Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA): A Pan-European Propensity Score Matched Study

Evaluating the efficacy of laparoscopic radical antegrade modular pancreatosplenectomy in selected early-stage left-sided pancreatic cancer: a propensity score matching study

BACKGROUND

Laparoscopic radical pancreatectomy is safe and beneficial for recectable pancreatic cancer, but the extent of resection for early-stage tumors remains controversial.

METHODS

Consecutive patients with left-sided pancreatic cancer who underwent either laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS, n = 54) or laparoscopic distal pancreatosplecnectomy (LDP, n = 131) between October 2020 and December 2022 were reviewed. The preoperative radiological selection criteria were as follows: (1) tumor diameter ≤ 4 cm; (2) located ≥ 1 cm from the celiac trunk; (3) didn't invade the fascial layer behind the pancreas.

RESULTS

After 1:1 propensity score matching (LRAMPS, n = 54; LDP, n = 54), baseline data were well-balanced with no differences. LRAMPS resulted in longer operation time (240.5 vs. 219.0 min, P = 0.020) and higher intraoperative bleeding volume (200 vs. 150 mL, P = 0.001) compared to LDP. Although LRAMPS harvested more lymph nodes (16 vs. 13, P = 0.008), there were no statistically significant differences in lymph node positivity rate (35.2% vs. 33.3%), R0 pancreatic transection margin (94.4% vs. 96.3%), and retroperitoneal margin (83.3% vs. 87.0%) rate. Postoperative complications did not significantly differ between the two groups. However, LRAMPS was associated with increased drainage volume (85.0 vs. 40.0 mL, P = 0.001), longer time to recover semi-liquid diet compared to LDP (5 vs. 4 days, P < 0.001) and increased daily bowel movement frequency. Tumor recurrence pattern and recurrence-free survival were comparable between the two groups, but the adjuvant chemotherapy regimens varied, and the completion rate of the 6-month intravenous chemotherapy was lower in the LRAMPS group compared to the LDP group (51.9% vs. 75.9%, P = 0.016).

CONCLUSIONS

LRAMPS did not provide oncological benefits over LDP for left-sided pancreatic cancer within the selection criteria, but it increased operation time, intraoperative bleeding, and postoperative bowel movement frequency. These factors impacted the regimen selection and completion of adjuvant chemotherapy, consequently compromising the potential benefits of LRAMPS in achieving better local control.

Robot-assisted approach using a laparoscopic articulating vessel-sealing device versus pure-robotic approach during distal pancreatectomy

Robotic distal pancreatectomy (RDP) has emerged as a minimally invasive approach to left-sided pancreatic tumors. This study aimed to evaluate the efficacy of the robot-assisted approach (RAA) using a laparoscopic articulating vessel-sealing device (LAVSD) during RDP by comparing it with the pure-robotic approach (PRA). Among 62 patients who underwent RDP between April 2020 and December 2023 at Fujita Health University, 22 underwent RAA (the RAA group). In RAA, console surgeons mainly prepared the surgical fields, and assistant surgeons actively dissected the adipose and connective tissues using LAVSD. The surgical outcomes of these patients were compared with those of 40 consecutive patients who underwent RDP with PRA. In total, 28 males and 34 females with a median age of 71 years were analyzed. The console surgeon's prior experience of performing RDP was similar between the groups (RAA; median, 6 [range, 0-36], PRA; median, 5.5 [range, 0-34] cases). The operation time was significantly shorter in the TST group (median, 300.5 [range, 202-557] vs. 363.5 [range, 230-556] min, p = 0.015). Major complications (Clavien-Dindo ≥ grade 3a) occurred less frequently in the RAA group (4.6% vs. 25.0%, p = 0.028). Although the median postoperative hospital stay was slightly shorter in the RAA group (median, 12 [range, 8-38] vs. 14.5 [8-44] days, p = 0.095), no statistically significant difference was observed. Compared with PRA, RAA using LAVSD is found to be safe and feasible in introducing RDP for operators with little experience.

Efficacy of Pancreatic Dissection With a Triple-row Stapler in Laparoscopic Distal Pancreatectomy: A Retrospective Observational Study

BACKGROUND

Postoperative pancreatic fistulas (POPFs) occur after 20% to 30% of laparoscopic distal pancreatectomies. This study aimed to evaluate the clinical efficacy of laparoscopic distal pancreatectomy using triple-row staplers in preventing POPFs.

METHODS

Between April 2016 and May 2023, 59 patients underwent complete laparoscopic distal pancreatectomies. There were more females (n=34, 57.6%) than males (n=25, 42.4%). The median age of the patients was 68.9 years. The patients were divided into slow-compression (n=19) and no-compression (n=40) groups and examined for pancreatic leakage. Both groups were examined with respect to age, sex, body mass index (BMI), pancreatic thickness at the pancreatic dissection site, pancreatic texture, diagnosis, operative time, blood loss, presence of POPF, date of drain removal, and length of hospital stay. In addition, risk factors for POPF were examined in a multivariate analysis.

RESULTS

Grade B POPFs were found in 9 patients (15.3%). Using univariate analysis, the operative time, blood loss, postoperative pancreatic fluid leakage, day of drain removal, and hospital stay were shorter in the no-compression group than in the slow-compression group. Using multivariate analysis, the absence of POPFs was significantly more frequent in the no-compression group (odds ratio, 5.69; 95% CI, 1.241-26.109; P =0.025). The no-compression pancreatic dissection method was a simple method for reducing POPF incidence.

CONCLUSIONS

The method of quickly dissecting the pancreas without compression yielded better results than the method of slowly dissecting the pancreas with slow compression. This quick dissection without compression was a simple and safe method that minimized postoperative pancreatic fluid leakage, shortened the operative time and length of hospital stay, and reduced medical costs. Therefore, this method might be a clinically successful option.

Evaluating the economic efficiency of open, laparoscopic, and robotic distal pancreatectomy: an updated systematic review and network meta-analysis

BACKGROUND

This study compared the cost-effectiveness of open (ODP), laparoscopic (LDP), and robotic (RDP) distal pancreatectomy (DP).

METHODS

Studies reporting the costs of DP were included in a literature search until August 2023. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, mean difference (MD), odds ratio (OR), and 95% credible intervals (CrIs) were calculated for outcomes of interest. Cluster analysis was performed to examine the similarity and classification of DP approaches into homogeneous clusters. A decision model-based cost-utility analysis was conducted for the cost-effectiveness analysis of DP strategies.

RESULTS

Twenty-six studies with 29,164 patients were included in the analysis. Among the three groups, LDP had the lowest overall costs, while ODP had the highest overall costs (LDP vs. ODP: MD - 3521.36, 95% CrI - 6172.91 to - 1228.59). RDP had the highest procedural costs (ODP vs. RDP: MD - 4311.15, 95% CrI - 6005.40 to - 2599.16; LDP vs. RDP: MD - 3772.25, 95% CrI - 4989.50 to - 2535.16), but incurred the lowest hospitalization costs. Both LDP (MD - 3663.82, 95% CrI - 6906.52 to - 747.69) and RDP (MD - 6678.42, 95% CrI - 11,434.30 to - 2972.89) had significantly reduced hospitalization costs compared to ODP. LDP and RDP demonstrated a superior profile regarding costs-morbidity, costs-mortality, costs-efficacy, and costs-utility compared to ODP. Compared to ODP, LDP and RDP cost $3110 and $817 less per patient, resulting in 0.03 and 0.05 additional quality-adjusted life years (QALYs), respectively, with positive incremental net monetary benefit (NMB). RDP costs $2293 more than LDP with a negative incremental NMB but generates 0.02 additional QALYs with improved postoperative morbidity and spleen preservation. Probabilistic sensitivity analysis suggests that LDP and RDP are more cost-effective options compared to ODP at various willingness-to-pay thresholds.

