Minimally invasive distal pancreatectomy and the cost of conversion

Conversion to open surgery in obese patients undergoing minimally invasive distal pancreatectomy: results from a multicenter analysis

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.

Robot-assisted versus laparoscopic pancreatoduodenectomy: a pan-European multicenter propensity-matched study

BACKGROUND

The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This study aimed to compare outcomes after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy in a pan-European cohort.

METHODS

An international multicenter retrospective study including patients after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy from 50 centers in 12 European countries (2009-2020). Propensity score matching was performed in a 1:1 ratio. The primary outcome was major morbidity (Clavien-Dindo ≥III).

RESULTS

Among 2,082 patients undergoing minimally invasive pancreatoduodenectomy, 1,006 underwent robot-assisted pancreatoduodenectomy and 1,076 laparoscopic pancreatoduodenectomy. After matching 812 versus 812 patients, the rates of major morbidity (31.9% vs 29.6%; P = .347) and 30-day/in-hospital mortality (4.3% vs 4.6%; P = .904) did not differ significantly between robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy, respectively. Robot-assisted pancreatoduodenectomy was associated with a lower conversion rate (6.7% vs 18.0%; P < .001) and higher lymph node retrieval (16 vs 14; P = .003). Laparoscopic pancreatoduodenectomy was associated with shorter operation time (446 minutes versus 400 minutes; P < .001), and lower rates of postoperative pancreatic fistula grade B/C (19.0% vs 11.7%; P < .001), delayed gastric emptying grade B/C (21.4% vs 7.4%; P < .001), and a higher R0-resection rate (73.2% vs 84.4%; P < .001).

CONCLUSION

This European multicenter study found no differences in overall major morbidity and 30-day/in-hospital mortality after robot-assisted pancreatoduodenectomy compared with laparoscopic pancreatoduodenectomy. Further, laparoscopic pancreatoduodenectomy was associated with a lower rate of postoperative pancreatic fistula, delayed gastric emptying, wound infection, shorter length of stay, and a higher R0 resection rate than robot-assisted pancreatoduodenectomy. In contrast, robot-assisted pancreatoduodenectomy was associated with a lower conversion rate and a higher number of retrieved lymph nodes as compared with laparoscopic pancreatoduodenectomy.

Systematic review and meta-analysis of cost-effectiveness of minimally invasive versus open pancreatic resections

BACKGROUND

The systematic review is aimed to evaluate the cost-effectiveness of minimally invasive surgery (MIS) and open distal pancreatectomy and pancreaticoduodenectomy.

METHOD

The MEDLINE, CENTRAL, EMBASE, Centre for Reviews and Dissemination, and clinical trial registries were systematically searched using the PRISMA framework. Studies of adults aged ≥ 18 year comparing laparoscopic and/or robotic versus open DP and/or PD that reported cost of operation or index admission, and cost-effectiveness outcomes were included. The risk of bias of non-randomised studies was assessed using the Newcastle-Ottawa Scale, while the Cochrane Risk of Bias 2 (RoB2) tool was used for randomised studies. Standardised mean differences (SMDs) with 95% confidence intervals (CI) were calculated for continuous variables.

RESULTS

Twenty-two studies (152,651 patients) were included in the systematic review and 15 studies in the meta-analysis (3 RCTs; 3 case-controlled; 9 retrospective studies). Of these, 1845 patients underwent MIS (1686 laparoscopic and 159 robotic) and 150,806 patients open surgery. The cost of surgical procedure (SMD 0.89; 95% CI 0.35 to 1.43; I2 = 91%; P = 0.001), equipment (SMD 3.73; 95% CI 1.55 to 5.91; I2 = 98%; P = 0.0008), and operating room occupation (SMD 1.17, 95% CI 0.11 to 2.24; I2 = 95%; P = 0.03) was higher with MIS. However, overall index hospitalisation costs trended lower with MIS (SMD - 0.13; 95% CI - 0.35 to 0.06; I2 = 80%; P = 0.17). There was significant heterogeneity among the studies.

CONCLUSION

Minimally invasive major pancreatic surgery entailed higher intraoperative but similar overall index hospitalisation costs.

Laparoscopic Resection of Pediatric Solid Pseudopapillary Tumors of the Pancreas

BACKGROUND

Solid pseudopapillary tumors (SPTs) of the pancreas arise rarely in children, are often large, and can associate intimately with splenic vessels. Splenic preservation is a fundamental consideration when resecting distal SPT. Occasionally, the main splenic vessels must be divided to resect the SPT with negative margins, but the spleen can be preserved if the short gastric vessels remain intact (ie, Warshaw procedure). The purpose of this study was to evaluate outcomes of distal pancreatectomy (DP) for SPT in children and to highlight 2 cases of splenic preservation using the Warshaw procedure.

METHODS

Patients 19 years and younger who were treated at a single children's hospital between July 2004 and January 2021 were examined. Patient characteristics were collected from the electronic medical record. A pediatric radiologist calculated SPT and pre- and post-operative (ie, non-infarcted) splenic volumes.

RESULTS

Eleven patients received DP for SPT. Six DPs were performed open and 5 laparoscopically. The spleen was preserved in 3 open and 4 laparoscopic DPs. A laparoscopic Warshaw procedure was performed in 2 patients. Laparoscopic resection associated with less frequent epidural use (P = .015), shorter time to full diet (P = .030), and post-operative length of stay (P = .009), compared to open resection. Average residual splenic volume after the laparoscopic Warshaw procedure was 70% of preoperative volume.

DISCUSSION

Laparoscopic DP for pediatric SPT achieved similar oncologic goals to open resection. Splenic preservation was feasible with laparoscopy in most cases and was successfully supplemented with the Warshaw procedure, which has not been previously reported for SPT resection in children.

Robotic minor hepatectomy: optimizing outcomes and cost of care

BACKGROUND

The advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost.

METHODS

We queried the medical record and cost data for patients who underwent open or robotic minor (1-2 segment) liver resection from 1/2016-8/2019. Financial data were normalized to Medicare reimbursements.

RESULTS

There were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm³), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p < 0.001) were significantly lower for patients who underwent robotic resection. These factors contributed to minor robotic liver resections costing $534 less than open resections ($3597 ± 1823 vs $4131 ± 1532, p = 0.03).

CONCLUSION

Patients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.