and 5 on WebSurg (P < .001). The median LAP-VEGaS score was 8 on YouTube and 14.5 on WebSurg (P < .001). The median LDP-SS score was 6 on YouTube and 9.5 on WebSurg (P = .001). According to the LAP-VEGaS, eleven (91.7%) of the WebSurg videos had a high score of 11 or more (P = .04). According to Spearman correlation analysis, there was a statistically significant positive correlation between LDP-SS and JAMA, GQS and LAP-VEGaS (r: .589, P = .002; r: .648, P = .001; r: .848, P < .001 respectively). CONCLUSIONS The WebSurg is superior to the YouTube in terms of educational and academic value, quality, accuracy, reliability and usability in scientific meetings for LDP videos.
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Affiliation(s)
- Hilmi Anil Dincer
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ömer Cennet
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ahmet Bulent Dogrul
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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9
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Stiles ZE, Tolley EA, Dickson PV, Deneve JL, Kocak M, Behrman SW. Nationwide analysis of unplanned conversion during minimally invasive distal pancreatectomy for pancreatic adenocarcinoma. HPB (Oxford) 2023; 25:1566-1572. [PMID: 37652810 DOI: 10.1016/j.hpb.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/22/2023] [Accepted: 08/14/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Utilization of minimally-invasive distal pancreatectomy (MIDP) for pancreatic adenocarcinoma has increased. While unplanned conversion to an open procedure during MIDP is associated with inferior short-term outcomes, the long-term consequences of conversion have not been adequately examined. METHODS Patients with pancreatic adenocarcinoma undergoing MIDP were selected from the National Cancer Database (2010-2015) and subdivided based on the occurrence of unplanned conversion. Post-operative outcomes and overall survival (OS) were examined. Conversion was additionally compared to a matched group of planned open resections. RESULTS Among 592 patients undergoing attempted MIDP, unplanned conversion occurred in 23.1%. Despite increased 90-day mortality among patients experiencing conversion, there was no difference in median OS between groups (25.0 vs 27.8 months, p = 0.095). For patients undergoing conversion, post-operative outcomes and long-term survival were similar when compared to a propensity-matched group of patients undergoing planned open resection. On multivariable analysis, treatment at an academic facility (OR 0.63) and a robotic approach (OR 0.50) were both significantly associated with completed MIDP. CONCLUSION Despite inferior post-operative outcomes compared to successful MIDP, unplanned conversion did not result in significantly reduced long term survival. MIDP can be attempted selectively but treatment at experienced centers via a robotic approach should be considered.
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Affiliation(s)
- Zachary E Stiles
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA; Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Elizabeth A Tolley
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mehmet Kocak
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephen W Behrman
- Department of Surgery, Baptist Memorial Medical Education, Memphis, TN, USA
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10
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Labadie KP, Melstrom LG, Lewis AG. Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience. J Surg Oncol 2023; 128:1347-1352. [PMID: 37781938 DOI: 10.1002/jso.27455] [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: 08/29/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023]
Abstract
Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.
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Affiliation(s)
- Kevin P Labadie
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Aaron G Lewis
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
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11
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Zwart MJ, van den Broek B, de Graaf N, Suurmeijer JA, Augustinus S, te Riele WW, van Santvoort HC, Hagendoorn J, Borel Rinkes IH, van Dam JL, Takagi K, Tran KT, Schreinemakers J, van der Schelling G, Wijsman JH, de Wilde RF, Festen S, Daams F, Luyer MD, de Hingh IH, Mieog JS, Bonsing BA, Lips DJ, Abu Hilal M, Busch OR, Saint-Marc O, Zeh HJ, Zureikat AH, Hogg ME, Koerkamp BG, Molenaar IQ, Besselink MG. The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following a Multicenter Training Program: "Standing on the Shoulders of Giants". Ann Surg 2023; 278:e1232-e1241. [PMID: 37288547 PMCID: PMC10631507 DOI: 10.1097/sla.0000000000005928] [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: 06/09/2023]
Abstract
OBJECTIVE To assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework. BACKGROUND The long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program. METHODS Post hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned." RESULTS Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome. CONCLUSIONS The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.
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Affiliation(s)
- Maurice J.W. Zwart
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bram van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
| | - José A. Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Wouter W. te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H.M. Borel Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L. van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Khé T.C. Tran
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Jan H. Wijsman
- Department of Surgery, Amphia Medical Center, Breda, the Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Misha D. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S.D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J. Lips
- Department of Surgery, Twente Medical Spectrum, Enschede, the Netherlands
| | - Mohamed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Herbert J. Zeh
- Department of Surgery, University of Texas, Southwestern, Dallas, TX
| | - Amer H. Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa E. Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, IL
| | - Bas G. Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Isaac Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
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12
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Perri G, van Hilst J, Li S, Besselink MG, Hogg ME, Marchegiani G. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. BJS Open 2023; 7:zrad081. [PMID: 37698977 PMCID: PMC10496870 DOI: 10.1093/bjsopen/zrad081] [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] [Received: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form. METHODS This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques. RESULTS Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models. CONCLUSION Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Shen Li
- Department of Surgical Oncology, University of Chicago, Chicago, Illinois, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Melissa E Hogg
- Department of HPB Surgery, NorthShore Health System, Evanston, Illinois, USA
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
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13
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Lof S, Claassen L, Hannink G, Al-Sarireh B, Björnsson B, Boggi U, Burdio F, Butturini G, Capretti G, Casadei R, Dokmak S, Edwin B, Esposito A, Fabre JM, Ferrari G, Fretland AA, Ftériche FS, Fusai GK, Giardino A, Groot Koerkamp B, D’Hondt M, Jah A, Kamarajah SK, Kauffmann EF, Keck T, van Laarhoven S, Manzoni A, Marino MV, Marudanayagam R, Molenaar IQ, Pessaux P, Rosso E, Salvia R, Soonawalla Z, Souche R, White S, van Workum F, Zerbi A, Rosman C, Stommel MWJ, Abu Hilal M, Besselink MG. Learning Curves of Minimally Invasive Distal Pancreatectomy in Experienced Pancreatic Centers. JAMA Surg 2023; 158:927-933. [PMID: 37378968 PMCID: PMC10308297 DOI: 10.1001/jamasurg.2023.2279] [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: 11/22/2022] [Accepted: 03/23/2023] [Indexed: 06/29/2023]
Abstract
Importance Understanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive distal pancreatectomy (MIDP) are mostly small, single-center series, thus providing limited data. Objective To evaluate the length of pooled learning curves of MIDP in experienced centers. Design, Setting, and Participants This international, multicenter, retrospective cohort study included MIDP procedures performed from January 1, 2006, through June 30, 2019, in 26 European centers from 8 countries that each performed more than 15 distal pancreatectomies annually, with an overall experience exceeding 50 MIDP procedures. Consecutive patients who underwent elective laparoscopic or robotic distal pancreatectomy for all indications were included. Data were analyzed between September 1, 2021, and May 1, 2022. Exposures The learning curve for MIDP was estimated by pooling data from all centers. Main Outcomes and Measures The learning curve was assessed for the primary textbook outcome (TBO), which is a composite measure that reflects optimal outcome, and for surgical mastery. Generalized additive models and a 2-piece linear model with a break point were used to estimate the learning curve length of MIDP. Case mix-expected probabilities were plotted and compared with observed outcomes to assess the association of changing case mix with outcomes. The learning curve also was assessed for the secondary outcomes of operation time, intraoperative blood loss, conversion to open rate, and postoperative pancreatic fistula grade B/C. Results From a total of 2610 MIDP procedures, the learning curve analysis was conducted on 2041 procedures (mean [SD] patient age, 58 [15.3] years; among 2040 with reported sex, 1249 were female [61.2%] and 791 male [38.8%]). The 2-piece model showed an increase and eventually a break point for TBO at 85 procedures (95% CI, 13-157 procedures), with a plateau TBO rate at 70%. The learning-associated loss of TBO rate was estimated at 3.3%. For conversion, a break point was estimated at 40 procedures (95% CI, 11-68 procedures); for operation time, at 56 procedures (95% CI, 35-77 procedures); and for intraoperative blood loss, at 71 procedures (95% CI, 28-114 procedures). For postoperative pancreatic fistula, no break point could be estimated. Conclusion and Relevance In experienced international centers, the learning curve length of MIDP for TBO was considerable with 85 procedures. These findings suggest that although learning curves for conversion, operation time, and intraoperative blood loss are completed earlier, extensive experience may be needed to master the learning curve of MIDP.
