Matched Case-Control Comparative Study of Laparoscopic Versus Open Pancreaticoduodenectomy for Malignant Lesions. Surg Laparosc Endosc Percutan Tech. 2018;28:47-51. [PMID: 28212257 DOI: 10.1097/sle.0000000000000381]

Surgeon Preference and Clinical Outcome of 3D Vision Compared to 2D Vision in Laparoscopic Surgery: Systematic Review and Meta-Analysis of Randomized Trials

Objective

To assess the added value of 3-dimensional (3D) vision, including high definition (HD) technology, in laparoscopic surgery in terms of surgeon preference and clinical outcome.

Background

The use of 3D vision in laparoscopic surgery has been suggested to improve surgical performance. However, the added value of 3D vision remains unclear as a systematic review of randomized controlled trials (RCTs) comparing 3D vision including HD technology in laparoscopic surgery is currently lacking.

Methods

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines with a literature search up to May 2023 using PubMed and Embase (PROSPERO, CRD42021290426). We included RCTs comparing 3D versus 2-dimensional (2D) vision in laparoscopic surgery. The primary outcome was operative time. Meta-analyses were performed using the random effects model to estimate the pooled effect size expressed in standard mean difference (SMD) with corresponding 95% confidence intervals (CIs). The level of evidence and quality was assessed according to the Cochrane risk of bias tool.

Results

Overall, 25 RCTs with 3003 patients were included. Operative time was reduced by 3D vision (-8.0%; SMD, -0.22; 95% CI, -0.37 to -0.06; P = 0.007; n = 3003; 24 studies; I 2 = 75%) compared to 2D vision. This benefit was mostly seen in bariatric surgery (-16.3%; 95% CI, -1.28 to -0.21; P = 0.006; 2 studies; n = 58; I 2 = 0%) and general surgery (-6.7%; 95% CI, -0.34 to -0.01; P = 0.036; 9 studies; n = 1056; I 2 = 41%). Blood loss was nonsignificantly reduced by 3D vision (SMD, -0.33; 95% CI, -0.68 to 0.017; P = 0.060; n = 1830; I 2 = 92%). No differences in the rates of morbidity (14.9% vs 13.5%, P = 0.644), mortality (0% vs 0%), conversion (0.8% vs 0.9%, P = 0.898), and hospital stay (9.6 vs 10.5 days, P = 0.078) were found between 3D and 2D vision. In 15 RCTs that reported on surgeon preference, 13 (87%) reported that the majority of surgeons favored 3D vision.

Conclusions

Across 25 RCTs, this systematic review and meta-analysis demonstrated shorter operative time with 3D vision in laparoscopic surgery, without differences in other outcomes. The majority of surgeons participating in the RCTs reported in favor of 3D vision.

Laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy for carcinoma of the ampulla of Vater in a medium-volume center: a propensity score matching analysis

OBJECTIVE

To compare the efficacy of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in a medium-volume medical center.

METHODS

Data for patients who underwent OPD or LPD for carcinoma of the ampulla of Vater (VPC) between January 2017 and June 2022 were acquired retrospectively. Propensity score-matching (PSM) analysis was performed to balance the baseline characteristics between the groups. The primary outcome was disease-free survival (DFS). Cox regression analysis was used to explore the independent risk factors for DFS.

RESULTS

A total of 124 patients with pathologically diagnosed VPC were included. After 1:1 matching, there were 23 cases each in the OPD and LPD groups. Kaplan-Meier survival analyses showed that the median DFS in the OPD and LPD groups was identical (16.0 months vs 16.0 months, respectively). Multivariate Cox regression analysis showed that low levels of alkaline phosphatase and γ-glutamyl transpeptidase, positive surgical margin, and lymph node enlargement were independent risk factors for DFS.

CONCLUSION

LPD in medium-volume centers with acceptable technical conditions may approach or even achieve the efficacy of LPD in large-volume centers.

