Outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing robotic (RPD) or open pancreaticoduodenectomies (OPD): a propensity score-weighted survival analysis

Outcomes evaluation of robotic versus laparoscopic pancreaticoduodenectomy: a propensity score matching and learning curve analysis

BACKGROUND

Limited research has been conducted on the short-term outcomes comparing laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), particularly in the post-learning curve stage. This study aims to investigate surgical efficacy and provide clinical practices for selecting suitable techniques between LPD and RPD.

METHODS

A retrospective study was conducted on consecutive patients who underwent RPD and LPD between April 2016 and December 2023. Baseline characteristics, pathological information, and perioperative data were analyzed. Propensity score matching (PSM) analysis was performed to ensure the comparability of important factors between the groups.

RESULTS

A total of 277 patients were enrolled in the study, of which 145 underwent RPD. Following PSM, 116 patients were included in each group and baseline characteristics were well matched. The RPD group demonstrated a lower conversion rate to laparotomy (5.2% vs. 18.1%, p = 0.002), reduced blood loss (350 vs. 500 ml, p = 0.031), and a higher rate of R0 resection (91.4% vs. 80.7%, p < 0.05) compared to the laparoscopic group. The incidence of B2-Grade postoperative pancreatic fistula (B2-POPF) was also lower in the RPD group compared to the LPD group (4.3% vs. 11.2%, p = 0.037). Among patients in the post-learning curve stage, perioperative outcomes were similar between the two groups.

CONCLUSION

RPD offered several advantages over LPD, including lower rates of conversion to open and blood loss, higher rates of R0 resection, and improved POPF outcomes. Other perioperative outcomes were comparable between the two groups. Both techniques appeared feasible and safe in experienced surgeons, though RPD was preferred in complex cases.

The postsurgical pancreas

BACKGROUND

Partial pancreatic resections are among the most complex surgical procedures in visceral tumor medicine and are associated with a high postoperative morbidity with a complication rate of 40-50 % of patients even in specialized centers.

METHODS

Description of typical surgical resection procedures and the resulting postoperative anatomy, typical normal postoperative findings, common postoperative complications, and radiological findings.

RESULTS AND CONCLUSION

CT is the most appropriate imaging technique for rapid and standardized visualization of postoperative anatomy and detection of clinically suspected complications after partial pancreatic resections. The most common complications are delayed gastric emptying, pancreatic fistula, acute pancreatitis, bile leakage, abscess, and hemorrhage. Radiologists must identify the typical surgical procedures, the postoperative anatomy, and normal postoperative findings as well as possible postoperative complications and know interventional treatment methods for common complications.

KEY POINTS

· Morbidity after pancreatic surgery remains high.. · CT is the best method for visualizing postoperative anatomy and is used for early detection of complications.. · Pancreatic fistula is the most common relevant complication after pancreatic resection.. · The ability of a center to manage complications is crucial to ensure the success of therapy..

CITATION FORMAT

· Fischbach R, Peller M, Perez D et al. The postsurgical pancreas. Fortschr Röntgenstr 2024; 196: 1037 - 1045.

Robotic Versus Laparoscopic Pancreaticoduodenectomy for Pancreatic Cancer: Evaluation and Analysis of Surgical Efficacy

BACKGROUND

Evidence is limited for the treatment of pancreatic cancer among minimally invasive pancreatoduodenectomy.

METHODS

This retrospective analysis evaluated patients who underwent robotic pancreaticoduodenectomy (RPD) or laparoscopic pancreaticoduodenectomy (LPD) from April 2016 to April 2023. Their baseline and perioperative data, including operative time, R0 resection rates, and severe complications rates, were analyzed, and the follow-up data, such as disease-free survival (DFS) and overall survival (OS), were collected.

RESULTS

A total of 253 cases of LPD and RPD were performed, and 101 cases with pancreatic cancer were included, of which 54 were LPD and 47 were RPD. The conversion rate (4.3% vs. 29.6%, p = 0.001) and blood loss (400 vs. 575 mL, p < 0.05) were lower in the RPD group. No significant difference was observed between the two groups in terms of operative time, vessel resection rates, and TNM-stage diagnosis; however, R0 resection rates (80.9% vs. 70.4%) and lymph node harvest (24.2 vs. 21.9) had a higher tendency in the RPD group, and postoperative length of stay was shorter in the RPD cohort (11 vs. 13 days). Moreover, improved 1- to 3-years DFS (75.7%, 61.7%, and 36.0% vs. 59.0%, 35.6%, and 21.9%) and OS (94.7%, 84.7%, and 50.8% vs. 84.1%, 63.6%, and 45.5%) was found in the RPD group in comparison with the LPD group.