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Affiliation(s)
- Sanne Lof
- Amsterdam UMC, Department of Surgery, University of Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, Fondazione Poliambulanza–Istituto Ospedaliero, Brescia, Italy
| | - Linda Claassen
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bilal Al-Sarireh
- Department of Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy
| | | | | | - Giovanni Capretti
- Department of Surgery, Humanitas University and IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Riccardo Casadei
- Department of Surgery, S Orsola-Malpighi Hospital, Bologna, Italy
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Bjørn Edwin
- The Intervention Center and Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Jean M. Fabre
- Department of Surgery, Saint-Éloi Hospital, Montpellier, France
| | - Giovanni Ferrari
- Department of Oncologic and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Asmund A. Fretland
- The Intervention Center and Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Fadhel S. Ftériche
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Giuseppe K. Fusai
- Division of Surgery and Interventional Science, Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk, Belgium
| | - Asif Jah
- Department of Hepato-Pancreato-Biliary Surgery and Transplantation, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Sivesh K. Kamarajah
- Department of Surgery, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | | | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Germany
| | - Stijn van Laarhoven
- Department of Hepato-Pancreato-Biliary Surgery and Transplantation, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Alberto Manzoni
- Department of Surgery, Fondazione Poliambulanza–Istituto Ospedaliero, Brescia, Italy
| | - Marco V. Marino
- Department of Emergency and General Surgery, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Ravi Marudanayagam
- Department of Surgery, Queen Elizabeth Hospital, University Hospitals of Birmingham NHS Trust, Birmingham, United Kingdom
| | - Izaak Q. Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, the Netherlands
| | - Patrick Pessaux
- Department of Viscerale and Digestive Surgery, Nouvel Hôpital Civil–IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Edoardo Rosso
- Department of Surgery, Centre Hospitalier de Luxembourg, Luxembourg
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - Regis Souche
- Department of Surgery, Saint-Éloi Hospital, Montpellier, France
| | - Steven White
- Department of Surgery, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas University and IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza–Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation, Southampton, United Kingdom
| | - Marc G. Besselink
- Amsterdam UMC, Department of Surgery, University of Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
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14
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Augustinus S, Schafrat PJM, Janssen BV, Bonsing BA, Brosens LAA, Busch OR, Crobach S, Doukas M, van Eijck CH, van der Geest LGM, Groot Koerkamp B, de Hingh IHJT, Raicu GM, van Santvoort HC, van Velthuysen ML, Verheij J, Besselink MG, Farina Sarasqueta A. Nationwide Impact of Centralization, Neoadjuvant Therapy, Minimally Invasive Surgery, and Standardized Pathology Reporting on R0 Resection and Overall Survival in Pancreatoduodenectomy for Pancreatic Cancer. Ann Surg Oncol 2023; 30:5051-5060. [PMID: 37210448 PMCID: PMC10319672 DOI: 10.1245/s10434-023-13465-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/22/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Surgeons aim for R0 resection in patients with pancreatic cancer to improve overall survival. However, it is unclear whether recent changes in pancreatic cancer care such as centralization, increased use of neoadjuvant therapy, minimally invasive surgery, and standardized pathology reporting have influenced R0 resections and whether R0 resection remains associated with overall survival. METHODS This nationwide retrospective cohort study included consecutive patients after pancreatoduodenectomy (PD) for pancreatic cancer from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Database (2009-2019). R0 resection was defined as > 1 mm tumor clearance at the pancreatic, posterior, and vascular resection margins. Completeness of pathology reporting was scored on the basis of six elements: histological diagnosis, tumor origin, radicality, tumor size, extent of invasion, and lymph node examination. RESULTS Among 2955 patients after PD for pancreatic cancer, the R0 resection rate was 49%. The R0 resection rate decreased from 68 to 43% (2009-2019, P < 0.001). The extent of resections in high-volume hospitals, minimally invasive surgery, neoadjuvant therapy, and complete pathology reports all significantly increased over time. Only complete pathology reporting was independently associated with lower R0 rates (OR 0.76, 95% CI 0.69-0.83, P < 0.001). Higher hospital volume, neoadjuvant therapy, and minimally invasive surgery were not associated with R0. R0 resection remained independently associated with improved overall survival (HR 0.72, 95% CI 0.66-0.79, P < 0.001), as well as in the 214 patients after neoadjuvant treatment (HR 0.61, 95% CI 0.42-0.87, P = 0.007). CONCLUSIONS The nationwide rate of R0 resections after PD for pancreatic cancer decreased over time, mostly related to more complete pathology reporting. R0 resection remained associated with overall survival.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Pascale J M Schafrat
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Boris V Janssen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - G Mihaela Raicu
- Department of Pathology, St Antonius Hospital and Pathology DNA, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Arantza Farina Sarasqueta
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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15
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Görgec B, Zwart M, Nota CL, Bijlstra OD, Bosscha K, de Boer MT, de Wilde RF, Draaisma WA, Gerhards MF, Liem MS, Lips DJ, Marsman HA, Mieog JSD, Molenaar QI, Nijkamp M, Te Riele WW, Terkivatan T, Vahrmeijer AL, Besselink MG, Swijnenburg RJ, Hagendoorn J. Implementation and Outcome of Robotic Liver Surgery in the Netherlands: A Nationwide Analysis. Ann Surg 2023; 277:e1269-e1277. [PMID: 35848742 PMCID: PMC10174096 DOI: 10.1097/sla.0000000000005600] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the nationwide implementation and surgical outcome of minor and major robotic liver surgery (RLS) and assess the first phase of implementation of RLS during the learning curve. BACKGROUND RLS may be a valuable alternative to laparoscopic liver surgery. Nationwide population-based studies with data on implementation and outcome of RLS are lacking. METHODS Multicenter retrospective cohort study including consecutive patients who underwent RLS for all indications in 9 Dutch centers (August 2014-March 2021). Data on all liver resections were obtained from the mandatory nationwide Dutch Hepato Biliary Audit (DHBA) including data from all 27 centers for liver surgery in the Netherlands. Outcomes were stratified for minor, technically major, and anatomically major RLS. Learning curve effect was assessed using cumulative sum analysis for blood loss. RESULTS Of 9437 liver resections, 400 were RLS (4.2%) procedures including 207 minor (52.2%), 141 technically major (35.3%), and 52 anatomically major (13%). The nationwide use of RLS increased from 0.2% in 2014 to 11.9% in 2020. The proportion of RLS among all minimally invasive liver resections increased from 2% to 28%. Median blood loss was 150 mL (interquartile range 50-350 mL] and the conversion rate 6.3% (n=25). The rate of Clavien-Dindo grade ≥III complications was 7.0% (n=27), median length of hospital stay 4 days (interquartile range 2-5) and 30-day/in-hospital mortality 0.8% (n=3). The R0 resection rate was 83.2% (n=263). Cumulative sum analysis for blood loss found a learning curve of at least 33 major RLS procedures. CONCLUSIONS The nationwide use of RLS in the Netherlands has increased rapidly with currently one-tenth of all liver resections and one-fourth of all minimally invasive liver resections being performed robotically. Although surgical outcomes of RLS in selected patient seem favorable, future prospective studies should determine its added value.
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Affiliation(s)
- Burak Görgec
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Maurice Zwart
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Carolijn L. Nota
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands
| | - Marieke T. de Boer
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Werner A. Draaisma
- Department of Surgery, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands
| | | | - Mike S. Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Daan J. Lips
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Quintus I. Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maarten Nijkamp
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Wouter W. Te Riele
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Türkan Terkivatan
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Rutger-Jan Swijnenburg
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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16
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Emmen AMLH, Görgec B, Zwart MJW, Daams F, Erdmann J, Festen S, Gouma DJ, van Gulik TM, van Hilst J, Kazemier G, Lof S, Sussenbach SI, Tanis PJ, Zonderhuis BM, Busch OR, Swijnenburg RJ, Besselink MG. Impact of shifting from laparoscopic to robotic surgery during 600 minimally invasive pancreatic and liver resections. Surg Endosc 2023; 37:2659-2672. [PMID: 36401105 PMCID: PMC10082117 DOI: 10.1007/s00464-022-09735-4] [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: 06/20/2022] [Accepted: 10/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many centers worldwide are shifting from laparoscopic to robotic minimally invasive hepato-pancreato-biliary resections (MIS-HPB) but large single center series assessing this process are lacking. We hypothesized that the introduction of robot-assisted surgery was safe and feasible in a high-volume center. METHODS Single center, post-hoc assessment of prospectively collected data including all consecutive MIS-HPB resections (January 2010-February 2022). As of December 2018, all MIS pancreatoduodenectomy and liver resections were robot-assisted. All surgeons had participated in dedicated training programs for laparoscopic and robotic MIS-HPB. Primary outcomes were in-hospital/30-day mortality and Clavien-Dindo ≥ 3 complications. RESULTS Among 1875 pancreatic and liver resections, 600 (32%) were MIS-HPB resections. The overall rate of conversion was 4.3%, Clavien-Dindo ≥ 3 complications 25.7%, and in-hospital/30-day mortality 1.8% (n = 11). When comparing the period before and after the introduction of robotic MIS-HPB (Dec 2018), the overall use of MIS-HPB increased from 25.3 to 43.8% (P < 0.001) and blood loss decreased from 250 ml [IQR 100-500] to 150 ml [IQR 50-300] (P < 0.001). The 291 MIS pancreatic resections included 163 MIS pancreatoduodenectomies (52 laparoscopic, 111 robotic) with 4.3% conversion rate. The implementation of robotic pancreatoduodenectomy was associated with reduced operation time (450 vs 361 min; P < 0.001), reduced blood loss (350 vs 200 ml; P < 0.001), and a decreased rate of delayed gastric emptying (28.8% vs 9.9%; P = 0.009). The 309 MIS liver resections included 198 laparoscopic and 111 robotic procedures with a 3.6% conversion rate. The implementation of robotic liver resection was associated with less overall complications (24.7% vs 10.8%; P = 0.003) and shorter hospital stay (4 vs 3 days; P < 0.001). CONCLUSION The introduction of robotic surgery was associated with greater implementation of MIS-HPB in up to nearly half of all pancreatic and liver resections. Although mortality and major morbidity were not affected, robotic surgery was associated with improvements in some selected outcomes. Ultimately, randomized studies and high-quality registries should determine its added value.
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Affiliation(s)
- Anouk. M. L. H. Emmen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B. Görgec
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - M. J. W. Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - F. Daams
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - J. Erdmann
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S. Festen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - D. J. Gouma
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - T. M. van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - G. Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - S. Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S. I. Sussenbach
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - P. J. Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B. M. Zonderhuis
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - O. R. Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - R. J. Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - M. G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - for HPB-Amsterdam
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
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17
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Concors SJ, Katz MHG, Ikoma N. Minimally Invasive Pancreatectomy: Robotic and Laparoscopic Developments. Surg Oncol Clin N Am 2023; 32:327-342. [PMID: 36925189 DOI: 10.1016/j.soc.2022.10.009] [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: 03/15/2023]
Abstract
Minimally invasive pancreatectomy is increasingly used. Although offering potential advantages over open approaches, minimally invasive pancreatectomy has many challenges to maintain high-quality of oncologic resection. Multiple patient and surgical factors should be considered in planning laparoscopic or robotic resection, including the learning curve required to produce proficiency. For pancreaticoduodenectomy, distal pancreatectomy, and other pancreatic resections, a safe, margin-negative resection remains the goal. National and societal guidelines for the adoption of minimally invasive pancreatectomy are ongoing and will continue to be important as these techniques are further adopted.
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Affiliation(s)
- Seth J Concors
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler, FCT 17.6022, Houston, TX 77030, USA. https://twitter.com/SethConcorsMD
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler, FCT 17.6022, Houston, TX 77030, USA. https://twitter.com/MKatzMD
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler, FCT 17.6022, Houston, TX 77030, USA.