Evolution of laparoscopic pancreaticoduodenectomy at Westmead Hospital

BACKGROUND

Despite its proposed benefits, laparoscopic pancreaticoduodenectomy (LPD) has not been widely adopted due to its technical complexity and steep learning curve. The aim of this study was to report a single surgeon's experience in the stepwise implementation of LPD and evolution of technique over a nine-year period in a moderate-high volume unit.

METHODS

Carefully selected patients underwent LPD initially by hybrid approach (laparoscopic resection and open reconstruction), which evolved into a total LPD (laparoscopic resection and reconstruction). Data was prospectively collected to include patient characteristics, intraoperative data, evolution of technique and postoperative outcomes.

RESULTS

A total of 25 patients underwent hybrid LPD (HLPD) and 20 patients underwent total LPD (TLPD). There was no 90-day mortality. Three patients developed a postoperative pancreatic fistula (POPF), all of which occurred in patients undergoing HLPD. There was no POPF in 20 consecutive TLPD. There was no evidence of anastomotic strictures in the hepaticojejunostomy in patients undergoing TLPD at long term follow up.

CONCLUSION

A gradual and cautious progression from HLPD to TLPD is essential to ensure safe implementation into a unit. LPD should only be considered in carefully selected patients, with outcomes subjected to regular and rigorous independent audit.

Perioperative Outcomes and Long-Term Survival of Laparoscopic Pancreaticoduodenectomy: A Retrospective Study of 653 Cases in a Single Institution

Introduction: Laparoscopic pancreaticoduodenectomy (LPD) is gaining wide acceptance within pancreatic surgery. However, longitudinal data are lacking. The aim of this study was to analyze and assess the short-term outcomes and long-term survival of LPD over a duration of 8 years. Methods: Patients who underwent LPD in our institution between November 2013 and September 2021 were included in this study. The perioperative outcomes were statistically analyzed. The long-term survival was studied over a median follow-up duration of 13 months. Results: In total, 653 consecutive patients treated at our institution were included, of which 617 cases underwent standard LPD and 36 cases underwent LPD with vascular resection. The rate of death in hospital, reoperation, postpancreatectomy hemorrhage, postoperative pancreatic fistula, and delayed gastric emptying were 4.4%, 10.3%, 11.9%, 12.9%, and 6.1% respectively. There were statistical differences in the intraoperative blood loss and transfusion, operation time, and the R0 resection rate between the LPD cases and LPD with vascular resection cases. A total of 526 cases were pathologically diagnosed of cancer. The 1-, 3-, and 5-year survival rates were 49.2%, 17.9%, and 17.9%, respectively, for pancreatic cancer with the median survival time of 12 months. The 1-, 3-, and 5-year survival rates were 76.9%, 60.8%, and 52.5%, respectively, for bile duct cancer with the median survival time of 35 months. The 1-, 3-, and 5-year survival rates were 80.2%, 62.2%, and 52.9%, respectively, for duodenal cancer with the median survival time of 53 months. The 1-, 3-, and 5-year survival rates were 72.5%, 54.5%, and 50%, respectively, for ampullary cancer with the median survival time of 55 months. Conclusion: LPD is a feasible and oncologically acceptable procedure with satisfying perioperative outcomes and long-term survival in a high-volume institution.

Laparoscopic versus open pancreaticoduodenectomy for pancreatic and periampullary tumor: A meta-analysis of randomized controlled trials and non-randomized comparative studies

Objective

This meta-analysis compares the perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to those of open pancreaticoduodenectomy (OPD) for pancreatic and periampullary tumors.

Background

LPD has been increasingly applied in the treatment of pancreatic and periampullary tumors. However, the perioperative outcomes of LPD versus OPD are still controversial.

Methods

PubMed, Web of Science, EMBASE, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) and non-randomized comparative trials (NRCTs) comparing LPD versus OPD for pancreatic and periampullary tumors. The main outcomes were mortality, morbidity, serious complications, and hospital stay. The secondary outcomes were operative time, blood loss, transfusion, postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), bile leak (BL), delayed gastric emptying (DGE), lymph nodes harvested, R0 resection, reoperation, and readmission. RCTs were evaluated by the Cochrane risk-of-bias tool. NRCTs were assessed using a modified tool from the Methodological Index for Non-randomized Studies. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42022338832).

