Robotic versus open pancreatoduodenectomy: a propensity score-matched analysis based on factors predictive of postoperative pancreatic fistula

Predicting postoperative pancreatic fistula after robotic pancreatoduodenectomy using International Study Group on Pancreatic Surgery and fistula risk scores: European multicentre retrospective cohort study

BACKGROUND

Postoperative pancreatic fistula represents the leading cause of morbidity and mortality after robotic pancreatoduodenectomy. Various scores have been proposed to stratify patients based on their postoperative pancreatic fistula risk, including three fistula risk scores, and two International Study Group for Pancreatic Surgery scores. This study compares the performance of these scores in patients undergoing robotic pancreatoduodenectomy.

METHODS

This is a multicentre European retrospective study in consecutive patients receiving robotic pancreatoduodenectomy for all indications (April 2014 to December 2021). The performance of the International Study Group for Pancreatic Surgery 4-tier (A-D) risk score, and its 3-tier (A-C) modification (International Study Group for Pancreatic Surgery 3-tier), fistula risk scores, alternative-fistula risk scores and the updated alternative-fistula risk scores in postoperative pancreatic fistula grade B/C prediction were compared based on their discrimination (area under the curve), calibration and clinical utility, evaluated through decision curve analyses.

RESULTS

Overall, 919 patients undergoing robotic pancreatoduodenectomy were included. The rate of grade B/C postoperative pancreatic fistula was 22.2% (n = 204). The area under the curve for the five scores differed only slightly: International Study Group for Pancreatic Surgery 0.63 (95% confidence interval (c.i.) 0.58 to 0.67), International Study Group for Pancreatic Surgery 3-tier 0.63 (95% c.i. 0.58 to 0.67), fistula risk scores 0.65 (95% c.i. 0.61 to 0.69), alternative-fistula risk scores 0.64 (95% c.i. 0.60 to 0.68) and updated alternative-fistula risk scores 0.65 (95% c.i. 0.60 to 0.69). The International Study Group for Pancreatic Surgery, International Study Group for Pancreatic Surgery 3-tier, fistula risk scores and alternative-fistula risk scores underestimated the risk of postoperative pancreatic fistula. In contrast, the updated alternative-fistula risk score was well-calibrated at low predicted risks, but overestimated postoperative pancreatic fistula risk for high-risk patients. In decision curve analyses, the updated alternative-fistula risk score showed a higher clinical utility compared with the four other risk scores.

CONCLUSION

The clinical utility of the updated alternative-fistula risk score for robotic pancreatoduodenectomy slightly outperformed the four other fistula risk scores, and might be used for patient counselling and patient stratification in clinical practice and research.

Complexity and Experience Grading to Guide Patient Selection for Minimally Invasive Pancreatoduodenectomy: An International Study Group for Pancreatic Surgery (ISGPS) Consensus

OBJECTIVE

To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD).

BACKGROUND

Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience.

METHODS

The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions.

RESULTS

The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification.

CONCLUSIONS

This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries.

Comparing Operative Outcomes and Resection Quality in Robotic vs Open Pancreaticoduodenectomy: A Meta-analysis of 54,000 Patients

BACKGROUND

High morbidity and mortality make pancreaticoduodenectomy (PD) one of the most complicated surgical procedures. This meta-analysis aimed to compare the outcomes of robotic pancreaticoduodenectomy (RPD) versus open pancreaticoduodenectomy (OPD).

METHOD

A comprehensive literature search of PubMed, Cochrane Central, and Google Scholar was conducted from inception to November 2024. Studies comparing RPD and OPD in adults aged ≥ 18 years were included. Data for the outcomes of interest were extracted.

RESULTS

Forty-one studies with a total of 54,287 patients were pooled. RPD is significantly superior to OPD in terms of overall postoperative complications (RR = 0.91, 95% CI: [0.86-0.97]; p = 0.001), wound infections (RR = 0.63, 95% CI: [0.49-0.81], p = 0.0004), estimated blood loss (WMD = -171.99 ml, 95% CI: [ -217.76 to -126.22], p < 0.01) and hospitalization duration (WMD = -1.33 days, 95% CI: [ -1.84 to -0.82], p < 0.01) with a longer operating time (WMD = 73.22 min, 95% CI: [56.20 to 90.23], p < 0.01).

CONCLUSION

In conclusion, RPD shows a lower risk of wound infections and overall postoperative morbidity compared to OPD. It has lower estimated blood loss, shorter hospitalization duration, and a longer operating time. The two approaches were comparable in terms of resection quality. More high-quality RCTs are required to draw definite conclusions.

Comparison of short-term outcomes of robotic versus open pancreaticoduodenectomy: a meta-analysis of randomized controlled trials and propensity-score-matched studies

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is used more commonly, but this surge is mostly based on observational data. This meta-analysis aimed to compare the short-term outcomes between RPD and open pancreaticoduodenectomy (OPD) using data collected from randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies.

