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Hariri HM, Perez SB, Turner KM, Wilson GC. Minimally Invasive Pancreas Surgery: Is There a Benefit? Surg Clin North Am 2024; 104:1083-1093. [PMID: 39237165 DOI: 10.1016/j.suc.2024.04.013] [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] [Indexed: 09/07/2024]
Abstract
Minimally invasive procedures minimize trauma to the human body while maintaining satisfactory therapeutic results. Minimally invasive pancreas surgery (MIPS) was introduced in 1994, but questions regarding its efficacy compared to an open approach were widespread. MIPS is associated with several perioperative advantages while maintaining oncological standards when performed by surgeons with a robust training regimen and frequent practice. Future research should focus on addressing learning curve discrepancies while identifying factors associated with shortening the time needed to attain technical proficiency.
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Affiliation(s)
- Hussein M Hariri
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Department of Surgical Oncology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45229, USA
| | - Samuel B Perez
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Northwestern University, Evanston, IL 60208, USA
| | - Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Cincinnati Research on Outcomes and Safety in Surgery (CROSS); Department of Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, Cincinnati, OH 45229, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Cincinnati Research on Outcomes and Safety in Surgery (CROSS); Department of Surgical Oncology, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45229, USA.
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2
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Menso JE, Rahimi AM, Zwart MJW, Daams F, de Hondt J, Karadza E, Montorsi RM, Nickel F, Bonjer HJ, van Dijkum EJMN, Besselink MG. Robotic hepaticojejunostomy training in novices using robotic simulation and dry-lab suturing (ROSIM): randomized controlled crossover trial. Surg Endosc 2024; 38:4906-4915. [PMID: 38958718 PMCID: PMC11362386 DOI: 10.1007/s00464-024-10914-8] [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: 12/07/2023] [Accepted: 05/05/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Robotic suturing training is in increasing demand and can be done using suture-pads or robotic simulation training. Robotic simulation is less cumbersome, whereas a robotic suture-pad approach could be more effective but is more costly. A training curriculum with crossover between both approaches may be a practical solution. However, studies assessing the impact of starting with robotic simulation or suture-pads in robotic suturing training are lacking. METHODS This was a randomized controlled crossover trial conducted with 20 robotic novices from 3 countries who underwent robotic suturing training using an Intuitive Surgical® X and Xi system with the SimNow (robotic simulation) and suture-pads (dry-lab). Participants were randomized to start with robotic simulation (intervention group, n = 10) or suture-pads (control group, n = 10). After the first and second training, all participants completed a robotic hepaticojejunostomy (HJ) in biotissue. Primary endpoint was the objective structured assessment of technical skill (OSATS) score during HJ, scored by two blinded raters. Secondary endpoints were force measurements and a qualitative analysis. After training, participants were surveyed regarding their preferences. RESULTS Overall, 20 robotic novices completed both training sessions and performed 40 robotic HJs. After both trainings, OSATS was scored higher in the robotic simulation-first group (3.3 ± 0.9 vs 2.5 ± 0.8; p = 0.049), whereas the median maximum force (N) (5.0 [3.2-8.0] vs 3.8 [2.3-12.8]; p = 0.739) did not differ significantly between the groups. In the survey, 17/20 (85%) participants recommended to include robotic simulation training, 14/20 (70%) participants preferred to start with robotic simulation, and 20/20 (100%) to include suture-pad training. CONCLUSION Surgical performance during robotic HJ in robotic novices was significantly better after robotic simulation-first training followed by suture-pad training. A robotic suturing curriculum including both robotic simulation and dry-lab suturing should ideally start with robotic simulation.
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Affiliation(s)
- Julia E Menso
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - A Masie Rahimi
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Maurice J W Zwart
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Joey de Hondt
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Emir Karadza
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Roberto M Montorsi
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Verona University Hospital, University of Verona, Verona, Italy
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Jaap Bonjer
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Els J M Nieveen van Dijkum
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Amsterdam, the Netherlands.
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3
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Celotto F, Ramacciotti N, Mangano A, Danieli G, Pinto F, Lopez P, Ducas A, Cassiani J, Morelli L, Spolverato G, Bianco FM. Da Vinci single-port robotic system current application and future perspective in general surgery: A scoping review. Surg Endosc 2024; 38:4814-4830. [PMID: 39110221 PMCID: PMC11362253 DOI: 10.1007/s00464-024-11126-w] [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: 05/13/2024] [Accepted: 07/27/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND The da Vinci Single-Port Robot System (DVSP) allows three robotic instruments and an articulated scope to be inserted through a single small incision. It received FDA approval in 2014 and was first introduced in 2018. The aim of this new system was to overcome the limitations of single-incision laparoscopic and robotic surgery. Since then, it has been approved for use only for urologic and transoral surgeries in some countries. It has been used as part of experimental protocols in general surgery. OBJECTIVE By obtaining the CE mark at the end of January 2024, DVSP will soon enter the European market. This review aims to comprehensively describe the applications of DVSP in general surgery. DESIGN A search of PubMed, Embase, and Ebsco databases up to March 2024 was conducted, with registration in PROSPERO (CRD42024536430), following the preferred reporting items for Systematic reviews and Meta-analyses for scoping review (PRISMA-Scr) guidelines. All the studies about the use of DVSP in general surgery were included. RESULTS Fifty-six studies were included. The following surgical areas of use were identified: transabdominal and transanal colorectal, cholecystectomy, abdominal wall repair, upper gastroesophageal tract, liver, pancreas, breast, and thyroid surgery. The reported surgical and short-term outcomes are promising; a wide range of procedures have been performed safely. Some groups have found advantages, such as faster discharge, shorter operative time, and less postoperative pain compared to multiport robotic surgery. CONCLUSION Five years after its initial clinical applications, the use of the DVSP in general surgery procedures has demonstrated feasibility and safety. Hernia repair, cholecystectomy, and colorectal surgery emerge as the most frequently conducted interventions with this robotic system. Nevertheless, there is anticipation for further studies with larger sample sizes and extended follow-up periods to provide more comprehensive insights and data on the long-term outcomes, including the incidence of incisional hernia.
