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Lee SW, Kim KS, Kim SH, Sim JY. Predicting Delayed Postoperative Length of Stay Following Robotic Kidney Transplantation: Development and Simulation of Perioperative Risk Factors. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1255. [PMID: 39202536 PMCID: PMC11356542 DOI: 10.3390/medicina60081255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 09/03/2024]
Abstract
Background and Objective: Early discharge following robot-assisted kidney transplantation (RAKT) is a cost-effective strategy for reducing healthcare expenses while maintaining favorable short- and long-term prognoses. This study aims to identify predictors of postoperative delayed discharge in RAKT patients and develop a predictive model to enhance clinical outcomes. Materials and Methods: This retrospective study included 146 patients aged 18 years and older who underwent RAKT at a single tertiary medical center from August 2020 to January 2024. Data were collected on demographics, comorbidities, social and medical histories, preoperative labs, surgical information, intraoperative data, and postoperative outcomes. The primary outcome was delayed postoperative discharge (length of hospital stay > 7 days). Risk factors for delayed discharge were identified through univariate and multivariate regression analyses, leading to the development of a risk scoring system, the effectiveness of which was evaluated through receiver operating characteristic curve analysis. Results: 110 patients (74.8%) were discharged within 7 days post-transplant, while 36 (24.7%) remained hospitalized for 8 days or longer. Univariate and multivariate logistic regression analyses identified ABO incompatibility, BUN levels, anesthesia time, and vasodilator use as risk factors for delayed discharge. The RAKT score, incorporating these factors, demonstrated a predictive performance with a C-statistic of 0.789. Conclusions: This study identified risk factors for delayed discharge after RAKT and developed a promising risk scoring system for real-world clinical application, potentially improving postoperative outcome stratification in RAKT recipients.
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Affiliation(s)
| | | | | | - Ji-Yeon Sim
- Brain Korea 21 Project, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (S.-W.L.); (K.-S.K.); (S.-H.K.)
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2
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Moris D, Zani S. The role of ERAS in robotic pancreaticoduodenectomy. Lancet Gastroenterol Hepatol 2024; 9:594-595. [PMID: 38870968 DOI: 10.1016/s2468-1253(24)00090-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Liu Q, Liu R. The role of ERAS in robotic pancreaticoduodenectomy - Authors' reply. Lancet Gastroenterol Hepatol 2024; 9:595-596. [PMID: 38870970 DOI: 10.1016/s2468-1253(24)00160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Qu Liu
- Faculty of Hepatopancreatobiliary Surgery, First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China; Department of Organ Transplantation, Third Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, First Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100853, China.
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Chen M, Yang J, Hou H, Zheng B, Xia S, Wang Y, Yu J, Wu G, Sun H, Jia X, Ning H, Chang H, Zhang X, Yuan Y, Wang Z. Analysis of factors influencing hospitalization cost of patients with distal radius fractures: an empirical study based on public traditional Chinese medicine hospitals in two cities, China. BMC Health Serv Res 2024; 24:605. [PMID: 38720277 PMCID: PMC11080218 DOI: 10.1186/s12913-024-10953-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/04/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Distal radius fractures (DRFs) have become a public health problem for all countries, bringing a heavier economic burden of disease globally, with China's disease economic burden being even more acute due to the trend of an aging population. This study aimed to explore the influencing factors of hospitalization cost of patients with DRFs in traditional Chinese medicine (TCMa) hospitals to provide a scientific basis for controlling hospitalization cost. METHODS With 1306 cases of DRFs patients hospitalized in 15 public TCMa hospitals in two cities of Gansu Province in China from January 2017 to 2022 as the study object, the influencing factors of hospitalization cost were studied in depth gradually through univariate analysis, multiple linear regression, and path model. RESULTS Hospitalization cost of patients with DRFs is mainly affected by the length of stay, surgery and operation, hospital levels, payment methods of medical insurance, use of TCMa preparations, complications and comorbidities, and clinical pathways. The length of stay is the most critical factor influencing the hospitalization cost, and the longer the length of stay, the higher the hospitalization cost. CONCLUSIONS TCMa hospitals should actively take advantage of TCMb diagnostic modalities and therapeutic methods to ensure the efficacy of treatment and effectively reduce the length of stay at the same time, to lower hospitalization cost. It is also necessary to further deepen the reform of the medical insurance payment methods and strengthen the construction of the hierarchical diagnosis and treatment system, to make the patients receive reasonable reimbursement for medical expenses, thus effectively alleviating the economic burden of the disease in the patients with DRFs.
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Affiliation(s)
- Mengen Chen
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 102400, China
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Jingyu Yang
- School of Health Management, Gansu University of Chinese Medicine, Lanzhou, 730000, China
- School of Public Health, Lanzhou University, Lanzhou, 730000, China
| | - Haojia Hou
- School of Public Health, Gansu University of Chinese Medicine, Lanzhou, 730000, China
| | - Baozhu Zheng
- School of Stomatology, Capital Medical University, Beijing, 100050, China
| | - Shiji Xia
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Yuhan Wang
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Jing Yu
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Guoping Wu
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Henong Sun
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Xuan Jia
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Hao Ning
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Hui Chang
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Xiaoxi Zhang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 102400, China
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
- Guang'anmen Hospital, China Academy of Chinese Medicine Sciences, Beijing, 100053, China
| | - Youshu Yuan
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 102400, China
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Zhiwei Wang
- School of Management, Beijing University of Chinese Medicine, Beijing, 102400, China.
- National Institute of Chinese Medicine Development and Strategy, Beijing, 102400, China.
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Khachfe HH, Hammad AY, AlMasri S, Nassour I, ElAsmar R, Liu H, de Silva A, Kraftician J, Lee KK, Zureikat AH, Paniccia A. Postoperative infectious complications worsen oncologic outcomes following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. J Surg Oncol 2024; 129:1097-1105. [PMID: 38316936 DOI: 10.1002/jso.27595] [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: 07/29/2023] [Revised: 12/18/2023] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) remains the only curative option for patients with pancreatic adenocarcinoma (PDAC). Infectious complications (IC) can negatively impact patient outcomes and delay adjuvant therapy in most patients. This study aims to determine IC effect on overall survival (OS) following PD for PDAC. STUDY DESIGN Patients who underwent PD for PDAC between 2010 and 2020 were identified from a single institutional database. Patients were categorized into two groups based on whether they experienced IC or not. The relationship between postoperative IC and OS was investigated using Kaplan-Meier and Cox-regression multivariate analysis. RESULTS Among 655 patients who underwent PD for PDAC, 197 (30%) experienced a postoperative IC. Superficial wound infection was the most common type of infectious complication (n = 125, 63.4%). Patients with IC had significantly more minor complications (Clavien-Dindo [CD] < 3; [59.4% vs. 40.2%, p < 0.001]), major complications (CD ≥ 3; [37.6% vs. 18.8%, p < 0.001]), prolonged LOS (47.2% vs 20.3%, p < 0.001), biochemical leak (6.1% vs. 2.8%, p = 0.046), postoperative bleeding (4.1% vs. 1.3%, p = 0.026) and reoperation (9.6% vs. 2.2%, p < 0.001). Time to adjuvant chemotherapy was delayed in patients with IC versus those without (10 vs. 8 weeks, p < 0.001). Median OS for patients who experienced no complication, noninfectious complication, and infectious complication was 33.3 months, 29.06 months, and 27.58 months respectively (p = 0.023). On multivariate analysis, postoperative IC were an independent predictor of worse OS (HR 1.32, p = 0.049). CONCLUSIONS IC following PD for PDAC independently predict worse oncologic outcomes. Thus, efforts to prevent and manage IC should be a priority in the care of patients undergoing PD for PDAC.
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Affiliation(s)
- Hussein H Khachfe
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abdulrahman Y Hammad
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samer AlMasri
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Nassour
- Department of Surgery, Division of Surgical Oncology, University of Florida, Gainesville, Florida, USA
| | - Rudy ElAsmar
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hao Liu
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Annissa de Silva
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jasmine Kraftician
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kenneth K Lee
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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6
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Bannone E, Marchegiani G. Robotic pancreatoduodenectomy: preparing for the future. Lancet Gastroenterol Hepatol 2024; 9:395-397. [PMID: 38428440 DOI: 10.1016/s2468-1253(24)00036-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/03/2024]
Affiliation(s)
- Elisa Bannone
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia 25124, Italy.
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
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DeLaura I, Sharib J, Creasy JM, Berchuck SI, Blazer DG, Lidsky ME, Shah KN, Zani S. Defining the learning curve for robotic pancreaticoduodenectomy for a single surgeon following experience with laparoscopic pancreaticoduodenectomy. J Robot Surg 2024; 18:126. [PMID: 38492057 DOI: 10.1007/s11701-023-01746-0] [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: 09/21/2023] [Accepted: 12/02/2023] [Indexed: 03/18/2024]
Abstract
Robotic pancreaticoduodenectomy (RPD) has a learning curve of approximately 30-250 cases to reach proficiency. The learning curve for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study describes the RPD learning curve for a single surgeon following experience with LPD. LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and learning curve were defined with respect to operative time using CUSUM analysis. Seventeen LPD and 69 RPD were analyzed LPD had an inverted learning curve possibly accounting for proficiency attained during the surgeon's fellowship and acquisition of new skills coinciding with more complex patient selection. The learning curve for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 479 min, p < 0.005), less EBL (250 vs 500, p < 0.02), and similar R0 resection. RPD also had improved LOS (7 vs 10 days, p < 0.007), and lower rates of surgical site infection (10% vs 47%, p < 0.002), DGE (19% vs 47%, p < 0.03), and readmission (13% vs 41%, p < 0.02). Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between LPD and RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.
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Affiliation(s)
- Isabel DeLaura
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Jeremy Sharib
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - John M Creasy
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Samuel I Berchuck
- Department of Statistical Science, Duke University, Durham, NC, 27710, USA
| | - Dan G Blazer
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Kevin N Shah
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Sabino Zani
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA.
