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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

What are the true benefits of robotic pancreaticoduodenectomy for patients with pancreatic cancer?

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, and multimodal treatment including high-quality surgery can improve survival outcomes. Pancreaticoduodenectomy (PD) has evolved with minimally invasive approaches including the implementation of robotic PD (RPD). In this special report, we review the literature whilst evaluating the 'true benefits' of RPD compared to open approach for the treatment of PDAC.

AREAS COVERED

We have performed a mini-review of studies assessing PD approaches and compared intraoperative characteristics, perioperative outcomes, post-operative complications and oncological outcomes.

EXPERT OPINION

RPD was associated with similar or longer operative times, and reduced intra-operative blood loss. Perioperative pain scores were significantly lower with shorter lengths of stay with the robotic approach. With regards to post-operative complications, post-operative pancreatic fistula rates were similar, with lower rates of clinically relevant fistulas after RPD. Oncological outcomes were comparable or superior in terms of margin status, lymph node harvest, time to chemotherapy and survival between RPD and OPD. In conclusion, RPD allows safe implementation of minimally invasive PD. The current literature shows that RPD is either equivalent, or superior in certain aspects to OPD. Once more centers gain sufficient experience, RPD is likely to demonstrate clear superiority over alternative approaches.

Effect of insurance status on perioperative outcomes after robotic pancreaticoduodenectomy: a propensity-score matched analysis

The influence of Medicaid or being uninsured is prevailingly thought to negatively impact a patient's socioeconomic and postoperative course, yet little has been published to support this claim specifically in reference to robotic pancreaticoduodenectomy. This study was undertaken to determine impact of health insurance type on perioperative outcomes in patients undergoing robotic pancreaticoduodenectomy. Following IRB approval, we prospectively followed 364 patients who underwent robotic pancreaticoduodenectomy. Patients were stratified by insurance status (i.e., Private, Medicare, and Medicaid/Uninsured); 100 patients were 2:2:1 propensity-score matched by age, BMI, ASA class, pathology, 8th edition AJCC staging, and tumor size. Perioperative variables were compared utilizing contingency testing and ANOVA. Statistical significance was accepted at a p-value ≤ 0.05 and data are presented as median (mean ± SD). The 100 patients undergoing propensity-score matching were 64 (65 ± 9.1) years old with a BMI of 27 (27 ± 4.9) kg/m2 and ASA class of 3 (3 ± 0.5). Operative duration was 421 (428 ± 105.9) minutes and estimated blood loss was 200 (385 ± 795.0) mL. There were 4 in-hospital deaths and 8 readmissions within 30 days of discharge. Total hospital cost was $32,064 (38,014 ± 22,205.94). After matching, no differences were found in pre-, intra-, and short-term postoperative variables among patients with different insurances, including hospital cost and time to initiate adjuvant treatment, which was 8 (9 ± 7.9) weeks for patients with malignant disease. In our hepatopancreaticobiliary program, health insurance status did not impact perioperative outcomes or hospital costs. These findings highlight that financial coverage does not influence quality of perioperative care, reinforcing the equity of robotic surgery.

International consensus guidelines on robotic pancreatic surgery in 2023

Background

With the rapid development of robotic surgery, especially for the abdominal surgery, robotic pancreatic surgery (RPS) has been applied increasingly around the world. However, evidence-based guidelines regarding its application, safety, and efficacy are still lacking. To harvest robust evidence and comprehensive clinical practice, this study aims to develop international guidelines on the use of RPS.

Methods

World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and the AGREE-II instrument were used to establish the Guideline Steering Group, Guideline Development Group, and Guideline Secretary Group, formulate 19 clinical questions, develop the recommendations, and draft the guidelines. Three online meetings were held on 04/12/2020, 30/11/2021, and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts. All the experts focusing on minimally invasive surgery from America, Europe and Oceania made great contributions to this consensus guideline.

Results

After a systematic literature review 176 studies were included, 19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence.

Conclusions

The international RPS guidelines can guide current practice for surgeons, patients, medical societies, hospital administrators, and related social communities. Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

A modified Blumgart anastomosis with a simple and practicable procedure after laparoscopic pancreaticoduodenectomy: our center's experience

BACKGROUND

Laparoscopic pancreaticoduodenectomy(LPD) has become the goal of lots of minimally invasive surgical centers in recent years. Postoperative pancreatic fistula(POPF) is still the barrier to attaining the above goal. Thus, improving anastomosis techniques to reduce the rate of POPF has been a hotspot of surgery. Blumgart pancreaticojejunostomy is considered one of the best anastomosis procedures, with low rates of POPF. However, the original Blumgart pancreaticojejunostomy method is not easy for laparoscopic operation. In consequence, we modified a Blumgart pancreaticojejunostomy technique with a simple and practicable procedure and applied to LPD.

