1
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Jones LR, Zwart MJW, de Graaf N, Wei K, Qu L, Jiabin J, Ningzhen F, Wang SE, Kim H, Kauffmann EF, de Wilde RF, Molenaar IQ, Chao YJ, Moraldi L, Saint-Marc O, Nickel F, Peng CM, Kang CM, Machado M, Luyer MDP, Lips DJ, Bonsing BA, Hackert T, Shan YS, Groot Koerkamp B, Shyr YM, Shen B, Boggi U, Liu R, Jang JY, Besselink MG, Abu Hilal M. Learning curve stratified outcomes after robotic pancreatoduodenectomy: International multicenter experience. Surgery 2024:S0039-6060(24)00375-1. [PMID: 39164152 DOI: 10.1016/j.surg.2024.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 01/30/2024] [Accepted: 05/21/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Robotic pancreatoduodenectomy is increasingly being implemented worldwide, with good results reported from individual expert centers. However, it is unclear to what extent outcomes will continue to improve during the learning curve, as large international studies are lacking. METHODS An international retrospective multicenter case series, including consecutive patients after robotic pancreatoduodenectomy from 18 centers in 8 countries in Europe, Asia, and South America until December 31, 2019, was conducted. A cumulative sum analysis was performed to determine the inflection points for the feasibility (operative time and blood loss) and proficiency (postoperative pancreatic fistula grade B/C and major morbidity) learning curves. Outcomes were compared in 3 groups on the basis of the learning curve inflection points. RESULTS Overall, 2,186 patients after robotic pancreatoduodenectomy were included. The feasibility learning curve was reached after 30-45 robotic pancreatoduodenectomy procedures and the proficiency learning curve after 90 robotic pancreatoduodenectomy procedures. These inflection points created 3 phases, which were associated with major morbidity (24.7%, 23.4%, and 12.3%, P < .001) but not 30-day mortality (2.1%, 2.0%, and 1.5%, P = .670). Other outcomes mostly continued to improve, including median operative time 432, 390, and 300 minutes (P < .0001), conversion 6.0%, 4.7%, and 2.7% (P = .002), bile leakage 7.2%, 4.1%, and 2.4% (P < .001), postpancreatectomy hemorrhage 6.5%, 6.1%, and 1.8% (n = 21) but not R0 resection (pancreatic ductal adenocarcinoma only) 78.5%, 73.9%, and 82.8% (P = .35), and 90-day mortality rate 3.1%, 3.5%, and 2.1% (P = .191). Centers performing >20 robotic pancreatoduodenectomies annually had lower rates of conversion, reoperation, and shorter median operative time as compared with centers performing 10-20 robotic pancreatoduodenectomies annually. CONCLUSION This international multicenter study demonstrates that most outcomes of robotic pancreatoduodenectomy continued to improve during 3 learning curve phases without a negative effect on 90-day mortality. Randomized studies are needed in high-volume centers that have surpassed the first learning curves, to compare these outcomes with the open approach.
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Affiliation(s)
- Leia R Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Maurice J W Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Nine de Graaf
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Kongyuan Wei
- Department of Surgery, Chinese PLA General Hospital, Beijing, China
| | - Liu Qu
- Department of Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jin Jiabin
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Fu Ningzhen
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, Taiwan
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Emanuele F Kauffmann
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, the Netherlands
| | - Ying Jui Chao
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Luca Moraldi
- Department of Surgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Felix Nickel
- Department of Surgery, University Hospital of Heidelberg, Germany
| | - Cheng-Ming Peng
- Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chang Moo Kang
- Department of Surgery, Yonsei University Severance Hospital, Sinchon-dong, South Korea
| | - Marcel Machado
- Department of Surgery, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - Thilo Hackert
- Department of Surgery, University Hospital of Heidelberg, Germany
| | - Yan-Shen Shan
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital, Taiwan
| | - Baiyong Shen
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rong Liu
- Department of Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, University Hospital Southampton NHS, United Kingdom.
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2
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Korrel M, van Hilst J, Bosscha K, Busch ORC, Daams F, van Dam R, van Eijck CHJ, Festen S, Groot Koerkamp B, van der Harst E, Lips DJ, Luyer MD, de Meijer VE, Mieog JSD, Molenaar IQ, Patijn GA, van Santvoort HC, van der Schelling GP, Stommel MWJ, Besselink MG. Nationwide use and Outcome of Minimally Invasive Distal Pancreatectomy in IDEAL Stage IV following a Training Program and Randomized Trial. Ann Surg 2024; 279:323-330. [PMID: 37139822 DOI: 10.1097/sla.0000000000005900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To assess the nationwide long-term uptake and outcomes of minimally invasive distal pancreatectomy (MIDP) after a nationwide training program and randomized trial. BACKGROUND Two randomized trials demonstrated the superiority of MIDP over open distal pancreatectomy (ODP) in terms of functional recovery and hospital stay. Data on implementation of MIDP on a nationwide level are lacking. METHODS Nationwide audit-based study including consecutive patients after MIDP and ODP in 16 centers in the Dutch Pancreatic Cancer Audit (2014 to 2021). The cohort was divided into three periods: early implementation, during the LEOPARD randomized trial, and late implementation. Primary endpoints were MIDP implementation rate and textbook outcome. RESULTS Overall, 1496 patients were included with 848 MIDP (56.5%) and 648 ODP (43.5%). From the early to the late implementation period, the use of MIDP increased from 48.6% to 63.0% and of robotic MIDP from 5.5% to 29.7% ( P <0.001). The overall use of MIDP (45% to 75%) and robotic MIDP (1% to 84%) varied widely between centers ( P <0.001). In the late implementation period, 5/16 centers performed >75% of procedures as MIDP. After MIDP, in-hospital mortality and textbook outcome remained stable over time. In the late implementation period, ODP was more often performed in ASA score III-IV (24.9% vs. 35.7%, P =0.001), pancreatic cancer (24.2% vs. 45.9%, P <0.001), vascular involvement (4.6% vs. 21.9%, P <0.001), and multivisceral involvement (10.5% vs. 25.3%, P <0.001). After MIDP, shorter hospital stay (median 7 vs. 8 d, P <0.001) and less blood loss (median 150 vs. 500 mL, P <0.001), but more grade B/C postoperative pancreatic fistula (24.4% vs. 17.2%, P =0.008) occurred as compared to ODP. CONCLUSION A sustained nationwide implementation of MIDP after a successful training program and randomized trial was obtained with satisfactory outcomes. Future studies should assess the considerable variation in the use of MIDP between centers and, especially, robotic MIDP.
