Minimally invasive surgical techniques for pancreatic cancer: ready for prime time?

Minimally invasive distal pancreatectomy for pancreatic adenocarcinoma: A propensity-matched national analysis on surgical outcomes and healthcare disparities

BACKGROUND

Pancreatic adenocarcinoma of distal pancreas is hard to treat due to late presentation. While open distal pancreatectomy with splenectomy has had favourable outcomes, it has also had many complications which were low among Minimally invasive procedures. This retrospective cohort analysis compares minimally invasive and open distal pancreatectomy (MIDP) outcomes using a national inpatient database.

METHODS

The study used 2016-2020 NIS data. The study included 1577 distal pancreatic malignant tumor surgery patients. There were 530 Minimally Invasive and 1047 Open groups. Propensity matched analysis was performed on surgical groups to reduce confounding variables.

RESULTS

In comparison to open procedures, minimally invasive techniques reduced hospital stays by 10 ​% (OR ​= ​0.90, 95 ​% CI 0.86-0.93). While not statistically significant, the unmatched analysis linked MIDP to lower in-hospital mortality. African Americans were 37 ​% less likely to undergo MIDP than Caucasians (OR ​= ​0.63, 95 ​% CI ​= ​0.40-0.96).

CONCLUSION

Nationwide analysis suggests MIDP may be a safe and effective surgical treatment for distal pancreatic adenocarcinoma. It may reduce hospital stays and mortality over open surgery. The study also suggests race may affect minimally invasive procedure rates.

Surgical Management of Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine tumors (PNETs) are relatively uncommon malignancies, characterized as either functional or nonfunctional secondary to their secretion of biologically active hormones. A wide range of clinical behavior can be seen, with the primary prognostic indicator being tumor grade as defined by the Ki67 proliferation index and mitotic index. Surgery is the primary treatment modality for PNETs. While functional PNETs should undergo resection for symptom control as well as potential curative intent, nonfunctional PNETs are increasingly managed nonoperatively. There is increasing data to suggest small, nonfunctional PNETs (less than 2 cm) are appropriate follow with nonoperative active surveillance. Evidence supports surgical management of metastatic disease if possible, and occasionally even surgical management of the primary tumor in the setting of widespread metastases. In this review, we highlight the evolving surgical management of local and metastatic PNETs.

Robotic pancreaticoduodenectomy: Where do we stand?

Pancreaticoduodenectomy (PD) is a complex operation accompanied by significant morbidity rates. Due to this complexity, the transition to minimally invasive PD has lagged behind other abdominal surgical operations. The safety, feasibility, favorable post-operative outcomes of robotic PD have been suggested by multiple studies. Compared to open surgery and other minimally invasive techniques such as laparoscopy, robotic PD offers satisfactory outcomes, with a non-inferior risk of adverse events. Trends of robotic PD have been on rise with centers substantially increasing the number the operation performed. Although promising, findings on robotic PD need to be corroborated in prospective trials.

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.

Proposed training pathway with initial experience to set up robotic hepatobiliary and pancreatic service

Although robot-assisted hepatobiliary and pancreatic (HPB) surgery has gained momentum over the last 2 decades, only a handful of units in the world perform major robotic resections. Adaptation of robotic surgery in the UK lags behind its European counterparts and this is mainly because of cost implications in a publicly funded National Health Service (NHS). We describe our experience of setting up a robotic HPB programme with clinical outcomes and propose a training pathway that would help prospective centres in setting up their own robotic HPB service with robust clinical governance oversight. After gaining colleagues' and departmental support, approval from the hospital clinical governance, finance department and new intervention procedure committee was sought. A team of two consultant surgeons, three assistants and three theatre staff went through a structured training programme sponsored mainly by the industry. Surgeon training consisted of online modules, simulation, wet lab, cadaveric training, case observations, proctored procedures followed by independent practice. All major cases were recorded and videos reviewed to improve performance. A total of 111 procedures were successfully completed with robotic assistance between April 2018 and March 2020. The programme started with robot-assisted cholecystectomy as index procedure and progressed on to more complex liver and pancreatic resections including major hepatectomy and Whipple's procedure. The training pathway followed by our team has been effective in setting up a safe robotic HPB programme and could be considered as a roadmap to start new Robotic HPB services.

Expectations of Hepato-Pancreato-Biliary Fellows; Do We Meet Them?

OBJECTIVE

There are 16 accredited hepatopancreatobiliary (HPB) fellowships in North America. The purpose of this study is to portray the expectations of the incoming HPB fellows about their training and its implication on their career.

