Changing trends and outcomes associated with the adoption of minimally-invasive pancreato-biliary surgery: Contemporary experience of a 'self-taught' early adopter in Southeast Asia

Oncological resection and perioperative outcomes of robotic, laparoscopic and open pancreatoduodenectomy for ampullary adenocarcinoma: a propensity score matched international multicenter cohort study

BACKGROUND

Ampullary adenocarcinoma (AAC) typically presents at an early stage due to biliary obstruction and therefore might be specifically suitable for minimally invasive pancreatoduodenectomy (MIPD). However, studies assessing MIPD specifically for AAC, including the robotic and laparoscopic approach, are limited. The aim of this study is to compare short- and long-term oncological resection and perioperative outcomes of robotic (RPD), laparoscopic (LPD) and open pancreatoduodenectomy (OPD) performed specifically for AAC.

METHODS

In this multicenter international cohort study, encompassing 35 centers from 11 countries, MIPD versus OPD and subgroup analyses of LPD versus RPD were undertaken. The primary outcomes regarded the oncological resection (R1 resection rate, lymph node yield) and 5-years overall survival. Secondary outcomes were perioperative outcomes (including intra-operative variables, surgical complications and hospital stay).

RESULTS

In total, patients with AAC who underwent OPD (1721) or MIPD (141) were included. After propensity-score matching, 134 patients per cohort were included. The MIPD group consisted of 53 RPDs and 71 LPDs (50 per group after PSM). There was no difference in overall survival between MIPD and OPD (61.6 % vs 56.2 %, P = 0.215). In the MIPD group, operative time was longer (439 vs 360 min, P < 0.001). Between RPD and LPD, overall survival was not significantly different (75.8 % vs 47.4 %, P = 0.098) and lymph node yield was higher in RPD (21 vs 18, P = 0.014).

CONCLUSION

In conclusion, patients with AAC seem to have comparable oncological resection and perioperative outcomes from MIPD compared to the traditional OPD. Both RPD as LPD appear to be safe alternatives for patients with AAC, which warrants confirmation by future randomized studies.

Impact of innovative technologies on quality and safety in surgery

Technological advancements gradually lead to the revision and transformation of healthcare, training, and research. Surgery is a field of medicine where the collaboration of human resources and the application of innovative technologies could elevate faithfulness and efficiency. The article, exploring the technologies and analyzing them in terms of their reliability, the benefits of performing precision surgeries, the effectiveness in the outcome of surgery with less psychosomatic fatigue, and the improvements in the training process for surgeons, emphasizes the safety and quality that can be achieved. The study was conducted by searching the relevant papers mainly from 2016-2024 using different online databases such as Web of Science, Google Scholar, and PubMed to examine the impact of adopting new technologies in medicine. This paper highlights that the use of innovative technologies in a wide range of surgical procedures could, by adapting interdisciplinary procedures, provide significant results in issues related to safety, quality, reliability, and training.

Minimally invasive versus open pancreatoduodenectomy for pancreatic ductal adenocarcinoma: Individual patient data meta-analysis of randomized trials

OBJECTIVE

Assessment of minimally invasive pancreatoduodenectomy (MIPD) in patients with pancreatic ductal adenocarcinoma (PDAC) is scarce and limited to non-randomized studies. This study aimed to compare oncological and surgical outcomes after MIPD compared to open pancreatoduodenectomy (OPD) for patients after resectable PDAC from published randomized controlled trials (RCTs).

METHODS

A systematic review was performed to identify RCTs comparing MIPD and OPD including PDAC (Jan 2015-July 2021). Individual data of patients with PDAC were requested. Primary outcomes were R0 rate and lymph node yield. Secondary outcomes were blood-loss, operation time, major complications, hospital stay and 90-day mortality.

RESULTS

Overall, 4 RCTs (all addressed laparoscopic MIPD) with 275 patients with PDAC were included. In total, 128 patients underwent laparoscopic MIPD and 147 patients underwent OPD. The R0 rate (risk difference(RD) -1%, P = 0.740) and lymph node yield (mean difference(MD) +1.55, P = 0.305) were comparable between laparoscopic MIPD and OPD. Laparoscopic MIPD was associated with less perioperative blood-loss (MD -91ml, P = 0.026), shorter length of hospital stay (MD -3.8 days, P = 0.044), while operation time was longer (MD +98.5 min, P = 0.003). Major complications (RD -11%, P = 0.302) and 90-day mortality (RD -2%, P = 0.328) were comparable between laparoscopic MIPD and OPD.