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Affiliation(s)
- Maarten Korrel
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
| | - Jony van Hilst
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Department of Surgery, OLVG Oost, Amsterdam
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch
| | - Olivier R C Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
| | - Freek Daams
- Cancer Center Amsterdam
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery, Amsterdam
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht
| | | | | | | | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht
| | | | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
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3
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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.
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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
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4
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Pagano D, Li Petri S, di Francesco F, Calamia S, Accardo C, Vella I, Barbàra M, Gruttadauria S. Which Factors Are Associated with Distal Pancreatectomy Outcomes' Optimization with the Application of an Enhanced Recovery After Surgery Program? J Laparoendosc Adv Surg Tech A 2024; 34:106-112. [PMID: 38029364 DOI: 10.1089/lap.2023.0445] [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] [Indexed: 12/01/2023] Open
Abstract
Background: Distal pancreatectomy (DP) represents the best therapeutic option for patients with body-tail pancreatic neoplasms (PNs). The enhanced recovery after surgery protocol is widely used for treating patients with PN to speed up postoperative recovery. This study aims to describe our institute's experience in the application of fast recovery protocol in a cohort of patients treated with DP, identifying predictors facilitating a decrease in the length of hospital stay. Patient and Methods: Were retrospectively enrolled 60 consecutive cases of DP performed from January 2016 to June 2022 in patients treated with enhanced recovery protocol, 25% of them were treated with spleen preserving procedure. Single-variable logistic regression models were used to evaluate the potential association between patient characteristics and the probability of postoperative complications. Standard linear regression models were used for length of stay, number of postoperative days (PODs) from surgery to full bowel function recovery, and PODs to the interruption of intravenous analgesia administration. Results: Thirty-four (57%) patients underwent open surgery and 26 (43%) laparoscopic surgery. Patients who underwent laparoscopic surgery and spleen-preserving procedures experienced a lower complication rate (P = .037), shorter length of stay, and time of analgesic requirements. With single-variable logistic regression models patients treated with laparoscopic surgery had statistically significant higher recovery times in terms of nasogastric tube removal (P = .004) and early enteral nutrition (P = .001). Conclusion: Continual refinement with enhanced recovery protocol for treating PN patients based on perioperative counseling and surgical decision-making is crucial to reduce patient morbidity and time for recovery.
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Affiliation(s)
- Duilio Pagano
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Sergio Li Petri
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Sergio Calamia
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Caterina Accardo
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Ivan Vella
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Marco Barbàra
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy
- Department of Surgery and Surgical and Medical Specialties, University of Catania, Catania, Italy
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5
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Dagorno C, Marique L, Korrel M, de Graaf N, Thouny C, Renault G, Ftériche FS, Aussilhou B, Maire F, Lévy P, Rebours V, Lesurtel M, Sauvanet A, Dokmak S. Long-term quality of life is better after laparoscopic compared to open pancreatoduodenectomy. Surg Endosc 2024; 38:769-779. [PMID: 38052888 DOI: 10.1007/s00464-023-10581-1] [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: 08/06/2023] [Accepted: 11/04/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Three randomized controlled trials have reported improved functional recovery after Laparoscopic pancreatoduodenectomy (LPD), as compared to open pancreatoduodenectomy (OPD). Long-term results regarding quality of life (QoL) are lacking. The aim of this study was to compare long-term QoL of LPD versus OPD. METHODS AND PATIENTS A monocentric retrospective cross-sectional study was performed among patients < 75 years old who underwent LPD or OPD for a benign or premalignant pathology in a high-volume center (2011-2021). An electronic three-part questionnaire was sent to eligible patients, including two diseases specific QoL questionnaires (the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire for cancer (QLQ-C30) and a pancreatic cancer module (PAN26) and a body image questionnaire. Patient demographics and postoperative data were collected and compared between LPD and OPD. RESULTS Among 948 patients who underwent PD (137 LPD, 811 OPD), 170 were eligible and 111 responded (58 LPD and 53 OPD). LPD versus OPD showed no difference in mean age (51 vs. 55 years, p = 0.199) and female gender (40% vs. 45%, p = 0.631), but LPD showed lower BMI (24 vs 26; p = 0.028) and higher preoperative pancreatitis (29% vs 13%; p = 0.041). The postoperative outcome showed similar Clavien-Dindo ≥ III morbidity (19% vs. 23%; p = 0.343) and length of stay (24 vs. 21 days, p = 0.963). After a similar median follow-up (3 vs. 3 years; p = 0.122), LPD vs OPD patients reported higher QoL (QLQ-C30: 49.6 vs 56.3; p = 0.07), better pancreas specific health status score (PAN20: 50.5 vs 55.5; p = 0.002), physical functioning (p = 0.002), and activities limitations (p = 0.02). Scar scores were better after LPD regarding esthetics (p = 0.001), satisfaction (p = 0.04), chronic pain at rest (p = 0.036), moving (p = 0.011) or in daily activities (p = 0.02). There was no difference in digestive symptoms (p = 0.995). CONCLUSION This monocentric study found improved long-term QoL in patients undergoing LPD, as compared to OPD, for benign and premalignant diseases. These results could be considered when choosing the surgical approach in these patients.
