Robotic Versus Laparoscopic Pancreaticoduodenectomy: An Up-To-Date System Review and Meta-Analysis

Reduced pancreatic fistula rates and comprehensive cost analysis of robotic versus open pancreaticoduodenectomy

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) has emerged as a promising surgical approach for the treatment of periampullary neoplasms, offering the potential benefits of minimally invasive surgery. However, the impact of RPD on clinically relevant pancreatic fistula (CR-PF) rates and overall costs compared to open pancreaticoduodenectomy (OPD) remains unclear, limiting its widespread adoption.

METHODS

This retrospective cohort study was conducted at a high-volume Japanese referral center from 2017 to 2023. A total of 193 patients diagnosed with periampullary neoplasms underwent either RPD (n = 81) or OPD (n = 112). To account for potential selection bias, propensity score matching (PSM) was used to balance patient demographics and clinical characteristics, resulting in two well-matched groups of 60 patients each. Perioperative outcomes, CR-PF rates, and a comprehensive cost analysis were evaluated.

RESULTS

RPD resulted in a significantly lower rate of CR-PF (10%) compared to OPD (33.3%) (p = 0.003). Additionally, patients who underwent RPD experienced shorter hospital stays (15 days) compared to those in the OPD group (22.5 days) (p < 0.001). Despite longer operative times for RPD (633 vs. 395 min; p < 0.001), total hospital costs were comparable between the two groups. The higher operative costs associated with RPD were offset by reduced postoperative complications and shorter hospitalization.

CONCLUSIONS

RPD offers significant clinical advantages, including lower CR-PF rates and reduced hospital stays, without increasing overall hospital costs compared to OPD. These findings support the feasibility and potential benefits of adopting RPD for the management of periampullary neoplasms in clinical practice.

Outcomes evaluation of robotic versus laparoscopic pancreaticoduodenectomy: a propensity score matching and learning curve analysis

BACKGROUND

Limited research has been conducted on the short-term outcomes comparing laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), particularly in the post-learning curve stage. This study aims to investigate surgical efficacy and provide clinical practices for selecting suitable techniques between LPD and RPD.

METHODS

A retrospective study was conducted on consecutive patients who underwent RPD and LPD between April 2016 and December 2023. Baseline characteristics, pathological information, and perioperative data were analyzed. Propensity score matching (PSM) analysis was performed to ensure the comparability of important factors between the groups.

RESULTS

A total of 277 patients were enrolled in the study, of which 145 underwent RPD. Following PSM, 116 patients were included in each group and baseline characteristics were well matched. The RPD group demonstrated a lower conversion rate to laparotomy (5.2% vs. 18.1%, p = 0.002), reduced blood loss (350 vs. 500 ml, p = 0.031), and a higher rate of R0 resection (91.4% vs. 80.7%, p < 0.05) compared to the laparoscopic group. The incidence of B2-Grade postoperative pancreatic fistula (B2-POPF) was also lower in the RPD group compared to the LPD group (4.3% vs. 11.2%, p = 0.037). Among patients in the post-learning curve stage, perioperative outcomes were similar between the two groups.

CONCLUSION

RPD offered several advantages over LPD, including lower rates of conversion to open and blood loss, higher rates of R0 resection, and improved POPF outcomes. Other perioperative outcomes were comparable between the two groups. Both techniques appeared feasible and safe in experienced surgeons, though RPD was preferred in complex cases.

Initial experience of robotic-assisted pancreaticoduodenectomy using the da Vinci SP system

BACKGROUND

In the era of robotic surgery, pancreatoduodenectomy (PD) has been performed with the Xi system. Recently, the advent of the SP system has allowed more minimally invasive surgery with reduced ports. We have applied the SP system to perform PD. We aimed to report our initial experience of robotic-assisted PD using the da Vinci single-port (SP) system to demonstrate the safety and feasibility of this platform.

METHODS

We retrospectively reviewed patients who underwent robotic-assisted pylorus-preserving pancreaticoduodenectomy (PPPD) between 2021 and 2023 at a single center. Robotic PPPD was performed using the da Vinci SP system with either four or two additional ports, utilizing a laparoscopic hybrid technique.

