Robotic distal pancreatectomy, a novel standard of care? First benchmark values for surgical outcomes from 14 international expert centers

Objective

Robotic distal pancreatectomy (DP) is emerging as the preferred treatment for body and tail tumors of the pancreas. To enable conclusive comparisons with the standard open or laparoscopic approaches and robotic surgery among centers, novel benchmark outcome values are urgently needed. Therefore, the aim of this study was to identify benchmark values from expert centers beyond the learning curve.

Methods

This multicenter study analyzed outcomes from consecutive patients undergoing robotic DP for resectable malignant or benign lesions from 14 international expert centers. After the learning curve, defined as the first 10 cases of robotic DP, all consecutive patients were included from the start of the program up to June 2020 with a minimum follow-up of 1 year. Benchmark patients were those without significant comorbidities including obesity (BMI >35 kg/m2) cardiac disease, chronic pulmonary disease.

Benchmark cutoff values were derived from the 75th or the 25th percentile of the median values of all benchmark centers.

Results

After reaching the learning curve, 289 (47%) of a total of 614 consecutive patients qualified as benchmark cases. The proportion of benchmark patients varied between 24%-64% per center. Benchmark cut-offs showed a low 6 month- postoperative mortality (<0.6%), but high overall morbidity (<58.3%). Benchmark cutoffs for operative time (<300 min), conversion rate (<3%), clinically relevant pancreatic fistulas (<26.9%), CCI at 90-days (<14.8), hospital stay (<7 days) and readmission rate (<22.9%). Benchmark cut-offs for complications remained unchanged after 3 months follow-up. For ductal adenocarcinoma benchmark cutoffs for number of lymph nodes were > 19 with an R0 resection rate of > 85%, and an overall survival of >86% and >52% after 1- and 5-years, respectively. Centers with a low cohort of benchmark patients (more difficult cases) had less clinically relevant pancreatic fistula (9% vs. 23%) and less overall complications (32% vs. 48%).

Conclusion

This benchmark analysis sets novel reference values for robotic DP, indicating favorable outcomes as compared to laparoscopic and open DP. These references values may serve for quality control of surgery in centers embarking in robotic DP, and include the procedure in the standard of care.

Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) is increasingly being performed because of perceived patient benefits. Whether conversion of MIPD to open pancreatoduodenectomy worsens outcome, and which risk factors are associated with conversion, is unclear.

METHODS

This was a post hoc analysis of a European multicentre retrospective cohort study of patients undergoing MIPD (2012-2017) in ten medium-volume (10-19 MIPDs annually) and four high-volume (at least 20 MIPDs annually) centres. Propensity score matching (1 : 1) was used to compare outcomes of converted and non-converted MIPD procedures. Multivariable logistic regression analysis was performed to identify risk factors for conversion, with results presented as odds ratios (ORs) with 95 per cent confidence intervals (c.i).

RESULTS

Overall, 65 of 709 MIPDs were converted (9.2 per cent) and the overall 30-day mortality rate was 3.8 per cent. Risk factors for conversion were tumour size larger than 40 mm (OR 2.7, 95 per cent c.i.1.0 to 6.8; P = 0.041), pancreatobiliary tumours (OR 2.2, 1.0 to 4.8; P = 0.039), age at least 75 years (OR 2.0, 1.0 to 4.1; P = 0.043), and laparoscopic pancreatoduodenectomy (OR 5.2, 2.5 to 10.7; P < 0.001). Medium-volume centres had a higher risk of conversion than high-volume centres (15.2 versus 4.1 per cent, P < 0.001; OR 4.1, 2.3 to 7.4, P < 0.001). After propensity score matching (56 converted MIPDs and 56 completed MIPDs) including risk factors, rates of complications with a Clavien-Dindo grade of III or higher (32 versus 34 per cent; P = 0.841) and 30-day mortality (12 versus 6 per cent; P = 0.274) did not differ between converted and non-converted MIPDs.

