Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach

Laparoscopic Pancreaticoduodenectomy With Open Reconstruction: The Buddha's Middle Path

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is not universally adopted because of its steep learning curve. Its technical complexity discourages many surgeons. We believe that laparoscopic pancreaticoduodenectomy with open reconstruction (LPOR) has all the benefits of LPD without its drawbacks and combines the ease of open surgery with the benefits of minimal access surgery. We assessed the feasibility and safety of LPOR and compared it with open pancreaticoduodenectomy (OPD), with the objectives being perioperative and short-term clinical/oncologic outcomes.

METHODS

Retrospective review of prospectively maintained database; study period from January 2013 to December 2019. Till 2015, we did only OPD. In 2016, we started with LPD but soon switched to LPOR. The resection part was done laparoscopically and the reconstruction part was done through a 8-cm mini-laparotomy.

RESULTS

We did 19 OPDs and 15 LPORs. Demographic data of the 2 groups were comparable. The duration of surgery was significantly longer in the LPOR group (360 vs. 410 min; P =0.01), whereas the blood loss and hospital stay were longer in the OPD group (520 vs. 360 mL; P =0.03 and 13 vs. 11 d; P =0.08, respectively). Clinically significant complication rates, including delayed gastric emptying and postoperative pancreatic fistulas, were not different in either group. No patients in the LPOR group had wound-related/pulmonary complications. Lymph node yield was similar in both groups (20 vs. 22) and we had 100% R0 resections.

CONCLUSIONS

LPOR was better than OPD in terms of short-term outcomes and was not inferior to OPD in terms of complications/oncologic outcomes.

Comparison of short-term outcomes of open and laparoscopic assisted pancreaticoduodenectomy for periampullary carcinoma: A propensity score-matched analysis

Backgrounds/Aims

Postoperative pancreatic fistula is the key worry in the ongoing debate about the safety and effectiveness of total laparoscopic pancreaticoduodenectomy (TLPD). Laparoscopic-assisted pancreaticoduodenectomy (LAPD), a hybrid approach combining laparoscopic resection and anastomosis with a small incision, is an alternative to TLPD. This study compares the short-term outcomes and oncological efficacy of LAPD vs. open pancreaticoduodenectomy (OPD).

Methods

A retrospective analysis of data of all patients who underwent LAPD or OPD for periampullary carcinoma at a tertiary care center in Northeast India from July 2019 to August 2023 was done. A total of 30 LAPDs and 30 OPDs were compared after 1:1 propensity score matching. Demographic data, intraoperative and postoperative data (30 days), and pathological data were compared.

Results

The study included a total of 93 patients, 30 underwent LAPD and 62 underwent OPD. After propensity score matching, the matched cohort included 30 patients in both groups. The LAPD presented several advantages over the OPD group, including a shorter incision length, reduced postoperative pain, earlier initiation of oral feeding, and shorter hospital stays. LAPD was not found to be inferior to OPD in terms of pancreatic fistula incidence (Grade B, 30.0% vs. 33.3%), achieving R0 resection (100% vs. 93.3%), and the number of lymph nodes harvested (12 vs. 14, p = 0.620). No significant differences in blood loss, short-term complications, pathological outcomes, readmissions, and early (30-day) mortality were observed between the two groups.

Conclusions

LAPD has comparable safety, technical feasibility, and short-term oncological efficacy.

Developments in pancreatic cancer surgery

Pancreatic cancer surgery, with one of the worst prognoses in oncology, is a challenge to the surgical community. Centralization of pancreatic surgery has led to the foundation of high-volume centers, thereby greatly facilitating the successful performance of more radical approaches. This review spotlights on recent advances in surgical approaches to pancreatic cancer and the risks and benefits of vascular reconstruction to improve resectability. Surgery being the only modality to achieve cure, multivisceral and vascular resections are being incorporated to improve dismal operability rates of < 10%. Great leaps have been made in neoadjuvant and adjuvant treatment, as targeted and specific chemotherapeutic agents are being continually added. The concept of borderline and locally advanced pancreatic tumors and the use of neoadjuvant chemorad has extended the indications of oncological resection in such tumors. Venous resections are being routinely performed so as to facilitate en bloc removal of tumors, while arterial resections, owing to the increased morbidity and mortality, are offered to highly selective cases. New techniques like the triangle operation and periarterial divestment have opened new viable surgical options. Although laparoscopic approach is time consuming, it offers reduced operative blood loss and a shortened hospital stay at specialized centers. Robotic surgery may produce better results in patients needing vascular resection and reconstruction, but the expenses involved and limited availability are major deterrents. Advanced techniques of surgical resection and vessel reconstruction provide a repository for curative-intent surgery in borderline resectable and locally advanced pancreatic cancer.