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Affiliation(s)
- Francesco Celotto
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.
| | - Niccolò Ramacciotti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alberto Mangano
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Giacomo Danieli
- Unit of Biostatistics, Epidemiology and Public Health (UBEP), Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Federico Pinto
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Paula Lopez
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Alvaro Ducas
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jessica Cassiani
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Luca Morelli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gaya Spolverato
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesco Maria Bianco
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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4
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Luo YC, Yang TY, Li W, Yu QJ, Xia X, Lin ZY, Chen RD, Cheng L. Perioperative and oncologic outcomes of robot-assisted versus open surgery for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. J Robot Surg 2024; 18:288. [PMID: 39039276 DOI: 10.1007/s11701-024-02046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 07/07/2024] [Indexed: 07/24/2024]
Abstract
This systematic review and meta-analysis aimed to compare perioperative and oncologic outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) treated with robotic-assisted surgery versus open laparotomy. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials (RCTs) and cohort studies up to June 15, 2024, were identified using PubMed, EMBASE, and Google Scholar. Additionally, reference lists of included studies, relevant review articles, and clinical guidelines were manually searched. The primary outcomes evaluated were length of stay, 90-day mortality, postoperative pancreatic fistula (POPF), and Post-pancreatectomy haemorrhage (PPH). Secondary outcomes included estimated blood loss, reoperation rate, lymph node yield, and operative time. The final analysis included 10 retrospective cohort studies involving 23,272 patients (2,179 robotic-assisted and 21,093 open surgery). There were no significant differences between the two procedures in terms of postoperative pancreatic fistula, Post-pancreatectomy haemorrhage, lymph node yield, and operative time. However, patients undergoing robotic-assisted surgery had shorter lengths of stay, lower 90-day mortality, and less estimated blood loss compared to those undergoing open surgery. The reoperation rate was higher for the robotic-assisted group. Robotic-assisted surgery for pancreatic ductal adenocarcinoma is safe and feasible. Compared to open surgery, it offers better perioperative and short-term oncologic outcomes, but with a higher risk of reoperation.
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Affiliation(s)
- Yu-Chuan Luo
- North Sichuan Medical College, Nanchong, China
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Ting-Yu Yang
- North Sichuan Medical College, Nanchong, China
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Wei Li
- North Sichuan Medical College, Nanchong, China
| | - Qian-Jun Yu
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Xin Xia
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Zhi-Yu Lin
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Ru-De Chen
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Long Cheng
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, China.
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5
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Emmen AMLH, Zwart MJW, Khatkov IE, Boggi U, Groot Koerkamp B, Busch OR, Saint-Marc O, Dokmak S, Molenaar IQ, D'Hondt M, Ramera M, Keck T, Ferrari G, Luyer MDP, Moraldi L, Ielpo B, Wittel U, Souche FR, Hackert T, Lips D, Can MF, Bosscha K, Fara R, Festen S, van Dieren S, Coratti A, De Hingh I, Mazzola M, Wellner U, De Meyere C, van Santvoort HC, Aussilhou B, Ibenkhayat A, de Wilde RF, Kauffmann EF, Tyutyunnik P, Besselink MG, Abu Hilal M. Robot-assisted versus laparoscopic pancreatoduodenectomy: a pan-European multicenter propensity-matched study. Surgery 2024; 175:1587-1594. [PMID: 38570225 DOI: 10.1016/j.surg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This study aimed to compare outcomes after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy in a pan-European cohort. METHODS An international multicenter retrospective study including patients after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy from 50 centers in 12 European countries (2009-2020). Propensity score matching was performed in a 1:1 ratio. The primary outcome was major morbidity (Clavien-Dindo ≥III). RESULTS Among 2,082 patients undergoing minimally invasive pancreatoduodenectomy, 1,006 underwent robot-assisted pancreatoduodenectomy and 1,076 laparoscopic pancreatoduodenectomy. After matching 812 versus 812 patients, the rates of major morbidity (31.9% vs 29.6%; P = .347) and 30-day/in-hospital mortality (4.3% vs 4.6%; P = .904) did not differ significantly between robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy, respectively. Robot-assisted pancreatoduodenectomy was associated with a lower conversion rate (6.7% vs 18.0%; P < .001) and higher lymph node retrieval (16 vs 14; P = .003). Laparoscopic pancreatoduodenectomy was associated with shorter operation time (446 minutes versus 400 minutes; P < .001), and lower rates of postoperative pancreatic fistula grade B/C (19.0% vs 11.7%; P < .001), delayed gastric emptying grade B/C (21.4% vs 7.4%; P < .001), and a higher R0-resection rate (73.2% vs 84.4%; P < .001). CONCLUSION This European multicenter study found no differences in overall major morbidity and 30-day/in-hospital mortality after robot-assisted pancreatoduodenectomy compared with laparoscopic pancreatoduodenectomy. Further, laparoscopic pancreatoduodenectomy was associated with a lower rate of postoperative pancreatic fistula, delayed gastric emptying, wound infection, shorter length of stay, and a higher R0 resection rate than robot-assisted pancreatoduodenectomy. In contrast, robot-assisted pancreatoduodenectomy was associated with a lower conversion rate and a higher number of retrieved lymph nodes as compared with laparoscopic pancreatoduodenectomy.
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Affiliation(s)
- Anouk M L H Emmen
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/AnoukEmmen
| | - Maurice J W Zwart
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/mauricezwart
| | - Igor E Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Russia
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Olivier Saint-Marc
- Service de Chirurgie Digestive, Endocrinienne et Thoracique, Center Hospitalier Universitaire Orleans, France
| | - Safi Dokmak
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France. University Paris Cité
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, the Netherlands
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital Kortrijk, Belgium
| | - Marco Ramera
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Tobias Keck
- Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Germany
| | - Giovanni Ferrari
- Department of Oncological and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Luca Moraldi
- Department of Oncology and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - Benedetto Ielpo
- Department of Surgery, HPB unit, University Mar Hospital, Parc Salut, Barcelona, Spain
| | - Uwe Wittel
- Department of Surgery, University of Freiburg, Germany
| | - Francois-Regis Souche
- Department de Chirurgie Digestive (A), Mini-invasive et Oncologigue, Hôspital Saint-Eloi, Montpellier, France
| | - Thilo Hackert
- Dept. of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, s-Hertogenbosch, the Netherlands
| | - Regis Fara
- Department of Surgery, Hôpital Européen Marseille, France
| | | | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Andrea Coratti
- Department of Oncology and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - Ignace De Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Michele Mazzola
- Department of Oncological and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Ulrich Wellner
- Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Germany
| | - Celine De Meyere
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital Kortrijk, Belgium
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, the Netherlands
| | - Béatrice Aussilhou
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France. University Paris Cité
| | - Abdallah Ibenkhayat
- Service de Chirurgie Digestive, Endocrinienne et Thoracique, Center Hospitalier Universitaire Orleans, France
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Pavel Tyutyunnik
- Department of Surgery, Moscow Clinical Scientific Center, Russia
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
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Liu M, Wei AC. Advances in Surgery and (Neo) Adjuvant Therapy in the Management of Pancreatic Cancer. Hematol Oncol Clin North Am 2024; 38:629-642. [PMID: 38429197 DOI: 10.1016/j.hoc.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
A multimodality approach, which usually includes chemotherapy, surgery, and/or radiotherapy, is optimal for patients with localized pancreatic cancer. The timing and sequence of these interventions depend on anatomic resectability and the biological suitability of the tumor and the patient. Tumors with vascular involvement (ie, borderline resectable/locally advanced) require surgical reassessments after therapy and participation of surgeons familiar with advanced techniques. When indicated, venous reconstruction should be offered as standard of care because it has acceptable morbidity. Morbidity and mortality of pancreas surgery may be mitigated when surgery is performed at high-volume centers.