CONCLUSION

Risk factors for conversion during MIPD include age, large tumour size, tumour location, laparoscopic approach, and surgery in medium-volume centres. Although conversion during MIPD itself was not associated with worse outcomes, the outcome in these patients was poor in general which should be taken into account during patient selection for MIPD.

[Duodenal somatostatinomas associated with von Recklinghausen's neurofibromatosis. Apropos of 2 cases]

Somatostatinomas are rare neuroendocrine tumors; they are essentially located in the pancreas and in the duodenum. The association with a neurofibromatosis type I is especially observed when the tumor is located in the ampulla of Vater. These tumors are not associated with a "somatostatin syndrome", but often present with gastrointestinal bleeding, abdominal pain and obstructive jaundice. The diagnosis is confirmed by immunohistochemical studies. The aim of this study is to report 2 cases of metastazing duodenal periampullary somatostatinomas associated with von Recklinghausen's disease and to discuss the prognosis of these tumors. Future genetic research are necessary as point out the familial feature of this association in one of our cases.

[Microscopic thyroid papillary cancers presenting as cervical lymph node metastases]

Microscopic papillary thyroid cancer (< 1 cm in diameter) is reputed to have an excellent prognosis. In 10 to 20% of cases, it presents in the form of lymph ode metastases. Immediately metastatic forms can be associated with unfavourable prognostic factors, such as multifocal tumours, extension to adjacent tissues, capsular effraction and development of distant metastases. We report 4 cases of microscopic papillary thyroid cancer presenting in the form of lymph node metastases. No primary thyroid lesion was palpable in any of these patients, but the subsequent course was complicated by ling metastases in one case. All patients underwent total thyroidectomy with lymph node dissection followed by adjuvant therapy with radioactive iodine and thyroxin inhibitory treatment. Lung metastases were observed in one case. The authors propose a therapeutic approach based on analysis of severity factors, which determine the recurrence rate.

Metastatic endocrine tumors: medical treatment, surgical resection, or liver transplantation

We reviewed our experience with 34 patients with metastatic endocrine tumors (METs) who were treated by different modalities. Eight patients were treated by chemotherapy or chemoembolization because of stable disease or surgical contraindications. Seventeen patients underwent curative or cytoreductive surgical resection. Nine patients received grafts based on the following criteria: no extrahepatic spread on imaging workup and nonresectable symptomatic metastatic disease. Of the eight medically treated patients, the five patients with initial stable clinical condition are alive 32 to 56 months after referral. Of the 17 patients treated by liver resection, 13 are alive 6 to 108 months after surgery, and 7 are disease-free. After curative resection, the 5-year actuarial survival and disease-free survival rates were 62% and 52%, respectively. Of the nine grafted patients, three patients grafted for carcinoid tumor are alive at 15, 24, and 62 months, one of whom has a late recurrence. Our results indicate that therapeutic indications for METs should be based on age, clinical symptoms, histologic type, and tumor extension: Patients with stable MET may benefit from surgical restraint; liver resection in patients with aggressive MET may provide good long-term palliation and possibly cure one-third of the patients; liver transplantation should be restricted to young patients with nonresectable carcinoid MET but remains a high-risk operation because of previous surgery and chemoembolization.

Surgical management of internal fistulas in Crohn's disease

BACKGROUND

Internal fistulas in Crohn's disease join a diseased intestinal segment to a "victim organ" (VO) that is affected by proximity. While the diseased segment is resected, the other can be sutured in selected cases.

STUDY DESIGN

Seventy-four patients with 100 internal fistulas were retrospectively reviewed to assess the results of this conservative operative approach.

RESULTS

Closure of the fistulous defect of the VO was achieved by resection (n = 41) or suture (n = 59). The VO was histologically unaffected by Crohn's disease in 86 cases. One patient died postoperatively. Three patients had postoperative fistulas after suture of the VO. There was no long-term recurrence of an internal fistula.

