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

Learning curve of robotic pancreatoduodenectomy by a single surgeon with extensive laparoscopic pancreatoduodenectomy experience

With the development of robotic systems, robotic pancreatoduodenectomies (RPDs) have been increasingly performed. However, the number of cases required by surgeons with extensive laparoscopic pancreatoduodenectomy (LPD) experience to overcome the learning curve of RPD remains unclear. Therefore, we aimed to analyze and explore the impact of different phases of the learning curve of RPD on perioperative outcomes. Clinical data were prospectively collected and retrospectively analyzed for 100 consecutive patients who underwent RPD performed by a single surgeon. This surgeon had previous experience with LPD, having performed 127 LPDs with low morbidity. The learning curve for RPD was analyzed using the cumulative sum (CUSUM) method based on operation time, and perioperative outcomes were compared between the learning and proficiency phases. Between April 2020 and November 2022, one hundred patients (56 men, 44 women) were included in this study. Based on the CUSUM curve of operation time, the learning curve for RPD was divided into two phases: phase I was the learning phase (cases 1-33) and phase II was the proficiency phase (cases 34-100). The operation time during the proficiency phase was significantly shorter than that during the learning phase. In the learning phase of RPD, no significant increases were observed in estimated blood loss, conversion to laparotomy, severe complications, postoperative pancreatic hemorrhage, clinical pancreatic fistula, or other perioperative complications compared to the proficiency phases of either RPD or LPD. A surgeon with extensive prior experience in LPD can safely surmount the RPD learning curve without increasing morbidity in the learning phase. The proficiency was significantly improved after accumulating experience of 33 RPD cases.

Analysis of the learning curve for laparoscopic pancreaticoduodenectomy based on a single surgeon's experience: a retrospective observational study

Purpose

Laparoscopic pancreaticoduodenectomy (LPD) is a highly challenging procedure, which prevents its widespread adoption despite its advantages of being a minimally invasive procedure. This study analyzed the learning curve for LPD based on a single surgeon's experience.

Methods

We retrospectively analyzed the medical records of 111 consecutive patients who underwent LPD by a single surgeon between March 2014 and October 2022. The learning curve was assessed using cumulative summation (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Surgical failure was defined as conversion to an open procedure or the occurrence of severe complications (Clavien-Dindo grade ≥III). Based on the learning curve analysis, we divided the learning curve into the early and late phases and compared the operative outcomes in each phase.

Results

Based on the CUSUM analysis, the operation time decreased after the first 33 cases. Based on the RA-CUSUM analysis, the LPD technique stabilized after the 44th case. In the late phase, operation time, length of stay, and incidence of delayed gastric emptying, severe complications, and surgical failure were significantly lower than in the early phase.

Conclusion

Our results indicate that 44 cases are required for stabilization of the LPD technique and improvement of operative outcomes.

Defining distal splenopancreatectomy by the mesopancreas

BACKGROUND

The implementation of the pathologic CRM (circumferential resection margin) staging system for pancreatic head ductal adenocarcinomas (hPDAC) resulted in a dramatic increase of R1 resections at the dorsal resection margin, presumably because of the high rate of mesopancreatic fat (MP) infiltration. Therefore, mesopancreatic excision (MPE) during pancreatoduodenectomy has recently been promoted and has demonstrated better local disease control, fueling the discussion of neoadjuvant downsizing regimes in MP + patients. However, it is unknown to what extent the MP is infiltrated in patients with distal pancreatic (tail/body) carcinomas (dPDAC). It is also unknown if the MP infiltration status affects surgical margin control in distal pancreatectomy (DP). The aim of our study was to histopathologically analyze MP infiltration and elucidate the influence of resection margin clearance on recurrence and survival in patients with dPDAC. Furthermore, the results were compared to a collective receiving MPE for hPDAC.

METHOD

Clinicopathological and survival parameters of 295 consecutive patients who underwent surgery for PDAC (n = 63 dPDAC and n = 232 hPDAC) were evaluated. The CRM evaluation was performed in a standardized fashion and the specimens were examined according to the Leeds pathology protocol (LEEPP). The MP area was histopathologically evaluated for cancerous infiltration.

RESULTS

In 75.4% of dPDAC patients the MP fat was infiltrated by vital tumor cells. The rates of MP infiltration and R0CRM- resections were similar between dPDAC and hPDAC patients (p = 0.497 and 0.453 respectively). MP- infiltration status did not correlate with CRM implemented resection status in dPDAC patients (p = 0.348). In overall survival analysis, resection status and MP status remained prognostic factors for survival. In follow up analysis. surgical margin clearance in dPDAC patients was associated with a significant improvement in local recurrence rates (5.2% in R0CRM- resected vs. 33.3 in R1/R0CRM + resected, p = 0.002).

CONCLUSION

While resection margin status was not affected by the MP status in dPDAC patients, the high MP infiltration rate, as well as improved survival in MP- dPDAC patients after R0CRM- resection, justify mesopancreatic excision during splenopancreatectomy. Larger scale studies are urgently needed to validate our results and to study the effect on neoadjuvant treatment in dPDAC patients.

A propensity score-matched analysis of laparoscopic versus open pancreaticoduodenectomy: Is there value to a laparoscopic approach?

BACKGROUND

Laparoscopic pancreaticoduodenectomy has been found safe and associated with advantages over open pancreaticoduodenectomy in prior studies. We compared outcomes of laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy at a single institution after applying technical aspects and perioperative care learned from laparoscopic pancreaticoduodenectomy to the open pancreaticoduodenectomy practice.

METHODS

From January 2010 to December 2020, all patients undergoing pancreaticoduodenectomy were identified, and information was collected in a prospective fashion. Open pancreaticoduodenectomy (n = 347) and laparoscopic pancreaticoduodenectomy (n = 242) were performed using the same selection criteria, operative technique, and recovery protocols at a single institution. Propensity score matching was performed, and then perioperative data and 90-day outcomes were compared, and statistical analysis was performed.