METHODS

We collected and retrospectively analyzed the perioperative clinical data of patients who underwent modified Blumgart anastomosis from February 2017 to September 2022. The above patients included 53 cases in open pancreaticojejunostomy(OPD) and 58 cases in LPD. After propensity score matching, 44 cases were included for comparison in each group.

RESULTS

After propensity score matching, the average time for pancreaticojejunostomy was about 30 min in the LPD group. The Clinically relevant POPF(CR-POPF) rate was 9.1%. The length of postoperative hospitalization was 13.1 days. Compared with the OPD group, The CR-POPF rate in the LPD group are not significant differences. But the postoperative length of hospital stay was significantly shorter in the LPD group. Besides, there were no other severely postoperative complications between two groups.

CONCLUSION

The modified Blumgart anastomosis technique applied to LPD in our Center not only has simple and convenient properties but also low rate of CR-POPF. And this method may be a good choice for surgeons to begin to carry out LPD.

Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE.

DATA SOURCES

Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles.

RESULTS

In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE.

CONCLUSIONS

Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.

Effect of laparoscopic pancreaticoduodenectomy on the incidence of surgical-site wound infection: A meta-analysis

A meta-analysis was conducted to assess the impact of robotic and laparoscopic pancreaticoduodenectomies on postoperative surgical site wound infections. A comprehensive computerised search of databases, such as PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang Data, was performed to identify studies comparing robotic pancreaticoduodenectomy (PD) with laparoscopicPD. Relevant studies were searched from the inception of the database construction until April 2023. The meta-analysis outcomes were analysed using odds ratios (OR) with corresponding 95% confidence intervals (CI). The RevMan 5.4 software was used for the meta-analysis. The findings of the meta-analysis showed that patients who underwent laparoscopic PD had a significantly lower incidence of surgical-site wound (16.52% vs. 18.92%, OR: 0.78, 95% CI: 0.68-0.90, P = .0005), superficial wound (3.65% vs. 7.57%, OR: 0.51, 95% CI: 0.39-0.68, P < .001), and deep wound infections (1.09% vs. 2.23%, OR: 0.53, 95% CI: 0.34-0.85, P = .008) than those who received robotic PD. However, because of variations in sample size between studies, some studies suffered from methodological quality deficiencies. Therefore, further validation of this result is needed in future studies with higher quality and larger sample sizes.

Effect of gastric ischemic conditioning prior to esophagectomy: systematic review and meta-analysis

Ischemia at the anastomotic site is thought to be a protagonist in the development of anastomosis-related complications while different strategies to overcome this problem have been reported. Gastric ischemic conditioning (GIC) prior to esophagectomy has been described with this intent. Evaluate the effect of GIC on anastomotic complications after esophagectomy. Scopus, Web of Science, MEDLINE, and PubMed were investigated up to March 31st, 2023. We considered articles that appraised short-term outcomes after GIC vs. no GIC in patients undergoing esophagectomy. Anastomotic leak (AL), anastomotic stricture (AS), and gastric conduit necrosis (GCN) were primary outcomes. Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures, whereas 95% confidence intervals (95% CIs) were used to calculate related inference. Fourteen studies (1760 patients) were included. Of those, 732 (41.6%) underwent GIC, while 1028 (58.4%) underwent one-step esophagectomy. Compared with no GIC, GIC was related to a reduced RR for AL (R RR = 0.63; 95% CI 0.47-0.86; p < 0.01) and AS (RR = 0.51; 95% CI 0.29-0.91; p = 0.02), whereas no differences were found for GCN (RR = 0.56; 95% CI 0.19-1.61; p = 0.28). Postoperative pneumonia (RR = 1.09; p = 0.99), overall complications (RR = 0.87; p = 0.19), operative time (SMD - 0.58; p = 0.07), hospital stay (SMD 0.66; p = 0.09), and 30-day mortality (RR = 0.69; p = 0.22) were comparable. GIC prior to esophagectomy seems associated with a reduced risk for AL and AS. Further studies are necessary to identify the subset of patients who can benefit from this procedure, the optimal technique, and the timing of GIC prior to esophagectomy.

A more radical perspective on surgical approach and outcomes in pancreatic cancer-a narrative review

Background and Objective

Pancreatic adenocarcinoma remains a dismal disease and is expected to become an even greater burden in the near future. This review focuses on the different surgical aspects for pancreaticoduodenectomy (PD), distal and total pancreatectomy (TP), incorporating lessons from both the western and eastern visions in treating pancreatic cancer.

Methods

We conducted an extensive literature review through PubMed, prioritizing papers published in the last 5 years, but older emblematic papers were also included. We included articles that explored the treatment of pancreatic adenocarcinoma, with focus on the surgical aspect and strategies to improve outcomes. References of selected articles were also reviewed to identify any missed studies. Only papers in English were included.