Results

Four RCTs and 35 NRCTs concerning a total of 40,230 patients (4,262 LPD and 35,968 OPD) were included. Meta-analyses showed no significant differences in mortality (OR 0.91, p = 0.35), serious complications (OR 0.97, p = 0.74), POPF (OR 0.93, p = 0.29), PPH (OR 1.10, p = 0.42), BL (OR 1.28, p = 0.22), harvested lymph nodes (MD 0.66, p = 0.09), reoperation (OR 1.10, p = 0.41), and readmission (OR 0.95, p = 0.46) between LPD and OPD. Operative time was significantly longer for LPD (MD 85.59 min, p < 0.00001), whereas overall morbidity (OR 0.80, p < 0.00001), hospital stay (MD -2.32 days, p < 0.00001), blood loss (MD -173.84 ml, p < 0.00001), transfusion (OR 0.62, p = 0.0002), and DGE (OR 0.78, p = 0.002) were reduced for LPD. The R0 rate was higher for LPD (OR 1.25, p = 0.001).

Conclusions

LPD is associated with non-inferior short-term surgical outcomes and oncologic adequacy compared to OPD when performed by experienced surgeons at large centers. LPD may result in reduced overall morbidity, blood loss, transfusion, and DGE, but longer operative time. Further RCTs should address the potential advantages of LPD over OPD.

Systematic review registration

PROSPERO, identifier CRD42022338832.

Comparison of safety and effectiveness between laparoscopic and open pancreatoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Validity of the laparoscopic approach in pancreatic head lesion remains debatable. This study aims to compare the safety and effectiveness of laparoscopic pancreatoduodenectomy (LPD) and open pancreatoduodenectomy (OPD) and investigate the source of heterogeneity from surgeons' and patients' perspectives.

METHOD

We searched PubMed, Cochrane, Embase, and Web of Science for studies published before February 1, 2021. Of 6578 articles, 81 were full-text reviewed. The primary outcome was mortality. Three independent reviewers screened and extracted the data and resolved disagreements by consensus. Studies were evaluated for quality using ROB2.0 and ROBINS-I. According to different study designs, sensitivity and meta-regression analyses were conducted to explore the heterogeneity source. This meta-analyses was also conducted to explore the learning curve's heterogeneity. This study was registered with PROSPERO, CRD42021234579.

RESULTS

We analyzed 34 studies involving 46,729 patients (4705 LPD and 42,024 OPD). LPD was associated with lower (P = 0.025) in unmatched studies (P = 0.017). No differences in mortality existed in randomized controlled trials (P = 0.854) and matched studies (P = 0.726). Sensitivity analysis found no significant difference in mortality in elderly patients, patients with pancreatic cancer, and in high- and low-volume hospitals (all P > 0.05). In studies at the early period of LPD (<40 cases), higher mortality (P < 0.001) was found (all P < 0.05).LPD showed non-inferiority in length of stay, complications, and survival outcomes in all analyses.

CONCLUSION

In high-volume centers with adequate surgical experience, LPD in selected patients appears to be a valid alternative to LPD with comparable mortality, LOS, complications, and survival outcomes.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

Adverse Impact of Intraoperative Conversion on the Postoperative Course Following Laparoscopic Pancreaticoduodenectomy

PURPOSE

The aim of the current study was to evaluate the adverse clinical impact of intraoperative conversion during laparoscopic pancreaticoduodenectomy (LPD).

MATERIALS AND METHODS

The medical records of patients who underwent pancreaticoduodenectomy (PD) were retrospectively reviewed. Perioperative clinical variables were compared between patients who underwent converted PD (cPD) and initially planned open PD (OPD) to investigate the clinical impact and predictive factors of intraoperative conversion during LPD.