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Affiliation(s)
- Mengyuan Liu
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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7
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Liu Q, Li M, Gao Y, Jiang T, Han B, Zhao G, Lin C, Lau WY, Zhao Z, Liu R. Effect of robotic versus open pancreaticoduodenectomy on postoperative length of hospital stay and complications for pancreatic head or periampullary tumours: a multicentre, open-label randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9:428-437. [PMID: 38428441 DOI: 10.1016/s2468-1253(24)00005-0] [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: 09/17/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND The flexibility of the robotic system in resection and reconstruction provides potential benefits in pancreaticoduodenectomy. Increasingly, robotic pancreaticoduodenectomy (RPD) has been reported with favourable outcomes, but high-level evidence is still scarce. We aimed to compare the short-term postoperative outcomes of RPD with those of open pancreaticoduodenectomy (OPD), and hypothesised that postoperative length of hospital stay would be shorter after RPD than after OPD. METHODS This multicentre, open-label randomised controlled trial was conducted at three high-volume hospitals in China. Patients were considered for participation in this trial if they were aged 18-75 years, had a resectable benign, premalignant, or malignant tumour in the pancreatic head or periampullary region; and were suitable for both RPD and OPD. Patients with distant metastases were excluded. Block randomisation was done with random block sizes of four, stratified by centre. Allocation was concealed via individual, sequentially numbered, opaque sealed envelopes. Eligible patients were randomly assigned to the RPD group or the OPD group in a 1:1 ratio by a masked research assistant. Surgeons and patients were not masked to trial group, but data collectors, postoperative outcome assessors, and data analysts were. All patients underwent RPD or OPD according to previously reported techniques. Participating surgeons had surpassed the learning curves of at least 40 RPD and 60 OPD procedures. The primary outcome was postoperative length of hospital stay, which was analysed in the modified intention-to-treat (mITT) population. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR2200056809) and is complete. FINDINGS Between March 5 and Dec 20, 2022, 292 patients were screened for eligibility, of whom 164 were enrolled and randomly assigned to the RPD group (n=82) or the OPD group (n=82). 161 patients who underwent surgical resection were included in the mITT analysis (81 in the RPD group and 80 in the OPD group). 94 (58%) participants were male and 67 (42%) were female. Postoperative length of hospital stay was significantly shorter in the RPD group than in the OPD group (median 11·0 days [IQR 9·0 to 19·5] vs 13·5 days [11·5 to 18·0]; median difference -2·0 [95% CI -4·0 to 0·0]; p=0·029). During a follow-up period of 90 days, six (7%) of 81 patients in the RPD group and five (6%) of 80 patients in the OPD group required readmission. Reasons for readmission were intra-abdominal haemorrhage (one in each group), vomiting (two in the RPD group and one in the OPD group), electrolyte disturbance (one in each group), and fever (two in each group). There were two (1%) in-hospital deaths within 90 days of surgery, one in each group. The postoperative 90-day mortality rate (difference -0·02% [-5·6 to 5·5]; p=1·00) and the incidence of severe complications (ie, Clavien-Dindo grade ≥3; difference -1·5% [-14·5 to 11·4]; p=0·82) were similar between the two groups. INTERPRETATION For surgeons who had passed the learning curve, RPD was safe and feasible with the advantage of shorter postoperative length of hospital stay than OPD. Future research should focus on the medium-term and long-term outcomes between RPD and OPD. FUNDING None.
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Affiliation(s)
- Qu Liu
- Faculty of Hepatopancreatobiliary Surgery, First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China; Department of Organ Transplantation, Third Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Mengyang Li
- Faculty of Hepatopancreatobiliary Surgery, First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yuanxing Gao
- Faculty of Hepatopancreatobiliary Surgery, First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Tao Jiang
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Bing Han
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guodong Zhao
- Faculty of Hepatopancreatobiliary Surgery, First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Chao Lin
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Wan Yee Lau
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Zhiming Zhao
- Faculty of Hepatopancreatobiliary Surgery, First 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, China.
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8
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Stefanova I, Vescio F, Nickel F, Merali N, Ammendola M, Lahiri RP, Pencavel TD, Worthington TR, Frampton AE. What are the true benefits of robotic pancreaticoduodenectomy for patients with pancreatic cancer? Expert Rev Gastroenterol Hepatol 2024; 18:133-139. [PMID: 38712525 DOI: 10.1080/17474124.2024.2351398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/01/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, and multimodal treatment including high-quality surgery can improve survival outcomes. Pancreaticoduodenectomy (PD) has evolved with minimally invasive approaches including the implementation of robotic PD (RPD). In this special report, we review the literature whilst evaluating the 'true benefits' of RPD compared to open approach for the treatment of PDAC. AREAS COVERED We have performed a mini-review of studies assessing PD approaches and compared intraoperative characteristics, perioperative outcomes, post-operative complications and oncological outcomes. EXPERT OPINION RPD was associated with similar or longer operative times, and reduced intra-operative blood loss. Perioperative pain scores were significantly lower with shorter lengths of stay with the robotic approach. With regards to post-operative complications, post-operative pancreatic fistula rates were similar, with lower rates of clinically relevant fistulas after RPD. Oncological outcomes were comparable or superior in terms of margin status, lymph node harvest, time to chemotherapy and survival between RPD and OPD. In conclusion, RPD allows safe implementation of minimally invasive PD. The current literature shows that RPD is either equivalent, or superior in certain aspects to OPD. Once more centers gain sufficient experience, RPD is likely to demonstrate clear superiority over alternative approaches.