Key Content and Findings

As evidence continues to build, it is clear that both systemic and surgical therapies have a fundamental and complementary role. State of art surgical treatment encompasses complete mesopancreas excision for radical lymphadenectomy. Preoperative planning of dissection planes, extensive knowledge of vascular anatomic variations, oncological principles and expertise for vascular resections are mandatory to perform a more radical operation, in pursuit of improved outcomes.

Conclusions

Based on current data, patient selection remains key and a more radical surgical approach brings more accomplishing results bringing as to believe that more is better.

Minimally invasive versus open pancreatoduodenectomy for pancreatic ductal adenocarcinoma: Individual patient data meta-analysis of randomized trials

OBJECTIVE

Assessment of minimally invasive pancreatoduodenectomy (MIPD) in patients with pancreatic ductal adenocarcinoma (PDAC) is scarce and limited to non-randomized studies. This study aimed to compare oncological and surgical outcomes after MIPD compared to open pancreatoduodenectomy (OPD) for patients after resectable PDAC from published randomized controlled trials (RCTs).

METHODS

A systematic review was performed to identify RCTs comparing MIPD and OPD including PDAC (Jan 2015-July 2021). Individual data of patients with PDAC were requested. Primary outcomes were R0 rate and lymph node yield. Secondary outcomes were blood-loss, operation time, major complications, hospital stay and 90-day mortality.

RESULTS

Overall, 4 RCTs (all addressed laparoscopic MIPD) with 275 patients with PDAC were included. In total, 128 patients underwent laparoscopic MIPD and 147 patients underwent OPD. The R0 rate (risk difference(RD) -1%, P = 0.740) and lymph node yield (mean difference(MD) +1.55, P = 0.305) were comparable between laparoscopic MIPD and OPD. Laparoscopic MIPD was associated with less perioperative blood-loss (MD -91ml, P = 0.026), shorter length of hospital stay (MD -3.8 days, P = 0.044), while operation time was longer (MD +98.5 min, P = 0.003). Major complications (RD -11%, P = 0.302) and 90-day mortality (RD -2%, P = 0.328) were comparable between laparoscopic MIPD and OPD.

CONCLUSIONS

This individual patient data meta-analysis of MIPD versus OPD in patients with resectable PDAC suggests that laparoscopic MIPD is non-inferior regarding radicality, lymph node yield, major complications and 90-day mortality and is associated with less blood loss, shorter hospital stay, and longer operation time. The impact on long-term survival and recurrence should be studied in RCTs including robotic MIPD.

Innovative suture technique for robotic hepaticojejunostomy: double-layer interrupted sutures

PURPOSE

Biliary reconstruction remains a technically demanding and complicated procedure in minimally invasive hepatopancreatobiliary surgeries. No optimal hepaticojejunostomy (HJ) technique has been demonstrated to be superior for preventing biliary complications. This study aimed to investigate the feasibility of our unique technique of posterior double-layer interrupted sutures in robotic HJ.

METHODS

We performed a retrospective analysis of a prospectively collected database. Forty-two patients who underwent robotic pancreatoduodenectomy using this technique between September 2020 and November 2022 at our center were reviewed. In the posterior double-layer interrupted technique, sutures were placed to bite the bile duct, posterior seromuscular layer of the jejunum, and full thickness of the jejunum.

RESULTS

The median operative time was 410 (interquartile range [IQR], 388-478) min, and the median HJ time was 30 (IQR, 28-39) min. The median bile duct diameter was 7 (IQR, 6-10) mm. Of the 42 patients, one patient (2.4%) had grade B bile leakage. During the median follow-up of 12.6 months, one patient (2.4%) with bile leakage developed anastomotic stenosis. Perioperative mortality was not observed. A surgical video showing the posterior double-layer interrupted sutures in the robotic HJ is included.

CONCLUSIONS

Posterior double-layer interrupted sutures in robotic HJ provided a simple and feasible method for biliary reconstruction with a low risk of biliary complications.

Comparative analysis of clinical efficacy between laparoscopic and open pancreaticoduodenectomy

Laparoscopic pancreaticoduodenectomy (LPD) is a technically demanding procedure but is gradually gaining acceptance in clinical practice. This study was performed to compare the short-term outcomes of LPD with open pancreaticoduodenectomy (OPD). The perioperative data of the patients who underwent LPD (n = 25) and OPD (n = 40) from January 1, 2017 to December 31, 2021 at Zhangjiagang Hospital Affiliated to Soochow University were collected and retrospectively analyzed. All patients received R0 resection, and none of the patients died within the perioperative period. The preoperative data (gender, age, body mass index [BMI], and preoperative bilirubin), the intraoperative data (operative time, number of retrieved lymph nodes), and postoperative data (level 1 monitoring time, postoperative fluid diet time, postoperative fluid feeding time, and hospitalization cost) were comparable between the 2 groups (P > .05). The estimated blood loss, abdominal drainage tube removal time, postoperative hospital stay, catheter removal time, and analgesic drug use were significantly lesser in the LPD group, when compared to the OPD group (P < .05). LPD is safe and feasible. Compared to OPD, LPD has less surgical trauma, less intraoperative bleeding, and faster postoperative recovery.

