Robotic versus laparoscopic distal pancreatectomy: A comparative study of clinical outcomes and costs analysis

Cost-effectiveness of robotic vs laparoscopic distal pancreatectomy. Results from the national prospective trial ROBOCOSTES

INTRODUCTION

Although several studies report that the robotic approach is more costly than laparoscopy, the cost-effectiveness of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) is still an issue. This study evaluates the cost-effectiveness of the RDP and LDP approaches across several Spanish centres.

METHODS

This study is an observational, multicenter, national prospective study (ROBOCOSTES). For one year from 2022, all consecutive patients undergoing minimally invasive distal pancreatectomy were included, and clinical, QALY, and cost data were prospectively collected. The primary aim was to analyze the cost-effectiveness between RDP and LDP.

RESULTS

During the study period, 80 procedures from 14 Spanish centres were analyzed. LDP had a shorter operative time than the RDP approach (192.2 min vs 241.3 min, p = 0.004). RDP showed a lower conversion rate (19.5% vs 2.5%, p = 0.006) and a lower splenectomy rate (60% vs 26.5%, p = 0.004). A statistically significant difference was reported for the Comprehensive Complication Index between the two study groups, favouring the robotic approach (12.7 vs 6.1, p = 0.022). RDP was associated with increased operative costs of 1600 euros (p < 0.031), while overall cost expenses resulted in being 1070.92 Euros higher than the LDP but without a statistically significant difference (p = 0.064). The mean QALYs at 90 days after surgery for RDP (0.9534) were higher than those of LDP (0.8882) (p = 0.030). At a willingness-to-pay threshold of 20,000 and 30,000 euros, there was a 62.64% and 71.30% probability that RDP was more cost-effective than LDP, respectively.

CONCLUSIONS

The RDP procedure in the Spanish healthcare system appears more cost-effective than the LDP.

IRON: A retrospective international multicenter study on robotic versus laparoscopic versus open approach in gallbladder cancer

OBJECTIVE

For patients with T1b gallbladder cancer or greater, an adequate lymphadenectomy should include at least 6 nodes. Studies comparing short- and long-term outcomes of the open approach with those of laparoscopy and robotic approaches are limited, with small sample sizes, and there are none comparing laparoscopic and robotic approaches. This study compared patients who underwent robotic, laparoscopic, and open resection of gallbladder cancer, evaluating short- and long-term outcomes.

METHODS

We conducted a multicenter retrospective study of patients with T1b gallbladder cancer or greater (excluding combined organ resection and T4) who underwent open, laparoscopic, and robotic liver resection and lymphadenectomy between January 2012 and December 2022. The 3 groups were matched in terms of patient baseline and disease characteristics based on propensity score matching, comparing robotic with open and robotic with laparoscopic groups.

RESULTS

We enrolled 575 patients from 37 institutions. After propensity score matching, the median number of harvested nodes was higher in the robotic group than in the open (7 vs 5; P = .0150) and laparoscopic groups (7 vs 4; P < .001). The Pringle maneuver time was shorter with robotic resection than with laparoscopy (38 vs 59 minutes; P = .0034), and the robotic group also had a lower conversion rate (3% vs 14%, respectively; P = .005) and less estimated blood loss than open and laparoscopic resections. The perioperative morbidity and mortality rates did not differ. The robotic and laparoscopic approaches were associated with faster functional recovery than the open group. In the multivariate analysis, the factors related to the retrieval of at least 6 nodes were the robotic approach over open (odds ratio, 5.1529) and over laparoscopy (odds ratio, 6.7289) and the center experience (≥20 minimally invasive liver resections/year) (odds ratio, 4.962). After a mean follow-up of 42.6 months, overall survival and disease-free survival were not different between groups.

CONCLUSION

Compared with open and laparoscopic surgeries, the robotic approach for gallbladder cancer performed in a center with appropriate experience in minimally invasive surgery can provide adequate node retrieval.

Nationwide cost-effectiveness and quality of life analysis of minimally invasive distal pancreatectomy

BACKGROUND

This study analyzed the Quality of Life (QoL) and cost-effectiveness of laparoscopic (LDP) versus robotic distal pancreatectomy (RDP).

METHODS

Consecutive patients submitted to LDP or RDP from 2010 to 2020 in four high-volume Italian centers were included, with a minimum of 12 months of postoperative follow-up were included. QoL was evaluated using the EORTC QLQ-C30 and EQ-5D questionnaires, self-reported by patients. After a propensity score matching, which included BMI, gender, operation time, multiorgan and vascular resections, splenic preservation, and pancreatic stump management, the mean differential cost and Quality-Adjusted Life Years (QALY) were calculated and plotted on a cost-utility plane.