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Affiliation(s)
- Irena Stefanova
- Hepato-Pancreato-Biliary (HPB) Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Francesca Vescio
- Hepato-Pancreato-Biliary (HPB) Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
- General Surgery Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Felix Nickel
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nabeel Merali
- Hepato-Pancreato-Biliary (HPB) Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
- Section of Oncology, Deptartment of Clinical & Experimental Medicine, FHMS, University of Surrey, Guildford, Surrey, UK
| | - Michele Ammendola
- General Surgery Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Rajiv P Lahiri
- Hepato-Pancreato-Biliary (HPB) Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim D Pencavel
- Hepato-Pancreato-Biliary (HPB) Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim R Worthington
- Hepato-Pancreato-Biliary (HPB) Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Adam E Frampton
- Hepato-Pancreato-Biliary (HPB) Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
- Section of Oncology, Deptartment of Clinical & Experimental Medicine, FHMS, University of Surrey, Guildford, Surrey, UK
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9
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Nickel F, Wise PA, Müller PC, Kuemmerli C, Cizmic A, Salg GA, Steinle V, Niessen A, Mayer P, Mehrabi A, Loos M, Müller-Stich BP, Kulu Y, Büchler MW, Hackert T. Short-term Outcomes of Robotic Versus Open Pancreatoduodenectomy: Propensity Score-matched Analysis. Ann Surg 2024; 279:665-670. [PMID: 37389886 DOI: 10.1097/sla.0000000000005981] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The goal of the current study was to investigate the perioperative outcomes of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) in a high-volume center. BACKGROUND Despite RPDs prospective advantages over OPD, current evidence comparing the 2 has been limited and has prompted further investigation. The aim of this study was to compare both approaches while including the learning curve phase for RPD. METHODS A 1:1 propensity score-matched analysis of a prospective database of RPD with OPD (2017-2022) at a high-volume center was performed. The main outcomes were overall- and pancreas-specific complications. RESULTS Of 375 patients who underwent PD (OPD n=276; RPD n=99), 180 were included in propensity score-matched analysis (90 per group). RPD was associated with less blood loss [500 (300-800) vs 750 (400-1000) mL; P =0.006] and more patients without a complication (50% vs 19%; P <0.001). Operative time was longer [453 (408-529) vs 306 (247-362) min; P <0.001]; in patients with ductal adenocarcinoma, fewer lymph nodes were harvested [24 (18-27) vs 33 (27-39); P <0.001] with RPD versus OPD. There were no significant differences for major complications (38% vs 47%; P =0.291), reoperation rate (14% vs 10%; P =0.495), postoperative pancreatic fistula (21% vs 23%; P =0.858), and patients with the textbook outcome (62% vs 55%; P =0.452). CONCLUSIONS Including the learning phase, RPD can be safely implemented in high-volume settings and shows potential for improved perioperative outcomes versus OPD. Pancreas-specific morbidity was unaffected by the robotic approach. Randomized trials with specifically trained pancreatic surgeons and expanded indications for the robotic approach are needed.
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Affiliation(s)
- Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp A Wise
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philip C Müller
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clare Hospital Basel, Basel, Switzerland
| | - Christoph Kuemmerli
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clare Hospital Basel, Basel, Switzerland
| | - Amila Cizmic
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel A Salg
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Verena Steinle
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Anna Niessen
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Mayer
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clare Hospital Basel, Basel, Switzerland
| | - Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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Nickel F, Studier-Fischer A, Hackert T. [Robotic pancreatic surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:165-174. [PMID: 38095648 DOI: 10.1007/s00104-023-02001-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 02/02/2024]
Abstract
Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2-3 years.
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Affiliation(s)
- Felix Nickel
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Alexander Studier-Fischer
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Thilo Hackert
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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11
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Chen H, Weng Y, Zhao S, Wang W, Ji Y, Peng C, Deng X, Shen B. Robotic versus open pancreatoduodenectomy in patients with pancreatic duct adenocarcinoma after the learning curve: a propensity score-matched analysis. Surg Endosc 2024; 38:821-829. [PMID: 38066192 DOI: 10.1007/s00464-023-10530-y] [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: 04/13/2023] [Accepted: 10/12/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Studies have demonstrated that the learning curve plays an important role in robotic pancreatoduodenectomy (RPD). Although improved short-term outcomes of RPD after the learning curve have been reported compared to open pancreatoduodenectomy (OPD), there is a lack of long-term survival analyses. METHODS Patients who underwent curative intended RPD and OPD for pancreatic duct adenocarcinoma (PDAC) between January 2017 and June 2020 were retrospectively reviewed. A 1:2 propensity score matching (PSM) analysis was performed to balance the baseline characteristics between the RPD and OPD groups. RESULTS Of the 548 patients (108 RPD and 440 OPD), 103 RPD patients were matched with 206 OPD patients after PSM. There were 194 (62.8%) men and 115 (37.2%) women, with a median age of 64 (58-69) years. The median overall survival (OS) in the RPD group was 33.2 months compared with 25.7 months in the OPD group (p = 0.058, log-rank). The median disease-free survival (DFS) following RPD was longer than the OPD (18.5 vs. 14.0 months, p = 0.011, log-rank). The RPD group has a lower incidence of local recurrence compared the OPD group (36.9% vs. 51.2%, p = 0.071). Multivariate Cox analysis demonstrated that RPD was independently associated with improved OS (HR 0.70, 95% CI 0.52-0.94, p = 0.019) and DFS (HR 0.66, 95% CI 0.50-0.88, p = 0.005). CONCLUSION After the learning curve, RPD had improved oncologic outcomes in PDAC patients compared to OPD. Future prospective randomized clinical trials will be required to validate these findings.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Shulin Zhao
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yuchen Ji
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Chenghong Peng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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12
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McCarron FN, Yoshino O, Müller PC, Wang H, Wang Y, Ricker A, Mantha R, Driedger M, Beckman M, Clavien PA, Vrochides D, Martinie JB. Expanding the utility of robotics for pancreaticoduodenectomy: a 10-year review and comparison to international benchmarks in pancreatic surgery. Surg Endosc 2023; 37:9591-9600. [PMID: 37749202 DOI: 10.1007/s00464-023-10426-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/31/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) is an emerging alternative to open pancreaticoduodenectomy (OPD). Although RPD offers various theoretical advantages, it is used in less than 10% of all pancreaticoduodenectomies. The aim of this study was to report our 10-year experience and compare RPD outcomes with international benchmarks for OPD. METHODS A retrospective review of a prospectively maintained institutional database was performed of consecutive patients who underwent RPD between January 2011 and December 2021. Patients were categorized into low-risk and high-risk groups according to the selection criteria set by the benchmark study. Their outcomes were compared to the international benchmark cut off values. Outcomes were then evaluated over time to identify improvements in practice and establish a learning curve. RESULTS Of 201 RPDs, 36 were low-risk and 165 high-risk patients. Compared to the OPD benchmarks, outcomes of low-risk patients were within the cutoff values. High-risk patients were outside the cutoff for blood transfusions (26% vs. ≤ 23%), overall complications (78% vs. ≤ 73%), grade I-II complications (68% vs. ≤ 62%), and readmissions (22% vs ≤ 21%). Oncologic outcomes for high-risk patients were within benchmark cutoffs. Cases at the end of the learning curve included more pancreatic cancer (42% from 17%) and fewer low-risk patients (10% from 24%) than those at the beginning. After 41 RPD there was a decline in conversion rates and operative time. Between 95 and 143 cases operative time, transfusion rates, and LOS declined significantly. Complications did not differ over time. CONCLUSION RPD yields results comparable to the established benchmarks in OPD in both low- and high-risk patients. Along the learning curve, RPD evolved with the inclusion of more high-risk cases while outcomes remained within benchmarks. Addition of a robotic HPB surgery fellowship did not compromise outcomes. These results suggest that RPD may be an option for high-risk patients at specialized centers.