RESULTS

A total of 589 patients underwent pancreaticoduodenectomy, including open pancreaticoduodenectomy (n = 347) and laparoscopic pancreaticoduodenectomy (n = 242). After excluding those undergoing total pancreatectomy or major vascular or concomitant organ resection, there were 497 patients (open pancreaticoduodenectomy = 301 and laparoscopic pancreaticoduodenectomy = 196). Propensity score matching was performed, and 187 open pancreaticoduodenectomy patients were matched to 187 laparoscopic pancreaticoduodenectomy patients. Operative time (475 vs 280 minutes) was longer, and estimated blood loss (150 vs 212 mL) was less for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy, respectively. Pancreatic fistula (18.8% vs 5.4%) and delayed gastric emptying (18.8% vs 9.7%) were higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy, respectively. Postpancreatectomy hemorrhage, major morbidity, mortality, hospital stay, and readmissions were nonsignificantly higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy. Intensive care use and overall costs were significantly higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy.

CONCLUSION

In our experience, open pancreaticoduodenectomy offers similar to improved outcomes over laparoscopic pancreaticoduodenectomy, with less use of perioperative resources, thereby offering better value to patients requiring pancreaticoduodenectomy.

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.

Impact of Unplanned Intra-Operative Conversions on Outcomes in Minimally Invasive Pancreatoduodenectomy

BACKGROUND

Minimally-invasive pancreatoduodenectomy (MIPD) is fraught with the risk of complication-related deaths (LEOPARD-2), a significant volume-outcome relationship and a long learning curve. With rates of conversion for MIPD approaching 40%, the impact of these on overall patient outcomes, especially, when unplanned, are yet to be fully elucidated. This study aimed to compare peri-operative outcomes of (unplanned) converted MIPD against both successfully completed MIPD and upfront open PD.

METHODS

A systematic review of major reference databases was undertaken. The primary outcome of interest was 30-day mortality. Newcastle-Ottawa scale was used to judge the quality of the studies. Meta-analysis was performed using pooled estimates, derived using random effects model.

RESULTS

Six studies involving 20,267 patients were included in the review. Pooled analysis demonstrated (unplanned) converted MIPD were associated with an increased 30-day (RR 2.83, CI 1.62- 4.93, p = 0.0002, I2 = 0%) and 90-day (RR 1.81, CI 1.16- 2.82, p = 0.009, I2 = 28%) mortality and overall morbidity (RR 1.41, CI 1.09; 1.82, p = 0.0087, I2 = 82%) compared to successfully completed MIPD. Patients undergoing (unplanned) converted MIPD experienced significantly higher 30-day mortality (RR 3.97, CI 2.07; 7.65, p < 0.0001, I2 = 0%), pancreatic fistula (RR 1.65, CI 1.22- 2.23, p = 0.001, I2 = 0%) and re-exploration rates (RR 1.96, CI 1.17- 3.28, p = 0.01, I2 = 37%) compared upfront open PD.

CONCLUSIONS

Patient outcomes are significantly compromised following unplanned intraoperative conversions of MIPD when compared to successfully completed MIPD and upfront open PD. These findings stress the need for objective evidence-based guidelines for patient selection for MIPD.

Risk stratification of clinically relevant delayed gastric emptying after pancreaticoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) remains one of the major complications after pancreaticoduodenectomy (PD), with discrepant reports of its contributing factors. This study aimed to develop a nomogram to identify potential predictors and predict the probability of DGE after PD.

METHODS

This retrospective study enrolled 422 consecutive patients who underwent PD from January 2019 to December 2021 at our institution. The LASSO algorithm and multivariate logistic regression were performed to identify independent risk and protective factors associated with clinically relevant delayed gastric emptying (CR-DGE). A nomogram was established based on the selected variables. Then, the calibration curve, ROC curve, decision curve analysis (DCA), and clinical impact curve (CIC) were applied to evaluate the predictive performance of our model. Finally, an independent cohort of 45 consecutive patients from January 2022 to March 2022 was enrolled to further validate the nomogram.

RESULTS

Among 422 patients, CR-DGE occurred in 94 patients (22.2%). A previous history of chronic gastropathy, intraoperative plasma transfusion ≥ 400 ml, end-to-side gastrointestinal anastomosis, intra-abdominal infection, incisional infection, and clinically relevant postoperative pancreatic fistula (CR-POPF) were identified as risk predictors. Minimally invasive pancreaticoduodenectomy (MIPD) was demonstrated to be a protective predictor of CR-DGE. The areas under the curve (AUCs) were 0.768 (95% CI, 0.706-0.830) in the development cohort, 0.766 (95% CI, 0.671-0.861) in the validation cohort, and 0.787 (95% CI, 0.633-0.940) in the independent cohort. Then, we built a simplified scale based on our nomogram for risk stratification.

CONCLUSIONS

Our study identified seven predictors and constructed a validated nomogram that effectively predicted CR-DGE for patients who underwent PD.

State-of-the-Art and Upcoming Innovations in Pancreatic Cancer Care: A Step Forward to Precision Medicine

Pancreatic cancer remains a social and medical burden despite the tremendous advances that medicine has made in the last two decades. The incidence of pancreatic cancer is increasing, and it continues to be associated with high mortality and morbidity rates. The difficulty of early diagnosis (the lack of specific symptoms and biomarkers at early stages), the aggressiveness of the disease, and its resistance to systemic therapies are the main factors for the poor prognosis of pancreatic cancer. The only curative treatment for pancreatic cancer is surgery, but the vast majority of patients with pancreatic cancer have advanced disease at the time of diagnosis. Pancreatic surgery is among the most challenging surgical procedures, but recent improvements in surgical techniques, careful patient selection, and the availability of minimally invasive techniques (e.g., robotic surgery) have dramatically reduced the morbidity and mortality associated with pancreatic surgery. Patients who are not candidates for surgery may benefit from locoregional and systemic therapy. In some cases (e.g., patients for whom marginal resection is feasible), systemic therapy may be considered a bridge to surgery to allow downstaging of the cancer; in other cases (e.g., metastatic disease), systemic therapy is considered the standard approach with the goal of prolonging patient survival. The complexity of patients with pancreatic cancer requires a personalized and multidisciplinary approach to choose the best treatment for each clinical situation. The aim of this article is to provide a literature review of the available treatments for the different stages of pancreatic cancer.

