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Bauschke A, Deeb AA, Kissler H, Rohland O, Settmacher U. [Anastomotic techniques in minimally invasive hepatobiliopancreatic surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:775-779. [PMID: 37405414 DOI: 10.1007/s00104-023-01901-1] [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: 05/16/2023] [Indexed: 07/06/2023]
Abstract
The established anastomotic techniques conventionally used in open surgery are increasingly being implemented in a minimally invasive approach and further developed. The aim of all innovations is to carry out a safe anastomosis with a feasible minimally invasive technique; however, there is currently no broad consensus about the role of laparoscopic and robotic surgery in performing pancreatic anastomotic techniques. Pancreatic fistulas determine the morbidity following a minimally invasive resection. The simultaneous minimally invasive resection and reconstruction of pancreatic processes and vascular structures is currently exclusively performed in specialized centers.
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Affiliation(s)
- Astrid Bauschke
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland.
| | - Aladdin Ali Deeb
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
| | - Hermann Kissler
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
| | - Oliver Rohland
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
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Chierici A, Frontali A, Granieri S, Facciorusso A, De' Angelis N, Cotsoglou C. Postoperative morbidity and mortality after pancreatoduodenectomy with pancreatic duct occlusion compared to pancreatic anastomosis: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:1395-1404. [PMID: 35450800 DOI: 10.1016/j.hpb.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/15/2022] [Accepted: 03/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatoduodenectomy is burdened by elevated postoperative morbidity. Pancreatic duct ligation or occlusion have been experimented as an alternative to reduce the insurgence of postoperative pancreatic fistula. The aim of this systematic review and meta-analysis was to compare postoperative mortality and morbidity (pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, pancreatic exocrine insufficiency and diabetes mellitus) between patients undergoing pancreatic anastomosis or pancreatic duct ligation/occlusion after pancreatoduodenectomy. METHODS A systematic review and meta-analysis of 13 studies was conducted following the PRISMA guidelines and the Cochrane protocol (PROSPERO ID: CRD42021249232). RESULTS No difference in postoperative mortality was highlighted. Pancreatic anastomosis was found to be protective considering all-grades pancreatic fistula (RR: 2.38, p = 0.0005), but pancreatic duct occlusion presented a 3-folded reduced risk to develop "grade C" pancreatic fistula (RR: 0.36, p = 0.1186), although not significant. Diabetes mellitus was more often diagnosed after duct occlusion (RR: 1.61, p < 0.0001); no difference was found in terms of pancreatic exocrine insufficiency (RR: 1.19, p = 0.151). CONCLUSION Postoperative mortality is not influenced by the pancreatic reconstruction technique. Pancreatic anastomosis is associated with a reduction in all-grades pancreatic fistula. More high-quality studies are needed to clarify if duct sealing could reduce the prevalence of "grade C" fistula.
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Affiliation(s)
- Andrea Chierici
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy.
| | - Alice Frontali
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
| | - Stefano Granieri
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
| | - Antonio Facciorusso
- Department of Medical Sciences, Gastroenterology Unit, Ospedali Riuniti di Foggia, Viale Luigi Pinto, 1, 71122, Foggia, Italy
| | - Nicola De' Angelis
- Unit of Digestive Surgery, University of Paris Est, UPEC, Créteil, France
| | - Christian Cotsoglou
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
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Morelli L, Furbetta N, Gianardi D, Guadagni S, Di Franco G, Bianchini M, Palmeri M, Masoni C, Di Candio G, Cuschieri A. Use of barbed suture without fashioning the "classical" Wirsung-jejunostomy in a modified end-to-side robotic pancreatojejunostomy. Surg Endosc 2020; 35:955-961. [PMID: 33025248 PMCID: PMC7820080 DOI: 10.1007/s00464-020-07991-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/14/2020] [Indexed: 02/08/2023]
Abstract
Background The treatment of the pancreatic stump is a critical step of pancreatoduodenectomy (PD). Robot-assisted surgery (RAS) can facilitate minimally invasive challenging abdominal procedures, including pancreatojejunostomy. However, one of the major limitations of RAS stems from its lack of tactile feedback that can lead to pancreatic parenchyma laceration during knot tying or during traction on the suture. Moreover, a Wirsung-jejunostomy is not always easy to execute, especially in cases with small diameter duct. Herein, we describe and video-report the technical details of a robotic modified end-to-side invaginated robotic pancreatojejunostomy (RmPJ) with the use of barbed suture instead of the “classical” Wirsung-jejunostomy. Methods The RmPJ technique consists of a double layer of absorbable monofilament running barbed suture (3–0 V-Loc), the outer layer is used to invaginate the pancreatic stump. Thereafter, a small enterotomy is made in the jejunum exactly opposite to the location of the pancreatic duct for stent insertion (usually 5 Fr) inside the duct. The internal layer provides a second barbed running suture placed between the pancreatic capsule/parenchyma and the jejunal seromuscular layer. Results A total of 14 patients underwent robotic PD with RmPJ at our Institution. The mean console time was (281.36 ± 31.50 min), while the mean operative time for