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18
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Karadza E, Haney CM, Limen EF, Müller PC, Kowalewski KF, Sandini M, Wennberg E, Schmidt MW, Felinska EA, Lang F, Salg G, Kenngott HG, Rangelova E, Mieog S, Vissers F, Korrel M, Zwart M, Sauvanet A, Loos M, Mehrabi A, de Santibanes M, Shrikhande SV, Abu Hilal M, Besselink MG, Müller-Stich BP, Hackert T, Nickel F. Development of biotissue training models for anastomotic suturing in pancreatic surgery. HPB (Oxford) 2023:S1365-182X(23)00041-2. [PMID: 36828741 DOI: 10.1016/j.hpb.2023.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 12/11/2022] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Anastomotic suturing is the Achilles heel of pancreatic surgery. Especially in laparoscopic and robotically assisted surgery, the pancreatic anastomosis should first be trained outside the operating room. Realistic training models are therefore needed. METHODS Models of the pancreas, small bowel, stomach, bile duct, and a realistic training torso were developed for training of anastomoses in pancreatic surgery. Pancreas models with soft and hard textures, small and large ducts were incrementally developed and evaluated. Experienced pancreatic surgeons (n = 44) evaluated haptic realism, rigidity, fragility of tissues, and realism of suturing and knot tying. RESULTS In the iterative development process the pancreas models showed high haptic realism and highest realism in suturing (4.6 ± 0.7 and 4.9 ± 0.5 on 1-5 Likert scale, soft pancreas). The small bowel model showed highest haptic realism (4.8 ± 0.4) and optimal wall thickness (0.1 ± 0.4 on -2 to +2 Likert scale) and suturing behavior (0.1 ± 0.4). The bile duct models showed optimal wall thickness (0.3 ± 0.8 and 0.4 ± 0.8 on -2 to +2 Likert scale) and optimal tissue fragility (0 ± 0.9 and 0.3 ± 0.7). CONCLUSION The biotissue training models showed high haptic realism and realistic suturing behavior. They are suitable for realistic training of anastomoses in pancreatic surgery which may improve patient outcomes.
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Affiliation(s)
- Emir Karadza
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Caelan M Haney
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Eldridge F Limen
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Philip C Müller
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Karl-Friedrich Kowalewski
- Department of Urology and Urooncological Surgery, University Medical Center Mannheim, Mannheim, Germany
| | - Marta Sandini
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Erica Wennberg
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Mona W Schmidt
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Mainz, Germany
| | - Eleni A Felinska
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Franziska Lang
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Gabriel Salg
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Hannes G Kenngott
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Elena Rangelova
- Section for Upper Abdominal Surgery at Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederique Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Maarten Korrel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Maurice Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Alain Sauvanet
- Department of HPB Surgery, Hôpital Beaujon, Clichy-Paris, France
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Martin de Santibanes
- Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Mohammad Abu Hilal
- Department of Surgery, Instituto Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery at Heidelberg University Hospital, Heidelberg, Germany.
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19
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Zwart MJW, Nota CLM, de Rooij T, van Hilst J, Te Riele WW, van Santvoort HC, Hagendoorn J, Borei Rinkes IHM, van Dam JL, Latenstein AEJ, Takagi K, Tran KTC, Schreinemakers J, van der Schelling GP, Wijsman JH, Festen S, Daams F, Luyer MD, de Hingh IHJT, Mieog JSD, Bonsing BA, Lips DJ, Hilal MA, Busch OR, Saint-Marc O, Zehl HJ, Zureikat AH, Hogg ME, Molenaar IQ, Besselink MG, Koerkamp BG. Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3). Ann Surg 2022; 276:e886-e895. [PMID: 33534227 DOI: 10.1097/sla.0000000000004783] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation. BACKGROUND Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking. METHODS A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit. RESULTS Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%. CONCLUSIONS This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.
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Affiliation(s)
- Maurice J W Zwart
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Carolijn L M Nota
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H M Borei Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Khé T C Tran
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Jan H Wijsman
- Department of Surgery, Amphia Ziekenhuis, Breda, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional Orleans, Orleans, France
| | - Herbert J Zehl
- Department of Surgery, University of Texas, Southwestern, Dallas, Texas
| | - Amer H Zureikat
- Department of Surgery, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, Illinois
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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20
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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21
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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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22
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Guo W, Ye X, Li J, Lu S, Wang M, Wang Z, Yao J, Yu S, Yuan G, He S. Comparison of surgical outcomes among open, laparoscopic, and robotic pancreatoduodenectomy: a single-center retrospective study. BMC Surg 2022; 22:348. [PMID: 36138358 PMCID: PMC9494911 DOI: 10.1186/s12893-022-01797-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/13/2022] [Indexed: 11/26/2022] Open
Abstract
Background There is no general consensus on the feasibility and safety of robotic pancreatoduodenectomy (RPD) and whether it increases surgical risks. The purpose of this study was to assess the safety, feasibility, and rationality of RPD by comparing perioperative data among open pancreatoduodenectomy (OPD), laparoscopic pancreatoduodenectomy (LPD), and RPD performed in our center in recent years. Methods Clinical data of patients had undergone RPD (n = 32), LPD (n = 21), and OPD (n = 86) in The First Affiliated Hospital of Guangxi Medical University between January 2016 and June 2020 were retrospectively collected and analyzed. Results RPD required more time for operation (537.2 min vs. 441.5 min, p < 0.001) than OPD did, but less time to remove abdominal drainage tube (12.5 d vs. 17.3 d, p = 0.001). The differences between the RPD group and LPD group were interesting, as the two groups had similar operation time (537.2 min vs. 592.9 min, p = 1.000) and blood loss (482.8 ml vs. 559.5 ml, p > 0.05), but the RPD group had a higher activity of daily living score on postoperative day 3 (35.8 vs. 25.7, p = 0.0017) and a lower rate of conversion to OPD (6.5% vs. 38.1%, p = 0.011). Regarding complications, such as the postoperative pancreatic fistula, abdominal hemorrhage, intra-abdominal infection, bile leakage, reoperation, and perioperative mortality, there were no significant differences among the three groups. Conclusions Not only is RPD feasible and reliable, it also offers significant advantages in that it improves postoperative recovery of skills needed for everyday life, has a low conversion rate to open surgery, and does not increase surgical risks.
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Affiliation(s)
- Wei Guo
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Xiaofei Ye
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Jiangfa Li
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Shiliu Lu
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Ming Wang
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Zefeng Wang
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Jianni Yao
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Shuiping Yu
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China. .,Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education, Nanning, 530021, Guangxi, China. .,Guangxi Key Laboratory of Immunology and Metabolism for Liver Diseases, Nanning, 530021, Guangxi, China.
| | - Guandou Yuan
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China. .,Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education, Nanning, 530021, Guangxi, China. .,Guangxi Key Laboratory of Immunology and Metabolism for Liver Diseases, Nanning, 530021, Guangxi, China.
| | - Songqing He
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China. .,Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education, Nanning, 530021, Guangxi, China. .,Guangxi Key Laboratory of Immunology and Metabolism for Liver Diseases, Nanning, 530021, Guangxi, China.
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23
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Ramia JM. Invited Commentary: Structured Training Programs for Minimally Invasive Pancreatic Surgery Should Be Mandatory. J Am Coll Surg 2022; 235:390-391. [PMID: 35972157 DOI: 10.1097/xcs.0000000000000255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Korrel M, Lof S, Alseidi AA, Asbun HJ, Boggi U, Hogg ME, Jang JY, Nakamura M, Besselink MG, Abu Hilal M. Framework for Training in Minimally Invasive Pancreatic Surgery: An International Delphi Consensus Study. J Am Coll Surg 2022; 235:383-390. [PMID: 35972156 DOI: 10.1097/xcs.0000000000000278] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous reports suggest that structured training in minimally invasive pancreatic surgery (MIPS) can ensure a safe implementation into standard practice. Although some training programs have been constructed, worldwide consensus on fundamental items of these training programs is lacking. This study aimed to determine items for a structured MIPS training program using the Delphi consensus methodology. STUDY DESIGN The study process consisted of 2 Delphi rounds among international experts in MIPS, identified by a literature review. The study committee developed a list of items for 3 key domains of MIPS training: (1) framework, (2) centers and surgeons eligible for training, and (3) surgeons eligible as proctor. The experts rated these items on a scale from 1 (not important) to 5 (very important). A Cronbach's α of 0.70 or greater was defined as the cut-off value to achieve consensus. Each item that achieved 80% or greater of expert votes was considered as fundamental for a training program in MIPS. RESULTS Both Delphi study rounds were completed by all invited experts in MIPS, with a median experience of 20 years in MIPS. Experts included surgeons from 31 cities in 13 countries across 4 continents. Consensus was reached on 38 fundamental items for the framework of training (16 of 35 items, Cronbach's α = 0.72), centers and surgeons eligible for training (19 of 30 items, Cronbach's α = 0.87), and surgeons eligible as proctor (3 of 10 items, Cronbach's α = 0.89). Center eligibility for MIPS included a minimum annual volume of 10 distal pancreatectomies and 50 pancreatoduodenectomies. CONCLUSION Consensus among worldwide experts in MIPS was reached on fundamental items for the framework of training and criteria for participating surgeons and centers. These items act as a guideline and intend to improve training, proctoring, and safe worldwide dissemination of MIPS.
