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Araujo RLC, Martinie JB. Robotic Revisional Pancreato-Jejunal Anastomosis. J Gastrointest Surg 2025:101999. [PMID: 39954770 DOI: 10.1016/j.gassur.2025.101999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Revised: 01/22/2025] [Accepted: 02/11/2025] [Indexed: 02/17/2025]
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Müller PC, Kuemmerli C, Billeter AT, Shen B, Jin J, Nickel F, Guidetti C, Kauffmann E, Purchla J, Tschuor C, Krohn PS, Burgdorf SK, Jonas JP, Bussmann FJ, Saint-Marc O, Iben-Khayat A, Andel PCM, Molenaar IQ, Wellner U, Keck T, Moeckli B, Toso C, Di Benedetto F, Valle V, Giulianotti P, Roulin D, Martinie JB, Rama M, Lavu H, Yeo C, Mavani PT, Shah MM, Kooby DA, He J, Boggi U, Hackert T, Borel-Rinkes IHM, Müller BP, Clavien PA. Competency, Proficiency, and Mastery: Learning Curves for Robotic Distal Pancreatectomy at 16 International Expert Centers. Ann Surg 2024:00000658-990000000-01130. [PMID: 39559857 DOI: 10.1097/sla.0000000000006592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the different phases of the learning curve for robotic distal pancreatectomy (RDP) in international expert centers. SUMMARY BACKGROUND DATA RDP is an emerging minimally invasive approach; however, only limited, mostly single center data are available on its safe implementation, including the learning curve. METHODS Consecutive patients undergoing elective RDP from 16 expert centers across three continents were included to assess the learning curve. Based on the first 100 RDPs at each center, three cutoffs were used to define the learning curve: operative time for competency, major complications (Clavien-Dindo grade ≥III) for proficiency, and textbook outcome for mastery. Clinical outcomes before and after the cutoffs were compared. RESULTS The learning curve analysis was conducted on 1109 of 2403 RDPs. Competency, proficiency, and mastery, respectively, were reached after 46, 63, and 73 RDP procedures. After competency, operative time decreased from 245 to 235 minutes (P=0.002). Attaining proficiency was reflected by a reduction in the rate of major complications from 20% to 15% (P=0.012), and mastery was associated with a higher proportion of patients with textbook outcome (71% vs. 63%; P=0.028). The postoperative pancreatic fistula rate remained stable along the learning curve, ranging between 18.5% and 21.5%. Previous laparoscopic experience accelerated the learning process by virtue of reduced operative time and an earlier decrease in major complications. CONCLUSION Competency, proficiency, and mastery for RDP were reached after 46, 63, and 73 procedures, respectively, at international expert centers. The findings highlight that the learning curves for intraoperative parameters are completed earlier; however, extensive experience is needed to master RDP.
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Ausania F, Gonzalez-Abós C, Landi F, Martinie JB, Vrochides D, Walsh M, Hossain SM, White S, Prabakaran V, Melstrom LG, Fong Y, Butturini G, Bignotto L, Valle V, Bing Y, Xiu D, Di Franco G, Sanchez-Bueno F, de'Angelis N, Laurent A, Giuliani G, Pernazza G, Esposito A, Salvia R, Bazzocchi F, Esposito L, Pietrabissa A, Pugliese L, Memeo R, Uyama I, Uchida Y, Ríos J, Coratti A, Morelli L, Giulianotti PC. Conversion to open surgery in obese patients undergoing minimally invasive distal pancreatectomy: results from a multicenter analysis. HPB (Oxford) 2024; 26:1172-1179. [PMID: 38853075 DOI: 10.1016/j.hpb.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/08/2024] [Accepted: 05/27/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Although minimally invasive distal pancreatectomy (MIDP) is considered a standard approach it still presents a non-negligible rate of conversion to open that is mainly related to some difficulty factors, as obesity. The aim of this study is to analyze the preoperative factors associated with conversion in obese patients with MIDP. METHODS In this multicenter study, all obese patients who underwent MIDP at 18 international expert centers were included. The preoperative factors associated with conversion to open surgery were analyzed. RESULTS Out of 436 patients, 91 (20.9%) underwent conversion to open, presenting higher blood loss, longer operative time and similar rate of major complications. Twenty (22%) patients received emergent conversion. At univariate analysis, the type of approach, radiological invasion of adjacent organs, preoperative enlarged lymphnodes and ASA ≥ III were significantly associated with conversion to open. At multivariate analysis, robotic approach showed a significantly lower conversion rate (14.6 % vs 27.3%, OR = 2.380, p = 0.001). ASA ≥ III (OR = 2.391, p = 0.002) and preoperative enlarged lymphnodes (OR = 3.836, p = 0.003) were also independently associated with conversion. CONCLUSION Conversion rate is significantly lower in patients undergoing robotic approach. Radiological enlarged lymphnodes and ASA ≥ III are also associated with conversion to open. Conversion is associated with poorer perioperative outcomes, especially in case of intraoperative hemorrhage.