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Seldomridge AN, Rasic G, Papageorge MV, Ng SC, de Geus SWL, Woods AP, McAneny D, Tseng JF, Sachs TE. Trends in access to minimally invasive pancreaticoduodenectomy for pancreatic cancers. HPB (Oxford) 2024; 26:333-343. [PMID: 38087704 DOI: 10.1016/j.hpb.2023.11.012] [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: 03/17/2023] [Revised: 09/26/2023] [Accepted: 11/17/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy (MIPD), including robotic (RPD) and laparoscopy (LPD), is becoming more frequently employed in the management of pancreatic ductal adenocarcinoma (PDAC), though the majority of operations are still performed via open approach (OPD). Access to technologic advances often neglect the underserved. Whether disparities in access to MIPD exist, remain unclear. METHODS The National Cancer Database (NCDB) was queried (2010-2020) for patients who underwent pancreatoduodenectomy for PDAC. Cochran-Armitage tests assessed for trends over time. Social determinants of health (SDH) were compared between approaches. Multinomial logistic models identified predictors of MIPD. RESULTS Of 16,468 patients, 80.03 % underwent OPD and 19.97 % underwent MIPD (22.60 % robotic; 77.40 % laparoscopic). Black race negatively predicted LPD (vs white (OR 0.822; 95 % CI 0.701-0.964)). Predictors of RPD included Medicare/other government insurance (vs uninsured or Medicaid (OR 1.660; 95 % CI 1.123-2.454)) and private insurance (vs uninsured or Medicaid (OR 1.597; 95 % CI 1.090-2.340)). Early (2010-2014) vs late (2015-2020) diagnosis, stratified by race, demonstrated an increase in Non-White patients undergoing OPD (13.15 % vs 14.63 %; p = 0.016), but not LPD (11.41 % vs 13.57 %;p = 0.125) or RPD (14.15 % vs 15.23 %; p = 0.774). CONCLUSION SDH predict surgical approach more than clinical stage, facility type, or comorbidity status. Disparities in race and insurance coverage are different between surgical approaches.
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Affiliation(s)
- Ashlee N Seldomridge
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA
| | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA
| | - Marianna V Papageorge
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA
| | - Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA
| | - Alison P Woods
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - David McAneny
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 85 East Concord Street, Boston, MA 02118, USA.
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Heckman JT, Martinez AE, Keim RL, Mazzaferro SE, Mir KS, Gorman MA, Shah US. Implementation of robotic pancreaticoduodenectomy at a community tertiary care hospital utilizing a comprehensive curriculum. Am J Surg 2024; 228:83-87. [PMID: 37620215 DOI: 10.1016/j.amjsurg.2023.08.013] [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: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We evaluated the outcomes of a robotic pancreaticoduodenectomy (RPD) program implemented at a community tertiary care hospital. METHODS A retrospective review of 65 RPD cases compared surgical outcomes and performance to benchmark data. RESULTS Postoperative complications occurred in 31% (20) of patients vs. ≤73% (variance -42), with grade IV complications in 3% (2) vs. ≤5% (variance -2). Postoperative pancreatic fistula type B frequency was 12% (8) vs. ≤15% (variance -3). One 90-day mortality occurred (1.5% vs. 1.6%). Failure to rescue rate was 7% vs. ≤9% (variance -2), and R1 resection rate was 2% vs. ≤39% (variance -37). There was a downward trend of operative time (rho = -0.600, P < 0.001), with a learning curve of 27 cases. Median hospital length of stay was 6 days vs. ≤15 days (variance -9). CONCLUSION Our comprehensive RPD training program resulted in improved operative performance and outcomes commensurate with benchmark thresholds.
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Affiliation(s)
- Jason T Heckman
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Ashley E Martinez
- Albany Medical College, 43 New Scotland Ave, Albany, NY, 12208, United States.
| | - Rebecca L Keim
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Sarah E Mazzaferro
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Kristin S Mir
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Michael A Gorman
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
| | - Ujas S Shah
- Department of Hepatobiliary, Pancreatic, and General Surgery, St. Peter's Health Partners, 319 S Manning Blvd, Ste 304, Albany, NY, 12208, United States
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10
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Cao H, Qiu J, Hu Y, Huang W, Liu X, Jin H. Anesthesia management experience for pediatric day-case PDA ligation under thoracoscopy assisted by a robot: a retrospective study. J Cardiothorac Surg 2023; 18:360. [PMID: 38115087 PMCID: PMC10729443 DOI: 10.1186/s13019-023-02471-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND To summarize the anesthesia management experience for pediatric day-case patent ductus arteriosus (PDA) ligation under robot-assisted thoracoscopy and explore the key points of anesthesia management for this procedure. METHODS The clinical data of 72 pediatric patients who underwent robot-assisted thoracoscopic day-case PDA ligation at the Children's Hospital, Zhejiang University School of Medicine from April 2021 to February 2023 were retrospectively analyzed. 0.3% ropivacaine local infiltration combined with S-ketamine 0.2 mg/kg intravenous injection was used for postoperative analgesia The patient's basic information and intraoperative conditions were analyzed, which included gender, age, weight, surgery time, anesthesia time, extubation time, intraoperative blood loss, MAP before pneumothorax, PaCO2 before pneumothorax, etc. Postoperative conditions were also monitored, such as PACU stay time, agitation during the recovery period, pain, and the incidence of nausea and vomiting. After discharge, the recovery status was assessed. RESULTS A total of 70 pediatric patients who met the criteria for day-case PDA ligation were included in this study. Before the occurrence of pneumothorax, the mean arterial pressure (MAP) of these 70 patients was 69.58 ± 12.52 mmHg, and during controlled hypotension, the MAP was 54.96 ± 11.23 mmHg. Before the occurrence of pneumothorax, the partial pressure of carbon dioxide (PaCO2) was 38.69 ± 3.38 mmHg, and during controlled hypotension, the PaCO2 was 51.42 ± 4.05 mmHg. Three cases experienced agitation during the recovery period, and four cases had mild pain, but there was no moderate or severe pain, nausea, or vomiting. Only 1 case of postoperative respiratory tract infection and 1 case of postoperative pneumothorax occurred. Within 30 days after discharge, the unplanned revisit rate, unplanned readmission rate, and surgical wound infection rate were all 0. The residual shunt rate detected by echocardiography was 0 after 1 month. CONCLUSIONS The children under the robot-assisted thoracoscopic day case PDA surgeries in this study have limited trauma, little bleeding, and little postoperative pain, though still at a risk of respiratory infection and pneumothorax.
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Affiliation(s)
- Huixia Cao
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Jinpeng Qiu
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Yaoqin Hu
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Wenfang Huang
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xiwang Liu
- Department of Cardiac Surgery, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Haiyan Jin
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.
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11
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Hogg ME. Next-Generation Opioid Scripts-Postpancreatectomy ERAS. JAMA Surg 2023; 158:e234161. [PMID: 37672262 DOI: 10.1001/jamasurg.2023.4161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
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12
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Park JY, Mirzaie S, Premji A, Seo Y, Mederos M, Hines J, Donahue T, Tomlinson J, King J, Girgis M. Learning Curves in Establishing a New Minimally Invasive Pancreas Program. Am Surg 2023; 89:4166-4170. [PMID: 37279455 DOI: 10.1177/00031348231177926] [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: 06/08/2023]
Abstract
INTRODUCTION Robotic pancreaticoduodenectomy (rPD) is a complex operation with a reported learning curve of 80 cases. Two recent graduates of a formal robotic complex general surgical oncology training program have been performing rPD at our institution since 2016, which had no previous institutional experience with rPD. OBJECTIVE To evaluate the learning curve associated with developing a new robotic pancreaticoduodenectomy (rPD) program by fellowship trained surgeons with institutional support. METHODS Sixty patients undergoing rPD from 2016 to 2022 were reviewed for and compared with proficiency benchmarks set by the University of Pittsburg experience. RESULTS By 30 cases, operative time met the proficiency benchmark of 391 minutes. Additionally, the entire cohort had comparable rates of clinically relevant postoperative pancreatic fistula (6.7% vs 3%, P = .6), 30-day mortality (0% vs 3%, P = .18), major complications (Clavien >2; 23% vs 17%, P = .14), and length of stay (6 vs 7 days, P = .49) when compared to the benchmark. CONCLUSION Perioperative outcomes were comparable to proficiency benchmarks from initiation of the new rPD program, and operative time reached proficiency benchmark by 30 cases. This data suggests that graduates of formal rPD training programs can safely establish new minimally invasive pancreas programs at sites with no previous institutional rPD experience.
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Affiliation(s)
- Joon Y Park
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sarah Mirzaie
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Aly Premji
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Youngji Seo
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Michael Mederos
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Joe Hines
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Timothy Donahue
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - James Tomlinson
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jonathan King
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Mark Girgis
- Department of Surgery, David Geffen School of Medicine, Los Angeles, CA, USA
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Bakhtiyar SS, Sakowitz S, Verma A, Richardson S, Curry J, Chervu NL, Blumberg J, Benharash P. Postoperative length of stay following kidney transplantation in patients without delayed graft function-An analysis of center-level variation and patient outcomes. Clin Transplant 2023; 37:e15000. [PMID: 37126410 DOI: 10.1111/ctr.15000] [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] [Received: 02/25/2023] [Revised: 04/04/2023] [Accepted: 04/13/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Early discharge after surgical procedures has been proposed as a novel strategy to reduce healthcare expenditures. However, national analyses of the association between discharge timing and post-transplant outcomes following kidney transplantation are lacking. METHODS This was a retrospective cohort study of all adult kidney transplant recipients without delayed graft function from 2014 to 2019 in the Organ Procurement and Transplantation Network and Nationwide Readmissions Databases. Recipients were divided into Early (LOS ≤ 4 days), Routine (LOS 5-7), and Delayed (LOS > 7) cohorts. RESULTS Of 61 798 kidney transplant recipients, 26 821 (43%) were discharged Early and 23 279 (38%) Routine. Compared to Routine, patients discharged Early were younger (52 [41-61] vs. 54 [43-62] years, p < .001), less commonly Black (33% vs. 34%, p < .001), and more frequently had private insurance (41% vs. 35%, p < .001). After adjustment, Early discharge was not associated with inferior 1-year patient survival (Hazard Ratio [HR] .74, 95% Confidence Interval [CI] 0.66-0.84) or increased likelihood of nonelective readmission at 90-days (HR .93, CI .89-.97), relative to Routine discharge. Discharging all Routine patients as Early would result in an estimated cost saving of ∼$40 million per year. Multi-level modeling of post-transplantation LOS revealed that 28.8% of the variation in LOS was attributable to interhospital differences rather than patient factors. CONCLUSIONS Early discharge after kidney transplantation appears to be cost-efficient and not associated with inferior post-transplant survival or increased readmission at 90 days. Future work should elucidate the benefits of early discharge and develop standardized enhanced recovery protocols to be implemented across transplant centers.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
- Department of Surgery, University of Colorado Anschutz Medical, Center, Denver, Colorado, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Shannon Richardson
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Jeremy Blumberg
- Division of Urology, Department of Surgery, University of California, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California, USA
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14
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Noba L, Rodgers S, Doi L, Chandler C, Hariharan D, Yip V. Costs and clinical benefits of enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy: an updated systematic review and meta-analysis. J Cancer Res Clin Oncol 2023; 149:6639-6660. [PMID: 36629919 PMCID: PMC10356629 DOI: 10.1007/s00432-022-04508-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/30/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However, evidence on cost benefit of ERAS in pancreaticoduodenectomy remains scarce. This review aimed to investigate cost benefit, compliance, and clinical benefits of ERAS in pancreaticoduodenectomy. METHODS A comprehensive literature search was conducted on Medline, Embase, PubMed, CINAHL and the Cochrane library to identify studies conducted between 2000 and 2021, comparing effect of ERAS programmes and traditional care on hospital cost, length of stay (LOS), complications, delayed gastric emptying (DGE), readmission, reoperation, mortality, and compliance. RESULTS The search yielded 3 RCTs and 28 cohort studies. Hospital costs were significantly reduced in the ERAS group (SMD = - 1.41; CL, - 2.05 to - 0.77; P < 0.00001). LOS was shortened by 3.15 days (MD = - 3.15; CI, - 3.94 to - 2.36; P < 0.00001) in the ERAS group. Fewer patients in the ERAS group had complications (RR = 0.83; CI, 0.76-0.91; P < 0.0001). Incidences of DGE significantly decreased in the ERAS group (RR = 0.72; CI, 0.55-0.94; P = 0.01). The number of deaths was fewer in the ERAS group (RR = 0.76; CI, 0.58-1.00; P = 0.05). CONCLUSION This review demonstrated that ERAS is safe and feasible in pancreaticoduodenectomy, improves clinical outcome such as LOS, complications, DGE and mortality rates, without changing readmissions and reoperations, while delivering significant cost savings. Higher compliance is associated with better clinical outcomes, especially LOS and complications.