RESULTS

The study population consisted of 564 patients. Among these, 271 (49%) patients were submitted to LDP, while 293 (51%) patients to RDP. After propensity score matching, the study population was composed of 159 patients in each group, with a median follow-up of 59 months. As regards the QoL analysis, global health and emotional functioning domains showed better results in the RDP group (p = 0.037 and p = 0.026, respectively), whereas the other did not differ. As expected, the median crude costs analysis confirmed that RDP was more expensive than LDP (16,041 Euros vs. 10,335 Euros, p < 0.001). However, the robotic approach had a higher probability of being more cost-effective than the laparoscopic procedure when a willingness to pay more than 5697 Euros/QALY was accepted.

CONCLUSION

RDP was associated with better QoL as explored by specific domains. Crude costs were higher for RDP, and the cost-effectiveness threshold was set at 5697 euros/QALY.

Evaluating the economic efficiency of open, laparoscopic, and robotic distal pancreatectomy: an updated systematic review and network meta-analysis

BACKGROUND

This study compared the cost-effectiveness of open (ODP), laparoscopic (LDP), and robotic (RDP) distal pancreatectomy (DP).

METHODS

Studies reporting the costs of DP were included in a literature search until August 2023. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, mean difference (MD), odds ratio (OR), and 95% credible intervals (CrIs) were calculated for outcomes of interest. Cluster analysis was performed to examine the similarity and classification of DP approaches into homogeneous clusters. A decision model-based cost-utility analysis was conducted for the cost-effectiveness analysis of DP strategies.

RESULTS

Twenty-six studies with 29,164 patients were included in the analysis. Among the three groups, LDP had the lowest overall costs, while ODP had the highest overall costs (LDP vs. ODP: MD - 3521.36, 95% CrI - 6172.91 to - 1228.59). RDP had the highest procedural costs (ODP vs. RDP: MD - 4311.15, 95% CrI - 6005.40 to - 2599.16; LDP vs. RDP: MD - 3772.25, 95% CrI - 4989.50 to - 2535.16), but incurred the lowest hospitalization costs. Both LDP (MD - 3663.82, 95% CrI - 6906.52 to - 747.69) and RDP (MD - 6678.42, 95% CrI - 11,434.30 to - 2972.89) had significantly reduced hospitalization costs compared to ODP. LDP and RDP demonstrated a superior profile regarding costs-morbidity, costs-mortality, costs-efficacy, and costs-utility compared to ODP. Compared to ODP, LDP and RDP cost $3110 and $817 less per patient, resulting in 0.03 and 0.05 additional quality-adjusted life years (QALYs), respectively, with positive incremental net monetary benefit (NMB). RDP costs $2293 more than LDP with a negative incremental NMB but generates 0.02 additional QALYs with improved postoperative morbidity and spleen preservation. Probabilistic sensitivity analysis suggests that LDP and RDP are more cost-effective options compared to ODP at various willingness-to-pay thresholds.

CONCLUSION

LDP and RDP are more cost-effective than ODP, with LDP exhibiting better cost savings and RDP demonstrating superior surgical outcomes and improved QALYs.

Postoperative outcomes and costs of laparoscopic versus robotic distal pancreatectomy: a propensity-matched analysis

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) make the robotic approach controversial. We sought to compare outcomes and cost of LDP and RDP using propensity matching analysis at our institution.

METHODS

Patients undergoing LDP or RDP between 2000 and 2021 were retrospectively identified. Patients were optimally matched using age, gender, American Society of Anesthesiologists status, body mass index, and tumor size. Between-group differences were analyzed using the Wilcoxon signed-rank test for continuous data, and the McNemar's test for categorical data. Outcomes included operative duration, conversion to open surgery, postoperative length of stay, pancreatic fistula rate, pseudocyst requiring intervention, and costs.

RESULTS

298 patients underwent MIDP, 180 (60%) were laparoscopic and 118 (40%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10, except for tumor type (0.16). RDP had longer operative times (268 vs 178 min, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), fewer biochemical pancreatic leaks (11.9% vs 34.7%, p < 0.01), and fewer interventional radiological drainage (0% vs 5.9%, p = 0.01). The number of pancreatic fistulas (11.9% vs 5.1%, p = 0.12), collections requiring antibiotics or intervention (11.9% vs 5.1%, p = 0.12), and conversion rates (3.4% vs 5.1%, p = 0.72) were comparable between the two groups. The total direct index admission costs for RDP were 1.01 times higher than for LDP for FY16-19 (p = 0.372), and 1.33 times higher for FY20-22 (p = 0.031).

CONCLUSIONS

Although RDP required longer operative times than LDP, postoperative stays were shorter. The procedure cost of RDP was modestly more expensive than LDP, though this was partially offset by reduced hospital stay and reintervention rate.

The Implications of Readmission on Cost and Patient Outcomes Following Distal Pancreatectomy and Splenectomy

BACKGROUND

Robotic platform usage for distal pancreatectomy and splenectomy has grown exponentially in recent years. This study aims to identify the impact of readmission following robotic distal pancreatectomy and splenectomy and to analyze the financial implications of these readmissions.

