Robotic vascular resections during Whipple procedure

Comparison of laparoscopic versus open pancreaticoduodenectomy combined with portal vein/superior mesenteric vein resection and reconstruction for pancreatic cancer: a propensity score matching analysis

Background

Open surgery is gradually replaced by minimally invasive surgery, but few studies have reported the feasibility of laparoscopic pancreaticoduodenectomy (LPD) combined with vascular resection and reconstruction. The present study compared the efficacy of LPD with open pancreaticoduodenectomy (OPD) combined with portal vein/superior mesenteric vein (PV/SMV) resection and reconstruction for pancreatic cancer.

Methods

The clinical data of patients who underwent PD combined with PV/SMV resection and reconstruction from March 2016 to August 2022 at our institution were retrospectively analyzed. The perioperative outcomes and survival outcomes were compared after propensity score matching (PSM).

Results

The original cohort included 64 patients. Sixteen pairs of patients were obtained by 1:1 PSM. The intraoperative blood loss was greater in the OPD group than in the LPD group (550 vs. 200 mL, P=0.04), and the PV clamp time was longer in the LPD group than in the OPD group (29.4 vs. 18.8 min, P<0.001). There was no significant difference in the incidence of postoperative complications. The median overall survival and progression-free survival were comparable between the two groups (P>0.05).

Conclusions

LPD combined with PV/SMV resection and reconstruction is safe and feasible in selected patients and results in similar perioperative outcomes and prognosis as open surgery.

Robotic Vascular Resection in Pancreatic Ductal Adenocarcinoma: A Systematic Review

(1) Background: This study comprehensively compared robotic pancreatic surgery with vascular resection (RPS-VR) to other surgical procedures in the treatment of pancreatic ductal adenocarcinoma (PDAC). (2) Methods: A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes. (3) Results: Findings indicate that robotic surgery with vascular resections (VRs) significantly prolongs the duration of surgery compared to other surgical procedures, and they notably demonstrate an equal hospital stay. While some studies reported a lower conversion rate and a higher rate of blood loss and blood transfusion in the RPS-VR group, others found no significant disparity. Furthermore, RPS-VR consistently correlated with comparable recurrence rates, free margins R0, postoperative mortality, and complication rates. Concerning the last one, certain reviews reported a higher rate of major complications. Overall survival and disease-free survival remained comparable between the RPS-VR and other surgical techniques in treating PDAC. (4) Conclusions: The analysis emphasizes how RPS-VR is a resembling approach in terms of surgical outcomes and aligns with existing literature findings in this field.

[Anastomotic techniques in minimally invasive hepatobiliopancreatic surgery]

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.

Computer-Aided Detection for Pancreatic Cancer Diagnosis: Radiological Challenges and Future Directions

Radiological imaging plays a crucial role in the detection and treatment of pancreatic ductal adenocarcinoma (PDAC). However, there are several challenges associated with the use of these techniques in daily clinical practice. Determination of the presence or absence of cancer using radiological imaging is difficult and requires specific expertise, especially after neoadjuvant therapy. Early detection and characterization of tumors would potentially increase the number of patients who are eligible for curative treatment. Over the last decades, artificial intelligence (AI)-based computer-aided detection (CAD) has rapidly evolved as a means for improving the radiological detection of cancer and the assessment of the extent of disease. Although the results of AI applications seem promising, widespread adoption in clinical practice has not taken place. This narrative review provides an overview of current radiological CAD systems in pancreatic cancer, highlights challenges that are pertinent to clinical practice, and discusses potential solutions for these challenges.

Robotic versus open pancreaticoduodenectomy for distal cholangiocarcinoma: a multicenter propensity score-matched study

BACKGROUND

Pancreatoduodenectomy is the only potentially curative treatment for distal cholangiocarcinoma (DCC). In this study, we sought to compare the perioperative and oncological outcomes of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) based on a multicenter propensity score-matched study.

METHODS

Consecutive patients with DCC who underwent RPD or OPD from five centers in China between January 2014 and June 2019 were included. A 1:1 propensity score matching (PSM) was performed. Univariable and multivariable Cox regression analyses were used to identify independent prognosis factors for overall survival (OS) and recurrence-free survival (RFS) of these patients.