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Affiliation(s)
- Lyrics Noba
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK.
| | - Sheila Rodgers
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK
| | - Lawrence Doi
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK
| | - Colin Chandler
- School of Health in Social Science, University of Edinburgh, 24 Buccleuch Place, Edinburgh, EH8 8LN, UK
| | - Deepak Hariharan
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR, UK
| | - Vincent Yip
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR, UK
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15
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Xie F, Wang D, Ge J, Liao W, Li E, Wu L, Lei J. Robotic approach together with an enhanced recovery programme improve the perioperative outcomes for complex hepatectomy. Front Surg 2023; 10:1135505. [PMID: 37334205 PMCID: PMC10272522 DOI: 10.3389/fsurg.2023.1135505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 05/04/2023] [Indexed: 06/20/2023] Open
Abstract
Objective Robotic surgery has more advantages than traditional surgical approaches to complex liver resection; however, the robotic approach is invariably associated with increased cost. Enhanced recovery after surgery (ERAS) protocols are beneficial in conventional surgeries. Methods The present study investigated the effects of robotic surgery combined with an ERAS protocol on perioperative outcomes and hospitalization costs of patients undergoing complex hepatectomy. Clinical data from consecutive robotic and open liver resections (RLR and OLR, respectively) performed in our unit in the pre-ERAS (January 2019-June 2020) and ERAS (July 2020-December 2021) periods were collected. Multivariate logistic regression analysis was performed to determine the impact of ERAS and surgical approaches-alone or in combination-on LOS and costs. Results A total of 171 consecutive complex liver resections were analyzed. ERAS patients had a shorter median LOS and decreased total hospitalization cost, without a significant difference in the complication rate compared with the pre-ERAS cohort. RLR patients had a shorter median LOS and decreased major complications, but with increased total hospitalization cost, compared with OLR patients. Comparing the four combinations of perioperative management and surgical approaches, ERAS + RLR had the shortest LOS and the fewest major complications, whereas pre-ERAS + RLR had the highest hospitalization costs. Multivariate analysis found that the robotic approach was protective against prolonged LOS, whereas the ERAS pathway was protective against high costs. Conclusions The ERAS + RLR approach optimized postoperative complex liver resection outcomes and hospitalization costs compared with other combinations. The robotic approach combined with ERAS synergistically optimized outcome and overall cost compared with other strategies, and may be the best combination for optimizing perioperative outcomes for complex RLR.
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Affiliation(s)
- Fei Xie
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dongdong Wang
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jin Ge
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenjun Liao
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Enliang Li
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linquan Wu
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Province Engineering Research Center of Hepatobiliary Disease, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Lei
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Province Engineering Research Center of Hepatobiliary Disease, Second Affiliated Hospital of Nanchang University, Nanchang, China
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16
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Mungo B, Hammad A, AlMasri S, Dogeas E, Nassour I, Singhi AD, Zeh HJ, Hogg ME, Lee KKW, Zureikat AH, Paniccia A. Pancreaticoduodenectomy for benign and premalignant pancreatic and ampullary disease: is robotic surgery the better approach? Surg Endosc 2023; 37:1157-1165. [PMID: 36138252 PMCID: PMC11189669 DOI: 10.1007/s00464-022-09632-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The robotic platform is increasingly being utilized in pancreatic surgery, yet its overall merits and putative advantages remain to be adjudicated. We hypothesize that the benefits of minimally invasive pancreatic surgery are maximized in pancreatic benign and premalignant disease, in the setting of friable pancreatic tissue and small pancreatic duct. METHODS Retrospective analysis of our prospectively maintained pancreatic database of all consecutive patients who underwent pancreaticoduodenectomy (PD) for benign or premalignant conditions between 2010 and 2020. Peri-operative outcomes and long-term complications were compared between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD). RESULTS One hundred and eighty eight (n = 188) patients met our inclusion criteria, of which 68 were OPD and 120 RPD. Malignant histologies were excluded. There were only minor differences in baseline characteristics between the two groups. Post-operative merits of the RPD included lower clinically relevant post-operative pancreatic fistula 10 (8.3%) vs 24 (35.3%), p < 0.001, fewer surgical site infections; 9 (7.5%) vs 11 (16.2%), p = 0.024, shorter operative time, greater lymph node yield; 29 (IQR 21, 38) vs 21 (IQR 13, 34), p = 0.001, and lower 90 days mortality; 1 (0.8%) vs 4 (5.9%), p = 0.039. Rates of long-term complications were similar, exception made for a higher occurrence of small bowel obstruction (SBO) 2 (1.7%) vs 4 (5.9%), p = 0.031 and need for surgical intervention for SBO 0 (0.0%) vs 2 (2.9%), p = 0.019 in the OPD group. CONCLUSION Our study suggests that RPD benefits include lower 90-day mortality, shorter LOS, and lower rates of selected complications compared to open pancreaticoduodenectomy.
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Affiliation(s)
- Benedetto Mungo
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Abdulrahman Hammad
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Samer AlMasri
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Epameinondas Dogeas
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Melissa E Hogg
- Department of Surgery, North Shore University, Chicago, IL, USA
| | - Kenneth K W Lee
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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17
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Castellanos CX, Paoletti M, Ulloa R, Kim C, Fong M, Xepoleas M, Sinha U, Kokot N, Swanson MS. Opioid Sparing Multimodal Analgesia for Transoral Robotic Surgery: Improved Analgesia and Narcotic Use Reduction. OTO Open 2023; 7:e17. [PMID: 36998552 PMCID: PMC10046737 DOI: 10.1002/oto2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/23/2022] [Indexed: 03/15/2023] Open
Abstract
Objective To compare postoperative pain scores and opioid consumption in patients after transoral robotic surgery (TORS). Study Design Single institution retrospective cohort study. Setting TORS was performed at a single academic tertiary care center. Methods This study compared traditional opioid-based and opioid-sparing multimodal analgesia (MMA) regimens in patients with oropharyngeal and supraglottic malignancy after TORS. Data were obtained from the electronic health records from August 2016 to December 2021. The average postoperative pain scores and total opioid consumption in morphine milligram equivalents were calculated for postoperative days (PODs) 0 to 3. The secondary objectives were to quantify and characterize opioid prescriptions upon hospital discharge. Results A total of 114 patients were identified for this study, 58 patients in the non-MMA cohort and 56 in the MMA cohort. Postoperative pain levels in the MMA cohort were statistically lower on POD 0 (p = 0.001), POD 1 (p = 0.001), and POD 3 (p = 0.004). Postoperative opioid consumption decreased significantly in the MMA cohort from 37.7 to 10.8 mg on POD 0 (p = 0.002), 65.9 to 19.9 mg on POD 1 (p < 0.001), 36.0 to 19.3 mg on POD 2 (p = 0.02), and 45.4 to 13.8 mg on POD 3 (p = 0.02). The number of patients discharged from the hospital with a prescription for narcotics was significantly lower in the MMA cohort (71.4%) compared with the non-MMA cohort (98.3%) (p < 0.001). Conclusion Implementation of our MMA pain protocol reduced pain levels and narcotic consumption in the immediate postoperative period.
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Affiliation(s)
- Carlos X. Castellanos
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Marcus Paoletti
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ruben Ulloa
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Celeste Kim
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Michelle Fong
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Meredith Xepoleas
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Uttam Sinha
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Niels Kokot
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mark S. Swanson
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
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18
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Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals. Ann Surg 2023; 277:101-108. [PMID: 33214486 DOI: 10.1097/sla.0000000000004642] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications. SUMMARY BACKGROUND DATA Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes. METHODS A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population). RESULTS A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02). CONCLUSIONS A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.