RESULTS

A total of 171 patients were included. Among them, 31 patients (19.3%) were found to have intraoperative conversion during LPD. Failure of progression due to severe adhesion (12 patients, 7%) and major vessel invasion (7 patients, 4%) were the two most frequent reasons for conversion. On multivariate analysis, age [Exp(β)=1.044, p=0.044] and pancreatic texture [Expa(β)=2.431, p=0.039) were found to be independent factors for predicting intraoperative conversion during LPD. In comparative analysis with the OPD group, the cPD group had a longer operation time (516.8 min vs. 449.9 min, p=0.001), higher rate of postoperative hemorrhage (12.1% vs. 0.85%, p=0.008), higher reoperation rate (9.1% vs. 0%, p=0.01), and higher cost (21886.4 USD vs. 17168.9 USD, p=0.018).

CONCLUSION

Intraoperative conversion during LPD can have an adverse clinical impact on the postoperative course following LPD. Appropriate patients selection and improvement of surgical techniques will be crucial for unnecessary intraoperative conversion and safe LPD.

Nomogram and a predictive model for postoperative hemorrhage in preoperative patients of laparoscopic pancreaticoduodectomy

To develop a predictive model and a nomogram for predicting postoperative hemorrhage in preoperative patients undergoing laparoscopic pancreaticoduodenectomy (LPD). A total of 409 LPD patients that underwent LPD by the same surgical team between January 2014 and December 2020 were included as the training cohort. The preoperative data of patients were statistically compared and analyzed for exploring factors correlated with postoperative hemorrhage. The predictive model was developed by multivariate logistic regression and stepwise (stepAIC) selection. A nomogram based on the predictive model was developed. The discriminatory ability of the predictive model was validated using the receiver operating characteristic (ROC) curve and leave-one-out method. The statistical analysis was performed using R 3.5.1 (www.r-project.org). The predictive model including the risk-associated factors of postoperative hemorrhage was as follows: 2.695843 − 0.63056 × (Jaundice = 1) − 1.08368 × (DM = 1) − 2.10445 × (Hepatitis = 1) + 1.152354 × (Pancreatic tumor = 1) + 1.071354 × (Bile duct tumor = 1) − 0.01185 × CA125 − 0.04929 × TT − 0.08826 × APTT + 26.03383 × INR − 1.9442 × PT + 1.979563 × WBC − 2.26868 × NEU − 2.0789 × LYM − 0.02038 × CREA + 0.00459 × AST. A practical nomogram based on the model was obtained. The internal validation of ROC curve was statistically significant (AUC = 0.7758). The validation by leave-one-out method showed that the accuracy of the model and the F measure was 0.887 and 0.939, respectively. The predictive model and nomogram based on the preoperative data of patients undergoing LPD can be useful for predicting the risk degree of postoperative hemorrhage.

A Case-matched Comparative Study of Laparoscopic Versus Open Pancreaticoduodenectomy

BACKGROUND

The laparoscopic approach to pancreaticoduodenectomy (LPD) is technically demanding, but may offer benefits over open surgery [open pancreaticoduodenectomy (OPD)]. The aim of this study was to compare the outcomes of these 2 approaches at a tertiary cancer center from the Middle East.

MATERIALS AND METHODS

Fifty consecutive patients who underwent LPD (n=12) and OPD (n=38) between 2015 and 2018 were considered. One surgeon performed LPD for "all comers," while 3 other surgeons performed open surgery. Patients were randomly matched on a 1:2 basis for pathology (benign vs. malignant), malignancy size (±1 cm), and whether the pancreatic duct was dilated (>3 mm).