First assistant experience in total laparoscopic pancreaticoduodenectomy: accelerating the learning curve for an operator

OBJECTIVE

Compare and analyze clinical data of total laparoscopic pancreaticoduodenectomy (TLPD) cases for surgeons with / without first assistant experience (FAE) in TLPD. Probe influence of FAE in TLPD on the learning curve for an operator.

METHODS

The clinical data of 239 patients, that underwent TLPD performed by two surgeons between January 2017 and January 2022) in our department, were consecutively collected and divided into two groups (A and B). Group A cases were operated by Surgeon A, with FAE of 57 TLPDs in our department prior to initial TLPD as an operator. Group B cases were operated by Surgeon B with no FAE of TLPD. Cumulative sum (CUSUM) method developed learning curves. Clinical data and both surgeons' learning curves were statistically compared between both groups.

RESULTS

Between both groups, no statistically significant variations were observed for pre-operative health conditions. Reduced surgical duration, blood loss and transfusion volume during surgery, together with reductions in major post-operative complication rates and reduced hospital/ICU stays were identified within Group A, having statistically significant variations. The technical plateau phases of the learning curves were approximately 25-41 cases and 35-51 cases, for Surgeon A and Surgeon B, respectively.

CONCLUSION

FAE in TLPD can accelerate the learning curve of TLPD for an operator, with safer surgical procedures and enhanced post-operative recovery.

Development of a difficulty scoring system for laparoscopic pancreatoduodenectomy in the initial stage of the learning curve: a retrospective cohort study

BACKGROUND

It remains uncertain how surgeons can safely pass the learning curve of laparoscopic pancreatoduodenectomy (LPD) without potentially harming patients. We aimed to develop a difficulty scoring system (DSS) to select an appropriate patient for surgeons.

MATERIALS AND METHODS

A total of 773 elective pancreatoduodenectomy surgeries between July 2014 and December 2019, including 346 LPD and 427 open pancreatoduodenectomy cases, were included. A 10-level DSS for LPD was developed, and an additional 77 consecutive LPD surgeries which could provide information of the learning stage I of LPD externally validated its performance between December 2019 and December 2021.

RESULTS

The incidences of postoperative complications (Clavien-Dindo≥III) gradually decreased from the learning curve stage I-III (20.00, 10.94, 5.79%, P =0.008, respectively). The DSS consisted of the following independent risk factors: (1) tumor location, (2) vascular resection and reconstruction, (3) learning curve stage, (4) prognostic nutritional index, (5) tumor size, and (6) benign or malignant tumor. The weighted Cohen's κ statistic of concordance between the reviewer's and calculated difficulty score index was 0.873. The C -statistics of DSS for postoperative complication (Clavien-Dindo≥III) were 0.818 in the learning curve stage I. The patients with DSS<5 had lower postoperative complications (Clavien-Dindo≥III) than those with DSS≥5 (4.35-41.18%, P =0.004) in the training cohort and had a lower postoperative pancreatic fistula (19.23-57.14%, P =0.0352), delayed gastric emptying (19.23-71.43%, P =0.001), and bile leakage rate (0.00-21.43%, P =0.0368) in validation cohort in the learning curve stage I.

CONCLUSION

We developed and validated a difficulty score model for patient selection, which could facilitate the stepwise adoption of LPD for surgeons at different stages of the learning curve.

Single-port laparoscopic pancreaticoduodenectomy

BACKGROUND

Performing a single-port laparoscopic pancreatectomy is technically challenging. Single-port laparoscopic pancreaticoduodenectomy (SPLPD) is rarely reported in English literature.

METHODS

Eighty-seven cases of laparoscopic pancreaticoduodenectomy (LPD) were performed by a single surgical team in the Department of Pancreatic Surgery, West China Hospital, Sichuan University between February 2020 and December 2020. Among these, 13 cases of LPD (group 1) were performed using a single-port device. Basing on the same inclusion and exclusion criteria, 68 cases of LPD performed using traditional 5-trocar were included as a control group (group 2). The patient's demographic characteristics, intraoperative, and postoperative variables were prospectively collected and retrospectively analyzed.

RESULTS

Five men and eight women were included in the SPLPD group. The median age of these patients was 57 years. The patients who underwent SPLPD required a longer operative time (332.7 ± 38.1 min vs. 305.8 ± 64.7 min; p = 0.03) than those in the LPD group. The estimated blood loss, conversion rate, blood transfusion rate, time to oral intake, postoperative hospital stays, and perioperative complications were comparable between the two groups. The short-term oncological outcomes, such as R0 rate and lymph node harvested, were comparable between the two groups. The 90-day mortality of all patients was zero.

CONCLUSIONS

SPLPD is a safe and feasible procedure for well-selected patients in an experienced minimally invasive pancreatic surgery team. SPLPD may provide several potential advantages, such as the requirement of fewer trocars, fewer abdominal complications, and reduced participation of assistants than conventional LPD.

A chronicle of the pancreatoduodenectomy technique development - from the surgeon's hand to the robotic arm

BACKGROUND

Pancreatoduodenectomy (PD) remains one of the most challenging abdominal surgical procedures.

METHODS

A review of the literature regarding the history of PD, starting from the pioneers, Walter Kausch and Alan Whipple, through the great surgeons of the last century, up to the present day.