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Han S, Du S, Jander C, Kuppusamy M, Sternbach J, Low DE, Hubka M. The impact of an enhanced recovery after surgery pathway for video-assisted and robotic-assisted lobectomy on surgical outcomes and costs: a retrospective single-center cohort study. J Robot Surg 2022; 17:1039-1048. [PMID: 36515818 DOI: 10.1007/s11701-022-01487-6] [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: 06/26/2022] [Accepted: 10/29/2022] [Indexed: 12/15/2022]
Abstract
To determine the impact of enhanced recovery after surgery (ERAS) pathway implementation on outcomes and cost of robotic- and video-assisted thoracoscopic (RATS and VATS) lobectomy. Retrospective review of 116 consecutive VATS and RATS lobectomies in the pre-ERAS (Oct 2018-Sep 2019) and ERAS (Oct 2019-Sep 2020) period. Multivariate analysis was used to determine the impact of ERAS and operative approach alone, and in combination, on length of hospital stay (LOS) and overall cost. Operative approach was 49.1% VATS, 50.9% RATS, with 44.8% pre-ERAS, and 55.2% ERAS (median age 68, 65.5% female). ERAS patients had shorter LOS (2.22 vs 3.45 days) and decreased total cost ($15,022 vs $20,155) compared with non-ERAS patients, while RATS was associated with decreased LOS (2.16 vs 4.19 days) and decreased total cost ($14,729 vs $20,484) compared with VATS. The combination of ERAS + RATS showed the shortest LOS and the lowest total cost (1.35 days and $13,588, P < 0.001 vs other combinations). On multivariate analysis, ERAS significantly decreased LOS (P = 0.001) and total cost (P = 0.003) compared with pre-ERAS patients; RATS significantly decreased LOS (P < 0.001) and total cost (P = 0.004) compared with VATS approach. ERAS implementation and robotic approach were independently associated with LOS reduction and cost savings in patients undergoing minimally invasive lobectomy. A combination of ERAS and RATS approach synergistically decreases LOS and overall cost.
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Affiliation(s)
- Shiwei Han
- Department of General and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Simo Du
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christina Jander
- Department of General and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Madhan Kuppusamy
- Department of General and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Joel Sternbach
- Department of General and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Donald E Low
- Department of General and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA
| | - Michal Hubka
- Department of General and Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA, 98101, USA.
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20
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Xu S, Zhang XP, Zhao GD, Zou WB, Zhao ZM, Hu MG, Gao YX, Tan XL, Liu Q, Liu R. Robotic versus open pancreaticoduodenectomy for distal cholangiocarcinoma: a multicenter propensity score-matched study. Surg Endosc 2022; 36:8237-8248. [PMID: 35534733 DOI: 10.1007/s00464-022-09271-1] [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: 01/17/2022] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pancreatoduodenectomy is the only potentially curative treatment for distal cholangiocarcinoma (DCC). In this study, we sought to compare the perioperative and oncological outcomes of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) based on a multicenter propensity score-matched study. METHODS Consecutive patients with DCC who underwent RPD or OPD from five centers in China between January 2014 and June 2019 were included. A 1:1 propensity score matching (PSM) was performed. Univariable and multivariable Cox regression analyses were used to identify independent prognosis factors for overall survival (OS) and recurrence-free survival (RFS) of these patients. RESULTS A total of 217 patients and 228 patients underwent RPD and OPD, respectively. After PSM, 180 patients in each group were enrolled. There were no significant differences in operative time, lymph node harvest, intraoperative transfusion, vascular resection, R0 resection, postoperative major morbidity, reoperation, 90-day mortality, and long-term survival between the two groups before and after PSM. Whereas, compared with the OPD group, the RPD group had significantly lower estimated blood loss (150.0 ml vs. 250.0 ml; P < 0.001), and a shorter postoperative length of stay (LOS) (12.0 days vs. 15.0 days; P < 0.001). Multivariable analysis showed carbohydrate antigen 19-9 (CA19-9), R0 resection, N stage, perineural invasion, and tumor differentiation significantly associated with OS and RFS of these patients. CONCLUSIONS RPD was comparable to OPD in feasibility and safety. For patients with DCC, RPD resulted in similar oncologic and survival outcomes as OPD.
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Affiliation(s)
- Shuai Xu
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
- School of Medicine, Nankai University, Tianjin, China
| | - Xiu-Ping Zhang
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Guo-Dong Zhao
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Wen-Bo Zou
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhi-Ming Zhao
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Ming-Gen Hu
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yuan-Xing Gao
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Xiang-Long Tan
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Qu Liu
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Rong Liu
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China.
- School of Medicine, Nankai University, Tianjin, China.
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Hogan BJ, Pai SL, Planinsic R, Suh KS, Hillingso JG, Ghani SA, Fan KS, Spiro M, Raptis DA, Vohra V, Auzinger G. Does multimodal perioperative pain management enhance immediate and short-term outcomes after living donor partial hepatectomy? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14649. [PMID: 35297508 DOI: 10.1111/ctr.14649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal analgesic strategy for patients undergoing donor hepatectomy is not known and the potential short- and long-term physical and psychological consequences of complications are significant. OBJECTIVES To identify whether a multimodal approach to pain of the donor intraoperatively enhances immediate and short-term outcomes after living liver donation, and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO 2021 CRD42021260699. RESULTS Nine studies assessing multi-modal analgesia strategies were included in a qualitative assessment. Interventions included local, regional, and neuro-axial anesthetic techniques, pharmacological intervention (NSAIDs, COX-2 inhibitors, ketamine, dexmedetomidine, and lidocaine), and acupuncture. Overall, there was a significant (40%) reduction in opioid requirement on day 1 and a significant reduction in pain scores in the intervention vs control groups. Significant reductions in either length of stay or post-operative complications were demonstrated in four of nine studies. CONCLUSIONS Opioid use for patients undergoing donor hepatectomy is likely to impact both their short- and long-term outcomes. To reduce post-operative pain scores, shorten length of hospital stay, and promote earlier post-operative return of bowel function, we recommend that multi-modal analgesia be offered to patients undergoing living donor hepatectomy. Further research is required to confirm which multi-modal techniques are most associated with enhanced recovery in living liver donors.
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Affiliation(s)
- Brian J Hogan
- Institute of Liver Studies, King's College Hospital, London, UK.,Cleveland Clinic London, London, UK
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Florida, USA
| | - Raymond Planinsic
- Anaesthesiology & Perioperative Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jens G Hillingso
- Department of Surgery and Transplantation, Rigshospitalet University of Copenhagen, Copenhagen, Denmark
| | | | - Ka Siu Fan
- Royal County Surrey Hospital, Surrey, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Vijay Vohra
- Liver Transplant, GI Anaesthesia and Intensive Care, Medanta - The Medicity Hospital, South Delhi, Delhi, India
| | - Georg Auzinger
- Institute of Liver Studies, King's College Hospital, London, UK.,Cleveland Clinic London, London, UK
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22
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Jian C, Zhou Z, Guan S, Fang J, Chen J, Zhao N, Bao H, Li X, Cheng X, Zhu W, Yang C, Shu X. Can an incomplete ERAS protocol reduce postoperative complications compared with conventional care in laparoscopic radical resection of colorectal cancer? A multicenter observational cohort and propensity score-matched analysis. Front Surg 2022; 9:986010. [PMID: 36090330 PMCID: PMC9458933 DOI: 10.3389/fsurg.2022.986010] [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] [Received: 07/04/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background The patients undergoing laparoscopic radical colorectomy in many Chinese hospitals do not achieve high compliance with the ERAS (enhanced recovery programs after surgery) protocol. Methods The clinical data from 1,258 patients were collected and divided into the non-ERAS and incomplete ERAS groups. Results A total of 1,169 patients were screened for inclusion. After propensity score-matched analysis (PSM), 464 pairs of well-matched patients were generated for comparative study. Incomplete ERAS reduced the incidence of postoperative complications (p = 0.002), both mild (6.7% vs. 10.8%, p = 0.008) and severe (3.2% vs. 6.0%, p = 0.008). Statistically, incomplete ERAS reduced indirect surgical complications (27,5.8% vs. 59, 12.7) but not local complications (19,4.1% vs. 19, 4.1%). The subgroup analysis of postoperative complications revealed that all patients benefited from the incomplete ERAS protocol regardless of sex (male, p = 0.037, 11.9% vs. 17.9%; female, p = 0.010, 5.9% vs. 14.8%) or whether neoadjuvant chemotherapy was administered (neoadjuvant chemotherapy, p = 0.015, 7.4% vs. 24.5%; no neoadjuvant chemotherapy, p = 0.018, 10.2% vs. 15.8%). Younger patients (<60 year, p = 0.002, 7.6% vs. 17.5%) with a low BMI (<22.84, 9.4% vs. 21.1%, p < 0.001), smaller tumor size (<4.0 cm, 8.1% vs. 18.1%, p = 0.004), no fundamental diseases (8.8% vs. 17.0%, p = 0.007), a low ASA score (1/2, 9.7% vs. 16.3%, p = 0.004), proximal colon tumors (ascending/transverse colon, 12.2% vs. 24.3%, p = 0.027), poor (6.1% vs. 23.7%, p = 0.012)/moderate (10.3% vs. 15.3%, p = 0.034) tumor differentiation and no preoperative neoadjuvant radiotherapy (10.3% vs. 16.9%, p = 0.004) received more benefit from the incomplete ERAS protocol. Conclusion The incomplete ERAS protocol decreased the incidence of postoperative complications, especially among younger patients (<60 year) with a low BMI (<22.84), smaller tumor size (<4.0 cm), no fundamental diseases, low ASA score (1/2), proximal colon tumors (ascending/transverse colon), poor/moderate differentiation and no preoperative neoadjuvant radiotherapy. ERAS should be recommended to as many patients as possible, although some will not exhibit high compliance. In the future, the core elements of ERAS need to be identified to improve the protocol.