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Wells AB, Butano VW, Phillips MC, Mckillop IH, Martinie JB, Baker EH, Iannitti DA. Outcomes after Surgical Microwave Ablation for the Treatment of Colorectal Liver Metastasis. J Am Coll Surg 2024; 239:276-285. [PMID: 38651746 DOI: 10.1097/xcs.0000000000001097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third most common cause of cancer mortality worldwide. Of these, approximately 25% will have liver metastasis. We performed 394 microwave ablations (MWAs) and analyzed outcomes for survival and ablation failure. STUDY DESIGN We conducted a retrospective review of patients who underwent a surgical MWA at a single-center high-volume institution from October 2006 to September 2022 using a prospectively maintained database. The primary outcome was overall survival. RESULTS A total of 394 operations were performed on 328 patients with 842 tumors undergoing MWA. Median tumor size was 1.5 cm (range 0.4 to 7.0 cm), with the median number of tumors ablated per operation being 1 (range 1 to 11). A laparoscopic approach was used 77.9% of the time. Concomitant procedures were performed 63% of the time, most commonly hepatectomy (22.3%), cholecystectomy (17.5%), and colectomy (6.6%). Clavien-Dindo grade III or IV complication occurred in 12 patients (3.6%), and all of these patients had undergone concomitant procedures. Mortality within 30 days occurred in 4 patients (1.2%). The rate of incomplete ablation was 1.5% per tumor. Local recurrence occurred at a rate of 6.3% per tumor. Black patients were found to have a higher incidence of incomplete ablation and local recurrence. One-year survival probability was 91% (95% CI 87.9 to 94.3), with a mean overall survival of 57.6 months (95% CI 49.9 to 65.4 months). CONCLUSIONS Surgical MWA offers a low-morbidity approach to treatment of colorectal liver metastasis, with low rate of failure. This large series reviews the outcomes of MWA as definitive treatment for colorectal liver metastasis.
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Butano VW, Phillips MC, Wells AB, Strand MS, McKillop IH, Baker EH, Martinie JB, Iannitti DA. Analysis of technical failure after 1,613 surgical microwave ablations: A propensity score-matched analysis. Surgery 2024; 176:775-784. [PMID: 38971698 DOI: 10.1016/j.surg.2024.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/29/2024] [Accepted: 05/19/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Microwave ablation is becoming increasingly common for the treatment of liver tumors. Despite numerous studies aimed at identifying risk factors for local recurrence after microwave ablation, a consensus on modifiable risk factors for failure remains elusive, partly because of the limited statistical power of these studies. This study investigated the incidence of technical failure after microwave ablation, encompassing both incomplete ablation and local recurrence, and aimed to identify modifiable factors that reduce technical failure. METHODS This retrospective review included patients who underwent surgical microwave ablation at a high-volume institution between October 2006 and March 2023. Univariate analysis, multivariate analysis, and propensity score matching were performed to identify risk factors for technical failure. RESULTS A total of 1,613 surgical microwave ablations were performed on 3,035 tumors, with 226 instances (14% per procedure, 7.4% per tumor) of technical failure. Incomplete ablation occurred at a rate of 1.7% per tumor, whereas local recurrence was identified in 6.5% of ablations in per-tumor analysis. Body mass index >25 was significant for failure (odds ratio, 1.50; 95% confidence interval, 1.07-2.11; P < .05), suggesting that more difficult targeting may lead to increased technical failure rates. African American race (odds ratio, 1.62; 95% confidence interval, 1.16-2.27; P < .05), pre-microwave ablation transarterial chemoembolization (odds ratio, 1.54; 95% confidence interval, 1.08-2.21; P < .05), and previous ablation (odds ratio, 1.58; 95% confidence interval, 1.09-2.29; P < .05) were found to be statistically significant. CONCLUSION On the basis of the largest microwave ablation database available to date, this study identified novel modifiable and nonmodifiable risk factors of microwave ablation failure. These results can lead to decreasing technical failure rates after microwave ablation.
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Davis JMK, Niazi MKK, Ricker AB, Tavolara TE, Robinson JN, Annanurov B, Smith K, Mantha R, Hwang J, Shrestha R, Iannitti DA, Martinie JB, Baker EH, Gurcan MN, Vrochides D. Predicting response to neoadjuvant chemotherapy for colorectal liver metastasis using deep learning on prechemotherapy cross-sectional imaging. J Surg Oncol 2024; 130:93-101. [PMID: 38712939 DOI: 10.1002/jso.27673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 04/13/2024] [Accepted: 04/28/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND AND OBJECTIVES Deep learning models (DLMs) are applied across domains of health sciences to generate meaningful predictions. DLMs make use of neural networks to generate predictions from discrete data inputs. This study employs DLM on prechemotherapy cross-sectional imaging to predict patients' response to neoadjuvant chemotherapy. METHODS Adult patients with colorectal liver metastasis who underwent surgery after neoadjuvant chemotherapy were included. A DLM was trained on computed tomography images using attention-based multiple-instance learning. A logistic regression model incorporating clinical parameters of the Fong clinical risk score was used for comparison. Both model performances were benchmarked against the Response Evaluation Criteria in Solid Tumors criteria. A receiver operating curve was created and resulting area under the curve (AUC) was determined. RESULTS Ninety-five patients were included, with 33,619 images available for study inclusion. Ninety-five percent of patients underwent 5-fluorouracil-based chemotherapy with oxaliplatin and/or irinotecan. Sixty percent of the patients were categorized as chemotherapy responders (30% reduction in tumor diameter). The DLM had an AUC of 0.77. The AUC for the clinical model was 0.41. CONCLUSIONS Image-based DLM for prediction of response to neoadjuvant chemotherapy in patients with colorectal cancer liver metastases was superior to a clinical-based model. These results demonstrate potential to identify nonresponders to chemotherapy and guide select patients toward earlier curative resection.