CONCLUSIONS

Surgical treatment of internal fistulas can be achieved safely by resection of the source of the fistula and suture repair of the VO when the latter is not affected by active Crohn's disease and when local conditions make it feasible.

Heterotopic gastric mucosa presenting as gallbladder polyps

The authors report the case of a 16-year-old man with recurrent abdominal pain. Ultrasonography showed two gallbladder polyps, one of them larger than 10 mm. Laparoscopic cholecystectomy was performed. Histologic examination revealed gastric heterotopia. The authors discuss the clinical, pathophysiologic and histologic features of the present case and those reported in the literature.

Long-term seton drainage for high anal fistulas in Crohn's disease--a sphincter-saving operation?

METHODS

Forty-one consecutive patients with Crohn's disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place.

RESULTS

Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two.

CONCLUSION

Long-term seton drainage for high and fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function.

Surgical management of ileosigmoid fistulas in Crohn's disease: role of preoperative colonoscopy

PURPOSE

Surgical treatment of ileosigmoid fistulas in Crohn's disease remains controversial and can be radical (resection of both segments) or conservative (ileal resection with suture or wedge resection of the sigmoid). At our institution, the sigmoid defect is sutured if the sigmoid is not affected by primary Crohn's disease or by important stricture; otherwise, the sigmoid is resected. We reviewed our experience to evaluate our results with this procedure.

METHODS

Thirty patients with ileosigmoid fistulas underwent operation. Among them, 15 had a preoperative colonoscopy, whereas others had no endoscopic work-up. In nine patients, the sigmoid was thought to be affected by Crohn's disease (n = 7) or stricture (n = 2) and was resected. In 21 patients, the sigmoid was thought to be affected by proximity, and a simple suture (n = 15) or wedge resection (n = 6) was performed. Eleven patients had a temporary stoma (37 percent). One had coloprotectomy.

RESULTS

One patient died postoperatively. One patient had postoperative sigmoidocutaneous fistula after conservative treatment. Histology of the sigmoid specimen showed Crohn's disease in 8 patients (27 percent), including 5 of 9 resected specimens, and 3 of 21 conservative procedures. All patients with Crohn's misdiagnosis did not have preoperative colonoscopy. Nine of 11 stomas were closed in a median delay of four months. With a median delay of nine years, four patients have again undergone surgery for recurrent colonic Crohn's disease, all of whom underwent surgery initially without preoperative colonoscopy.

CONCLUSION

Preoperative endoscopic assessment of the colon is a reliable guide to use when choosing between sigmoid resection or a conservative approach and can result in reduced morbidity and improved long-term results.

[Pancreatic trauma: diagnostic and therapeutic emergency. Apropos of 35 cases]

35 consecutive pancreatic trauma were operated (21 blunt trauma and 14 penetrating injuries). 30 patients were operated in emergency and diagnosis was suspected before laparotomy in only one case. 12 patients had a superficial lesion, 21 had a wirsung disruption (14 in the left pancreas, 7 in the right pancreas), 2 had a diffuse pancreatitis. For the 30 patients operated in emergency, 20 had a conservative treatment, 10 had a resection. 5 patients died (14.2%), from exsanguination (2 cases), missed diagnosis or inadequate treatment (2 cases), sepsis after adequate management (1 case). Our experience suggests that an aggressive diagnosis management in emergency, with pre or pre-operative wirsungography, could determined with precision the type of the lesion and permit an adequate management, to decrease mortality.

[110 consecutive laparotomies for hepatic metastasis]

From 1978 to 1988, we performed 110 laparotomies for hepatic metastases. With 41 resections for colorectal metastases, the survival was 34% at 3 years. The operative mortality was 7%. With 25 resections for non colorectal liver metastases, the survival was 42% at 1 year, 12% at 3 years. The results, compared with those of literature justify, in the absence of any other potential curative treatment, to remove colorectal liver metastases. For metastases from other tumours, results of resection for endocrine tumours and few sarcomas invite us to an aggressive approach.