How to deal with right hepatic artery coming from the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review

BACKGROUND

Anatomical variations in the liver arterial supply are quite common and can affect the surgical strategy when performing a minimally invasive pancreaticoduodenectomy (MIPD). Their presence must be preemptively detected to avoid postoperative liver and biliary complications.

DATA SOURCES

Following the PRISMA guidelines and the Cochrane protocol we conducted a systematic review on the management of an accessory or replaced right hepatic artery (RHA) arising from the superior mesenteric artery when performing an MIPD.

RESULTS

Five studies involving 118 patients were included. The most common reported management of the aberrant RHA was conservative (97.0%); however, patients undergoing aberrant RHA division without reconstruction did not develop liver or biliary complications. No differences in postoperative morbidity or long-term oncological related overall survival were reported in all the included studies when comparing MIPD in patients with standard anatomy to those with aberrant RHA.

CONCLUSIONS

MIPD in patients with aberrant RHA is feasible without increase in morbidity and mortality. As preoperative strategy is crucial, we suggested planning an MIPD with an anomalous RHA focusing on preoperative vascular aberrancy assessment and different strategies to reduce the risk of liver ischemia.

Robotic versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis

BACKGROUND

Pancreaticoduodenectomy (PD) is complex procedure with high morbidity in the elderly. This retrospective study aimed to compare post-operative outcomes in patients ≥75 years of age who underwent robot-assisted (RA)PD and open PD.

METHODS

We analyzed 2502 patients ≥75 years of age who underwent PD from 2015 to 2018 in the National Surgical Quality Improvement Program (NSQIP) database. RAPD and open PD patients were propensity score matched 1:5 to assess the 30-day outcomes of interest: postoperative complications, length of stay, discharge destination, and readmissions.

RESULTS

Of 725 matched patients, 110 underwent RAPD, 615 OPD, and 12 were converted to an open operation. Post-operative outcomes were largely similar between cohorts. RAPD was associated a shorter length of stay (median 8 days, interquartile range [IQR] 6 to 11) than OPD (median 8 days, IQR 7 to 13) (p = 0.003). However, RAPD was associated with more readmissions (28.1% vs. 17.7%; p = 0.02).

CONCLUSIONS

RAPD in patients ≥75 years of age appears to be safe and has a similar complication profile to open PD. Randomized or well-designed prospective matched studies are needed to confirm these findings.

Development of biotissue training models for anastomotic suturing in pancreatic surgery

BACKGROUND

Anastomotic suturing is the Achilles heel of pancreatic surgery. Especially in laparoscopic and robotically assisted surgery, the pancreatic anastomosis should first be trained outside the operating room. Realistic training models are therefore needed.

METHODS

Models of the pancreas, small bowel, stomach, bile duct, and a realistic training torso were developed for training of anastomoses in pancreatic surgery. Pancreas models with soft and hard textures, small and large ducts were incrementally developed and evaluated. Experienced pancreatic surgeons (n = 44) evaluated haptic realism, rigidity, fragility of tissues, and realism of suturing and knot tying.

RESULTS

In the iterative development process the pancreas models showed high haptic realism and highest realism in suturing (4.6 ± 0.7 and 4.9 ± 0.5 on 1-5 Likert scale, soft pancreas). The small bowel model showed highest haptic realism (4.8 ± 0.4) and optimal wall thickness (0.1 ± 0.4 on -2 to +2 Likert scale) and suturing behavior (0.1 ± 0.4). The bile duct models showed optimal wall thickness (0.3 ± 0.8 and 0.4 ± 0.8 on -2 to +2 Likert scale) and optimal tissue fragility (0 ± 0.9 and 0.3 ± 0.7).

CONCLUSION

The biotissue training models showed high haptic realism and realistic suturing behavior. They are suitable for realistic training of anastomoses in pancreatic surgery which may improve patient outcomes.

Prospective cohort study on short-term outcomes of 3D-laparoscopic pancreaticoduodenectomy with stented pancreaticogastrostomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy, either laparoscopic or robotic, is a high-risk procedure with demanding learning curve. The aim of this prospective cohort study was to evaluate short-term clinical and oncologic outcomes of 3D-laparoscopic pancreaticoduodenectomy (3dLPD) with stented pancreaticogastrostomy (sPG) and Roux-en-Y gastroenterostomy (ryGES).

METHODS

Between March 2016 and July 2021, 347 consecutive patients underwent 3dLPD for confirmed or suspected pancreatic or periampullary tumors. Pancreatic duct diameter measured 3 mm or less in 221 (64%) and pancreatic texture was soft in 191 (55%) patients. Simultaneous resection of the superior mesenteric or portal vein was performed in 52 (15%) patients.