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Affiliation(s)
- Chenxing Jian
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Minimally Invasive Surgery, Affiliated Hospital of Putian University, Teaching Hospital of Fujian Medical University, Putian, China
| | - Zili Zhou
- Department of Gastrointestinal Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Shen Guan
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Jianying Fang
- Department of Minimally Invasive Surgery, Affiliated Hospital of Putian University, Teaching Hospital of Fujian Medical University, Putian, China
| | - Jinhuang Chen
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Zhao
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haijun Bao
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xianguo Li
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xukai Cheng
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhong Zhu
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunkang Yang
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Xiaogang Shu
- Department of Gastrointestinal Surgery and Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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23
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Mulchandani J, Shetty N, Kulkarni A, Shetty S, Sadat MS, Kudari A. Short-term and pathologic outcomes of robotic versus open pancreatoduodenectomy for periampullary and pancreatic head malignancy: an early experience. J Robot Surg 2022; 16:859-866. [PMID: 34546523 DOI: 10.1007/s11701-021-01309-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
Open pancreatoduodenectomy (OPD) is associated with high perioperative morbidity. Adoption of robot-assisted pancreatoduodenectomy (RAPD) has been slow despite ergonomic advantages, improved visualization and dexterity. We aim to report our experience comparing operative and short-term outcomes following RAPD and OPD. We did retrospective analysis of prospectively maintained database, including all consecutive patients who underwent RAPD or OPD between January 2016 and August 2019. 48 patients were included, 21 in RAPD group and 27 in OPD group. RAPD was associated with longer mean operative time (440 vs. 414.1 min) but had significantly less mean intra-operative blood loss (256.9 vs. 404.5 ml), median length of ICU stay (1 vs. 3 days), overall length of stay (11 vs. 13 days) and lower rates of SSI (23.8% vs. 63%). Both groups showed equal incidence of POPF, comparable R0 resection rates (100% vs. 96.3%) and median number of lymph nodes harvested (14 vs. 18). Rate of open conversion was 28.6% (n = 6), most commonly for bleeding (66.6%) and mesenteric vessel involvement (33.3%). When compared to first ten RAPD cases, mean operative time (483.5 vs. 400.5 min) and rate of conversion (36.36% vs. 20%) was less in last eleven cases. RAPD is significantly better than OPD in terms of intra-operative blood loss, length of ICU stay, length of total stay and SSI. The longer operative time and conversion rate associated with RAPD progressively decreased as experience accumulated and the learning curve was crossed. Further randomized controlled trials are needed to investigate cost-effectiveness and long-term oncologic survival in RAPD patients.
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Affiliation(s)
- Jayant Mulchandani
- Department of Surgical Gastroenterology and General Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - Nikhitha Shetty
- Department of Surgical Gastroenterology and General Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - Aditya Kulkarni
- Department of Surgical Gastroenterology and General Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - Sanjeev Shetty
- Department of Surgical Gastroenterology and General Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - Mohamed Shies Sadat
- Department of Surgical Gastroenterology and General Surgery, Narayana Health City, Bengaluru, Karnataka, India
| | - Ashwinikumar Kudari
- Department of Surgical Gastroenterology and General Surgery, Narayana Health City, Bengaluru, Karnataka, India.
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24
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Minimally Invasive vs Open Pancreatectomy for Pancreatic Neuroendocrine Tumors: Multi-Institutional 10-Year Experience of 1,023 Patients. J Am Coll Surg 2022; 235:315-330. [PMID: 35839409 DOI: 10.1097/xcs.0000000000000257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Resection of pancreatic neuroendocrine tumors (PNETs) may be associated with adverse perioperative outcomes compared with pancreatic adenocarcinoma given the high-risk nature of soft glands with small pancreatic ducts. The effect of minimally invasive surgery (MIS) pancreatectomy on outcomes of PNETs remains to be examined, which is the aim of this study. STUDY DESIGN Between 2009 and 2019, 1,023 patients underwent pancreatectomy for PNETs at 4 institutions. Clinicopathologic data and perioperative outcomes of patients who underwent MIS (n = 447) and open resections (n = 576) were compared. RESULTS Of the 1,023 patients, 51% were male, the mean age was 58, the median tumor size was 2.1 cm, and 73% were grade 1 PNETs. There were 318 (31%) pancreatoduodenectomies (PDs), 541 (53%) distal pancreatectomies (DPs), 80 (7.8%) enucleation (ENs), 72 (7%) central pancreatectomies (CPs), and 12 (1.2%) total pancreatectomies. Almost half of the patients (N = 447, 44%) had MIS operations, of which 230 (51%) were robotic and 217 (49%) were laparoscopic. Compared with open operations, MIS PDs had significantly lower operative blood loss (150 vs 400 mL, p < 0.001) and rate of clinically relevant postoperative pancreatic fistulas (CR-POPFs; 13% vs 27%, p = 0.030), and MIS DPs had a shorter length of stay (5 vs 6 days, p < 0.001). Although MIS DPs and ENs had CR-POPFs comparable with open operations, MIS CPs had a higher CR-POPF rate (45% vs 15%, p = 0.013). After adjusting for pathological differences, MIS pancreatectomy was associated with recurrence-free survival and overall survival comparable with open pancreatectomy. CONCLUSIONS MIS pancreatectomy for PNETs is associated with improved outcomes or outcomes comparable with open resection.
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25
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Di Franco G, Lorenzoni V, Palmeri M, Furbetta N, Guadagni S, Gianardi D, Bianchini M, Pollina LE, Melfi F, Mamone D, Milli C, Di Candio G, Turchetti G, Morelli L. Robot-assisted pancreatoduodenectomy with the da Vinci Xi: can the costs of advanced technology be offset by clinical advantages? A case-matched cost analysis versus open approach. Surg Endosc 2022; 36:4417-4428. [PMID: 34708294 DOI: 10.1007/s00464-021-08793-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/17/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Robot-assisted pancreatoduodenectomy (RPD) has shown some advantages over open pancreatoduodenectomy (OPD) but few studies have reported a cost analysis between the two techniques. We conducted a structured cost-analysis comparing pancreatoduodenectomy performed with the use of the da Vinci Xi, and the traditional open approach, and considering healthcare direct costs associated with the intervention and the short-term post-operative course. MATERIALS AND METHODS Twenty RPD and 194 OPD performed between January 2011 and December 2020 by the same operator at our high-volume multidisciplinary center for robot-assisted surgery and for pancreatic surgery, were retrospectively analyzed. Two comparable groups of 20 patients (Xi-RPD-group) and 40 patients (OPD-group) were obtained matching 1:2 the RPD-group with the OPD-group. Perioperative data and overall costs, including overall variable costs (OVCs) and fixed costs, were compared. RESULTS No difference was reported in mean operative time: 428 min for Xi-RPD-group versus 404 min for OPD, p = 0.212. The median overall length of hospital stay was significantly lower in the Xi-RPD-group: 10 days versus 16 days, p = 0.001. In the Xi-RPD-group, consumable costs were significantly higher (€6149.2 versus €1267.4, p < 0.001), while hospital stay costs were significantly lower: €5231.6 versus €8180 (p = 0.001). No significant differences were found in terms of OVCs: €13,483.4 in Xi-RPD-group versus €11,879.8 in OPD-group (p = 0.076). CONCLUSIONS Robot-assisted surgery is more expensive because of higher acquisition and maintenance costs. However, although RPD is associated to higher material costs, the advantages of the robotic system associated to lower hospital stay costs and the absence of difference in terms of personnel costs thanks to the similar operative time with respect to OPD, make the OVCs of the two techniques no longer different. Hence, the higher costs of advanced technology can be partially compensated by clinical advantages, particularly within a high-volume multidisciplinary center for both robot-assisted and pancreatic surgery. These preliminary data need confirmation by further studies.
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Affiliation(s)
- Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | | | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | | | - Franca Melfi
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Domenica Mamone
- Pharmaceutical Unit: Medical Device Management, University Hospital of Pisa, Pisa, Italy
| | - Carlo Milli
- Board of Directors, University Hospital of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | | | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy. .,Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy. .,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
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26
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Chen S, He Z, Yao S, Xiong K, Shi J, Wang G, Qian K, Wang X. Enhanced Recovery After Surgery Protocol Optimizes Results and Cost of Laparoscopic Radical Nephrectomy. Front Oncol 2022; 12:840363. [PMID: 35444945 PMCID: PMC9013878 DOI: 10.3389/fonc.2022.840363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To assess the impact of enhanced recovery after surgery (ERAS) protocols in laparoscopic radical nephrectomy (LRN). Methods The clinical data of 89 patients underwent LRN in Zhongnan Hospital of Wuhan University from February 2019 to September 2021 were collected (40 in the ERAS group and 49 in the pre-ERAS group). The clinical characteristics, prognosis, and length of hospital stay (LOS) were compared between the two groups using t test, Mann-Whitney test, and chi-square test. Results Total LOS and postoperative LOS were significantly shorter in ERAS group than in pre-ERAS group [15.0 (13.5-19.5) vs. 12.0 (10.0-14.0), P < 0.001; 8.0 (7.0-10.0) vs. 7.0 (5.0-8.8), P = 0.001]. Compared with the pre-ERAS group, the hospitalization expenses of the ERAS group were also lower (P = 0.023). In addition, the incidence of postoperative complications in the ERAS group also decreased (P = 0.054). Conclusions ERAS protocol in LRN could help accelerate the recovery of patients and is worthy of clinical promotion.
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Affiliation(s)
- Siming Chen
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhiwen He
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shijie Yao
- Department of Gynecological Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kangping Xiong
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jiageng Shi
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Gang Wang
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
- Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
| | - Kaiyu Qian
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
- Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
| | - Xinghuan Wang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
- Department of Biological Repositories, Frontier Science Center for Immunology and Metabolism, Medical Research Institute, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
- *Correspondence: Xinghuan Wang,
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27
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Robertson FP, Parks RW. A review of the current evidence for the role of minimally invasive pancreatic surgery following neo-adjuvant chemotherapy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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28
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Benzing C, Timmermann L, Winklmann T, Haiden LM, Hillebrandt KH, Winter A, Maurer MM, Felsenstein M, Krenzien F, Schmelzle M, Pratschke J, Malinka T. Robotic versus open pancreatic surgery: a propensity score-matched cost-effectiveness analysis. Langenbecks Arch Surg 2022; 407:1923-1933. [PMID: 35312854 PMCID: PMC9399018 DOI: 10.1007/s00423-022-02471-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/14/2022] [Indexed: 12/21/2022]
Abstract
Background Robotic pancreatic surgery (RPS) is associated with high intraoperative costs compared to open pancreatic surgery (OPS). However, it remains unclear whether several advantages of RPS such as reduced surgical trauma and a shorter postoperative recovery time could lead to a reduction in total costs outweighing the intraoperative costs. The study aimed to compare patients undergoing OPS and RPS with regards to cost-effectiveness in a propensity score-matched (PSM) analysis. Methods Patients undergoing OPS and RPS between 2017 and 2019 were included in this monocentric, retrospective analysis. The controlling department provided financial data (costs and revenues, net loss/profit). A propensity score-matched analysis was performed or OPS and RPS (matching criteria: age, American society of anesthesiologists (ASA) score, gender, body mass index (BMI), and type of pancreatic resection) with a caliper 0.2. Results In total, 272 eligible OPS cases were identified, of which 252 met all inclusion criteria and were thus included in the further analysis. The RPS group contained 92 patients. The matched cohorts contained 41 patients in each group. Length of hospital stay (LOS) was significantly shorter in the RPS group (12 vs. 19 days, p = 0.003). Major postoperative morbidity (Dindo/Clavien ≥ 3a) and 90-day mortality did not differ significantly between OPS and RPS (p > 0.05). Intraoperative costs were significantly higher in the RPS group than in the OPS group (7334€ vs. 5115€, p < 0.001). This was, however, balanced by other financial categories. The overall cost-effectiveness tended to be better when comparing RPS to OPS (net profit—RPS: 57€ vs. OPS: − 2894€, p = 0.328). Binary logistic regression analysis revealed major postoperative complications, longer hospital stay, and ASA scores < 3 were linked to the risk of net loss (i.e., costs > revenue). Conclusions Surgical outcomes of RPS were similar to those of OPS. Higher intraoperative costs of RPS are outweighed by advantages in other categories of cost-effectiveness such as decreased lengths of hospital stay.