CONCLUSION

LDP and RDP are more cost-effective than ODP, with LDP exhibiting better cost savings and RDP demonstrating superior surgical outcomes and improved QALYs.

Intraoperative Video Analysis of Pancreatic Stump and Stapler Closure-Induced Pancreatic Fistula in Laparoscopic Distal Pancreatectomy: A Retrospective Study

Objectives Pancreatic stump closure in laparoscopic distal pancreatectomy (Lap-DP) is commonly performed using an automatic stapler. Herein, the magnification effect of laparoscopy was used to observe the pancreatic stump and retrospectively investigate factors that may cause postoperative pancreatic fistula. Methods This is a single-center retrospective study. We selected 62 cases of Lap-DP performed between March 2016 and May 2022. We retrospectively analyzed 54 cases where pancreatic transection sites could be observed using an intraoperative video. Pancreatic transection was performed using the Powered ECHELON FLEX®+ GST® System (Ethicon, Somerville, USA). For quantitative studies, we investigated the factors that cause pancreatic fistula and other factors causing pancreatic fistula. Results Pancreatic parenchymal hemorrhage and injury occurred in 22.2% and 29.6% of cases, respectively. International Study Group of Pancreatic Surgery grade B/C pancreatic fistula was observed in 12 cases (22.2%). Univariate analysis of pancreatic (n = 12) and nonpancreatic (n = 42) fistula groups showed no significant differences in pancreatic thickness. The pancreatic fistula group had a significantly high incidence of the hard pancreas (p = .009), pancreatic parenchymal bleeding (p = .002), and pancreatic parenchymal damage (p < .001). Multivariate analysis revealed that pancreatic parenchymal damage was an independent cause of pancreatic fistula (hazard ratio, 81.4 (8.5-772.3), p < .001). Conclusion Pancreatic parenchymal damage due to compression during pancreatic stump closure using an automatic stapler in Lap-DP may cause pancreatic fistula.

Postoperative outcomes and costs of laparoscopic versus robotic distal pancreatectomy: a propensity-matched analysis

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) make the robotic approach controversial. We sought to compare outcomes and cost of LDP and RDP using propensity matching analysis at our institution.

METHODS

Patients undergoing LDP or RDP between 2000 and 2021 were retrospectively identified. Patients were optimally matched using age, gender, American Society of Anesthesiologists status, body mass index, and tumor size. Between-group differences were analyzed using the Wilcoxon signed-rank test for continuous data, and the McNemar's test for categorical data. Outcomes included operative duration, conversion to open surgery, postoperative length of stay, pancreatic fistula rate, pseudocyst requiring intervention, and costs.

RESULTS

298 patients underwent MIDP, 180 (60%) were laparoscopic and 118 (40%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10, except for tumor type (0.16). RDP had longer operative times (268 vs 178 min, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), fewer biochemical pancreatic leaks (11.9% vs 34.7%, p < 0.01), and fewer interventional radiological drainage (0% vs 5.9%, p = 0.01). The number of pancreatic fistulas (11.9% vs 5.1%, p = 0.12), collections requiring antibiotics or intervention (11.9% vs 5.1%, p = 0.12), and conversion rates (3.4% vs 5.1%, p = 0.72) were comparable between the two groups. The total direct index admission costs for RDP were 1.01 times higher than for LDP for FY16-19 (p = 0.372), and 1.33 times higher for FY20-22 (p = 0.031).

CONCLUSIONS

Although RDP required longer operative times than LDP, postoperative stays were shorter. The procedure cost of RDP was modestly more expensive than LDP, though this was partially offset by reduced hospital stay and reintervention rate.

Comparison of perioperative and oncologic outcomes after open, laparoscopic, and robotic distal pancreatectomy: a single-center retrospective study

As minimally invasive surgery gains grounds, surgeons are switching more towards laparoscopic distal pancreatectomy (LDP) and robotic distal pancreatectomy (RDP) as opposed to open distal pancreatectomy (ODP). Through this study, we aimed at exploring the differences in perioperative and oncologic outcomes among the three surgical methods. We retrospectively collected data from 303 patients who underwent distal pancreatectomy (DP) at a single high-volume institution between June 2015 and December 2021. We equally compared the perioperative and oncologic outcomes in patients who underwent ODP, LDP, and RDP by analyzing clinicopathologic and survival data. We consecutively included 303 cases in the study: open = 147 (48.5%), laparoscopic = 50 (16.5%), and robotic = 106 (35.0%). The median tumor size was significantly larger in the ODP group (P < 0.001) compared to the others. Cases in the RDP group experienced a longer duration of surgery (P < 0.001), smaller amount of blood loss (P < 0.001), smaller amount of blood transfusion (P = 0.042), and a shorter duration of hospital stay (p = 0.040) compared to cases in the ODP group. There was no significant difference observed when comparing other postoperative outcomes across the groups. Overall survival (OS) and progression-free survival (PFS) were similar across the significant differences among the three groups. The short-term postoperative and oncologic outcomes observed in the RDP and LDP groups were not inferior to those in the ODP group. The RDP has some perioperative advantages over the ODP. Therefore, RDP and LDP can safely and feasibly be performed in selected pancreatic tumors by experienced pancreatic surgeons.

Study International Multicentric Pancreatic Left Resections (SIMPLR): Does Surgical Approach Matter?

BACKGROUND

Minimally invasive surgery is increasingly preferred for left-sided pancreatic resections. The SIMPLR study aims to compare open, laparoscopic, and robotic approaches using propensity score matching analysis.

METHODS

This study included 258 patients with tumors of the left side of the pancreas who underwent surgery between 2016 and 2020 at three high-volume centers. The patients were divided into three groups based on their surgical approach and matched in a 1:1 ratio.

RESULTS

The open group had significantly higher estimated blood loss (620 mL vs. 320 mL, p < 0.001), longer operative time (273 vs. 216 min, p = 0.003), and longer hospital stays (16.9 vs. 6.81 days, p < 0.001) compared to the laparoscopic group. There was no difference in lymph node yield or resection status. When comparing open and robotic groups, the robotic procedures yielded a higher number of lymph nodes (24.9 vs. 15.2, p = 0.011) without being significantly longer. The laparoscopic group had a shorter operative time (210 vs. 340 min, p < 0.001), shorter ICU stays (0.63 vs. 1.64 days, p < 0.001), and shorter hospital stays (6.61 vs. 11.8 days, p < 0.001) when compared to the robotic group. There was no difference in morbidity or mortality between the three techniques.

CONCLUSION

The laparoscopic approach exhibits short-term benefits. The three techniques are equivalent in terms of oncological safety, morbidity, and mortality.

Pancreatic stump closure after distal pancreatectomy: Systematic review and meta-analysis of randomized clinical trials comparing non-autologous versus no reinforcement: Value of prediction intervals

BACKGROUND

This meta-analysis of randomized trials aimed to assess the benefits and harms of non-autologous versus no reinforcement of the pancreatic stump following distal pancreatectomy (DP).