RESULTS

A total of 217 patients and 228 patients underwent RPD and OPD, respectively. After PSM, 180 patients in each group were enrolled. There were no significant differences in operative time, lymph node harvest, intraoperative transfusion, vascular resection, R0 resection, postoperative major morbidity, reoperation, 90-day mortality, and long-term survival between the two groups before and after PSM. Whereas, compared with the OPD group, the RPD group had significantly lower estimated blood loss (150.0 ml vs. 250.0 ml; P < 0.001), and a shorter postoperative length of stay (LOS) (12.0 days vs. 15.0 days; P < 0.001). Multivariable analysis showed carbohydrate antigen 19-9 (CA19-9), R0 resection, N stage, perineural invasion, and tumor differentiation significantly associated with OS and RFS of these patients.

CONCLUSIONS

RPD was comparable to OPD in feasibility and safety. For patients with DCC, RPD resulted in similar oncologic and survival outcomes as OPD.

Comparing Minimally Invasive and Open Pancreaticoduodenectomy for the Treatment of Pancreatic Cancer: a Win Ratio Analysis

INTRODUCTION

Despite its rising adoption, the use of minimally invasive (MIS) pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer remains controversial. We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel statistical approach.

METHODS

Patients undergoing PD for pancreatic adenocarcinoma 2010-2016 were identified from the National Cancer Database (NCDB). Patients were paired based on age, sex, race, tumor size, Charlson-Deyo score, and receipt of neoadjuvant chemotherapy. The win ratio was calculated based on 30-day and 3-year mortality, receipt of adjuvant chemotherapy, surgical margin status, examination of at least 11 lymph nodes, extended length of stay, and 30-day readmission.

RESULTS

Among 18,936 patients, median age was 67 (IQR: 60-74); most patients had stage II disease at diagnosis (n = 16,530, 87.3%) and tumor size ≥ 2 cm (n = 15,880, 83.9%). The majority of patients underwent open PD (n = 16,409, 86.7%) versus MIS PD (n = 2527, 13.3%). For every matched patient-patient pair, the odds of the patient undergoing MIS PD "winning" were 1.14 (95%CI 1.13-1.15) higher versus open PD. The benefits of MIS PD were most pronounced among patients with tumor size < 2 cm (WR 1.21, 95%CI 1.13-1.30 versus ≥ 2 cm, WR 1.13, 95%CI 1.12-1.14) and patients who received neoadjuvant chemotherapy prior to resection (WR 1.28, 95%CI 1.23-1.32 versus no neoadjuvant chemotherapy, WR 1.13, 95%CI 1.11-1.14).

CONCLUSIONS

MIS PD may be preferable to open PD based on a hierarchical composite outcome that considered short-term, long-term, and oncologic outcomes.

Robotic versus open pancreaticoduodenectomy with vascular resection for pancreatic ductal adenocarcinoma: surgical and oncological outcomes from pilot experience

PURPOSE

Venous resection and reconstruction (VR) is a feasible surgical technique to achieve optimal outcomes in selected patients with pancreatic ductal adenocarcinoma (PDAC) who undergo open pancreaticoduodenectomy (OPD). However, data regarding patient outcomes in patients who undergo VR in robotic-assisted pancreaticoduodenectomy (RPD) are scarce.

METHODS

All patients with a diagnosis of PDAC who underwent upfront open or robotic pancreatoduodenectomy with VR in a high-volume institution for pancreatic surgery between 2011 and 2019 were retrospectively reviewed. Perioperative and long-term outcomes were compared between the RPD and OPD cohorts.

RESULTS

A total of 84 patients were included in the final analysis, 14 patients underwent RPD with VR and 70 who had OPD with VR. Reconstructed venous patency, postoperative 30-day morbidity, and 90-day mortality were comparable; however, lymph node resection rates were lower in the RPC cohort (p = 0.029). No difference was identified in 3-year survival rates between the two groups (34.0% versus 25.7% respectively, p = 0.667).

CONCLUSION

RPD with VR is a feasible approach for patients with PDAC and venous invasion. Further studies are needed to assess long-term outcomes compared to the open approach.