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Affiliation(s)
- Maarten Korrel
- From the Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands (Korrel, Lof, Besselink)
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Korrel, Lof, Abu Hilal)
| | - Sanne Lof
- From the Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands (Korrel, Lof, Besselink)
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Korrel, Lof, Abu Hilal)
| | - Adnan A Alseidi
- Division of Surgery, University of California, San Francisco, CA (Alseidi)
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL (Asbun)
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy (Boggi)
| | - Melissa E Hogg
- Department of Surgery, NorthShore University Health System, Evanston, IL (Hogg)
| | - Jin-Young Jang
- Departments of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea (Jang)
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (Nakamura)
| | - Marc G Besselink
- From the Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands (Korrel, Lof, Besselink)
| | - Mohammad Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Korrel, Lof, Abu Hilal)
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK (Abu Hilal)
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25
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Wang ZK, Lin JX, Huang JB, Lu J, Huang ZN, Xie JW, Wang JB, Chen QY, Cao LL, Lin M, Tu RH, Lin JL, Zheng HL, Li P, Zheng CH, Huang CM. A national advanced training program for laparoscopic radical gastrectomy has a positive impact on surgical trainees: A before and after study (ATP-LRG-1). Int J Surg 2022; 104:106781. [PMID: 35963576 DOI: 10.1016/j.ijsu.2022.106781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Due to the high technical requirements of laparoscopic radical gastrectomy (LRG), establishing an effective training system to promote clinical technology and operation specifications is necessary. We aimed to evaluate the effect of a national advanced training program for LRG (ATP-LRG). MATERIALS AND METHODS The contents of the training include the following: 1) detailed technique descriptions; 2) prevention and solving of intraoperative complications; 3) live surgery performance; 4) theory and practice of clinical research; 5) comments on trainees' videos; and 6) questions, answers, and discussions. This retrospective before and after study surveyed 875 trainees from January 2015 to October 2020. Endpoints were general surgical skills (GSS), laparoscopic gastrectomy acceptance (LGA), and clinical research possibilities (CRP). The analysis took place in December 2021. RESULTS The response rate was 70.5% (617/875). ATP-LRG reportedly had a positive impact on the LRG practice of 99.5% (614/617) of trainees. Their GSS (before vs. after: 16.5 ± 3.7 vs. 20.3 ± 3.1, P < 0.001), LGA (4.2 ± 0.9 vs. 4.6 ± 0.7, P < 0.001), and CRP (2.6 ± 1.2 vs. 3.2 ± 1.1, P < 0.001) significantly improved. The improvement in GSS for those with professional titles of associate chief surgeons and below was significantly higher than that for chief surgeons (4.0 ± 3.0 vs 3.3 ± 2.4, P = 0.017), while those of LGA and CRP were not. The annual number of operations before training was negatively correlated with improvement in GSS (P < 0.001, Pearson's correlation coefficient: 0.14). Multivariate logistic regression showed that those with professional titles of associate chief surgeons and below (odds ratio [OR]: 1.719, 95% confidence interval [CI]: 1.038-2.846, P = 0.035), and with annual number of operations before training being <60, (OR: 5.257, 95% CI: 2.573-10.742, P < 0.001) were most prone to high-GSS improvement. CONCLUSION The nationwide ATP-LRG facilitates the improvement of trainees' GSS, LGA, and CRP levels. Surgeons with lower professional titles and fewer performed operations are most likely to improve their GSS through training.
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Affiliation(s)
- Zu-Kai Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Fujian Province Minimally Invasive Medical Center, China
| | - Jiao-Bao Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ze-Ning Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Fujian Province Minimally Invasive Medical Center, China
| | - Jia-Bin Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Fujian Province Minimally Invasive Medical Center, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Long-Long Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Mi Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ru-Hong Tu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ju-Li Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hua-Long Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Fujian Province Minimally Invasive Medical Center, China.
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Fujian Province Minimally Invasive Medical Center, China.
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Fujian Province Minimally Invasive Medical Center, China.
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26
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Zwart MJW, Görgec B, Arabiyat A, Nota CLM, van der Poel MJ, Fichtinger RS, Berrevoet F, van Dam RM, Aldrighetti L, Fuks D, Hoti E, Edwin B, Besselink MG, Abu Hilal M, Hagendoorn J, Swijnenburg RJ. Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery. HPB (Oxford) 2022; 24:322-331. [PMID: 34772622 DOI: 10.1016/j.hpb.2021.08.939] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking. METHODS An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association. RESULTS The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery. CONCLUSION In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.
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Affiliation(s)
- Maurice J W Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Burak Görgec
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands; Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Abdullah Arabiyat
- Department of Surgery, The Royal Lancaster Infirmary, University Hospitals of Morecambe Bay, United Kingdom
| | - Carolijn L M Nota
- Department of Surgery, UMC Utrecht Cancer Center/Regional Academic Cancer Center Utrecht (RAKU), Utrecht, the Netherlands
| | - Marcel J van der Poel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Ghent, Ghent, Belgium
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Luca Aldrighetti
- Department of Surgery, Hepatobiliary Surgery Unit, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - David Fuks
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Emir Hoti
- Department of Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - Bjørn Edwin
- Interventional Centre and Department of Hepato-pancreato-biliary Surgery, Oslo University Hospital and Institute for Medicine, University in Oslo, Norway
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy.
| | - Jeroen Hagendoorn
- Department of Surgery, UMC Utrecht Cancer Center/Regional Academic Cancer Center Utrecht (RAKU), Utrecht, the Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands.
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27
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Park Y, Hwang DW, Lee JH, Song KB, Jun E, Lee W, Hong S, Kim SC. Minimally invasive distal pancreatectomy: Chronologic changes in the trends and clinical outcomes through a 15-year, single-center experience with 2212 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:540-551. [PMID: 35112510 DOI: 10.1002/jhbp.1122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND We identified the chronologic changes in the clinical outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors in a single high-volume center over a period of 15 years. METHODS Between 2005 and 2019, 2212 patients underwent planned MIDP. Chronologic changes were analyzed according to 5-year intervals (P1, P2, P3). Furthermore, we assessed the prognostic factors of open conversion and postoperative complications. RESULTS MIDP has steadily increased during the last 15 years when compared to open distal pancreatectomy, from 10.8% to 84.9%. Also, MIDP for pancreatic ductal adenocarcinoma (PDAC) has been steadily increasing from 5.6% to 68.4%. According to the 5-year intervals, lengths of hospital stay decreased, but age and American Society of Anesthesiologists (ASA) ≥3 increased; conversely, the rates of Clavien-Dindo classification ≥grade 3 (9.5%) and postoperative pancreatic fistula (39.7%) showed no differences. The 90-day mortality and open conversion rates were 0.2% and 3.5%, respectively. Multivariate logistic regression analysis revealed malignancy and extended pancreatectomy were risk factors for open conversion. Furthermore, the poor prognostic factors for severe complications were malignancy, extended pancreatectomy, and ASA ≥3. CONCLUSION MIDP has become a popular procedure not only for benign cases but also for malignant ones. However, well-organized training, experience and skill are necessary, especially for poor-performance patients and extensively malignant conditions.
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Affiliation(s)
- Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Convergence Medicine, Asan Institute for Life Sciences, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea.,Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sarang Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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28
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Vladimirov M, Bausch D, Stein HJ, Keck T, Wellner U. Hybrid Laparoscopic Versus Open Pancreatoduodenectomy. A Meta-Analysis. World J Surg 2022; 46:901-915. [PMID: 35043246 PMCID: PMC8885482 DOI: 10.1007/s00268-021-06372-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Hybrid laparoscopic techniques have been proposed as a good transition from open to complete minimally invasive approach especially in complex surgical procedures. This meta-analysis aimed to compare the outcomes of hybrid laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy. METHODS A systematic literature research was performed according to PRISMA guidelines. A broad search strategy with terms "laparoscopy" and "pancreatoduodenectomy" was used. Included studies were analyzed by quantitative meta-analysis using the metafor package for R software. RESULTS Of 655 identified articles, 627 were excluded and 28 articles fully assessed, including 14 comparative studies, 8 case series and 6 case reports. Extracted data included intraoperative variables and postoperative outcome parameters. The predefined inclusion criteria were met by 14 comparative studies, and 371 patients were pooled in the meta-analysis. Hybrid laparoscopic pacreatoduodenectomy was associated with significantly longer operative time (I2 0%, p = 0,01, Mean HPD 494,6 min, Mean OPD 421,6 min, WMD 67 min, 95% CI 14-120 min). For all other postoperative outcome parameters, no statistically significant differences were found. A nonsignificant reduction in intraoperative transfusion rate (I2 20%, p = 0,2, proportion HPD 2%, proportion OPD 1,6%, OR 0,44, 95% CI 0,16-1,27) and blood loss (I2 95%, p = 0,1, Mean HPD 397,2 ml, Mean OPD 1017,8 ml, MD - 601 ml, 95% CI - 1311-108) was observed for hybrid pancreatoduodenectomy in comparison to open surgery. CONCLUSIONS This meta-analysis demonstrates significantly increased operation time for hybrid laparoscopic compared to open pancreatoduodenectomy. Intraoperative variables as well as postoperative parameters and major morbidity were comparable for both techniques. Overall results of this meta-analysis demonstrated the hybrid technique as a safe procedure in high-volume centers offering aspects of a safe transition to fully laparoscopic pancreatoduodenectomy.
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Affiliation(s)
- Miljana Vladimirov
- Klinik für Allgemein, Viszeral- und Thoraxchirurgie, PMU Nürnberg, Nuremberg, Deutschland
| | - Dirk Bausch
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Hubert J Stein
- Klinik für Allgemein, Viszeral- und Thoraxchirurgie, PMU Nürnberg, Nuremberg, Deutschland
| | - Tobias Keck
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - Ulrich Wellner
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
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29
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Zwart MJW, Jones LR, Fuente I, Balduzzi A, Takagi K, Novak S, Stibbe LA, de Rooij T, van Hilst J, van Rijssen LB, van Dieren S, Vanlander A, van den Boezem PB, Daams F, Mieog JSD, Bonsing BA, Rosman C, Festen S, Luyer MD, Lips DJ, Moser AJ, Busch OR, Abu Hilal M, Hogg ME, Stommel MWJ, Besselink MG. Performance with robotic surgery versus 3D- and 2D-laparoscopy during pancreatic and biliary anastomoses in a biotissue model: pooled analysis of two randomized trials. Surg Endosc 2022; 36:4518-4528. [PMID: 34799744 PMCID: PMC9085660 DOI: 10.1007/s00464-021-08805-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/17/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Robotic surgery may improve surgical performance during minimally invasive pancreatoduodenectomy as compared to 3D- and 2D-laparoscopy but comparative studies are lacking. This study assessed the impact of robotic surgery versus 3D- and 2D-laparoscopy on surgical performance and operative time using a standardized biotissue model for pancreatico- and hepatico-jejunostomy using pooled data from two randomized controlled crossover trials (RCTs). METHODS Pooled analysis of data from two RCTs with 60 participants (36 surgeons, 24 residents) from 11 countries (December 2017-July 2019) was conducted. Each included participant completed two pancreatico- and two hepatico-jejunostomies in biotissue using 3D-robotic surgery, 3D-laparoscopy, or 2D-laparoscopy. Primary outcomes were the objective structured assessment of technical skills (OSATS: 12-60) rating, scored by observers blinded for 3D/2D and the operative time required to complete both anastomoses. Sensitivity analysis excluded participants with excess experience compared to others. RESULTS A total of 220 anastomoses were completed (robotic 80, 3D-laparoscopy 70, 2D-laparoscopy 70). Participants in the robotic group had less surgical experience [median 1 (0-2) versus 6 years (4-12), p < 0.001], as compared to the laparoscopic group. Robotic surgery resulted in higher OSATS ratings (50, 43, 39 points, p = .021 and p < .001) and shorter operative time (56.5, 65.0, 81.5 min, p = .055 and p < .001), as compared to 3D- and 2D-laparoscopy, respectively, which remained in the sensitivity analysis. CONCLUSION In a pooled analysis of two RCTs in a biotissue model, robotic surgery resulted in better surgical performance scores and shorter operative time for biotissue pancreatic and biliary anastomoses, as compared to 3D- and 2D-laparoscopy.