DESIGN

A 29-questions survey was sent out to all HPB fellows starting in August 2017. The survey was divided in 3 sections depicting background, in-training and postfellowship expectations. Descriptive statistics were generated for aggregate survey responses.

SETTING

This study was performed through an online questionnaire that was sent to the participants via e-mail. The answers were processed in our offices in Methodist Richardson Medical Center, in Richardson, Texas which is a private tertiary medical center part of the Methodist Health System.

PARTICIPANTS

Participants were all incoming HPB Fellows (In HPB fellowship programs accredited by the Fellowship Council) starting their fellowship in August 2017.

RESULTS

We had a 94% response rate. Forty-six percent of fellows anticipate doing about 150 to 250 HPB cases during the fellowship, and all 15 fellows anticipate having at least 1 publication during fellowship. Despite that >90% of fellows believe that minimally invasive surgery (MIS) approaches will be more frequently utilized in HPB surgery, only 3/15 anticipate being able to apply MIS techniques and only 54% will be robotically trained. Interestingly the majority of fellows believe that the attending should be performing the case the first few months.

CONCLUSION

The trainees believe that case volume is the most important factor for choosing a fellowship and for adequate training. Most of the fellows anticipate doing adequate number of cases but only the minority feels they will be adequately trained in MIS-robotic techniques.

Laparoscopic pancreaticoduodenectomy: are the best times coming?

BACKGROUND

The introduction of laparoscopic technology has greatly promoted the development of surgery, and the trend of minimally invasive surgery is becoming more and more obvious. However, there is no consensus as to whether laparoscopic pancreaticoduodenectomy (LPD) should be performed routinely.

MAIN BODY

We summarized the development of laparoscopic pancreaticoduodenectomy (LPD) in recent years by comparing with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD) and evaluated its feasibility, perioperative, and long-term outcomes including operation time, length of hospital stay, estimated blood loss, and overall survival. Then, several relevant issues and challenges were discussed in depth.

CONCLUSION

The perioperative and long-term outcomes of LPD are no worse and even better in length of hospital stay and estimated blood loss than OPD and RPD except for a few reports. Though with strict control of indications, standardized training, and learning, ensuring safety and reducing cost are still and will always the keys to the healthy development of LPD; the best times for it are coming.

Robotic versus laparoscopic distal pancreatectomy: an up-to-date meta-analysis

Background

Laparoscopic distal pancreatectomy (LDP) reduces postoperative morbidity, hospital stay and recovery as compared with open distal pancreatectomy. Many authors believe that robotic surgery can overcome the difficulties and technical limits of LDP thanks to improved surgical manipulation and better visualization. Few studies in the literature have compared the two methods in terms of surgical and oncological outcome. The aim of this study was to compare the results of robotic (RDP) and laparoscopic distal pancreatectomy.

Methods

A systematic review and meta-analysis was conducted of control studies published up to December 2016 comparing LDP and RDP. Two Reviewers independently assessed the eligibility and quality of the studies. The meta-analysis was conducted using either the fixed-effect or the random-effect model.

Results

Ten studies describing 813 patients met the inclusion criteria. This meta-analysis shows that the RDP group had a significantly higher rate of spleen preservation [OR 2.89 (95% confidence interval 1.78-4.71, p < 0.0001], a lower rate of conversion to open OR 0.33 (95% CI 0.12-0.92), p = 0.003] and a shorter hospital stay [MD -0.74; (95% CI -1.34 -0.15), p = 0.01] but a higher cost than the LDP group, while other surgical outcomes did not differ between the two groups.

Conclusion

This meta-analysis suggests that the RDP procedure is safe and comparable in terms of surgical results to LDP. However, even if the RDP has a higher cost compared to LDP, it increases the rate of spleen preservation, reduces the risk of conversion to open surgery and is associated to shorter length of hospital stay.

Minimally Invasive Surgical Approaches for Pancreatic Adenocarcinoma: Recent Trends

BACKGROUND

Pancreatic resection for cancer represents a real challenge for every surgeon. Recent improvements in laparoscopic experience, minimally invasive surgical techniques and instruments make now the minimally invasive approach a real "triumph." There is no doubt that minimally invasive surgery has replaced with great success conventional surgery in many fields, including surgical oncology.

METHODS AND RESULTS

However, its progress in pancreatic resection for adenocarcinoma has been dramatically slow. Recent evidence supports the notion that minimally invasive distal pancreatectomy is safe and feasible and that is becoming the procedure of choice mainly for benign or low-grade malignant lesions in the distal pancreas. On the other side, minimally invasive pancreatoduodenectomy has not yet been widely accepted and there is enormous skepticism when applied for pancreatic head adenocarcinoma. In this review, we summarize the current evidence on the potential applications of minimally invasive surgical approaches for this aggressive, heterogeneous, and enigmatic type of cancer.