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Affiliation(s)
- Claire Dagorno
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Lancelot Marique
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Maarten Korrel
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Camille Thouny
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Gilles Renault
- Plateforme d'Imagerie du Vivant (PIV), Hôpital Cochin, Paris, France
| | - Fadhel Samir Ftériche
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Béatrice Aussilhou
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Frédérique Maire
- Department of Pancreatology, APHP, Hôpital Beaujon, DMU DIGEST, Clichy, France
| | - Philippe Lévy
- Department of Pancreatology, APHP, Hôpital Beaujon, DMU DIGEST, Clichy, France
- Université de Paris Cité, Paris, France
| | - Vinciane Rebours
- Department of Pancreatology, APHP, Hôpital Beaujon, DMU DIGEST, Clichy, France
- Université de Paris Cité, Paris, France
| | - Mickael Lesurtel
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France
- Université de Paris Cité, Paris, France
| | - Alain Sauvanet
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France
- Université de Paris Cité, Paris, France
| | - Safi Dokmak
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, APHP, Hôpital Beaujon, DMU DIGEST, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
- Université de Paris Cité, Paris, France.
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6
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Ricci C, Kauffmann EF, Pagnanelli M, Fiorillo C, Ferrari C, De Blasi V, Panaro F, Rosso E, Zerbi A, Alfieri S, Boggi U, Casadei R. Minimally invasive versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma: an entropy balancing analysis. HPB (Oxford) 2024; 26:44-53. [PMID: 37775352 DOI: 10.1016/j.hpb.2023.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 06/25/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The safety and efficacy of minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS) remain to be established in pancreatic cancer (PDAC) METHODS: Eighty-five open (O)-RAMPS were compared to 93 MI-RAMPS. The entropy balance matching approach was used to compare the two cohorts, eliminating the selection bias. Three models were created. Model 1 made O-RAMPS equal to the MI-RAMPS cohort (i.e., compared the two procedures for resectable PDAC); model 2 made MI-RAMPS equal to O-RAMPS (i.e., compared the two procedures for borderline-resectable PDAC); model 3, compared robotic and laparoscopic RAMPS. RESULTS O-RAMPS and MI-RAMPS showed "non-small" differences for BMI, comorbidity, back pain, tumor size, vascular resection, anterior or posterior RAMPS, multi-visceral resection, stump management, grading, and neoadjuvant therapy. Before reweighting, O-RAMPS had fewer clinically relevant postoperative pancreatic fistulae (CR-POPF) (20.0% vs. 40.9%; p = 0.003), while MI-RAMPS had a higher mean of lymph nodes (25.7 vs. 31.7; p = 0.011). In model 1, MI-RAMPS and O-RAMPS achieved similar results. In model 2, O-RAMPS was associated with lower comprehensive complication index scores (MD = 11.2; p = 0.038), and CR-POPF rates (OR = 0.2; p = 0.001). In model 3, robotic-RAMPS had a higher probability of negative resection margins. CONCLUSION In patients with anatomically resectable PDAC, MI-RAMPS is feasible and as safe as O-RAMPS.
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Affiliation(s)
- Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy.
| | | | - Michele Pagnanelli
- Section of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Rome, Italy; CRMPG (Gemelli Pancreatic Advanced Research Center), Italy
| | - Cecilia Ferrari
- Department of Digestive Surgery and Transplantation, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier University, Montpellier, France
| | - Vito De Blasi
- Department of Surgery, Centre Hospitalier de Luxembourg, Luxembourg
| | - Fabrizio Panaro
- Department of Digestive Surgery and Transplantation, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier University, Montpellier, France
| | - Edoardo Rosso
- Department of Surgery, Centre Hospitalier de Luxembourg, Luxembourg
| | - Alessandro Zerbi
- Section of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Rome, Italy; CRMPG (Gemelli Pancreatic Advanced Research Center), Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
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Espin Alvarez F, García-Domingo MI, Cremades Pérez M, Pardo Aranda F, Vidal Piñeiro L, Herrero Fonollosa E, Navinés López J, Zárate Pinedo A, Camps-Lasa J, Cugat Andorrà E. Laparoscopic and robotic distal pancreatectomy: the choice and the future. Cir Esp 2023; 101:765-771. [PMID: 37119949 DOI: 10.1016/j.cireng.2023.04.017] [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: 09/29/2022] [Revised: 01/03/2023] [Accepted: 02/21/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION Distal pancreatectomy (DP) is currently well established as a minimally invasive surgery (MIS) procedure, using either a laparoscopic (LDP) or robotic (RDP) approach. METHODS Out of 83 DP performed between January 2018 and March 2022, 57 cases (68.7%) were performed using MIS: 35 LDP and 22 RDP (da Vinci Xi). We have assessed the experience with the two techniques and analyzed the value of the robotic approach. Cases of conversion have been examined in detail. RESULTS The mean operative times for LDP and RDP were 201.2 (SD 47.8) and 247.54 (SD 35.8) minutes, respectively (P = NS). No differences were observed in length of hospital stay or conversion rate: 6 (5-34) vs. 5.6 (5-22) days, and 4 (11.4%) vs. 3 (13.6%) cases, respectively (P = NS). The readmission rate was 3/35 patients (11.4%) treated with LDP and 6/22 (27.3%) cases of RDP (P = NS). There were no differences in morbidity (Dindo-Clavien ≥ III) between the two groups. Mortality was one case in the robotic group (a patient with early conversion due to vascular involvement). The rate of R0 resection was greater and statistically significant in the RDP group (77.1% vs. 90.9%) (P = .04). CONCLUSION Minimally invasive distal pancreatectomy (MIDP) is a safe and feasible procedure in selected patients. Surgical planning and stepwise implementation based on prior experience help surgeons successfully perform technically demanding procedures. RDP could be the approach of choice in distal pancreatectomy, and it is not inferior to LDP.