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Affiliation(s)
- Maurice J. W. Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
| | - Leia R. Jones
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands ,grid.415090.90000 0004 1763 5424Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ignacio Fuente
- grid.414775.40000 0001 2319 4408Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Alberto Balduzzi
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands ,grid.411475.20000 0004 1756 948XGeneral and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Kosei Takagi
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands ,grid.261356.50000 0001 1302 4472Department of Gastroenterological Surgery, Transplant, and Surgical Oncology, Okayama University, Okayama, Japan
| | - Stephanie Novak
- grid.412689.00000 0001 0650 7433Department of Surgery, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Luna A. Stibbe
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
| | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
| | - L. Bengt van Rijssen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
| | - Aude Vanlander
- grid.5342.00000 0001 2069 7798Department of Surgery, University Hospital Ghent, University of Ghent, Ghent, Belgium
| | - Peter B. van den Boezem
- grid.10417.330000 0004 0444 9382Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Freek Daams
- grid.12380.380000 0004 1754 9227Department of Surgery, Amsterdam UMC, VU University, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. Sven D. Mieog
- grid.10419.3d0000000089452978Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bert A. Bonsing
- grid.10419.3d0000000089452978Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Camiel Rosman
- grid.10417.330000 0004 0444 9382Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sebastiaan Festen
- grid.440209.b0000 0004 0501 8269Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Misha D. Luyer
- grid.413532.20000 0004 0398 8384Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Daan J. Lips
- grid.415214.70000 0004 0399 8347Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Arthur J. Moser
- grid.38142.3c000000041936754XDepartment of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA USA
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
| | - Mohammad Abu Hilal
- grid.415090.90000 0004 1763 5424Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Melissa E. Hogg
- grid.240372.00000 0004 0400 4439Department of Surgery, Northshore University Health System, Chicago, IL USA
| | - Martijn W. J. Stommel
- grid.10417.330000 0004 0444 9382Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, De Boelelaan 1117 (ZH-7F), 1081 HV Amsterdam, The Netherlands
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30
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van der Heijde N, Lof S, Busch OR, de Hingh I, de Kleine RH, Molenaar IQ, Mungroop TH, Stommel MW, Besselink MG, van Eijck C. Incidence and impact of postoperative pancreatic fistula after minimally invasive and open distal pancreatectomy. Surgery 2021; 171:1658-1664. [PMID: 34906371 DOI: 10.1016/j.surg.2021.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/21/2021] [Accepted: 11/11/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Previous studies reported a higher rate of postoperative pancreatic fistula after minimally invasive distal pancreatectomy compared to open distal pancreatectomy. It is unknown whether the clinical impact of postoperative pancreatic fistula after minimally invasive distal pancreatectomy is comparable with that after open distal pancreatectomy. We aimed to compare not only the incidence of postoperative pancreatic fistula, but more importantly, also its clinical impact. METHODS This is a post hoc analysis of a multicenter randomized trial investigating a possible beneficial impact of a fibrin patch on the rate of clinically relevant postoperative pancreatic fistula (International Study Group for Pancreatic Surgery grade B/C) after distal pancreatectomy. Primary outcomes of the current analysis are the incidence and clinical impact of postoperative pancreatic fistula after both minimally invasive distal pancreatectomy and open distal pancreatectomy. RESULTS From October 2010 to August 2017, 252 patients undergoing distal pancreatectomy were randomized, and data of 247 patients were available for analysis: 87 minimally invasive distal pancreatectomy and 160 open distal pancreatectomies. The postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was significantly higher than that after open distal pancreatectomy (28.7% vs 16.9%, P = .029). More patients were discharged with an abdominal surgical drain after minimally invasive distal pancreatectomy compared to open distal pancreatectomy (30/87, 34.5% vs 26/160, 16.5%, P = .001). In patients with postoperative pancreatic fistula, additional percutaneous catheter drainage procedures were performed less often (52% vs 84.6%, P = .012), with fewer drainage procedures (median [range], 2 [1-4] vs 2, [1-7], P = .014) after minimally invasive distal pancreatectomy. CONCLUSION In this post hoc analysis, the postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was higher than that after open distal pancreatectomy, whereas the clinical impact was less.
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Affiliation(s)
- Nicky van der Heijde
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Sanne Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht and St Antonius Hospital Nieuwegein, The Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
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31
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Al Abbas AI, Wang C, Hamad AB, Knab LM, Rice MK, Moser AJ, Zeh HJ, Zureikat AH, Hogg ME. Mentorship and formal robotic proficiency skills curriculum improve subsequent generations' learning curve for the robotic distal pancreatectomy. HPB (Oxford) 2021; 23:1849-1855. [PMID: 34059420 DOI: 10.1016/j.hpb.2021.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy is the accepted standard of care. The robotic distal (RDP) learning curve is 20-40 surgeries with operating time (ORT) as the most significant factor. This study evaluates how formal mentorship and a robotic skills curriculum impact the learning curve for subsequent generation surgeons. METHODS Consecutive RDP from 2008 to 2017 were evaluated. First Generation was two surgeons who started program without training or mentorship. Second Generation was the two surgeons who joined the program with mentorship. Third Generation was fellows who benefited from both formal training and mentorship. Multivariable models (MVA) were performed for ORT, clinically relevant pancreatic fistula (CR-POPF), and major complications (Clavien≥3). RESULTS A total of 296 RDP were performed of which 187 did not include other procedures: First Generation (n = 71), Second Generation (n = 50), and Third Generation (n = 66). ORT decreased by generation (p < 0.001) without any differences in CR-POPF or Clavien≥3. On MVA, earlier generation (p = 0.019), pre-operative albumin (p = 0.001) and pancreatic adenocarcinoma (p = 0.019) were predictive of ORT. Increased BMI (p = 0.049) and neoadjuvant therapy (p = 0.046) were predictive of CR-POPF. Fellow participation at the console increased over time. CONCLUSION Formal mentorship and a skills curriculum decreased the learning curve and complications were largely dependent on patient factors.
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Affiliation(s)
- Amr I Al Abbas
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Chi Wang
- Northshore University Healthsystem, Evanston, IL, USA
| | - Ahmad B Hamad
- Ohio State University Medical Center, Columbus, OH, USA
| | - L Mark Knab
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - MaryJoe K Rice
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - A James Moser
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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32
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Lateral lymph node dissection in rectal cancer: State of the art review. Eur J Surg Oncol 2021; 48:2315-2322. [PMID: 34802862 DOI: 10.1016/j.ejso.2021.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/24/2021] [Accepted: 11/01/2021] [Indexed: 12/20/2022] Open
Abstract
Half of the local regional recurrences from rectal cancer are nowadays located in the lateral compartments, most likely due to lateral lymph node (LLN) metastases. There is evidence that a lateral lymph node dissection (LLND) can lower the lateral local recurrence rate. An LLND without neoadjuvant (chemo)radiotherapy in patients with or without suspected LLN metastases has been the standard of care in the East, while Western surgeons believed LLN metastases to be cured by neoadjuvant treatment and total mesorectal excision (TME) only. An LLND in patients without enlarged LLNs might result in overtreatment with low rates of pathological LLNs, but in patients with enlarged LLNs who are treated with (C)RT and TME only, the risk of a lateral local recurrence significantly increases to 20%. Certain Eastern and Western centers are increasingly performing a selective LLND after neoadjuvant treatment in the presence of suspicious LLNs due to new scientific insights, but (inter)national consensus on the indication and surgical approach of LLND is lacking. An LLND is an anatomically challenging procedure with intraoperative risks such as bleeding and postoperative morbidity. It is therefore essential to carefully select the patients who will benefit from this procedure and where possible to perform the LLND in a minimally invasive manner to limit these risks. This review gives an overview of the current evidence of the assessment of LLNs, the indications for LLND, the surgical technique, pitfalls in performing this procedure and the future studies are discussed, aiming to contribute to more (inter)national consensus.