CONCLUSIONS

This individual patient data meta-analysis of MIPD versus OPD in patients with resectable PDAC suggests that laparoscopic MIPD is non-inferior regarding radicality, lymph node yield, major complications and 90-day mortality and is associated with less blood loss, shorter hospital stay, and longer operation time. The impact on long-term survival and recurrence should be studied in RCTs including robotic MIPD.

Figures do matter: A literature review of 4587 robotic pancreatic resections and their implications on training

BACKGROUND

The use of robotic assistance in minimally invasive pancreatic resection is quickly growing.

METHODS

We present a systematic review of the literature regarding all types of robotic pancreatic resection (RPR). Our aim is to show for which procedures there is enough experience to permit safe training and provide an estimation of how many centers could serve as teaching institutions.

RESULTS

Sixty-four studies reporting on 4587 RPRs were analyzed. A total of 2598 pancreatoduodenectomies (PD) were reported by 28 centers from Europe (6/28; 21.4%), the Americas (11/28; 39.3%), and Asia (11/28; 39.3%). Six studies reported >100 robot PD (1694/2598; 65.2%). A total of 1618 distal pancreatectomies (DP) were reported by 29 centers from Europe (10/29; 34.5%), the Americas (10/29; 34.5%), and Asia (9/29; 31%). Five studies reported >100 robotic DP (748/1618; 46.2%). A total of 154 central pancreatectomies were reported by six centers from Europe (1/6; 16.7%), the Americas (2/6; 33.3%), and Asia (3/6; 50%). Only 49 total pancreatectomies were reported. Finally, 168 enucleations were reported in seven studies (with a mean of 15.4 cases per study). A single center reported on 60 enucleations (35.7%). Results of each type of robotic procedure are also presented.

CONCLUSIONS

Experience with RPR is still quite limited. Despite high case volume not being sufficient to warrant optimal training opportunities, it is certainly a key component of every successful training program and is a major criterion for fellowship accreditation. From this review, it appears that only PD and DP can currently be taught at few institutions worldwide.

Evolution and trends in the adoption of laparoscopic liver resection in Singapore: Analysis of 300 cases

ABSTRACT Introduction: The introduction of laparoscopic surgery has changed abdominal surgery. We evaluated the evolution and changing trends associated with adoption of laparoscopic liver resection (LLR) and the experience of a surgeon without prior LLR experience. Methods: A retrospective review of 310 patients who underwent LLR performed by a single surgeon from 2011 to 2020 was conducted. Exclusion criteria were patients who underwent laparoscopic liver surgeries such as excision biopsy, local ablation, drainage of abscesses and deroofing of liver cysts. There were 300 cases and the cohort was divided into 5 groups of 60 patients. Results: There were 288 patients who underwent a totally minimally invasive approach, including 28 robotic-assisted procedures. Open conversion occurred for 13 (4.3%) patients; the conversion rate decreased significantly from 10% in the initial period to 3.3% subsequently. There were 83 (27.7%) major resections and 131 (43.7%) resections were performed for tumours in the difficult posterosuperior location. There were 152 (50.7%) patients with previous abdominal surgery, including 52 (17.3%) repeat liver resections for recurrent tumours, and 60 patients had other concomitant operations. According to the Iwate criteria, 135 (44.7%) were graded as high/expert difficulty. Major morbidity (>grade 3a) occurred in 12 (4.0%) patients and there was no 30-day mortality. Comparison across the 5 patient groups demonstrated a significant trend towards older patients, higher American Society of Anesthesiologists (ASA) score, increasing frequency of LLR with previous abdominal surgery, increasing frequency of portal hypertension and huge tumours, decreasing blood loss and decreasing transfusion rate across the study period. Surgeon experience (≤60 cases) and Institut Mutualiste Montsouris (IMM) high grade resections were independent predictors of open conversion. Open conversion was associated with worse perioperative outcomes such as increased blood loss, transfusion rate, morbidity and length of stay. Conclusion: LLR can be safely adopted for resections of all difficulty grades, including major resections and for tumours located in the difficult posterosuperior segments, with a low open conversion rate. Keywords: Laparoscopic hepatectomy, laparoscopic liver resection, robotic hepatectomy, robotic liver resection, Singapore

Propensity-Score Matched Analyses Comparing Clinical Outcomes of Minimally Invasive Versus Open Distal Pancreatectomies: A Single-Center Experience

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is being adopted increasingly worldwide. This study aimed to compare the short-term outcomes of patients who underwent MIDP versus open distal pancreatectomy (ODP).