CONCLUSIONS

Moreover, the potential future applications of these approaches are discussed with the hope to improve the quality of life as well as the survival rates of pancreatic cancer patients.

Laparoscopic distal pancreatectomy: many meta-analyses, few certainties

In recent years, an increasing of the level of evidence occurred with a significant number of meta-analyses. A question remains open: can LDP be considered the "new gold standard" for benign and malignant body-tail pancreatic disease? A systematic literature search was conducted to identify all meta-analyses published up to 2016. The primary endpoint was to evaluate the clinical safety of LDP. The secondary endpoints were to evaluate: the length of hospital stay (LOS), readmission rate, postoperative pancreatic fistula (POPF), overall postoperative morbidity and oncologic safety. Nine studies were found to be suitable for the analysis. Data regarding clinical safety were extractable in all meta-analyses but a "between study" homogeneity was available only in 7. The safety of LDP was sustained by six meta-analyses in benign/low grade of malignancy body-tail pancreatic lesions, by one in ductal adenocarcinoma (PDAC). LDP has a shorter LOS compared to open distal pancreatectomy (ODP), demonstrated by three meta-analyses. Readmission rate in LDP procedures was lower than in ODP; these data are sustained by one meta-analysis. LDP is not inferior to ODP regarding the occurrence of POPF (seven meta-analyses); overall morbidity rate was lower in LDP than ODP for benign or low-grade malignant tumor. The use of the LDP in PDAC is sustained from one study. In conclusion, LDP can be considered a safe alternative to ODP. LDP could have some advantages but the data do not permit to define this procedure as the first choice or as the new gold standard.

Pancreatic cancer

Pancreatic cancer is a highly lethal disease, for which mortality closely parallels incidence. Most patients with pancreatic cancer remain asymptomatic until the disease reaches an advanced stage. There is no standard programme for screening patients at high risk of pancreatic cancer (eg, those with a family history of pancreatic cancer and chronic pancreatitis). Most pancreatic cancers arise from microscopic non-invasive epithelial proliferations within the pancreatic ducts, referred to as pancreatic intraepithelial neoplasias. There are four major driver genes for pancreatic cancer: KRAS, CDKN2A, TP53, and SMAD4. KRAS mutation and alterations in CDKN2A are early events in pancreatic tumorigenesis. Endoscopic ultrasonography and endoscopic ultrasonography-guided fine-needle aspiration offer high diagnostic ability for pancreatic cancer. Surgical resection is regarded as the only potentially curative treatment, and adjuvant chemotherapy with gemcitabine or S-1, an oral fluoropyrimidine derivative, is given after surgery. FOLFIRINOX (fluorouracil, folinic acid [leucovorin], irinotecan, and oxaliplatin) and gemcitabine plus nanoparticle albumin-bound paclitaxel (nab-paclitaxel) are the treatments of choice for patients who are not surgical candidates but have good performance status.

Safety in Numbers: Progressive Implementation of a Robotics Program in an Academic Surgical Oncology Practice

Background Robotic-assisted surgery has potential benefits over laparoscopy yet little has been published on the integration of this platform into complex surgical oncology. We describe the outcomes associated with integration of robotics into a large surgical oncology program, focusing on metrics of safety and efficiency. Methods A retrospective review of a prospectively maintained database of robotic procedures from July 2009 to October 2014 identifying trends in volume, operative time, complications, conversion to open, and 90-day mortality. Results Fourteen surgeons performed 1236 cases during the study period: thyroid (246), pancreas/duodenum (458), liver (157), stomach (56), colorectal (129), adrenal (38), cholecystectomy (102), and other (48). There were 38 conversions to open (3.1%), 230 complications (18.6%), and 13 mortalities (1.1%). From 2009 to 2014, operative volume increased (7 cases/month vs 24 cases/month; P < .001) and procedure time decreased (471 ± 166 vs 211 ± 140 minutes; P < .001) with statistically significant decreases for all years except 2014 when volume and time plateaued. Conversion to open decreased (12.1% vs 1.7%; P = .009) and complications decreased (48.5% vs 12.3%; P < .001) despite increasing complexity of cases performed. There were 13 deaths within 90 days (5/13 30-day mortality) and 2 (15.4%) were from palliative surgeries. Conclusions Implementation of a diverse robotic surgical oncology program utilizing multiple surgeons is safe and feasible. As operative volume increased, operative time, complications, and conversions to open decreased and plateaued at approximately 3 years. No unanticipated adverse events attributable to the introduction of this platform were observed.