RESULTS

Of the 14 patients, six underwent the SP + 4 ports approach, and eight underwent the SP + 2 ports approach. The mean patient age was 60.2 years, and the mean body mass index was 22.5 ± 2.3 kg/m2. The mean operative time was 444.29 ± 59.6 min, with an estimated intraoperative blood loss of < 500 ml in all cases. There were two cases of postoperative pancreatic fistula and one case of bile leak.

CONCLUSION

Robot-assisted PPPD using the da Vinci SP system is safe and feasible, with acceptable perioperative outcomes. We also report a successful SP + 2 port PPPD. Owing to the unique structure of the da Vinci SP system, our method has the potential to reduce the number of trocar sites and provide a gateway for better, minimally invasive surgeries. However, further reports assessing the experience are essential to establish its wide clinical practice.

Comparison of Short-Term Outcomes Between Robotic-Assisted and Open Pancreatoduodenectomy: A Retrospective Cohort Study With Inverse Probability of Treatment Weighting (IPTW) Analysis

BACKGROUND

The advantages of robotic-assisted pancreatoduodenectomy (RPD) in comparison with open pancreatoduodenectomy (OPD) have not been well-established. We aimed to compare their short-term outcomes by inverse probability of treatment weighting (IPTW) analysis.

METHODS

Patients who underwent RPD/OPD at our hospital were recruited. Stabilised IPTW were performed to adjust observed covariates. Short-term outcomes were compared.

RESULTS

After IPTW, the effective sample comprised 807 patients (199 RPD, 608 OPD) with balanced clinicopathological characteristics. RPD had a longer operation time, fewer intraoperative blood loss (IBL), and lower blood transfusion rate than OPD. RPD was associated with a lower incidence of clinically relevant postoperative pancreatic fistula and reoperation but did not reach statistical significance. In pancreatic adenocarcinoma, RPD had a significantly higher number of lymph nodes examined. There were no significant differences in postoperative morbidities and length-of-stay.

CONCLUSIONS

RPD was associated with fewer IBL and transfusion rates than OPD. RPD can be considered feasible and safe.

Comparing the operative, oncological, post-operative outcomes and complications of robotic and laparoscopic pancreaticoduodenectomy for the treatment of pancreatic and periampullary cancers: a systematic review and meta-analysis with subgroup analysis

The majority of previously published meta-analyses compare robotic and laparoscopic pancreaticoduodenectomy (RPD vs. LPD) across both benign and malignant lesions. This meta-analysis aims on focusing exclusively on malignant lesions, providing a detailed and targeted evaluation of operative, oncologic, and post-operative outcomes. This systematic review and meta-analysis adhered to PRISMA 2020 guidelines and the Cochrane Handbook and followed a pre-registered protocol on PROSPERO. A comprehensive search of PubMed, Scopus, and Cochrane Library databases was conducted up to August 1, 2024. Risk of bias was performed with the ROBINS-I tool. We calculated the odds ratios and the mean differences for the dichotomous and continuous outcomes, respectively. Sensitivity analysis was conducted to evaluate the robustness of findings. Subgroup analyses were performed for pancreatic cancer cases exclusively. In total, eight studies involving 6648 patients (1964 RPD and 4684 LPD) were included. Significant outcomes included reduced length of hospitalization for RPD (MD = -0.94, P = 0.005) and lower conversion rates (OR = 0.20, P < 0.00001). In addition, the number of harvested lymph nodes was significantly higher for RPD (MD = 1.02, P = 0.01). Overall morbidity was significantly lower for RPD (OR = 0.50, P = 0.05). Non-significant differences were observed for estimated blood loss (P = 0.72), operative duration (P = 0.28), blood transfusion rates (P = 0.12), R0 resection rates (P = 0.60), major complications (P = 0.54), pancreatic fistula rates (P = 0.06), delayed gastric emptying (P = 0.58), reoperation rates (P = 0.20), and 90-day mortality (P = 0.97). Sensitivity analysis reduced heterogeneity without altering significant results, with the exception of overall morbidity which became non-significant in some cases, highlighting study-specific influences. Subgroup analysis for pancreatic cancer showed consistent findings with the main analysis, except overall morbidity, which became non-significant, suggesting that periampullary cancers may have influenced the observed benefits of RPD. Further analysis was limited by data availability. While RPD offers potential benefits, including shorter hospitalization, lower conversion rates, higher number of harvested lymph nodes and lower morbidity, the limited number of high-quality studies, study heterogeneity, and conflicting evidence with prior meta-analyses underscore the need for further well-designed trials focusing on specific patient populations to guide surgical decision-making. PROSPERO registration CRD42025634636.