RESULTS

Postoperative complications were observed in 189 (54%) patients, with severe complications (Clavien-Dindo grade > 2) in 68 (20%) including 4 (1.2%) deaths. Clinically relevant pancreatic fistula (cPOPF) occurred in 88 (25%), hemorrhage in 25 (7%), and bile leakage in 10 (3%) patients. Clinical pancreatic fistula was strongly associated with soft pancreatic texture and small pancreatic duct diameter (p < 0.001) and managed by endoscopic trans-gastric drainage in 34 (38.6%) patients, reoperation in 12 (13.6%), and ICU admission in 11 (12.5%). The remaining 31 (35%) patients with cPOPF were managed without invasive intervention. Median length of hospital stay after surgery was 13 (range 5-112; IQR 8-18) days. In pancreatic adenocarcinoma (PDAC) the R0-resection rate was 66/186 (36%), R1-indirect 95/186 (51%), and R1-direct 25 (13%). Median number of locoregional lymph nodes retrieved in PDAC was 21 (IQR 15-28). R0-resection rate for malignancy other than PDAC was 78/86 (91%) with a median of 16 (IQR 12-22) locoregional lymph nodes retrieved.

CONCLUSION

3dLPD with sPG and ryGES is associated with 1.2% mortality and 25% cPOPF. About two-third of patients with cPOPF were managed with some type of invasive intervention, whereas the intraoperatively placed drains sufficed in one-third of patients.

CLINICAL TRIAL REGISTRY

Clinicaltrials.gov NCT02671357.

A chronicle of the pancreatoduodenectomy technique development - from the surgeon's hand to the robotic arm

BACKGROUND

Pancreatoduodenectomy (PD) remains one of the most challenging abdominal surgical procedures.

METHODS

A review of the literature regarding the history of PD, starting from the pioneers, Walter Kausch and Alan Whipple, through the great surgeons of the last century, up to the present day.

RESULTS

The greatest development of the PD technique took place at the end of the twentieth century. Over the last 40 years, there have been huge technological advances in medicine, which have resulted in the introduction of laparoscopic and robotic techniques for abdominal surgery. However, it turns out that PD is still performed as it used to be "by the surgeon's hand" via laparotomy rather than using the most modern robot or laparoscope and is currently recommended by experts for treatment of pancreatic head cancer (PHC). This is mainly caused by not many data comparing these three PD methods. Moreover, increasingly the results achieved by surgeons advanced in minimally invasive pancreatic resections are comparable to or even better than those achieved by the open method in reference centres. Robot-assisted PD appears to be gaining an advantage over laparoscopic technique in the efficacy of PHC treatment. The obstacles most inhibiting the use of surgical robotics are the high cost of the device and procedure, and the long learning curve. A bright future lies ahead for both methods, with the robotic technique in the forefront.

CONCLUSIONS

Despite significant advances in access and surgical technique, PD remains a challenging surgical procedure requiring a big surgeon's experience.

Laparoscopic versus open pancreaticoduodenectomy for pancreatic and periampullary tumor: A meta-analysis of randomized controlled trials and non-randomized comparative studies

Objective

This meta-analysis compares the perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to those of open pancreaticoduodenectomy (OPD) for pancreatic and periampullary tumors.

Background

LPD has been increasingly applied in the treatment of pancreatic and periampullary tumors. However, the perioperative outcomes of LPD versus OPD are still controversial.

Methods

PubMed, Web of Science, EMBASE, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) and non-randomized comparative trials (NRCTs) comparing LPD versus OPD for pancreatic and periampullary tumors. The main outcomes were mortality, morbidity, serious complications, and hospital stay. The secondary outcomes were operative time, blood loss, transfusion, postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), bile leak (BL), delayed gastric emptying (DGE), lymph nodes harvested, R0 resection, reoperation, and readmission. RCTs were evaluated by the Cochrane risk-of-bias tool. NRCTs were assessed using a modified tool from the Methodological Index for Non-randomized Studies. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42022338832).

Results

Four RCTs and 35 NRCTs concerning a total of 40,230 patients (4,262 LPD and 35,968 OPD) were included. Meta-analyses showed no significant differences in mortality (OR 0.91, p = 0.35), serious complications (OR 0.97, p = 0.74), POPF (OR 0.93, p = 0.29), PPH (OR 1.10, p = 0.42), BL (OR 1.28, p = 0.22), harvested lymph nodes (MD 0.66, p = 0.09), reoperation (OR 1.10, p = 0.41), and readmission (OR 0.95, p = 0.46) between LPD and OPD. Operative time was significantly longer for LPD (MD 85.59 min, p < 0.00001), whereas overall morbidity (OR 0.80, p < 0.00001), hospital stay (MD -2.32 days, p < 0.00001), blood loss (MD -173.84 ml, p < 0.00001), transfusion (OR 0.62, p = 0.0002), and DGE (OR 0.78, p = 0.002) were reduced for LPD. The R0 rate was higher for LPD (OR 1.25, p = 0.001).

