1
|
Rayman S, Ross SB, Sucandy I, Syblis C, Pattilachan TM, Christodoulou M, Rosemurgy A. Weighing the outcomes: the role of BMI in complex robotic esophageal and hepatobiliary operations. Updates Surg 2024; 76:1031-1039. [PMID: 38460102 DOI: 10.1007/s13304-024-01757-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/08/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND The correlation between body mass index (BMI) and surgical outcomes has emerged as a critical consideration in complex abdominal operations. While elevated BMI is often associated with increased perioperative risk, its specific effects on the outcomes of robotic surgeries remain inadequately explored. This study assesses the impact of BMI on perioperative variables of complex esophageal and hepatopancreaticobiliary (HPB) robotic operations. METHODS Following IRB approval, we prospectively followed 607 patients undergoing pancreaticoduodenectomy, trans-hiatal esophagectomy (THE), major liver resection or distal pancreatectomy with splenectomy, all performed robotically. Perioperative data retrieved included operative duration, estimated blood loss (EBL), intraoperative and postoperative complications, conversions to an 'open' operation and length of stay (LOS). Z scores were assigned to each variable to standardize operations, and the variables were then regressed against BMI. For illustrative purposes, data are presented as median(mean ± standard deviation). RESULTS Between 2012 and 2020, surgeries included 71 THE, 122 distal pancreatectomies with splenectomies, 129 major hepatectomies and 285 pancreaticoduodenectomies. Median age was 67(65 ± 12.5) years old, and BMI was 27(28 ± 5.5) kg/m2. Operative duration for all operations was 349(355 ± 124.5) min and had a positive correlation with increasing BMI (p = 0.004), specifically for robotic THE and robotic pancreaticoduodenectomy, with both operative durations having positive correlation with increasing BMI (p = 0.02 and p = 0.05). No significant correlation with BMI was found for EBL, intraoperative or postoperative complications, conversion to 'open' surgery, or LOS. CONCLUSION Elevated BMI is associated with longer operative durations in select robotic surgeries, such as trans-hiatal esophagectomy and pancreaticoduodenectomy, and highlights the need for strategic planning in these patients.
Collapse
Affiliation(s)
- Shlomi Rayman
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
- Department of General Surgery, Assuta Medical Center, Ashdod, Israel
- Affiliated to the Faculty of Health and Science, Ben-Gurion University, Beer-Sheba, Israel
| | - Sharona B Ross
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA.
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Cameron Syblis
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Tara M Pattilachan
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| |
Collapse
|
2
|
Nickel F, Wise PA, Müller PC, Kuemmerli C, Cizmic A, Salg GA, Steinle V, Niessen A, Mayer P, Mehrabi A, Loos M, Müller-Stich BP, Kulu Y, Büchler MW, Hackert T. Short-term Outcomes of Robotic Versus Open Pancreatoduodenectomy: Propensity Score-matched Analysis. Ann Surg 2024; 279:665-670. [PMID: 37389886 DOI: 10.1097/sla.0000000000005981] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The goal of the current study was to investigate the perioperative outcomes of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) in a high-volume center. BACKGROUND Despite RPDs prospective advantages over OPD, current evidence comparing the 2 has been limited and has prompted further investigation. The aim of this study was to compare both approaches while including the learning curve phase for RPD. METHODS A 1:1 propensity score-matched analysis of a prospective database of RPD with OPD (2017-2022) at a high-volume center was performed. The main outcomes were overall- and pancreas-specific complications. RESULTS Of 375 patients who underwent PD (OPD n=276; RPD n=99), 180 were included in propensity score-matched analysis (90 per group). RPD was associated with less blood loss [500 (300-800) vs 750 (400-1000) mL; P =0.006] and more patients without a complication (50% vs 19%; P <0.001). Operative time was longer [453 (408-529) vs 306 (247-362) min; P <0.001]; in patients with ductal adenocarcinoma, fewer lymph nodes were harvested [24 (18-27) vs 33 (27-39); P <0.001] with RPD versus OPD. There were no significant differences for major complications (38% vs 47%; P =0.291), reoperation rate (14% vs 10%; P =0.495), postoperative pancreatic fistula (21% vs 23%; P =0.858), and patients with the textbook outcome (62% vs 55%; P =0.452). CONCLUSIONS Including the learning phase, RPD can be safely implemented in high-volume settings and shows potential for improved perioperative outcomes versus OPD. Pancreas-specific morbidity was unaffected by the robotic approach. Randomized trials with specifically trained pancreatic surgeons and expanded indications for the robotic approach are needed.