Comparative analysis of opioid use between robotic and open pancreatoduodenectomy

BACKGROUND/PURPOSE

Risk-stratified pancreatectomy clinical pathways using regional anesthesia and multimodality analgesia have decreased overall opioid use, but the additional benefits of robotic surgery in opioid reduction for pancreatoduodenectomy (PD) are unknown. We compared the inpatient opioid use between robotic PD and open PD.

METHODS

Patients undergoing open PD within a protocol evaluating preincisional regional anesthetic block bundles were compared to consecutively-treated patients undergoing robotic PD identified from a prospectively maintained single-institutional database. Clinical characteristics, operative outcomes, pain scores and inpatient oral morphine equivalent (OME) use were compared between patients treated with robotic or open PD. Patients with a history of continuous-release opioid dependence were excluded.

RESULTS

Of 114 total patients, 25 underwent robotic PD and 89 underwent open PD. Intraoperative opioid use was not different (P = .87), nor were cumulative pain scores. Robotic PD patients used significantly fewer OMEs per day on postoperative days 1-4 (P = .039), used fewer total OMEs during hospitalization (robotic: median = 79, IQR 42.5-141; open: median = 126, IQR 61.3-203.8; P = .0036) and were discharged with fewer OMEs (robotic: median = 0, IQR 0-43.8; open: median = 25, IQR 0-75; P = .009) despite a shorter length of stay (robotic: median = 4, open: median = 5, P = .002).

CONCLUSIONS

Robotic PD patients required fewer inpatient OMEs than open PD while maintaining similar pain scores. A higher percentage of robotic PD patients tapered off of opioids prior to discharge than open surgery patients treated with a standardized opioid reduction protocol despite a shorter length of stay. These results provide a rationale for choosing robotic PD when feasible to minimize opioid use.

Hybrid Laparoscopic Versus Open Pancreatoduodenectomy. A Meta-Analysis

INTRODUCTION

Hybrid laparoscopic techniques have been proposed as a good transition from open to complete minimally invasive approach especially in complex surgical procedures. This meta-analysis aimed to compare the outcomes of hybrid laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy.

METHODS

A systematic literature research was performed according to PRISMA guidelines. A broad search strategy with terms "laparoscopy" and "pancreatoduodenectomy" was used. Included studies were analyzed by quantitative meta-analysis using the metafor package for R software.

RESULTS

Of 655 identified articles, 627 were excluded and 28 articles fully assessed, including 14 comparative studies, 8 case series and 6 case reports. Extracted data included intraoperative variables and postoperative outcome parameters. The predefined inclusion criteria were met by 14 comparative studies, and 371 patients were pooled in the meta-analysis. Hybrid laparoscopic pacreatoduodenectomy was associated with significantly longer operative time (I² 0%, p = 0,01, Mean HPD 494,6 min, Mean OPD 421,6 min, WMD 67 min, 95% CI 14-120 min). For all other postoperative outcome parameters, no statistically significant differences were found. A nonsignificant reduction in intraoperative transfusion rate (I² 20%, p = 0,2, proportion HPD 2%, proportion OPD 1,6%, OR 0,44, 95% CI 0,16-1,27) and blood loss (I² 95%, p = 0,1, Mean HPD 397,2 ml, Mean OPD 1017,8 ml, MD - 601 ml, 95% CI - 1311-108) was observed for hybrid pancreatoduodenectomy in comparison to open surgery.

CONCLUSIONS

This meta-analysis demonstrates significantly increased operation time for hybrid laparoscopic compared to open pancreatoduodenectomy. Intraoperative variables as well as postoperative parameters and major morbidity were comparable for both techniques. Overall results of this meta-analysis demonstrated the hybrid technique as a safe procedure in high-volume centers offering aspects of a safe transition to fully laparoscopic pancreatoduodenectomy.

Laparoscopic hybrid pancreaticoduodenectomy: Initial single center experience

Backgrounds/Aims

Pancreaticoduodenectomy (PD) is the gold standard for the treatment of periampullary tumors. Many specialized centers have adopted the totally laparoscopic or hybrid laparoscopic PD (LPD). However, this procedure has not yet been standardized and serious debate is taking place towards its safety and feasibility. Herein, we report our recent experience whit hybrid-LPD.

Methods

During 2019 in our department 56 PD were performed and 21 (37.5%) underwent hybrid-LPD. We have retrospectively reviewed the short-term outcomes of these patients.

Results

Main indication was pancreatic adenocarcinoma (71,4%). The median operative time and intraoperative blood loss were respectively 425 min (range, 226 to 576) and 317 ml (range 60 to 800 ml). Conversion to an open procedure was required in 4 patients (19%): 2 with suspected vein involvement, 1 for mesenteric panniculitis and 1 for biliary injury. The post-operative complication rate was 42.8% (9/21). Regarding post-operative pancreatic fistula, three patients (14.2%) had grade B and 1 grade C (4.7%). Median length of hospital stay was 14 days (range 9-23) and 90- days mortality was 4.7%. The mean number of harvested lymph nodes was 17.7 (range 12 to 26). The rate of margins R0 was 80%; R1 ＞0<1 mm was 10.5% and R1 0 mm was 9.5%.