METHODS

We prospectively followed 137 patients after robotic distal pancreatectomy and splenectomy. Readmission was defined as rehospitalization within 30 days post-discharge. Total cost incorporated initial and readmission hospital costs, when applicable. Outcomes were analyzed using chi-square/Fisher's exact test and Student's t test. Data are presented as median (mean ± SD).

RESULTS

Of 137 patients, 20 (14%) were readmitted. Readmitted patients were 67 (66 ± 10.3) years old and had a BMI of 30 (30 ± 7.0) kg/m2; 9 (45%) had previous abdominal operations. Non-readmitted patients were 67 (62 ± 14.7) years old and had a BMI of 28 (28 ± 5.7) kg/m2; 37 (32%) had previous abdominal operations (P = NS, for all). Readmitted patients vs non-readmitted patients had operative durations of 327 (363 ± 179.1) vs 251 (293 ± 176.4) minutes (P = .10), estimated blood loss (EBL) of 90 (159 ± 214.6) vs 100 (244 ± 559.4) mL (P = .50), and tumor diameter of 3 (4 ± 2.0) vs 3 (4 ± 2.9) cm (P = 1.00). Initial length of stay (LOS) for readmitted patients vs patients who were not readmitted was 5 (5 ± 2.7) vs 4 (5 ± 3.0) days (P = 1.00); total hospital cost of those readmitted, including both admissions, was $29,095 (32,324 ± 20,227.38) vs $24,663 (25,075 ± 10,786.45) (P = .018) for those not readmitted.

DISCUSSION

Despite a similar perioperative course, readmissions were associated with increased costs. We propose thorough consideration before readmission and increased patient education initiatives will reduce readmissions after robotic distal pancreatectomy and splenectomy.

[Robotic pancreatic surgery]

Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2-3 years.

New era of robotic surgery: first case in Spain of right hemicolectomy on Hugo RAS surgical platform

We describe the first robot-assisted right hemicolectomy performed in Spain using the new Hugo RAS (robotic-assisted surgery) (Medtronic, Minneapolis, Minnesota, USA). No conversion was registered, and no intraoperative complications or technical failures of the system were recorded. The operative time was 200 min, the docking time was 5 min and the length of the hospital stay was 8 days. We conclude that a right hemicolectomy using the Hugo RAS system is safe and feasible. Our earlier experience provides important skills for those who are starting to use this new robotic system.

A Comparison of Robotic Versus Laparoscopic Distal Pancreatectomy for Benign or Malignant Lesions: A Meta-Analysis

Background: The momentum of robotic surgery is increasing, and it has great prospects in pancreatic surgery. It has been widely accepted and expanding to more and more centers. Robotic distal pancreatectomy (RDP) is the most recent advanced minimally invasive approach for pancreatic lesions and malignancies. However, laparoscopic distal pancreatectomy (LDP) also showed good efficacy. We compared the effect of RDP with LDP using a meta-analysis. Methods: From January 2010 to June 2023, clinical trials of RDP versus LDP were determined by searching PubMed, Medline, and EMBASE. A meta-analysis was conducted to compare the effect of RDP with LDP. This meta-analysis evaluated the R0 resection rate, lymph node metastasis rate, conversion to open surgery rate, spleen preservation rate, intraoperative blood loss, postoperative pancreatic fistula, postoperative hospital stay, 90-day mortality rate, surgical cost, and total cost. Results: This meta-analysis included 38 studies. Conversion to open surgery, blood loss, and 90-day mortality in the RDP group were all significantly less than that in the LDP group (P < .05). There was no difference in lymph node resection rate, R0 resection rate, or postoperative pancreatic fistula between the two groups (P > .05). Spleen preservation rate in the LDP group was higher than that in the RDP group (P < .05). Operation cost and total cost in the RDP group were both more than that in the LDP group (P < .05). It is uncertain which group has an advantage in postoperative hospital stay. Conclusions: To some degree, RDP and LDP were indeed worth comparing in clinical practice. However, it may be difficult to determine which is absolute advantage according to current data. Large sample randomized controlled trials are needed to confirm which is better treatment. PROSPERO ID: CRD4202345576.

Robot-assisted Nissen fundoplication with the new HUGO™ Robotic assisted system: First worldwide report with system description, docking settings and video

BACKGROUND

Robotic surgery has gained worldwide acceptance over the past decade, with several studies showing that this technique is safe and feasible.

METHODS

We describe the first robot-assisted Nissen fundoplication for hiatal hernia performed with the new Hugo™ RAS (Robotic assisted surgery) system (Medtronic, Minneapolis, MN, USA) in Spain. The innovation of this system is the open surgical console with a 3D-HD display, a system tower and four independent arm carts.