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Ricker AB, Baker EH, Strand MS, Kalabin A, Butano V, Wells A, Phillips M, Wang H, McKillop I, Iannitti G, Casingal J, Martinie JB, Vrochides D, Iannitti DA. Surgical microwave ablation for the treatment of hepatocellular carcinoma in 791 operations. HPB (Oxford) 2024; 26:379-388. [PMID: 38102029 DOI: 10.1016/j.hpb.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/03/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality and often arises in the setting of cirrhosis. The present series reviews outcomes following 791 operations. METHODS Retrospective review surgical MWA for HCC from March 2007 through December 2022 at a high-volume institution was performed using a prospective database. Primary outcome was overall survival. RESULTS A total of 791 operations in 623 patients and 1156 HCC tumors were treated with surgical MWA. Median tumor size was 2 cm (range 0.25-10 cm) with an average of 1 tumor ablated per operation (range 1-7 tumors). Nearly 90 % of patients had cirrhosis with a median MELD score of 8 (IQR = 6-11). Mortality within 30 days occurred in 13 patients (1.6 %). Per tumor, the rate of incomplete ablation was 2.25 % and local recurrence was 2.95 %. Previous ablation and tumor size were risk factors for recurrence. One-year overall survival was 82.0 % with a median overall survival of 36.5 months (95 % CI 15.7-93.7) and median disease-free survival of 15.9 months (range 5.7-37.3 months). CONCLUSION Surgical MWA offers a low-morbidity approach for treatment of HCC, affording low rates of incomplete ablation and local recurrence.
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Ceppa EP, Collings AT, Abdalla M, Onkendi E, Nelson DW, Ozair A, Miraflor E, Rahman F, Whiteside J, Shah MM, Ayloo S, Dirks R, Kumar SS, Ansari MT, Sucandy I, Ali K, Douglas S, Polanco PM, Vreeland TJ, Buell J, Abou-Setta AM, Awad Z, Kwon CH, Martinie JB, Sbrana F, Pryor A, Slater BJ, Richardson W, Jeyarajah R, Alseidi A. SAGES/AHPBA guidelines for the use of microwave and radiofrequency liver ablation for the surgical treatment of hepatocellular carcinoma or colorectal liver metastases less than 5 cm. Surg Endosc 2023; 37:8991-9000. [PMID: 37957297 DOI: 10.1007/s00464-023-10468-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/07/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver's two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies. METHODS A systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations. RESULTS The panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence). CONCLUSION Given the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.
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McCarron FN, Yoshino O, Müller PC, Wang H, Wang Y, Ricker A, Mantha R, Driedger M, Beckman M, Clavien PA, Vrochides D, Martinie JB. Expanding the utility of robotics for pancreaticoduodenectomy: a 10-year review and comparison to international benchmarks in pancreatic surgery. Surg Endosc 2023; 37:9591-9600. [PMID: 37749202 DOI: 10.1007/s00464-023-10426-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/31/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) is an emerging alternative to open pancreaticoduodenectomy (OPD). Although RPD offers various theoretical advantages, it is used in less than 10% of all pancreaticoduodenectomies. The aim of this study was to report our 10-year experience and compare RPD outcomes with international benchmarks for OPD. METHODS A retrospective review of a prospectively maintained institutional database was performed of consecutive patients who underwent RPD between January 2011 and December 2021. Patients were categorized into low-risk and high-risk groups according to the selection criteria set by the benchmark study. Their outcomes were compared to the international benchmark cut off values. Outcomes were then evaluated over time to identify improvements in practice and establish a learning curve. RESULTS Of 201 RPDs, 36 were low-risk and 165 high-risk patients. Compared to the OPD benchmarks, outcomes of low-risk patients were within the cutoff values. High-risk patients were outside the cutoff for blood transfusions (26% vs. ≤ 23%), overall complications (78% vs. ≤ 73%), grade I-II complications (68% vs. ≤ 62%), and readmissions (22% vs ≤ 21%). Oncologic outcomes for high-risk patients were within benchmark cutoffs. Cases at the end of the learning curve included more pancreatic cancer (42% from 17%) and fewer low-risk patients (10% from 24%) than those at the beginning. After 41 RPD there was a decline in conversion rates and operative time. Between 95 and 143 cases operative time, transfusion rates, and LOS declined significantly. Complications did not differ over time. CONCLUSION RPD yields results comparable to the established benchmarks in OPD in both low- and high-risk patients. Along the learning curve, RPD evolved with the inclusion of more high-risk cases while outcomes remained within benchmarks. Addition of a robotic HPB surgery fellowship did not compromise outcomes. These results suggest that RPD may be an option for high-risk patients at specialized centers.