fashioning the RmPJ was 37.31 ± 7.80 min. Ten out of 14 patients were discharged within postoperative day 8. No clinically relevant pancreatic fistulas were encountered, while two patients developed biochemical leaks. Conclusions RmPJ is feasible and reproducible irrespective of pancreatic duct size and parenchyma, and can enhance the surgical workflow of this operation. Specifically, the use of barbed sutures allows the exploitation of the potential advantages of the RAS, while minimizing the negative effect caused by the main disadvantage of the robotic approach, its absence of tactile feedback, by ensuring uniform tension on the continuous suture lines used, especially during the reconstructive phase of the operation. Electronic supplementary material The online version of this article (10.1007/s00464-020-07991-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy. .,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
| | - Niccolò Furbetta
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Caterina Masoni
- Vascular Surgery Unit, Department of Cardiovascular Surgery, University of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Alfred Cuschieri
- Institute for Medical Science and Technology, University of Dundee, Dundee, Scotland, UK
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Giglio MC, Cassese G, Tomassini F, Rashidian N, Montalti R, Troisi RI. Post-operative morbidity following pancreatic duct occlusion without anastomosis after pancreaticoduodenectomy: a systematic review and meta-analysis. HPB (Oxford) 2020; 22:1092-1101. [PMID: 32471694 DOI: 10.1016/j.hpb.2020.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic duct occlusion (PDO) without anastomosis is a technique proposed to mitigate the clinical consequences of postoperative pancreatic fistulas (POPF) after pancreaticoduodenectomy. The aim of this study was to appraise the morbidity following PDO through a systematic review and meta-analysis. METHODS A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of PDO following pancreaticoduodenectomy. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modeling. Meta-regression analyses were performed to examine the impact of moderators on the overall estimates. RESULTS Sixteen studies involving 1000 patients were included. Pooled postoperative mortality was 2.7%. A POPF was reported in 29.7% of the patients. Clinically relevant POPFs occurred in 13.5% of the patients, while intra-abdominal abscess and haemorrhages occurred in 6.7% and 5.5% of the patients, respectively. Re-operation was necessary in 7.6% of the patients. Postoperatively new onset diabetes occurred in 15.8% of patients, more frequently after the use of chemical substances for PDO (p = 0.003). CONCLUSIONS PDO is associated with significant morbidity including new onset of post-operative diabetes. The risk of new onset post-operative diabetes is associated with the use of chemical substance for PDO. Further evidence is needed to evaluate the potential benefits of PDO in patients at high risk of POPF.
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Affiliation(s)
- Mariano C Giglio
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Gianluca Cassese
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Federico Tomassini
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Ghent, Belgium
| | - Nikdokht Rashidian
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Ghent, Belgium
| | - Roberto Montalti
- Department of Public Health, Federico II University Naples, Naples, Italy
| | - Roberto I Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.
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Müller-Debus CF, Thomaschewski M, Zimmermann M, Wellner UF, Bausch D, Keck T. Robot-Assisted Pancreatic Surgery: A Structured Approach to Standardization of a Program and of the Operation. Visc Med 2020; 36:104-112. [PMID: 32355667 DOI: 10.1159/000506909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/28/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction The use of robots in minimal invasive surgery has become increasingly common in recent years. Robot-assisted pancreatoduodenectomy preponderates against a laparoscopic procedure especially due to the greater flexibility of instruments and therefore a better handling and a better angulation. Furthermore, there are benefits of enlarged 3-D visibility, software-based tremor control, and reduced physical exertion of the surgeon. Methods and Results This review delivers a point-by-point approach to the setup of a robot-assisted pancreatic program and a detailed approach to robot-assisted pancreatoduodenectomy. Results In our standardized standard operating procedure approach we use 5 trocars, i.e., 4 robotic trocars and 1 assist trocar. We prefer the position of the robot ports in a straight horizontal line with a distance of 20 cm from the operational field. The operation is dissected into 11 standardized procedural steps as follows: (1) access to the pancreas and visualization, (2) extended Kocher manoeuvre, (3) lower rim and mesentericoportal axis, (4) upper rim and hepatoduodenal ligament, (5) dissection of the pancreatic neck, (6) mesenteric root and pars IV duodeni, (7) mesopancreas, (8) pancreatic anastomosis reconstruction, (9) bilioenteric anastomosis, (10) dudenojejunal anastomosis, and (11) drainage and closure. The setup of the pancreas program and the structured approach to complex pancreatic resections are elucidated. Summary This review describes the approach to robot-assisted pancreatic surgery in a high-volume pancreas center on a structural and procedural level to support the establishment of such programs at other locations.
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Affiliation(s)
| | - Michael Thomaschewski
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Markus Zimmermann
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
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