METHODS

We searched PubMed, Cochrane Library, Embase, and Web of Science databases for RCTs and PSM studies comparing RPD and OPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Twenty-four studies, encompassing two RCTs and 22 PSM studies, were included, with a total of 9393 patients (RPD group: 3919 patients; OPD group: 5474 patients). Although RPD was associated with a longer operative time (MD, 61.61 min), patients may benefit from reduced blood loss (MD, -154.05 ml), shorter length of stay (MD, -1.60 days), lower blood transfusion rate (RR, 0.85), and wound infection rate (RR, 0.61). There were no significant differences observed in 30-day readmission (RR, 0.99), 90-day mortality (RR, 0.97), overall morbidity (RR, 0.88), major complications (RR, 1.01), reoperation (RR, 1.08), bile leak (RR, 1.01), chylous leak (RR, 0.98), postoperative pancreatic fistula (RR, 0.97), post-pancreatectomy hemorrhage (RR, 1.15), delayed gastric emptying (RR, 0.88), number of harvested lymph nodes (MD, -0.12), and R0 resection (RR, 1.01) between the groups.

CONCLUSIONS

Although some short-term outcomes were similar between RPD and OPD, RPD exhibited reduced intraoperative blood loss, shorter hospital stays, lower wound infection, and blood transfusion rates. In the future, RPD may become a safe and effective alternative to OPD.

Robotic Pancreaticoduodenectomy for Pancreatic Head Tumour: A Single-Centre Analysis

Background: The robotic approach is an appealing way to perform minimally invasive pancreaticoduodenectomy. We compare robotic cases' short-term and oncological outcomes to a historical cohort of open cases. Methods: Data were collected in a prospective database between 2016 and 2024; complications were graded using the ISGPS definition for the specific pancreas-related complications and the Clavien-Dindo classification for overall complications. Furthermore, the Comprehensive Complication Index was calculated. All patients undergoing pancreaticoduodenectomy were included, except those with acute or chronic pancreatitis, vascular tumour involvement or multi-visceral resections. Only the subset of patients with malignancy was regarded for the oncologic outcome. Results: In total, 100 robotic and 102 open pancreaticoduodenectomy cases are included. Equal proportions of patients have a main pancreatic duct ≤3 mm (p = 1.00) and soft consistency of the pancreatic remnant (p = 0.78). Surgical time is longer for robotic pancreaticoduodenectomy (p < 0.01), and more patients have delayed gastric emptying (44% and 28.4%, p = 0.03). In the robotic group, the number of patients without any postoperative complications is higher (p = 0.02), and there is less chyle leak (p < 0.01). Ninety-day mortality, postoperative pancreatic fistula, and postpancreatectomy haemorrhage are similar. The lymph node retrieval and R0 resection rates are comparable. Conclusions: In conclusion, after robotic pancreaticoduodenectomy, remembering all cases during the learning curve are included, less chyle leak is observed, the proportion of patients without any complication is significantly larger, the surgical duration is longer, and more patients have delayed gastric emptying. Oncological results, i.e., lymph node yield and R0 resection rate, are comparable to open pancreaticoduodenectomy.

Learning curve stratified outcomes after robotic pancreatoduodenectomy: International multicenter experience

BACKGROUND

Robotic pancreatoduodenectomy is increasingly being implemented worldwide, with good results reported from individual expert centers. However, it is unclear to what extent outcomes will continue to improve during the learning curve, as large international studies are lacking.

METHODS

An international retrospective multicenter case series, including consecutive patients after robotic pancreatoduodenectomy from 18 centers in 8 countries in Europe, Asia, and South America until December 31, 2019, was conducted. A cumulative sum analysis was performed to determine the inflection points for the feasibility (operative time and blood loss) and proficiency (postoperative pancreatic fistula grade B/C and major morbidity) learning curves. Outcomes were compared in 3 groups on the basis of the learning curve inflection points.

RESULTS

Overall, 2,186 patients after robotic pancreatoduodenectomy were included. The feasibility learning curve was reached after 30-45 robotic pancreatoduodenectomy procedures and the proficiency learning curve after 90 robotic pancreatoduodenectomy procedures. These inflection points created 3 phases, which were associated with major morbidity (24.7%, 23.4%, and 12.3%, P < .001) but not 30-day mortality (2.1%, 2.0%, and 1.5%, P = .670). Other outcomes mostly continued to improve, including median operative time 432, 390, and 300 minutes (P < .0001), conversion 6.0%, 4.7%, and 2.7% (P = .002), bile leakage 7.2%, 4.1%, and 2.4% (P < .001), postpancreatectomy hemorrhage 6.5%, 6.1%, and 1.8% (n = 21) but not R0 resection (pancreatic ductal adenocarcinoma only) 78.5%, 73.9%, and 82.8% (P = .35), and 90-day mortality rate 3.1%, 3.5%, and 2.1% (P = .191). Centers performing >20 robotic pancreatoduodenectomies annually had lower rates of conversion, reoperation, and shorter median operative time as compared with centers performing 10-20 robotic pancreatoduodenectomies annually.

CONCLUSION

This international multicenter study demonstrates that most outcomes of robotic pancreatoduodenectomy continued to improve during 3 learning curve phases without a negative effect on 90-day mortality. Randomized studies are needed in high-volume centers that have surpassed the first learning curves, to compare these outcomes with the open approach.

Impact of hepatic artery variation on surgical and oncological outcomes in robotic pancreaticoduodenectomy

BACKGROUND

In patients with hepatic artery variation (HAV), feasibility and justification of robotic pancreatoduodenectomy (RPD) for periampullary lesions have been not been well established.

METHODS

A total of 600 patients with periampullary lesions receiving RPD or open pancreaticoduodenectomy (OPD) were identified from our prospectively collected computer database. Surgical outcomes, oncological radicality, and survival outcomes after RPD in HAV ( +) and (-) patients were compared.