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Affiliation(s)
- Francisco Espin Alvarez
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain.
| | - María Isabel García-Domingo
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Spain
| | - Manel Cremades Pérez
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain
| | - Fernando Pardo Aranda
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain
| | - Laura Vidal Piñeiro
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain
| | - Eric Herrero Fonollosa
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Spain
| | - Jordi Navinés López
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain
| | - Alba Zárate Pinedo
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain
| | - Judith Camps-Lasa
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Spain
| | - Esteban Cugat Andorrà
- Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain; Unidad de Cirugía de Hepatobiliopancreática, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Spain
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8
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Chang JH, Hossain MS, Stackhouse K, Dahdaleh F, Denbo J, Augustin T, Simon R, Joyce D, Matthew Walsh R, Naffouje S. The role of minimally invasive surgery in resectable distal pancreatic adenocarcinoma. HPB (Oxford) 2023; 25:1213-1222. [PMID: 37357114 DOI: 10.1016/j.hpb.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/10/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND In distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), we hypothesize that minimally invasive DP (MIDP) carries short-term benefits over ODP (ODP) in the absence of postoperative pancreatic fistula (POPF). METHODS NSQIP database was queried to select patients who underwent DP for PDAC with available report on POPF. The population was divided into No-POPF vs. POPF groups. In each group, propensity-score matching was applied to compare 30-day outcomes of ODP vs. MIDP. RESULTS There were 2,824 patients; 2,332 (82%) had No-POPF and 492 (21%) had POPF. In No-POPF patients, 921 pairs were matched between ODP and MIDP. MIDP patients had slightly longer operations (227 vs. 205 minutes; p < 0.001), but lower rates of surgical site complications (1% vs. 2.9%; p = 0.002), postoperative transfusion (7.1% vs. 11.0%; p = 0.003), overall morbidity (21.1% vs. 26.3%; p = 0.009), and one-day shorter median length of stay (LOS) (5 vs. 6 days; p = 0.001). In the POPF group, 172 pairs were matched. There was no difference in morbidity, mortality, reoperation, LOS, and home discharge. Similar conclusions were drawn in the intention-to-treat and per-protocol analyses. CONCLUSION POPF is common following DP for PDAC. In the absence of POPF, MIDP is associated with fewer postoperative morbidities and shorter LOS.
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Affiliation(s)
- Jenny H Chang
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA
| | - Mir S Hossain
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA
| | - Kathryn Stackhouse
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA
| | - Fadi Dahdaleh
- Edward-Elmhurst Medical Group, Department of Surgical Oncology, Naperville, IL, USA
| | - Jason Denbo
- H. Lee Moffitt Cancer Center & Research Institute, Department of Gastrointestinal Oncology, Tampa, FL, USA
| | - Toms Augustin
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA
| | - Robert Simon
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA
| | - Daniel Joyce
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA
| | - R Matthew Walsh
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA
| | - Samer Naffouje
- Cleveland Clinic, Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland, OH, USA.
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9
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Nicolais L, Mohamed A, Fitzgerald TL. Minimally invasive distal pancreatectomy for adenocarcinoma of the pancreas. Surg Oncol 2023; 50:101970. [PMID: 37459676 DOI: 10.1016/j.suronc.2023.101970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/07/2023] [Accepted: 07/01/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Minimally invasive (MI) surgery has been widely adopted to treat left-sided pancreatic cancer. However, outcomes are not clearly defined. MATERIALS Retrospective cohort study utilizing NCDB and NSQIP data. RESULTS Patients undergoing distal pancreatectomy for pancreatic adenocarcinoma from 2004 to 2016 were included (n = 7347). Utilizing NSQIP (n = 2406), patients were divided into two groups: intention-to-treat (ITT) MI (including MI converted to open, n = 929) and open (n = 1477). Patients undergoing open pancreatectomy were more likely to have longer length of stay (6 vs. 5 days, p=<0.001). On multivariate analysis, open procedures were not associated with mortality (OR 1.24; CI 0.51-3.30, p = 0.64), serious complications (OR 1.03; CI 0.90-1.37, p = 0.79), and any complications (OR 1.07; CI 0.86-1.32, p = 0.56). NCDB patients (n = 4941) were also divided into two groups, ITT MI (n = 1,769, 36%) and open group (n = 3,172, 64%). The median survival was lower in open procedure patients, 23 vs. 27.1 months (p < 0.001). This finding was maintained on multivariable analysis (HR 1.16; CI 1.03-1.32, p = 0.017). CONCLUSION Based on these data, MI distal pancreatectomy could be considered a standard of care for pancreatic cancer when technically feasible. Although morbidity and mortality were similar, the laparoscopic approach had a shorter length of stay and could hasten recovery.
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Affiliation(s)
- Laura Nicolais
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA
| | - Abdimajid Mohamed
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA
| | - Timothy L Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA.