RESULTS

Six patients were excluded, leaving 44 patients, of whom 33 were matched (LPD n=11, OPD n=22). The groups were comparable for age (57 vs. 63 y, P=0.123) and sex distribution (female; 55% vs. 45%, P=0.721), tumor size (3 cm in each group), frequency of pancreatic duct dilatation (45% in each group), and malignant pathology (82% in each group). There were no conversions to open surgery. Although the operating time for LPD was significantly longer (680 vs. 313 min, P<0.0001), LPD was associated with significantly shorter primary (4.7 vs. 7.8 d, P<0.0001) and total hospital stay that included readmissions (4.7 vs. 8.9 d, P<0.0001). There were no significant differences in blood loss (200 vs. 325 mL, P=0.082), overall complication rate (36.4% vs. 59.1%, P=0.282), or clinically significant complications (9.1% vs. 22.2%, P=0.643) and readmissions (0 vs. 4 patients). In patients with malignant disease, there were no differences with regard to the number of lymph nodes retrieved (18 vs. 12, P=0.095) and frequency of R0 resections (77.8% in each group).

CONCLUSION

In experienced hands, the laparoscopic approach to pancreaticoduodenectomy seems to offer advantages over open surgery in terms of reduction in hospital stay while maintaining an equivalent oncologic resection.

Fistula risk score-adjusted comparison of postoperative pancreatic fistula following laparoscopic vs open pancreatoduodenectomy

BACKGROUND

To evaluate a risk-adjusted comparison of clinically relevant postoperative pancreatic fistula POPF (CR-POPF) following laparoscopic pancreatoduodenectomy (LPD) vs open pancreatoduodenectomy (OPD) using the fistula risk score (FRS).

METHODS

We retrospectively analyzed 579 patients who underwent LPD (n = 274) or OPD (n = 305) between 2012 and 2019 at two tertiary hospitals. Using the FRS, the risk was stratified into four categories; negligible, low, intermediate and high risk.

RESULTS

The median FRS was significantly higher in the LPD than in the OPD group (5.4 ± 1.2 vs 3.9 ± 1.8, P < .001). The overall incidence of CR-POPF in the LPD vs OPD groups were 16.4% vs 17.7% (P = .187). When POPF risks were stratified by FRS, CR-POPF following LPD vs OPD in patients with low risk (0% vs 6.3%, P = .294), intermediate risk (16.1% vs 22.9%, P = .053) and high risk (33.3% vs 27.3%, P = .577) were not significantly different.

CONCLUSION

Despite a higher risk score in the LPD group, the CR-POPF was similar following both procedures in the unadjusted and FRS-risk-adjusted comparisons. The CR-POPF was more significantly affected by patient risk factors such as the soft pancreas and small pancreatic duct.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Laparoscopic versus open pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matching analysis

BACKGROUND

A growing body of evidence supports the use of laparoscopic pancreaticoduodenectomy (LPD) as an efficient and feasible surgical technique. However, few studies have investigated its applicability in pancreatic ductal adenocarcinoma (PDAC), and the long-term efficacy of LPD on PDAC remains unclear. This study aimed to compare the short- and long-term outcomes between LPD and open pancreaticoduodenectomy (OPD) for PDAC.

METHODS

The data of patients who had OPD or LPD for PDAC between January 2013 and September 2017 were retrieved. Their postoperative outcomes and survival were compared after propensity score matching.

RESULTS

A total of 309 patients were included. After a 2:1 matching, 93 cases in the OPD group and 55 in the LPD group were identified. Delayed gastric emptying (DGE), particularly grade B/C DGE, occurred less frequently in the LPD group than in the OPD group (1.8% vs. 36.6%, P < 0.001; 1.8% vs. 22.6%, P = 0.001). The overall complication rates were significantly lower in the LPD group than in the OPD group (49.1% vs. 71.0%, P = 0.008), whereas the rates of major complications were similar (10.9% vs. 14.0%, P = 0.590). In addition, the median overall survival was comparable between the two groups (20.0 vs. 18.7 months, P = 0.293).

CONCLUSION

LPD was found to be technically feasible with efficacy similar to OPD for patients with PDAC.

Is total laparoscopic pancreaticoduodenectomy superior to open procedure? A meta-analysis

BACKGROUND

Laparoscopy has been widely used in general surgical procedures, but total laparoscopic pancreaticoduodenectomy (TLPD) is still a complex and challenging surgery that is only performed in a small number of patients at a few large academic medical centers. Although the safety and feasibility of TLPD have been established, few studies have compared it with open pancreaticoduodenectomy (OPD) with regard to perioperative and oncological outcomes. Therefore, we carried out a meta-analysis to evaluate whether TLPD is superior to OPD.