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33
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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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34
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Görgec B, Fichtinger RS, Ratti F, Aghayan D, Van der Poel MJ, Al-Jarrah R, Armstrong T, Cipriani F, Fretland ÅA, Suhool A, Bemelmans M, Bosscha K, Braat AE, De Boer MT, Dejong CHC, Doornebosch PG, Draaisma WA, Gerhards MF, Gobardhan PD, Hagendoorn J, Kazemier G, Klaase J, Leclercq WKG, Liem MS, Lips DJ, Marsman HA, Mieog JSD, Molenaar QI, Nieuwenhuijs VB, Nota CL, Patijn GA, Rijken AM, Slooter GD, Stommel MWJ, Swijnenburg RJ, Tanis PJ, Te Riele WW, Terkivatan T, Van den Tol PMP, Van den Boezem PB, Van der Hoeven JA, Vermaas M, Edwin B, Aldrighetti LA, Van Dam RM, Abu Hilal M, Besselink MG. Comparing practice and outcome of laparoscopic liver resection between high-volume expert centres and nationwide low-to-medium volume centres. Br J Surg 2021; 108:983-990. [PMID: 34195799 DOI: 10.1093/bjs/znab096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/28/2020] [Accepted: 02/18/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Based on excellent outcomes from high-volume centres, laparoscopic liver resection is increasingly being adopted into nationwide practice which typically includes low-medium volume centres. It is unknown how the use and outcome of laparoscopic liver resection compare between high-volume centres and low-medium volume centres. This study aimed to compare use and outcome of laparoscopic liver resection in three leading European high-volume centres and nationwide practice in the Netherlands. METHOD An international, retrospective multicentre cohort study including data from three European high-volume centres (Oslo, Southampton and Milan) and all 20 centres in the Netherlands performing laparoscopic liver resection (low-medium volume practice) from January 2011 to December 2016. A high-volume centre is defined as a centre performing >50 laparoscopic liver resections per year. Patients were retrospectively stratified into low, moderate- and high-risk Southampton difficulty score groups. RESULTS A total of 2425 patients were included (1540 high-volume; 885 low-medium volume). The median annual proportion of laparoscopic liver resection was 42.9 per cent in high-volume centres and 7.2 per cent in low-medium volume centres. Patients in the high-volume centres had a lower conversion rate (7.4 versus 13.1 per cent; P < 0.001) with less intraoperative incidents (9.3 versus 14.6 per cent; P = 0.002) as compared to low-medium volume centres. Whereas postoperative morbidity and mortality rates were similar in the two groups, a lower reintervention rate (5.1 versus 7.2 per cent; P = 0.034) and a shorter postoperative hospital stay (3 versus 5 days; P < 0.001) were observed in the high-volume centres as compared to the low-medium volume centres. In each Southampton difficulty score group, the conversion rate was lower and hospital stay shorter in high-volume centres. The rate of intraoperative incidents did not differ in the low-risk group, whilst in the moderate-risk and high-risk groups this rate was lower in high-volume centres (absolute difference 6.7 and 14.2 per cent; all P < 0.004). CONCLUSION High-volume expert centres had a sixfold higher use of laparoscopic liver resection, less conversions, and shorter hospital stay, as compared to a nationwide low-medium volume practice. Stratification into Southampton difficulty score risk groups identified some differences but largely outcomes appeared better for high-volume centres in each risk group.
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Affiliation(s)
- B Görgec
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Department of Surgery, Fondazione Poliambulanza - Istituto Ospedaliero, Brescia, Italy
| | - R S Fichtinger
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands and RWTH Aachen, Germany
| | - F Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - D Aghayan
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Norway
| | - M J Van der Poel
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - R Al-Jarrah
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - T Armstrong
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - F Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Å A Fretland
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - A Suhool
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M Bemelmans
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands and RWTH Aachen, Germany
| | - K Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - A E Braat
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M T De Boer
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - C H C Dejong
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands and RWTH Aachen, Germany
| | - P G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - W A Draaisma
- Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands
| | - M F Gerhards
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - P D Gobardhan
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - J Hagendoorn
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - G Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J Klaase
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands.,Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - W K G Leclercq
- Department of Surgery, Máxima Medical Centre, Veldhoven, the Netherlands
| | - M S Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - D J Lips
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands.,Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - H A Marsman
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Q I Molenaar
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - C L Nota
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - G A Patijn
- Department of Surgery, Isala, Zwolle, the Netherlands
| | - A M Rijken
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - G D Slooter
- Department of Surgery, Máxima Medical Centre, Veldhoven, the Netherlands
| | - M W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R J Swijnenburg
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Tanis
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - W W Te Riele
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - T Terkivatan
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - P M P Van den Tol
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - P B Van den Boezem
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J A Van der Hoeven
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - M Vermaas
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - B Edwin
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Norway
| | - L A Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - R M Van Dam
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands and RWTH Aachen, Germany.,GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | - M Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Department of Surgery, Fondazione Poliambulanza - Istituto Ospedaliero, Brescia, Italy
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
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35
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Klompmaker S, van der Vliet WJ, Thoolen SJ, Ore AS, Verkoulen K, Solis-Velasco M, Canacari EG, Kruskal JB, Khwaja KO, Tseng JF, Callery MP, Kent TS, Moser AJ. Procedure-specific Training for Robot-assisted Distal Pancreatectomy. Ann Surg 2021; 274:e18-e27. [PMID: 30946088 DOI: 10.1097/sla.0000000000003291] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality. BACKGROUND RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce. METHODS A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy. RESULTS After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP. CONCLUSION Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.
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Affiliation(s)
- Sjors Klompmaker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Walderik J van der Vliet
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
- Department of Surgery, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Stijn J Thoolen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Ana Sofia Ore
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Koen Verkoulen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
- Department of Surgery, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Monica Solis-Velasco
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Elena G Canacari
- Department of Nursing, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jonathan B Kruskal
- Medical Executive Committee, Beth Israel Deaconess Medical Center, Boston, MA
| | - Khalid O Khwaja
- The Transplant Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University, Boston, MA
| | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - A James Moser
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
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Deiro G, De Pastena M, Paiella S, Balduzzi A, Montagnini G, Andreotti E, Casetti L, Landoni L, Salvia R, Esposito A. Assessment of difficulty in laparoscopic distal pancreatectomy: A modification of the Japanese difficulty scoring system - A single-center high-volume experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:770-777. [PMID: 34114743 PMCID: PMC8518381 DOI: 10.1002/jhbp.1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/22/2021] [Accepted: 05/29/2021] [Indexed: 11/13/2022]
Abstract
Background The Japanese difficulty scoring system (DSS) was developed to assess the difficulty of laparoscopic distal pancreatectomy (LDP). The study aimed to validate a modified DSS (mDSS) in a European high‐volume center. Methods Patients' clinical data underwent LDP for benign and malignant pancreatic lesion between September 2013 and February 2020 were reviewed. Expert laparoscopic surgeons performed the procedures. The mDSS consisted of seven variables, such as type of operation, malignancy, neoadjuvant therapy, pancreatic resection line, tumor close to major vessels, tumor extension to peripancreatic tissue, and left‐sided portal hypertension and/or splenomegaly. According to the difficulty level and previous score, the mDSS was subdivided into three classes: low, intermediate, and high. Surrogates of case complexity (operative time, intraoperative blood loss and blood transfusion requirements, conversion rate) were used to validate the new scoring system. Results The study population included 140 LDP. Ninety‐five (68%), 35 (25%) and 10 (7%) patients belonged to low, intermediate, and high difficulty groups. The mDSS identified the complexity of the surgical case of the series for all the surrogates of complexity considered, namely conversion rate (P = .004), operative time (P = .033) and intraoperative blood loss (P = .009). No differences were recorded in the postoperative outcomes (P > .05). Conclusion The mDSS for LDP better stratified the pancreatic procedures according to their complexity. The new scoring system may allow an appropriate preoperative evaluation of surgical difficulty, facilitating LDP's training program. Future prospective studies are needed to validate the mDSS.
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Affiliation(s)
- Giacomo Deiro
- 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
| | - Salvatore Paiella
- 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
| | - Greta Montagnini
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Elena Andreotti
- 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
| | - Luca Landoni
- 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
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Vining CC, Skowron KB, Hogg ME. Robotic gastrointestinal surgery: learning curve, educational programs and outcomes. Updates Surg 2021; 73:799-814. [PMID: 33484423 DOI: 10.1007/s13304-021-00973-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/06/2021] [Indexed: 02/07/2023]
Abstract
The use of the robotic platform for gastrointestinal surgery was introduced nearly 20 years ago. However, significant growth and advancement has occurred primarily in the last decade. This is due to several advantages over traditional laparoscopic surgery allowing for more complex dissections and reconstructions. Several randomized controlled trials and retrospective reviews have demonstrated equivalent oncologic outcomes compared to open surgery with improved short-term outcomes. Unfortunately, there are currently no universally accepted or implemented training programs for robotic surgery and robotic surgery experience varies greatly. Additionally, several limitations to the robotic platform exist resulting in a distinct learning curve associated with various procedures. Therefore, implementation of robotic surgery requires a multidisciplinary team approach with commitment and investment from clinical faculty, operating room staff and hospital administrators. Additionally, there is a need for wider distribution of educational modules to train more surgeons and reduce the associated learning curve. This article will focus on the implementation of the robotic platform for surgery of the pancreas, stomach, liver, colon and rectum with an emphasis on the associated learning curve, educational platforms to develop proficiency and perioperative outcomes.
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Affiliation(s)
- Charles C Vining
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Kinga B Skowron
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Walgreens Building, Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA.
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A systematic scoping review of the initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for pancreatic malignancy. Surg Endosc 2021; 35:4930-4944. [PMID: 33988769 DOI: 10.1007/s00464-021-08528-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is a validated surgical approach for the surgical treatment of pancreatic malignancies of the body and tail of the pancreas. Open (O-) RAMPS is an established technique that offers oncological efficacy and acceptable post-operative outcomes when compared to standard distal pancreatectomy for pancreatic malignancies. This review aimed to determine the types of evidence available for L-RAMPS, and its selection criteria and reported outcomes, using systematic scoping review methodology. METHODS A systematic review of available literature was performed in September 2020. Data extracted included patient selection criteria, technical details, total number of L-RAMPS procedures performed, lymph nodes retrieved, resection margins, survival, LOS and complications. RESULTS Eight papers were eligible for inclusion, totalling 92 cases. There were no studies that directly compared O- to L-RAMPS. All reports were small retrospective cohorts with 3-30 patients. Selection criteria were reported in 4/8 studies and differed between studies. Technique descriptions were included in 6/8 studies. Studies reported a median of 5 (range 1-9) out of ten operative and clinical outcomes, including operative time median range 188-431 min, intraoperative blood loss median range 18-445 mL, R0 resection rate median range 91-100%, number of lymph nodes median range 11-43, and length of stay median range 12-20 days. CONCLUSIONS L-RAMPS is infrequently reported in the literature. There are currently no data to allow for direct comparison of O- and L-RAMPS. Reports of L-RAMPS have an acceptable oncological and safety profile. A standardised description of the operative technique and outcome reporting, as well as specific training initiatives may be beneficial to broaden the application of L-RAMPS.