RESULTS

The greatest development of the PD technique took place at the end of the twentieth century. Over the last 40 years, there have been huge technological advances in medicine, which have resulted in the introduction of laparoscopic and robotic techniques for abdominal surgery. However, it turns out that PD is still performed as it used to be "by the surgeon's hand" via laparotomy rather than using the most modern robot or laparoscope and is currently recommended by experts for treatment of pancreatic head cancer (PHC). This is mainly caused by not many data comparing these three PD methods. Moreover, increasingly the results achieved by surgeons advanced in minimally invasive pancreatic resections are comparable to or even better than those achieved by the open method in reference centres. Robot-assisted PD appears to be gaining an advantage over laparoscopic technique in the efficacy of PHC treatment. The obstacles most inhibiting the use of surgical robotics are the high cost of the device and procedure, and the long learning curve. A bright future lies ahead for both methods, with the robotic technique in the forefront.

CONCLUSIONS

Despite significant advances in access and surgical technique, PD remains a challenging surgical procedure requiring a big surgeon's experience.

Pancreatic head cancer - Current surgery techniques

Pancreatic head cancer is a highly fatal disease. For now, surgery offers the only potential long-term cure albeit with a high risk of complications. However, the progress of surgical technique during the past decade has resulted in 5-year survival approaching 30% after resection and adjuvant chemotherapy. This paper presents current data on the recommended extent of lymphadenectomy, the resection margin, on the definition of resectable and borderline resectable tumors and mesopancreas. Surgical techniques proposed to improve PD are presented: the artery first approach, the uncinate process first, the mesopancreas first approach, the triangle operation, periarterial divestment, and multiorgan resection.

Application of Clavien-Dindo classfication-grade in evaluating overall efficacy of laparoscopic pancreaticoduodenectomy

Background

The Clavien-Dindo classification (CDC) has been widely accepted and applied in clinical practice. We investigated its effectiveness in prediction of major complications (LPPC) after laparoscopic pancreaticoduodenectomy (LPD) and associated risk factors.

Methods

A retrospective analysis was conducted covering clinical data of 793 patients undergoing LPD from April 2015 to November 2021. CDC was utilized to grade postoperative complications and analyze the differences. Risk factors of LPPC were identified according to univariate and multivariate analyses.

Resluts

For the 793 patients undergoing laparoscopic pancreaticoduodenectomy in the northeast of China, LPPC was reported in 260 (32.8%) patients, pancreatic fistula in 169 (21.3%), biliary fistula in 44 (5.5%), delayed gastric emptying in 17(2.1%), post pancreatectomy hemorrhage in 55 (6.9%), intestinal fistula in 7 (0.8%), abdominal infections in 59 (7.4%) and pulmonary complication in 28 (3.5%). All complications were classified into five levels with the C-D classification (Grade I-V), with 83 (31.9%) patients as grade I, 91 (35.0%) as grade II, 38 (14.6%) as grade IIIa, 24 (9.2%) as grade IIIb, 9 (3.5%) as grade IV and 15 (5.8%) as grade V. 86 (10.8%) patients experienced major complications (grade III-V).The results of univariate and multivariate analysis revealed the independent risk factors for laparoscopic pancreaticoduodenectomy complications to be preoperative total bilirubin (P = 0.029, OR = 1.523), soft pancreas texture (P < 0.001, OR = 1.399), male (P = 0.038, OR = 1.396) and intraoperative transfusion (P = 0.033, OR = 1.517). Preoperative total bilirubin (P = 0.036, OR = 1.906) and intraoperative transfusions (P = 0.004, OR = 2.123) were independently associated with major postoperative complications. The influence of different bilirubin levels on C-D grade of complications was statistically significant (P = 0.036, OR = 1.906).

Conclusions

The Clavien-Dindo classification (CDC) may serve as a valid tool to predict major postoperative complications and contribute to perioperative management and comparison of surgical techniques in different medical centers.

Reliability of stroke volume or pulse pressure variation as dynamic predictors of fluid responsiveness in laparoscopic surgery: a systematic review

The reliability of stroke volume variation (SVV) and pulse pressure variation (PPV) in predicting fluid responsiveness during laparoscopic surgery remains unclear. We conducted the present systematic review to summarize the current evidence. We reviewed studies that investigated the reliability of SVV and PPV in laparoscopic surgery. Seven studies were included in the final analysis. Two studies demonstrated that the area under the receiver operating characteristic curve (AUROC) for SVV was less than 0.8, and five studies reported that the AUROC was > 0.8. The pooled AUROC for SVV and PPV was more than 0.8 with high heterogeneities between the included studies. Most individual studies have suggested that SVV and PPV are sufficiently reliable for predicting fluid responsiveness during laparoscopic surgery. However, the limited number of patients, varied apparatus used to define fluid responsiveness, diverse definitions of fluid responsiveness, and different fluids used to perform fluid challenges in the included studies render firm conclusions about SVV's and PPV's reliability impossible.

Delayed gastric emptying is associated with increased risk of mortality in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma

Delayed gastric emptying (DGE) is common in patients undergoing pancreaticoduodenectomy (PD). The effect of DGE on mortality is less clear. We sought to identify predictors of mortality in patients undergoing PD for pancreatic adenocarcinoma hypothesizing DGE to independently increase risk of 30-day mortality. The ACS-NSQIP targeted pancreatectomy database (2014–2017) was queried for patients with pancreatic adenocarcinoma undergoing PD. A multivariable logistic regression analysis was performed. Separate sensitivity analyses were performed adjusting for postoperative pancreatic fistula (POPF) grades A–C. Out of 8011 patients undergoing PD, 1246 had DGE (15.6%). About 8.5% of patients with DGE had no oral intake by postoperative day-14. The DGE group had a longer median operative duration (373 vs. 362 min, p = 0.019), and a longer hospital length of stay (16.5 vs. 8 days, p < 0.001). After adjusting for age, gender, comorbidities, preoperative chemotherapy, preoperative radiation, open versus laparoscopic approach, vascular resection, deep surgical space infection (DSSI), postoperative percutaneous drain placement, and development of a POPF, DGE was associated with an increased risk for 30-day mortality (OR 3.25, 2.16–4.88, p < 0.001). On sub-analysis, grades A and B POPF were not associated with risk of mortality while grade C POPF was associated with increased risk of mortality (OR 5.64, 2.24–14.17, p < 0.001). The rate of DGE in patients undergoing PD in this large database was over 15%. DGE is associated with greater than three times the increased associated risk of mortality, even when controlling for POPF, DSSI, and other known predictors of mortality.