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Ausania F, Landi F, González-Abós C, Martinie JB, Vrochides D, Walsh M, Hossain SM, White S, Prabakaran V, Melstrom LG, Fong Y, Valle V, Bing Y, Xiu D, Di Franco G, De' Angelis N, Laurent A, Giuliani G, Pernazza G, Memeo R, Rios J, Coratti A, Morelli L, Giulianotti PC. Robotic versus laparoscopic distal pancreatectomy for pancreatic adenocarcinoma in obese patients. Int J Med Robot 2023:e2596. [PMID: 37937476 DOI: 10.1002/rcs.2596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/08/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Robotic distal pancreatectomy (RDP) is associated with a lower conversion rate and less blood loss than laparoscopic distal pancreatectomy (LDP). LDP has similar oncological outcomes as open surgery in PDAC. The aim of this study was to compare perioperative and oncological outcomes in obese patients with RDP versus LDP for PDAC. MATERIALS AND METHODS Retrospectively, all obese patients who underwent RDP or LDP for PDAC between 2012 and 2022 at 12 international expert centres were included. RESULTS out of 372, 81 patients were included. All baseline features were comparable between the two groups. RDP was associated with decreased blood loss (495mlLDP vs. 188mlRDP; p = 0.003), lower conversion rate (13.5%RDP vs. 36.4%LDP; p = 0.019) and lower rate of Clavien-Dindo ≥3 complications (13.5%RDP vs. 36.4%LDP; p = 0.019). Overall and disease-free survival were comparable. CONCLUSIONS In obese patients with left-sided PDAC, the robotic approach was associated with improved intraoperative outcomes and fewer severe complications.
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McCarron FN, Vrochides D, Martinie JB. Current progress in robotic hepatobiliary and pancreatic surgery at a high-volume center. Ann Gastroenterol Surg 2023; 7:863-870. [PMID: 37927925 PMCID: PMC10623982 DOI: 10.1002/ags3.12737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/18/2023] [Accepted: 08/19/2023] [Indexed: 11/07/2023] Open
Abstract
There has been steady growth in the adoption of robotic HPB procedures world-wide over the past 20 years, but most of this increase has occurred only recently. Not surprisingly, the vast majority of robotics has been in the United States, with very few, select centers of adoption in Italy, South Korea, and Brazil, to name a few. We began our robotic HPB program in 2008, well before almost all other centers in the world, with the most notable exception of Giullianotti and colleagues. Our program began gradually, with smaller cases carefully selected to optimize the strengths of the original robotic platform and included complex biliary and pancreatic resections. We performed the first reported series of choledochojejunostomy for benign biliary strictures and first series of completion cholecystectomies. We began performing robotic distal pancreatectomies and longitudinal pancreaticojejunostomies, reporting our early experience for each of these procedures. Over time we progressed to robotic pancreaticoduodenectomies. Initially, these were performed with planned conversions until we were able to optimize efficiency. Now we have performed over 200 robotic whipples, reaching a 100% robotic completion rate by 2020. Finally, we have added robotic major hepatectomies, including resections for hilar cholangiocarcinoma to our repertoire. Since the program began, we have performed over 1600 robotic HPB cases. Outcomes from our program have shown superior lymph node harvest, lower DGE rates, shorter hospitalizations, and fewer rehab admissions with similar overall complications to open and laparoscopic procedures, signifying that over time a robotic HPB program is not only feasible but advantageous as well.
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Ausania F, Landi F, Martinie JB, Vrochides D, Walsh M, Hossain SM, White S, Prabakaran V, Melstrom LG, Fong Y, Butturini G, Bignotto L, Valle V, Bing Y, Xiu D, Di Franco G, Sanchez-Bueno F, de'Angelis N, Laurent A, Giuliani G, Pernazza G, Esposito A, Salvia R, Bazzocchi F, Esposito L, Pietrabissa A, Pugliese L, Memeo R, Uyama I, Uchida Y, Rios J, Coratti A, Morelli L, Giulianotti PC. Robotic versus laparoscopic distal pancreatectomy in obese patients. Surg Endosc 2023; 37:8384-8393. [PMID: 37715084 PMCID: PMC10615948 DOI: 10.1007/s00464-023-10361-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Although robotic distal pancreatectomy (RDP) has a lower conversion rate to open surgery and causes less blood loss than laparoscopic distal pancreatectomy (LDP), clear evidence on the impact of the surgical approach on morbidity is lacking. Prior studies have shown a higher rate of complications among obese patients undergoing pancreatectomy. The primary aim of this study is to compare short-term outcomes of RDP vs. LDP in patients with a BMI ≥ 30. METHODS In this multicenter study, all obese patients who underwent RDP or LDP for any indication between 2012 and 2022 at 18 international expert centers were included. The baseline characteristics underwent inverse probability treatment weighting to minimize allocation bias. RESULTS Of 446 patients, 219 (50.2%) patients underwent RDP. The median age was 60 years, the median BMI was 33 (31-36), and the preoperative diagnosis was ductal adenocarcinoma in 21% of cases. The conversion rate was 19.9%, the overall complication rate was 57.8%, and the 90-day mortality rate was 0.7% (3 patients). RDP was associated with a lower complication rate (OR 0.68, 95% CI 0.52-0.89; p = 0.005), less blood loss (150 vs. 200 ml; p < 0.001), fewer blood transfusion requirements (OR 0.28, 95% CI 0.15-0.50; p < 0.001) and a lower Comprehensive Complications Index (8.7 vs. 8.9, p < 0.001) than LPD. RPD had a lower conversion rate (OR 0.27, 95% CI 0.19-0.39; p < 0.001) and achieved better spleen preservation rate (OR 1.96, 95% CI 1.13-3.39; p = 0.016) than LPD. CONCLUSIONS In obese patients, RDP is associated with a lower conversion rate, fewer complications and better short-term outcomes than LPD.