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van der Heijde N, Vissers FL, Boggi U, Dokmak S, Edwin B, Hackert T, Khatkov IE, Keck T, Besselink MG, Abu Hilal M. Designing the European registry on minimally invasive pancreatic surgery: a pan-European survey. HPB (Oxford) 2021; 23:566-574. [PMID: 32933843 DOI: 10.1016/j.hpb.2020.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 07/08/2020] [Accepted: 08/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The recent Miami international evidence-based guidelines on minimally invasive pancreatic surgery (MIPS) advise all centers that perform MIPS to participate in multicenter registries to safeguard optimal outcomes and patient safety. During the design phase of a pan-European registry on MIPS, the European consortium of Minimally Invasive Pancreatic Surgery (E-MIPS) sought input from European HPB surgeons. METHODS An anonymous online questionnaire with 23 questions on MIPS practice was sent to all member centers of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and E-MIPS. RESULTS Completed questionnaires were obtained from 98 centers in 23 countries, of which 75 (76.5%) were academic centers. Centers had a median annual pancreatoduodenectomy volume of 45. The most-performed MIPS procedure was laparoscopic distal pancreatectomy (93.9% of centers). Minimally invasive pancreatoduodenectomy was performed in 49% of all centers. Some 25 centers already participated in an ongoing national registry, and were willing to share their data with the European registry on MIPS. The most mentioned (45.4%) maximum time for processing one patient's data into the registry was 10-15 min. CONCLUSION This European survey showed considerable support for the European registry on MIPS.
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Affiliation(s)
- Nicky van der Heijde
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom; Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Frederique L Vissers
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Safi Dokmak
- Department of Surgery, Beaujon Hospital, Clichy, France
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Igor E Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Tobias Keck
- Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom; Department of Surgery, Instituto Fondazione Poliambulanza, Brescia, Italy.
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Hoehn RS, Nassour I, Adam MA, Winters S, Paniccia A, Zureikat AH. National Trends in Robotic Pancreas Surgery. J Gastrointest Surg 2021; 25:983-990. [PMID: 32314230 DOI: 10.1007/s11605-020-04591-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Robotic pancreatic surgery is expanding throughout centers across the country. We investigated national trends in the use and outcomes for robotic-assisted pancreaticoduodenectomy (RPD) and distal pancreatectomy (RDP) for primary pancreatic tumors. METHODS The National Cancer Database was queried for RPD and RDP performed during three time periods: 2010-2012, 2013-2014, and 2015-2016. These time periods were compared for patient and center factors as well as surgical outcomes. RESULTS The use of robotic surgery increased during the study period. Most centers performed a low volume of robotic surgery (RPD, 82% of centers averaged < 1 case/year; RDP, 87% averaged < 1 case/year). From the first to last time period, the proportion of cases performed at academic centers decreased (RPD, 83% to 56%; RDP, 77% to 58%, p < 0.001) while patient characteristics remained largely unchanged. For RPD, improvements in mortality (6.7 to 1.8%, p = 0.013) and lymphadenectomy (18 to 21 nodes, p = 0.035) were observed, with no changes in conversion to open surgery, negative margin resections, or readmissions. For RDP, length of stay decreased (7 to 6 days, p = 0.048), but there were no changes in other outcomes. Compared with academic centers, non-academic centers had equivalent rates of conversion to open surgery, negative margins, and 90-day mortality. On multivariate analysis, there was no difference in survival between academic and non-academic centers. DISCUSSION Robotic pancreas surgery is expanding to a greater variety of centers nationwide with preservation of key surgical outcomes. These findings support the continued rigorous training and proliferation of qualified robotic pancreas surgeons going forward.
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Affiliation(s)
- Richard S Hoehn
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Nassour
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohamed A Adam
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sharon Winters
- UPMC Network Cancer Registry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, 5150 Center Ave., Suite 421, UPMC Cancer Pavilion, Pittsburgh, PA, 15232, USA.
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van Hilst J, de Graaf N, Abu Hilal M, Besselink MG. The Landmark Series: Minimally Invasive Pancreatic Resection. Ann Surg Oncol 2021; 28:1447-1456. [PMID: 33341916 PMCID: PMC7892688 DOI: 10.1245/s10434-020-09335-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic resections are among the most technically demanding procedures, including a high risk of potentially life-threatening complications and outcomes strongly correlated to hospital volume and individual surgeon experience. Minimally invasive pancreatic resections (MIPRs) have become a part of standard surgical practice worldwide over the last decade; however, in comparison with other surgical procedures, the implementation of minimally invasive approaches into clinical practice has been rather slow. OBJECTIVE The aim of this study was to highlight and summarize the available randomized controlled trials (RCTs) evaluating the role of minimally invasive approaches in pancreatic surgery. METHODS A WHO trial registry and Pubmed database literature search was performed to identify all RCTs comparing MIPRs (robot-assisted and/or laparoscopic distal pancreatectomy [DP] or pancreatoduodenectomy [PD]) with open pancreatic resections (OPRs). RESULTS Overall, five RCTs on MIPR versus OPR have been published and seven RCTs are currently recruiting. For DP, the results of two RCTs were in favor of minimally invasive distal pancreatectomy (MIDP) in terms of shorter hospital stay and less intraoperative blood loss, with comparable morbidity and mortality. Regarding PD, two RCTs showed similar advantages for MIPD. However, concerns were raised after the early termination of the third multicenter RCT on MIPD versus open PD due to higher complication-related mortality in the laparoscopic group and no clear other demonstrable advantages. No RCTs on robot-assisted pancreatic procedures are available as yet. CONCLUSION At the current level of evidence, MIDP is thought to be safe and feasible, although oncological safety should be further evaluated. Based on the results of the RCTs conducted for PD, MIPD cannot be proclaimed as the superior alternative to open PD, although promising outcomes have been demonstrated by experienced centers. Future studies should provide answers to the role of robotic approaches in pancreatic surgery and aim to identity the subgroups of patients or indications with the greatest benefit of MIPRs.
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Affiliation(s)
- Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Nine de Graaf
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.
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Korrel M, Vissers FL, van Hilst J, de Rooij T, Dijkgraaf MG, Festen S, Groot Koerkamp B, Busch OR, Luyer MD, Sandström P, Abu Hilal M, Besselink MG, Björnsson B. Minimally invasive versus open distal pancreatectomy: an individual patient data meta-analysis of two randomized controlled trials. HPB (Oxford) 2021; 23:323-330. [PMID: 33250330 DOI: 10.1016/j.hpb.2020.10.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) has been suggested to reduce postoperative outcomes as compared to open distal pancreatectomy (ODP). Recently, the first randomized controlled trials (RCTs) comparing MIDP to ODP were published. This individual patient data meta-analysis compared outcomes after MIDP versus ODP combining data from both RCTs. METHODS A systematic literature search was performed to identify RCTs on MIDP vs. ODP, and individual patient data were harmonized. Primary endpoint was the rate of major (Clavien-Dindo ≥ III) complications. Sensitivity analyses were performed in high-risk subgroups. RESULTS A total of 166 patients from the LEOPARD and LAPOP RCTs were included. The rate of major complications was 21% after MIDP vs. 35% after ODP (adjusted odds ratio 0.54; p = 0.148). MIDP significantly reduced length of hospital stay (6 vs. 8 days, p = 0.036), and delayed gastric emptying (4% vs. 16%, p = 0.049), as compared to ODP. A trend towards higher rates of postoperative pancreatic fistula was observed after MIDP (36% vs. 28%, p = 0.067). Outcomes were comparable in high-risk subgroups. CONCLUSION This individual patient data meta-analysis showed that MIDP, when performed by trained surgeons, may be regarded as the preferred approach for distal pancreatectomy. Outcomes are improved after MIDP as compared to ODP, without obvious downsides in high-risk subgroups.
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Affiliation(s)
- Maarten Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Frederique L Vissers
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, OLVG Oost, Amsterdam, the Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Per Sandström
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Mohammad Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom; Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - Bergthor Björnsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Takagi K, Umeda Y, Yoshida R, Yagi T, Fujiwara T, Zureikat AH, Hogg ME, Koerkamp BG. Surgical training model and safe implementation of robotic pancreatoduodenectomy in Japan: a technical note. World J Surg Oncol 2021; 19:55. [PMID: 33608019 PMCID: PMC7896387 DOI: 10.1186/s12957-021-02167-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/09/2021] [Indexed: 01/15/2023] Open
Abstract
Background Growing evidence for the advantages of robotic pancreatoduodenectomy (RPD) has been demonstrated internationally. However, there has been no structured training program for RPD in Japan. Herein, we present the surgical training model of RPD and a standardized protocol for surgical technique. Methods The surgical training model and surgical technique were standardized in order to implement RPD safely, based on the Dutch training system collaborated with the University of Pittsburgh Medical Center. Results The surgical training model included various trainings such as basic robotic training, simulation training, biotissue training, and a surgical video review. Furthermore, a standardized protocol on the surgical technique was established to understand the tips, tricks, and pitfalls of RPD. Conclusions Safe implementation of RPD can be achieved through the completion of a structured training program and learning surgical technique. A nationwide structured training system should be developed to implement the program safely in Japan. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02167-9.