Conclusions

Hydrid-LPD is safe and feasible. Careful patient selection and increasing experience can reduce the risk of post-operative complications.

Does center or surgeon volume influence adoption of minimally invasive versus open pancreatoduodenectomy? A systematic review and meta-regression

BACKGROUND

There has been increasing uptake of minimally invasive pancreatoduodenectomy during the past decade, but it remains a highly specialized procedure as benefits over open pancreatoduodenectomy remain contentious. This study aimed to evaluate current evidence on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy in terms of impact of center volume on outcomes.

METHODS

A systematic review of articles on comparative cohort and registry studies on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy published until 31st December 2019 were identified, and meta-analyses were performed. Primary endpoints were International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula and 30-day mortality.

RESULTS

After screening 7,390 studies, 43 comparative cohort studies (8,755 patients) with moderate methodological quality and 3 original registry studies (43,735 patients) were included. For the cohort studies, the median annual hospital minimally invasive pancreatoduodenectomy volume was 10. No significant differences were found in grade B/C postoperative pancreatic fistula (odds ratio: 0.98, 95% confidence interval: 0.78-1.23) or 30-day mortality (odds ratio: 1.14, 95% confidence interval: 0.65-2.01) between minimally invasive pancreatoduodenectomy when compared with open. No publication biases were present and meta-regression identified no confounding for grade B/C postoperative pancreatic fistula, center volume or 30-day mortality. Minimally invasive pancreatoduodenectomy was only strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection, shorter length of stay, and significantly higher rates of R0 margin resections.

CONCLUSION

Minimally invasive pancreatoduodenectomy remains noninferior to open pancreatoduodenectomy for grade B/C postoperative pancreatic fistula but is strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection. Minimally invasive pancreatoduodenectomy can be adopted safely with good outcomes irrespective of annual center resection volume.

Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its Adoption in Singapore

Despite the potential clinical advantages offered by laparoscopic pancreatic surgery (LPS), the main obstacle to its widespread adoption is the technically demanding nature of the procedure and its steep learning curve. LPS and robotic pancreatic surgery (RPS) have been proven to result in superior short-term perioperative outcomes and equivalent long-term oncological outcomes compared to the conventional open approach, with the caveat that they are performed by expert surgeons who have been trained to perform such procedures. The primary challenge faced by most pancreatic surgeons is the steep learning curve associated with these complex procedures and the need to undergo surgical training, especially with regards to laparoscopic and robotic pancreaticoduodenectomy. Current evidence suggests that RPS may help to shorten the lengthy learning curve required for LPS. More robust evidence—in the form of large randomised controlled trials—is needed to determine whether LPS and RPS can be safely adopted universally. Ann Acad Med Singapore 2020;49:377–83 Key words: Laparoscopic pancreatectomy, Laparoscopic pancreaticoduodenectomy, Minimally invasive pancreatic surgery, Robotic pancreatectomy, Robotic pancreaticoduodenectomy

Hybrid pancreatoduodenectomy in laparoscopic and robotic surgery: a single-center experience in China

BACKGROUND

Minimally invasive surgery is beneficial for pancreatic surgery, and the indication has been expanded to pancreatoduodenectomy (PD). The aim of this study was to share our experiences with hybrid PD in laparoscopic and robotic surgery.

METHODS

Sixty-four patients underwent hybrid PD in which specimen resection and gastrojejunostomy were performed through the laparoscopic route and pancreatojejunostomy and hepaticojejunostomy were performed via a robotic approach by the same surgeon at a single institution between July 2016 and June 2019. The primary endpoint was complications; secondary endpoints were operative time (OT), the length of hospital stay, and blood loss. The data for the patients were retrospectively obtained from electrical medical records.

RESULTS

All patients underwent surgery with the hybrid procedure. The mean OTs and estimated blood loss (EBL) were 309.7 ± 77.6 min (range 17-620 min), 160 ± 31.7 mL (range 50-800 mL). The mean number of lymph nodes retrieved was 7.3 ± 6.7 (range 0-37), and that among 45 malignant cases was 8.42 ± 6.7 (range 1-37). The average length of postoperative stay in the hospital was 11.14 ± 7.03 days (range 6-47 days). Clinically relevant postoperative pancreatic fistulas (POPFs) occurred in 39 (60.9%) cases, and most were biochemical leak POPF (29 cases, 45.3%); only 10 (15.6%) cases were grade B/C (8 cases were Grade B and 2 cases were Grade C treated with digital subtraction angiography). Bile leakage occurred in 2 (3.1%) patients. One (1.5%) patient had a gastric fistula, and 3 (4.7%) developed postoperative delayed gastric emptying categorized as International Study Group of Pancreatic Surgery (ISGPS) Grade A. Three (4.7%) patients were readmitted for postoperative bleeding, and 2 (3.1%) died within 30 days.