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10
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Ota M, Asakuma M, Taniguchi K, Ito Y, Komura K, Tanaka T, Yamakawa K, Ogura T, Nishioka D, Hirokawa F, Uchiyama K, Lee SW. Short-term Outcomes of Laparoscopic and Open Distal Pancreatectomy Using Propensity Score Analysis: A Real-world Retrospective Cohort Study. Ann Surg 2023; 278:e805-e811. [PMID: 36398656 DOI: 10.1097/sla.0000000000005758] [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: 11/19/2022]
Abstract
OBJECTIVE This study aimed to compare the short-term outcomes between laparoscopic and open distal pancreatectomy for lesions of the distal pancreas from a real-world database. BACKGROUND Reports on the benefits of laparoscopic distal pancreatectomy include 2 randomized controlled trials; however, large-scale, real-world data are scarce. METHODS We analyzed the data of patients undergoing laparoscopic or open distal pancreatectomy for benign or malignant pancreatic tumors from April 2008 to May 2020 from a Japanese nationwide inpatient database. We performed propensity score analyses to compare the inhospital mortality, morbidity, readmission rate, reoperation rate, length of postoperative stay, and medical cost between the 2 groups. RESULTS From 5502 eligible patients, we created a pseudopopulation of patients undergoing laparoscopic and open distal pancreatectomy using inverse probability of treatment weighting. Laparoscopic distal pancreatectomy was associated with lower inhospital mortality during the period of admission (0.0% vs 0.7%, P <0.001) and within 30 days (0.0% vs 0.2%, P =0.001), incidence of reoperation during the period of admission (0.7% vs 1.7%, P =0.018), postpancreatectomy hemorrhage (0.4% vs 2.0%, P <0.001), ileus (1.1% vs 2.8%, P =0.007), and shorter postoperative length of stay (17 vs 20 d, P <0.001). CONCLUSIONS The propensity score analysis revealed that laparoscopic distal pancreatectomy was associated with better outcomes than open surgery in terms of inhospital mortality, reoperation rate, postoperative length of stay, and incidence of postoperative complications such as postpancreatectomy hemorrhage and ileus.
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Affiliation(s)
- Masato Ota
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Mitsuhiro Asakuma
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Kohei Taniguchi
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Yuri Ito
- Department of Medical Statistics, Research and Development Center, Osaka Medical and Pharmaceutical University
| | - Kazumasa Komura
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Tomohito Tanaka
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Kazuma Yamakawa
- Translational Research Program, Osaka Medical and Pharmaceutical University
| | - Takeshi Ogura
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University
| | - Daisuke Nishioka
- Department of Medical Statistics, Research and Development Center, Osaka Medical and Pharmaceutical University
| | - Fumitoshi Hirokawa
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
| | - Sang-Woong Lee
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University
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11
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Kauffmann EF, Napoli N, Di Dato A, Salamone A, Ginesini M, Gianfaldoni C, Viti V, Amorese G, Cappelli C, Vistoli F, Boggi U. Practical implications of tumor proximity to landmark vessels in minimally invasive radical antegrade modular pancreatosplenectomy. Updates Surg 2023; 75:1533-1540. [PMID: 37458902 PMCID: PMC10435633 DOI: 10.1007/s13304-023-01584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/05/2023] [Indexed: 08/18/2023]
Abstract
Careful preoperative planning is key in minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS). This retrospective study aims to show the practical implications of computed tomography distance between the right margin of the tumor and either the left margin of the spleno-mesenteric confluence (d-SMC) or the gastroduodenal artery (d-GDA). Between January 2011 and June 2022, 48 minimally invasive RAMPS were performed for either pancreatic cancer or malignant intraductal mucinous papillary neoplasms. Two procedures were converted to open surgery (4.3%). Mean tumor size was 31.1 ± 14.7 mm. Mean d-SMC was 21.5 ± 18.5 mm. Mean d-GDA was 41.2 ± 23.2 mm. A vein resection was performed in 10 patients (20.8%) and the pancreatic neck could not be divided by an endoscopic stapler in 19 operations (43.1%). In patients requiring a vein resection, mean d-SMC was 10 mm (1.5-15.5) compared to 18 mm (10-37) in those without vein resection (p = 0.01). The cut-off of d-SMC to perform a vein resection was 17 mm (AUC 0.75). Mean d-GDA was 26 mm (19-39) mm when an endoscopic stapler could not be used to divide the pancreas, and 46 mm (30-65) when the neck of the pancreas was stapled (p = 0.01). The cut-off of d-GDA to safely pass an endoscopic stapler behind the neck of the pancreas was 43 mm (AUC 0.75). Computed tomography d-SMC and d-GDA are key measurements when planning for MI-RAMPS.
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Affiliation(s)
- Emanuele Federico Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Virginia Viti
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carla Cappelli
- Diagnostic and Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
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12
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Fernandes EDSM, de Mello FPT, Braga EP, de Souza GO, Andrade R, Pimentel LS, Girão CL, Siqueira M, Moraes-Junior JMA, de Oliveira RV, Goldaracena N, Torres OJM. A more radical perspective on surgical approach and outcomes in pancreatic cancer-a narrative review. J Gastrointest Oncol 2023; 14:1964-1981. [PMID: 37720458 PMCID: PMC10502544 DOI: 10.21037/jgo-22-763] [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: 08/09/2022] [Accepted: 12/30/2022] [Indexed: 09/19/2023] Open
Abstract
Background and Objective Pancreatic adenocarcinoma remains a dismal disease and is expected to become an even greater burden in the near future. This review focuses on the different surgical aspects for pancreaticoduodenectomy (PD), distal and total pancreatectomy (TP), incorporating lessons from both the western and eastern visions in treating pancreatic cancer. Methods We conducted an extensive literature review through PubMed, prioritizing papers published in the last 5 years, but older emblematic papers were also included. We included articles that explored the treatment of pancreatic adenocarcinoma, with focus on the surgical aspect and strategies to improve outcomes. References of selected articles were also reviewed to identify any missed studies. Only papers in English were included. Key Content and Findings As evidence continues to build, it is clear that both systemic and surgical therapies have a fundamental and complementary role. State of art surgical treatment encompasses complete mesopancreas excision for radical lymphadenectomy. Preoperative planning of dissection planes, extensive knowledge of vascular anatomic variations, oncological principles and expertise for vascular resections are mandatory to perform a more radical operation, in pursuit of improved outcomes. Conclusions Based on current data, patient selection remains key and a more radical surgical approach brings more accomplishing results bringing as to believe that more is better.