METHODS

It was performed in accordance with PRISMA 2020 and AMSTAR 2 Guidelines. (registered in PROSPERO ID: EROCRD42021286863).

RESULTS

Nine relevant articles (between 2009 and 2021) were retrieved, comparing non-autologous reinforcement (757 patients) with non-reinforcement (740 patients) after PD. Pooled analysis showed a statistically significant lower rate of postoperative pancreatic fistula (POPF) in the reinforcement group (RR ​= ​0.677; 95 ​% CI [0.479, 0.956], p ​= ​0.027). The 95 ​% predictive interval (0.267-1.718) showed heterogeneity. Non-autologous reinforcement other than with "Tachosil®" was effective (subgroup analysis). No statistically significant differences were found between the two groups with regard to secondary outcomes.

CONCLUSIONS

This meta-analysis showed that covering the stump with non-autologous reinforcement other than Tachosil® had a preventive effect on the onset of POPF.

Role of minimally invasive surgery in the management of localized pancreatic ductal adenocarcinoma: a review

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.

A multi-institutional randomized phase III study comparing minimally invasive distal pancreatectomy versus open distal pancreatectomy for pancreatic cancer; Japan Clinical Oncology Group study JCOG2202 (LAPAN study)

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP), including laparoscopic and robotic distal pancreatectomy, has gained widespread acceptance over the last decade owing to its favorable short-term outcomes. However, evidence regarding its oncologic safety is insufficient. In March 2023, a randomized phase III study was launched in Japan to confirm the non-inferiority of overall survival in patients with resectable pancreatic cancer undergoing MIDP compared with that of patients undergoing open distal pancreatectomy (ODP).

METHODS

This is a multi-institutional, randomized, phase III study. A total of 370 patients will be enrolled from 40 institutions within 4 years. The primary endpoint of this study is overall survival, and the secondary endpoints include relapse-free survival, proportion of patients undergoing radical resection, proportion of patients undergoing complete laparoscopic surgery, incidence of adverse surgical events, and length of postoperative hospital stay. Only a credentialed surgeon is eligible to perform both ODP and MIDP. All ODP and MIDP procedures will undergo centralized review using intraoperative photographs. The non-inferiority of MIDP to ODP in terms of overall survival will be statistically analyzed. Only if non-inferiority is confirmed will the analysis assess the superiority of MIDP over ODP.

DISCUSSION

If our study demonstrates the non-inferiority of MIDP in terms of overall survival, it would validate its short-term advantages and establish its long-term clinical efficacy.

TRIAL REGISTRATION

This trial is registered with the Japan Registry of Clinical Trials as jRCT 1,031,220,705 [ https://jrct.niph.go.jp/en-latest-detail/jRCT1031220705 ].

[Robotic pancreatic surgery]

Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2-3 years.

Effect of laparoscopic and open distal pancreatectomy on postoperative wound complications in patients with pancreatic cancer: A meta-analysis

At present, it is regarded as a safe and efficient operation to treat terminal pancreatic disease. In this paper, we present a summary of the results of the clinical trials that have been conducted to evaluate the efficacy of laparoscopic and open-access pancreatic resection for pancreatic carcinoma of the end of the pancreas. Systematic review of the comparison between laparoscopy and open-access pancreatic resection was conducted. Comparative studies published before October 2023 were included. The selection of the studies was done according to a particular classification and exclusion criterion. A few of our results, which were post-surgery, were associated with injury, were compared. Where appropriate, the reliability of the data has been corroborated by a sensitive analysis. Six trials of 2075 patients with pancreatic cancer who underwent distal pancreatic resection to be included in the definitive data analysis. Among them, 447 were treated with open-access surgery and 296 were treated with laparoscope. Six trials showed that there was no statistically significant difference in the risk of postoperative wound infection in patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery(OR, 1.66; 95% CI, 0.76-3.61 p = 0.20). Four trials did not reveal any statistically significant differences in the risk of postoperative haemorrhage among patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery (OR, 1.84; 95% CI, 0.54-6.26 p = 0.33). Both trials did not reveal any statistically significant difference in the duration of operation for patients with pancreas cancer who received a distal pancreatectomy between laparoscopy and open surgery (MD, 13.58; 95% CI, -7.31-34.46 p = 0.2). Based on these meta-analyses, the use of laparoscopy or open surgery was not associated with an increase in the risk of postoperative infection or haemorrhage. Furthermore, the duration of the two operations did not differ significantly. These two procedures appear to be a safe and viable choice in the treatment of pancreatic carcinoma. Nevertheless, a randomized, controlled study should be performed to verify the validity of this observation.

Minimally invasive versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma: an entropy balancing analysis

BACKGROUND

The safety and efficacy of minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS) remain to be established in pancreatic cancer (PDAC) METHODS: Eighty-five open (O)-RAMPS were compared to 93 MI-RAMPS. The entropy balance matching approach was used to compare the two cohorts, eliminating the selection bias. Three models were created. Model 1 made O-RAMPS equal to the MI-RAMPS cohort (i.e., compared the two procedures for resectable PDAC); model 2 made MI-RAMPS equal to O-RAMPS (i.e., compared the two procedures for borderline-resectable PDAC); model 3, compared robotic and laparoscopic RAMPS.

RESULTS

O-RAMPS and MI-RAMPS showed "non-small" differences for BMI, comorbidity, back pain, tumor size, vascular resection, anterior or posterior RAMPS, multi-visceral resection, stump management, grading, and neoadjuvant therapy. Before reweighting, O-RAMPS had fewer clinically relevant postoperative pancreatic fistulae (CR-POPF) (20.0% vs. 40.9%; p = 0.003), while MI-RAMPS had a higher mean of lymph nodes (25.7 vs. 31.7; p = 0.011). In model 1, MI-RAMPS and O-RAMPS achieved similar results. In model 2, O-RAMPS was associated with lower comprehensive complication index scores (MD = 11.2; p = 0.038), and CR-POPF rates (OR = 0.2; p = 0.001). In model 3, robotic-RAMPS had a higher probability of negative resection margins.

CONCLUSION

In patients with anatomically resectable PDAC, MI-RAMPS is feasible and as safe as O-RAMPS.

International survey on opinions and use of robot-assisted and laparoscopic minimally invasive pancreatic surgery: 5-year follow up

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.

Nationwide analysis of unplanned conversion during minimally invasive distal pancreatectomy for pancreatic adenocarcinoma

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.

Improving the prognosis of pancreatic cancer: insights from epidemiology, genomic alterations, and therapeutic challenges

Pancreatic cancer, notorious for its late diagnosis and aggressive progression, poses a substantial challenge owing to scarce treatment alternatives. This review endeavors to furnish a holistic insight into pancreatic cancer, encompassing its epidemiology, genomic characterization, risk factors, diagnosis, therapeutic strategies, and treatment resistance mechanisms. We delve into identifying risk factors, including genetic predisposition and environmental exposures, and explore recent research advancements in precursor lesions and molecular subtypes of pancreatic cancer. Additionally, we highlight the development and application of multi-omics approaches in pancreatic cancer research and discuss the latest combinations of pancreatic cancer biomarkers and their efficacy. We also dissect the primary mechanisms underlying treatment resistance in this malignancy, illustrating the latest therapeutic options and advancements in the field. Conclusively, we accentuate the urgent demand for more extensive research to enhance the prognosis for pancreatic cancer patients.