Feasibility and safety of robotic-assisted total pancreatectomy: a pilot western series

This study was designed to demonstrate non-inferiority of robot-assisted total pancreatectomy (RATP) to open total pancreatectomy (OPT) based on an intention-to-treat analysis, having occurrence of severe post-operative complications (SPC) as primary study endpoint. The two groups were matched (2:1) by propensity scores. Assuming a rate of SPC of 22.5% (non-inferiority margin: 15%; α: 0.05; β: 0.20; power: 80%), a total of 25 patients were required per group. During the study period (October 2008–December 2019), 209 patients received a total pancreatectomy. After application of exclusion and inclusion criteria, matched groups were extracted from an overall cohort of 132 patients (OPT: 107; RATP: 25). Before matching, the two groups were different with respect to prevalence of cardiac disease (24.3% versus 4.0%; p = 0.03), presence of jaundice (45.8% versus 12.0%; p = 0.002), presence of a biliary drainage (23.4% versus 0; p  = 0.004), history of weight loss (28.0% versus 8.0%; p = 0.04), and vein involvement (55.1% versus 28.0%) (p = 0.03). After matching, the two groups (OTP: 50; RATP: 25) were well balanced. Regarding primary study endpoint, SPC developed in 13 patients (26.0%) after OTP and in 6 patients (24.0%) after RATP (p = 0.85). Regarding secondary study endpoints, RATP was associated with longer median operating times [475 (408.8–582.5) versus 585 min (525–637.5) p = 0.003]. After a median follow-up time of 23.7 months (10.4–71), overall survival time [22.6 (11.2–81.2) versus NA (27.3–NA) p = 0.006] and cancer-specific survival [22.6 (11.2–NA) versus NA (27.3–NA) p = 0.02] were improved in patients undergoing RATP. In carefully selected patients, robot-assisted total pancreatectomy is non-inferior to open total pancreatectomy regarding occurrence of severe post-operative complications.

Real robotic total mesopancreas excision (TMpE) assisted by hanging manoeuver (HM): Standardised technique

BACKGROUND

Pancreaticoduodenectomy (PD) is one of the most demanding interventions for digestive surgeons. R0 resection is a key point for the overall survival and disease-free survival. Total mesopancreas excision (TMpE) has been described by laparotomy but laparoscopy did not provide good results probably because of the technical difficulties of the approach. We propose a standardised total robotic approach.

METHODS

In this step-by-step technical description, we propose as example, a case of a 53-year-old man with a pancreatic head adenocarcinoma with doubts about the invasion of the mesopancreas surrounding superior mesenteric artery. The mesopancreas hanging manoeuver allows us to perform a TMpE.

RESULTS

The surgery performed was a robotic artery first pancreaticoduodenectomy with TMpE. The pathological result was pancreatic ductal adenocarcinoma pT2, N1 (1/23), M0, V0, L0, Pn0, R0.

CONCLUSIONS

Robotic approach is safe, effective and reproductible. Through a standardised technique, it may overcome some of the technical difficulties of laparoscopic PD.

Perioperative outcomes of robotic pancreaticoduodenectomy: a single surgeon's experience with 55 consecutive cases

Background

Robotic pancreaticoduodenectomy (RPD) has been increasingly performed for patients with periampullary tumours and tumours in the pancreatic head. This method offers several technical advantages compared to open and laparoscopic surgeries. However, the surgical results often vary depending on the experience of different pancreatic centres.

Methods

A retrospective study of our first 55 cases of RPD from August 2016 to April 2020 was conducted to evaluate the perioperative outcomes of RPD and to summarize the operative experiences in a single intuition. Benign and malignant tumours in the pancreatic head or periampullary tumours without obvious vascular and adjacent organ invasion were included in this study. Perioperative characteristics and postoperative complications of the enrolled patients were retrospectively collected.

Results

The first 17 cases were robot-assisted laparoscopic pancreaticoduodenectomy (RA-LPD) and the remaining 38 patients underwent total RPD. The RA-LPD group had a remarkably longer operative time than the total RPD group (415.3±89.2 vs. 362.4±75.6 min, P=0.047). The incidences of biliary leakage, chyle leakage, DGE, intra-abdominal infection and intra-abdominal haemorrhage were 3.6%, 0.0%, 5.5%, 9.1% and 5.5%, respectively. Two patients underwent relaparotomy due to severe intra-abdominal haemorrhage. The median length of hospital stay was 14 (11 to 19) days. There were no deaths during the perioperative period.

Conclusions

RPD is a technically feasible procedure for selected patients with periampullary tumours and tumours in the pancreatic head in experienced hands.