Robotic pancreaticoduodenectomy for pancreatic adenocarcinoma: role in 2014 and beyond

Minimally invasive surgery (MIS) for pancreatic adenocarcinoma has found new avenues for performing pancreaticoduodenectomy (PD) procedures, a historically technically challenging operation. Multiple studies have found laparoscopic PD to be safe, with equivalent oncologic outcomes as compared to open PD. In addition, several series have described potential benefits to minimally invasive PD including fewer postoperative complications, shorter hospital length of stay, and decreased postoperative pain. Yet, despite these promising initial results, laparoscopic PDs have not become widely adopted by the surgical community. In fact, the vast majority of pancreatic resections performed in the United States are still performed in an open fashion, and there are only a handful of surgeons who actually perform purely laparoscopic PDs. On the other hand, robotic assisted surgery offers many technical advantages over laparoscopic surgery including high-definition, 3-D optics, enhanced suturing ability, and more degrees of freedom of movement by means of fully-wristed instruments. Similar to laparoscopic PD, there are now several case series that have demonstrated the feasibility and safety of robotic PD with seemingly equivalent short-term oncologic outcomes as compared to open technique. In addition, having the surgeon seated for the procedure with padded arm-rests, there is an ergonomic advantage of robotics over both open and laparoscopic approaches, where one has to stand up for prolonged periods of time. Future technologic innovations will likely focus on enhanced robotic capabilities to improve ease of use in the operating room. Last but not least, robotic assisted surgery training will continue to be a part of surgical education curriculum ensuring the increased use of this technology by future generations of surgeons.

Clinical outcomes of 15 consecutive patients who underwent laparoscopic insulinoma resection: The usefulness of monitoring intraoperative blood insulin during laparoscopic pancreatectomy

BACKGROUND

Insulinoma is a very serious functional tumor. Surgeons should confirm complete resection of insulinomas before completing the operation, even in laparoscopic surgery.

METHODS

Between August 2007 and September 2014, 15 consecutive patients with biochemical evidence of an insulinoma underwent laparoscopic pancreatectomy. Intraoperatively, a peripheral arterial blood sample was taken, and insulin was measured by quick insulin assay. Insulin levels were determined before anesthesia induction, every 30 min thereafter, and every 30 min for at least 1 h after tumor resection to confirm insulin levels did not increase before surgery was completed.

RESULTS

All 15 patients (3 men and 12 women, average age 57.2 years) successfully underwent laparoscopic resection. One patient had two tumors, and the remaining 14 patients had one tumor each (three in the head, five in the body, and eight in the tail of the pancreas). Preoperative localization and regionalization studies identified the tumor correctly through CT (12/15 [80.0%]), MRI (9/12 [75.0%]), angiography (11/13 [84.6%]), endoscopic ultrasonography (7/10 [70.0%]), and selective arterial calcium injection (14/14 [100%]). Intraoperative ultrasonography detected 13 of 15 tumors (86.7%), and intraoperative blood insulin monitoring confirmed the complete resection of 16 of 16 tumors (100%). All patients were discharged with normal insulin levels and have been followed up for 3-88 months. There has been no recurrence of symptoms in any patients and none has died.

CONCLUSION

Complete removal of an insulinoma can be reliably predicted by intraoperative blood insulin monitoring even in laparoscopic pancreatectomies.

Minimally invasive pancreatic surgery - a review

During the past 20 years the application of a minimally invasive approach to pancreatic surgery has progressively increased. Distal pancreatectomy is the most frequently performed procedure, because of the absence of a reconstructive phase. However, middle pancreatectomy and pancreatoduodenectomy have been demonstrated to be safe and feasible as well. Laparoscopic distal pancreatectomy is recognized as the gold standard treatment for small tumors of the pancreatic body-tail, with several advantages over the traditional open approach in terms of patient recovery. The surgical treatment of lesions of the pancreatic head via a minimally invasive approach is still limited to a few highly experienced surgeons, due to the very challenging resection and complex anastomoses. Middle pancreatectomy and enucleation are indicated for small and benign tumors and offer the maximum preservation of the parenchyma. The introduction of a robotic platform more than ten years ago increased the interest of many surgeons in minimally invasive treatment of pancreatic diseases. This new technology overcomes all the limitations of laparoscopic surgery, but actual benefits for the patients are still under investigation. The increased costs associated with robotic surgery are under debate too. This article presents the state of the art of minimally invasive pancreatic surgery.