Robotic Distal Pancreatectomy Yields Superior Outcomes Compared to Laparoscopic Technique: A Single Surgeon Experience of 123 Consecutive Cases

Technical limitations of laparoscopic distal pancreatectomy (LDP), in comparison to robotic distal pancreatectomy (RDP), may translate to high conversion rates and morbidity. LDP and RDP procedures performed between December 2008 and January 2023 in our tertiary referral hepatobiliary and pancreatic centres were analysed and compared with regard to short-term outcomes. A total of 62 consecutive LDP cases and 61 RDP cases were performed. There was more conversion to open surgeries in the laparoscopic group compared with the robotic group (21.0% vs. 1.6%, p = 0.001). The LDP group also had a higher rate of postoperative complications (43.5% vs. 23.0%, p = 0.005). However, there was no significant difference between the two groups in terms of major complication or pancreatic fistular after operations (p = 0.20 and p = 0.71, respectively). For planned spleen-preserving operations, the RDP group had a shorter mean operative time (147 min vs. 194 min, p = 0.015) and a reduced total length of hospital stay compared with the LDP group (4 days vs. 7 days, p = 0.0002). The failure rate for spleen preservation was 0% in RDP and 20% (n = 5/25) in the LDP group (p = 0.009). RDP offered a better method for splenic preservation with Kimura's technique compared with LDP to avoid the risk of splenic infarction and gastric varices related to ligation and division of splenic pedicles. RDP should be the standard operation for the resection of pancreatic tumours at the body and tail of the pancreas without involving the celiac axis or common hepatic artery.

Preoperative nutritional support in patients undergoing pancreatic surgery affects PREPARE score accuracy

Background

This study aimed to validate the accuracy of the Preoperative Pancreatic Resection (PREPARE) risk score in pancreatic resection patients.

Patients and methods

This prospective study included 216 patients who underwent pancreatic resection between January 2015 and December 2018. All patients in our cohort with weight loss or lack of appetite received dietary advice and preoperative oral nutritional supplementation (600 kcal/day). Demographic, clinicopathological, operative, and postoperative data were collected prospectively. The PREPARE score and the predicted risk of major complications were computed for each patient. Differences in major postoperative complications were analyzed using a multivariate Cox proportional hazards regression model. The predicted and observed risks of major complications were tested using the C-statistic.

Results

The study included 216 patients [117 men (54.2%)] with a median age of 65.0 (30.0-83.0) years. The majority of patients were classified as American Society of Anesthesiologists (ASA)' Physical Status score II (N = 164/216; 75.9%) and as "low risk" PREPARE score (N = 185/216; 85.6%) before the surgery. Only 4 (1.9%) patients were malnourished, with albumin levels of less than 3.5 g/dl. The most common type of pancreatic resection was a pylorus-preserving pancreaticoduodenectomy (N = 122/216; 56.5%). Major morbidity and 30-day mortality rates were 11.1% and 1.9%, respectively. The type of surgical procedure (hazard ratio [HR]: 3.849; 95% confidence interval [CI]: 1.208-12.264) and ASA score (HR: 3.089; 95% CI: 1.067-8.947) were significantly associated with the incidence of major postoperative complications in multivariate analysis. The receiver operating characteristic curve was 0.657 for incremental values and 0.559 for risk categories, indicating a weak predictive model.

Conclusion

The results of the present study suggest that the PREPARE risk score has low accuracy in predicting the risk of major complications in patients with consistent preoperative nutritional support. This limits the use of PREPARE risk score in future preoperative clinical routines.

Robotic versus laparoscopic distal pancreatectomy in obese patients

BACKGROUND

Although robotic distal pancreatectomy (RDP) has a lower conversion rate to open surgery and causes less blood loss than laparoscopic distal pancreatectomy (LDP), clear evidence on the impact of the surgical approach on morbidity is lacking. Prior studies have shown a higher rate of complications among obese patients undergoing pancreatectomy. The primary aim of this study is to compare short-term outcomes of RDP vs. LDP in patients with a BMI ≥ 30.

METHODS

In this multicenter study, all obese patients who underwent RDP or LDP for any indication between 2012 and 2022 at 18 international expert centers were included. The baseline characteristics underwent inverse probability treatment weighting to minimize allocation bias.

RESULTS

Of 446 patients, 219 (50.2%) patients underwent RDP. The median age was 60 years, the median BMI was 33 (31-36), and the preoperative diagnosis was ductal adenocarcinoma in 21% of cases. The conversion rate was 19.9%, the overall complication rate was 57.8%, and the 90-day mortality rate was 0.7% (3 patients). RDP was associated with a lower complication rate (OR 0.68, 95% CI 0.52-0.89; p = 0.005), less blood loss (150 vs. 200 ml; p < 0.001), fewer blood transfusion requirements (OR 0.28, 95% CI 0.15-0.50; p < 0.001) and a lower Comprehensive Complications Index (8.7 vs. 8.9, p < 0.001) than LPD. RPD had a lower conversion rate (OR 0.27, 95% CI 0.19-0.39; p < 0.001) and achieved better spleen preservation rate (OR 1.96, 95% CI 1.13-3.39; p = 0.016) than LPD.

CONCLUSIONS

In obese patients, RDP is associated with a lower conversion rate, fewer complications and better short-term outcomes than LPD.

The role of minimally invasive surgery in resectable distal pancreatic adenocarcinoma

BACKGROUND

In distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), we hypothesize that minimally invasive DP (MIDP) carries short-term benefits over ODP (ODP) in the absence of postoperative pancreatic fistula (POPF).

METHODS

NSQIP database was queried to select patients who underwent DP for PDAC with available report on POPF. The population was divided into No-POPF vs. POPF groups. In each group, propensity-score matching was applied to compare 30-day outcomes of ODP vs. MIDP.

RESULTS

There were 2,824 patients; 2,332 (82%) had No-POPF and 492 (21%) had POPF. In No-POPF patients, 921 pairs were matched between ODP and MIDP. MIDP patients had slightly longer operations (227 vs. 205 minutes; p < 0.001), but lower rates of surgical site complications (1% vs. 2.9%; p = 0.002), postoperative transfusion (7.1% vs. 11.0%; p = 0.003), overall morbidity (21.1% vs. 26.3%; p = 0.009), and one-day shorter median length of stay (LOS) (5 vs. 6 days; p = 0.001). In the POPF group, 172 pairs were matched. There was no difference in morbidity, mortality, reoperation, LOS, and home discharge. Similar conclusions were drawn in the intention-to-treat and per-protocol analyses.

CONCLUSION

POPF is common following DP for PDAC. In the absence of POPF, MIDP is associated with fewer postoperative morbidities and shorter LOS.

Short-term Outcomes of Laparoscopic and Open Distal Pancreatectomy Using Propensity Score Analysis: A Real-world Retrospective Cohort Study

OBJECTIVE

This study aimed to compare the short-term outcomes between laparoscopic and open distal pancreatectomy for lesions of the distal pancreas from a real-world database.

BACKGROUND

Reports on the benefits of laparoscopic distal pancreatectomy include 2 randomized controlled trials; however, large-scale, real-world data are scarce.

METHODS

We analyzed the data of patients undergoing laparoscopic or open distal pancreatectomy for benign or malignant pancreatic tumors from April 2008 to May 2020 from a Japanese nationwide inpatient database. We performed propensity score analyses to compare the inhospital mortality, morbidity, readmission rate, reoperation rate, length of postoperative stay, and medical cost between the 2 groups.