CONCLUSIONS

RPD had advantages in surgical safety and oncological outcomes compared with LPD, but was similar to the latter in perioperative outcomes. Long-term outcomes require further study.

Perioperative and oncologic outcomes of robot-assisted versus open surgery for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to compare perioperative and oncologic outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) treated with robotic-assisted surgery versus open laparotomy. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials (RCTs) and cohort studies up to June 15, 2024, were identified using PubMed, EMBASE, and Google Scholar. Additionally, reference lists of included studies, relevant review articles, and clinical guidelines were manually searched. The primary outcomes evaluated were length of stay, 90-day mortality, postoperative pancreatic fistula (POPF), and Post-pancreatectomy haemorrhage (PPH). Secondary outcomes included estimated blood loss, reoperation rate, lymph node yield, and operative time. The final analysis included 10 retrospective cohort studies involving 23,272 patients (2,179 robotic-assisted and 21,093 open surgery). There were no significant differences between the two procedures in terms of postoperative pancreatic fistula, Post-pancreatectomy haemorrhage, lymph node yield, and operative time. However, patients undergoing robotic-assisted surgery had shorter lengths of stay, lower 90-day mortality, and less estimated blood loss compared to those undergoing open surgery. The reoperation rate was higher for the robotic-assisted group. Robotic-assisted surgery for pancreatic ductal adenocarcinoma is safe and feasible. Compared to open surgery, it offers better perioperative and short-term oncologic outcomes, but with a higher risk of reoperation.

Albumin-Bilirubin (ALBI) Score and Systemic Immune-Inflammation Indexes Used As Pretreatment Outcome Predictors in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Robotic or Open Whipple Procedures: A Logistic Regression Analysis

Background Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer (PC) in the United States. In patients with resectable PC, identification of pretreatment biomarkers before surgery can help in the decision-making process by weighing the benefits of neo-adjuvant therapy, surgical procedure, and adjuvant therapy. The purpose of this study was to determine if the albumin-bilirubin (ALBI) score and immune-inflammatory marker levels can be used in combination as pretreatment predictors of mortality risk in patients undergoing the Whipple procedure (alternatively, pancreatoduodenectomy (PD)) for PDAC. Methods This retrospective study included 115 patients with PDAC who underwent open or robotic Whipple procedures between January 2013 and December 2022 at a single tertiary medical center. Logistic regression analysis was used to find the association between predictors and mortality. Machine learning algorithms were used to calculate the performance of the different models. Results Bivariate analysis showed that the variables "sex" and "body mass index (BMI)" had a potential association with mortality, although statistical significance was not achieved for sex (p = 0.07). Patients with BMIs >25 kg/m2 had a higher risk of mortality compared to patients with BMIs ≤24.9 kg/m2 (odds ratio (OR) = 2.2, 95% CI = 1.03-4.8, p = 0.04). Higher (more positive) ALBI scores (>-2.24) were also associated with increased mortality risk (OR = 4.6, 95% CI = 2-10.5, p = 0.0003). When the cutoff values of the inflammatory markers were used to categorize these variables, values greater than the cutoff values were associated with an increased risk of mortality. In the multivariate logistic regression model, an ALBI score >-2.24 (OR = 4.3, 95% CI = 1.8-10.3, p = 0.0008), neutrophil-to-lymphocyte ratio (NLR) >3.5 (OR = 3.3, 95% CI = 1.4-7.9, p = 0.007), and being a woman (OR = 2.6, 95% CI = 1.1-6.4, p = 0.03) remained influential predictors of increased mortality (c value = 0.77). Conclusion The ALBI score and the NLR are easily accessible markers; their use, combined with a patient's sex, can provide useful pre-surgical information regarding mortality risk after PD. This can aid in treatment planning as well as expedite decisions about the type of Whipple procedure, adjuvant therapy, and surveillance, which can subsequently improve a patient's outcomes and survival.