RESULTS

The surgical procedures were completed without conversion. No intraoperative complications or technical failures of the system were recorded. The operative time was 97 min, the docking time was 3 min, and the length of hospital stay was three days.

CONCLUSIONS

This case report shows the safety and feasibility of Nissen fundoplication for hiatal hernia with the Hugo™ RAS system and provides relevant data that may assist early adopters of this surgical platform.

Robotic versus laparoscopic distal pancreatectomy on perioperative outcomes: a systematic review and meta-analysis

Robotic surgery has become a promising surgical method in minimally invasive pancreatic surgery due to its three-dimensional visualization, tremor filtration, motion scaling, and better ergonomics. Numerous studies have explored the benefits of RDP over LDP in terms of perioperative safety and feasibility, but no consensus has been achieved yet. This article aimed to evaluate the benefits and drawbacks of RDP and LDP for perioperative outcomes. By June 2022, all studies comparing RDP to LDP in the PubMed, the Embase, and the Cochrane Library database were systematically reviewed. According to the heterogeneity, fix or random-effects models were used for the meta-analysis of perioperative outcomes. Odds ratio (OR), weighted mean differences (WMD), and 95% confidence intervals (CI) were calculated. A sensitivity analysis was performed to explore potential sources of high heterogeneity and a trim and fill analysis was used to evaluate the impact of publication bias on the pooled results. Thirty-four studies met the inclusion criteria. RDP provides greater benefit than LDP for higher spleen preservation (OR 3.52 95% CI 2.62-4.73, p < 0.0001) and Kimura method (OR 1.93, 95% CI 1.42-2.62, p < 0.0001) in benign and low-grade malignant tumors. RDP is associated with lower conversion to laparotomy (OR 0.41, 95% CI 0.33-0.52, p < 0.00001), and shorter postoperative hospital stay (WMD - 0.57, 95% CI - 0.92 to - 0.21, p = 0.002), but it is more costly. In terms of postoperative complications, there was no difference between RDP and LDP except for 30-day mortality (RDP versus LDP, 0.1% versus 1.0%, p = 0.03). With the exception of its high cost, RDP appears to outperform LDP on perioperative outcomes and is technologically feasible and safe. High-quality prospective randomized controlled trials are advised for further confirmation as the quality of the evidence now is not high.

Minimally invasive distal pancreatectomy: Laparoscopic versus robotic approach-A cohort study

Background and Aims

There is no consensus on the superiority of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP).

Methods

Data of patients undergoing RDP and LDP were prospectively collected and compared.

Results

There were 65 RDP and 112 LDP. RDP took a shorter operation time than LDP. Overall, DP with splenectomy took a longer operation time than that with spleen preservation. This difference was only significant in LDP group. In both RDP and LDP groups, splenectomy was associated with increased blood loss, as compared with spleen preservation. No significant differences were observed in surgical morbidity between RDP and LDP. The hospital cost in RDP was almost double that of LDP, with a median of 13,404 versus 7765 USD.

Conclusion

LDP is comparable to RDP in regard to surgical outcomes. LDP with spleen preservation is highly recommended whenever possible and feasible for benign or low malignant lesions in terms of lower costs and less blood loss.

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.

A comparison of robotic versus laparoscopic distal pancreatectomy: Propensity score matching analysis

BACKGROUND

The aim of this study was to assess the perioperative and pathologic outcomes of robotic distal pancreatectomy compared with a laparoscopic approach.

METHODS

A total of 121 robotic distal pancreatectomies and 992 laparoscopic distal pancreatectomies were retrospectively evaluated, comparing the demographic, perioperative and pathologic outcomes. After 1:2 propensity score matching (PSM) with 11 demographic variables, the factors were analysed again.

RESULTS

Following PSM, 104 robotic distal pancreatectomy patients were compared with 208 laparoscopic distal pancreatectomy patients. The operation time and proportion of spleen preservation were not different between the groups. The rates of open conversion were lower, whereas the hospital costs were higher in the robotic group. Other perioperative outcomes and pathologic factors did not differ between the groups.

CONCLUSIONS

Although robotic distal pancreatectomy is more expensive, this operation is feasible, with a higher probability of proceeding with the planned operation and with low open conversion rate.

Central vascular ligation and mesentery based abdominal surgery

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Robotic versus laparoscopic distal pancreatectomies: A systematic review and meta-analysis on costs and perioperative outcome

AIM

The aim of this meta-analysis is to compare perioperative outcomes and costs of robotic and laparoscopic distal pancreatectomy (RDP and LDP).

MATERIAL AND METHODS

In accordance with the PRISMA guidelines, we searched Medline, EMBASE, Cochrane and Web of Science for reports published before December 2020.