CONCLUSION

Hybrid PD with laparoscopic and robot surgery is safe and feasible. OT can be reduced by switching from the laparoscopic approach to the robotic procedure at the appropriate timepoint.

Lessons Learned from the Introduction of Laparoscopic Pancreaticoduodenectomy

Introduction: Minimally invasive techniques have been suggested to achieve enhanced recovery and improved outcome after pancreaticoduodenectomy (PD). This study describes our experience and a stepwise technical implementation of the laparoscopic pancreaticoduodenectomy (LPD) during early introduction in 2016. Methods: A team of three hepatopancreaticobiliary surgeons with extensive experience in open pancreaticoduodenectomy (OPD) and with advanced laparoscopic skills started a proctor-guided program with LPD. The first 20 carefully selected cases were prospectively reviewed and compared with a matched OPD cohort. Results: In 20 months, 20 minimally invasive PDs were performed. Reviewing the first 10 LPD cases, 7 patients (70%) had anastomosis-related complications, versus 16% in OPD (P = .001). After consulting an international LPD expert, the team switched to a hybrid technique consisting of LPD followed by open reconstruction through midline minilaparotomy (LPD-OR). In the following 10 cases of LPD-OR, no anastomosis-related complications did occur (P = .342 OPD versus LPD-OR). Conclusion: Safe introduction of new techniques in minimally invasive major abdominal surgery is imperative. Based on our single-center experience, LPD-OR may be safer in the earliest phase of the learning curve of minimally invasive PD, as part of a stepwise implementation toward the fully laparoscopic technique.

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.

Laparoscopic pancreatoduodenectomy with open or laparoscopic reconstruction during the learning curve: a multicenter propensity score matched study

BACKGROUND

Laparoscopic pancreatoduodenectomy with open reconstruction (LPD-OR) has been suggested to lower the rate of postoperative pancreatic fistula reported after laparoscopic pancreatoduodenectomy with laparoscopic reconstruction (LPD). Propensity score matched studies are, lacking.

METHODS

This is a multicenter prospective cohort study including patients from 7 Dutch centers between 2014-2018. Patients undergoing LPD-OR were matched LPD patients in a 1:1 ratio based on propensity scores. Main outcomes were postoperative pancreatic fistulas (POPF) grade B/C and Clavien-Dindo grade ≥3 complications.

RESULTS

A total of 172 patients were included, involving the first procedure for all centers. All 56 patients after LPD-OR could be matched to a patient undergoing LPD. With LPD-OR, the unplanned conversion rate was 21% vs. 9% with LPD (P < 0.001). Median blood loss (300 vs. 400 mL, P = 0.85), operative time (401 vs. 378 min, P = 0.62) and hospital stay (10 vs. 12 days, P = 0.31) were comparable for LPD-OR vs. LPD, as were Clavien-Dindo grade ≥3 complications (38% vs. 52%, P = 0.13), POPF grade B/C (23% vs. 21%, P = 0.82), and 90-day mortality (4% vs. 4%, P > 0.99).

CONCLUSION

In this propensity matched cohort performed early in the learning curve, no benefit was found for LPD-OR, as compared to LPD.

Perioperative outcomes of laparoscopic pancreaticoduodenectomy for benign and borderline malignant periampullary disease compared to open pancreaticoduodenectomy

PURPOSE

The objective of this study was to compare perioperative outcomes between laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for benign and borderline malignant periampullary diseases.

METHODS

Of 107 pancreaticoduodenectomy cases for non-malignant diseases from March 1993 to July 2017, 76 patients underwent OPD and 31 patients received LPD. To adjust for baseline differences and selection bias, operative outcomes and complications were compared after propensity score matching (PSM).

RESULTS

After 1:1 PSM, well-matched 31 patients in each group were evaluated. As a result, significant differences were observed between two groups in some aspects: mean operative time (LPD 426.8 ± 98.58 vs. OPD 355.03 ± 100.0 min, p = 0.031), estimated blood loss (LPD 477.42 ± 374.80 vs. OPD 800.00 ± 531.35 ml, p = 0.008), and postoperative hospital stay (LPD 14.74 ± 5.40 vs. OPD 23.81 ± 11.63 days, p < 0.001). The average visual analogue scores for pain observed from patients in LPD group on postoperative day (POD) 1 (4.23 ± 1.83 vs. 5.55 ± 2.50, p = 0.021) and POD 3 (3.32 ± 1.66 vs. 5.26 ± 2.76, p = 0.002) were significantly less than those from patients in OPD group, as well. There were no significant differences between groups about major complications including the rate of postoperative pancreatic fistula.