Pulmonary infection after hepatic resection: Associated factors and impact on outcomes

BACKGROUND AND AIMS

Postoperative pulmonary complications are frequent after hepatectomy. The aim of this retrospective study was to use preoperative and intraoperative data to establish specific factors associated with post-hepatectomy pneumonia (PHPN).

METHODS

Patients underwent minor or major hepatectomy for cancer or non-cancer treatment. Surgical procedure was performed by laparoscopy or laparotomy. PHPN was defined as a new radiologic finding associated with fever, leucocytosis and purulent bronchial secretions. The incidence, associated factors and prognosis of PHPN were investigated.

RESULTS

In 399 patients undergoing planned hepatectomy, 49 (12.3%) developed pneumonia. Of 81 patients (20.3%) with cirrhosis, 77 were Child-Pugh A and 4 were Child-Pugh B. Hepatectomy indication was cancer in 331 patients (of which metastasis in 213). Laparoscopy rate was 31.3%. In multivariate analysis, the main factors statistically associated with PHPN were: chronic obstructive pulmonary disease (COPD) (odds ratio [OR] = 4.17; 95% confidence interval [CI], 1.60-10.84; P = 0.003), intraoperative blood transfusion (OR = 2.46; 95% CI 1.01-5.70; P = 0.001), laparotomy (OR = 3.01; 95% CI 1.09-8.27; P = 0.03), and nasogastric tube maintained at day 1 (OR = 2.09; 95% CI 1.03-4.22; P = 0.04). Length of stay was significantly different between groups without PHPN (10.2 days) versus with PHPN (26.4 days; P < 0.001). Intra-hospital and one-year mortality were greater in the PHPN group than the pneumonia-free group (8.16 vs 0% and 18.4 vs 3.4%, respectively; P < 0.001).

CONCLUSIONS

COPD, transfusion and laparotomy (versus laparoscopy) are factors associated with PHPN and impaired survival.

Laparoscopic Pancreaticoduodenectomy in Elderly Patients: Systematic Review and Meta-Analysis

Background

The safety and efficacy of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients who often suffer from pre-existing conditions (e.g., cardiovascular diseases) and poor functional reserve remain unclear. This meta-analysis aimed to evaluate the safety and efficacy of LPD in elderly patients.

Methods

A systematic literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane Library databases. All studies published from their inception to January 2022 reporting perioperative outcomes after LPD in elderly patients were included in the search (Group 1, comparing the perioperative outcomes of LPD and OPD in elderly patients; Group 2, comparing the perioperative outcomes after LPD between elderly and non-elderly patients). The evaluated outcomes included perioperative mortality, postoperative complications, conversion, operative time, estimated blood loss (EBL), postoperative hospital stay (POHS), and readmission.

Results

In total 8 studies were included in the meta-analysis. Pooled analysis of Group 1 showed that EBL, 90-day mortality, major morbidity, bile leak, POH, abdominal infection, reoperation, POP, POCE, and readmission were not significantly different between the LPD and the OPD group. LPD was associated with longer operative time, lower POPF rate, lower DEG rate, and shorter POHS. Pooled analysis of Group 2 showed that mortality, major morbidity, POPF, DEG, bile leak, POH, abdominal infection, reoperation, conversion, operative time, EBL, and readmission were not significantly different between the elderly and the non-elderly group. The POHS of elderly group was significantly longer than non-elderly group.

Conclusion

LPD may be a safe and feasible procedure for elderly patients and is associated with short POHS.

Anaesthesia for Pancreatic Surgery

This article provides a broad perspective on the salient perioperative issues encountered when caring for patients undergoing pancreatic surgery in the setting of pancreatic cancer. It describes the epidemiology of pancreatic cancer, the indications for and evolution of pancreatic resection surgery, the challenges faced perioperatively including patient selection, optimization, anesthetic considerations, postoperative analgesia, fluid management, and nutrition and discusses some of the common complications and their management. It finishes by outlining the future directions for research and development required to continue improving outcomes for these patients.

A Propensity-Matched Analysis of the Postoperative Venous Thromboembolism Rate After Pancreatoduodenectomy Based on Operative Approach

BACKGROUND

The use of minimally invasive approaches for pancreatoduodenectomy has increased in recent years, but the risk of postoperative VTE is undefined. We aimed to compare venous thromboembolism (VTE) rates after open and minimally invasive pancreatoduodenectomy using an administrative dataset.

METHODS

Patients who underwent pancreatoduodenectomy within the National Surgical Quality Improvement Program targeted pancreatectomy database (2016-2018) were identified. VTE was compared between patients who underwent open or minimally invasive pancreatoduodenectomy directly and after propensity score matching 1:1 for demographics, comorbidities, and peri-/intra-operative factors.

RESULTS

A total of 12,227 patients underwent pancreatoduodenectomy during the study period (open: n = 11,217; minimally invasive: n = 1010). Before matching, the VTE rate was higher among patients who underwent minimally invasive pancreatoduodenectomy (5.2% vs. 3.8%, p = 0.033), and minimally invasive resection was independently associated with VTE (OR = 1.46, 95%CI = 1.09-2.06). After matching, there were 916 patients per group without differences in demographics or comorbidities. Patients who underwent minimally invasive pancreatoduodenectomy had longer median operative times (422 vs. 348 min). The VTE rate remained higher following minimally invasive pancreatoduodenectomy after matching (5.1% vs. 2.9%, p = 0.018), mainly driven by a higher DVT rate (3.9% vs. 1.7%, p = 0.005).