Laparoscopic distal pancreatectomy: Educating surgeons about advanced laparoscopic surgery

INTRODUCTION

Laparoscopic distal pancreatectomy (Lap-DP) has been recognized worldwide as a feasible and highly beneficial procedure. The aim of this study is to investigate whether Lap-DP techniques are being implemented safely by surgeons training to perform this procedure.

METHODS

We retrospectively compared the perioperative outcomes of Lap-DP in patients operated on by the surgeon originating this procedure at our hospital (expert surgeon group [E group], n = 47) and patients operated on by surgeons training to perform this procedure (training surgeons group [T group], n = 53).

RESULTS

The median operating times for the E group and T group were 321 min (range, 150-653 min) and 314 min (range, 173-629 min), respectively; these times were not significantly different (P = 0.4769). The median blood loss in the T group (100 mL; range, 0-1950 mL) was significantly smaller than in the E group (280 mL; range, 0-1920 mL) (P = 0.0003). There were no significant intergroup differences in other operative results: combined operation ratio, spleen- and splenic vessels-preserving ratio, hand-assisted procedure ratio, and the ratio of transition to open. The frequency of pancreatic fistulas in the E group and T group was 12.8% and 16.9%, respectively; these rates were not significantly different (P = 0.5886). There were no significant differences between the two groups in terms of other complications and reoperation rates. The median hospital stay for the E group was significantly shorter than for the T group (10 vs 13 days; P = 0.0307).

CONCLUSION

This retrospective analysis shows that teaching safe Lap-DP techniques to surgeons is reflected in stable perioperative outcomes.

Robotic surgery of the pancreas

Pancreatic surgery is one of the most challenging and complex fields in general surgery. While minimally invasive surgery has become the standard of care for many intra-abdominal pathologies the overwhelming majority of pancreatic surgery is performed in an open fashion. This is attributed to the retroperitoneal location of the pancreas, its intimate relationship to major vasculature and the complexity of reconstruction in the case of pancreatoduodenectomy. Herein, we describe the application of robotic technology to minimally invasive pancreatic surgery. The unique capabilities of the robotic platform have made the minimally invasive approach feasible and safe with equivalent if not better outcomes (e.g., decreased length of stay, less surgical site infections) to conventional open surgery. However, it is unclear whether the robotic approach is truly superior to traditional laparoscopy; this is a key point given the substantial costs associated with procuring and maintaining robotic capabilities.

High performing whipple patients: factors associated with short length of stay after open pancreaticoduodenectomy

INTRODUCTION

Despite the decreasing mortality of pancreaticoduodenectomy (PD), it continues to be associated with prolonged length of postoperative hospital stay (LOS). This study aimed to determine factors that could predict short LOS after PD. Additionally, as preliminary data of minimally invasive PD emerges, we sought to determine the average LOS after open PD at a high-volume center to set a standard to which minimally invasive PD can be compared.

METHODS

A total of 634 consecutive patients who underwent open PD between January 2007 and December 2012 at the Massachusetts General Hospital comprised the study cohort. "High performers" were defined as patients with postoperative LOS ≤5 days.

RESULTS

Median LOS was 7 days. A total of 61 patients (9.6%) had LOS ≤5 days and were deemed "high performing." In multivariate logistic regression analysis, male gender (p = 0.032), neoadjuvant chemoradiation (p = 0.001), epidural success (p = 0.019), epidural duration ≤3 days (p = 0.001), lack of complications (p < 0.001), surgery on Thursday or Friday (p = 0.001), and discharge on Monday through Wednesday (p < 0.001) were independently associated with LOS ≤5 days. Readmission rate, time to readmission, and mortality were not different between the two groups. The proportion of patients with pancreatic ductal adenocarcinoma who went on to receive adjuvant therapy was no different if LOS was ≤5 or >5 days, but high performance was predictive of beginning therapy <8 weeks after surgery (p = 0.010).

CONCLUSION

In our experience, median LOS was 7 days, and early discharge (≤5 days) after open PD is safe and feasible in about 10 % of patients. These high performers are more likely to be male, have received neoadjuvant therapy, and had successful epidural analgesia. High performers with cancer are more likely to start chemotherapy <8 weeks after surgery. Minimally invasive PD should be compared to this high standard for median LOS, among other quality metrics, to justify its increased cost, operative duration, and learning curve.

Duodenopancreatectomy: open or minimally invasive approach?

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach may enhance patient recovery and reduce postoperative complications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures.

METHODS

A systematic literature review was conducted to identify studies comparing MIPD and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.

RESULTS

For the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419 patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD.

CONCLUSIONS

The MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.