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Affiliation(s)
- Christian Benzing
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Lea Timmermann
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Winklmann
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lena Marie Haiden
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Karl Herbert Hillebrandt
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Axel Winter
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Max Magnus Maurer
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthäus Felsenstein
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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29
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Karunakaran M, Jonnada PK, Chandrashekhar SH, Vinayachandran G, Kaambwa B, Barreto SG. Enhancing the cost-effectiveness of surgical care in pancreatic cancer: a systematic review and cost meta-analysis with trial sequential analysis. HPB (Oxford) 2022; 24:309-321. [PMID: 34848126 DOI: 10.1016/j.hpb.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CP) based on Enhanced recovery after surgery (ERAS®) are increasingly utilised in patients undergoing pancreatoduodenectomy (PD). This systematic review aimed to compare the impact of CPs versus conventional care (CC) on peri-PD costs. METHODS A systematic review of major reference databases was undertaken. Quality assessment was performed using the CHEERS checklist. Incremental cost-effectiveness ratios were calculated as part of the cost-effectiveness analysis. A meta-analysis was performed using random-effects models and Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 14 studies meeting inclusion criteria were included for full qualitative synthesis. All studies reported a reduction in overall costs, length of stay and overall complication rates for CPs when compared to CC. Meta-analysis performed on nine studies demonstrated significantly reduced costs in the CP group, with considerable heterogeneity (Pooled mean difference of $ 4.28 × 103, p < 0.01, I2 = 95%). Cost-effectiveness analysis in relation to complications demonstrated dominance of CPs over CC in being cheaper as well as more effective. TSA supported the cost benefit of enhanced-recovery CPs, displaying minimal type 1 error. CONCLUSION Peri-PD CPs result in significant cost-reduction in comparison to CC.
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Affiliation(s)
- Monish Karunakaran
- Department of Surgical Gastroenterology, SK Hospital, Thiruvananthapuram, India
| | - Pavan K Jonnada
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, India
| | - Sagar H Chandrashekhar
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta- The Medicity, Gurgaon, India
| | | | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
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30
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Saouli A, Rahota RG, Ziouziou I, Elhouadfi O, Karmouni T, Elkhader K, Koutani A, Andalousi AIA, Ploussard G. Safety and feasibility of same-day discharge laparoscopic radical prostatectomy: a systematic review. World J Urol 2022; 40:1367-1375. [PMID: 35157103 PMCID: PMC8853082 DOI: 10.1007/s00345-022-03944-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 01/21/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose Day case or same-day discharge (SDD) pure laparoscopic or robot-assisted radical prostatectomy (RP) has risen over the last few years with the aim of discharging patients within 24 h, reducing costs and length of stay, and facilitating return to active life. We perform a systematic review of literature to evaluate the feasibility of SDD RP. Methods A systematic review search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Embase. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. Results Based on the literature search of 509 articles, 12 (1378 patients) met the inclusion criteria (mean age: 63 years). All studies were unicentric except one. The mean SDD surgeries experience per centre was 66 cases .The means operative time and blood loss were 154 min and 126.5 ml, respectively. Mean SDD failure was 7.4%. Concomitant lymph node dissection was performed in 56.2%. The overall complication rate was 10.2% of cases; with a majority of Clavien grade I or II. Mean readmission rate after discharge was 5%. SDD generated cost reductions compared to inpatient surgery with variable differences according to the considered healthcare system. Conclusions Day-case RP is a safe and feasible strategy in selected cases with multicentre proofs of concept. Its widespread use in routine practice needs further research due to biases in patient selection. Implementation of peri-operative pathways such as ERAS and prehabilitation improves patient adherence to SDD. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-022-03944-1.
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Affiliation(s)
- Amine Saouli
- Department of Urology B, Ibn Sina Hospital, CHU Ibn Sina, Rabat, Morocco.
- Faculty of Medicine and Pharmacy, Mohammed V University, Souissi, Rabat, Morocco.
| | | | - Imad Ziouziou
- Department of Urology, University Hospital of Agadir, Agadir, Morocco
| | - Othmane Elhouadfi
- Department of Urology B, Ibn Sina Hospital, CHU Ibn Sina, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Souissi, Rabat, Morocco
| | - Tarik Karmouni
- Department of Urology B, Ibn Sina Hospital, CHU Ibn Sina, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Souissi, Rabat, Morocco
| | - Khalid Elkhader
- Department of Urology B, Ibn Sina Hospital, CHU Ibn Sina, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Souissi, Rabat, Morocco
| | - Abdellatif Koutani
- Department of Urology B, Ibn Sina Hospital, CHU Ibn Sina, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Souissi, Rabat, Morocco
| | - Ahmed Iben Attya Andalousi
- Department of Urology B, Ibn Sina Hospital, CHU Ibn Sina, Rabat, Morocco
- Faculty of Medicine and Pharmacy, Mohammed V University, Souissi, Rabat, Morocco
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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: 14] [Impact Index Per Article: 7.0] [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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Jin J, Shi Y, Chen M, Qian J, Qin K, Wang Z, Chen W, Jin W, Lu F, Li Z, Wu Z, Jian L, Han B, Liang X, Sun C, Wu Z, Mou Y, Yin X, Huang H, Chen H, Gemenetzis G, Deng X, Peng C, Shen B. Robotic versus Open Pancreatoduodenectomy for Pancreatic and Periampullary Tumors (PORTAL): a study protocol for a multicenter phase III non-inferiority randomized controlled trial. Trials 2021; 22:954. [PMID: 34961558 PMCID: PMC8711152 DOI: 10.1186/s13063-021-05939-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 12/15/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is a complex and challenging procedure that requires meticulous tissue dissection and proficient suturing skills. Minimally invasive surgery with the utilization of robotic platforms has demonstrated advantages in perioperative patient outcomes in retrospective studies. The development of robotic pancreatoduodenectomy (RPD) in specific has progressed significantly, since first reported in 2003, and high-volume centers in pancreatic surgery are reporting large patient series with improved pain management and reduced length of stay. However, prospective studies to assess objectively the feasibility and safety of RPD compared to open pancreatoduodenectomy (OPD) are currently lacking. METHODS/DESIGN The PORTAL trial is a multicenter randomized controlled, patient-blinded, parallel-group, phase III non-inferiority trial performed in seven high-volume centers for pancreatic and robotic surgery in China (> 20 RPD and > 100 OPD annually in each participating center). The trial is designed to enroll and randomly assign 244 patients with an indication for elective pancreatoduodenectomy for malignant periampullary and pancreatic lesions, as well as premalignant and symptomatic benign periampullary and pancreatic disease. The primary outcome is time to functional recovery postoperatively, measured in days. Secondary outcomes include postoperative morbidity and mortality, as well as perioperative costs. A sub-cohort of 128 patients with pancreatic adenocarcinoma (PDAC) will also be compared to assess the percentage of patients who undergo postoperative adjuvant chemotherapy within 8 weeks, in each arm. Secondary outcomes in this cohort will include patterns of disease recurrence, recurrence-free survival, and overall survival. DISCUSSION The PORTAL trial is designed to assess the feasibility and safety of RPD compared to OPD, in terms of functional recovery as described previously. Additionally, this trial will explore whether RPD allows increased access to postoperative adjuvant chemotherapy, in a sub-cohort of patients with PDAC. TRIAL REGISTRATION ClinicalTrials.gov NCT04400357 . Registered on May 22, 2020.
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Affiliation(s)
- Jiabin Jin
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yusheng Shi
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengmin Chen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfeng Qian
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kai Qin
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhen Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Wei Chen
- Department of Pancreaticobiliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Weiwei Jin
- Department of Gastroenterology and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, China
| | - Fengchun Lu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Zheyong Li
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zehua Wu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Li Jian
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Han
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiao Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chuandong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Yiping Mou
- Department of Gastroenterology and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, China
| | - Xiaoyu Yin
- Department of Pancreaticobiliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Hao Chen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Georgios Gemenetzis
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of Hepatopancreatobiliary and Transplant Surgery, Royal Infirmary Edinburgh, Edinburgh, UK.
- Department of Pancreatobiliary Surgery, Glasgow Royal Infirmary, Glasgow, UK.
| | - Xiaxing Deng
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Chenghong Peng
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Comment on "500 Minimally Invasive Robotic Pancreatoduodenectomies: One Decade of Optimizing Performance". Ann Surg 2021; 274:e732-e733. [PMID: 33351487 DOI: 10.1097/sla.0000000000004015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Current status of minimally invasive surgery for pancreatic cancer. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Gong J, Luo L, Liu H, Li C, Tang Y, Zhou Y. How Much Benefit Can Patients Acquire from Enhanced Recovery After Surgery Protocols with Percutaneous Endoscopic Lumbar Interbody Fusion? Int J Gen Med 2021; 14:3125-3132. [PMID: 34239321 PMCID: PMC8260044 DOI: 10.2147/ijgm.s318876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/16/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose We aimed to explore the role of enhanced recovery after surgery (ERAS) in patients who underwent percutaneous endoscopic lumbar interbody fusion (PELIF). Patients and Methods We performed a retrospective, observational, cohort study on 91 patients who underwent PELIF for degenerative disc disease. The primary outcomes were postoperative opioid consumption, hospital length of stay (LOS), and hospital cost. Results Forty-six patients comprised the ERAS group, and 45 patients comprised the pre-ERAS group (control group). The groups had comparable demographic characteristics. Good compliance with the ERAS pathway was observed in the ERAS group. Patients in the ERAS group used significantly fewer morphine equivalents compared with the pre-ERAS group (25.0 vs 33.3, respectively; p = 0.017). Hospital LOS did not decrease significantly in the ERAS group compared with the pre-ERAS group (3.1days vs 3.4 days, respectively; p = 0.096). Likewise, there was no significant difference in hospital cost between the pre-ERAS group and the ERAS group ($10,598.60 vs $10,384.50, respectively; p = 0.468). Conclusion In the present study, the benefit of ERAS in the context of PELIF was limited. Although a multidisciplinary ERAS protocol can improve analgesia and decrease opioid consumption, no significant reduction in hospital LOS and cost was observed.