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Affiliation(s)
- Frances N McCarron
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC, 2820, USA.
| | - Osamu Yoshino
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Philip C Müller
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Huaping Wang
- Department of Surgery, Carolinas Center for Surgical Outcomes, Wake Forest Center for Biomedical Informatics, Charlotte, NC, USA
| | - Yifan Wang
- Division of HPB and Transplantation, Department of Surgery, McGill University, Montreal, Canada
| | - Ansley Ricker
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Rohit Mantha
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Driedger
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Beckman
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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13
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Zdanowski AH, Wennerblom J, Rystedt J, Andersson B, Tingstedt B, Williamsson C. Predictive Factors for Delayed Gastric Emptying After Pancreatoduodenectomy: A Swedish National Registry-Based Study. World J Surg 2023; 47:3289-3297. [PMID: 37702776 PMCID: PMC10694105 DOI: 10.1007/s00268-023-07175-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy (PD). DGE causes prolonged hospital stay and a decrease in quality of life. This study analyzes predictive factors for development of DGE after PD, also in the absence of surgical complications. METHOD Data from the Swedish National Pancreatic Cancer Registry for patients undergoing standard and pylorus preserving open PD from January 2010 until June 30, 2018, were collected. Data were analyzed in two groups, no DGE and DGE. A subgroup of patients with DGE but without surgical complications was compared to patients without DGE or any other surgical complication. RESULTS In total, 2503 patients were included, of which 470 (19%) had DGE. In the DGE group, 238 had other coexisting surgical complications and 232 had not. Postoperative pancreatic fistula (OR = 4.22, p < 0.001), surgical infection (OR = 1.44, p = 0.013), heart disease (OR = 1.32, p = 0.023) and medical complications (OR = 1.35, p = 0.025) increased the risk for DGE. A standard PD compared with pylorus preserving resection (OR = 1.69, p = 0.001) and a reconstruction with a pancreaticojejunostomy compared with a pancreaticogastrostomy (OR = 1.83, p < 0.001) increased the risk. For patients without surgical complications, a standard PD and reconstruction with pancreaticojejunostomy still increased the risk for DGE. CONCLUSION DGE is more common after standard PD compared to pylorus preserving PD and after reconstruction with PJ compared to PG in this national cohort, both in the presence of other surgical complications as well as in the absence of other complications.
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Affiliation(s)
- A Hörberg Zdanowski
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - J Wennerblom
- Department of Surgery, Institute of Clinical Sciences Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - J Rystedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - Caroline Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden.
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14
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Yu G, Xu S, Kong J, He J, Liu J. Development and validation of web calculators to predict early recurrence and long-term survival in patients with duodenal papilla carcinoma after pancreaticoduodenectomy. BMC Cancer 2023; 23:1129. [PMID: 37985973 PMCID: PMC10662559 DOI: 10.1186/s12885-023-11632-5] [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: 02/01/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Duodenal papilla carcinoma (DPC) is prone to relapse even after radical pancreaticoduodenectomy (PD) (including robotic, laparoscopic and open approach). This study aimed to develop web calculators to predict early recurrence (ER) (within two years after surgery) and long-term survival in patients with DPC after PD. METHODS Patients with DPC after radical PD were included. Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Two web calculators were developed based on independent risk factors in the training cohort and then tested in the validation cohort. RESULTS Of the 251 patients who met the inclusion criteria, 180 and 71 patients were enrolled in the training and validation cohorts, respectively. Multivariate logistic regression analysis revealed that tumor size [Odds Ratio (OR) 1.386; 95% confidence interval (CI) 1070-1.797; P = 0.014]; number of lymph node metastasis (OR 2.535; 95% CI 1.114-5.769; P = 0.027), perineural invasion (OR 3.078; 95% CI 1.147-8.257; P = 0.026), and tumor differentiation (OR 3.552; 95% CI 1.132-11.152; P = 0.030) were independent risk factors for ER. Nomogram based on the above four factors achieved good C-statistics of 0.759 and 0.729 in predicting ER in the training and the validation cohorts, respectively. Time-dependent ROC analysis (timeROC) and decision curve analysis (DCA) revealed that the nomogram provided superior diagnostic capacity and net benefit compared with single variable. CONCLUSIONS This study developed and validated two web calculators that can predict ER and long-term survival in patients with DPC with high degree of stability and accuracy.
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Affiliation(s)
- Guangsheng Yu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial HospitalAffiliated to, Shandong First Medical University , 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Shuai Xu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial HospitalAffiliated to, Shandong First Medical University , 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Junjie Kong
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial HospitalAffiliated to, Shandong First Medical University , 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Jingyi He
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial HospitalAffiliated to, Shandong First Medical University , 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Jun Liu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial HospitalAffiliated to, Shandong First Medical University , 324 Jingwu Road, Jinan, 250021, Shandong, China.
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15
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Huang XT, Wang XY, Xie JZ, Cai JP, Chen W, Chen LH, Yin XY. Learning curves of resection and reconstruction procedures in robotic-assisted pancreatoduodenectomy by a single surgeon: a retrospective cohort study of 160 consecutive cases. Gastroenterol Rep (Oxf) 2023; 11:goad042. [PMID: 37502197 PMCID: PMC10371495 DOI: 10.1093/gastro/goad042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/04/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023] Open
Abstract
Background Robotic-assisted pancreatoduodenectomy (RPD) has been routinely performed in a few of centers worldwide. This study aimed to evaluate the perioperative outcomes and the learning curves of resection and reconstruction procedures in RPD by one single surgeon. Methods Consecutive patients undergoing RPD by a single surgeon at the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between July 2016 and October 2022 were included. The perioperative outcomes and learning curves were retrospectively analysed by using cumulative sum (CUSUM) analyses. Results One-hundred and sixty patients were included. According to the CUSUM curve, the times of resection and reconstruction procedures were shortened significantly after 30 cases (median, 284 vs 195 min; P < 0.001) and 45 cases (median, 138 vs 120 min; P < 0.001), respectively. The estimated intraoperative blood loss (median, 100 vs 50 mL; P < 0.001) and the incidence of clinically relevant post-operative pancreatic fistula (29.2% vs 12.5%; P = 0.035) decreased significantly after 20 and 120 cases, respectively. There were no significant differences in the total number of lymph nodes examined, post-operative major complications, or post-operative length-of-stay between the two groups. Conclusions Optimization of the resection procedure and the acquisition of visual feedback facilitated the performance of RPD. RPD was a safe and feasible procedure in the selected patients.
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Affiliation(s)
| | | | | | - Jian-Peng Cai
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wei Chen
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Liu-Hua Chen
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiao-Yu Yin
- Corresponding author. Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, Guangzhou, Guangdong 510080, P. R. China.