RESULTS

From 5502 eligible patients, we created a pseudopopulation of patients undergoing laparoscopic and open distal pancreatectomy using inverse probability of treatment weighting. Laparoscopic distal pancreatectomy was associated with lower inhospital mortality during the period of admission (0.0% vs 0.7%, P <0.001) and within 30 days (0.0% vs 0.2%, P =0.001), incidence of reoperation during the period of admission (0.7% vs 1.7%, P =0.018), postpancreatectomy hemorrhage (0.4% vs 2.0%, P <0.001), ileus (1.1% vs 2.8%, P =0.007), and shorter postoperative length of stay (17 vs 20 d, P <0.001).

CONCLUSIONS

The propensity score analysis revealed that laparoscopic distal pancreatectomy was associated with better outcomes than open surgery in terms of inhospital mortality, reoperation rate, postoperative length of stay, and incidence of postoperative complications such as postpancreatectomy hemorrhage and ileus.

Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial

Background

The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking.

Methods

In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of -7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265).

Findings

Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI -6.2 to 13.6%; p_{non-inferiority} = 0.039). Median lymph node yield was comparable (22.0 [16.0-30.0] vs 23.0 [14.0-32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0-30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5-5.5] vs 5 [95% CI 4.7-5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67-1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group.

Interpretation

This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer.

Funding

Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.

State-of-the-Art and Upcoming Innovations in Pancreatic Cancer Care: A Step Forward to Precision Medicine

Pancreatic cancer remains a social and medical burden despite the tremendous advances that medicine has made in the last two decades. The incidence of pancreatic cancer is increasing, and it continues to be associated with high mortality and morbidity rates. The difficulty of early diagnosis (the lack of specific symptoms and biomarkers at early stages), the aggressiveness of the disease, and its resistance to systemic therapies are the main factors for the poor prognosis of pancreatic cancer. The only curative treatment for pancreatic cancer is surgery, but the vast majority of patients with pancreatic cancer have advanced disease at the time of diagnosis. Pancreatic surgery is among the most challenging surgical procedures, but recent improvements in surgical techniques, careful patient selection, and the availability of minimally invasive techniques (e.g., robotic surgery) have dramatically reduced the morbidity and mortality associated with pancreatic surgery. Patients who are not candidates for surgery may benefit from locoregional and systemic therapy. In some cases (e.g., patients for whom marginal resection is feasible), systemic therapy may be considered a bridge to surgery to allow downstaging of the cancer; in other cases (e.g., metastatic disease), systemic therapy is considered the standard approach with the goal of prolonging patient survival. The complexity of patients with pancreatic cancer requires a personalized and multidisciplinary approach to choose the best treatment for each clinical situation. The aim of this article is to provide a literature review of the available treatments for the different stages of pancreatic cancer.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy

Because distal pancreatectomy (DP) has no reconstructive steps and less frequent vascular involvement, it is thought to be the easier counterpart of pancreaticoduodenectomy. This procedure has a high surgical risk and the overall incidences of perioperative morbidity (mainly pancreatic fistula), and mortality are still high, in addition to the challenges that accompany delayed access to adjuvant therapies (if any) and prolonged impairment of daily activities. Moreover, surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes. From this perspective, new surgical approaches, and aggressive techniques, such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection, could lead to improved survival in those affected by more locally advanced tumors. Conversely, minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress. The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications, length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy. Because a dedicated multidisciplinary team is crucial to pancreatic surgery, hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign, borderline, and malignant diseases of the pancreas. The purpose of this review is to examine the state of the art in distal pancreatectomies, with a special focus on minimally invasive approaches and oncological-directed techniques. The widespread reproducibility, cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

Laparoscopic distal pancreatectomy is more cost-effective than open resection: results from a Swedish randomized controlled trial

BACKGROUND

Laparoscopic distal pancreatectomy is being implemented worldwide. The aim of this study was to perform a cost-effectiveness analysis from a health care perspective.

METHODS

This cost-effectiveness analysis was based on the randomized controlled trial LAPOP, where 60 patients were randomized to open or laparoscopic distal pancreatectomy. For the follow-up of two years, resource use from a health care perspective was recorded, and health-related quality of life was assessed using the EQ-5D-5L. The per-patient mean cost and quality-adjusted life years (QALYs) were compared using nonparametric bootstrapping.

RESULTS

Fifty-six patients were included in the analysis. The mean health care costs were lower, €3863 (95% CI: -€8020 to €385), for the laparoscopic group. Postoperative quality of life improved with laparoscopic resection and resulted in a gain in QALYs of 0.08 (95% CI: -0.09 to 0.25). The laparoscopic group had lower costs and improved QALYs in 79% of bootstrap samples. With a cost-per-QALY threshold of €50 000, 95.4% of the bootstrap samples were in favour of laparoscopic resection.

CONCLUSION

Laparoscopic distal pancreatectomy is associated with numerically lower health care costs and improvements in QALYs compared with the open approach. The results support the ongoing transition from open to laparoscopic distal pancreatectomies.

Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge

Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.

Robotic versus laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

BACKGROUND

Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy (RDP) for pancreatic ductal adenocarcinoma (PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC.

METHODS

Patients who underwent RDP or laparoscopic distal pancreatectomy (LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed.

RESULTS

Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time (209.7 vs. 163.2 min; P = 0.003), lower open conversion rate (0% vs. 4.8%; P < 0.001), higher cost (15 722 vs. 12 699 dollars; P = 0.003), and a higher rate of achievement of an R0 resection margin (90.5% vs. 61.9%; P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant inter-group difference (9.5% vs. 9.5%). The median disease-free survival (34.5 vs. 17.3 months; P = 0.588) and overall survival (37.7 vs. 21.9 months; P = 0.171) were comparable between the groups.

CONCLUSIONS

RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.

Minimally Invasive Pancreatectomy: Robotic and Laparoscopic Developments

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.

Advantages of laparoscopic distal pancreatectomy: Systematic review and meta-analysis of randomized and matched studies

BACKGROUND

We sought to provide a meta-analysis and credibility assessment of available randomized controlled trials and propensity score matched studies when assessing early and oncologic outcomes of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.

METHODS

The MEDLINE, Scopus, Web of Science, and Cochrane databases were searched for pertinent literature up to June 2022. Random-effect meta-analyses were applied. Trial sequential analysis was applied to verify whether results were true- or false-positive or -negative findings.

RESULTS

Thirteen studies were identified (2 randomized controlled trials and 11 propensity score matched studies). The early outcomes were assessed on 12 studies, including 4,346 patients. In this population, laparoscopic distal pancreatectomy decreased postoperative stay (mean difference = 1.8 days; P = .001) and estimated blood loss (mean difference = 148 mL; P = .001), and trial sequential analysis confirmed these as true-positive findings. Laparoscopic distal pancreatectomy and open distal pancreatectomy had similar operating times (P = .165), and trial sequential analysis confirmed this as a true-negative finding. Major morbidity, mortality, and readmission were similar, but results were inconclusive by trial sequential analysis. Oncologic outcomes were assessed on 5 studies, including 2,430 patients. In this population, laparoscopic distal pancreatectomy showed higher R0 resection rate (OR = 1.46; P = .001) and shorter time to adjuvant therapy (mean difference 4.0 days P = .003). A survival benefit was observed at 1 year after laparoscopic distal pancreatectomy (OR = 1.45; P = .001), which was not confirmed at 3 years (P = .650).

