Application of minimally invasive pancreatic surgery: an Italian survey

Expanding the utility of robotics for pancreaticoduodenectomy: a 10-year review and comparison to international benchmarks in pancreatic surgery

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is an emerging alternative to open pancreaticoduodenectomy (OPD). Although RPD offers various theoretical advantages, it is used in less than 10% of all pancreaticoduodenectomies. The aim of this study was to report our 10-year experience and compare RPD outcomes with international benchmarks for OPD.

METHODS

A retrospective review of a prospectively maintained institutional database was performed of consecutive patients who underwent RPD between January 2011 and December 2021. Patients were categorized into low-risk and high-risk groups according to the selection criteria set by the benchmark study. Their outcomes were compared to the international benchmark cut off values. Outcomes were then evaluated over time to identify improvements in practice and establish a learning curve.

RESULTS

Of 201 RPDs, 36 were low-risk and 165 high-risk patients. Compared to the OPD benchmarks, outcomes of low-risk patients were within the cutoff values. High-risk patients were outside the cutoff for blood transfusions (26% vs. ≤ 23%), overall complications (78% vs. ≤ 73%), grade I-II complications (68% vs. ≤ 62%), and readmissions (22% vs ≤ 21%). Oncologic outcomes for high-risk patients were within benchmark cutoffs. Cases at the end of the learning curve included more pancreatic cancer (42% from 17%) and fewer low-risk patients (10% from 24%) than those at the beginning. After 41 RPD there was a decline in conversion rates and operative time. Between 95 and 143 cases operative time, transfusion rates, and LOS declined significantly. Complications did not differ over time.

CONCLUSION

RPD yields results comparable to the established benchmarks in OPD in both low- and high-risk patients. Along the learning curve, RPD evolved with the inclusion of more high-risk cases while outcomes remained within benchmarks. Addition of a robotic HPB surgery fellowship did not compromise outcomes. These results suggest that RPD may be an option for high-risk patients at specialized centers.

401 consecutive minimally invasive distal pancreatectomies: lessons learned from 20 years of experience

BACKGROUND

This study aimed to discuss and report the trend, outcomes, and learning curve effect after minimally invasive distal pancreatectomy (MIDP) at two high-volume centres.

METHODS

Patients undergoing MIDP between January 1999 and December 2018 were retrospectively identified from prospectively maintained electronic databases. The entire cohort was divided into two groups constituting the "early" and "recent" phases. The learning curve effect was analyzed for laparoscopic (LDP) and robotic distal pancreatectomy (RDP). The follow-up was at least 2 years.

RESULTS

The study population included 401 consecutive patients (LDP n = 300, RDP n = 101). Twelve surgeons performed MIDP during the study period. Although patients were more carefully selected in the early phase, in terms of median age (49 vs. 55 years, p = 0.026), ASA class higher than 2 (3% vs. 9%, p = 0.018), previous abdominal surgery (10% vs. 34%, p < 0.001), and pancreatic adenocarcinoma (PDAC) (7% vs. 15%, p = 0.017), the recent phase had similar perioperative outcomes. The increase of experience in LDP was inversely associated with the operative time (240 vs 210 min, p < 0.001), morbidity rate (56.5% vs. 40.1%, p = 0.005), intra-abdominal collection (28.3% vs. 17.3%, p = 0.023), and length of stay (8 vs. 7 days, p = 0.009). Median survival in the PDAC subgroup was 53 months.

CONCLUSION

In the setting of high-volume centres, the surgical training of MIDP is associated with acceptable rates of morbidity. The learning curve can be largely achieved by several team members, improving outcomes over time. Whenever possible resection of PDAC guarantees adequate oncological results and survival.

A worldwide survey on proctological practice during COVID-19 lockdown (ProctoLock 2020): a cross-sectional analysis

AIM

Proctology is one of the surgical specialties that has suffered the most during COVID-19 pandemic. Using a cross-sectional non-incentivised World Wide Web survey, we aimed to snapshot the current status of proctological practice in six world regions.

METHOD

Surgeons affiliated to renowned scientific societies with an interest in coloproctology were invited to join the survey. Members of the ProctoLock Working Group enhanced recruitment by direct invitation. The predictive power of respondents' and hospitals' demographics on the change of status of surgical and outpatient activities was calculated.

RESULTS

Respondents (n = 1050) were mostly men (79%), with a mean age of 46.9 years, at consultant level (79%), practising in academic hospitals (53%) offering a dedicated proctology service (68%). A total of 119 (11%) tested positive for SARS-CoV-2. The majority (54%) came from Europe. Participants from Asia reported a higher proportion of unaltered practice (17%), while those from Europe had the highest proportion of fully stopped practice (20%). The likelihood of ongoing surgical practice was higher in men (OR 1.54, 95% CI 1.13-2.09; P = 0.006), in those reporting readily availability of personal protective equipment (PPE) (OR 1.40, 1.08-1.42; P = 0.012) and in centres that were partially or not at all involved in COVID-19 care (OR 2.95, 2.14-4.09; P < 0.001). This chance decreased by 2% per year of respondent's age (P = 0.001).