RESULTS

The incidence of HAV was 16%, including 12.7% in patients with RPD and 23.0% in those with OPD. In the HAV ( +) group, vascular injury rate had no statistical difference between the RPD (3.7%) and OPD (9.1%) patients, P = 0.404. Among the RPD patients, those with HAV ( +) had longer operation time (8.5 ± 2.5 vs. 7.7 ± 2.0 h, P = 0.013) and higher vascular injury (3.8% vs. 0.6%, P = 0.024) when compared with the HAV (-) patients. There was no significant difference between the HAV ( +) and (-) patients with RPD regarding blood loss, open conversion, vascular resection, and surgical mortality and morbidity. There was no survival difference between the HAV ( +) and (-) patients with pancreatic head adenocarcinoma after RPD. There was no survival difference between RPD and OPD in the HAV ( +) group.

CONCLUSIONS

When compared with OPD, RPD is feasible and justifiable without increasing vascular injury rate for patients with HAV ( +). Hepatic artery variation has no negative impact on surgical, oncological, and survival outcomes following an RPD, if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Defining the operative time threshold for safety in patients undergoing robotic pancreaticoduodenectomy

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is a safe and efficacious procedure in appropriately selected patients, though frequently with increased operative times compared to open pancreaticoduodenectomy (OPD).

METHODS

From 2014 to 2019, patients who underwent elective, low-risk, RPDs and OPDs in the NSQIP database were isolated. The operative time threshold (OTT) for safety in RPD patients was estimated by identifying the operative time at which complication rates for RPD patients exceeded the complication rate of the benchmark OPD control.

RESULTS

Of 6270 patients identified, 939 (15%) underwent RPD and 5331 (85%) underwent OPD. The incidence of major morbidity or mortality for the OPD cohort was 35.1%. The OTT was identified as 7.7 h. Patients whose RPDs were above the OTT experienced a higher incidence of major morbidity (42.5% vs. 35.0%, p < 0.01) and 30-day mortality (2.7% vs. 1.2%, p = 0.03) than the OPD cohort. Preoperative obstructive jaundice (OR: 1.47, [95% CI: 1.08-2.01]) and pancreatic duct size <3 mm (OR: 2.44, [95% CI: 1.47-4.06]) and 3-6 mm (OR: 2.15, [95% CI: 1.31-3.52]) were risk factors for prolonged RPDs on multivariable regression.

CONCLUSION

The operative time threshold for safety, identified at 7.7 h, should be used to improve patient selection for RPDs and as a competency-based quality benchmark.

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.

Minimally invasive versus open pancreatoduodenectomy for pancreatic and peri-ampullary neoplasm (DIPLOMA-2): study protocol for an international multicenter patient-blinded randomized controlled trial

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) aims to reduce the negative impact of surgery as compared to open pancreatoduodenectomy (OPD) and is increasingly becoming part of clinical practice for selected patients worldwide. However, the safety of MIPD remains a topic of debate and the potential shorter time to functional recovery needs to be confirmed. To guide safe implementation of MIPD, large-scale international randomized trials comparing MIPD and OPD in experienced high-volume centers are needed. We hypothesize that MIPD is non-inferior in terms of overall complications, but superior regarding time to functional recovery, as compared to OPD.

METHODS/DESIGN

The DIPLOMA-2 trial is an international randomized controlled, patient-blinded, non-inferiority trial performed in 14 high-volume pancreatic centers in Europe with a minimum annual volume of 30 MIPD and 30 OPD. A total of 288 patients with an indication for elective pancreatoduodenectomy for pre-malignant and malignant disease, eligible for both open and minimally invasive approach, are randomly allocated for MIPD or OPD in a 2:1 ratio. Centers perform either laparoscopic or robot-assisted MIPD based on their surgical expertise. The primary outcome is the Comprehensive Complication Index (CCI®), measuring all complications graded according to the Clavien-Dindo classification up to 90 days after surgery. The sample size is calculated with the following assumptions: 2.5% one-sided significance level (α), 80% power (1-β), expected difference of the mean CCI® score of 0 points between MIPD and OPD, and a non-inferiority margin of 7.5 points. The main secondary outcome is time to functional recovery, which will be analyzed for superiority. Other secondary outcomes include post-operative 90-day Fitbit™ measured activity, operative outcomes (e.g., blood loss, operative time, conversion to open surgery, surgeon-reported outcomes), oncological findings in case of malignancy (e.g., R0-resection rate, time to adjuvant treatment, survival), postoperative outcomes (e.g., clinically relevant complications), healthcare resource utilization (length of stay, readmissions, intensive care stay), quality of life, and costs. Postoperative follow-up is up to 36 months.

DISCUSSION

The DIPLOMA-2 trial aims to establish the safety of MIPD as the new standard of care for this selected patient population undergoing pancreatoduodenectomy in high-volume centers, ultimately aiming for superior patient recovery.

TRIAL REGISTRATION

ISRCTN27483786. Registered on August 2, 2023.