Collapse
Affiliation(s)
- Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp A Wise
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philip C Müller
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clare Hospital Basel, Basel, Switzerland
| | - Christoph Kuemmerli
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clare Hospital Basel, Basel, Switzerland
| | - Amila Cizmic
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel A Salg
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Verena Steinle
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Anna Niessen
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Mayer
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clare Hospital Basel, Basel, Switzerland
| | - Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
3
|
Liu R, Abu Hilal M, Besselink MG, Hackert T, Palanivelu C, Zhao Y, He J, Boggi U, Jang JY, Panaro F, Goh BKP, Efanov M, Nagakawa Y, Kim HJ, Yin X, Zhao Z, Shyr YM, Iyer S, Kakiashvili E, Han HS, Lee JH, Croner R, Wang SE, Marino MV, Prasad A, Wang W, He S, Yang K, Liu Q, Wang Z, Li M, Xu S, Wei K, Deng Z, Jia Y, van Ramshorst TME. International consensus guidelines on robotic pancreatic surgery in 2023. Hepatobiliary Surg Nutr 2024; 13:89-104. [PMID: 38322212 PMCID: PMC10839730 DOI: 10.21037/hbsn-23-132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 11/10/2023] [Indexed: 02/08/2024]
Abstract
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.
Collapse
Affiliation(s)
- Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Mohammed Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Chinnusamy Palanivelu
- Department of Minimal Invasive Hernia Surgery, GEM Hospital and Research Centre, Chennai, Tamil Nadu, India
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital Beijing, Beijing, China
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Fabrizio Panaro
- Department of Surgery/Division of HBP Surgery & Transplantation, University of Montpellier, Montpellier, France
| | - Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Hong-Jin Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Xiaoyu Yin
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhiming Zhao
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei
| | - Shridhar Iyer
- Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, National University Hospital, Singapore, Singapore
| | - Eli Kakiashvili
- Department of Surgery, Galilee Medical Center, Nahariya, Israel
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Jae Hoon Lee
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Roland Croner
- Department of General-, Vascular-, Visceral- and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei
| | - Marco Vito Marino
- General Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Arun Prasad
- Department of General and Minimal Access Surgery and Robotic Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Wei Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Songqing He
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Kehu Yang
- EvidenceBased Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Qu Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Zizheng Wang
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Mengyang Li
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Shuai Xu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Kongyuan Wei
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhaoda Deng
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yuze Jia
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Tess M. E. van Ramshorst
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Morelli L, Furbetta N, Palmeri M, Guadagni S, Di Franco G, Gianardi D, Cervelli R, Lorenzoni V, Comandatore A, Carpenito C, Di Candio G, Cuschieri A. Initial 50 consecutive full-robotic pancreatoduodenectomies without conversion by a single surgeon: a learning curve analysis from a tertiary referral high-volume center. Surg Endosc 2023; 37:3531-3539. [PMID: 36596929 PMCID: PMC9810244 DOI: 10.1007/s00464-022-09784-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/27/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Several studies report on a learning curve for robotic pancreatoduodenectomy (R-PD) ranging between 20 and 80 operations, with conversion rates varying between 1.1 and 35%. However, as these publications mostly refer to initial robotic experiences and do not take into account the previous surgical background in pancreatic surgery (PS) and in robotic-assisted surgery (RAS), the center's volume, as well as the platform used, we aimed to perform a surgical outcomes analysis with a particular view to these aspects. METHODS Intraoperative and perioperative outcomes of the first 50 consecutive R-PD performed with the da Vinci Xi by the same surgeon, within a tertiary referral high-volume center, between January 2018 and March 2022, were analyzed. The surgeon was previously experienced in both PS and RAS. Shewhart control chart and cumulative sum (CUSUM) analysis were used to evaluate the learning curve of R-PD. RESULTS All the operations were performed with a full-robotic technique, without any conversion to open surgery. Twenty of 50 patients (40%) had a BMI ≥ 25 kg/m2, while 24/50 (48%) had undergone previous abdominal surgery. Mean console time was 276.30 ± 31.16 min. The median post-operative length of hospital stay was 10 days, while 20/50 (40%) patients were discharged within post-operative day 8. Six patients (12%) had major complications (Clavien-Dindo grade 3 or above). There was no 30-day mortality. Shewhart control chart and CUSUM analysis did not show a significant learning curve during the study period. CONCLUSIONS An extensive prior experience in both PS and RAS, within a tertiary referral high-volume center with availability of the da Vinci Xi platform, can significantly flatten the learning curve and, therefore, enable safe performance of challenging operations, i.e., pancreatoduodenectomies with a minimally invasive approach, with very low risk of conversion to open surgery, even in the first 50 operations.