AIM

To compare the treatment outcomes of TLPD and OPD in order to assess the safety and feasibility of TLPD.

METHODS

We conducted a systematic search of studies comparing TLPD with OPD that were published in the PubMed, EMBASE, and Cochrane Library databases through December 31, 2018. The studies comparing TLPD and OPD with at least one of the outcomes we were interested in and with more than 10 cases in each group were included in this analysis. The Newcastle-Ottawa scale was used to assess the quality of the nonrandomized controlled trials and the Jadad scale was used to assess the randomized controlled trials. Intraoperative data, postoperative complications, and oncologic outcomes were evaluated. The meta-analysis was performed using Review Manager Software version 5.3. Random or fixed-effects meta-analyses were undertaken to measure the pooled estimates.

RESULTS

A total of 4790 articles were initially identified for our study. After screening, 4762 articles were excluded and 28 studies representing 39771 patients (3543 undergoing TLPD and 36228 undergoing OPD) were eventually included. Patients who underwent TLPD had less intraoperative blood loss [weighted mean difference (WMD) = -260.08 mL, 95% confidence interval (CI): (-336.02, -184.14) mL, P < 0.00001], a lower blood transfusion rate [odds ratio (OR) = 0.51, 95%CI: 0.36-0.72, P = 0.0001], a lower perioperative overall morbidity (OR = 0.82, 95%CI: 0.73-0.92, P = 0.0008), a lower wound infection rate (OR = 0.48, 95%CI: 0.34-0.67, P < 0.0001), a lower pneumonia rate (OR = 0.72, 95%CI: 0.60-0.85, P = 0.0002), a shorter duration of intensive care unit (ICU) stay [WMD = -0.28 d, 95%CI (-2.88, -1.29) d, P < 0.00001] and a shorter length of hospital stay [WMD = -3.05 d, 95%CI (-3.93, -2.17), P < 0.00001], a lower rate of discharge to a new facility (OR = 0.55, 95%CI: 0.39-0.78, P = 0.0008), and a lower 30-d readmission rate (OR = 0.81, 95%CI: 0.68-0.95, P = 0.10) than those who underwent OPD. In addition, the TLPD group had a higher R0 rate (OR = 1.28, 95%CI: 1.13-1.44, P = 0.0001) and more lymph nodes harvested (WMD = 1.32, 95%CI: 0.57-2.06, P = 0.0005) than the OPD group. However, the patients who underwent TLPD experienced a significantly longer operative time (WMD = 77.92 min, 95%CI: 40.89-114.95, P < 0.0001) and had a smaller tumor size than those who underwent OPD [WMD = -0.32 cm, 95%CI: (-0.58, -0.07) cm, P = 0.01]. There were no significant differences between the two groups in the major morbidity, postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, bile leak, gastroenteric anastomosis fistula, intra-abdominal abscess, bowel obstruction, fluid collection, reoperation, ICU admission, or 30-d and 90-d mortality rates. For malignant tumors, the 1-, 2-, 3-, 4- and 5-year overall survival rates were not significantly different between the two groups.

CONCLUSION

This meta-analysis indicates that TLPD is safe and feasible, and may be a desirable alternative to OPD, although a longer operative time is needed and only smaller tumors can be treated.

Minimally invasive pancreatoduodenectomy is associated with lower morbidity compared to open pancreatoduodenectomy: An updated meta-analysis of randomized controlled trials and high-quality nonrandomized studies

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) is being increasingly performed as an alternative to open pancreatoduodenectomy (OPD) in selected patients. Our study aimed to present a meta-analysis of the high-quality studies conducted that compared MIPD to OPD performed for pancreatic head and periampullary diseases.