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Affiliation(s)
- Junfeng Gong
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Liwen Luo
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Huan Liu
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Changqing Li
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Yu Tang
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Yue Zhou
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
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Zureikat AH, Beane JD, Zenati MS, Al Abbas AI, Boone BA, Moser AJ, Bartlett DL, Hogg ME, Zeh HJ. 500 Minimally Invasive Robotic Pancreatoduodenectomies: One Decade of Optimizing Performance. Ann Surg 2021; 273:966-972. [PMID: 31851003 PMCID: PMC7871451 DOI: 10.1097/sla.0000000000003550] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study aims to present the outcomes of our decade-long experience of robotic pancreatoduodenectomy and provide insights into successful program implementation. BACKGROUND Despite significant improvement in mortality over the past 30 years, morbidity following open pancreatoduodenectomy remains high. We implemented a minimally invasive pancreatic surgery program based on the robotic platform as one potential method of improving outcomes for this operation. METHODS A retrospective review of a prospectively maintained institutional database was performed to identify patients who underwent robotic pancreatoduodenectomy (RPD) between 2008 and 2017 at the University of Pittsburgh. RESULTS In total, 500 consecutive RPDs were included. Operative time, conversion to open, blood loss, and clinically relevant postoperative pancreatic fistula improved early in the experience and have remained low despite increasing complexity of case selection as reflected by increasing number of patients with pancreatic cancer, vascular resections, and higher Charlson Comorbidity scores (all P<0.05). Operating room time plateaued after 240 cases at a median time of 391 minutes (interquartile rang 340-477). Major complications (Clavien >2) occurred in less than 24%, clinically relevant postoperative pancreatic fistula in 7.8%, 30- and 90-day mortality were 1.4% and 3.1% respectively, and median length of stay was 8 days. Outcomes were not impacted by integration of trainees or expansion of selection criteria. CONCLUSIONS Structured implementation of robotic pancreatoduodenectomy can be associated with excellent outcomes. In the largest series of RPD, we establish benchmarks for the surgical community to consider when adopting this approach.
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Affiliation(s)
- Amer H. Zureikat
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joal D. Beane
- The Ohio State University, Division of Surgical Oncology, Columbus, OH
| | - Mazen S. Zenati
- Division of General Surgery and Epidemiology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amr I. Al Abbas
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Brian A. Boone
- Division of Surgical Oncology, Department of Surgery, West Virginia University, Morgantown, WV
| | - A. James Moser
- Institute for Hepato-biliary and Pancreatic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - David L. Bartlett
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa E. Hogg
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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Anesthesiologists' Role in Value-based Perioperative Care and Healthcare Transformation. Anesthesiology 2021; 134:526-540. [PMID: 33630039 DOI: 10.1097/aln.0000000000003717] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients' health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients.
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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: 51] [Impact Index Per Article: 17.0] [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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Dittrich L, Biebl M, Malinka T, Knoop M, Pratschke J. Minimally invasive pancreatic surgery—will robotic surgery be the future? Eur Surg 2021. [DOI: 10.1007/s10353-020-00689-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
SummaryDue to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.
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Lin R, Lin X, Pan M, Lu F, Yang Y, Wang C, Fang H, Chen Y, Huang H. Perioperative outcomes of robotic pancreaticoduodenectomy: a single surgeon's experience with 55 consecutive cases. Gland Surg 2021; 10:122-129. [PMID: 33633969 DOI: 10.21037/gs-20-552] [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] [Indexed: 01/08/2023]
Abstract
Background Robotic pancreaticoduodenectomy (RPD) has been increasingly performed for patients with periampullary tumours and tumours in the pancreatic head. This method offers several technical advantages compared to open and laparoscopic surgeries. However, the surgical results often vary depending on the experience of different pancreatic centres. Methods A retrospective study of our first 55 cases of RPD from August 2016 to April 2020 was conducted to evaluate the perioperative outcomes of RPD and to summarize the operative experiences in a single intuition. Benign and malignant tumours in the pancreatic head or periampullary tumours without obvious vascular and adjacent organ invasion were included in this study. Perioperative characteristics and postoperative complications of the enrolled patients were retrospectively collected. Results The first 17 cases were robot-assisted laparoscopic pancreaticoduodenectomy (RA-LPD) and the remaining 38 patients underwent total RPD. The RA-LPD group had a remarkably longer operative time than the total RPD group (415.3±89.2 vs. 362.4±75.6 min, P=0.047). The incidences of biliary leakage, chyle leakage, DGE, intra-abdominal infection and intra-abdominal haemorrhage were 3.6%, 0.0%, 5.5%, 9.1% and 5.5%, respectively. Two patients underwent relaparotomy due to severe intra-abdominal haemorrhage. The median length of hospital stay was 14 (11 to 19) days. There were no deaths during the perioperative period. Conclusions RPD is a technically feasible procedure for selected patients with periampullary tumours and tumours in the pancreatic head in experienced hands.
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Affiliation(s)
- Ronggui Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xianchao Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maoen Pan
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Fengchun Lu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Yang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Congfei Wang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haizong Fang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanchang Chen
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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Hue JJ, Bachman KC, Gray KE, Linden PA, Worrell SG, Towe CW. Does Timing of Robotic Esophagectomy Adoption Impact Short-Term Postoperative Outcomes? J Surg Res 2020; 260:220-228. [PMID: 33360305 DOI: 10.1016/j.jss.2020.11.077] [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: 06/28/2020] [Revised: 10/13/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes. METHODS The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors. RESULTS There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient -2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality. CONCLUSIONS When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.
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Affiliation(s)
- Jonathan J Hue
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio.
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Pineda-Solis K, Burchard PR, Ruffolo LI, Schoeniger LO, Linehan DC, Moalem J, Galka E. Early Prediction of Length of Stay After Pancreaticoduodenectomy. J Surg Res 2020; 260:499-505. [PMID: 33358193 DOI: 10.1016/j.jss.2020.11.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/10/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is an evidence-based clinical pathway designed to standardize and optimize care. We studied the impact of ERAS and sought to identify the most important recommendations to predict shorter length of stay (LOS) after pancreaticoduodenectomy (PD). METHODS We retrospectively reviewed all patients undergoing PD at our institution between January 2014 and June 2018. We compared clinicopathologic outcomes for patients before and after ERAS implementation. We defined "A-recommendations" as those that were graded "strong" and had "moderate" or "high" levels of evidence. We then compared outcomes of the ERAS group with adherence to "A-recommendations" and performed a subset analysis of "A-recommendations" over the first 72 h after surgery, which we termed "early factors". RESULTS A total of 191 patients underwent PD during the study period. We excluded 87 patients who had minimally invasive PD (22), vascular reconstruction (53), or both (12). Of the 104 patients studied, 56 (54%) were pre-ERAS and 48 (46%) were ERAS. There were no differences in comorbidities or demographics between these groups, and morbidity, mortality, and readmission rates were also similar (P > 0.6). Median LOS was 3.5 d shorter in the ERAS group (7 versus 10.5 d, P < 0.001). Adherence to "A-recommendations" within ERAS was associated with a decreased LOS (r = -0.52 P = 0.0001). Patients with >5 "early factors" had a median LOS of 6 d, whereas patients with <5 "early factors" had a median LOS of 9 d (P = 0.008). CONCLUSIONS ERAS is an effective protocol that standardizes care and reduces LOS after PD. Implementation of ERAS resulted in a 3.5-day reduction in our LOS with no change in morbidity, mortality, or readmissions. Adherence to ERAS protocol "A-recommendations" and ≥5 "early factors" may be predictive of shortened LOS.
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Affiliation(s)
- Karen Pineda-Solis
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA.
| | - Paul R Burchard
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luis I Ruffolo
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luke O Schoeniger
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - David C Linehan
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jacob Moalem
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Galka
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
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Aiolfi A, Lombardo F, Bonitta G, Danelli P, Bona D. Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy. Updates Surg 2020; 73:909-922. [PMID: 33315230 PMCID: PMC8184540 DOI: 10.1007/s13304-020-00916-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/26/2020] [Indexed: 12/14/2022]
Abstract
The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.
| | - Francesca Lombardo
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Piergiorgio Danelli
- Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
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Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Kamarajah SK, Abu Hilal M, White SA. Does center or surgeon volume influence adoption of minimally invasive versus open pancreatoduodenectomy? A systematic review and meta-regression. Surgery 2020; 169:945-953. [PMID: 33183790 DOI: 10.1016/j.surg.2020.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/29/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There has been increasing uptake of minimally invasive pancreatoduodenectomy during the past decade, but it remains a highly specialized procedure as benefits over open pancreatoduodenectomy remain contentious. This study aimed to evaluate current evidence on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy in terms of impact of center volume on outcomes. METHODS A systematic review of articles on comparative cohort and registry studies on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy published until 31st December 2019 were identified, and meta-analyses were performed. Primary endpoints were International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula and 30-day mortality. RESULTS After screening 7,390 studies, 43 comparative cohort studies (8,755 patients) with moderate methodological quality and 3 original registry studies (43,735 patients) were included. For the cohort studies, the median annual hospital minimally invasive pancreatoduodenectomy volume was 10. No significant differences were found in grade B/C postoperative pancreatic fistula (odds ratio: 0.98, 95% confidence interval: 0.78-1.23) or 30-day mortality (odds ratio: 1.14, 95% confidence interval: 0.65-2.01) between minimally invasive pancreatoduodenectomy when compared with open. No publication biases were present and meta-regression identified no confounding for grade B/C postoperative pancreatic fistula, center volume or 30-day mortality. Minimally invasive pancreatoduodenectomy was only strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection, shorter length of stay, and significantly higher rates of R0 margin resections. CONCLUSION Minimally invasive pancreatoduodenectomy remains noninferior to open pancreatoduodenectomy for grade B/C postoperative pancreatic fistula but is strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection. Minimally invasive pancreatoduodenectomy can be adopted safely with good outcomes irrespective of annual center resection volume.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, United Kingdom.