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Affiliation(s)
- Kosei Takagi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan. .,Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Yuzo Umeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Ryuichi Yoshida
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takahito Yagi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, North Shore Hospital, Chicago, IL, USA
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Rice MK, Hodges JC, Bellon J, Borrebach J, Al Abbas AI, Hamad A, Knab LM, Moser AJ, Zureikat AH, Zeh HJ, Hogg ME. Association of Mentorship and a Formal Robotic Proficiency Skills Curriculum With Subsequent Generations' Learning Curve and Safety for Robotic Pancreaticoduodenectomy. JAMA Surg 2021; 155:607-615. [PMID: 32432666 DOI: 10.1001/jamasurg.2020.1040] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Learning curves are unavoidable for practicing surgeons when adopting new technologies. However, patient outcomes are worse in the early stages of a learning curve vs after mastery. Therefore, it is critical to find a way to decrease these learning curves without compromising patient safety. Objective To evaluate the association of mentorship and a formal proficiency-based skills curriculum with the learning curves of 3 generations of surgeons and to determine the association with increased patient safety. Design, Setting, and Participants All consecutive robotic pancreaticoduodenectomies (RPDs) performed at the University of Pittsburgh Medical Center between 2008 and 2017 were included in this study. Surgeons were split into generations based on their access to mentorship and a proficiency-based skills curriculum. The generations are (1) no mentorship or curriculum, (2) mentorship but no curriculum, and (3) mentorship and curriculum. Univariable and multivariable analyses were used to create risk-adjusted learning curves by surgical generation and to analyze factors associated with operating room time, complications, and fellows completing the full resection. The participants include surgical oncology attending surgeons and fellows who participated in an RPD at University of Pittsburgh Medical Center between 2008 and 2017. Main Outcomes and Measures The primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2. Results We identified 514 RPDs completed between 2008 and 2017, of which 258 (50.2%) were completed by first-generation surgeons, 151 (29.3%) were completed by the second generation, and 82 (15.9%) were completed by the third generation. There was no statistically significant difference between groups with respect to age (66.3-67.3 years; P = .52) or female sex (n = 34 [41.5%] vs n = 121 [46.9%]; P = .60). There was a significant decrease in ORT (P < .001), from 450.8 minutes for the first-generation surgeons to 348.6 minutes for the third generation. Additionally, across generations, Clavien-Dindo classification higher than grade 2 (n = 74 [28.7%] vs n = 30 [9.9%] vs n = 12 [14.6%]; P = .01), conversion rates (n = 18 [7.0%] vs n = 7 [4.6%] vs n = 0; P = .006), and estimated blood loss (426 mL vs 288.6 mL vs 254.7 mL; P < .001) decreased significantly with subsequent generations. There were no significant differences in postoperative pancreatic fistula. Conclusions and Relevance In this study, ORT, conversion rates, and estimated blood loss decreased across generations without a concomitant rise in adverse patient outcomes. These findings suggest that a proficiency-based curriculum coupled with mentorship allows for the safe introduction of less experienced surgeons to RPD without compromising patient safety.
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Affiliation(s)
- MaryJoe K Rice
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Jacob C Hodges
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Johanna Bellon
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey Borrebach
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amr I Al Abbas
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Ahmad Hamad
- Department of Surgery, Ohio State University Medical Center, Columbus
| | - L Mark Knab
- Department of Surgery, Loyola University Medical Center, Chicago, Illinois
| | - A James Moser
- Department of Surgery, Beth Israel Deaconess, Boston, Massachusetts
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Melissa E Hogg
- Department of Surgery, NorthShore University Health System, Chicago, Illinois
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45
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Schwarz JL, Hogg ME. Current state of minimally invasive pancreatic surgery. J Surg Oncol 2021; 123:1370-1386. [PMID: 33559146 DOI: 10.1002/jso.26412] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 12/16/2022]
Abstract
The growth in minimally invasive pancreatic surgery (MIPS) has been accompanied by a recent surge in evidence-based data available to analyze patient outcomes. A small complement of randomized control trials as well as a multitude of observational studies have demonstrated both consistent similarities and differences between MIPS and the open approach, although abundant questions remain. This review highlights the available literature and emphasizes key factors for evaluating laparoscopic and robotic pancreatic surgery.
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Affiliation(s)
- Jason L Schwarz
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
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46
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Jones LR, Zwart MJW, Molenaar IQ, Koerkamp BG, Hogg ME, Hilal MA, Besselink MG. Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs. Scand J Surg 2021; 109:29-33. [PMID: 32192422 DOI: 10.1177/1457496920911815] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. MATERIALS AND METHODS A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. RESULTS A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. CONCLUSION Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy.
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Affiliation(s)
- L R Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M J W Zwart
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M E Hogg
- Department of Surgery, NorthShore University HealthSystem, Chicago, IL, USA
| | - M A Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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47
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Balduzzi A, van der Heijde N, Alseidi A, Dokmak S, Kendrick ML, Polanco PM, Sandford DE, Shrikhande SV, Vollmer CM, Wang SE, Zeh HJ, Hilal MA, Asbun HJ, Besselink MG. Risk factors and outcomes of conversion in minimally invasive distal pancreatectomy: a systematic review. Langenbecks Arch Surg 2020; 406:597-605. [PMID: 33301071 PMCID: PMC8106568 DOI: 10.1007/s00423-020-02043-2] [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: 09/30/2020] [Accepted: 11/20/2020] [Indexed: 12/16/2022]
Abstract
Purpose The reported conversion rates for minimally invasive distal pancreatectomy (MIDP) range widely from 2 to 38%. The identification of risk factors for conversion may help surgeons during preoperative planning and patient counseling. Moreover, the impact of conversion on outcomes of MIDP is unknown. Methods A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). The PubMed, Cochrane, and Embase databases were searched for studies concerning conversion to open surgery in MIDP. Results Of the 828 studies screened, eight met the eligibility criteria, resulting in a combined dataset including 2592 patients after MIDP. The overall conversion rate was 17.1% (range 13.0–32.7%) with heterogeneity between studies associated with the definition of conversion adopted. Only one study divided conversion into elective and emergency conversion. The main indications for conversion were vascular involvement (23.7%), concern for oncological radicality (21.9%), and bleeding (18.9%). The reported risk factors for conversion included a malignancy as an indication for surgery, the proximity of the tumor to vascular structures in preoperative imaging, higher BMI or visceral fat, and multi-organ resection or extended resection. Contrasting results were seen in terms of blood loss and length of stay in comparing converted MIDP and completed MIDP patients. Conclusion The identified risk factors for conversion from this study can be used for patient selection and counseling. Surgeon experience should be considered when contemplating MIDP for a complex patient. Future studies should divide conversion into elective and emergency conversion.
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Affiliation(s)
- A Balduzzi
- Department of Surgery, University Hospital, Verona, Italy
| | - N van der Heijde
- Department of Surgery, Southampton University Hospital, Southampton, UK.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Alseidi
- Department of Surgery, University of California, San Francisco, CA, USA
| | - S Dokmak
- Department of Surgery, Beaujon Hospital, Paris, France
| | - M L Kendrick
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - P M Polanco
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - D E Sandford
- Department of Surgery, Washington University, St. Louis, MO, USA
| | - S V Shrikhande
- Department of Surgery, Tata Memorial Hospital, Mumbai, India
| | - C M Vollmer
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - S E Wang
- Department of Surgery, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - H J Zeh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, UK.,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - H J Asbun
- Hepatobiliary and Pancreas, Miami Cancer Institute, Miami, FL, USA
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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48
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Partelli S, Ricci C, Rancoita PMV, Montorsi R, Andreasi V, Ingaldi C, Arru G, Pecorelli N, Crippa S, Alberici L, Di Serio C, Casadei R, Falconi M. Preoperative predictive factors of laparoscopic distal pancreatectomy difficulty. HPB (Oxford) 2020; 22:1766-1774. [PMID: 32340858 DOI: 10.1016/j.hpb.2020.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is a challenging operation due to technical complexity and tumor-related factors. Aim of this study was to identify preoperative risk factors affecting LDP difficulty. METHODS Consecutive patients who underwent LDP between 2015 and 2018 at San Raffaele Hospital and Policlinico S.Orsola-Malpighi Hospital were enrolled retrospectively. Three variables were used to define surgical difficulty: conversion to open, duration of surgery >3rd quartile and intraoperative blood loss >3rd quartile. The presence of ≥1 of these 3 variables was considered as another measure of difficulty. RESULTS Overall, 191 patients were included. Conversion to open was required in 25 patients (13%). At multiple regression analysis, tumor proximity to major vessels was the only independent predictor of conversion from laparoscopic to open (p < 0.001). No variables independently predicted an excessive duration of surgery. Male gender (p = 0.033) and increasing parenchymal thickness at resection line (p = 0.018) were independent predictors of excessive blood loss. Increasing parenchymal thickness at resection line (p = 0.014) and tumor proximity to major vessels (p = 0.002) were significant risk factors for the presence of ≥1 outcome of surgical difficulty. CONCLUSION Male gender, increasing parenchymal thickness at resection line and tumor proximity to major vessels represent preoperative risk factors of LDP difficulty.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Paola M V Rancoita
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Roberto Montorsi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Carlo Ingaldi
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Giaime Arru
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Laura Alberici
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Clelia Di Serio
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy.
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49
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Hayashi H, Baba H. Current statement and safe implementation of minimally invasive surgery in the pancreas. Ann Gastroenterol Surg 2020; 4:505-513. [PMID: 33005845 PMCID: PMC7511570 DOI: 10.1002/ags3.12366] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 12/19/2022] Open
Abstract
Minimally invasive pancreatic resection has become very popular in modern pancreatic surgery. Evidence of the benefits of a minimally invasive approach is accumulating thanks to prospective and randomized controlled studies. Minimally invasive surgery provides advantages to the surgeon due to the high definition of the surgical field and the freedom of fine movement of the robot, but should be considered only in selected patients and in high-volume centers. Minimally invasive distal pancreatectomy for benign and low-grade malignant tumors has established a secure position over open distal pancreatectomy, since it is associated with a shorter hospital stay, reduced blood loss, and equivalent complication rates. Minimally invasive distal pancreatectomy for pancreatic ductal adenocarcinoma appears to be a feasible, safe, and oncologically equivalent technique in experienced hands. On the other hand, the feasibility and safety of minimally invasive pancreaticoduodenectomy are still controversial compared with open pancreaticoduodenectomy. The choice of either technique among open, laparoscopic, and robotic approaches depends on surgeons' experience and hospital resources with a focus on patient safety. Further studies are needed to prove the perioperative and oncological advantages of minimally invasive surgery compared to open surgery in the pancreas. Here, we review the current status of minimally invasive pancreatic surgery and its safe implementation.
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Affiliation(s)
- Hiromitsu Hayashi
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hideo Baba
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
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50
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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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