RESULTS

The literature search identified 11 papers (1 187 patients). RDP showed a lower conversion rate (odds ratio: 2.56, 95% confidence intervals [CI]: 1.31 to 5.00) with no significant differences in bleeding and operative time, complications ≥ Clavien-Dindo grade III, pancreatic fistulas and length of stay. Despite RDP presenting higher costs in all included studies, none of these differences were significant. However, RDP showed higher total costs than LDP (standardized mean differences [SMD]: -1.18, 95% CI: -1.97 to -0.39). A subgroup analysis according to the continent of origin showed that studies coming from Asian research groups kept showing significant differences (SMD: -2.62, 95% CI: -3.38 to -1.85), while Western groups did not confirm these findings.

CONCLUSION

Based on low-quality evidence, despite some potential technical advantages, RDP still seems to be costlier than LDP.

Cost-effectiveness and quality of life analysis of laparoscopic and robotic distal pancreatectomy: a propensity score-matched study

BACKGROUND

This study analyzed the Quality of Life (QoL) and cost-effectiveness of laparoscopic (LDP) versus robotic distal pancreatectomy (RDP).

METHOD

All patients who underwent LDP or RDP from 2011 to 2017 and with a minimum postoperative follow-up of 12 months were included in the study. To minimize bias, a propensity score-matched analysis (1:2) was performed. Two different questionnaires (EORTC QLQ-C30 and EQ-5D) were completed by the patients. The mean differential cost and mean differential Quality Adjusted Life Years (QALY) were calculated and plotted on a cost-utility plane.

RESULTS

The study population consisted of 152 patients. After having applied the propensity score matching, the final population included 103 patients divided into RDP group (n = 37, 36%) and LDP (n = 66, 64%). No differences were found between groups regarding the baseline, intraoperative, postoperative, and pathological variables (p > 0.05). The QoL analysis showed a significant improvement in the RDP group on the postoperative social function, nausea, vomiting, and financial status (p = 0.010, p = 0.050, and p = 0.030, respectively). As expected, the crude costs analysis confirmed that RDP was more expensive than LDP (12,053 Euros vs. 5519 Euros, p < 0.001). However, the robotic approach had a higher probability of being more cost-effective than the laparoscopic procedure when a willingness to pay of more than 4800 Euros/QALY was accepted.

CONCLUSION

RDP was associated with QoL improvement in specific domains. Crude costs were higher relative to LDP. Cost-effectiveness threshold resulted to be 4800 euros/QALY. The increasing worldwide diffusion of the robotic technology, with easier access and possible cost reduction, could increase the sustainability of this procedure.

[Evidence for robotics in oncological pancreatic surgery]

Robotic surgical procedures have been implemented and have become an important development in pancreatic surgery with an increasing acceptance worldwide. Nearly all types of pancreatic surgery have now been performed robotically and especially standardized resections, such as distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) have gained importance despite a potentially long learning curve and high associated procedural costs. The present review article summarizes the available literature and evidence on the respective procedures focused on their use for indications of malignancy.

"Kimura-first" strategy for robotic spleen-preserving distal pancreatectomy: experiences from 61 consecutive cases in a single institution

BACKGROUND

Robotic spleen-preserving distal pancreatectomy (RSPDP) is an ideal procedure for benign and low-grade malignant tumors in the distal pancreas, and two splenic preservation techniques (the Kimura and Warshaw techniques) can be used for RSPDP. This study aimed to evaluate the feasibility and safety of the "Kimura-first" strategy for RSPDP and to investigate the risk factors affecting the preservation of the spleen and splenic vessels.

METHODS

The electronic medical records of patients who underwent robotic distal pancreatectomy (RDP) between October 2016 and December 2019 at our institution were retrospectively reviewed. Univariate and multivariate analyses were conducted to identify the risk factors influencing preservation of the spleen and splenic vessels during RDP.

RESULTS

Sixty-one patients scheduled for RSPDP who received RDP were included in this study [Kimura technique, 41 patients; Warshaw technique, 11 patients; and robotic distal pancreatectomy with splenectomy (RDPS), 9 patients]. The overall splenic preservation rate with RDP was 85.2% (52/61). The preservation rate of splenic vessels with the Kimura technique with RSPDP was 78.8% (41/52). The RSPDP group had remarkably less estimated blood loss (EBL; median 50 vs. 300 mL, P=0.000) and a lower morbidity rate (13.5% vs. 44.4%, P=0.047) than the RDPS group. The logistic regression models showed that obvious splenic vessel compression by the tumor was an independent risk factor for splenic vessel preservation with RSPDP (OR 0.021, 95% CI: 0.002-0.271, P=0.003) and RDP (OR 0.019, 95% CI: 0.002-0.176, P=0.000).

CONCLUSIONS

The "Kimura-first" strategy is feasible and safe for RSPDP, with high rates of splenic and splenic vessel preservation. Obvious splenic vessel compression by the tumor can be used as a predictor of splenic vessel preservation with planned RDP.