Risk factors for delayed gastric emptying in pancreaticoduodenectomy

The study of robotic pancreaticouodenectomy (RPD) focusing on delayed gastric emptying (DGE) is seldom reported. This study explored the incidence of DGE in RPD with extracorporeal hand-sewn gastrojejunostomy involving downward positioning of the stomach. Patients with periampullary lesions undergoing RPD or open pancreaticouodenectomy (OPD) were included for comparison. A variety of clinical factors were evaluated for the risk of developing DGE. There were 409 (68.2%) RPD and 191 (31.8%) OPD in this study. DGE occurred in 7.7% of patients after pancreaticoduodenectomy, with 4.4% in RPD and 14.7% in OPD, p < 0.001. Nausea/vomiting (12.6% vs. 6.3%) and jaundice (9.9% vs. 5.2%) were significant preoperative risk factors for DGE, while malignancy (8.7% vs. 2.2%) and lymph node involvement (9.8% vs. 5.6%) were significant pathological risk factors. Intraoperative blood loss > 200 c.c. was the other factor related to DGE (11.2% vs. 4.4% in those with blood loss ≤ 200 c.c.). None of the postoperative complications was significantly associated with DGE. Hospital stay was significantly longer in the group with DGE (median, 37 vs. 20 days in the group without DGE). After multivariate analysis by binary logistic regression, compared with OPD, RPD was the only independent factor associated with a lower incidence of DGE. RPD with extracorporeal hand-sewn antecolic, antiperistaltic, and inframesocolic gastrojejunostomy via a small umbilical wound involving careful downward positioning of the stomach was associated with a low incidence of DGE and presented as the most powerful independent predictor of this condition.

Minimally Invasive Pancreatoduodenectomy: Contemporary Practice, Evidence, and Knowledge Gaps

Minimally invasive pancreatoduodenectomy has gained popularity throughout the last decade. For laparoscopic pancreatoduodenectomy, some high-level evidence exists, but with conflicting results. There are currently no published randomized controlled trials comparing robotic and open pancreatoduodenectomy. Comparative long-term data for patients with pancreatic ductal adenocarcinoma is lacking to date. Based on the existing evidence, current observed benefits of minimally invasive pancreatoduodenectomy over open pancreatoduodenectomy seem scarce, but retrospective data indicate the safety of these procedures in selected patients. As familiarity with the robotic platform increases, studies have shown an expansion in indications, also including patients with vascular involvement and even indicating favorable results in patients with obesity and high-risk morphometric features. Several ongoing randomized controlled trials aim to investigate potential differences in short- and long-term outcomes between minimally invasive and open pancreatoduodenectomy. Their results are much awaited.

Robotic pancreas surgery: an overview of history and update on technique, outcomes, and financials

The use robotics in surgery is gaining momentum. This approach holds substantial promise in pancreas surgery. Robotic surgery for pancreatic lesions and malignancies has become well accepted and is expanding to more and more center annually. The number of centers using robotics in pancreatic surgery is rapidly increasing. The most studied robotic pancreas surgeries are pancreaticoduodenectomy and distal pancreatectomy. Most studies are in their early phases, but they report that robotic pancreas surgery is safe feasible. Robotic pancreas surgery offers several advantages over open and laparoscopic techniques. Data regarding costs of robotics versus conventional techniques is still lacking. Robotic pancreas surgery is still in its early stages. It holds promise to become the new surgical standard for pancreatic resections in the future, however, more research is still needed to establish its safety, cost effectiveness and efficacy in providing the best outcomes.

Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers

The objective of the study is to compare the safety and efficacy of robot-assisted pancreaticoduodenectomy (PD) with open PD. The PubMed, EMBASE and Cochrane Library databases were searched for the literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio (RR) and weighted mean difference (WMD) and their 95% confidence intervals (CIs) were calculated using fixed-effect or random effect models. 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) (WMD = - 175.65, 95% CI (- 251.85, - 99.44), P < 0.00001), wound infection rate (RR = 0.60, 95% CI (0.44, 0.81), P = 0.001), reoperation rate (RR = 0.61, 95% CI (0.41, 0.91), P = 0.02), hospital day (WMD = - 2.95, 95% CI (- 5.33, - 0.56), P = 0.02), intraoperative blood transfusion (RR = 0.56, 95% CI (0.42, 0.76), P = 0.0001), overall complications (RR = 0.78, 95% CI (0.64, 0.95), P = 0.01), and clinical postoperative pancreatic fistula (POPF) (RR = 0.54, 95% CI (0.41, 0.70), P < 0.0001). In terms of lymph node clearance (WMD = 0.48, 95% CI (- 2.05, 3.02), P = 0.71), R0 rate (RR = 1.05, 95% CI (1.00, 1.11), P = 0.05), postoperative pancreatic fistula (RR = 1, 95% CI (0.85, 1.19), P = 0.97), bile leakage (RR = 0.99, 95% CI (0.54, 1.83), P = 0.98), delayed gastric emptying (DGE) (RR = 0.79, 95% CI (0.60, 1.03), P = 0.08), 90-day mortality (RR = 0.82, 95% CI (0.62, 1.10), P = 0.19), and severe complications (RR = 0.98, 95% CI (0.71, 1.36), P = 0.91), and there were no significant differences between the two groups. Robotic surgery was inferior to open surgery in terms of operational time (WMD = 80.85, 95% CI (16.09, 145.61), P = 0.01). RPD is not inferior to OPD, and it is even more advantageous for EBL, wound infection rate, reoperation rate, hospital stay, intraoperative transfusion, overall complications and clinical POPF. However, these findings need to be further verified by high-quality randomized controlled trials.