METHODS

A systematic review of the available literature was performed to identify those studies conducted that compared MIPD to OPD. Here, all randomized controlled trials identified were included, while the selection of high-quality, nonrandomized comparative studies were based on a validated tool (i.e., Methodological Index for Nonrandomized Studies). Intraoperative outcomes, postoperative recovery, oncologic clearance, and postoperative complications were also evaluated.

RESULTS

Sixteen studies matched the selection criteria, including a total of 3168 patients (32.1% MIPD, 67.9% OPD). The pooled data showed that MIPD was associated with a longer operative time (weighted mean difference [WMD] = 80.89 minutes, 95% confidence interval [CI]: 39.74-122.05, P < .01), less blood loss (WMD = -227.62 mL, 95% CI: -305.48 to -149.75, P < .01), shorter hospital stay (WMD = -4.68 days, 95% CI: -5.52 to -3.84, P < .01), and an increase in retrieved lymph nodes (WMD = 1.85, 95% CI: 1.33-2.37, P < .01). Furthermore, the overall morbidity was significantly lower in the MIPD group (OR = 0.67, 95% CI: 0.54-0.82, P < .01), as were total postoperative pancreatic fistula (POPF) (OR = 0.79, 95% CI: 0.63-0.99, P = .04), delayed gastric emptying (DGE) (OR = 0.71, 95% CI: 0.52-0.96, P = .02), and wound infection (OR = 0.56, 95% CI: 0.39-0.79, P < .01). However, there were no statistically significant differences observed in major complications, clinically significant POPFs, reoperation rate, and mortality.

CONCLUSION

Our study suggests that MIPD is a safe alternative to OPD, as it is associated with less blood loss and better postoperative recovery in terms of the overall postoperative complications as well as POPF, DGE, and wound infection. Methodologic high-quality comparative studies are required for further evaluation.

The Yonsei experience of 104 laparoscopic pancreaticoduodenectomies: a propensity score-matched analysis with open pancreaticoduodenectomy

BACKGROUND

With continued technical advances in surgical instruments and growing expertise, several surgeons have performed laparoscopic pylorus preserving pancreaticoduodenectomy (L-PPPD) safely with good results, and the laparoscopic approach is being performed more frequently. We performed over 100 cases of L-PPPD and compared their outcomes to those of open PPPD (O-PPPD) using the large sample size. The aim of the present study was to evaluate the safety and feasibility of L-PPPD compared with O-PPPD.

METHODS

From September 2012 to June 2017, PPPD was performed for 217 patients at Yonsei University Severance Hospital by a single surgeon. Patients were divided into two groups: those who underwent O-PPPD (n = 113) and those who underwent L-PPPD (n = 104). We performed a 1:1 propensity score-matched (PSM) analysis and retrospectively analyzed the demographic and surgical outcomes. We also reviewed all previous studies of more than 100 cases.

RESULTS

The L-PPPD group had lesser intraoperative blood loss than the O-PPPD group (548.1 ml vs. 244.7 ml; p < 0.001). Both groups showed similar rates of negative resection margins (99.1% vs. 96.2%; p = 0.196). Overall complication rates did not differ significantly between O-PPPD and L-PPPD (39.8% vs. 35.6%; p = 0.519). The clinically relevant postoperative pancreatic fistula (POPF) rates in the O-PPPD and L-PPPD groups were 18.8% and 13.5%, respectively (p = 0.311). There was no difference in 30- and 90-day mortality rates between the two groups (p = 0.479). Similar results were obtained after PSM analysis.

CONCLUSIONS

L-PPPD can be a good alternative option for well-selected patients with periampullary lesions requiring PPPD.

Laparoscopic pancreaticoduodenectomy: are the best times coming?

Background

The introduction of laparoscopic technology has greatly promoted the development of surgery, and the trend of minimally invasive surgery is becoming more and more obvious. However, there is no consensus as to whether laparoscopic pancreaticoduodenectomy (LPD) should be performed routinely.