Comparison of 3 Minimally Invasive Methods Versus Open Distal Pancreatectomy: A Systematic Review and Network Meta-Analysis

Supplemental Digital Content is available in the text.

The efficacy and safety of open distal pancreatectomy (DP), laparoscopic DP, robot-assisted laparoscopic DP, and robotic DP have not been established. The authors aimed to comprehensively compare these 4 surgical methods using a network meta-analysis.

Meta-analysis of short-term outcomes comparing robot-assisted and laparoscopic distal pancreatectomy

Aim: To evaluate and compare the short-term outcomes of robotic surgery and laparoscopic approach in distal pancreatectomy (DP). Materials & methods: EMBASE, PubMed, the Cochrane Library, CNKI and Wan Fang database were retrieved from the inception of electronic databases to June 2019. All analyses were performed using Stata/SE 15.1 version (StataCorp). Results: Twenty-two papers were included, four of which were prospective studies and the rest were retrospective studies. There was significant difference in spleen preservation rate (odds ratio: 2.020; 95% CI: 1.085-3.758; p = 0.027), operation time (mean difference [MD]: 27.372; 95% CI: 8.236-47.210; p = 0.000), the length of hospital stay (MD: -0.911; 95% CI: -1.287 to -0.535; p = 0.000), conversion rate (rate difference: -0.090; 95% CI: -1.287 to -0.535; p = 0.000), operation cost (MD: 2816.564; 95% CI: 1782.028-3851.064; p = 0.000). However, no significant difference was detected in estimated blood loss, total complication, severe complication, lymph nodules harvest, blood transfusion rate, total pancreatic fistula, severe pancreatic fistula, R0 resection rate and mortality. Conclusion: Both robotic and laparoscopic DP are safe and feasible. Although robotic DP increases the operation cost, the spleen-preserving rate is much higher. Robotic surgery may be an alternative approach to DP.

Robotic-assisted gastrectomy compared with open resection: a comparative study of clinical outcomes and cost-effectiveness analysis

In the last decade, there have clearly been important changes in the surgical approach of gastric cancer treatment due to an increased interest in the minimally invasive surgical approach (MIS). The higher cost of robotic surgery procedures remains an important issue of debate. The objective of the study is to compare the main operative and clinical outcomes and to assess the incremental cost-effectiveness ratios (ICERs) of the two techniques. This is a prospective cost-effectiveness and clinical study when comparing the robotic gastrectomy (RG) technique with open gastrectomy (OG) in gastric cancer. Outcome parameters included surgical and post-operative costs, quality-adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). The incremental utility was 0.038 QALYs and the estimated ICER for patients was dominated by robotic approach. The probability that the robotic approach was cost effective was 94.04% and 94.20%, respectively, at a WTP threshold of 20,000€ and 30,000€ per QALY gained. RG for gastric cancer represents a cost-effective procedure compared with the standard OG.

Comparison of robotic vs laparoscopic vs open distal pancreatectomy. A systematic review and network meta-analysis

INTRODUCTION

The current evidence comparing oncological adequacy and effectiveness of robotic and laparoscopic distal pancreatectomy to open distal pancreatectomy for pancreatic adenocarcinoma is inconclusive. Recent pairwise meta-analyses demonstrated reduced blood loss and length of stay as the principal advantages of RDP and LDP compared to ODP. The aim of this study was to compare the three approaches to distal pancreatectomy conducting a pairwise meta-analysis and consequently network meta-analysis.

METHODS

A systematic literature search was performed using the databases, EMBASE, Pubmed, the Cochrane library, and Google Scholar. Meta-analyses were performed using both fixed-effect and random-effect models.

RESULTS

RDP cohort represented only 11% of the total sample; significantly younger patients with smaller size tumours were included in the RDP and LDP cohorts compared to ODP cohort. Significantly less blood loss and shorter length of stay were the advantages of both RDP and LDP compared to ODP. The ODP cohort included significantly more specimens with positive resection margins compared to RDP and LDP cohorts.

DISCUSSION

The results of the present study demonstrate that reduced blood losses and shorter length of stay are the advantages of RDP and LDP compared to ODP. However, demographic discrepancies, underpowered RDP sample and differences in oncological burden do not permit certain conclusions regarding the oncological safety of RDP and LDP for pancreatic adenocarcinoma.

Robotic-assisted versus laparoscopic left pancreatectomy at a high-volume, minimally invasive center

INTRODUCTION

While minimally invasive left pancreatectomy has become more widespread and generally accepted over the last decade, opinions on modality of minimally invasive approach (robotic or laparoscopic) remain mixed with few institutions performing a significant portion of both operative approaches simultaneously.