CONCLUSIONS

Minimally invasive pancreatoduodenectomy is associated with a higher postoperative VTE rate compared to open pancreatoduodenectomy.

Anterior approach in situ resection for total laparoscopic pancreaticoduodenectomy

Background

Laparoscopic pancreaticoduodenectomy (LPD) is gaining popularity in last decade. However, it is still technical challenging to perform LPD for patients with large periampullary tumors.

Methods

From January 2019 to January 2020, 13 cases of LPD were performed via anterior approach. Data were collected prospectively in terms of demographic characteristics (age, gender, body mass index, pathological diagnosis and tumor size), intra-operative variables (operative time, estimated blood loss, transfusion), and post-operative variables (time for oral intake, post-operative hospital stay, and complications).

Results

There were five male patients and eight female patients included in this study. The median age of these patients was 52.7 ± 14.5 years. The median size of tumors was 7.2 ± 2.9 cm. One patient converted to open surgery because of uncontrollable hemorrhage. The median operative time was 356 ± 47 min. The median estimated blood loss was 325 ± 216 ml. The mean post-operative hospital stay was 12.4 ± 1.9 days. One patient suffered from grade B pancreatic fistula. One patient suffered from delayed gastric emptying which was cured by conservative therapy. 90-day mortality was zero.

Conclusions

Laparoscopic pancreaticoduodenectomy via anterior approach is safe and feasible for patients with large periampullary tumors. Its oncological benefit requires further investigation.

Multicenter comparison of totally laparoscopic and totally robotic pancreaticoduodenectomy: Propensity score and learning curve-matching analyses

BACKGROUND

Few studies have compared laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) despite emerging use of minimally invasive pancreaticoduodenectomy (MIPD). The present study therefore compares perioperative outcomes of LPD and RPD patients, and evaluates safety and feasibility of MIPD.

METHODS

This retrospective multicenter analysis evaluated MIPD patients through June 2020 performed by three experienced pancreatic surgeons at three different institutions. Perioperative outcomes were compared before and after propensity score-matching analyses, and learning curves based on operation time were used for additional matching analysis.

RESULTS

Of 362 patients, 282 underwent LPD and 80 underwent RPD. Open conversion rate was significantly higher in LPD (P = .001). There were no significant differences in rates of major complications (Clavien-Dindo ≥III) and clinically relevant postoperative pancreatic fistula (CR-POPF). After matching, operation time (P = .001) and hospital stay (P = .027) were significantly shorter in RPD, but there were no differences in major complications and CR-POPF. Propensity score-matched comparison after learning curve attainment showed shorter operation time (P = .037) and hospital stay (P = .014) in RPD, and no differences in major complications and CR-POPF.

CONCLUSION

RPD had several advantages compared with LPD, including shorter operative time and hospital stay, and lower open conversion rate. Postoperative complications including CR-POPF showed comparable results in two groups. Both LPD and RPD seemed to be feasible and safe approaches in experienced hands.

Surgery for pancreatic cancer: current controversies and challenges

Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.

Outcomes of laparoscopic, robotic, and open pancreatoduodenectomy: A network meta-analysis of randomized controlled trials and propensity-score matched studies

BACKGROUND

This network meta-analysis was performed to determine the optimal surgical approach for pancreatoduodenectomy by comparing outcomes after laparoscopic pancreatoduodenectomy, robotic pancreatoduodenectomy and open pancreatoduodenectomy.

METHODS

A systematic search of the PubMed, EMBASE, Scopus, and Web of Science databases was conducted to identify eligible randomized controlled trials and propensity-score matched studies.

RESULTS

Four randomized controlled trials and 23 propensity-score matched studies comprising a total of 4,945 patients were included for analysis. Operation time for open pancreatoduodenectomy was shorter than both laparoscopic pancreatoduodenectomy (mean difference -57.35, 95% CI 26.25-88.46 minutes) and robotic pancreatoduodenectomy (mean difference -91.08, 95% CI 48.61-133.56 minutes), blood loss for robotic pancreatoduodenectomy was significantly less than both laparoscopic pancreatoduodenectomy (mean difference -112.58, 95% CI 36.95-118.20 mL) and open pancreatoduodenectomy (mean difference -209.87, 95% CI 140.39-279.36 mL), both robotic pancreatoduodenectomy and laparoscopic pancreatoduodenectomy were associated with reduced rates of delayed gastric emptying compared with open pancreatoduodenectomy (odds ratio 0.59, 95% CI 0.39-0.90 and odds ratio 0.69, 95% CI 0.50-0.95, respectively), robotic pancreatoduodenectomy was associated with fewer wound infections compared with open pancreatoduodenectomy (odds ratio 0.35, 95% CI 0.18-0.71), and laparoscopic pancreatoduodenectomy patients enjoyed significantly shorter length of stay compared with open pancreatoduodenectomy (odds ratio 0.43, 95% CI 0.28-0.95). There were no differences in other outcomes.

CONCLUSION

This network meta-analysis of high-quality studies suggests that when laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy are performed in high-volume centers, short-term perioperative and oncologic outcomes are largely comparable, if not slightly improved, compared with traditional open pancreatoduodenectomy. These findings should be corroborated in further prospective randomized studies.