Perioperative outcomes of robotic vs laparoscopic pancreatoduodenectomy: a meta-analysis and trial sequential analysis

BACKGROUND

Minimally invasive pancreatoduodenectomy has gained widespread acceptance among hepatopancreatobiliary surgeons due to its demonstrated advantages in perioperative outcomes compared to the conventional open approach. This meta-analysis, along with trial sequential analysis, aimed to compare the outcomes of robotic pancreatoduodenectomy and laparoscopic pancreatoduodenectomy based on the current available evidence.

METHODS

A systematic search of PubMed, Cochrane, Scopus, and Web of Science was conducted from inception to July 2024. We assessed intraoperative and postoperative outcomes, including open conversion rates, readmission, reoperation, and mortality. Additional factors, such as blood loss and the number of lymph nodes resected, were also evaluated. Quality assessment was performed using Cochrane's risk of bias tools. Subgroup analysis was conducted based on propensity score matching status, and trial sequential analysis was applied to statistically significant results on first analysis.

RESULTS

We meta-analyzed seventeen studies, with a total of 5,483 patients. The meta-analysis reported lower rates of open conversion (OR 0.40; 95% CI 0.26-0.61; p = < 0.001) and a higher number of lymph nodes resected (MD 3.5; 95% CI 1.45-5.55; p = 0.0008) in the RPD group. These results remained consistent after subgroup analysis. Trial sequential analysis confirmed true positive results, indicating that further studies are unnecessary to detect a significant difference. However, other perioperative outcomes did not show statistical significance and failed to reach the required information size for definitive conclusions.

CONCLUSION

This meta-analysis of non-randomized cohorts found lower rates of open conversion and a higher number of lymph nodes resected in patients undergoing robotic pancreatoduodenectomy. However, the initial analysis did not reveal statistically significant differences in transfusion rates, multivisceral and vascular resections, hemorrhage, delayed gastric emptying, mortality, or readmission rates. Future studies should focus on randomized designs, target more specific populations, and include long-term outcomes for a more comprehensive analysis.

Postoperative complications and surgical outcomes of robotic versus laparoscopic pancreaticoduodenectomy: a meta-analysis of propensity-score-matched studies

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is used more commonly, but high-level evidence is still scarce. This meta-analysis aimed to compare the short-term outcomes between RPD and laparoscopic pancreaticoduodenectomy (LPD) using data collected from propensity score-matched (PSM) studies.

MATERIALS AND METHODS

We searched PubMed, Cochrane Library, Embase, and Web of Science databases for PSM studies comparing RPD and LPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated.

RESULTS

Ten PSM studies were included, encompassing 8106 patients (RPD group: 3695 patients; LPD group: 4411 patients). Compared with LPD, RPD was associated with a lower conversion rate (RR, 0.56) and blood transfusion rate (RR, 0.49), as well as a higher number of harvested lymph nodes (MD, 2.15). There were no significant differences observed in 30-day readmission (RR, 1.02), 90-day mortality (RR, 1.01), overall morbidity (RR, 0.94), major complications (RR, 1.06), operative time (MD, -8.00 min), blood loss (MD, -19.37 mL), reoperation (RR, 0.95), bile leak (RR, 0.93), chylous leak (RR, 1.40), postoperative pancreatic fistula (RR, 1.06), delayed gastric emptying (RR, 0.92), wound infection (RR, 1.12), length of stay (MD, -0.32 days), and R0 resection (RR, 0.98) between the groups.