Conclusions

LPD is associated with non-inferior short-term surgical outcomes and oncologic adequacy compared to OPD when performed by experienced surgeons at large centers. LPD may result in reduced overall morbidity, blood loss, transfusion, and DGE, but longer operative time. Further RCTs should address the potential advantages of LPD over OPD.

Systematic review registration

PROSPERO, identifier CRD42022338832.

Neuraxial anesthesia in hepato-pancreatic-bilio surgery: a first western pilot study of 46 patients

The most common anesthetic approach in hepato-pancreatic-biliary (HPB) surgery is general anesthesia (GA), but it may result in increased morbidity and mortality and peri-operative risks especially in frail patients. The aim of this study was to assess the safety and effectiveness of neuraxial anesthesia (NA) in HPB in a pilot clinical series. This analysis was conducted on 46 consecutive patients undergoing HPB surgery in an Italian Tertial referral center. Data were prospectively collected and retrospectively analyzed. continuous spinal anesthesia (CSA), combined spino-epidural anesthesia (CSEA) and peridural anesthesia (PA) were used in major and minor hepatectomies and bilio-pancreatic surgery instead of GA. NA was evaluated by analyzing the surgical and anesthesiological short-term outcomes. 46 patients were considered eligible for the study between February 2018 and May 2020. The average age was 69.07 (±  9.95) years. 22 were males and 24 were females. According to the ASA score, 19 (41.30%) patients had ASA II, 22 (47.83%) had ASA III and 5 (10.87%) had ASA IV. 22 (47.83%) patients underwent CSA, 20 (43.48%) CSEA and 4 (8.69%) PA. We performed 8 major and 19 minor hepatectomies, 7 bilio-digestive derivations, 5 Whipple procedures, 4 iatrogenic biliary duct injuries, 2 splenopancreatectomies and 1 hepatic cyst fenestration. Clavien-Dindo ≥ 3 was observed in 3 patients. The conversion rate to endotracheal intubation occurring in 3 of 46 (6.52%) patients. After surgery, no local or pulmonary complications and delirium were reported in our series. The present study demonstrates that NA is a safe and feasible option in selected patients, if performed in referral centers by well-trained anaesthesiologists and surgeons.

Robotic pancreatoduodenectomy: trends in technique and training challenges

BACKGROUND

More complex cases are being performed robotically. This study aims to characterize trends in robotic pancreatoduodenectomy (RPD) over time and assess opportunities for advanced trainees.

METHODS

Using the ACS-NSQIP database from 2014 to 2019, PD cases were characterized by operative approach (open-OPN, laparoscopic-LAP, robotic-ROB). Proficiency and postoperative outcomes were described by approach over time.

RESULTS

24,268 PDs were identified, with the ROB approach increasing from 2.8% to 7.5%. Unplanned conversion increased over time for LAP (27.7-39.0%, p = 0.003) but was unchanged for ROB cases (14.8-14.7%, p = 0.257). Morbidity increased for OPN PD (35.5-36.8%, p = 0.041) and decreased for ROB PD (38.7-30.3%, p = 0.010). Mean LOS was lower in ROB than LAP/OPN (9.5 vs. 10.9 vs. 10.9 days, p < 0.00001). Approximately, 100 AHPBA, SSO, and ASTS fellows are being trained each year in North America; however, only about 5 RPDs are available per trainee per year which is far below that recommended to achieve proficiency.

CONCLUSION

Over a 6-year period, a significant increase was observed in the use of RPD without a concomitant increase in conversion rates. RPD was associated with decreased morbidity and length of stay. Despite this shift, the number of cases being performed is not adequate for all fellows to achieve proficiency before graduation.

Pancreatic head cancer - Current surgery techniques

Pancreatic head cancer is a highly fatal disease. For now, surgery offers the only potential long-term cure albeit with a high risk of complications. However, the progress of surgical technique during the past decade has resulted in 5-year survival approaching 30% after resection and adjuvant chemotherapy. This paper presents current data on the recommended extent of lymphadenectomy, the resection margin, on the definition of resectable and borderline resectable tumors and mesopancreas. Surgical techniques proposed to improve PD are presented: the artery first approach, the uncinate process first, the mesopancreas first approach, the triangle operation, periarterial divestment, and multiorgan resection.

Total laparoscopic pancreaticoduodenectomy with left posterior superior mesenteric artery first-approach and plexus-preserving circumferential lymphadenectomy: step-by-step technique with a surgical case report (with video)

Introduction

Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of the Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “superior mesenteric artery (SMA)-first approach,” “systematic mesopancreas dissection,” and “circumferential lymphadenectomy around SMA” in increasing R0 resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly.