CONCLUSION

Laparoscopic distal pancreatectomy is superior to open distal pancreatectomy for most of the early outcomes analyzed. The operating time was equalized as a result of the learning curve. Results from patients with pancreatic cancer suggest at least an oncologic noninferiority of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.

Does minimally invasive surgery have a different impact on recurrence and overall survival in patients with pancreatic head versus body/tail cancer?

OBJECTIVE

This study sought to investigate the impact of minimally invasive surgery (MIS) on recurrence and overall survival between patients with pancreatic head versus body/tail cancers.

METHODS

The risk factors associated with recurrence and long-term outcomes were analyzed according to tumor location and operative modality.

RESULTS

A total of 288 and 87 patients underwent surgical resection for pancreatic head cancer and body/tail cancer, respectively. The perioperative outcomes and histopathologic results were comparable in open and MIS approach in both head and body/tail groups. There was no difference in local or systemic recurrence patterns and disease-free and overall survival rates according to primary tumor location and surgical modality. During subgroup analysis by stage; however, patients with stage III pancreatic head cancer in the MIS group had a decreased disease-free survival compared with those in the open surgery group (p = 0.020). On multivariate analysis, MIS was not a risk factor of total or local recurrences.

CONCLUSIONS

Recurrence patterns and overall survival rates of patients did not differ according to tumor location and surgical approach. However, patients with stage III pancreatic head cancer in the MIS group showed inferior disease-free survival relative to patients who underwent open surgery.

Preliminary experience with a new robotic technique to facilitate distal pancreatectomy with spleen preservation: left lateral approach in right lateral decubitus position

Spleen-preserving distal pancreatectomy (SP-DP), for patients with benign or small low-grade malignant tumors of the body or tail of the pancreas, is the ideal procedure although it is technically demanding. The robotic da Vinci system has been introduced to overcome these technical challenges and reduce operative risks. We report our experience of a new variation in surgical technique: the left lateral approach robotic spleen-preserving distal pancreatectomy (RSP-DP) in right lateral decubitus position. We performed this new variant of SP-DP, in five patients, using the da Vinci Xi system. Technical and clinical feasibility are described. The mean age and body mass index were 53.4 years and 31.4 kg/m², respectively. The mean total operative time was 323 min. The estimated mean blood loss was 240 ml. In all patients, the spleen could be preserved. In four patients, the splenic vessels were also preserved. One patient required a Warshaw technique due to significant fibrosis attached to the splenic vein. The postoperative period of all patients was uneventful except the presence of biochemical leak (BL) in two patients that only required maintenance of the drainage at home. The mean length of hospital stay was 6 days after surgery. The left lateral approach robotic SP-DP in right lateral decubitus position is a feasible and safe procedure for distal benign or small low-grade malignant tumors of the left pancreas. The right lateral decubitus position associated to robotic surgery can facilitate this complex procedure, especially when splenic vessels preservation is indicated, with a lower risk of conversion and shortening of the learning curve.

Robot-Assisted Versus Laparoscopic Distal Pancreatectomy in Patients with Resectable Pancreatic Cancer: An International, Retrospective, Cohort Study

BACKGROUND

Robot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking.

METHODS

An international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010-2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival.

RESULTS

In total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively.

CONCLUSIONS

In selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials.

Robot-assisted versus laparoscopic distal pancreatectomy: a systematic review and meta-analysis including patient subgroups

BACKGROUND

Robot-assisted distal pancreatectomy (RDP) has been suggested to hold some benefits over laparoscopic distal pancreatectomy (LDP) but consensus and data on specific subgroups are lacking. This systematic review and meta-analysis reports the surgical and oncological outcome and costs between RDP and LDP including subgroups with intended spleen preservation and pancreatic ductal adenocarcinoma (PDAC).

METHODS

Studies comparing RDP and LDP were included from PubMed, Cochrane Central Register, and Embase (inception-July 2022). Primary outcomes were conversion and unplanned splenectomy. Secondary outcomes were R0 resection, lymph node yield, major morbidity, operative time, intraoperative blood loss, in-hospital mortality, operative costs, total costs and hospital stay.

RESULTS

Overall, 43 studies with 6757 patients were included, 2514 after RDP and 4243 after LDP. RDP was associated with a longer operative time (MD = 18.21, 95% CI 2.18-34.24), less blood loss (MD = 54.50, 95% CI - 84.49-24.50), and a lower conversion rate (OR = 0.44, 95% CI 0.36-0.55) compared to LDP. In spleen-preserving procedures, RDP was associated with more Kimura procedures (OR = 2.23, 95% CI 1.37-3.64) and a lower rate of unplanned splenectomies (OR = 0.32, 95% CI 0.24-0.42). In patients with PDAC, RDP was associated with a higher lymph node yield (MD = 3.95, 95% CI 1.67-6.23), but showed no difference in the rate of R0 resection (OR = 0.96, 95% CI 0.67-1.37). RDP was associated with higher total (MD = 3009.31, 95% CI 1776.37-4242.24) and operative costs (MD = 3390.40, 95% CI 1981.79-4799.00).

CONCLUSIONS

RDP was associated with a lower conversion rate, a higher spleen preservation rate and, in patients with PDAC, a higher lymph node yield and similar R0 resection rate, as compared to LDP. The potential benefits of RDP need to be weighed against the higher total and operative costs in future randomized trials.

Postoperative complications and short-term prognosis of laparoscopic pancreaticoduodenectomy vs. open pancreaticoduodenectomy for treating pancreatic ductal adenocarcinoma: a retrospective cohort study

BACKGROUND

Although laparoscopic pancreaticoduodenectomy (LPD) has been accepted worldwide for treating pancreatic ductal adenocarcinoma (PDA), it is a very technical and challenging procedure. Also, it is unclear whether LPD is superior to open pancreaticoduodenectomy (OPD). This study summarized the experience and efficacy of LPD for treating PDA in our medical center.

METHODS

This retrospective cohort study included patients with PDA admitted at the Affiliated Hospital of Jiangnan University from October 2019 and January 2021. Patients received either LPD or OPD. Clinical outcomes (operation time, duration of anesthesia, intraoperative hemorrhage), postoperative complications, and short-term outcomes were compared. Cox proportional hazard model and Kaplan-Meier method were used to analyze overall survival (OS) and progression-free survival (PFS).

RESULTS

Among the PDA patients, 101 patients underwent surgical treatment, 4 patients converted from LPD to OPD, and 7 of them received conservative treatment. Forty-six patients were cured of LPD, and 1 of them died shortly after the operation. Moreover, 44 patients received OPD, and there were 2 postoperative deaths. There were significant differences in the location of the operation time, duration of anesthesia, postoperative hemorrhage, abdominal infections, and postoperative pneumonia between the two groups (all p < 0.05). Multivariate analysis showed that LPD was an independent factor negatively correlated with the incidence of pneumonia (relative risk (RR) = 0.072, 95%CI: 0.016-0.326, p = 0.001) and abdominal infection (RR = 0.182, 95%CI: 0.047-0.709, p = 0.014). Also, there were no differences in OS (hazard ratio (HR) = 1.46, 95%CI: 0.60-3.53, p = 0.40) and PFS (HR = 1.46, 95%CI: 0.64-3.32, p = 0.37) at 12 months between the two groups.