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Ricker AB, Davis JM, Motz BM, Watson M, Beckman M, Driedger M, Martinie JB, Vrochides D. External validation of the Japanese difficulty score for laparoscopic hepatectomy in patients undergoing robotic-assisted hepatectomy. Surg Endosc 2023; 37:7288-7294. [PMID: 37558825 DOI: 10.1007/s00464-023-10330-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/19/2023] [Indexed: 08/11/2023]
Abstract
INTRODUCTION The Japanese difficulty score (JDS) categorizes laparoscopic hepatectomy into low, intermediate, and high complexity procedures, and correlates with operative and postoperative outcomes. We sought to perform a validation study to determine if the JDS correlates with operative and postoperative indicators of surgical complexity for patients undergoing robotic-assisted hepatectomy. METHODS Retrospective review of 657 minimally invasive hepatectomy procedures was performed between January 2008 through March 2019. Outcomes included operative time, estimated blood loss (EBL), blood transfusion, complications, post-hepatectomy liver failure (PHLF), length of stay, 30-day readmission, and 30-day and 90-day mortality. Patients were grouped based on JDS defined as: low (< 4), intermediate (4-6), and high (7 +) complexity procedures. Statistical comparisons were analyzed by ANOVA or χ2 test. RESULTS 241 of 657 patients underwent robotic-assisted resection. Of these patients, 137 were included in the analysis based on JDS: 25 low, 58 intermediate, and 54 high. High JDS was associated with more major resections (≥ 4 contiguous segments) versus minor resections (median JDS 8 vs. 5, P < 0.0001). High JDS was associated with significantly longer operative times, higher EBL, and more blood transfusions. High JDS was associated with higher rates of PHLF at 16.7%, compared with 5.2% intermediate and 0.0% low, (P = 0.018). Complication rates, 30-day readmissions, and mortality rates were similar between groups. Median LOS was longer in patients with high JDS compared with intermediate and low (4 days vs. 3 days vs. 2 days; P = 0.0005). DISCUSSION Higher JDS was associated with multiple indicators of operative complexity, including greater extent of resection, increased operative time, EBL, blood transfusion, PHLF, and LOS. This validation study supports the ability of the JDS to categorize patients undergoing robotic-assisted hepatectomy by complexity.
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Wang Y, Yoshino O, Driedger MR, Beckman MJ, Vrochides D, Martinie JB. Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis. HPB (Oxford) 2023; 25:813-819. [PMID: 37045742 DOI: 10.1016/j.hpb.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/29/2023] [Accepted: 03/19/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Pancreatic necrosectomy with concomitant internal drainage is a single-stage treatment option for walled-off pancreatic necrosis (WOPN). However, an optimal minimally invasive technique has not been established. We evaluated the safety and single-intervention success rate of robotic pancreatic necrosectomy and internal drainage. METHODS Patients with WOPN undergoing robotic pancreatic necrosectomy and internal drainage at a single institution from 2011-2022 were identified. The primary outcome was the rate of clinical symptom resolution following the index surgical intervention. RESULTS 57 patients underwent robotic pancreatic necrosectomy and internal drainage, consisting of robotic cystgastrostomy (RCG, n = 37), robotic cystjejunostomy (RCJ, n = 13) and robotic fistulojejunostomy (RFJ, n = 7). Surgery was performed a median of 102 (range 28-1153) days following the onset of necrotizing pancreatitis. The median operative time was 187 (91-344) minutes and there were 2 (3.5%) conversions. The median length of hospital stay was 4 (2-38) days. Postoperative morbidity was 11%, and there was one (1.8%) 90-day mortality. At a median follow-up of 5.5 months, 53 (93%) patients had clinical symptom resolution after their index procedure and did not require any reintervention. CONCLUSION In select patients, robotic pancreatic necrosectomy and internal drainage is safe and achieves a high single-intervention success rate.