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16
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Lin ZY, Zhang XP, Zhao GD, Li CG, Wang ZH, Liu R, Hu MG. Short-term outcomes of robotic versus open hepatectomy among overweight patients with hepatocellular carcinoma: a propensity score-matched study. BMC Surg 2023; 23:153. [PMID: 37286991 DOI: 10.1186/s12893-023-02058-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/26/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Robotic hepatectomy (RH) has gradually been accepted as it has overcome some of the limitations of open hepatectomy (OH). This study was to compare short-term outcomes in RH and OH for overweight (preoperative body mass index ≥ 25 kg/m²) patients with hepatocellular carcinoma (HCC). METHODS Perioperative and postoperative data from these patients who underwent RH or OH between January 2010 and December 2020 were retrospectively analyzed. Propensity score matching (PSM) analysis was performed to determine the impact of RH versus OH on the prognosis of overweight HCC patients. RESULTS All 304 overweight HCC patients were included, 172 who were underwent RH, and 132 who were underwent OH. After the 1:1 PSM, there were 104 patients in both RH and OH groups. After PSM, the RH group of patients had a shorter operative time, less estimated blood loss (EBL), a longer total clamping time, a shorter postoperative length of stay (LOS), less chance of surgical site infection and less rates of blood transfusion (all P < 0.05) compared to the OH patients. The differences between operative time, EBL and LOS were more significant in obese patients. RH was found to be an independent protective factor of EBL ≥ 400ml relative to OH in overweight patients for the first time. CONCLUSIONS RH was safe and feasible in overweight HCC patients. Compared with OH, RH has advantages in terms of operative time, EBL, postoperative LOS, and surgical site infection. Carefully selected overweight patients should be considered for RH.
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Affiliation(s)
- Zhao-Yi Lin
- Medical School of Chinese PLA, Beijing, 100853, China
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Xiu-Ping Zhang
- Medical School of Chinese PLA, Beijing, 100853, China
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Guo-Dong Zhao
- Medical School of Chinese PLA, Beijing, 100853, China
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Cheng-Gang Li
- Medical School of Chinese PLA, Beijing, 100853, China
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Zhao-Hai Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Rong Liu
- Medical School of Chinese PLA, Beijing, 100853, China.
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
| | - Ming-Gen Hu
- Medical School of Chinese PLA, Beijing, 100853, China.
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
- Department of Hepatobiliary, Pancreatic Surgical Oncology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
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17
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Nakata K, Abe T, Ideno N, Nakamura S, Ikenaga N, Nagayoshi K, Mizuuchi Y, Moriyama T, Ohuchida K, Nakamura M. A left-sided approach for wide mobilization of the pancreas with complete dissection of the Treitz ligament (with video). Surg Endosc 2023:10.1007/s00464-023-10065-2. [PMID: 37142715 DOI: 10.1007/s00464-023-10065-2] [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: 10/07/2022] [Accepted: 04/01/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND In recent years, the number of minimally invasive pancreatoduodenectomy (MIPD) has been increasing; however, the procedure has not been widely accepted due to its complexity and difficulty. We have developed a technique to mobilize the pancreas head using a left-sided approach with a focus on the complete dissection of the Treitz ligament. METHODS This technique focuses on the secure mobilization of the pancreas head using a left-sided approach. First, the transverse mesocolon is flipped upward and the anterior side of the mesojejunum is excised to expose the first jejunal artery (1st JA) from the distal side to its origin. During the procedure, the left sides of the SMA and Treitz ligament are exposed. The Treitz ligament is retracted to the left side and dissected anteriorly. Thereafter, the jejunum is flipped to the right side and the retroperitoneum around the origin of the jejunum and duodenum is dissected to identify the inferior vena cava (IVC). The rest of the Treitz ligament is dissected posteriorly and complete resection of the Treitz ligament releases the limitation of duodenal immobility. Thereafter, dissection proceeds along the anterior wall of the IVC, and mobilization of the pancreas head is completed from the left side. RESULTS A total of 75 consecutive patients underwent MIPD from April 2016 to July 2022. The median operation times of laparoscopic and robotic procedures were 528 min (356-757 min) and 739 min (492-998 min), respectively. The volume of blood loss during laparoscopic and robotic procedures was 415 g (60-4360 g) and 211 g (17-1950 g), respectively. There was no mortality in any of the cases. CONCLUSION Mobilization of the pancreas head and left-sided approach using a caudal view will be a safe and useful technique for MIPD.
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Affiliation(s)
- Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Toshiya Abe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Noboru Ideno
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - So Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kenoki Ohuchida
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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Kemp Bohan PM, Chang SC, Grunkemeier GL, Spitzer HV, Carpenter EL, Adams AM, Vreeland TJ, Nelson DW. Impact of Mediating and Confounding Variables on the Volume-Outcome Association in the Treatment of Pancreatic Cancer. Ann Surg Oncol 2023; 30:1436-1448. [PMID: 36460898 DOI: 10.1245/s10434-022-12908-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/28/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND High-volume centers (HVC), academic centers (AC), and longer travel distances (TD) have been associated with improved outcomes for patients undergoing surgery for pancreatic adenocarcinoma (PAC). Effects of mediating variables on these associations remain undefined. The purpose of this study is to examine the direct effects of hospital volume, facility type, and travel distance on overall survival (OS) in patients undergoing surgery for PAC and characterize the indirect effects of patient-, disease-, and treatment-related mediating variables. PATIENTS AND METHODS Using the National Cancer Database, patients with non-metastatic PAC who underwent resection were stratified by annual hospital volume (< 11, 11-19, and ≥ 20 cases/year), facility type (AC versus non-AC), and TD (≥ 40 versus < 40 miles). Associations with survival were evaluated using multiple regression models. Effects of mediating variables were assessed using mediation analysis. RESULTS In total, 19,636 patients were included. Treatment at HVC or AC was associated with lower risk of death [hazard ratio (HR) 0.90, confidence interval (CI) 0.88-0.92; HR 0.89, CI 0.86-0.91, respectively]. TD did not impact OS. Patient-, disease-, and treatment-related variables explained 25.5% and 41.8% of the survival benefit attained from treatment at HVC and AC, reducing the survival benefit directly attributable to each variable to 4.9% and 6.4%, respectively. CONCLUSIONS Treatment of PAC at HVC and AC was associated with improved OS, but the magnitude of this benefit was less when mediating variables were considered. From a healthcare utilization and cost-resource perspective, further research is needed to identify patients who would benefit most from selective referral to HVC or AC.
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Affiliation(s)
| | - Shu-Ching Chang
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Portland, OR, USA
| | - Gary L Grunkemeier
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Portland, OR, USA
| | - Holly V Spitzer
- Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | | | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX, USA.