METHODS

A retrospective review of all patients who underwent a DP in our institution between 2005 and 2019 was performed. Propensity score matching based on relevant baseline factors was used to match patients in the ODP and MIDP groups in a 1:1 manner. Outcomes reported include operative duration, blood loss, postoperative length of stay, morbidity, mortality, postoperative pancreatic fistula rates, reoperation and readmission.

RESULTS

In total, 444 patients were included in this study. Of 122 MIDP patients, 112 (91.8%) could be matched. After matching, the median operating time for MIDP was significantly longer than ODP [260 min (200-346.3) vs 180 (135-232.5), p < 0.001], while postoperative stay for MIDP was significantly shorter [median 6 days (5-8) versus 7 days (6-9), p = 0.015]. There were no significant differences noted in any of the other outcomes measured. Over time, we observed a decrease in the operation times of MIDP performed at our institution.

CONCLUSION

Adoption of MIDP offers advantages over ODP in terms of a shorter postoperative hospital stay, without an increase in morbidity and/or mortality but at the expense of a longer operation time.

Learning curve of laparoscopic and robotic pancreas resections: a systematic review

BACKGROUND

Minimally invasive pancreatic resection has been shown recently in some randomized trials to be superior in selected perioperative outcomes compared with open resection when performed by experienced surgeons. However, minimally invasive pancreatic resection is associated with a long learning curve. This study aims to summarize the current evidence on the learning curve of minimally invasive pancreatic resection and define the number of cases required to surmount the learning curve.

METHODS

A systematic search was performed on PubMed, Embase, Scopus, and the Cochrane database using a detailed search strategy. Studies that did not describe the learning curve were excluded from the study. Data on the method of learning curve analysis, single surgeon versus institutional learning curve, and outcome measures were extracted and analyzed.

RESULTS

A total of 32 studies were included in the pooled analysis: 12 on laparoscopic pancreatoduodenectomy, 9 on robotic pancreatoduodenectomy, 12 on laparoscopic distal pancreatectomy, and 3 on robotic distal pancreatectomy. Sample population was comparable between laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy (median 63 vs 65). Six of 12 studies and 7 of 9 studies used nonarbitrary methods of analysis in laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy, respectively. Operating time was used as the single outcome measure in 4 of 12 studies in laparoscopic pancreatoduodenectomy and 5 of 9 studies in robotic pancreatoduodenectomy. Overall, there was no significant difference between the number of cases required to surmount the learning curve for laparoscopic pancreatoduodenectomy versus robotic pancreatoduodenectomy (laparoscopic pancreatoduodenectomy 34.1 [95% confidence interval 30.7-37.7] versus robotic pancreatoduodenectomy 36.7 [95% confidence interval 32.9-41.0]; P = .8241) and laparoscopic distal pancreatectomy versus robotic distal pancreatectomy (laparoscopic distal pancreatectomy 25.3 [95% confidence interval 22.5-28.3] versus robotic distal pancreatectomy 20.7 [95% confidence interval 15.8-26.5]; P = .5997.) CONCLUSION: This study provides a detailed summary of existing evidence around the learning curve in minimally invasive pancreatic resection. There was no significant difference between the learning curve for robotic pancreatoduodenectomy versus laparoscopic pancreatoduodenectomy and robotic distal pancreatectomy versus laparoscopic distal pancreatectomy. These findings were limited by the retrospective nature and heterogeneity of the studies published to date.

Robotic transduodenal ampullectomy: Case report and review of the literature

Ampullary neoplasms are relatively uncommon lesions with a risk of progression to malignancy. Depending on its nature, size and location, it may be best treated with endoscopic papillotomy, pancreaticoduodenectomy or transduodenal ampullectomy. Transduodenal ampullectomy offers a higher chance of complete resection compared to endoscopic papillotomy, and carries lower morbidity than a pancreaticoduodenectomy, making it the ideal choice for localised ampullary tumour not involving the ducts but not amenable to complete endoscopic resection. While traditionally performed via open surgery, it has been attempted via laparoscopic approach and more recently robotic approach. We present a case of a 63-year-old man who underwent a robotic transduodenal ampullectomy for ampullary adenoma with high grade dysplasia, and review the literature surrounding robotic transduodenal ampullectomy.