CONCLUSIONS

Although LPD and RPD had similar surgical outcomes, RPD had the perioperative advantage over LPD in decreasing conversion rates and blood transfusion rates and increasing the number of lymph nodes harvested. Further randomized controlled trials evaluating the potential advantages of RPD over LPD are warranted.

Comparison of surgical outcomes between single-layer and double-layer pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis

INTRODUCTION

Postoperative pancreatic fistula (POPF) is the most severe complication after pancreaticoduodenectomy (PD), and this study investigates the effects of single-layer and double-layer pancreaticojejunostomy (PJ) on POPF.

EVIDENCE ACQUISITION

Four electronic databases were systematically searched until March 2024: PubMed, Web of Science, Embase, and Cochrane Library. Statistical analysis was performed using Review Manager (RevMan) software. Mean difference (MD) or odds ratios (OR) with 95% confidence intervals (CI) were used to indicate continuous or dichotomous variables, respectively. Ten studies were included, comprising 1811 patients.

EVIDENCE SYNTHESIS

Compared to the double-layer PJ group, the single-layer PJ group had a similar POPF rate (OR=0.73; P=0.28) and grade C POPF rate (OR=0.55; P=0.12), but a lower grade B POPF rate (OR=0.50; 95% CI: 0.31-0.81; P=0.005). The clinically relevant POPF (CR-POPF) rate was lower in the single-layer PJ group (OR=0.47; 95% CI: 0.31-0.73; P<0.001), especially in the 2017 International Study Group of Pancreatic Surgery (ISGPS) criteria subgroup (OR=0.44; 95% CI: 0.27-0.73; P=0.001), the China subgroup (OR=0.41; 95% CI: 0.26-0.64; P<0.001), and the minimally invasive subgroup (OR=0.40; 95% CI: 0.22-0.74; P=0.003).

CONCLUSIONS

Compared with double-layer PJ, single-layer PJ after PD might reduce the incidence of CR-POPF.

Achievement of international benchmark outcomes for robotic pancreaticoduodenectomy in a low volume country

BACKGROUND

Recently, there has been an increase in the utilisation of the robotic platform to perform minimally invasive pancreaticoduodenectomy in high volume centres, with the goal of reducing morbidity and improving patient outcomes. This study reports the successful implementation of a robotic pancreaticoduodenectomy (RPD) programme in the relatively low volume setting of Australia, measured against established, internationally accepted benchmarks for low-risk open pancreaticoduodenectomy (OPD).

METHODS

Retrospective review of a prospectively maintained database for consecutive RPD at two Brisbane hospitals was performed, comparing data to internationally established benchmarks for low-risk OPD. A structured RPD programme was implemented by two surgeons across a study period spanning May 2017 to December 2023.

RESULTS

Over the study period, seventy-two consecutive RPDs were performed, with 79 % for malignancy. Perioperative outcomes for transfusions, conversion rate, postoperative fistula rate, morbidity, mortality and oncological outcomes were all within established benchmark cutoffs for low-risk open pancreaticoduodenectomy (OPD), although operative time exceeded the benchmark value by 0.7hrs.

CONCLUSION

A carefully implemented RPD programme in the low volume Australian setting is feasible, with high quality outcomes achievable when compared to established benchmarks for low-risk OPD and to reported RPD series published by high volume pioneering centres.

Short-term surgical outcomes of open, laparoscopic, and robot-assisted pancreatoduodenectomy: A comparative, single-center, retrospective study

PURPOSE

Although laparoscopic pancreaticoduodenectomy (LPD) and robot-assisted pancreaticoduodenectomy (RPD) are gradually gaining popularity, their advantages over open pancreaticoduodenectomy (OPD) remain controversial. This study aimed to compare the short-term outcomes of OPD, LPD, and RPD to elucidate the advantages and disadvantages of each procedure.

METHODS

We retrospectively analyzed 16 LPD, 43 RPD, and 36 OPD procedures performed at a single center between April 2020 and May 2024. Clinical data, including operative time, estimated blood loss, postoperative complications, length of hospital stay, and hospitalization costs, were retrospectively collected and analyzed.