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Yoshino O, Wang Y, McCarron F, Motz B, Wang H, Baker E, Iannitti D, Martinie JB, Vrochides D. Major hepatectomy in elderly patients: possible benefit from robotic platform utilization. Surg Endosc 2023:10.1007/s00464-023-10062-5. [PMID: 37173594 DOI: 10.1007/s00464-023-10062-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 04/01/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Robotic surgery has been increasingly utilized, yet its application for hepato-pancreato-biliary (HPB) procedures remains low due to technical complexity, perceived financial burden, and unproven clinical benefits. We hypothesized that the robotic approach would be associated with improved clinical outcomes following major hepatectomy compared with the laparoscopic approach among elderly patients who would benefit from the advantages of minimally invasive surgery. METHODS A retrospective review of consecutive patients who underwent major hepatectomy between January 2010 and December 2021 at Carolinas Medical Center was performed. Inclusion criteria were age ≥ 65 years and major hepatectomy of three segments or more. Patients who underwent multiple liver resections, vascular/biliary reconstruction, or concomitant extrahepatic procedures (except cholecystectomy) were excluded. Categorical variables were compared using Chi-square or Fisher's exact test when more than 20% of cells had expected frequencies less than five, and Wilcoxon two-sample or Kruskal-Wallis tests were used for continuous or ordinal variables. Results are described as median and interquartile range (IQR). Multivariate analyses were used on postoperative admission days. RESULTS There were 399 major hepatectomies performed during this time period, of which 125 met the criteria and were included. There were no differences in perioperative demographics among patients who underwent robotic hepatectomy (RH, n = 39) and laparoscopic hepatectomy (LH, n = 32). There was no difference in operative time, blood loss, or major complication rates. However, RH had lower rates of conversion to an open procedure (2.6% versus 31.3%, p = 0.002), shorter length of hospital stay [LOS, 4 (3-7) versus 6 (4-8.5) days, p ≤ 0.0001], cumulative LOS [4 (3-7) versus 6 (4.5-9) days, p ≤ 0.0001], and lower rates of intensive care unit (ICU) admission (7.7% versus 75%, p ≤ 0.001), with a trend toward fewer rehabilitation requirements. CONCLUSIONS Robot major hepatectomy shows clinical advantages in elderly patients, including shorter hospital and ICU stays. These advantages, as well as reduced rehabilitation requirements associated with minimally invasive surgery, could overcome the current perceived financial disadvantages of robotic hepatectomy.
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Yoshino O, Vrochides D, Martinie JB. Robotic distal pancreas-sparing duodenectomy (duodenal sleeve resection) with transmesenteric approach: robotic approach for tumors in the third and fourth parts of the duodenum. Surg Endosc 2023; 37:3246-3252. [PMID: 36631534 DOI: 10.1007/s00464-022-09841-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/16/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Minimally invasive resection of the retroperitoneal duodenum is complicated because of its anatomical location, and the proximity of the ampulla of Vater and vascular structures. Benign or indolent pathology can add complexity to operative decision-making for these already challenging surgeries, and operations associated with lower morbidity may be considered. This study describes a novel robotic transmesenteric approach to duodenal sleeve resection for non-malignant lesions. METHODS A retrospective review was performed on a prospectively maintained institutional database between 2011 and 2021. The Da Vinci XI or SI platform (Intuitive Surgical, Sunnyvale, CA) was used in all cases. RESULTS Critical steps in robotic sleeve duodenectomy include the following: (1) techniques for avoiding damage to the ampulla; (2) Kocherization and reverse Kocherization; and (3) A transmesenteric approach for further mobilization of the duodenum. Nineteen patients were referred by experienced gastrointestinal endoscopists after endoscopic management was deemed unsuitable or their resections were incomplete. The histological diagnoses were either symptomatic benign or indolent duodenal pathology. All 19 patients underwent robotic duodenal sleeve resection during the study period. Lesions were located in the third to fourth parts of the duodenum. The median operative time was 216 min (IQR: 199-225), and the estimated intraoperative blood loss was 50 ml (IQR: 50.0-93.7). The 90 day readmission rate was 15.7% (3/19), and no 90-day mortality was observed. CONCLUSION This small case series of a transmesenteric approach for robotic sleeve duodenectomy demonstrates its feasibility and safety in this potentially challenging operation.
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Wang Y, Motz BM, Strand MS, Martinie JB, Vrochides D, Baker E, Iannitti DA. Hepatolithiasis caused by right hepatic artery branches forming an arterial ring compressing the common hepatic duct. J Surg Case Rep 2022; 2022:rjac492. [PMID: 36329778 PMCID: PMC9624198 DOI: 10.1093/jscr/rjac492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/05/2022] [Indexed: 12/05/2022] Open
Abstract
Anatomic variations of the hepatic artery do not usually cause biliary obstruction. We present a 51-year-old male who developed biliary obstruction and hepatolithiasis due to extrinsic compression of the common hepatic duct (CHD) by an arterial ring formed by the anterior and posterior branches of the right hepatic artery. We performed a surgical bile duct exploration and used intraoperative direct cholangioscopy to guide clearance of hepatolithiasis. Herein, we review the existing literature on CHD compression caused by topographical variants of the hepatic artery and discuss diagnostic and treatment strategies.
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Robinson J, Tschuor C, McKillop IH, Baker EH, Iannitti DA, Vrochides D, Martinie JB. Robotic Revision of Hepaticojejunostomy for Benign Biliary Stricture. Am Surg 2022:31348221096834. [PMID: 35575212 DOI: 10.1177/00031348221096834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surgical revision of biliary enteric anastomoses (BEA) can be a challenging undertaking and a robotic platform may provide advantages that address many of the technical obstacles. We present our technical approach and outcomes for patients undergoing robotic revision of BEA for benign strictures. A retrospective review was performed for robot-assisted benign BEA revision at our institution. Operative details, perioperative metrics, and outcomes are reported. Four patients underwent anastomotic revision following previously failed non-operative management. There were no intraoperative complications, mean length of stay was 4-days, and all patients experienced resolution of presenting clinical signs and symptoms. No patients required reoperation and there was no mortality. Postoperative outcomes were consistent with findings reported for other interventional modalities. Based on our experience we conclude robotic intervention in this context is safe and improves the technical feasibility of this complex procedure.