Propensity score-matched comparison of the oncological feasibility and survival outcomes for pancreatic adenocarcinoma with robotic and open pancreatoduodenectomy

BACKGROUND

This study is to clarify the feasibility of and justification for robotic pancreaticoduodenectomy (RPD) in patients with pancreatic adenocarcinoma.

METHODS

A 1-to-1 propensity score-matched comparison of RPD and open pancreaticoduodenectomy (OPD) was performed based on six covariates commonly used to predict the survival outcome for pancreatic adenocarcinoma.

RESULTS

A total of 130 patients were enrolled, with 65 in each study group after propensity score matching. The median operating time was longer for RPD (8.3 h vs. 7.0 h, P = 0.002). However, RPD was associated with less blood loss, lower overall surgical complication rate, and lower incidence of delayed gastric emptying. The resection radicality was oncologically similar between these two groups, but the median lymph node yield was higher for RPD (18 vs. 16, P = 0.038). Before propensity score matching, the 5-year survival was better in RPD (27.0% vs. 17.6%, P = 0.006). After matching, there was still a trend towards improved overall survival in the RPD group; however, the difference in 5-year survival between RPD and OPD was not significant (24.5% vs. 19.7%, P = 0.088).

CONCLUSION

RPD is not only technically feasible with no increase in surgical risk but also oncologically justifiable without compromising survival outcome. However, unlike randomized control trials, the limitations in this propensity score-matched analysis only accounted for 6 observed covariates commonly used to predict the survival outcome in patients with pancreatic adenocarcinoma, and confounders not included in this study could also affect our results.

Robotic pancreaticoduodenectomy provides better histopathological outcomes as compared to its open counterpart: a meta-analysis

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p < 0.00001]. EBL was significantly decreased in robotic PD [MD (95%CI) = - 191.35 (- 238.12, - 144.59); p < 0.00001]. Number of lymph nodes harvested was significantly higher in robotic PD [MD (95%CI) = 2.88 (1.12, 4.65); p = 0.001]. This meta-analysis found that robotic PD provides better histopathological outcomes as compared to open PD at the cost of longer operating time. Furthermore, robotic PD did not have any detrimental impact on clinical outcomes, with lower wound infection rates.

Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs

INTRODUCTION

There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy.

MATERIALS AND METHODS

A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy.

RESULTS

A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy.

CONCLUSION

Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy.

Minimally Invasive Pancreaticoduodenectomy in Elderly Patients: Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) for pancreatic head or periampullary lesions is being utilized with increasing frequency. However, few data are available for the elderly. The objective of this study is to assess the safety and feasibility of MIPD in elderly population, by making a comparison with conventional open pancreaticoduodenectomy (OPD) and with non-elderly population.

METHODS

We conducted a systematic search to identify all eligible studies in Cochrane Library, Ovid, and PubMed from their inception up to April 2020.

RESULTS

Seven retrospective studies involving 2727 patients were included. Of these, 3 compared MIPD and OPD in elderly patients, 2 compared MIPD in elderly and non-elderly patients, and 2 included both outcomes. Compared to those with OPD, elderly patients who underwent MIPD were associated with less 90-day mortality (OR 0.56, 95% CI 0.32-0.97; P = 0.04) and fewer delayed gastric emptying (OR 0.54, 95% CI 0.33-0.88; P = 0.01). On the other hand, no significant difference was observed in terms of 30-day mortality, major morbidity, postoperative pancreatic fistula (grade B/C), postoperative hemorrhage, reoperation, 30-day readmission, and operative time. For patients who have treated with MIPD, elderly did not reveal worse outcomes than non-elderly.

CONCLUSION

MIPD is a safe and feasible procedure for select elderly patients if performed by experienced surgeons from high-volume pancreatic surgery centers. However, further randomized studies are required to confirm this.

[Evidence in minimally invasive surgery of the pancreas]

Minimally invasive pancreatic surgery lags behind the development of other fields of application of minimally invasive surgery. After a very slow development over the last two decades minimally invasive pancreatic surgery has currently gained wider acceptance especially in centers. This is due if nothing else, to the increasing availability of robotic assistance systems, which provide maneuverable instruments as well as a 3‑dimensional and enlarged view. Meanwhile, the technical feasibility for even complex pancreatic resections has been shown. This gives rise to the question whether laparoscopic or robotic techniques can generate equal or better results (evidence) with respect to perioperative morbidity, survival after oncological resection and the quality of life. As with all innovative techniques, which are implemented in surgery, the transferability to a wider audience, teaching methods and cost-effectiveness have to be evaluated. This article presents the current scientific evidence for laparoscopic and robotic pancreatic head and left-sided pancreatic surgery.

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.

Robotic-assisted versus open pancreaticoduodenectomy for patients with benign and malignant periampullary disease: a systematic review and meta-analysis of short-term outcomes

BACKGROUND

Although several non-randomized studies comparing robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) recently demonstrated that the two operative techniques could be equivalent in terms of safety outcomes and short-term oncologic efficacy, no definitive answer has arrived yet to the question as to whether robotic assistance can contribute to reducing the high rate of postoperative morbidity.

METHODS

Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases. Prospective and retrospective studies comparing RPD and OPD as surgical treatment for periampullary benign and malignant lesions were included in the systematic review and meta-analysis with no limits of language or year of publication.