RESULTS

RPD demonstrated a significantly longer operative time (553 min) than OPD (446 min) and LPD (453 min) but a significantly lower estimated blood loss than OPD (150 mL vs. 400 mL, p < .001). Postoperative complication rates (Clavien-Dindo grade ≥3) were lower for RPD (24.4%) than those for OPD (50.0%) and LPD (68.8%). RPD also showed a significantly lower rate of clinically relevant postoperative pancreatic fistula (14.6% vs. 38.9% for OPD and 43.8% for LPD) and a shorter duration of hospitalization (11 vs. 28 days for OPD and 21 days for LPD, p < .001). Hospitalization costs were higher for RPD (20 109 USD) than for OPD (18 487 USD, p < .001), with LPD (20 496 USD) and RPD costs being similar.

CONCLUSIONS

RPD appears to offer advantages in terms of reduced blood loss and postoperative complications and shortened hospital stay despite longer operative times and higher hospitalization costs. Therefore, RPD may be a more beneficial approach than OPD or LPD in pancreatic surgery.

Robotic versus laparoscopic pancreaticoduodenectomy for pancreatic and periampullary tumors: a meta-analysis

Objective

The value of robotic pancreaticoduodenectomy (RPD) compared with laparoscopic pancreaticoduodenectomy (LPD) for pancreatic and periampullary tumors is controversial. This study aims to assess the available literature and compare the short outcomes of RPD and LPD.

Methods

The PubMed, Cochrane Library, Embase, and Web of Science databases were searched to identify available research published up to 24 July, 2024. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

Results

Seventeen studies with a total of 9417 patients (RPD group: 3334 patients; LPD group: 6083 patients) were included in this meta-analysis. The RPD group had lower overall morbidity (RR, 0.79), conversion (RR, 0.29) and blood transfusion rates (RR, 0.61), shorter length of stay (MD, -0.72 days), and higher number of harvested lymph nodes (MD, 0.62) than the LPD group. There were no significant differences in 90-day mortality (RR, 0.89), major complications (RR, 0.87), operative time (MD, -3.74 mins), blood loss (MD, -24.14 mL), reoperation (RR, 0.94), bile leak (RR, 0.62), postoperative pancreatic hemorrhage (RR, 0.96), postoperative pancreatic fistula (RR, 0.74), delayed gastric emptying (RR, 1.24), and R0 resection (RR, 1.00) between the groups.

Conclusions

Compared with LPD, RPD for pancreatic and periampullary tumors could be safe and effective, and it has superior surgical outcomes. Further randomized controlled trials to verify the potential advantages of RPD over LPD are necessary.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=581133, identifier CRD42024581133.

Exploring the landscape of minimally invasive pancreatic surgery: Progress, challenges, and future directions

Minimally invasive surgery (MI) has become the standard of care for many surgical procedures aimed at reducing the burden on patients. However, its adoption in pancreatic surgery (PS) has been limited by the pancreas's unique location and the complexity of the dissection and reconstruction phases. These factors continue to contribute to PS having one of the highest morbidity and mortality rates in general surgery. Despite a rough start, MIPS has gained widespread acceptance in clinical practice recently. Robust evidence supports MI distal pancreatectomy safety, even in oncological cases, indicating its potential superiority over open surgery. However, definitive evidence of MI pancreaticoduodenectomy (MIPD) feasibility and safety, particularly for malignant lesions, is still lacking. Nonetheless, reports from high-volume centers are emerging, suggesting outcomes comparable to those of the open approach. The robotic PS increasing adoption, facilitated by the wider availability of robotic platforms, may further facilitate the transition to MIPD by overcoming the technical constraints associated with laparoscopy and accelerating the learning curve. Although the MIPS implementation process cannot be stopped in this evolving world, ensuring patient safety through strict outcome monitoring is critical. Investing in younger surgeons with structured and recognized training programs can promote safe expansion.

Comparisons of laparoscopic and robotic pancreaticoduodenectomy using barbed and conventional sutures for pancreaticojejunostomy: a propensity score matching study

BACKGROUND

There are limited data on the effect of different sutures and surgical approaches on the quality of pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy (MIPD). This study compares the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between the use of barbed sutures (BSs) and conventional sutures (CSs).