CONCLUSIONS

LPD is a safe procedure and provides less postoperative pain and the shortening length of hospitalization. LPD may serve the feasible alternative approach for benign and borderline malignant periampullary disease.

Initial experience with robotic pancreatic surgery in Singapore: single institution experience with 30 consecutive cases

BACKGROUND

Presently, the worldwide experience with robotic pancreatic surgery (RPS) is increasing although widespread adoption remains limited. In this study, we report our initial experience with RPS.

METHODS

This is a retrospective review of a single institution prospective database of 72 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2017. Of these, 30 patients who underwent RPS were included in this study of which 25 were performed by a single surgeon.

RESULTS

The most common procedure was robotic distal pancreatectomy (RDP) which was performed in 20 patients. This included eight subtotal pancreatectomies, two extended pancreatecto-splenectomies (en bloc gastric resection) and 10 spleen-saving-RDP. Splenic preservation was successful in 10/11 attempted spleen-saving-RDP. Eight patients underwent pancreaticoduodenectomies (five hybrid with open reconstruction), one patient underwent a modified Puestow procedure and one enucleation of uncinate tumour. Four patients had extended resections including two RDP with gastric resection and two pancreaticoduodenectomies with vascular resection. There was one (3.3%) open conversion and seven (23.3%) major (>Grade II) morbidities. Overall, there were four (13.3%) clinically significant (Grade B) pancreatic fistulas of which three required percutaneous drainage. These occurred after three RDP and one robotic enucleation. There was one reoperation for port-site hernia and no 30-day/in-hospital mortalities. The median post-operative stay was 6.5 (range: 3-36) days and there were six (20%) 30-day readmissions.

CONCLUSION

Our initial experience showed that RPS can be adopted safely with a low open conversion rate for a wide variety of procedures including pancreaticoduodenectomy.

Minimally invasive surgical approach versus open procedure for pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging abdominal procedures. Safety and feasibility remain controversial when comparing MIPD with open pancreaticoduodenectomy (OPD). The aim of this systematic review and meta-analysis was to evaluate the feasibility and safety of MIPD versus OPD.

METHODS

A systematic review of the literature was performed to identify studies comparing MIPD and OPD. Postoperative complications, intraoperative outcomes and oncologic data, and postoperative recovery were compared.

RESULTS

There were 27 studies that matched the selection criteria. Totally 1306 cases of MIPD and 5603 cases of OPD were included. MIPD was associated with a reduction in postoperative hemorrhage (odds ratio [OR] 1.60; 95% confidence interval [CI] 1.03-2.49; P = .04) and wound infection (OR 0.44, 95% CI 0.30-0.66, P < .0001). MIPD was also associated with less estimated blood loss (mean difference [MD] -300.14 mL, 95% CI -400.11 to -200.17 mL, P < .00001), a lower transfusion rate (OR 0.46, 95% CI 0.35-0.61; P < .00001) and a shorter length of hospital stay (MD -2.95 d, 95% CI -3.91 to -2.00 d, P < .00001) than OPD. Meanwhile, the MIPD group had a higher R0 resection rate (OR 1.45, 95% CI 1.18-1.78, P = .0003) and more lymph nodes harvested (MD 1.34, 95% CI 0.14-2.53, P = .03). However, the minimally invasive approach proved to have much longer operative time (MD 71.00 minutes; 95% CI 27.01-115.00 minutes; P = .002) than OPD. Finally, there were no significant differences between the 2 procedures in postoperative pancreatic fistula (P = .30), delayed gastric emptying (P = .07), bile leakage (P = .98), mortality (P = .88), tumor size (P = .15), vascular resection (P = .68), or reoperation rate (P = .11).

CONCLUSIONS

Our results suggest that MIPD is currently safe, feasible, and worthwhile. Future large-volume, well-designed randomized controlled trials (RCT) with extensive follow-up are awaited to further clarify this role.

Minimally invasive pancreaticoduodenectomy for periampullary disease: a comprehensive review of literature and meta-analysis of outcomes compared with open surgery

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear.

METHODS

Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis.

RESULTS

One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes.

CONCLUSION

Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.

Minimally invasive pancreatic cancer surgery: What is the current evidence?