Learning Curve in Laparoscopic Pancreaticoduodenectomy: Using Risk-Adjusted Cumulative Summation Methods

Background: Laparoscopic pancreaticoduodenectomy (LPD) is one of the most technically challenging operations of minimally invasive surgery. We aimed to analyze the learning curve of a single surgeon who conducted 115 LPDs at a single center. Materials and Methods: From August 2015 to August 2020, 115 patients underwent LPD. Patient characteristics and perioperative variables were retrospectively collected and analyzed. Cumulative summation (CUSUM) and risk-adjusted cumulative summation (RA-CUSUM) analyses were used to evaluate the LPD learning curve. All variables were compared after dividing the learning curve phases. Results: After 74 cases, operative time improved based on the CUSUM analysis of the operation time. From the RA-CUSUM analysis, three distinct phases of the learning curve were identified (phase I: 1-42 cases, phase II: 43-73 cases, and phase III: 74-115 cases). The mean operative time was significantly lower in phase III compared with that in phases I and II (348.5 minutes versus 444.6 minutes and 439.9 minutes, P < .001 and P < .001, respectively). The rate of estimated blood loss >500 mL was significantly decreased among the three phases (P = .017). The conversion rate significantly decreased from 11.9% in phase I to 6.5% in phase II to 0% in phase III (P = .023). The rates of overall complication (Clavien-Dindo >IIIA), postoperative pancreatic fistula, and postpancreatectomy hemorrhage were significantly decreased as phases progressed. Postoperative hospital stay, 30-day mortality, and 30-day readmission did not significantly differ among phases. Conclusions: According to learning curve analyses, the LPD failure rate plateaued after 42 cases and stabilized after 73 cases.

The effect of cold application on episiotomy pain: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To evaluate the effectiveness of cold application methods in reducing postpartum episiotomy pain.

BACKGROUND

Many women suffer from pain after giving birth due to an episiotomy. This prolonged pain affects their daily lives as they recover. Various methods can help alleviate this pain; however, the effects of cold application specifically are still under discussion.

DESIGN

Systematic review and meta-analysis were used.

METHODS

In this review, we investigated studies from the CINAHL, PubMed, Google Scholar and Science Direct databases that met PICOS inclusion criteria. We also assessed the studies' methodological quality with the JADAD and JBI checklists. This study was performed based on the Guidelines of Systematic Reporting of Examination presented in the PRISMA checklist (Appendix S1). The search protocol has been registered at the PROSPERO International Prospective Register of Systematic Reviews.

RESULTS

A total of seven published studies including 700 total participants were included in this review. Various cold application methods (cold gel pack/pad, crushed ice gel pad, ice pack) significantly reduced the pain after an episiotomy. Ice packs in particular did not significantly differ from lavender oil and acupressure in reducing pain after an episiotomy.

CONCLUSIONS

Cold application methods can be an effective, non-pharmacological midwifery and nursing intervention to reduce pain after an episiotomy.

RELEVANCE TO CLINICAL PRACTICE

The use of cold application methods to reduce pain after episiotomy may reduce the need for pharmacological medication in women due to the reduction in pain in the perineum.

Clinical Application of a Modified Double Purse-String Continuous Suture Technique for Pancreaticojejunostomy: Reliable for Laparoscopic Surgery and Small Size Main Pancreatic Duct

Background

The technical challenge of pancreatojejunostomy (PJ) is the greatest barrier for surgeons to complete pancreatoduodenectomy (PD). The authors present an easy-to-master PJ anastomosis technique with limited technical requirements. This technique uses two layers of sutures and double purse-string sutures to complete the entire anastomosis. This anastomosis technique has achieved good results in laparoscopic surgery (LS) and small size main pancreatic duct (MPD).

Methods

From February 2015 to August 2020, 63 patients who met the surgical indications underwent a modified double purse-string continuous suture pancreaticojejunostomy technique in our center. We collected patient demographic characteristics and perioperative outcomes and analyzed these data.

Results

A total of 63 patients underwent PD using our new anastomosis technique. Thirty-eight patients underwent LS, and 26 patients had a small MPD (<3 mm). The median operative time (OT) was 270 min, and the median estimated blood loss (EBL) was 200 ml. Ten patients had grade B postoperative pancreatic fistula (POPF), while no patients had grade C POPF. No 90-day mortality was observed. There were significant differences in the OT and postoperative hospital stay (PHS) among groups with different surgical procedures, while there were no significant differences among groups with different MPD sizes. Neither the surgical procedure nor the MPD size affected early postoperative complications.

Conclusion

This new technique can not only reduce the incidence of POPF but also is reliable for LS and surgeries with small size MPD. Therefore, this technique is worthy of clinical promotion and application in the future.

Impact of the highest amylase level in drain fluid on surgical outcomes and postoperative interventions in patients undergoing pancreaticoduodenectomy

OBJECTIVES

The clinical significance of the highest drain fluid amylase (DFA) level beyond pancreaticoduodenectomy (PD) postoperative day three (POD 3) remains unclear. This study investigated the impact of highest DFA level beyond POD 3 on postoperative pancreatic fistula (POPF) severity and outcomes of patients undergoing PD with POPF.

METHODS

Patient demographics of biochemical POPF and clinically relevant POPF (CR-POPF) were compared. Predictive factors were assessed using binary logistic regression. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of highest DFA (beyond POD 3). We compared length of hospital stay, surgical mortality rates, and need for postoperative interventions by highest DFA level.

RESULTS

Patients with CR-POPF had an older age (p = 0.039), required intraoperative blood transfusion (p = 0.006), and had greater highest DFA levels (p = 0.001) than those with biochemical POPF. The optimal highest DFA cutoff was 2014.5 U/L. Multivariate analysis showed that percentage of patients with intraoperative blood transfusion (p = 0.011; odds ratio, 3.716) and a highest DFA > 2014.5 U/L beyond POD 3 (p = 0.001; odds ratio, 5.722) was predictive of CR-POPF.

CONCLUSION

Highest DFA > 2014.5 U/L beyond POD 3 is an independent predictor for CR-POPF. At a highest DFA >2014.5 U/L, 30-day surgical mortality rate, length of stay, and need for postoperative interventions did not differ.

Is Laparoscopic Pancreaticoduodenectomy Feasible for Pancreatic Ductal Adenocarcinoma?