Collapse
Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy.
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Rosa Cervelli
- Interventional Radiology Division, Imaging Department, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | | | - Annalisa Comandatore
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Cristina Carpenito
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
- Multidisciplinary Center of Robotic Surgery, University Hospital of Pisa, Pisa, Italy
| | - Alfred Cuschieri
- Institute for Medical Science and Technology, University of Dundee, Dundee, Scotland, UK
| |
Collapse
|
5
|
Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma. J Surg Res 2023; 284:164-172. [PMID: 36577229 DOI: 10.1016/j.jss.2022.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Conflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC). METHODS All patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan-Meier survival analysis. RESULTS Of the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC. CONCLUSIONS Obesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.
Collapse
|
6
|
Ouyang L, Liu RD, Ren YW, Nie G, He TL, Li G, Zhou YQ, Huang ZP, Zhang YJ, Hu XG, Jin G. Nomogram predicts CR-POPF in open central pancreatectomy patients with benign or low-grade malignant pancreatic neoplasms. Front Oncol 2022; 12:1030080. [PMID: 36591477 PMCID: PMC9797993 DOI: 10.3389/fonc.2022.1030080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Central pancreatectomy (CP) is a standard surgical procedure for benign and low-grade malignant pancreatic neoplasms in the body and neck of the pancreas. Higher incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) after CP than after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has been reported, but no nomogram for prediction of CR-POPF after open CP has been previously established. Methods Patients undergoing open CP for benign or low-grade malignant pancreatic neoplasms in the department of Hepatobiliary and Pancreatic (HBP) surgery of Shanghai Changhai Hospital affiliated to Naval Medical University between January 01, 2009 and December 31,2020 were enrolled. Pre-, intra- and post-operative parameters were analyzed retrospectively. Results A total of 194 patients, including 60 men and 134 women, were enrolled with median age of 52 years (21~85 years). 84 patients (43.3%) were overweight (BMI>23.0 Kg/m2) and 14 (7.2%) were obese (BMI>28.0 Kg/m2). Pathological diagnoses ranged from serous cystic neoplasm (32.5%), solid pseudopapillary neoplasm (22.2%), pancreatic neuroendocrine tumor (20.1%), intraductal papillary mucinous neoplasm (18.0%) to mucinous cystic neoplasm (5.2%). All patients had soft pancreatic texture. Main pancreatic duct diameters were ≤0.3cm for 158 patients (81.4%) and were ≥0.5cm in only 12 patients (6.2%). A stapler (57.7%) or hand-sewn closure (42.3%) were used to close the pancreatic remnant. The pancreatic anastomosis techniques used were duct to mucosa pancreaticojejunostomy (PJ)-interrupted suture (47.4%), duct to mucosa PJ-continuous suture (43.3%), duct to mucosa "HO" half-purse binding PJ (5.2%) and invaginating pancreaticogastrostomy (4.1%). Post-surgical incidences of CR-POPF of 45.9%, surgical site infection of 28.9%, postpancreatectomy hemorrhage of 7.7% and delayed gastric emptying of 2.1% were found. Obesity and pancreatic anastomosis technique were independent risk factors of CR-POPF, with a concordance index of 0.675 and an Area Under the Curve of 0.678. Discussion This novel nomogram constructed according to obesity and pancreatic anastomosis technique showed moderate predictive performance of CR-POPF after open CP.