Surgery remains the only option to cure pancreatic cancer. Although the use of laparoscopy in oncology is rapidly growing worldwide, its efficacy in pancreatic surgery remains controversial. A number of studies have compared outcomes of minimally invasive and open pancreatic resections. However, they are mostly non-randomized trials including relatively small groups of patients. In addition, most of these studies were conducted in high-volume pancreatic centres. It seems that despite longer operative time, laparoscopy may be beneficial in terms of morbidity, blood loss and hospital stay. Thus far, very little is known about the long-term outcomes of laparoscopic surgery for pancreatic cancer. Our aim was to review current evidence for the use of minimally invasive techniques in patients with pancreatic malignancy.

Minimally Invasive Versus Open Pancreatoduodenectomy: Systematic Review and Meta-analysis of Comparative Cohort and Registry Studies

OBJECTIVE

This study aimed to appraise and to evaluate the current evidence on minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy only in comparative cohort and registry studies.

BACKGROUND

Outcomes after MIPD seem promising, but most data come from single-center, noncomparative series.

METHODS

Comparative cohort and registry studies on MIPD versus open pancreatoduodenectomy published before August 23, 2015 were identified systematically and meta-analyses were performed. Primary endpoints were mortality and International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula (POPF).

RESULTS

After screening 2293 studies, 19 comparative cohort studies (1833 patients) with moderate methodological quality and 2 original registry studies (19,996 patients) were included. For cohort studies, the median annual hospital MIPD volume was 14. Selection bias was present for cancer diagnosis. No differences were found in mortality [odds ratio (OR) = 1.1, 95% confidence interval (CI) = 0.6-1.9] or POPF [(OR) = 1.0, 95% CI = 0.8 to 1.3]. Publication bias was present for POPF. MIPD was associated with prolonged operative times [weighted mean difference (WMD) = 74 minutes, 95% CI = 29-118], but lower intraoperative blood loss (WMD = -385 mL, 95% CI = -616 to -154), less delayed gastric emptying (OR = 0.6, 95% = CI 0.5-0.8), and shorter hospital stay (WMD = -3 days, 95% CI = -5 to -2). For registry studies, the median annual hospital MIPD volume was 2.5. Mortality after MIPD was increased in low-volume hospitals (7.5% vs 3.4%; P = 0.003).

CONCLUSIONS

Outcomes after MIPD seem promising in comparative cohort studies, despite the presence of bias, whereas registry studies report higher mortality in low-volume centers. The introduction of MIPD should be closely monitored and probably done only within structured training programs in high-volume centers.

A systemic review and an updated meta-analysis: minimally invasive vs open pancreaticoduodenectomy

The feasible of minimally invasive pancreaticoduodenectomy (MIPD) remains controversial when compared with open pancreaticoduodenectomy (OPD). We conducted a systemic review and meta-analysis to summarise the available evidence to compare MIPD vs OPD. We systemically searched PubMed, EMBASE and Web of Science for studies published through February 2016. The primary endpoint was postoperative pancreatic fistula (POPF, grade B/C). A total of 27 studies involving 14,231 patients (2,377 MIPD and 11,854 OPD) were included. MIPD was associated with longer operative times (P < 0.01) and increased mortality (P < 0.01), but decreased estimated blood loss (P < 0.01), decreased delayed gastric emptying (P < 0.01), increased R0 resection rate (P < 0.01), decreased wound infection (P = 0.03) and shorter hospital stays (P < 0.01). There were no significant differences in BMI (P = 0.43), tumor size (P = 0.17), lymph nodes harvest (P = 0.57), POPF (P = 0.84), reoperation (P = 0.25) and 5-year survival rates (P = 0.82) for MIPD compared with OPD. Although there was an increased operative cost (P < 0.01) for MIPD compared with OPD, the postoperative cost was less (P < 0.01) with the similar total costs (P = 0.28). MIPD can be a reasonable alternative to OPD with the potential advantage of being minimally invasive. However, MIPD should be performed in high-volume centers and more randomized-controlled trials are needed to evaluate the appropriate indications of MIPD.

Minimally invasive versus open pancreatoduodenectomy-systematic review and meta-analysis

Purpose

The purpose of this systematic review was to compare minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) by using meta-analytical techniques.

Methodology

Medline, Embase, and Cochrane Library were searched for eligible studies. Data from included studies were extracted for the following outcomes: operative time, overall morbidity, pancreatic fistula, delayed gastric emptying, blood loss, postoperative hemorrhage, yield of harvested lymph nodes, R1 rate, length of hospital stay, and readmissions. Random and fix effect meta-analyses were undertaken.

Results

Initial reference search yielded 747 articles. Thorough evaluation resulted in 12 papers, which were analyzed. The total number of patients was 2186 (705 in MIPD group and 1481 in OPD). Although there were no differences in overall morbidity between groups, we noticed reduced blood loss, delayed gastric emptying, and length of hospital stay in favor of MIPD. In contrary, meta-analysis of operative time revealed significant differences in favor of open procedures. Remaining parameters did not differ among groups.