Use of Reinforced Staplers Decreases the Rate of Postoperative Pancreatic Fistula Compared to Bare Staplers After Minimally Invasive Distal Pancreatectomies

Background: Postoperative pancreatic fistula (POPF) is the most common and important cause of morbidity after distal pancreatectomy. Various transection and closure techniques of the pancreatic stump have been proposed with no robust evidence unanimously supporting one technique over the other. This study aims to compare the outcomes of minimally invasive distal pancreatectomy (MIDP) performed with reinforced stapler (RS) versus bare stapler (BS) with particular attention to the POPF. Methods: Retrospective review of 90 consecutive elective MIDP performed at a single institution between 2014 and 2019 was performed. The primary outcome was POPF as defined by the latest International Study Group of Pancreatic Fistula classification. MIDP with RS was adopted by two surgeons who subsequently performed all their consecutive surgeries with RS. Results: There were 25 and 65 patients who underwent MIDP with RS and BS, respectively. There were 8 (8.9%) open conversions and 17 (18.9%) patients experienced a POPF. Patients who underwent MIDP with RS had a significantly lower POPF rate (4% versus 24.6%, P = .025), lower major (>grade 2) morbidity rate (4% versus 21.5%, P = .046), and lower readmission rate (4% versus 27.7%, P = .014). On multivariate analysis, only the use of BS and obesity (body mass index ≥27.5) was independently associated with the development of a POPF. Conclusion: MIDP performed with RS was associated with a significantly lower rate of POPF, major morbidity, and readmissions compared to BS. The use of RS was protective against POPF.

Emergency laparoscopic surgery for ruptured pancreatic pseudocyst: Report of two cases and review of the literature

Pancreatic pseudocyst (PP) is a known complication of pancreatitis. When a rupture occurs, patients often become haemodynamically unstable and require emergency surgery for source control. Conventionally, such a procedure is carried out through open technique due to patient, surgeon and technical factors. We present two cases of emergency laparoscopic surgery performed for ruptured PP. Our first patient was a 53-year-old male with a ruptured 17.6 cm pancreatic body pseudocyst who underwent a laparoscopic washout, adhesiolysis, necrosectomy, distal pancreatectosplenectomy and cholecystectomy. The second patient was a 66-year-old male with a ruptured 11 cm pancreatic body pseudocyst who underwent laparoscopic surgery, subsequently converted to hand-assisted surgery. We compare our cases with the existing literature and discuss pertinent management considerations. In conclusion, we demonstrated that emergency laparoscopic adhesiolysis, necrosectomy and distal pancreatosplenectomy are feasible and safe for the management of ruptured pseudocyst when performed by an experienced surgeon. However, further studies are needed to determine the advantages or limitations of the minimally invasive surgical approach for the management of these complicated cases.

Adoption of Robotic Liver, Pancreatic and Biliary Surgery in Singapore: A Single Institution Experience with Its First 100 Consecutive Cases

Introduction: Presently, robotic hepatopancreatobiliary surgery (RHPBS) is increasingly adopted worldwide. This study reports our experience with the first 100 consecutive cases of RHPBS in Singapore. Methods: Retrospective review of a single-institution prospective database of the first 100 consecutive RHPBS performed over 6 years from February 2013 to February 2019. Eighty-six cases were performed by a single surgeon. Results: The 100 consecutive cases included 24 isolated liver resections, 48 pancreatic surgeries (including 2 bile duct resections) and 28 biliary surgeries (including 8 with concomitant liver resections). They included 10 major hepatectomies, 15 pancreaticoduodenectomies, 6 radical resections for gallbladder carcinoma and 8 hepaticojejunostomies. The median operation time was 383 minutes, with interquartile range (IQR) of 258 minutes and there were 2 open conversions. The median blood loss was 200ml (IQR 350ml) and 15 patients required intra-operative blood transfusion. There were no post-operative 90-day nor in-hospital mortalities but 5 patients experienced major (> grade 3a) morbidities. The median post-operative stay was 6 days (IQR 5 days) and there were 12 post-operative 30-day readmissions. Comparison between the first 50 and the subsequent 50 patients demonstrated a significant reduction in blood loss, significantly lower proportion of malignant indications, and a decreasing frequency in liver resections performed. Conclusion: Our experience with the first 100 consecutive cases of RHPBS confirms its feasibility and safety when performed by experienced laparoscopic hepatopancreatobiliary surgeons. It can be performed for even highly complicated major hepatopancreatobiliary surgery with a low open conversion rate. Keywords: Biliary surgery, hepaticojejunostomy, liver resection, pancreas, pancreaticoduodenectomy