METHODS

A retrospective cohort study was conducted on 253 consecutive patients who had undergone MIPD from July 2016 to April 2023. Patients were excluded if conversion to open surgery or open anastomosis was necessary. 220 patients were enrolled and divided into BS (n = 148) and CS (n = 72) groups. After 1:1 propensity score matching (PSM), 67 cases remained in each group. Univariate and multivariate analyses identified factors associated with CR-POPF. Comparisons were also made between laparoscopic (LPD) and robotic (RPD) pancreaticoduodenectomy.

RESULTS

After PSM, BSs were associated with significantly lower rates of CR-POPF (7.5 vs. 22.4%, P = 0.015) and severe complications (Clavien-Dindo ≥ III) (7.5vs. 19.4%, P = 0.043). No significant differences were found in operative time, length of postoperative hospital stay, or other major morbidities. Multivariate analyses revealed BMI ≥ 22 kg/m2 (OR = 5.048, 95% CI: 1.256-20.287, P = 0.023) and the use of BSs (OR = 0.196, 95% CI: 0.059-0.653, P = 0.008) as the independent predictors of CR-POPF. There were no significant differences in postoperative outcomes between the LPD and RPD groups, but RPD was associated with significantly shorter operative time (402.8 min vs. 429.4 min, P = 0.015).

CONCLUSIONS

In conclusion, using BSs for PJ during MIPD is feasible and has the potential to reduce CR-POPF and severe complications.

Robotic Versus Laparoscopic Pancreaticoduodenectomy for Pancreatic Cancer: Evaluation and Analysis of Surgical Efficacy

BACKGROUND

Evidence is limited for the treatment of pancreatic cancer among minimally invasive pancreatoduodenectomy.

METHODS

This retrospective analysis evaluated patients who underwent robotic pancreaticoduodenectomy (RPD) or laparoscopic pancreaticoduodenectomy (LPD) from April 2016 to April 2023. Their baseline and perioperative data, including operative time, R0 resection rates, and severe complications rates, were analyzed, and the follow-up data, such as disease-free survival (DFS) and overall survival (OS), were collected.

RESULTS

A total of 253 cases of LPD and RPD were performed, and 101 cases with pancreatic cancer were included, of which 54 were LPD and 47 were RPD. The conversion rate (4.3% vs. 29.6%, p = 0.001) and blood loss (400 vs. 575 mL, p < 0.05) were lower in the RPD group. No significant difference was observed between the two groups in terms of operative time, vessel resection rates, and TNM-stage diagnosis; however, R0 resection rates (80.9% vs. 70.4%) and lymph node harvest (24.2 vs. 21.9) had a higher tendency in the RPD group, and postoperative length of stay was shorter in the RPD cohort (11 vs. 13 days). Moreover, improved 1- to 3-years DFS (75.7%, 61.7%, and 36.0% vs. 59.0%, 35.6%, and 21.9%) and OS (94.7%, 84.7%, and 50.8% vs. 84.1%, 63.6%, and 45.5%) was found in the RPD group in comparison with the LPD group.

CONCLUSIONS

RPD had advantages in surgical safety and oncological outcomes compared with LPD, but was similar to the latter in perioperative outcomes. Long-term outcomes require further study.

Clinical effectiveness of robotic versus laparoscopic and open surgery: an overview of systematic reviews

OBJECTIVE

To undertake a review of systematic reviews on the clinical outcomes of robotic-assisted surgery across a mix of intracavity procedures, using evidence mapping to inform the decision makers on the best utilisation of robotic-assisted surgery.

ELIGIBILITY CRITERIA

We included systematic reviews with randomised controlled trials and non-randomised controlled trials describing any clinical outcomes.

DATA SOURCES

Ovid Medline, Embase and Cochrane Library from 2017 to 2023.

DATA EXTRACTION AND SYNTHESIS

We first presented the number of systematic reviews distributed in different specialties. We then mapped the body of evidence across selected procedures and synthesised major findings of clinical outcomes. We used a measurement tool to assess systematic reviews to evaluate the quality of systematic reviews. The overlap of primary studies was managed by the corrected covered area method.