CONCLUSIONS

LPD could be efficacy and feasible for managing selected PDA patients. Also, LPD has a better effect in reducing postoperative pneumonia and abdominal infection compared to OPD.

Blood loss in laparoscopic distal pancreatectomy could be underestimated

BACKGROUND

Previous studies have reported that laparoscopic distal pancreatectomy (LDP) has an advantage in reducing blood loss over open distal pancreatectomy (ODP). This study was performed to investigate whether blood loss is truly reduced in LDP.

METHODS

A total of 113 patients undergoing DP from 2014 to 2022 were classified into Open and LDP groups and compared by statistical analysis. Estimated blood loss (EBL) was calculated from the perioperative changes in the hematocrit, hemoglobin, or red blood cell volume, and actual blood loss (ABL) was taken from the operative record.

RESULTS

ABL was significantly lower in the LDP than ODP group (50[5-1350] vs 335 [5-1950] ml, P < .01). However, there were no significant differences in EBL calculated from the hematocrit (406 [66-1990] vs 540 [23-1490] ml, P = .14), hemoglobin, or red blood cell volume. EBL showed more linear correlations with ABL in the ODP group (r = 0.64-0.73) than in the LDP group (r = 0.52-0.57). In the multivariate analysis for ABL, ODP (P = .02) and operative time (P < .01) were significant factors. In contrast, no significant factors were found for EBL.

CONCLUSIONS

Intraoperative blood loss may be underestimated in LDP, and a new evaluation method needs to be established.

Risk factor analysis and prediction of postoperative clinically relevant pancreatic fistula after distal pancreatectomy

OBJECTIVE

Postoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) is a serious complication. In the present study, we aimed to identify the risk factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF) and establish a nomogram model for predicting CR-POPF after DP.

METHODS

In total, 115 patients who underwent DP at the General Hospital of Northern Theater Command between January 2005 and December 2020 were retrospectively studied. Univariate and multivariable logistic regression analyses were used to identify the independent risk factors associated with CR-POPF. Then, a nomogram was formulated based on the results of multivariable logistic regression analysis. The predictive performance was evaluated with receiver operating characteristic (ROC) curves. Decision curve and clinical impact curve analyses were used to validate the clinical application value of the model.

RESULTS

The incidence of CR-POPF was 33.0% (38/115) in the present study. Multivariate logistic regression analysis identified the following variables as independent risk factors for POPF: body mass index (BMI) (OR 4.658, P = 0.004), preoperative albumin level (OR 7.934, P = 0.001), pancreatic thickness (OR 1.256, P = 0.003) and pancreatic texture (OR 3.143, P = 0.021). We created a nomogram by incorporating the above mentioned risk factors. The nomogram model showed better predictive value, with a concordance index of 0.842, sensitivity of 0.710, and specificity of 0.870 when compared to each risk factor. Decision curve and clinical impact curve analyses also indicated that the nomogram conferred a high clinical net benefit.

CONCLUSION

Our nomogram could accurately and objectively predict the risk of postoperative CR-POPF in individuals who underwent DP, which could help clinicians with early identification of patients who might develop CR-POPF and early development of a suitable fistula mitigation strategy and postoperative management.

Postoperative Poor Oral Intake After Distal Pancreatectomy

OBJECTIVES

Poor oral intake (POI) without an identifiable cause is frequently observed after distal pancreatectomy (DP). This study was designed to investigate the incidence and risk factors of POI after DP, and its impact on the length of hospital stay.

METHODS

The prospectively collected data of patients who received DP were retrospectively reviewed. A diet protocol after DP was followed, and POI after DP was defined as the oral intake being less than 50% of the daily requirement and parenteral calorie supply being required on postoperative day 7.

RESULTS

Of the 157 patients, 21.7% (34) experienced POI after DP. The multivariate analysis revealed that the remnant pancreatic margin (head; hazard ratio, 7.837; 95% confidence interval, 2.111-29.087; P = 0.002) and postoperative hyperglycemia >200 mg/dL (hazard ratio, 5.643; 95% confidence interval, 1.482-21.494; P = 0.011) were independent risk factors for POI after DP. The length of hospital stay (median [range]) of the POI group was significantly longer than that of the normal diet group (17 [9-44] vs 10 [5-44] days; P < 0.001).

CONCLUSIONS

Patients undergoing pancreatic resection at pancreatic head portion should follow a postoperative diet, and postoperative glucose levels should be strictly regulated.

Preoperative serum CA19-9 predicts postoperative pancreatic fistula in PDAC patients: retrospective analysis at a single institution

Background

Postoperative pancreatic fistula (POPF) is a critical complication of pancreatectomy in patients with pancreatic ductal adenocarcinoma (PDAC). Recent papers reported that serum carbohydrate antigen (CA)19-9 levels predicted long-term prognosis. We investigated whether preoperative serum CA19-9 levels were associated with POPF in PDAC patients.

Methods

This cohort study was conducted at a single institution retrospectively. Clinicopathologic features were determined using medical records.

Results

Among of 196 consecutive patients who underwent pancreatectomy against PDAC, 180 patients whose CA19-9 levels were above the measurement sensitivity, were registered in this study. The patients consisted of 122 patients who underwent pancreaticoduodenectomy and 58 patients who underwent distal pancreatectomy. Several clinicopathological factors, including CA 19-9 level, as well as surgical factors were determined retrospectively based on the medical records. Patients with high CA19-9 levels had a significantly higher incidence of POPF than those with low levels (43.9 vs. 13.0%, P < 0.0001). The receiver operating characteristic curves calculated that the cutoff CA19-9 value to predict POPF was 428 U/mL. CA19-9, BMI, curability, and histology were statistically significant risk factors for POPF by univariate analysis. Multivariate analysis showed that CA19-9 and BMI levels were statistically significant independent risk factors for POPF. CA19-9 levels were correlated with both histology and curability. Disease free survival and overall survival of patients with higher levels of CA19-9 were significantly shorter than that of patients with lower levels of preoperative serum CA19-9.

Conclusions

In patients undergoing pancreatectomy for PDAC, higher preoperative CA19-9 levels are a significant predictor for POPF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01825-3.

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

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.

The effect of minimally invasive or open radical antegrade modular pancreatosplenectomy on pancreatic cancer: A multicenter randomized clinical trial protocol

Background

Radical antegrade modular pancreatosplenectomy (RAMPS) has been proven to improve R0 resection and lymph harvest in treating patients with distal pancreatic cancer. The development of minimally invasive surgery has advantages in postoperative recovery. Therefore, minimally invasive (MI-) RAMPS may combine the advantages of both benefits to improve survival. Nevertheless, evidence to validate the safety and efficacy of MI-RAMPS is limited.

Method/Design

The MIRROR trial will be the first multicenter prospective randomized clinical trial to investigate the outcome of MI-RAMPS. The hypothesis is that MI-RAMPS is superior in postoperative recovery. The primary outcome is the length of postoperative stay. Based on the hypothesis and primary outcome, the sample size is 250 patients (125 participants in each group). The trial will investigate factors related to surgical safety, short-term outcome, pathological assessment, and survival as secondary outcomes.

Conclusion

This study will offer a relatively higher level of evidence to further illustrate the accessibility and benefits of MI-RAMPS for the treatment of distal pancreatic cancer.