RESULTS

18 non-randomized studies were included for quantitative synthesis with 13,639 patients allocated to RPD (n = 1593) or OPD (n = 12,046). RPD and OPD showed equivalent results in terms of mortality (3.3% vs 2.8%; P = 0.84), morbidity (64.4% vs 68.1%; P = 0.12), pancreatic fistula (17.9% vs 15.9%; P = 0.81), delayed gastric emptying (16.8% vs 16.1%; P = 0.98), hemorrhage (11% vs 14.6%; P = 0.43), and bile leak (5.1% vs 3.5%; P = 0.35). Estimated intra-operative blood loss was significantly lower in the RPD group (352.1 ± 174.1 vs 588.4 ± 219.4; P = 0.0003), whereas operative time was significantly longer for RPD compared to OPD (461.1 ± 84 vs 384.2 ± 73.8; P = 0.0004). RPD and OPD showed equivalent results in terms of retrieved lymph nodes (19.1 ± 9.9 vs 17.3 ± 9.9; P = 0.22) and positive margin status (13.3% vs 16.1%; P = 0.32).

CONCLUSIONS

RPD is safe and feasible as surgical treatment for malignant or benign disease of the pancreatic head and the periampullary region. Equivalency in terms of surgical radicality including R0 curative resection and number of harvested lymph nodes between the two groups confirmed the reliability of RPD from an oncologic point of view.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection

OBJECTIVE

The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).

SUMMARY BACKGROUND DATA

MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking.

METHODS

The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.

RESULTS

After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.

CONCLUSION

The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Pancreatic head cancer: Open or minimally invasive pancreaticoduodenectomy?

Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons. Pancreaticoduodenectomy (PD) continues to be the operative standard of care and potentially curative procedure for pancreatic head cancer. Despite the rapid development of minimally invasive techniques, whether the efficacy of minimally invasive pancreaticoduodenectomy (MIPD) is noninferior or superior to open pancreaticoduodenectomy (OPD) remains unclear. In this review, we summarized the history of OPD and MIPD and the latest staging and classification information for pancreatic head cancer as well as the proposed recommendations for MIPD indications for patients with pancreatic head cancer. By reviewing the MIPD- vs. OPD-related literature, we found that MIPD shows noninferiority or superiority to OPD in terms of safety, feasibility, enhanced recovery after surgery (ERAS) and several short-term and long-term outcomes. In addition, we analyzed and summarized the different MIPD outcomes in the USA, Europe and China. Certain debates over MIPD have continued, however, selection bias, the large number of low-volume centers, the steep MIPD learning curve, high conversion rate and administration of neoadjuvant therapy may limit the application of MIPD for pancreatic head cancer.

Robotic versus open pancreaticoduodenectomy: a meta-analysis of short-term outcomes

BACKGROUND

Although robotic surgery is popular around the world, its safety and efficacy over classical open surgery is still controversial. The purpose of this article is to compare the safety and efficacy of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD).

METHODS

A literature search of PubMed, Web of Science, and the Cochrane Library database up to July 29, 2018 was performed and the meta-analysis was performed using RevMan 5.2 software with Fixed and random effects models applied. The IRB approval and written consent were not needed for this paper.

RESULTS

Twelve non-randomized retrospective studies and 1 non-randomized prospective study consisting of 2403 patients were included in this meta-analysis. There were 788 (33%) patients in the RPD group and 1615 (67%) patients in the OPD group. Although RPD was associated with a longer operative time (weighted mean difference [WMD]: 71.74 min; 95% CI 23.37-120.12; p = 0.004), patient might benefit from less blood loss (WMD: - 374.03 ml; 95% CI - 506.84 to - 241.21; p < 0.00001), shorter length of stay (WMD: - 5.19 day; 95% CI - 8.42 to - 1.97; p = 0.002), and lower wound infection rate (odds ratio: 0.17; 95% CI 0.04-0.80; p = 0.02). No statistically significant difference was observed in positive margin rate, lymph nodes harvested, postoperative complications, reoperation or readmission rate, and mortality rate.

CONCLUSIONS

Robotic pancreaticoduodenectomy is a safe and feasible alternative to open pancreaticoduodenectomy with regard to short-term outcomes. Further studies on the long-term outcomes of these surgical techniques are needed.

Operative results and patient satisfaction after robotic pancreaticoduodenectomy

BACKGROUND/OBJECTIVE

There are no reports available on patient satisfaction and quality-of-life after robotic pancreaticoduodenectomy (RPD). This study aimed to evaluate not only surgical outcomes but also patient satisfaction after RPD.

METHODS

Prospectively collected data for RPD were analyzed for surgical outcomes. Questionnaires were sent to patients to assess patient satisfaction regarding RPD.

RESULTS

The study included 105 patients who underwent RPD, with 44 (41.9%) patients presenting with associated surgical complications. There were no significant differences between the without and with complication groups in median console time (390 min. Vs. 373 min.), blood loss (100 mL vs. 100 mL), and harvested lymph node number (14 vs. 15). There was no surgical mortality in this study. Major complications ≥ Clavien-Dindo III occurred in 7.6% of the total 105 RPD patients. The most common complication was chyle leakage (18.1%), followed by postoperative pancreatic fistula (5.7%), intra-abdominal abscess (4.8%), delayed gastric emptying (3.8%), and post pancreatectomy hemorrhage (3.8%). Almost all of the patients responded to this RPD-related survey with "fair" to "excellent" grades for all items, except 1 (<1%) poor grade for operation service and 2 (1.9%) "not good" grades for diet tolerance.