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Robinson JN, Davis JMK, Pickens RC, Cochran AR, King L, Salibi P, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Vrochides D. Enhanced Recovery After Surgery ® in Octogenarians Undergoing Hepatopancreatobiliary Surgery. Am Surg 2021:31348211054063. [PMID: 34866406 DOI: 10.1177/00031348211054063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in perioperative care have increased the frequency of surgical intervention performed on the very elderly (≥80 years). This study aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) on outcomes for octogenarians after major hepatopancreatobiliary (HPB) surgery. Patients ≥80 years old in a single HPB ERAS program (September 2015-July 2018) were prospectively tracked in the ERAS Interactive Audit System (EIAS). Postoperative length of stay (LOS) as well as 30-day major complications, readmissions, and mortality were compared to a pre-ERAS octogenarian control. Since ERAS implementation, octogenarians comprised 7.3% (27 of 370) of patients who underwent pancreaticoduodenectomy (n=17), distal pancreatectomy (n=7), or hepatectomy (n=3). Thirty-day readmissions decreased after ERAS implementation (50% to 15%, P=.037). Thirty-day major complications, mortality, and LOS were similar with 64% median protocol compliance. ERAS for octogenarians in HPB surgery is safe and may contribute to more sustainable recovery resulting in reduced readmissions.
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Tschuor C, Pickens RC, Isenberg EE, Motz BM, Salibi PN, Robinson JN, Murphy KJ, Iannitti DA, Baker EH, Vrochides D, Martinie JB. Robotic Resection of Gallbladder Cancer: A Single-Center Retrospective Comparative Study to Open Resection. Am Surg 2021:31348211047491. [PMID: 34652250 DOI: 10.1177/00031348211047491] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Minimally invasive surgery is gaining support for resection of gallbladder cancer (GBC). This study aims to compare operative and early outcomes of robotic resection (RR) to open resection (OR) from a single institution performing a high volume of robotic HPB surgery. METHODS Twenty patients with GBC underwent RR from January 2013 to August 2019. Outcomes were compared to a historical control of 23 patients with OR. Radical cholecystectomy for suspected GBC and completion operations for incidental GBC after routine cholecystectomy were both included. RESULTS Robotic resection had lower blood loss compared to OR (150 vs 350 mL, P = .002) and shorter postoperative length of stay (2.5 vs 6 days, P < .001), while median operative time was similar (193 vs 208 min, P = .604). There were no statistical differences in 30-day major complications or readmissions. No 30-day mortalities occurred. There was no statistical difference in survival trend (P = .438) or median lymph node harvest (5 vs 3, P = .189) for RR compared to OR. CONCLUSION Robotic resection of GBC is safe and efficient, with lower length of hospital stay and blood loss compared to OR. Technical benefits of robotic-assisted surgery may prove advantageous though larger studies are still needed.
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Tschuor C, Lyman WB, Passeri M, Salibi PN, Baimas-George M, Iannitti DA, Baker EH, Vrochides D, Martinie JB. Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study. Int J Med Robot 2021; 17:e2312. [PMID: 34261193 DOI: 10.1002/rcs.2312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Reoperation following a previous subtotal or aborted cholecystectomy presents a challenging surgical scenario that has traditionally required an open completion cholecystectomy. The aim of this study was to describe an institutional experience with a robotic-assisted approach to completion cholecystectomy. METHODS A database was retrospectively audited to identify all patients who underwent robotic-assisted cholecystectomy performed by two hepatopancreatobiliary surgeons at a single centre from 2010 to 2019. RESULTS Twenty six patients who underwent a robotic-assisted completion cholecystectomy were identified. Median operative time was 142 min (48-247 min) with a blood loss of 50 cc (0-500 cc). Minor complications (Clavien-Dindo ≤ II 90 days) occurred in three patients (11.5%) with no major complication or mortality reported. Median hospital length of stay was 1 day (0-6 days) with one patient readmitted. CONCLUSION This study represents to our knowledge the largest series of robotic-assisted completion cholecystectomies to date. The robotic approach appears to be a safe and effective procedure associated with a low morbidity and high success rate.
