Laparoscopic versus open distal pancreatectomy for pancreatic adenocarcinoma: a systematic review and meta-analysis

The contribution of laparoscopic distal pancreatectomy videos on YouTube to the learning curve in the COVID-19 pandemic

There is no standardization in videos uploaded to Youtube. Were the videos capable of contributing to adequate technical quality and surgical training? We are aiming to answer these questions in this paper. It is a cross-sectional study. In January 2022, we searched the Youtube platform using the keyword "distal pancreatectomy." The substantiality, transparency, reliability, quality, popularity and educational values of the video content were evaluated after exclusion criteria. These parameters were evaluated using we the modified Journal of American Medical Association benchmark criteria, Global Quality Score (GQS), Video Power Index, modified laparoscopic pancreatectomy scoring system. The videos uploaded after the pandemic had a statistically significant higher GQS score (P < .001). Video Power Index, like GQS, had a statistically significant difference before and after the pandemic. (P = .046). There was no significant difference in the evaluation of the reliability and substantiality. Until the development of Youtube videos is completed, peer-reviewed, more reliable and content-rich online education platforms should be preferred in the first place. Care should be taken to watch selected videos on Youtube videos.

Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer: A technical review

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, was launched to minimize incisional traumatic effects in the 1990s. Minor SILS, such as cholecystectomies, have been gaining in popularity over the past few decades. Its application in complicated hepatopancreatobiliary (HPB) surgeries, however, has made slow progress due to instrumental and technical limitations, costs, and safety concerns. While minimally invasive abdominal surgery is pushing the boundaries, advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety, including hepatectomies, distal pancreatectomies (DP), and pancreaticoduodenectomies (PD). In contrast, advanced SILS for HPB malignancy has only been reported in a few small case series. Most of the procedures involved minor liver resections and DP; major hepatectomies were rarely described. Single-incision laparoscopic PD has not yet been reported. We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.

Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization?

BACKGROUND

Although laparoscopic distal pancreatectomy (LDP) versus open approaches (ODP) for pancreatic adenocarcinoma (PDAC) is associated with reduced morbidity, its impact on optimal adjuvant chemotherapy (AC) utilization remains unclear. Furthermore, it is uncertain whether oncologic resection quality markers are equivalent between approaches.

METHODS

The National Cancer Database (NCDB) was queried between 2010 and 2016 for PDAC patients undergoing DP. Effect of LDP vs ODP and institutional case volumes on margin status, hospital stay, 30-day and 90-day mortality, administration of and delay to AC, and 30-day unplanned readmission were analyzed using binary and linear logistic regression. Cox multivariable regression was used to correct for confounders.

RESULTS

The search yielded 3411 patients; 996 (29.2%) had LDP and 2415 (70.8%) had ODP. ODP had higher odds of readmission [odds ratio (OR) 1.681, p = 0.01] and longer hospital stay [β 1.745, p = 0.004]. No difference was found for 30-day mortality [OR 1.689, p = 0.303], 90-day mortality [OR 1.936, p = 0.207], and overall survival [HR 1.231, p = 0.057]. The highest-volume centers had improved odds of AC [OR 1.275, p = 0.027] regardless of approach. LDP conferred lower margin positivity [OR 0.581, p = 0.005], increased AC use [3rd quartile: OR 1.844, p = 0.026; 4th quartile; OR 2.144, p = 0.045], and fewer AC delays [4th quartile: OR 0.786, p = 0.045] in higher-volume centers.

CONCLUSIONS

In selected patients, LDP offers an oncologically safe alternative to ODP for PDAC independent of institutional volume. However, additional oncologic benefit due to optimal AC utilization and lower positive margin rates in higher volume centers suggests that LDP by experienced teams can achieve best possible cancer outcomes.

Laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic cancer: a single-institution comparative study

Background

Laparoscopic distal pancreatosplenectomy is an effective and safe surgical modality for treating benign and borderline distal pancreatic tumors, but rarely for pancreatic cancer. This study aimed to compare the feasibility and safety of laparoscopic and open radical antegrade modular pancreatosplenectomy for pancreatic cancer.

Methods

Fifty-one patients with pancreatic cancer who underwent radical antegrade modular pancreatosplenectomy at Ningbo Medical Center Lihuili Hospital between January 2014 and July 2018 were enrolled. 20 patients underwent laparoscopic radical antegrade modular pancreatosplenectomy and 31 patients received open radical antegrade modular pancreatosplenectomy. Postoperative and short-term outcomes of the two groups of patients were analyzed.