Case presentation

Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10-mm-sized mass in distal bile duct referred to as Vater’s tumor. We used 5 trocars, and the patient was placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, and lymph node groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated as well as the extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, which was 1 of 7 LN no. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative.

Conclusions

This technique was safe and effective to perform precise level 2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02730-y.

Laparoscopic Versus Open Pancreatoduodenectomy: Cost-Effectiveness Analysis

Background and Objectives: The role of laparoscopy during a pancreatoduodenectomy (PD) is not clearly defined. The purpose of this study was thus to compare the cost-effectiveness between laparoscopic pancreatoduodenectomy (LPD) and open pancreatoduodenectomy (OPD). Materials and Methods: From 2010 to 2019, 140 patients underwent PD (60 LPD and 80 OPD). After 60-60 matching, the clinical-pathological characteristics, surgical technique, and type of rehabilitation were identical in both groups. Complications, R0 resection, and cost were compared. Results: Complication rates were 48% (12% Clavien-Dindo grade 3-4) in the LPD group and 64% (22% Clavien-Dindo grade 3-4) in the OPD group. The LPD group had significantly fewer pulmonary complications (6%) than the OPD group (20%) (P = .04). The oncological quality of the R0 resection did not differ between the two groups. The operating time was 312 ± 50 minutes in the OPD group and 392 ± 75 minutes in the LPD group (P < .001). The mean length of hospital stay was significantly shorter for the LPD group (13 ± 10) days compared to the OPD group (19 ± 8) days (P = .02). The average cost of total hospital stay was significantly lower for the LPD group compared to the OPD group (P = .02). Conclusions: Despite longer operative times, LPD had fewer (pulmonary) complications and reduced hospital costs.

Robot-assisted pancreatoduodenectomy with the da Vinci Xi: can the costs of advanced technology be offset by clinical advantages? A case-matched cost analysis versus open approach

BACKGROUND

Robot-assisted pancreatoduodenectomy (RPD) has shown some advantages over open pancreatoduodenectomy (OPD) but few studies have reported a cost analysis between the two techniques. We conducted a structured cost-analysis comparing pancreatoduodenectomy performed with the use of the da Vinci Xi, and the traditional open approach, and considering healthcare direct costs associated with the intervention and the short-term post-operative course.

MATERIALS AND METHODS

Twenty RPD and 194 OPD performed between January 2011 and December 2020 by the same operator at our high-volume multidisciplinary center for robot-assisted surgery and for pancreatic surgery, were retrospectively analyzed. Two comparable groups of 20 patients (Xi-RPD-group) and 40 patients (OPD-group) were obtained matching 1:2 the RPD-group with the OPD-group. Perioperative data and overall costs, including overall variable costs (OVCs) and fixed costs, were compared.

RESULTS

No difference was reported in mean operative time: 428 min for Xi-RPD-group versus 404 min for OPD, p = 0.212. The median overall length of hospital stay was significantly lower in the Xi-RPD-group: 10 days versus 16 days, p = 0.001. In the Xi-RPD-group, consumable costs were significantly higher (€6149.2 versus €1267.4, p < 0.001), while hospital stay costs were significantly lower: €5231.6 versus €8180 (p = 0.001). No significant differences were found in terms of OVCs: €13,483.4 in Xi-RPD-group versus €11,879.8 in OPD-group (p = 0.076).

CONCLUSIONS

Robot-assisted surgery is more expensive because of higher acquisition and maintenance costs. However, although RPD is associated to higher material costs, the advantages of the robotic system associated to lower hospital stay costs and the absence of difference in terms of personnel costs thanks to the similar operative time with respect to OPD, make the OVCs of the two techniques no longer different. Hence, the higher costs of advanced technology can be partially compensated by clinical advantages, particularly within a high-volume multidisciplinary center for both robot-assisted and pancreatic surgery. These preliminary data need confirmation by further studies.

Application of intraoperative navigation in 3D laparoscopic pancreaticoduodenectomy: A case report

Laparoscopic pancreaticoduodenectomy is one of the most challenging operations in abdominal surgery, with a high risk and numerous potential complications. Laparoscopy can magnify the surgical field, improving vision, but it cannot see through and identify the internal structures of the surgical field. Intraoperative navigation is a technology currently being developed; it projects the three-dimensional (3D) image established before surgery onto the surgical area during surgery, locates the anatomical landmarks, matches the 3D image with the actual image, and then displays the relationship between the tumor and the surrounding blood vessels. The important structures such as tumors, blood vessels, bile ducts and pancreatic ducts are quickly identified. Secondary injuries are reduced, the operation speed is increased and the surgical safety is improved. The present study describes the use of surgical navigation technology in the 3D laparoscopic pancreaticoduodenectomy of a 64-year-old man. The present paper reports the treatment process of the case, the application of surgical navigation technology in the operation and discusses the advantages of surgical navigation technology in 3D laparoscopic pancreaticoduodenectomy.