Clinical Trial Registration

Clinicaltrials.gov, NCT03770559.

Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma

Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.

The short-term outcomes of distal pancreatectomy with portal vein/superior mesenteric vein resection

BACKGROUND

Portal vein/superior mesenteric vein (PV/SMV) resection during distal pancreatectomy (DP) is often associated with technical difficulties due to the close anatomic relationship between pancreatic head and PV/SMV. In this paper, we present our operative technique and short-term outcomes of DP combined with venous resection (DP-VR) for left-sided pancreatic cancer (PC).

METHODS

We reviewed 368 consecutive cases of DP for PC from January 2013 to December 2018 in our institution, and identified 41 patients (11.1%) who had undergone DP-VR. The remaining 327 DP patients (88.9%) were matched to DP-VR using propensity scores in the proportion of 1:2. Demographics, intraoperative details, postoperative complications and the pathological results were compared between the two groups.

RESULTS

Out of the 41 DP-VR cases, in 14 (34.1%) venous resection with primary closure was performed, while the remaining 27 (65.9%) underwent end-to-end anastomosis without graft. A propensity-score-matched analysis revealed that DP-VR caused an increased risk of postoperative bleeding (17.1% vs. 3.7%, P = 0.016) and delayed gastric emptying (9.8% vs. 1.2%, P = 0.042) compared to standard DP. Overall morbidity (46.3% vs. 36.6%, P = 0.332), postoperative pancreatic fistula (31.7% vs. 26.8%, P = 0.672), R0 resection (58.5% vs. 67.1%, P = 0.223), 30-day reoperation (2.4% vs. 3.7%, P = 0.719), and 90-day mortality (0% vs. 2.5%, P = 0.550) were comparable between the two groups. In postoperative computed tomographic scans of 34 patients (82.9%) at a 90-day follow-up, PV/SMV stenosis was suggested in two patients (5.9%).

CONCLUSION

Despite the higher rates of postoperative bleeding, DP-VR was found to be a feasible and safe surgery with acceptable postoperative morbidity and mortality compared to standard DP for left-sided pancreatic cancer.

Laparoscopic versus open distal pancreatectomy with or without splenectomy: A propensity score analysis in Japan

BACKGROUND

Although the laparoscopic approach has been applied to distal pancreatectomy, its benefits with regard to the short-term outcomes of distal pancreatectomy remain unclear.

MATERIALS AND METHODS

Using a Japanese nationwide inpatient database, we identified patients who underwent laparoscopic (n = 6647) and open (n = 21,843) distal pancreatectomy between July 2012 and March 2020. We conducted a 1:2 propensity score-matched analysis with adjustment for background characteristics (e.g., comorbidities, preoperative diagnosis, and hospital background) to compare in-hospital morbidity and mortality, reoperation requirement, duration of anesthesia and drainage, postoperative length of stay, and total hospitalization costs. For sensitivity analyses, we performed overlap propensity score-weighted analysis, instrumental variable analysis, and subgroup analyses for hospital volume, patients with benign tumors, and those with malignant tumors that required splenectomy.

RESULTS

In-hospital morbidity and mortality were 27% and 0.7%, respectively. The 1:2 propensity score-matched analysis showed that compared to open surgery, laparoscopic surgery was significantly associated with lower in-hospital morbidity (odds ratio [95% confidence interval]: 0.78 [0.73 to 0.84]) and mortality (0.26 [0.14 to 0.50]), lower occurrence of postoperative pancreatic fistula (0.78 [0.72 to 0.85]), postoperative bleeding (0.59 [0.51 to 0.69]), and reoperation (0.65 [0.58 to 0.75]), longer duration of anesthesia (difference, 59 [56 to 63] minutes), shorter duration of drainage (difference, -4.0 [-4.5 to -3.6] days) and postoperative length of stay (difference, -4.4 [-4.9 to -3.9] days), and lower total hospitalization costs (difference, -1510 [-1776 to -1243] US dollars). The sensitivity analyses showed compatible results with those from the main analysis.

CONCLUSION

In this large nationwide cohort, laparoscopic distal pancreatectomy showed lower in-hospital morbidity, mortality, and total hospitalization costs than open distal pancreatectomy. Laparoscopic distal pancreatectomy may be a favorable procedure in terms of both complications and costs.

Endoscopic ultrasonography as additional preoperative workup is valuable in half of the patients with a pancreatic body or tail lesion

BACKGROUND

The management of pancreatic body and tail lesions is underexposed. It remains unclear whether endoscopic ultrasonography (EUS) increases the accuracy of the preoperative workup. This study assessed the diagnostic value and safety of EUS in addition to cross-sectional imaging in a surgical cohort of patients with pancreatic body or tail lesions.

METHODS

A multicenter retrospective cohort study was performed of patients who underwent distal pancreatectomy from 2010 to 2017. The composite primary outcome was the additional value of EUS, defined as: (a) EUS confirmed an uncertain diagnosis on cross-sectional imaging, (b) EUS was correct in case of discrepancy with cross-sectional imaging, or (c) EUS provided tissue diagnosis for neoadjuvant treatment. Furthermore, serious adverse events and needle tract seeding were assessed.

RESULTS

In total, 181 patients were included, of whom 123 (68%) underwent EUS besides cross-sectional imaging. Postoperative pathology was heterogeneous: 91 was malignant, 49 premalignant, 41 benign. Most lesions were solid (n = 117). EUS had additional value in 59/123 (48%) patients; 27/50 (54%) of cystic and 32/73 (44%) of solid lesions. No serious adverse event or needle tract seeding following EUS occurred.

CONCLUSION

EUS had additional value besides cross-sectional imaging in half of the patients and showed low associated risks.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos)

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear.

PATIENTS AND METHODS

Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups.

RESULTS

The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification.

CONCLUSIONS

The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.

Pancreatic ductal adenocarcinoma and invasive intraductal papillary mucinous tumor: Different prognostic factors for different overall survival

BACKGROUND

It is unclear whether invasive intraductal papillary mucinous neoplasm (IPMN) has different clinical and prognostic characteristics, beyond histological factors, when compared to pancreatic ductal adenocarcinoma (PDAC).

AIMS

compare prognostic features of resected PDAC and invasive IPMN METHODS: A retrospective study of patients resected for PDAC or invasive IPMN realized at Humanitas Cancer Center's Pancreatic Surgery Unit, Milan, Italy, between 2010 and 2016. Data recorded included patient demographics, onset symptoms, preoperative health status, tumor features, histology and surgical characteristics. Overall survival was estimated using Kaplan-Meier and prognostic factors for survival were assessed by multivariate Cox regression.

RESULTS

A total of 332 patients were included (PDAC, n = 289; invasive IPMN, n = 43). Patients with invasive IPMN had better overall survival than PDAC patients (median: 76.6 versus 25.6 months; 5-year OS rate: 65.4% vs. 14.2%; p < 0.001). PDAC histology was associated with a significantly higher risk of death than IPMN (hazard ratio 1.815, 95% CI: 1.02, 3.24; p = 0.044). Survival was also worse with PDAC in early-stage disease (IA-IB-IIA, N0). In multivariate analysis, independent predictors of worse survival included perineural invasion, preoperative ASA physical status ≥3 and pain at diagnosis.

CONCLUSIONS

Patients with IPMN had a better prognosis than PDAC patients, regardless of disease stage.