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Robinson J, Sulzer JK, Motz B, Baker EH, Martinie JB, Vrochides D, Iannitti DA. Long-Term Clinical Outcomes of an Antibiotic-Coated Non-Cross-linked Porcine Acellular Dermal Graft for Abdominal Wall Reconstruction for High-Risk and Contaminated Wounds. Am Surg 2021; 88:1988-1995. [PMID: 34053226 DOI: 10.1177/00031348211023392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Abdominal wall reconstruction in high-risk and contaminated cases remains a challenging surgical dilemma. We report long-term clinical outcomes for a rifampin-/minocycline-coated acellular dermal graft (XenMatrix™ AB) in complex abdominal wall reconstruction for patients with a prior open abdomen or contaminated wounds. METHODS Patients undergoing abdominal wall reconstruction at our institution at high risk for surgical site occurrence and reconstructed with XenMatrix™ AB with intent-to-treat between 2014 and 2017 were included. Demographics, operative characteristics, and outcomes were collected. The primary outcome was hernia recurrence. The secondary outcomes included length of stay, surgical site occurrence, readmission, morbidity, and mortality. RESULTS Twenty-two patients underwent abdominal wall reconstruction using XenMatrix™ AB during the study period. Two patients died while inpatient from progression of their comorbid diseases and were excluded. Sixty percent of patients had an open abdomen at the time of repair. All patients were from modified Ventral Hernia Working Group class 2 or 3. There were a total of four 30-day infectious complications including superficial cellulitis/fat necrosis (15%) and one intraperitoneal abscess (5%). No patients required reoperation or graft excision. Median clinical follow-up was 38.2 months with a mean of 35.2 +/- 18.5 months. Two asymptomatic recurrences and one symptomatic recurrence were noted during this period with one planning for elective repair of an eventration. Follow-up was extended by phone interview which identified no additional recurrences at a median of 45.5 and mean of 50.5 +/-12.7 months. CONCLUSION We present long-term outcomes for patients with high-risk and contaminated wounds who underwent abdominal wall reconstruction reinforced with XenMatrix™ AB to achieve early, permanent abdominal closure. Acceptable outcomes were noted.
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Baimas-George M, Watson M, Murphy KJ, Sarantou J, Vrochides D, Martinie JB, Baker EH, Mckillop IH, Iannitti DA. Treatment of spontaneously ruptured hepatocellular carcinoma: use of laparoscopic microwave ablation and washout. HPB (Oxford) 2021; 23:444-450. [PMID: 32994101 DOI: 10.1016/j.hpb.2020.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ruptured, or bleeding, hepatocellular carcinoma (rHCC) is a relatively rare disease presentation associated with high acute mortality rates. This study sought to evaluate outcomes following laparoscopic microwave ablation (MWA) and washout in rHCC. METHODS A retrospective single-center review was performed to identify patients with rHCC (2008-2018). The treatment algorithm consisted of transarterial embolization (TAE) or trans-arterial chemoembolization (TACE) followed by laparoscopic MWA and washout. RESULTS Fifteen patients with rHCC were identified (n = 5 single lesion, n = 5 multifocal disease, n = 5 extrahepatic metastatic disease). Median tumor size was 83 mm (range 5-228 mm), and 10 of 15 underwent TAE or TACE followed by laparoscopic MWA/washout. One patient required additional treatment for bleeding after MWA with repeat TAE. Thirty-day mortality was 6/15. For those patients discharged (n = 9), additional treatments included chemotherapy (n = 5), TACE (n = 3), and/or partial lobectomy (n = 2). Median follow-up was 18.2 months and median survival was 431 days (range 103-832) (one-year survival n = 7; two-year survival n = 4; three-year survival n = 3). Six patients had post-operative imaging from which one patient demonstrated recurrence. CONCLUSION Using laparoscopic MWA with washout may offer advantage in the treatment of ruptured HCC. It not only achieves hemostasis but also could have oncologic benefit by targeting local tumor and decreasing peritoneal carcinomatosis risk.
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K Anderson M, C Pickens R, Davis J, H Baker E, H Baker E, B Martinie J, Vrochides D. Antiplatelet therapy after pancreaticoduodenectomy with portal vein resection as the optimal preventative strategy for maintaining primary vein patency. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2021. [DOI: 10.5348/100096z04ma2021ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Watson MD, Baimas-George MR, Murphy KJ, Pickens RC, Iannitti DA, Martinie JB, Baker EH, Vrochides D, Ocuin LM. Pure and Hybrid Deep Learning Models can Predict Pathologic Tumor Response to Neoadjuvant Therapy in Pancreatic Adenocarcinoma: A Pilot Study. Am Surg 2020; 87:1901-1909. [PMID: 33381979 DOI: 10.1177/0003134820982557] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant therapy may improve survival of patients with pancreatic adenocarcinoma; however, determining response to therapy is difficult. Artificial intelligence allows for novel analysis of images. We hypothesized that a deep learning model can predict tumor response to NAC. METHODS Patients with pancreatic cancer receiving neoadjuvant therapy prior to pancreatoduodenectomy were identified between November 2009 and January 2018. The College of American Pathologists Tumor Regression Grades 0-2 were defined as pathologic response (PR) and grade 3 as no response (NR). Axial images from preoperative computed tomography scans were used to create a 5-layer convolutional neural network and LeNet deep learning model to predict PRs. The hybrid model incorporated decrease in carbohydrate antigen 19-9 (CA19-9) of 10%. Accuracy was determined by area under the curve. RESULTS A total of 81 patients were included in the study. Patients were divided between PR (333 images) and NR (443 images). The pure model had an area under the curve (AUC) of .738 (P < .001), whereas the hybrid model had an AUC of .785 (P < .001). CA19-9 decrease alone was a poor predictor of response with an AUC of .564 (P = .096). CONCLUSIONS A deep learning model can predict pathologic tumor response to neoadjuvant therapy for patients with pancreatic adenocarcinoma and the model is improved with the incorporation of decreases in serum CA19-9. Further model development is needed before clinical application.
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