Simple Summary

Pancreatic cancer is known to be one of the most lethal malignant diseases in gastrointestinal tract. Margin-negative pancreatectomy followed by postoperative adjuvant chemotherapy is essential treatment for long-term survival. Due to anatomical complexity and technical difficulty, laparoscopic pancreaticoduodenectomy is still controversial. However, with the advance of laparoscopic surgery, laparoscopic pancreatic resection of pancreatic head cancer has been carefully applied in well selected patients. The accumulating data are suggesting its technical feasibility, safety, and potential equivalent long-term oncologic outcome. In this review, the current status of laparoscopic pancreaticoduodenectomy for pancreatic head cancer is summarized. In addition, potential surgical indications and future perspectives of laparoscopic pancreaticoduodenectomy for pancreatic cancer are discussed for safe implementation in our clinical practice.

Abstract

Margin-negative radical pancreatectomy is the essential condition to obtain long-term survival of patients with pancreatic cancer. With the investigation for early diagnosis, introduction of potent chemotherapeutic agents, application of neoadjuvnat chemotherapy, advancement of open and laparoscopic surgical techniques, mature perioperative management, and patients’ improved general conditions, survival of the resected pancreatic cancer is expected to be further improved. According to the literatures, laparoscopic pancreaticoduodenectomy (LPD) is also thought to be good alternative strategy in managing well-selected resectable pancreatic cancer. LPD with combined vascular resection is also feasible, but only expert surgeons should handle these challenging cases. LPD for pancreatic cancer should be determined based on surgeons’ proficiency to fulfil the goals of the patient’s safety and oncologic principles.

Risk factors and preventive measures for postoperative pancreatic fistula after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD), which can lead to slow recovery, deterioration, and even reoperation and death. At present, the mortality rate after PD has decreased, but the incidence of POPF is still high. Therefore, exploring the risk factors and prevention strategies for pancreatic fistula has become a hot research topic in pancreatic surgery. This paper summarizes the nature, risk factors, and preventive measures for POPF.

Comparison of Perioperative and Oncological Outcomes of Hybrid and Totally Laparoscopic Pancreatoduodenectomy

BACKGROUND Laparoscopic pancreatoduodenectomy (LPD) is a complicated procedure accompanied with high morbidity. Hybrid LPD is usually used as an alternative/transitional approach. This study aimed to prove whether the hybrid procedure is a safe procedure during a surgeon's learning curve of LPD. MATERIAL AND METHODS There were 48 hybrid LPD patients and 62 TLPD patients selected from January 2016 to December 2018; their demographics, surgical outcomes, and oncological data were retrospectively collected. Patient follow-up for the study continued until February 2020. RESULTS Patient demographics and baseline parameters were well balanced between the 2 groups. Intraoperative conditions, overall operation time was shorter for TLPD compared to hybrid LPD (407.79 minutes versus 453.29 minutes, respectively; P=0.035) and blood loss was less in TLPD patients compared to hybrid LPD patients (100.00 mL versus 300.00 mL, respectively; P<0.001). There was no difference in transfusion rates between the 2 groups (hybrid LPD 16.7% versus TLPD 4.8%; P=0.084). Postoperative outcomes and intensive care unit (ICU) stay was longer in the hybrid LPD patient group (hybrid LPD 1-day versus TLPD 0-day, P=0.002) and postoperative hospital stay was similar between the 2 groups (P=0.503). Reoperation rates, in-hospital, 30-day mortality, and 90-day mortality rates were comparable between the 2 groups (P=0.276, 1.000, 1.000, 0.884, respectively). Surgical site infection, bile leak, Clavien-Dindo classification (CDC) ≥3, delayed gastric emptying, grade B/C postoperative pancreatic fistulae, and grade B/C post pancreatectomy hemorrhage were not different between the 2 groups (P=0.526, 0.463, 0.220, 0.089, 0.165, 0.757, respectively). The tumor size, margin status, lymph nodes harvested, and metastasis were similar in the 2 groups (P=0.767, 0.438, 0.414, 0.424, respectively). In addition, the median overall survival rates were comparable between the 2 groups (hybrid LPD 29.0 months versus TLPD 30.0 months, P=0.996) as were the progression-free survival rates (hybrid LPD 11.0 months versus TLPD 12.0 months, P=0.373) CONCLUSIONS Hybrid LPD was comparable to TLPD. Hybrid LPD could be performed safely when some surgeons first started LPD (during the operative learning curve), while for skilled surgeons, TLPD could be applied initially.

Effectiveness of a psychoeducational intervention for caregivers of People With Dementia with regard to burden, anxiety and depression: A systematic review

AIM

To assess the effectiveness of psychoeducational interventions with respect to burden, anxiety and depression in family caregivers of People With Dementia living at home.

BACKGROUND

In dementia, the family assumes the role of main caregiver, maintaining the patient in a good state of health. Nevertheless, burden, anxiety and depression may have negative repercussions in caregivers. Therefore, professional supports through psychoeducational programmes are recommended as interventions for improving caregivers' health.

DESIGN

A quantitative systematic review.

DATA SOURCES

Electronic searches were performed in CINAHL/AMED/CENTRAL/Web of Science/LILACS/PUBMED from January 2005-August 2018.

REVIEW METHODS

The review was conducted using the JADAD scale to assess bias risk and the quality of the randomized controlled trials (RCTs) and the CONSORT instrument to assess study quality report. The extracted data were reviewed by independent reviewer pairs. The review was reported using PRISMA.

RESULTS

A total of 18 RCTs met inclusion criteria. Seven were classified as Technology-based Interventions and 11 as Group-based Interventions.

CONCLUSION

Psychoeducational interventions for caregivers allow them to increase their knowledge of the illness, develop problem-solving skills and facilitate social support. Technology-based Interventions significantly affect burden while Group-based Interventions affect anxiety, depression, insomnia and burden and quality of life and self-efficacy.

IMPACT

Research findings can be used to classify caregivers in future interventions according to illness stage to obtain more precise results.