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19
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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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20
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Kalabin A, Mani VR, Kruse RL, Schlesselman C, Li KY, Staveley-O'Carroll KF, Kimchi ET. New perspectives on robotic pancreaticoduodenectomy: An analysis of the National Cancer Database. World J Gastrointest Surg 2023; 15:60-71. [PMID: 36741067 PMCID: PMC9896499 DOI: 10.4240/wjgs.v15.i1.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/23/2022] [Accepted: 12/23/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma is a common malignancy. Despite all advancements, the prognosis remains, poor with an overall 5-year survival of only 10.8%. Recently, a robotic platform has become an attractive tool for treating pancreatic cancer (PC). While recent studies indicated improved lymph node (LN) harvest during robotic pancreaticoduodenectomy (PD), data on long-term outcomes are insufficient.
AIM To evaluate absolute LN harvest during PD. Secondary outcomes included evaluating the association between LN harvest and short- and long-term oncological outcomes for three different surgical approaches.
METHODS We conducted an analysis of the National Cancer Database, including patients diagnosed with PC who underwent open, laparoscopic, or robotic PD in 2010-2018. One-way analysis of variance was used to compare continuous variables, chi-square test - for categorical. Overall survival was defined as the time between surgery and death. Median survival time was estimated with the Kaplan-Meier method, and groups were compared with the Wilcoxon test. A Cox proportional hazards model was used to assess the association of covariates with survival after controlling for patient characteristics and procedure type.
RESULTS 17169 patients were included, 8859 (52%) males; mean age 65; 14509 (85%) white. 13816 (80.5%) patients had an open PD, 2677 (15.6%) and 676 (3.9%) - laparoscopic and robotic PD respectively. Mean comorbidity index (Charlson-Deyo Score) 0.50. On average, 18.84 LNs were harvested. Mean LN harvest during open, laparoscopic and robotic PD was 18.59, 19.65 and 20.70 respectively (P < 0.001). On average 2.49 LNs were positive for cancer and did not differ by the procedure type (P = 0.26). Vascular invasion was noted in 42.6% of LNs and did differ by the approach: 42.1% for open, 44.0% for laparoscopic and 47.2% for robotic PD (P = 0.015). Median survival for open PD was 26.1 mo, laparoscopic - 27.2 mo, robotic - 29.1 mo (P = 0.064). Survival was associated with higher LN harvest, while higher number of positive LNs was associated with higher mortality.
CONCLUSION Our study suggests that robotic PD is associated with increased intraoperative LN harvest and has comparable short-term oncological outcomes and survival compared to open and laparoscopic approaches.
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Affiliation(s)
- Aleksandr Kalabin
- Department of Surgery, University of Missouri, Columbia, MO 65212, United States
| | - Vishnu R Mani
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Robin L Kruse
- Department of Surgery, University of Missouri, Columbia, MO 65212, United States
| | - Chase Schlesselman
- Department of Surgery, University of Missouri, Columbia, MO 65212, United States
| | - Kai Yu Li
- Department of Surgery, University of Missouri, Columbia, MO 65212, United States
| | | | - Eric T Kimchi
- Department of Surgery, University of Missouri, Columbia, MO 65212, United States
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21
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Zhang XP, Xu S, Hu MG, Zhao ZM, Wang ZH, Zhao GD, Li CG, Tan XL, Liu R. Short- and long-term outcomes after robotic and open liver resection for elderly patients with hepatocellular carcinoma: a propensity score-matched study. Surg Endosc 2022; 36:8132-8143. [PMID: 35534731 DOI: 10.1007/s00464-022-09236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Robotic liver resection (RLR) has increasingly been accepted as it has overcome some of the limitations of open liver resection (OLR), while the outcomes following RLR in elderly patients with hepatocellular carcinoma (HCC) are still uncertain. This study aimed to evaluate the short and long-term outcomes of RLR vs. OLR in elderly HCC patients. METHODS Perioperative data of elderly patients (≥ 65 years) with HCC who underwent RLR or OLR between January 2010 and December 2020 were retrospectively analyzed. A 1:2 propensity score-matched (PSM) analysis was performed to minimize the differences between RLR and OLR groups. 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 Of the 427 elderly HCC patients included in this study, 113 underwent RLR and 314 underwent OLR. After the 1:2 PSM, there were 100 and 178 patients in the RLR and the OLR groups, respectively. The RLR group had a less estimated blood loss (EBL), a shorter postoperative length of stay (LOS), and a lower complications rate (all P < 0.05), compared with the OLR group before and after PSM. Univariable and multivariable analyses showed that advanced age and surgical approaches were not independent risk factors for long-term prognosis. The two groups of elderly patients who were performed RLR or OLR had similar OS (median OS 52.8 vs. 57.6 months) and RFS (median RFS 20.4 vs. 24.6 months) rates after PSM. CONCLUSIONS RLR was comparable to OLR in feasibility and safety. For elderly patients with HCC, RLR resulted in similar oncologic and survival outcomes as OLR.
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Affiliation(s)
- 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
| | - 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
| | - 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
| | - 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
| | - Zhao-Hai Wang
- 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
| | - Cheng-Gang Li
- 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
| | - 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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22
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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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23
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Napoli N, Kauffmann EF, Caputo R, Ginesini M, Asta F, Gianfaldoni C, Amorese G, Vistoli F, Boggi U. Outcomes of double-layer continuous suture hepaticojejunostomy in pancreatoduodenectomy and total pancreatectomy. HPB (Oxford) 2022; 24:1738-1747. [PMID: 35654670 DOI: 10.1016/j.hpb.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/21/2022] [Accepted: 05/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aims to describe the technique and the results of double-layer continuous suture hepaticojejunostomy (HJ) following pancreatoduodenectomy (PD) and total pancreatectomy (TP). METHODS A prospectively maintained database was analyzed retrospectively to identify incidence and severity of biliary leaks (BL) (ISGLS definition), as well as of HJ stenosis (HJS), cholangitis, and need for redo-HJ (in patients with a follow-up ≥3 years) in a consecutive series of 800 procedures (PD = 603; TP = 197). Predictors of biliary complications were also identified. RESULTS BLs occurred in 5 patients (0.6%), including 2 (0.3%) combined pancreatic and biliary leaks. Rates of HJS, cholangitis, and need for redo-HJ were 6.1%, 5.4%, and 2.0%, respectively. Incidence of BL was 0.6% in open procedures (4/587) and 0.4% in robotic operations (1/213). Incidence of late biliary complications was also equivalent in open and robotic procedures. Occurrence of BL was predicted by ASA IV status and duodenal cancer, HJS by any associated vascular procedure and hepatic duct size < 8 mm, cholangitis by any associated vascular procedure and normal bilirubin/hepatic enzymes, and redo HJ by history of cholecystectomy and neuroendocrine tumor/cancer. DISCUSSION Double layer continuous suture HJ is associated with low BL rates, and an acceptable incidence of late complications.