RESULTS

Our search identified 165 systematic reviews published addressing clinical evidence of robotic-assisted surgery. We found that for all outcomes except operative time, the evidence was largely positive or neutral for robotic-assisted surgery versus both open and laparoscopic alternatives. Evidence was more positive versus open. The evidence for the operative time was mostly negative. We found that most systematic reviews were of low quality due to a failure to deal with the inherent bias in observational evidence.

CONCLUSION

Robotic surgery has a strong clinical effectiveness evidence base to support the expanded use of robotic-assisted surgery in six common intracavity procedures, which may provide an opportunity to increase the proportion of minimally invasive surgeries. Given the high incremental cost of robotic-assisted surgery and longer operative time, future economic studies are required to determine the optimal use of robotic-assisted surgery capacity.

Learning curve of robotic pancreatoduodenectomy by a single surgeon with extensive laparoscopic pancreatoduodenectomy experience

With the development of robotic systems, robotic pancreatoduodenectomies (RPDs) have been increasingly performed. However, the number of cases required by surgeons with extensive laparoscopic pancreatoduodenectomy (LPD) experience to overcome the learning curve of RPD remains unclear. Therefore, we aimed to analyze and explore the impact of different phases of the learning curve of RPD on perioperative outcomes. Clinical data were prospectively collected and retrospectively analyzed for 100 consecutive patients who underwent RPD performed by a single surgeon. This surgeon had previous experience with LPD, having performed 127 LPDs with low morbidity. The learning curve for RPD was analyzed using the cumulative sum (CUSUM) method based on operation time, and perioperative outcomes were compared between the learning and proficiency phases. Between April 2020 and November 2022, one hundred patients (56 men, 44 women) were included in this study. Based on the CUSUM curve of operation time, the learning curve for RPD was divided into two phases: phase I was the learning phase (cases 1-33) and phase II was the proficiency phase (cases 34-100). The operation time during the proficiency phase was significantly shorter than that during the learning phase. In the learning phase of RPD, no significant increases were observed in estimated blood loss, conversion to laparotomy, severe complications, postoperative pancreatic hemorrhage, clinical pancreatic fistula, or other perioperative complications compared to the proficiency phases of either RPD or LPD. A surgeon with extensive prior experience in LPD can safely surmount the RPD learning curve without increasing morbidity in the learning phase. The proficiency was significantly improved after accumulating experience of 33 RPD cases.

Robotic pancreaticoduodenectomy in patients with overweight or obesity: a meta-analysis protocol

INTRODUCTION

The prevalence of overweight or obesity among patients undergoing pancreaticoduodenectomy is on the rise. The utilisation of robotic assistance has the potential to enhance the feasibility of performing minimally invasive pancreaticoduodenectomy in this particular group of patients who are at a higher risk. The objective of this meta-analysis is to assess the safety and effectiveness of robotic pancreaticoduodenectomy in individuals with overweight or obesity.

METHODS AND ANALYSIS

This investigation will systematically search for randomised controlled trials (RCTs) and non-randomised comparative studies that compare robotic pancreaticoduodenectomy with open or laparoscopic pancreaticoduodenectomy in patients with overweight or obesity, using PubMed, Embase and the Cochrane Library databases. The methodological quality of studies will be evaluated using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for observational studies. RevMan software (V.5.4.1) will be used for statistical analysis. The OR and weighted mean differences will be calculated separately for dichotomous and continuous data. The selection of a fixed-effects or random-effects model will depend on the level of heterogeneity observed among the included studies.

ETHICS AND DISSEMINATION

This study will be conducted based on data in the published literature from publicly available databases. Therefore, ethics approval is not applicable. The results will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023462321.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparing oncologic and surgical outcomes of robotic and laparoscopic pancreatoduodenectomy in patients with pancreatic cancer: a propensity-matched analysis

INTRODUCTION

Minimally invasive Pancreatoduodenectomy (MIPD), or the Whipple procedure, is increasingly utilized. No study has compared laparoscopic (LPD) and robotic (RPD) approaches, and the impact of the learning curve on oncologic, technical, and post-operative outcomes remains relatively understudied.

