The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following a Multicenter Training Program: "Standing on the Shoulders of Giants"

OBJECTIVE

To assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework.

BACKGROUND

The long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program.

METHODS

Post hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned."

RESULTS

Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome.

CONCLUSIONS

The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.

A nationwide assessment of hepatocellular adenoma resection: Indications and pathological discordance

Hepatocellular adenomas (HCAs) are benign liver tumors associated with bleeding or malignant transformation. Data on the indication for surgery are scarce. We analyzed indications and outcome of patients operated for HCAs < 50 mm compared to HCAs ≥ 50 mm. Changes in final postoperative diagnosis were assessed. We performed a retrospective study that included patients who underwent resection for (suspected) HCAs in the Netherlands from 2014 to 2019. Indication for resection was analyzed and stratified for small (<50 mm) and large (≥50 mm) tumors. Logistic regression analysis was performed on factors influencing change in tumor diagnosis. Out of 222 patients who underwent surgery, 44 (20%) patients had a tumor <50 mm. Median age was 46 (interquartile range [IQR], 33-56) years in patients with small tumors and 37 (IQR, 31-46) years in patients with large tumors ( p  = 0.016). Patients with small tumors were more frequently men (21% vs. 5%, p  = 0.002). Main indications for resection in patients with small tumors were suspicion of (pre)malignancy (55%), (previous) bleeding (14%), and male sex (11%). Patients with large tumors received operations because of tumor size >50 mm (52%), suspicion of (pre)malignancy (28%), and (previous) bleeding (5.1%). No difference was observed in HCA-subtype distribution between small and large tumors. Ninety-six (43%) patients had a postoperative change in diagnosis. Independent risk factors for change in diagnosis were tumor size <50 mm (adjusted odds ratio [aOR], 3.4; p  < 0.01), male sex (aOR, 3.7; p  = 0.03), and lack of hepatobiliary contrast-enhanced magnetic resonance imaging (CE-MRI) (aOR, 1.8; p  = 0.04). Resection for small (suspected) HCAs was mainly indicated by suspicion of (pre)malignancy, whereas for large (suspected) HCAs, tumor size was the most prevalent indication. Male sex, tumor size <50 mm, and lack of hepatobiliary CE-MRI were independent risk factors for postoperative change in tumor diagnosis.

[Internal hernia following laparoscopic gastric bypass]

BACKGROUND

Internal herniation following a laparoscopic Roux-en-Y gastric bypass (LRYGB) operation is a complication whereby the small bowel herniates through to the newly formed peritoneal compartment. Medical history, physical examination and laboratory tests are often non-specific and could lead to misdiagnosis.

CASE DESCRIPTION

A 46-year-old male with a history of a gastric bypass came to the emergency department with colicky upper-abdominal pain. The patient was initially diagnosed with symptomatic cholelithiasis and a laparoscopic cholecystectomy was performed. However, the pain persisted and the internal hernia was finally identified and repaired during the third abdominal operation.

CONCLUSION

Internal herniation must be considered in patients with a history of laparoscopic Roux-en-Y gastric bypass and upper-abdominal pain, especially because such operations are being performed more frequently. When there is a high suspicion of internal herniation, a diagnostic laparoscopy must be performed and the entire small intestine must be systematically inspected.

[Gastric bypass surgery effective for morbid obesity]

OBJECTIVE

Evaluation of the results of Roux-en-Y gastric bypass in morbid obesity.

DESIGN

Descriptive.

METHODS

All patients undergoing gastric bypass surgery in St. Antonius Hospital in Nieuwegein, the Netherlands, between 2002 and 2008 were analysed. Indications were a body mass index (BMI) >or= 40 kg/m2 or a BMI >or= 35 kg/m2 with severe co-morbidity. Principal outcomes were excess weight loss after at least 1 year of follow-up, surgery-related morbidity and mortality.

RESULTS

290 patients with a median age of 42.5 years (range: 21-66) underwent gastric bypass surgery (open: n = 233, laparoscopic: n = 57). The median preoperative overweight above standard weight was 78.7 kg (range: 30.1-190.3) and the median BMI was 49.5 kg/m2 (range: 33.2-84.9). This concerned a secondary intervention after a previous unsuccessful bariatric procedure in 99/290 patients (34.1%). There were 189 patients with a follow-up of more than 1 year. The procedure was successful (>or= 50% excess weight loss) in 135/189 patients (71.4%). The median excess weight loss was 58.6% (range: 7.7-102.4). The BMI decreased by a median of 16.2 kg/m(2) (range: 0.9-42.9). Patients undergoing primary surgery lost a higher percentage of excess weight than patients undergoing secondary surgery (median percentage excess weight loss 61.4% versus 53.5% , and a median decrease in BMI of 17.8 versus 11.9 kg/m2). The most frequently occurring early complications (within 30 days of surgery) were anastomotic leak (n = 15) and wound infection (n = 11). Late complications included anastomotic stricture (n = 18) and cicatricial hernia (n = 15). Mortality was 0.7% (n = 2).

CONCLUSION

Gastric bypass surgery was an effective treatment strategy for morbid obesity and had acceptable surgery-related morbidity and mortality.

Endovascular Recanalization of Chronic Long-Segment Occlusions of the Inferior Vena Cava:Midterm Results

PURPOSE

To report the midterm results of endovascular recanalization of chronic long-segment (> 5 cm) occlusions of the inferior vena cava (IVC) with stent placement.

METHODS

Nine patients (5 men; median age 30 years, range 14-58) with disabling complaints for more than 6 months caused by IVC occlusions were treated by endovascular recanalization. Mean occlusion length was 11 cm (range 6-22); some occlusions extended to the iliac (n = 3) or common femoral (n = 2) veins. All procedures were performed under local anesthesia via a bilateral femoral (n = 7) or popliteal (n = 2) approach. In 3 patients, combined access to the brachial or internal jugular vein was necessary. Patients with acute-on-chronic thrombosis were pretreated with urokinase. After guidewire recanalization, the chronic occlusions were predilated and self-expanding Wallstents were implanted.

RESULTS

The initial technical and clinical success was 100%. The venous clinical severity score (pain, venous edema, inflammation, and active ulceration) decreased from a mean 8 +/- 2 to 5 +/- 1 after the procedure. Over a median follow-up of 9 months (mean 21, range 4- 110), 3 patients died. One rethrombosis occurred, and an asymptomatic restenosis was discovered on routine imaging. The primary patency rate was 78%, and the 9-month occlusion-free survival rate was 56%.

CONCLUSION

Endovascular recanalization of chronic long-segment occlusions of the IVC is a safe and worthwhile technique to offer patients with debilitating symptoms.