Results

The mean operation time, length of postoperative hospital stay, and overall postoperative morbidity were similar in the two groups (P>0.05). The laparoscopic radical antegrade modular pancreatosplenectomy group lost less blood (252.5±198.3 vs. 472.6±428.0 mL, P=0.037) and had lower transfusion rates (10.0% vs. 35.4%, P=0.041) than the open radical antegrade modular pancreatosplenectomy group. The laparoscopic group also had statistically significantly earlier passing of first flatus (2.5±0.8 vs. 3.2±1.2 days, P=0.028) and first oral intake (2.9±1.0 vs. 3.7±1.6 days, P=0.042). Furthermore, the rates of postoperative pancreatic fistula (45.0% vs. 32.3%) and overall complications (70.0% vs. 74.2%) were not statistically difference between the two groups. The survival rates at 6 months, 1 year, and 2 years after surgery were not statistically difference between the laparoscopic and open groups (94.4% vs. 93.5, 67.0% vs. 78.0%, and 50.2% vs. 38.3%, respectively).

Conclusions

The results of this study show that laparoscopic radical antegrade modular pancreatosplenectomy is feasible and safe for the treatment of pancreatic cancer.

Variation in Hospital Utilization of Minimally Invasive Distal Pancreatectomy for Localized Pancreatic Neoplasms

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) for localized neoplasms has been demonstrated to be feasible and safe. However, national adoption of the technique is poorly understood. Objectives of this study were to identify factors associated with use of minimally invasive distal pancreatectomy for localized neoplasms and assess hospital variation in MIDP utilization.

METHODS

Retrospective cohort study of patients with pancreatic cysts, stage I pancreatic ductal adenocarcinoma, and stage I pancreatic neuroendocrine tumors undergoing distal pancreatectomy from the ACS NSQIP Pancreas Targeted Dataset. Factors associated with use of MIDP were identified using multivariable logistic regression and hospital-level variation was assessed.

RESULTS

Analysis included 3,059 patients at 139 hospitals. Overall, 64.5% of patients underwent minimally invasive distal pancreatectomy. Patients were more likely to undergo MIDP if they had lower ASA classification (P = 0.004) or BMI ≥ 30 (P < 0.001) and less likely if they had pancreatic adenocarcinoma (P < 0.001). There was notable hospital variability in utilization (range 0 to 100% of cases). Hospital-level utilization of minimally invasive distal pancreatectomy did not appear to be driven by patient selection, as hierarchical analysis demonstrated that only 1.8% of observed hospital variation was attributable to measured patient selection factors.

CONCLUSION

Utilization of MIDP for localized pancreatic neoplasms is highly variable. While some patient-level factors are associated with MIDP use, hospital adoption of MIDP appears to be the primary driver of utilization. Monitoring hospital-level use of MIDP may be a useful quality measure to monitor uptake of emerging techniques in pancreatic surgery.

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.

Does tumor size influence the outcome of laparoscopic distal pancreatectomy?

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned.

METHODS

Patients who underwent LDP for pancreatic solitary tumors in 1997-2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5 cm (group I); from 3.5 cm to 7.0 cm (group II), and ≥7 cm (group III).

RESULTS

218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5 mm (p < 0.001). Nine procedures (2.1%) were converted including 1(0.5%), 5(3.4%) and 3(5.2%) in the groups I, II and III (p = 0.036). Median operative time was longer in the group III compared with the groups I and II - 195 vs 158 and 159 min (p = 0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R = 0.103; P = 0.035) and no correlation between tumor size and blood loss (R = 0.075; P = 0.125). Hospital stay was 5 days, similar in all groups.Postoperative morbidity was similar - 38.5, 32 and 34% in the group I, II and III.

CONCLUSION

LDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.

Advanced laparoscopic HPB surgery: Experience in Seoul National University Bundang Hospital

The worldwide trend in surgery has moved from open surgery to minimally invasive surgery. Likewise, the application of minimally invasive surgery in the hepato-pancreato-biliary (HBP) field is also rapidly expanding. The field of HBP surgery can be divided into liver, pancreas and biliary fields. Minimally invasive liver surgery is recently developed. However, laparoscopic liver resection in difficult areas is challenging. However, with the accumulation of experiences, laparoscopic liver resection for difficult areas is performed more than before. With more propagation, more and more liver resection will be performed by laparoscopic approach. In minimally surgery for the pancreas, distal pancreatectomy has become a well-recommended procedure in benign and borderline malignancy. There have been several systemic reviews that show advantages of laparoscopic distal pancreatectomy. The reports on laparoscopic pancreaticoduodenectomy (PD) are slowly increasing in spite of technical difficulty, with several systemic reviews showing advantages of the procedure. However, more PD will be performed as robotic-assisted procedures in the future. The laparoscopic surgery for biliary tract malignancy is still in early stages. The laparoscopic surgery for gallbladder cancer has been contraindicated, although there have been encouraging reports from expert centers. The laparoscopic surgery for Klatskin tumor is still an experimental procedure. Robotic-assisted procedures for the surgery of cholangiocarcinoma will be the future. Robotic-assisted surgery for the HBP field is still not well-developed. However, with the necessity of more precise manipulation like intracorporeal suturing, robotic-assisted surgery will be used more often in the field of HBP surgery.

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.