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes

BACKGROUND

Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV).

METHODS

Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics.

RESULTS

Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004).

CONCLUSIONS

RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

3D-laparoscopic pancreaticoduodenectomy with superior mesenteric or portal vein resection for pancreatic cancer

BACKGROUND

Minimally invasive pancreaticoduodenectomy with synchronous vein resection for pancreatic cancer is controversial. The aim of this study was to evaluate outcomes and describe the surgical technique of 3d-laparoscopic pylorus-resecting pancreaticoduodenectomy (3dLPD) with venous resection for pancreatic cancer.

METHODS

A retrospective cohort analysis was performed with 26 patients [male/female 11/15; median age 68 (range 45-83) years] who underwent 3dLPD with stented pancreaticogastrostomy and superior mesenteric or portal vein resection for pancreatic adenocarcinoma between November 2016 and June 2019. Median follow-up time after surgery was 12 months (range 3-32).

RESULTS

Median operating time was 340 min (range 240-420) and intra-operative blood loss was 100 mL (range 0-1000). Type of venous resection and reconstruction was wedge-resection with primary closure (n = 22), wedge-resection with reconstruction using a peritoneal patch (n = 3), and segmental resection with primary end-to-end reconstruction (n = 1). Laparoscopy was converted to open surgery in 4 (15%) patients. Postoperative complications occurred in 10 (38%) patients including severe complications (Clavien-Dindo grade > 2) in 4 (15%). Postoperative mortality was zero. R0 resection was achieved in 21 (81%) patients. Median number of lymph nodes retrieved was 25 (range 10-45). Venous patency was observed in 23 (88%) patients with a median patency duration of 11 months (range 0-31).

CONCLUSIONS

3dLPD with simultaneous venous resection for pancreatic cancer results in acceptable reconstruction patency and adequacy of surgical oncology without compromising clinical outcomes.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Surgical, survival, and oncological outcomes after vascular resection in robotic and open pancreaticoduodenectomy

BACKGROUND

To evaluate the surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV)/portal vein (PV) resection by either robotic PD (RPD) or open PD (OPD).

METHODS

Data of patients with periampullary lesions undergoing PD were retrieved from a prospectively collected computer database. Surgical risks as well as oncological and survival outcomes were compared between patients with (vein resection group) and without SMV/PV resection (without vein resection group).

RESULTS

A total of 391 patients undergoing pancreaticoduodenectomy were enrolled, including 43 (11.0%) and 384 (89.0%) patients with and without vein resection, respectively. Eleven (25.6%) of PDs with vein resection were performed using the robotic approach. Operation time in the vein resection group was significantly longer (median of 8 vs. 7 h). Blood loss, curative resection (R0) rate, and harvested lymph node number were similar between these two groups. Surgical outcomes including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), chyle leakage, wound infection, and hospital stay were not significantly different between the two groups. There was no survival difference between these groups, with 1- and 3-year survival rates of 92.6% and 26.5%, respectively, for vein resection group, vs. 70.3% and 37.2%, respectively, for the without vein resection group.

CONCLUSIONS

PD with vein resection is technically feasible by OPD and RPD in selected patients. Additional SMV/PV would not increase the surgical risks of PD and could achieve similar survival outcomes for pancreatic head adenocarcinoma when compared to PD without vein resection.

Pitfalls of minimally invasive pancreatoduodenectomy

Minimally invasive approaches to abdominal surgical procedures have provided superior outcomes when compared to the open approach and thus have become the standard of care. However, minimally invasive pancreatoduodenectomy (MIPD) presents unique difficulties for both laparoscopic and robotic platforms and remains controversial. Ongoing concerns continue about the minimally invasive approach creating meaningful benefit when system-wide data may suggest MIPD results in increased morbidity and mortality during the learning curve. This treatise explores the current state of MIPD, reviewing the volume and quality of data that supports benefit while contrasting the benefits to the unique challenges associated with MIPD that may lead to unacceptable rates of complications and death. We conclude that in a handful of centers, MIPD confers an iterative but not transformative benefit. Significant barriers to the wide-spread acceptance of MIPD are apparent and persist, including: lack of high level data confirming clinical benefit, well defined patient selection criteria, formal education programs that address challenges of the learning curve, and ultimately value.