METHODS

247 minimally invasive left pancreatectomies were retrospectively identified in a prospectively maintained institutional REDCap™ database, 135 laparoscopic left pancreatectomy (LLP) and 108 robotic-assisted left pancreatectomy (RLP). Demographics, intraoperative variables, postoperative outcomes, and OR costs were compared between LLP and RLP with an additional subgroup analysis for procedures performed specifically for pancreatic adenocarcinoma (35 LLP and 23 RLP) focusing on pathologic outcomes and 2-year actuarial survival.

RESULTS

There were no significant differences in preoperative demographics or indications between LLP and RLP with 34% performed for chronic pancreatitis and 23% performed for pancreatic adenocarcinoma. While laparoscopic cases were faster (p < 0.001) robotic cases had a higher rate of splenic preservation (p < 0.001). Median length of stay was 5 days for RLP and LLP, and rate of clinically significant grade B/C pancreatic fistula was approximately 20% for both groups. Conversion rates to laparotomy were 4.3% and 1.8% for LLP and RLP approaches respectively. RLP had a higher rate of readmission (p = 0.035). Pathologic outcomes and 2-year actuarial survival were similar between LLP and RLP. LLP on average saved $206.67 in OR costs over RLP.

CONCLUSIONS

This study demonstrates that at a high-volume center with significant minimally invasive experience, both LLP and RLP can be equally effective when used at the discretion of the operating surgeon. We view the laparoscopic and robotic platforms as tools for the modern surgeon, and at our institution, given the technical success of both operative approaches, we will continue to encourage our surgeons to approach a difficult operation with their tool of choice.

Robotic versus conventional laparoscopic distal pancreatic resection: a systematic review and meta-analysis

BACKGROUND

Robotic surgery offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes in patients undergoing distal pancreatectomy through laparoscopic (LDP) or robotic (RDP) approaches.

METHOD

A systematic literature search was conducted for studies reporting minimally invasive surgery for distal pancreatectomy. Meta-analysis of intraoperative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using random effects models.

RESULT

Twenty non-randomised studies including 3112 patients (793 robotic and 2319 laparoscopic) were considered appropriate for inclusion. LDP had significantly shorter operating time than RDP (mean: 28, p < 0.001) but no significant difference in blood loss (mean: 52 mL, p = 0.07). RDP was associated with significantly lower conversion rates than LDP (OR 0.48, p < 0.001), but no difference in spleen preservation rate and R0 resection. There were no significant differences in overall and major complications, overall and high-grade pancreatic fistula. However, RDP was associated with a shorter length of hospital stay (mean: 1, p < 0.001).

CONCLUSION

Robotic distal pancreatectomy appears to offer some advantages compared to conventional laparoscopic surgery, although both techniques appear equivalent. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques are needed.

Meta-analysis of studies comparing conservative treatment with antibiotics and appendectomy for acute appendicitis in the adult

BACKGROUND

Appendectomy is considered the first treatment choice for appendicitis. However, controversy exists since conservative therapy is associated with fewer complications than appendectomy for patients with acute appendicitis (AA). This meta-analysis aimed to compare the outcomes between conservative therapy and appendectomy in the management of adult AA.

METHODS

A literature search was performed to screen eligible clinical studies. Subgroup analyses of the uncomplicated population, complicated population and mixed population of randomized clinical trials were subsequently performed. Clinical outcomes included the overall effective rate of treatment, complication rate, relapse rate (reoperation rate) and overall length of stay (LOS).

RESULTS

Eleven trials totalling 2751 patients (conservative = 1463, appendectomy = 1288) were analysed. Patients receiving conservative treatment had a lower overall effective rate (OR: 0.11 ~ 0.17) and complication rate (OR: 0.21 ~ 0.51). The conservative group had a higher reoperation rate (5.6, 95% CI: 3.1% ~ 10.2%) than the appendectomy group (OR: 9.58 ~ 14.29). Conservative treatment was associated with a shorter overall length of stay (0.47 day, 95% CI: 0.45 ~ 0.5 day) than appendectomy.

CONCLUSIONS

For both uncomplicated and complicated adult AA, non-operative management with antibiotics was associated with significantly fewer complications and a shorter length of stay but a lower effective rate and higher relapse rate.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Minimally Invasive Approaches to Pancreatic Cancer

In pancreatic cancer, resection combined with neoadjuvant and/or adjuvant therapy remains the only chance for cure and/or prolonged survival. A minimally invasive approach to pancreatic cancer has gained increased acceptance and popularity. The aim of minimally invasive surgery of the pancreas includes limiting trauma, decreasing length of hospitalization, lessening cost, decreasing blood loss, and allowing for a more meticulous oncologic dissection. New advances and routine use in practice have helped progress the field making the minimally invasive approach more feasible. In this article, the minimally invasive surgical approaches to proximal, central, and distal pancreatic cancer are described and literature reviewed.