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, United Kingdom
| | - Steven A White
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, United Kingdom
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Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers. Updates Surg 2020; 73:893-907. [PMID: 33159662 DOI: 10.1007/s13304-020-00912-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/26/2020] [Indexed: 02/08/2023]
Abstract
The objective of the study is to compare the safety and efficacy of robot-assisted pancreaticoduodenectomy (PD) with open PD. The PubMed, EMBASE and Cochrane Library databases were searched for the literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio (RR) and weighted mean difference (WMD) and their 95% confidence intervals (CIs) were calculated using fixed-effect or random effect models. 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) (WMD = - 175.65, 95% CI (- 251.85, - 99.44), P < 0.00001), wound infection rate (RR = 0.60, 95% CI (0.44, 0.81), P = 0.001), reoperation rate (RR = 0.61, 95% CI (0.41, 0.91), P = 0.02), hospital day (WMD = - 2.95, 95% CI (- 5.33, - 0.56), P = 0.02), intraoperative blood transfusion (RR = 0.56, 95% CI (0.42, 0.76), P = 0.0001), overall complications (RR = 0.78, 95% CI (0.64, 0.95), P = 0.01), and clinical postoperative pancreatic fistula (POPF) (RR = 0.54, 95% CI (0.41, 0.70), P < 0.0001). In terms of lymph node clearance (WMD = 0.48, 95% CI (- 2.05, 3.02), P = 0.71), R0 rate (RR = 1.05, 95% CI (1.00, 1.11), P = 0.05), postoperative pancreatic fistula (RR = 1, 95% CI (0.85, 1.19), P = 0.97), bile leakage (RR = 0.99, 95% CI (0.54, 1.83), P = 0.98), delayed gastric emptying (DGE) (RR = 0.79, 95% CI (0.60, 1.03), P = 0.08), 90-day mortality (RR = 0.82, 95% CI (0.62, 1.10), P = 0.19), and severe complications (RR = 0.98, 95% CI (0.71, 1.36), P = 0.91), and there were no significant differences between the two groups. Robotic surgery was inferior to open surgery in terms of operational time (WMD = 80.85, 95% CI (16.09, 145.61), P = 0.01). RPD is not inferior to OPD, and it is even more advantageous for EBL, wound infection rate, reoperation rate, hospital stay, intraoperative transfusion, overall complications and clinical POPF. However, these findings need to be further verified by high-quality randomized controlled trials.
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Schmidt CR, Harris BR, Musgrove KA, Rao P, Marsh JW, Thomay AA, Hogg ME, Zeh HJ, Zureikat AH, Boone BA. Formal robotic training diminishes the learning curve for robotic pancreatoduodenectomy: Implications for new programs in complex robotic surgery. J Surg Oncol 2020; 123:375-380. [PMID: 33135785 DOI: 10.1002/jso.26284] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/19/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The learning curve associated with robotic pancreatoduodenectomy (RPD) is a hurdle for new programs to achieve optimal results. Since early analysis, robotic training has recently expanded, and the RPD approach has been refined. The purpose of this study is to examine RPD outcomes for surgeons who implemented a new program after receiving formal RPD training to determine if such training reduces the learning curve. METHODS Outcomes for consecutive patients undergoing RPD at a single tertiary institution were compared to optimal RPD benchmarks from a previously reported learning curve analysis. Two surgical oncologists with formal RPD training performed all operations with one surgeon as bedside assistant and the other at the console. RESULTS Forty consecutive RPD operations were evaluated. Mean operative time was 354 ± 54 min, and blood loss was 300 ml. Length of stay was 7 days. Three patients (7.5%) underwent conversion to open. Pancreatic fistula affected five patients (12.5%). Operative time was stable over the study and lower than the reported benchmark. These RPD operative outcomes were similar to reported surgeon outcomes after the learning curve. CONCLUSION This study suggests formal robotic training facilitates safe and efficient adoption of RPD for new programs, reducing or eliminating the learning curve.
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Affiliation(s)
- Carl R Schmidt
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Britney R Harris
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Kelsey A Musgrove
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Pavan Rao
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - J Wallis Marsh
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Alan A Thomay
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Melissa E Hogg
- Department of Surgery, Northshore University Health System, Chicago, Illinois, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian A Boone
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
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Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction. Am J Otolaryngol 2020; 41:102649. [PMID: 32717682 DOI: 10.1016/j.amjoto.2020.102649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS). METHODS In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge. RESULTS The mean MED administered postoperatively was lower in the ERAS group (17.6 mg) than in the control group (65.0 mg) (p < .001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p = .042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p < .001). CONCLUSION The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.
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Wang XY, Cai JP, Huang CS, Huang XT, Yin XY. Impact of enhanced recovery after surgery protocol on pancreaticoduodenectomy: a meta-analysis of non-randomized and randomized controlled trials. HPB (Oxford) 2020; 22:1373-1383. [PMID: 32811766 DOI: 10.1016/j.hpb.2020.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 05/31/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been widely applied in many surgical specialties. However, with respect to the impact of ERAS on pancreaticoduodenectomy (PD), there still exist some controversies. METHODS Literature search was performed in PubMed, Web of Science and the Cochrane Library from January, 1990 to July, 2019. A meta-analysis was performed using fixed-effects or random-effects models. RESULTS Twenty-two studies containing 4147 patients were identified. The entire pooled data showed that ERAS significantly reduced overall and minor morbidity (RR: 0.80, 95% CI: 0.72-0.88, p < 0.001; RR: 0.78, 95% CI: 0.69-0.88, p < 0.001, respectively), but didn't affect major morbidity (RR: 0.97, 95% CI: 0.84-1.13, p = 0.72). ERAS markedly reduced the incidences of delayed gastric emptying (DGE) (RR: 0.69, 95% CI: 0.55-0.88, p = 0.002), incisional infection (RR: 0.75, 95% CI: 0.60-0.94, p = 0.01) and intra-abdominal infection (RR: 0.79, 95% CI: 0.63-1.00, p = 0.05), but didn't influence clinically-relevant postoperative pancreatic fistula (CR-POPF) (RR: 0.86, 95% CI: 0.73-1.01, p = 0.07). Shorter length of stay (LOS) (WMD: -5.07, 95% CI: -6.71 to -3.43, p < 0.001) was noted in ERAS group, without increasing 30-day readmission (RR: 1.03, 95% CI: 0.86-1.24, p = 0.71) and mortality (RR: 0.70, 95% CI: 0.41-1.21, p = 0.20). CONCLUSION ERAS significantly reduced overall and minor morbidity, incidences of DGE, incisional and intra-abdominal infections, and shortened LOS in PD, without increasing 30-day readmission and mortality. However, more large-scale randomized controlled trials are still needed to confirm the findings.
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Affiliation(s)
- Xi-Yu Wang
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian-Peng Cai
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chen-Song Huang
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xi-Tai Huang
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yu Yin
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Bernhard JC, Robert G, Ricard S, Michiels C, Capon G, Boulenger de Hautecloque A, Bensadoun H, Gay J, Rogier J, Tauzin-Fin P, Gross-Goupil M, Benard A, Nouette K, Roullet S, Ferrière JM. Day-case robotic-assisted partial nephrectomy: feasibility and preliminary results of a prospective evaluation (UroCCR-25 AMBU-REIN study). World J Urol 2020; 40:1351-1357. [PMID: 32514670 DOI: 10.1007/s00345-020-03283-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Robotic partial nephrectomy (RPN) is a minimally-invasive technique used to treat renal tumors. A clinical pathway and prospective research protocol (AMBU-REIN) were specifically set up to establish and assess the routine use of day-case RPN. METHODS The AMBU-REIN study was conducted in the framework of the French research network on kidney cancer UroCCR (NCT03293563). We present our initial experience of patients treated using day-case RPN and released from our hospital on the same day, focusing on patient selection, safety and patient satisfaction using the EVAN-G validated questionnaire. RESULTS Between September 2016 and September 2019, 429 RPN were performed and 82 patients were consecutively selected for day-case RPN. Patients were managed using transperitoneal RPN with off-clamp tumorectomy for 66/82 cases. Mean tumor size was 2.7 ± 1.2 cm. There were no immediate severe postoperative complications; 7/82 patients were kept under observation overnight and discharged the following day. The follow-up at day 30 indicated postoperative complications, readmissions, and mortality rates of 1.2, 1.2, and 0%, respectively. Next-day patient satisfaction questionnaires indicated that patients were generally highly satisfied, with a mean ± standard deviation global score of 83.6 ± 10.3%. "Attention" was rated the highest overall (mean 94.8 ± 10.5%), while "pain management" scored the lowest (61.2 ± 20.5%). CONCLUSIONS This prospective case series is the first to demonstrate the safety and feasibility of day-case RPN. For selected patients and through a dedicated, nurse-led clinical pathway, it provided a high level of patient satisfaction. Expected benefits on healthcare cost savings warrant further investigation.
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Affiliation(s)
- Jean-Christophe Bernhard
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France.
- French Research Network on Kidney Cancer UroCCR, Bordeaux, France.
| | - Grégoire Robert
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | - Solène Ricard
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
- French Research Network on Kidney Cancer UroCCR, Bordeaux, France
| | - Clément Michiels
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | - Grégoire Capon
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | | | - Henri Bensadoun
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | - Joséphine Gay
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
- French Research Network on Kidney Cancer UroCCR, Bordeaux, France
| | - Julien Rogier
- Department of Anesthesiology, University Hospital of Bordeaux, Bordeaux, France
| | - Patrick Tauzin-Fin
- Department of Anesthesiology, University Hospital of Bordeaux, Bordeaux, France
| | - Marine Gross-Goupil
- Department of Medical Oncology, University Hospital of Bordeaux, Bordeaux, France
| | - Antoine Benard
- Methodology Unit, Public Health Department, University Hospital of Bordeaux, Bordeaux, France
| | - Karine Nouette
- Department of Anesthesiology, University Hospital of Bordeaux, Bordeaux, France
| | - Stéphanie Roullet
- Department of Anesthesiology, University Hospital of Bordeaux, Bordeaux, France
| | - Jean-Marie Ferrière
- Department of Urology, University Hospital of Bordeaux, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
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