CONCLUSION

Several factors including different screening policies and resource capacity affected the current status of proctological practice. This information may help health authorities to formulate effective preventive strategies to limit curtailment of care of these patients during the pandemic.

Perspectives from Italy during the COVID-19 pandemic: nationwide survey-based focus on minimally invasive HPB surgery

The safety of minimally invasive procedures during COVID pandemic remains hotly debated, especially in a country, like Italy, where minimally invasive techniques have progressively and pervasively entered clinical practice, in both the hepatobiliary and pancreatic community. A nationwide snapshot of the management of HPB minimally invasive surgery activity during COVID-19 pandemic is provided: a survey was developed and conducted within AICEP (Italian Association of HepatoBilioPancreatic Surgeons) with the final aim of conveying the experience, knowledge, and opinions into a unitary report enabling more efficient crisis management. Results from the survey (81 respondents) show that, in Italian hospitals, minimally invasive surgery maintains its role despite the COVID-19 pandemic, with the registered reduction of cases being proportional to the overall reduction of the HPB surgical activity. Respondents agree that the switch from minimally invasive to open technique can be considered as a valid option for cases with a high technical complexity. Several issues merit specific attention: screening for virus positivity should be universally performed; only expert surgical teams should operate on positive patients and specific technical measures to lower the biological risk of contamination during surgery must be followed. Future studies specifically designed to establish the true risks in minimally invasive surgery are suggested. Furthermore, a standard and univocal process of prioritization of patients from Regional Healthcare Systems is advisable.

The Italian National Registry for minimally invasive pancreatic surgery: an initiative of the Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS)

The value of minimally invasive pancreatic surgery (MIPS) is still uncertain, despite the growing number of publications, including reviews and meta-analyses, and the quick diffusion of these procedures worldwide. The Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS) was created under the auspices of three Scientific Societies: Associazione Italiana Studio Pancreas (AISP), Associazione Italiana Chirurgia Epato-Bilio-Pancreatica (AICEP, former IT-IHPBA), and Società Italiana di Chirurgia Endoscopica (SICE). The main aim of IGoMIPS is to develop and implement a national registry for MIPS. IGoMIPS was founded on February 22, 2019 in Pisa. The IGoMIPS registry became operational in September 2019, following approval by the Ethic Committees of founding Institutions, inscription into the Registry of Patient Registries (RoPR), and a wrap-up meeting held in Bologna during the Annual Congress of the Italian Surgical Society. During this meeting IGoMIPS members approved that the Italian Registry will provide data to the European Registry, while retaining the right to analyze and publish Italian data. An audience survey was also conducted to obtain information on perceived value and current implementation of MIPS in founding Institutions. MIPS is performed in 94.7% of IGoMIPS centers, including pancreaticoduodenectomy in 42.1%. Robotic assistance was employed in 52.6% of Institutions. The annual volume of MIPS was 6-10 cases in 38.9% of the centers, 11-20 cases in 16.7%, 21-30 cases in 22.2%, and > 30 cases in 22.2%. The registry was felt to be extremely important for both safety improvement and educational purposes by 94.5% of the centers.

Hybrid pancreatoduodenectomy in laparoscopic and robotic surgery: a single-center experience in China

BACKGROUND

Minimally invasive surgery is beneficial for pancreatic surgery, and the indication has been expanded to pancreatoduodenectomy (PD). The aim of this study was to share our experiences with hybrid PD in laparoscopic and robotic surgery.

METHODS

Sixty-four patients underwent hybrid PD in which specimen resection and gastrojejunostomy were performed through the laparoscopic route and pancreatojejunostomy and hepaticojejunostomy were performed via a robotic approach by the same surgeon at a single institution between July 2016 and June 2019. The primary endpoint was complications; secondary endpoints were operative time (OT), the length of hospital stay, and blood loss. The data for the patients were retrospectively obtained from electrical medical records.

RESULTS

All patients underwent surgery with the hybrid procedure. The mean OTs and estimated blood loss (EBL) were 309.7 ± 77.6 min (range 17-620 min), 160 ± 31.7 mL (range 50-800 mL). The mean number of lymph nodes retrieved was 7.3 ± 6.7 (range 0-37), and that among 45 malignant cases was 8.42 ± 6.7 (range 1-37). The average length of postoperative stay in the hospital was 11.14 ± 7.03 days (range 6-47 days). Clinically relevant postoperative pancreatic fistulas (POPFs) occurred in 39 (60.9%) cases, and most were biochemical leak POPF (29 cases, 45.3%); only 10 (15.6%) cases were grade B/C (8 cases were Grade B and 2 cases were Grade C treated with digital subtraction angiography). Bile leakage occurred in 2 (3.1%) patients. One (1.5%) patient had a gastric fistula, and 3 (4.7%) developed postoperative delayed gastric emptying categorized as International Study Group of Pancreatic Surgery (ISGPS) Grade A. Three (4.7%) patients were readmitted for postoperative bleeding, and 2 (3.1%) died within 30 days.

CONCLUSION

Hybrid PD with laparoscopic and robot surgery is safe and feasible. OT can be reduced by switching from the laparoscopic approach to the robotic procedure at the appropriate timepoint.