Equivalency of short-term perioperative outcomes after open, laparoscopic and robotic ileal anal pouch anastomosis. Does procedure complexity override operative approach?

Background

Ileal pouch anal anastomosis is the treatment of choice for patients with chronic ulcerative colitis and familial adenomatous polyposis undergoing a proctocolectomy and desiring bowel continuity. It is a technically complex operation associated with significant morbidity and may be performed by an open, laparoscopic, or robotic approach. However, there is a paucity of data regarding the comparative perioperative outcomes between these 3 techniques outside of institutional studies.

Methods

The NSQIP targeted proctectomy data set was used to identify patients who underwent open, laparoscopic, and robotic ileal pouch anal anastomosis between 2016 and 2019. Thirty-day outcomes between different surgical approaches were compared using univariate and multivariable analysis.

Results

During the study period, 1,067 open, 971 laparoscopic, and 341 robotic ileal pouch anal anastomosis were performed. The most frequent indications were inflammatory bowel disease (64%), malignancy (18%), and familial adenomatous polyposis (7%). Mean age of the cohort was 43 ± 15 years with 43% female and 76% with body mass index ≤ 30 kg/m². Overall morbidity was 26.8% for the entire cohort with 4% anastomotic leak, 6% reoperation, 21% ileus, and 21% readmission rate. After adjusting for available confounders, operative approach was not associated with better short-term outcomes, including length of stay, overall morbidity, anastomotic leak, reoperation, incidence of ileus, and 30-day readmissions.

Conclusion

Ileal pouch anal anastomosis continues to be associated with significant postoperative morbidity regardless of operative approach. Patient-related advantages in terms of perioperative outcomes for laparoscopic and robotic platforms compared to open surgery are less pronounced in complex operations such as ileal pouch anal anastomosis.

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Ileal anal pouch anastomosis is a technically complex operation associated with significant postoperative 30-day morbidity.

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Postoperative morbidity is similar between open, laparoscopic, and robotic approaches.

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In complex operations such as ileal anal pouch anastomosis, the short-term perioperative advantages of minimally invasive approaches may not be clinically evident.

Robotic versus open pancreatic surgery: a propensity score-matched cost-effectiveness analysis

Background

Robotic pancreatic surgery (RPS) is associated with high intraoperative costs compared to open pancreatic surgery (OPS). However, it remains unclear whether several advantages of RPS such as reduced surgical trauma and a shorter postoperative recovery time could lead to a reduction in total costs outweighing the intraoperative costs. The study aimed to compare patients undergoing OPS and RPS with regards to cost-effectiveness in a propensity score-matched (PSM) analysis.

Methods

Patients undergoing OPS and RPS between 2017 and 2019 were included in this monocentric, retrospective analysis. The controlling department provided financial data (costs and revenues, net loss/profit). A propensity score-matched analysis was performed or OPS and RPS (matching criteria: age, American society of anesthesiologists (ASA) score, gender, body mass index (BMI), and type of pancreatic resection) with a caliper 0.2.

Results

In total, 272 eligible OPS cases were identified, of which 252 met all inclusion criteria and were thus included in the further analysis. The RPS group contained 92 patients. The matched cohorts contained 41 patients in each group. Length of hospital stay (LOS) was significantly shorter in the RPS group (12 vs. 19 days, p = 0.003). Major postoperative morbidity (Dindo/Clavien ≥ 3a) and 90-day mortality did not differ significantly between OPS and RPS (p > 0.05). Intraoperative costs were significantly higher in the RPS group than in the OPS group (7334€ vs. 5115€, p < 0.001). This was, however, balanced by other financial categories. The overall cost-effectiveness tended to be better when comparing RPS to OPS (net profit—RPS: 57€ vs. OPS: − 2894€, p = 0.328). Binary logistic regression analysis revealed major postoperative complications, longer hospital stay, and ASA scores < 3 were linked to the risk of net loss (i.e., costs > revenue).

Conclusions

Surgical outcomes of RPS were similar to those of OPS. Higher intraoperative costs of RPS are outweighed by advantages in other categories of cost-effectiveness such as decreased lengths of hospital stay.

Surgical Treatment of Pancreatic Ductal Adenocarcinoma

Simple Summary

Surgery is the only potential cure for pancreatic ductal adenocarcinoma and should always be combined with adjuvant chemotherapy or other multimodal treatment. Besides the advances in such multimodal approaches, there has been substantial progress in surgical techniques to especially address advanced resections. These techniques include specific operative steps, such as ‘artery first’ or ‘uncinate first’ approaches as well as techniques that allow safe vascular resection and reconstruction to achieve radical tumor removal. Most recently, also minimally-invasive and robotic approaches have been adopted for pancreatic cancer surgery; however, there is no high-level evidence on these evolving techniques especially with regards to long-term results compared to conventional surgical techniques.

Abstract

Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.

Surgical Treatment of Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.

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.