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Affiliation(s)
- Eduardo de Souza M. Fernandes
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Hospital Universitário Clementino Fraga Filho-UFRJ, Rio de Janeiro, RJ, Brazil
| | - Felipe Pedreira T. de Mello
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Eduardo Pinho Braga
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
| | - Gabrielle Oliveira de Souza
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
| | - Ronaldo Andrade
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Leandro Savattone Pimentel
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Camila Liberato Girão
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Munique Siqueira
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - José Maria A. Moraes-Junior
- Department of Hepatopancreatobiliary Surgery, São Domingos Hospital-Rede Dasa, São Luís, MA, Brazil
- Department of Gastrointestinal and Transplant Surgery, Hospital Presidente Dutra, São Luis, MA, Brazil
| | | | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Orlando Jorge M. Torres
- Department of Hepatopancreatobiliary Surgery, São Domingos Hospital-Rede Dasa, São Luís, MA, Brazil
- Department of Gastrointestinal and Transplant Surgery, Hospital Presidente Dutra, São Luis, MA, Brazil
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13
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Korrel M, Jones LR, van Hilst J, Balzano G, Björnsson B, Boggi U, Bratlie SO, Busch OR, Butturini G, Capretti G, Casadei R, Edwin B, Emmen AM, Esposito A, Falconi M, Groot Koerkamp B, Keck T, de Kleine RH, Kleive DB, Kokkola A, Lips DJ, Lof S, Luyer MD, Manzoni A, Marudanayagam R, de Pastena M, Pecorelli N, Primrose JN, Ricci C, Salvia R, Sandström P, Vissers FL, Wellner UF, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial. THE LANCET REGIONAL HEALTH. EUROPE 2023; 31:100673. [PMID: 37457332 PMCID: PMC10339208 DOI: 10.1016/j.lanepe.2023.100673] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023]
Abstract
Background The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking. Methods In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of -7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265). Findings Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI -6.2 to 13.6%; pnon-inferiority = 0.039). Median lymph node yield was comparable (22.0 [16.0-30.0] vs 23.0 [14.0-32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0-30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5-5.5] vs 5 [95% CI 4.7-5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67-1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group. Interpretation This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer. Funding Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.
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Affiliation(s)
- Maarten Korrel
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Leia R. Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Jony van Hilst
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Gianpaolo Balzano
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bergthor Björnsson
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olivier R. Busch
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Giovanni Capretti
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Bjørn Edwin
- The Intervention Center, Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anouk M.L.H. Emmen
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Massimo Falconi
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Ruben H.J. de Kleine
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dyre B. Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Arto Kokkola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Daan J. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Sanne Lof
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Misha D.P. Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Nicolò Pecorelli
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - John N. Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Claudio Ricci
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Per Sandström
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Frederique L.I.M. Vissers
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marcel G.W. Dijkgraaf
- Amsterdam UMC, University of Amsterdam, Department of Epidemiology and Data Science, Amsterdam, the Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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14
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Johansen K, Lindhoff Larsson A, Lundgren L, Gasslander T, Hjalmarsson C, Sandström P, Lyth J, Henriksson M, Björnsson B. Laparoscopic distal pancreatectomy is more cost-effective than open resection: results from a Swedish randomized controlled trial. HPB (Oxford) 2023:S1365-182X(23)00138-7. [PMID: 37198071 DOI: 10.1016/j.hpb.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/21/2023] [Accepted: 04/30/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy is being implemented worldwide. The aim of this study was to perform a cost-effectiveness analysis from a health care perspective. METHODS This cost-effectiveness analysis was based on the randomized controlled trial LAPOP, where 60 patients were randomized to open or laparoscopic distal pancreatectomy. For the follow-up of two years, resource use from a health care perspective was recorded, and health-related quality of life was assessed using the EQ-5D-5L. The per-patient mean cost and quality-adjusted life years (QALYs) were compared using nonparametric bootstrapping. RESULTS Fifty-six patients were included in the analysis. The mean health care costs were lower, €3863 (95% CI: -€8020 to €385), for the laparoscopic group. Postoperative quality of life improved with laparoscopic resection and resulted in a gain in QALYs of 0.08 (95% CI: -0.09 to 0.25). The laparoscopic group had lower costs and improved QALYs in 79% of bootstrap samples. With a cost-per-QALY threshold of €50 000, 95.4% of the bootstrap samples were in favour of laparoscopic resection. CONCLUSION Laparoscopic distal pancreatectomy is associated with numerically lower health care costs and improvements in QALYs compared with the open approach. The results support the ongoing transition from open to laparoscopic distal pancreatectomies.
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Affiliation(s)
- Karin Johansen
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anna Lindhoff Larsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Linda Lundgren
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas Gasslander
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Per Sandström
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Lyth
- Centre for Medical Technology Assessment, Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Martin Henriksson
- Centre for Medical Technology Assessment, Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
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15
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Concors SJ, Katz MHG, Ikoma N. Minimally Invasive Pancreatectomy: Robotic and Laparoscopic Developments. Surg Oncol Clin N Am 2023; 32:327-342. [PMID: 36925189 DOI: 10.1016/j.soc.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Minimally invasive pancreatectomy is increasingly used. Although offering potential advantages over open approaches, minimally invasive pancreatectomy has many challenges to maintain high-quality of oncologic resection. Multiple patient and surgical factors should be considered in planning laparoscopic or robotic resection, including the learning curve required to produce proficiency. For pancreaticoduodenectomy, distal pancreatectomy, and other pancreatic resections, a safe, margin-negative resection remains the goal. National and societal guidelines for the adoption of minimally invasive pancreatectomy are ongoing and will continue to be important as these techniques are further adopted.