A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population

INTRODUCTION

Minimally invasive surgery (MIS) has become standard of care for many gastrointestinal surgical procedures. Despite possible clinical benefits, MIS may be underutilized in some populations. The aim of this study was to access the utilization of MIS among Medicare patients undergoing hepatopancreatic procedures and define clinical outcomes, as well as costs, of minimally invasive techniques compared with the conventional open approach.

METHODS

The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. Primary outcomes of the analysis included perioperative clinical outcomes such as rates of complications, index hospitalization length-of-stay (LOS), failure-to-rescue, rates, and causes of 90-day readmission, as well as 90-day mortality. Secondary outcomes were Medicare payments for index hospitalization and readmission. Multivariable logistic regression was used to investigate the impact of MIS on clinical outcomes and health expenditures.

RESULTS

A total of 13,716 (90.6%) patients underwent open resection, while MIS was performed in 1424 (9.4%) patients. LOS was shorter among patients undergoing MIS (mean 7.3 ± SD 7.3) versus open (mean 9.3 ± SD 9.1) surgery (p < 0.001). The incidence of perioperative complications was lower following MIS (open 25.5%, n = 3492 vs. MIS 17.2%, n = 245) (p < 0.001). Rates of failure-to-rescue were similar among patients undergoing an open versus MIS pancreatic procedure (open 19.4%, n = 271 vs. MIS 13.4%, n = 17) (p = 0.09). In contrast, 90-day readmission (open 31.1%, n = 1630 vs. MIS 24.1%, n = 201, p < 0.001), as well as 90-day mortality (open 7.7%, n = 404 vs. MIS 4.2%, n = 35, p < 0.001) were lower among patients undergoing pancreatic resections via an MIS approach. In contrast, failure-to-rescue and readmission, as well as mortality, were all comparable among patients undergoing a liver resection, regardless as to whether the operation was performed open or via an MIS approach (all p > 0.05). Mean total payments for open pancreatic surgery were on average $1421 higher in the open versus MIS pancreatic group (p = 0.01); in contrast, there was no difference in the overall payment for hepatic resection (p > 0.05).

CONCLUSION

The MIS approach was underutilized among patients undergoing liver and pancreatic procedures. MIS was associated with lower complication and readmission and shorter LOS, as well as comparable/slightly lower Medicare payments, compared with the open approach. The MIS approach should strongly be considered among older patients undergoing liver and pancreatic procedures.

Advances in surgery for pancreatic cancer

Over the past 135 years, the field of pancreatic surgery for treatment of pancreatic malignancies has been a challenge to the surgical community. Originally filled with unacceptably high morbidity and mortality, these obstacles have been overcome through the work of numerous great surgeons in recent decades. Today, despite the improved safety of operating on the pancreas, patients still suffer from high rates of malignant recurrence and poor overall survival. Recent advances in pancreatic surgery aim to further improve the morbidity of these operations while increasing the number of patients who are both candidates for surgical resection and those who receive complete resections. This review focuses on recent literature describing the pros and cons of minimally invasive approaches to pancreatic surgery and the risks and benefits of vascular reconstruction to improve resectability. Both topics are currently debated amongst pancreatic surgeons and this article summarizes the varied viewpoints and their impact on outcomes in pancreas cancer surgery.

Oncologic outcomes after robot-assisted versus laparoscopic distal pancreatectomy: Analysis of the National Cancer Database

BACKGROUND

How the oncologic outcomes after robotic distal pancreatectomy (RDP) compare to those after laparoscopic distal pancreatectomy (LDP) remains unknown.

METHODS

Using the National Cancer Database (NCDB), we analyzed all patients undergoing LDP or RDP for resectable pancreatic adenocarcinoma over a 4-year period (2010-2013).

RESULTS

Of the 704 eligible patients, 605 (86%) underwent LDP and 99 (14%) underwent RDP. The median follow-up for patients was 25 months. There were no differences in the two groups with respect to sociodemographic, clinicopathologic, or treatment characteristics. On comparing LDP versus RDP, there was no difference in the margin-positive rate (15% vs 16%; P = 0.84); lymph nodes examined (12 vs 11; P = 0.67); overall survival (hazard ratio [HR], 1.1, 95% confidence intervals [CI], 0.7 to 1.7; 28 vs 25 months; P = 0.71); hospital stay (6 vs 5 days; P = 0.14); time to chemotherapy (50 vs 52 days; P = 0.65); 30-day readmission (9.4% vs 9.1%; P = 0.92); and mortality (1% vs 0%; P = 0.28). Patients undergoing LDP had a significantly higher conversion rate to open or minimally invasive pancreatic cancer resections compared with RDP (27% vs 10%; P < 0.001).

CONCLUSION

The early national experience with RDP demonstrates similar oncologic outcomes to LDP, with a significantly lower conversion rate.

Robotics in HPB surgery

Some major procedures and an assessment of their impact in the field