Conclusion

Our review suggests that although MIPD takes longer, it may be associated with reduced blood loss, shortened LOS, and comparable rate of perioperative complications. Due to heterogeneity of included studies and differences in baseline characteristics between analyzed groups, the analysis of short-term oncological outcomes does not allow drawing unequivocal conclusions.

Electronic supplementary material

The online version of this article (doi:10.1007/s00423-017-1583-8) contains supplementary material, which is available to authorized users.

How I Do It: Hybrid Laparoscopic and Robotic Pancreaticoduodenectomy

Minimally invasive pancreatic resections remain technically challenging. Distal pancreatectomy has been embraced at multiple centers as an acceptable minimally invasive technique in selected patients. In contrast, minimally invasive pancreaticoduodenectomy has not achieved broad acceptance, partly due to technical challenges. We detail a minimally invasive technique that utilizes both laparoscopic and robotic approaches which capitalizes on the advantages of each. Our early results have encouraged the continued development of this minimally invasive pancreatic surgery program. This hybrid technique may be an approach that is useful for surgeons striving to adopt the advantages of minimally invasive surgery for their patients.

Systemic Review of the Feasibility and Advantage of Minimally Invasive Pancreaticoduodenectomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD), which includes laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is a complex procedure that needs to be performed by experienced surgeons. However, the safety and oncologic performance have not yet been conclusively determined.

METHODS

A systematic literature search was performed using the Embase, Medline, and PubMed databases to identify all studies published up to March 2015. Articles written in English containing the keywords: "pancreaticoduodenectomy" or "Whipple operation" combined with "laparoscopy," "laparoscopic," "robotic," "da vinci," or "minimally invasive surgery" were selected. Furthermore, to increase the power of evidence, articles describing more than ten MIPDs were selected for this review.

RESULTS

Twenty-six articles matched the review criteria. A total of 780 LPDs and 248 RPDs were included in the current review. The overall conversion rate to open surgery was 9.1 %. The weighted average operative time was 422.6 min, and the weighted average blood loss was 321.1 mL. The weighted average number of harvested lymph nodes was 17.1, and the rate of microscopically positive tumor margins was 8.4 %. The cumulative morbidity was 35.9 %, and a pancreatic fistula was reported in 17.0 % of cases. The average length of hospital stay was 12.4 days, and the mortality rate was 2.2 %.

CONCLUSIONS

In conclusion, after reviewing one-thousand cases in the current literature, we conclude that MIPD offers a good perioperative, postoperative, and oncologic outcome. MIPD is feasible and safe in well-selected patients.

Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy

BACKGROUNDS AND OBJECTIVE

The technique of minimally invasive pancreatic surgeries has evolved rapidly, including minimally invasive pancreaticoduodenectomy (MIPD). However, controversy on safety and feasibility remains when comparing the MIPD with the open pancreaticoduodenectomy (OPD); therefore, we aimed to compare MIPD and OPD with a systemic review and meta-analysis.

METHODS

Multiple electronic databases were systematically searched to identify studies (up to February 2016) comparing MIPD with OPD. Intra-operative outcomes, oncologic data, postoperative complications and postoperative recovery were evaluated.

RESULTS

Twenty-two retrospective studies including 6120 patients (1018 MIPDs and 5102 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (WMD -312.00 ml, 95 % CI -436.30 to -187.70 ml, p < 0.001), transfusion rate (OR 0.41, 95 % CI 0.30-0.55, p < 0.001), wound infection (OR 0.37, 95 % CI 0.20-0.66, p < 0.001) and length of hospital stay (WMD -3.57 days, 95 % CI -5.17 to -1.98 days, p < 0.001). Meanwhile, MIPD group has a higher R0 resection rate (OR 1.47, 95 % CI 1.18-1.82, p < 0.001) and more lymph nodes harvest (WMD 1.74, 95 % CI 1.03-2.45, p < 0.001). However, it had longer operation time (WMD 83.91 min, 95 % CI 36.60-131.21 min, p < 0.001). There were no significant differences between the two procedures in morbidities (p = 0.86), postoperative pancreatic fistula (p = 0.17), delayed gastric empting (p = 0.65), vascular resection (p = 0.68), reoperation (p = 0.33) and mortality (p = 0.90).

CONCLUSIONS

MIPD can be a reasonable alternative to OPD with potential advantages. However, further large-volume, well-designed RCTs with extensive follow-ups are suggested to confirm and update the findings of our analysis.

Early experience with robotic pancreatic surgery in a Canadian institution

BACKGROUND

Pancreatic resections have traditionally been associated with substantial morbidity and mortality. The robotic platform is believed to improve technical aspects of the procedure while offering minimally invasive benefits. We sought to determine the safety and feasibility of the first robotic pancreaticoduodenectomies performed at our institution.