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Affiliation(s)
- Seth J Concors
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler, FCT 17.6022, Houston, TX 77030, USA. https://twitter.com/SethConcorsMD
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler, FCT 17.6022, Houston, TX 77030, USA. https://twitter.com/MKatzMD
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler, FCT 17.6022, Houston, TX 77030, USA.
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16
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Cucchetti A, Bocchino A, Crippa S, Solaini L, Partelli S, Falconi M, Ercolani G. Advantages of laparoscopic distal pancreatectomy: Systematic review and meta-analysis of randomized and matched studies. Surgery 2023; 173:1023-1029. [PMID: 36564287 DOI: 10.1016/j.surg.2022.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/31/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND We sought to provide a meta-analysis and credibility assessment of available randomized controlled trials and propensity score matched studies when assessing early and oncologic outcomes of laparoscopic distal pancreatectomy compared with open distal pancreatectomy. METHODS The MEDLINE, Scopus, Web of Science, and Cochrane databases were searched for pertinent literature up to June 2022. Random-effect meta-analyses were applied. Trial sequential analysis was applied to verify whether results were true- or false-positive or -negative findings. RESULTS Thirteen studies were identified (2 randomized controlled trials and 11 propensity score matched studies). The early outcomes were assessed on 12 studies, including 4,346 patients. In this population, laparoscopic distal pancreatectomy decreased postoperative stay (mean difference = 1.8 days; P = .001) and estimated blood loss (mean difference = 148 mL; P = .001), and trial sequential analysis confirmed these as true-positive findings. Laparoscopic distal pancreatectomy and open distal pancreatectomy had similar operating times (P = .165), and trial sequential analysis confirmed this as a true-negative finding. Major morbidity, mortality, and readmission were similar, but results were inconclusive by trial sequential analysis. Oncologic outcomes were assessed on 5 studies, including 2,430 patients. In this population, laparoscopic distal pancreatectomy showed higher R0 resection rate (OR = 1.46; P = .001) and shorter time to adjuvant therapy (mean difference 4.0 days P = .003). A survival benefit was observed at 1 year after laparoscopic distal pancreatectomy (OR = 1.45; P = .001), which was not confirmed at 3 years (P = .650). CONCLUSION Laparoscopic distal pancreatectomy is superior to open distal pancreatectomy for most of the early outcomes analyzed. The operating time was equalized as a result of the learning curve. Results from patients with pancreatic cancer suggest at least an oncologic noninferiority of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Antonio Bocchino
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Leonardo Solaini
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
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17
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Chen JW, van Ramshorst TME, Lof S, Al-Sarireh B, Bjornsson B, Boggi U, Burdio F, Butturini G, Casadei R, Coratti A, D'Hondt M, Dokmak S, Edwin B, Esposito A, Fabre JM, Ferrari G, Ftériche FS, Fusai GK, Groot Koerkamp B, Hackert T, Jah A, Jang JY, Kauffmann EF, Keck T, Manzoni A, Marino MV, Molenaar Q, Pando E, Pessaux P, Pietrabissa A, Soonawalla Z, Sutcliffe RP, Timmermann L, White S, Yip VS, Zerbi A, Abu Hilal M, Besselink MG. Robot-Assisted Versus Laparoscopic Distal Pancreatectomy in Patients with Resectable Pancreatic Cancer: An International, Retrospective, Cohort Study. Ann Surg Oncol 2023; 30:3023-3032. [PMID: 36800127 PMCID: PMC10085922 DOI: 10.1245/s10434-022-13054-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/22/2022] [Indexed: 02/18/2023]
Abstract
BACKGROUND Robot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking. METHODS An international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010-2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival. RESULTS In total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively. CONCLUSIONS In selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials.
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Affiliation(s)
- Jeffrey W Chen
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tess M E van Ramshorst
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Sanne Lof
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bergthor Bjornsson
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, University Hospital of Pisa, Pisa, Italy
| | - Fernando Burdio
- Department of Surgery, University Hospital del Mar, Barcelona, Spain
| | | | - Riccardo Casadei
- Department of Surgery, Sant'Orsola Malphigi Hospital, Bologna, Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Bjørn Edwin
- The Intervention Center, Department of Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Jean M Fabre
- Department of Surgery, Saint-Éloi Hospital, Montpellier, France
| | | | - Fadhel S Ftériche
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Asif Jah
- Department of HPB Surgery and Transplantation, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | | | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marco V Marino
- Department of Emergency and General Surgery, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elizabeth Pando
- Department of Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Patrick Pessaux
- Department of Hepato-Biliary and Pancreatic Surgery, Nouvel Hôpital Civil, Institut Hospitalo-Universitaire de Strasbourg, Strasbourg, France
| | - Andrea Pietrabissa
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, Birmingham, UK
| | | | - Steven White
- Department of Surgery, The Freeman Hospital, Newcastle Upon Tyne, Newcastle, UK
| | - Vincent S Yip
- Department of HPB Surgery, The Royal London Hospital, Bartshealth NHS Trust, London, UK
| | - Alessandro Zerbi
- Department of Surgery, Humanitas University and IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
| | - Marc G Besselink
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, The Netherlands. .,Cancer Center Amsterdam, Amsterdam, The Netherlands.