CONCLUSIONS

RPD is a feasible procedure with acceptable surgical outcomes. This patient survey with high patient satisfaction rates indicates that RPD provides acceptable satisfaction results, and the robotic approach for a major operation such as RPD has probably a higher priority than cost concerns. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Minimally invasive pancreatoduodenectomy is associated with lower morbidity compared to open pancreatoduodenectomy: An updated meta-analysis of randomized controlled trials and high-quality nonrandomized studies

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) is being increasingly performed as an alternative to open pancreatoduodenectomy (OPD) in selected patients. Our study aimed to present a meta-analysis of the high-quality studies conducted that compared MIPD to OPD performed for pancreatic head and periampullary diseases.

METHODS

A systematic review of the available literature was performed to identify those studies conducted that compared MIPD to OPD. Here, all randomized controlled trials identified were included, while the selection of high-quality, nonrandomized comparative studies were based on a validated tool (i.e., Methodological Index for Nonrandomized Studies). Intraoperative outcomes, postoperative recovery, oncologic clearance, and postoperative complications were also evaluated.

RESULTS

Sixteen studies matched the selection criteria, including a total of 3168 patients (32.1% MIPD, 67.9% OPD). The pooled data showed that MIPD was associated with a longer operative time (weighted mean difference [WMD] = 80.89 minutes, 95% confidence interval [CI]: 39.74-122.05, P < .01), less blood loss (WMD = -227.62 mL, 95% CI: -305.48 to -149.75, P < .01), shorter hospital stay (WMD = -4.68 days, 95% CI: -5.52 to -3.84, P < .01), and an increase in retrieved lymph nodes (WMD = 1.85, 95% CI: 1.33-2.37, P < .01). Furthermore, the overall morbidity was significantly lower in the MIPD group (OR = 0.67, 95% CI: 0.54-0.82, P < .01), as were total postoperative pancreatic fistula (POPF) (OR = 0.79, 95% CI: 0.63-0.99, P = .04), delayed gastric emptying (DGE) (OR = 0.71, 95% CI: 0.52-0.96, P = .02), and wound infection (OR = 0.56, 95% CI: 0.39-0.79, P < .01). However, there were no statistically significant differences observed in major complications, clinically significant POPFs, reoperation rate, and mortality.

CONCLUSION

Our study suggests that MIPD is a safe alternative to OPD, as it is associated with less blood loss and better postoperative recovery in terms of the overall postoperative complications as well as POPF, DGE, and wound infection. Methodologic high-quality comparative studies are required for further evaluation.

Initial experience with laparoscopic and robotic surgery for the treatment of periampullary tumours: single institution experience with the first 30 consecutive cases

BACKGROUND

Concerns have been raised about the safety of minimally invasive surgery (MIS) for pancreatoduodenectomy (PD) during the early learning phase. In this study, we present our initial experience with MIS for periampullary tumours.

METHODS

Retrospective review of the first 30 consecutive patients who underwent laparoscopic (LS)/robotic surgery (RS) for periampullary tumours between 2014 and 2017.

RESULTS

Twenty-seven patients underwent PD, including three total pancreatectomies (TPs) and three underwent palliative bypasses. Twenty underwent LS, of which 18 were hybrid PDs, including two TPs and two bypasses. Ten patients underwent RS, of which nine were PDs, including one TP and one bypass. Five of 10 RSs were totally MIS procedures. There were four PDs with venous resection, of which three were by RS. There were four (13.3%) open conversions all in the LS cohort. There were five (16.7%) major (>grade 2) morbidities, including three pancreatic fistulas (two grade B and one grade C). There was no 30-day and one (3.3%) 90-day mortality. Comparison between RS and LS demonstrated that RS had a higher likelihood of being completed via totally MIS (five (50%) versus 0, P = 0.002), tended to have a shorter post-operative stay (eight (range 6-36) versus 14.5 (range 6-62) days, P = 0.058) but tended to be associated with a longer operation time (670 (range 500-930) versus 577 (range 235-715) min, P = 0.056).

CONCLUSION

Our initial experience demonstrated that both LS and RS can be safely adopted for the treatment of periampullary tumours. The learning curve for RS seemed to be shorter than LS as we could transition more quickly from hybrid PDs to totally MIS safely.

Robotic and laparoscopic surgery of the pancreas: an historical review

Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas including distal pancreatectomy and pancreatoduodenectomy. The progression from open surgery to laparoscopy to robotic surgery has occurred for many operations including adrenalectomy, thyroidectomy, colon resection, prostatectomy, gastrectomy and others. Data to show a benefit to the patient are scarce for robotic surgery, although both laparoscopic and robotic surgery of the pancreas have been shown not to be inferior with regard to major operative and oncologic outcomes. While there were serious concerns when laparoscopy was first used in patients with malignancies, robotic surgery has been used in many benign and malignant conditions with no obvious deterioration of outcomes. Robotic surgery for malignancies of the pancreas is well accepted and expanding to more centers. The importance of centers of excellence, surgeon experience supported by a codified mastery-based training program and international registries is widely accepted. Robotic pancreatic surgery is associated with slightly decreased blood loss and decreased length of stay compared to open surgery. Major oncologic outcomes appear to have been preserved, with some studies showing higher rates of R0 resection and tumor-free margins. Patients with lesions of the pancreas should find a surgeon they trust and do not need to be concerned with the operative approach used for their resection. The step-wise approach that has characterized the growth in robotic surgery of the pancreas, in contradistinction to the frenzy that accompanied the introduction of laparoscopic cholecystectomy, has allowed the identification of areas for improvement, many of which lie at the junction of engineering and medical practice. Refinements in robotic surgery depend on a partnership between engineers and clinicians.