Main body

We summarized the development of laparoscopic pancreaticoduodenectomy (LPD) in recent years by comparing with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD) and evaluated its feasibility, perioperative, and long-term outcomes including operation time, length of hospital stay, estimated blood loss, and overall survival. Then, several relevant issues and challenges were discussed in depth.

Conclusion

The perioperative and long-term outcomes of LPD are no worse and even better in length of hospital stay and estimated blood loss than OPD and RPD except for a few reports. Though with strict control of indications, standardized training, and learning, ensuring safety and reducing cost are still and will always the keys to the healthy development of LPD; the best times for it are coming.

Surgical and oncological outcomes of our first 59 cases of robotic pancreaticoduodenectomy

PURPOSE

Robotics has shown encouraging results for a number of technically demanding abdominal surgeries including pancreaticoduodenectomy, which has originally represented a relative contraindication to the application of the minimally-invasive technique. We aimed to investigate the perioperative, clinicopathologic, and oncological outcomes of robot-assisted pancreaticoduodenectomy by assessing a consecutive series of totally robotic procedures.

METHODS

All consecutive patients who underwent robotic pancreaticoduodenectomy were included in the present analysis. Perioperative, clinicopathologic and oncological outcomes were examined. In order to investigate the role of the learning curve, surgical outcomes were also used to compare the early and the late phase of our experience.

RESULTS

A total of 59 patients underwent surgery. Median hospital stay was 9 days (5 - 110), with an overall morbidity and mortality of 37% and 3%, respectively. Of note, the rate of clinically relevant pancreatic fistula was 11.8%. R0 resections were achieved in 96% of patients and the 3-year disease-free and overall survivals were 37.2 and 61.9%, respectively. Overall, surgical outcomes did not vary significantly between the first and the late phase of the series.

CONCLUSIONS

Robotic pancreaticoduodenectomy can be performed competently. It satisfies all features of oncological adequacy and may offer a number of advantages over standard procedures in terms of surgical results.

Expanding laparoscopic pancreaticoduodenectomy to pancreatic-head and periampullary malignancy: major findings based on systematic review and meta-analysis

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) remains to be established as a safe and effective alternative to open pancreaticoduodenectomy (OPD) for pancreatic-head and periampullary malignancy. The purpose of this meta-analysis was to compare LPD with OPD for these malignancies regarding short-term surgical and long-term survival outcomes.

METHODS

A literature search was conducted before March 2018 to identify comparative studies in regard to outcomes of both LPD and OPD for the treatment of pancreatic-head and periampullary malignancies. Morbidity, postoperative pancreatic fistula (POPF), mortality, operative time, estimated blood loss, hospitalization, retrieved lymph nodes, and survival outcomes were compared.

RESULTS

Among eleven identified studies, 1196 underwent LPD, and 8247 were operated through OPD. The pooled data showed that LPD was associated with less morbidity (OR = 0.57, 95%CI: 0.41~ 0.78, P < 0.01), less blood loss (WMD = - 372.96 ml, 95% CI, - 507.83~ - 238.09 ml, P < 0.01), shorter hospital stays (WMD = - 197.49 ml, 95% CI, - 304.62~ - 90.37 ml, P < 0.01), and comparable POPF (OR = 0.85, 95%CI: 0.59~ 1.24, P = 0.40), and overall survival (HR = 1.03, 95%CI: 0.93~ 1.14, P = 0.54) compared to OPD. Operative time was longer in LPD (WMD = 87.68 min; 95%CI: 27.05~ 148.32, P < 0.01), whereas R0 rate tended to be higher in LPD (OR = 1.17; 95%CI: 1.00~ 1.37, P = 0.05) and there tended to be more retrieved lymph nodes in LPD (WMD = 1.15, 95%CI: -0.16~ 2.47, P = 0.08), but these differences failed to reach statistical significance.

CONCLUSIONS

LPD can be performed as safe and effective as OPD for pancreatic-head and periampullary malignancy with respect to both surgical and oncological outcomes. LPD is associated with less intraoperative blood loss and postoperative morbidity and may serve as a promising alternative to OPD in selected individuals in the future.