METHODS

We retrospectively reviewed data on all patients who underwent robotic-assisted pancreaticoduodenectomy (RAPD) between July 2010 and June 2014 and compared them to outcomes of patients undergoing hybrid laparoscopic pancreaticoduodenectomies (HLAPD) during the same time period.

RESULTS

Fifteen patients were scheduled for RAPD; 2 were converted to an open approach and 1 to a mini-laparotomy during the laparoscopic portion of the procedure. Patients who had RAPD (n = 12) had a median duration of surgery of 596.6 (range 509-799) minutes, estimated blood loss of 275 (range 50-1000) mL and median length of stay of 7.5 (range 5-57) days. Mean total opioid use up to postoperative day 7 was 142.599 ± 68.2 versus 176.9 ± 112.7 mg equivalents of intravenous morphine for RAPD and HLAPD, respectively. There was no significant difference between RAPD and HLAPD in any parameters, highlighting the safety and feasibility of a step-wise minimally invasive learning platform. Most patients in the RAPD group had malignant pathology (88.2%). Oncologic outcomes were maintained with no significant difference in ability to resect lymph nodes or achieve negative margins. There were 4 (28.5%) Clavien I-II complications and 3 (29.4%) Clavien III- IV complications, 2 of which required readmission. There were no reported deaths at 90 days. Complication, pancreatic leak and mortality rates did not differ significantly from our laparoscopic experience.

CONCLUSION

Outcomes of RAPD and HLAPD were comparable at our centre, even during the early stages of our learning curve. These results also highlight the safety, feasibility and patient benefits of a step-wise transition from open to hybrid to fully robotic pancreaticoduodenectomies in a high-volume academic centre.

Laparoscopy-assisted pancreaticoduodenectomy as minimally invasive surgery for periampullary tumors: a comparison of short-term clinical outcomes of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy

BACKGROUND

Few reports have described laparoscopy-assisted pancreaticoduodenectomy (LAPD) as an alternative to the conventional open approach for periampullary tumors. The safety and feasibility of this procedure remain to be determined. In this study, we compared the short-term clinical outcomes of LAPD with those of open pancreaticoduodenectomy (OPD).

METHODS

A retrospective review of patients who had undergone pancreaticoduodenectomy for periampullary tumors between June and December 2014 was conducted. Patient demographic data and their pathological and short-term clinical parameters were compared between the LAPD and OPD groups.

RESULTS

Fifty-two patients were included in the study: 18 had undergone LAPD and 34 had undergone OPD. The mean operation time was longer for LAPD than for OPD (531.1 vs. 383.2 min, P < 0.001). The estimated blood loss, rate of blood transfusion, surgical resection margin status, and number of lymph nodes retrieved were similar in both groups. Overall morbidity and the incidence of pancreatic fistula did not differ significantly between the two groups. However, the mean length of hospital stay was significantly shorter in the LAPD group (12.6 vs. 18.6 days, P = 0.001).

CONCLUSION

LAPD is a technically safe and feasible alternative treatment for periampullary tumors, with short-term clinical outcomes equivalent to those of OPD, with a shorter hospital stay.

Laparoscopic pancreatectomy: Did the indications change? A review from literature

Pancreatic Cancer (PC) is the fourth cause of death for tumors in Western countries. Symptoms are not specific, and can vary according to the tumor size and place. Diagnostic workup includes CA 19-9, CT and MRI. Surgery is the only treatment for PC, associated to radio-chemo therapy. Laparoscopic approaches are actually used for PC treatment in few specialized centers, and could be an alternative to laparotomic surgery. The aim of our study is to evaluate the efficacy of laparoscopy for PC treatment compared to laparotomy. We reviewed 19 articles in literature to assess the feasibility and efficacy of Laparoscopic Distal Pancreatectomy (LDP) and Laparoscopic Pancreaticoduodenectomy (LPD). The results have shown that LDP is nowadays a safe technique, and the outcomes are comparable to laparotomic surgery. Regarding to LPD instead, results are controversial and the data are still not sufficient to consider this technique as a valid alternative to laparotomic surgery.

Balancing surgical innovation with cost and efficiency

The standard approach to neoplasia of the pancreatic head is pancreaticoduodenectomy, otherwise known as the Whipple procedure. Traditionally, this operation is performed through an open laparotomy incision. In high-volume centres, and when performed by appropriately qualified surgeons, the Whipple procedure is safe and effective management for diseases of the pancreatic head. Still, this operation remains one of the most complex abdominal procedures. With the proliferation of minimally invasive surgery, more complex operations are being performed using laparoscopy and other minimal access techniques. A group from McGill University and the Montreal Jewish General Hospital have prospectively evaluated their experience with minimally invasive pancreaticoduodenectomy and have compared this experience to the open approach. This is the first comparative series of its kind from Canada.