A propensity score-matched analysis of robotic versus open pancreatoduodenectomy for pancreatic cancer based on margin status

BACKGROUND

No study has shown the oncologic non-inferiority of robotic pancreatoduodenectomy (RPD) versus open pancreatoduodenectomy (OPD) for pancreatic cancer (PC).

METHODS

This is a single institution propensity score matched study comparing RPD and ODP for resectable PC, based on factors predictive of R1 resection (≤ 1 mm). Only patients operated on after completion of the learning curve in both procedures and for whom circumferential margins were assessed according to the Leeds pathology protocol were included. The primary study endpoint was the rate of R1 resection. Secondary study endpoints were as follows: number of examined lymph nodes (N), rate of perioperative transfusions, percentage of patients receiving adjuvant therapies, occurrence of local recurrence, overall survival, disease-free survival, and sample size calculation for randomized controlled trials (RCT).

RESULTS

Factors associated with R1 resection were tumor diameter, number of positive N, N ratio, logarithm odds of positive N, and duodenal infiltration. The matching process identified 20 RPDs and 24 OPDs. All RPDs were completed robotically. R1 resection was identified in 11 RPDs (55.0%) and in 10 OPDs (41.7%) (p = 0.38). There was no difference in the rate of R1 at each margin as well as in the proportion of patients with multiple R1 margins. RPD and OPD were also equivalent with respect to all secondary study endpoints, with a trend towards lower rate of blood transfusions in RPD. Based on the figures presented herein, a non-inferiority RCT comparing RPD and OPD having the rate of R1 resection as the primary study endpoint requires 3355 pairs.

CONCLUSIONS

RPD and OPD achieved the same rate of R1 resections in resectable PC. RPD was also non-inferior to OPD with respect to all secondary study endpoints. Because of the high number of patients required to run a RCT, further assessment of RPD for PC would require the implementation of an international registry.

Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy: A propensity score-matched study

BACKGROUND

This study is to clarify the feasibility of robotic pancreaticoduodenectomy in terms of surgical risks, clinically relevant postoperative pancreatic fistula, and oncologic outcomes compared with open pancreaticoduodenectomy by using propensity score matching. Traditional open pancreaticoduodenectomy and robotic pancreaticoduodenectomy have been compared only in small, retrospective, and nonrandomized cohort studies with variable quality.

METHODS

Prospectively collected data for pancreaticoduodenectomy were evaluated. Comparison between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy was carried out after propensity-score matching. A total of 117 robotic pancreaticoduodenectomy and 128 open pancreaticoduodenectomy cases were performed during the study period. After propensity score matching, 87 cases were included for comparison in each cohort.

RESULTS

Longer operation time, less blood loss, more lymph nodes harvested, and less delayed gastric emptying were noted in the robotic pancreaticoduodenectomy cases. We found no significant difference regarding the overall postoperative complications by Clavien-Dindo classification, postpancreatectomy hemorrhage, wound infection rate, and postoperative hospital stay. Clinically relevant postoperative pancreatic fistula was not significantly different between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy, regardless of the Callery risk factor, with overall clinically relevant postoperative pancreatic fistula of 8.0% by robotic pancreaticoduodenectomy and 12.6% by open pancreaticoduodenectomy after propensity score matching. We found no survival difference between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy when the comparison was specifically performed for each primary periampullary malignancy.

CONCLUSION

Robotic pancreaticoduodenectomy is associated with less blood loss, less delayed gastric emptying, and more lymph node yield. Propensity scored-matched analysis revealed that robotic pancreaticoduodenectomy is not inferior to open pancreaticoduodenectomy in terms of clinically relevant postoperative pancreatic fistula, surgical risks, and survival outcomes.

Robotic versus standard open pancreatectomy: a propensity score-matched analysis comparison

Interest in robotic pancreatectomy has been greatly increasing over the last decade. However, evidence supporting the benefits of robotic over open pancreatectomy is still outstanding. This study aims to assess the safety and efficacy of robotic pancreatectomy compared with the conventional open surgical approach. Propensity score-matched (1:1) was used to balance age, sex, BMI, ASA, tumor size, and malignancy of 17 robotic pancreaticoduodenectomies (PD), 12 pancreatic enucleations (PE), and 28 distal pancreatectomies (DP); and was compared with the open standard approach. Robotic PD was associated with longer operative time (594 vs. 413 min; p = 0.03) and decreased blood loss (190 vs. 394 ml; p = 0.001). Robotic PE showed a lower mean length of hospital stay (8.4 vs. 12.8 days; p = 0.04) and, in addition, robotic DP showed less blood loss (175 vs. 375 ml; p = 0.01), less severe morbidities (7.14 vs. 17.9%; p = 0.02), and a reduced mean length of hospital stay (8.9 vs. 15.1; p = 0.001). Overall, conversion rate was 4 (7%). Robotic pancreatectomy is as safe and effective as the standard open surgical approach with reduced blood loss in PD and DP, length of hospital stay in PE and DP, and severe morbidity in DP.