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Affiliation(s)
- Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | | | - Rosilde Caputo
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Fabio Asta
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
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24
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Short-term outcomes of robotic versus open pancreaticoduodenectomy in elderly patients: A multicenter retrospective cohort study. Int J Surg 2022; 104:106819. [DOI: 10.1016/j.ijsu.2022.106819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 02/07/2023]
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25
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Weng Y, Shen Z, Gemenetzis G, Jin J, Chen H, Deng X, Peng C, Shen B. Oncological outcomes of robotic pancreatectomy in patients with pancreatic cancer who receive adjuvant chemotherapy: A propensity score-matched retrospective cohort study. Int J Surg 2022; 104:106801. [DOI: 10.1016/j.ijsu.2022.106801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022]
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Bahra M, Ossami Saidy RR. Current status of robotic surgery for hepato-pancreato-biliary malignancies. Expert Rev Anticancer Ther 2022; 22:939-946. [PMID: 35863758 DOI: 10.1080/14737140.2022.2105211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Robotic surgery is an emerging aspect of gastrointestinal surgery. Hepato-pancreato-biliary surgery is currently being explored for a broad spectrum of indications, entities, and postoperative outcomes. Noninferiority and financial aspects are the focus of studies. In this review, the impact on oncological therapies is assessed. AREAS COVERED An extensive literature review was conducted, and relevant studies and articles and reviews for robotic surgery in the field of hepato-pancreato-biliary surgery were examined. Special attention was given to the oncological aspects of robotic surgery and its possible impact on the therapy of malignant neoplasms. EXPERT OPINION Robotic-assisted surgery for oncological indications is promising, in part, an established technique that has already shown its advantages in the last decade, although high-quality studies are missing. Upcoming experience must consider the oncological benefit and putative new indications in a rapidly changing field of anti-neoplastic regimens. Also, robotic surgery may possess the ability to accelerate digitalization and AI-based augmentation in this context.
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Affiliation(s)
- Marcus Bahra
- Krankenhaus Waldfriede, Akademisches Lehrkrankenhaus der Charité, Zentrum für Onkologische Oberbauchchirurgie und Robotik, Argentinische Allee 40, 14163 Berlin
| | - Ramin Raul Ossami Saidy
- Krankenhaus Waldfriede, Akademisches Lehrkrankenhaus der Charité, Zentrum für Onkologische Oberbauchchirurgie und Robotik, Argentinische Allee 40, 14163 Berlin
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27
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Single-port (SP) robotic pancreatic surgery using the da Vinci SP system: A retrospective study on prospectively collected data in a consecutive patient cohort. Int J Surg 2022; 104:106782. [DOI: 10.1016/j.ijsu.2022.106782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/04/2022] [Accepted: 07/07/2022] [Indexed: 01/04/2023]
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A commentary on "Robotic versus open pancreaticoduodenectomy, comparing therapeutic indexes; a systematic review" (Int J Surg 2022;101:106633). Int J Surg 2022; 104:106692. [PMID: 35705175 DOI: 10.1016/j.ijsu.2022.106692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 05/28/2022] [Indexed: 11/21/2022]
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Schmidt T, Belyaev O, Uhl W, Bruns CJ. [Surgical treatment of pancreatic cancer-What is new?]. Chirurg 2022; 93:446-452. [PMID: 35357553 DOI: 10.1007/s00104-022-01618-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/03/2022]
Abstract
The incidence of pancreatic ductal adenocarcinoma is continuously increasing and will become the second leading cause of cancer-related death in Europe and the USA by 2030. With a 5-year overall survival rate of less than 10% the prognosis remains poor. So far surgical tumor resection remains the only curative treatment option, which is now partially supported by multimodal neoadjuvant and adjuvant therapy concepts. Due to the aggressive tumor biology patients with advanced pancreatic cancer in particular can profit from these multimodal therapy concepts. Additionally, in recent years surgical treatment was optimized, the criteria for tumor resectablity were defined and minimally invasive surgery was widely introduced. This review article summarizes the newest developments and the new German S3 guidelines concerning surgery of pancreatic cancer.
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Affiliation(s)
- Thomas Schmidt
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Orlin Belyaev
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Universitätsklinikum, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Waldemar Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Universitätsklinikum, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Christiane J Bruns
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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Evaluating the learning curve of robotic radical antegrade modular pancreatosplenectomy: A retrospective cohort study. Int J Surg 2022; 101:106612. [DOI: 10.1016/j.ijsu.2022.106612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/14/2022] [Accepted: 04/06/2022] [Indexed: 11/21/2022]
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Hii A, Liu DS, Kholmurodova F, Irvine T, Bright T, Watson DI, Thompson SK. Partial Fundoplication is Effective Treatment for Female Patients with Gastroesophageal Reflux and Scleroderma: A Multicenter Comparative Cohort Study. World J Surg 2021; 46:147-153. [PMID: 34590163 DOI: 10.1007/s00268-021-06326-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with scleroderma often suffer from dysphagia and gastroesophageal reflux disease (GERD). Partial fundoplication is a validated anti-reflux procedure for GERD but may worsen dysphagia in scleroderma patients. Its utility in these patients is unknown. Here, we evaluate the efficacy and acceptability of partial fundoplication for the treatment of medically refractory GERD in patients with scleroderma. METHODS Analysis of a prospectively maintained database of patients who underwent fundoplication across 14 hospitals between 1991 and 2019. Perioperative outcomes, reintervention rates, heartburn, dysphagia, and patient satisfaction were assessed at 3 months, 1- and 3-years post-surgery. RESULTS A total of 17 patients with scleroderma were propensity score matched to 526 non-scleroderma controls. All underwent a partial fundoplication. Perioperative outcomes including complication rate, length of stay, and need for reoperation were similar between the two groups. Compared to baseline, both groups reported significantly improved heartburn at 3 months, 1- and 3-years following partial fundoplication. Surgery was equally effective at controlling heartburn across all follow-up timepoints in patients with or without scleroderma. Dysphagia to solids was more common in patients with scleroderma than controls at 3-months post-surgery, but was not significantly different to controls at 1- and 3-year follow-up. Satisfaction scores were high and comparable between both groups across all postoperative timepoints, with 100% of patients with scleroderma reporting that their initial choice to undergo surgery was correct. CONCLUSIONS Partial fundoplication controls reflux and is associated with a transient period of dysphagia to solids in patients with scleroderma. This approach is safe, effective and acceptable for patients with scleroderma and medically refractory GERD.
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Affiliation(s)
- Amanda Hii
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia
| | - David S Liu
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia. .,Department of Surgery, Austin Hospital, Heidelberg, VIC, 3084, Australia.
| | - Feruza Kholmurodova
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - Tanya Irvine
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - Tim Bright
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia.,Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - David I Watson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia.,Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - Sarah K Thompson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia.,Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
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