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18
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Dai M, Zhang H, Yang Y, Xiu D, Peng B, Sun B, Cao F, Wu Z, Wang L, Yuan C, Chen H, Wang Z, Tian X, Wang H, Liu W, Xu J, Liu Q, Zhao Y. The effect of minimally invasive or open radical antegrade modular pancreatosplenectomy on pancreatic cancer: A multicenter randomized clinical trial protocol. Front Oncol 2022; 12:965508. [PMID: 36185308 PMCID: PMC9521034 DOI: 10.3389/fonc.2022.965508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022] Open
Abstract
Background Radical antegrade modular pancreatosplenectomy (RAMPS) has been proven to improve R0 resection and lymph harvest in treating patients with distal pancreatic cancer. The development of minimally invasive surgery has advantages in postoperative recovery. Therefore, minimally invasive (MI-) RAMPS may combine the advantages of both benefits to improve survival. Nevertheless, evidence to validate the safety and efficacy of MI-RAMPS is limited. Method/Design The MIRROR trial will be the first multicenter prospective randomized clinical trial to investigate the outcome of MI-RAMPS. The hypothesis is that MI-RAMPS is superior in postoperative recovery. The primary outcome is the length of postoperative stay. Based on the hypothesis and primary outcome, the sample size is 250 patients (125 participants in each group). The trial will investigate factors related to surgical safety, short-term outcome, pathological assessment, and survival as secondary outcomes. Conclusion This study will offer a relatively higher level of evidence to further illustrate the accessibility and benefits of MI-RAMPS for the treatment of distal pancreatic cancer. Clinical Trial Registration Clinicaltrials.gov, NCT03770559.
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Affiliation(s)
- Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- *Correspondence: Menghua Dai, ; Yupei Zhao,
| | - Hanyu Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Dianrong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Cao
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Lei Wang
- Department of Pancreatic Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chunhui Yuan
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Hua Chen
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Hangyan Wang
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Wenjing Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jianwei Xu
- Department of Pancreatic Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiaofei Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- *Correspondence: Menghua Dai, ; Yupei Zhao,
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19
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Holm MB, Verbeke CS. Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma. Curr Oncol 2022; 29:6551-6563. [PMID: 36135084 PMCID: PMC9498008 DOI: 10.3390/curroncol29090515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.
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Affiliation(s)
- Maia Blomhoff Holm
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
| | - Caroline Sophie Verbeke
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
- Correspondence: ; Tel.: +47-405-578-36
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Ghotbi J, Sahakyan M, Søreide K, Fretland ÅA, Røsok B, Tholfsen T, Waage A, Edwin B, Labori KJ, Yaqub S, Kleive D. Minimally Invasive Pancreatoduodenectomy: Contemporary Practice, Evidence, and Knowledge Gaps. Oncol Ther 2022; 10:301-315. [PMID: 35829933 DOI: 10.1007/s40487-022-00203-6] [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: 03/30/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022] Open
Abstract
Minimally invasive pancreatoduodenectomy has gained popularity throughout the last decade. For laparoscopic pancreatoduodenectomy, some high-level evidence exists, but with conflicting results. There are currently no published randomized controlled trials comparing robotic and open pancreatoduodenectomy. Comparative long-term data for patients with pancreatic ductal adenocarcinoma is lacking to date. Based on the existing evidence, current observed benefits of minimally invasive pancreatoduodenectomy over open pancreatoduodenectomy seem scarce, but retrospective data indicate the safety of these procedures in selected patients. As familiarity with the robotic platform increases, studies have shown an expansion in indications, also including patients with vascular involvement and even indicating favorable results in patients with obesity and high-risk morphometric features. Several ongoing randomized controlled trials aim to investigate potential differences in short- and long-term outcomes between minimally invasive and open pancreatoduodenectomy. Their results are much awaited.
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Affiliation(s)
- Jacob Ghotbi
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Mushegh Sahakyan
- The Intervention Center, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Åsmund Avdem Fretland
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,The Intervention Center, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Bård Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Tore Tholfsen
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Anne Waage
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Center, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sheraz Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.
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Tran ML, Holm MB, Verbeke CS. Tumour Size and T-Stage in Pancreatic Cancer Resection Specimens Depend on the Pathology Examination Approach. Cancers (Basel) 2022; 14:cancers14102471. [PMID: 35626076 PMCID: PMC9139767 DOI: 10.3390/cancers14102471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 12/17/2022] Open
Abstract
In the eighth edition of the TNM classification for pancreatic ductal adenocarcinoma (PDAC), stages T1 to T3 are defined by tumour size, size measurement being deemed objective and accurate. This study investigated whether various, currently used approaches to tumour measurement result in different tumour sizes and differences in T-stage assignment. In a series of 315 resected PDAC, tumour sizes were measured as follows: macroscopically in a single or in two perpendicular planes and with or without microscopic corroboration. Comparison of the resulting tumour sizes showed that both macroscopic measurement in two planes and microscopic corroboration gave significantly different results (p < 0.001). Compared to the most simple approach (macroscopic measurement in one plane), the comprehensive approach (macroscopic measurement in two planes with microscopic corroboration) resulted in a larger tumour size in 263 (83%) cases (mean absolute size difference: 10 mm; mean relative size change: 36%). T-stage assignment differed in 142 (45%) cases between the simple and comprehensive approach and affected 87%, 38% and 48% of the cases deemed to be stage T1, T2 and T3, respectively. In conclusion, tumour size and T-stage are highly approach-dependent. Consensus on an accurate method is required to ensure comparability of these basic data.
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Affiliation(s)
- My Linh Tran
- Department of Pathology, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway; (M.L.T.); (M.B.H.)
| | - Maia Blomhoff Holm
- Department of Pathology, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway; (M.L.T.); (M.B.H.)
- Department of Pathology, Oslo University Hospital, 0379 Oslo, Norway
| | - Caroline Sophie Verbeke
- Department of Pathology, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway; (M.L.T.); (M.B.H.)
- Department of Pathology, Oslo University Hospital, 0379 Oslo, Norway
- Correspondence: ; Tel.: +47-405-578-36
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