Collapse
Affiliation(s)
- Liu Ouyang
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ren-dong Liu
- Department of Hepatobiliary Surgery, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Yi-wei Ren
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Gang Nie
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Tian-lin He
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Gang Li
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ying-qi Zhou
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhi-ping Huang
- Department of Hepatobiliary Surgery, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Yi-jie Zhang
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China,*Correspondence: Gang Jin, ; Xian-gui Hu, ; Yi-jie Zhang,
| | - Xian-gui Hu
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China,*Correspondence: Gang Jin, ; Xian-gui Hu, ; Yi-jie Zhang,
| | - Gang Jin
- Department of the Hepatobiliary and Pancreatic (HBP) Surgery, Changhai Hospital, Naval Medical University, Shanghai, China,*Correspondence: Gang Jin, ; Xian-gui Hu, ; Yi-jie Zhang,
| |
Collapse
|
7
|
Minimally invasive approaches increase postoperative complications in obese patients undergoing pancreaticoduodenectomy during the initial development period: a propensity score matching study. Surg Endosc 2022; 37:2770-2780. [PMID: 36477639 DOI: 10.1007/s00464-022-09773-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Obesity increases surgical risks in various abdominal surgeries and its impact on open pancreaticoduodenectomy (OPD) and minimally invasive pancreaticoduodenectomy (MIPD) remains unknown. This study aimed to compare the surgical outcomes of OPD and MIPD in obese and non-obese patients by propensity score matching (PSM) analysis during the implementation of MIPD. METHODS We retrospectively reviewed all pancreaticoduodenectomies from December 2014 to May 2021. Obesity was defined as body mass index > 25 kg/m2 according to World Health Organization International Obesity Task Force. PSM was used to minimize the selection bias of MIPD. RESULTS Among 462 pancreaticoduodenectomies (339 OPDs, 123 MIPDs), there were 313 patients in the non-obese group (MIPD: 78, OPD: 235) and 149 patients in the obese group (MIPD: 45, OPD: 104). After PSM, there were 70 MIPD/106 OPD patients in the non-obese group and 38 MIPD/54 OPD patients in the obese group. The obese MIPD patients had more fluid collection (36.8% vs 9.8%, p = 0.002), a higher Clavien-Dindo (CD) grade (p = 0.007), more major complications (42.1% vs 14.8%, p = 0.004), and longer operative times (306 min vs 264 min, p < 0.001) than the obese OPD patients. The non-obese MIPD patients had lower CD grades (p = 0.02), longer operative times (294 vs 264 min, p < 0.001), and less blood loss (100 mL vs 200 mL) than the non-obese OPD patients. MIPD was a strong predictor of major complication (CD ≥ 3) in obese patients (odds ratio 3.11, 95% CI: 1.40-6.95, p = 0.005). CONCLUSIONS Minimally invasive approaches deteriorate the CD grade, fluid collection, and major complications in obese patients undergoing pancreaticoduodenectomy during the initial development period. Non-obese patients may benefit from MIPD over OPD in terms of less blood loss and lower CD grades. The impact of BMI on MIPD should be considered when assessing the surgical risks.
Collapse
|
8
|
Enderes J, Pillny C, Matthaei H, Manekeller S, Kalff JC, Glowka TR. Obesity Does Not Influence Delayed Gastric Emptying Following Pancreatoduodenectomy. BIOLOGY 2022; 11:biology11050763. [PMID: 35625491 PMCID: PMC9138317 DOI: 10.3390/biology11050763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/10/2022] [Accepted: 05/15/2022] [Indexed: 12/20/2022]
Abstract
Background: The data about obesity on postoperative outcome after pancreatoduodenectomy (PD) are inconsistent, specifically in relation to gastric motility and delayed gastric emptying (DGE). Methods: Two hundred and eleven patients were included in the study and patients were retrospectively analyzed in respect to pre-existing obesity (obese patients having a body mass index (BMI) ≥ 30 kg/m2 vs. non-obese patients having a BMI < 30 kg/m2, n = 34, 16% vs. n = 177, 84%) in relation to demographic factors, comorbidities, intraoperative characteristics, mortality and postoperative complications with special emphasis on DGE. Results: Obese patients were more likely to develop clinically relevant pancreatic fistula grade B/C (p = 0.008) and intraabdominal abscess formations (p = 0.017). However, clinically relevant DGE grade B/C did not differ (p = 0.231) and, specifically, first day of solid food intake (p = 0.195), duration of intraoperative administered nasogastric tube (NGT) (p = 0.708), rate of re-insertion of NGT (0.123), total length of NGT (p = 0.471) or the need for parenteral nutrition (p = 0.815) were equally distributed. Moreover, mortality (p = 1.000) did not differ between the two groups. Conclusions: Obese patients do not show a higher mortality rate and are not at higher risk to develop DGE. We thus show that in our study, PD is feasible in the obese patient in regard to postoperative outcome with special emphasis on DGE.
Collapse
|