METHODS

The National Cancer Database was queried for patients undergoing LPD or RPD from 2010 to 2020 with a diagnosis of pancreatic cancer. Outcomes were compared between approaches using propensity-score matching (PSM); the impact of annual center-level volume of MIPD was also assessed by dividing volume into quartiles.

RESULTS

A total of 3,342 patients were included. Most (n = 2,716, 81.3%) underwent LPD versus RPD (n = 626, 18.7%). There was a high rate (20.2%, n = 719) of positive margins. Mean length-of-stay (LOS) was 10.4 ± 8.9 days. Thirty-day mortality was 2.8% (n = 92) and ninety-day mortality was 5.7% (n = 189). PSM matched 625 pairs of patients receiving LPD or RPD. After PSM, there was no differences between groups based on age, sex, race, CCI, T-stage, neoadjuvant chemo/radiotherapy, or type of PD. After PSM, there was a higher rate of conversion to open (HR = 0.68, 95%CI = 0.50-0.92)., but there was no difference in LOS (HR = 1.00, 95%CI = 0.92-1.11), 30-day readmission (HR = 1.08, 95% CI = 0.68-1.71), 30-day (HR = 0.78, 95% CI = 0.39-1.56) or 90-day mortality (HR = 0.70, 95% CI = 0.42-1.16), ability to receive adjuvant therapy (HR = 1.15, 95% CI = 0.92-1.44), nodal harvest (HR = 1.01, 95%CI = 0.94-1.09) or positive margins (HR = 1.19, 95% CI = 0.89-1.59). Centers in lower quartiles of annual volume of MIPD demonstrated reduced nodal harvest (p = 0.005) and a higher rate of conversion to open (p = 0.038). Higher-volume centers had a shorter LOS (p = 0.012), higher rate of initiation of adjuvant therapy (p = 0.042), and, most strikingly, a reduction in 90-day mortality (p = 0.033).

CONCLUSION

LPD and RPD have similar surgical and oncologic outcomes, with a lower rate of conversion to open in the robotic cohort. The robotic technique does not appear to eliminate the "learning curve", with higher volume centers demonstrating improved outcomes, especially seen at minimum annual volume of 5 cases.

Implementation and outcome of minimally invasive pancreatoduodenectomy in Europe: a registry-based retrospective study - a critical appraisal of the first 3 years of the E-MIPS registry

BACKGROUND

International multicenter audit-based studies focusing on the outcome of minimally invasive pancreatoduodenectomy (MIPD) are lacking. The European Registry for Minimally Invasive Pancreatic Surgery (E-MIPS) is the E-AHPBA endorsed registry aimed to monitor and safeguard the introduction of MIPD in Europe.

MATERIALS AND METHODS

A planned analysis of outcomes among consecutive patients after MIPD from 45 centers in 14 European countries in the E-MIPS registry (2019-2021). The main outcomes of interest were major morbidity (Clavien-Dindo grade ≥3) and 30-day/in-hospital mortality.

RESULTS

Overall, 1336 patients after MIPD were included [835 robot-assisted (R-MIPD) and 501 laparoscopic MIPD (L-MIPD)]. Overall, 20 centers performed R-MIPD, 15 centers L-MIPD, and 10 centers both. Between 2019 and 2021, the rate of centers performing L-MIPD decreased from 46.9 to 25%, whereas for R-MIPD this increased from 46.9 to 65.6%. Overall, the rate of major morbidity was 41.2%, 30-day/in-hospital mortality 4.5%, conversion rate 9.7%, postoperative pancreatic fistula grade B/C 22.7%, and postpancreatectomy hemorrhage grade B/C 10.8%. Median length of hospital stay was 12 days (IQR 8-21). A lower rate of major morbidity, postoperative pancreatic fistula grade B/C, postpancreatectomy hemorrhage grade B/C, delayed gastric emptying grade B/C, percutaneous drainage, and readmission was found after L-MIPD. The number of centers meeting the Miami Guidelines volume cut-off of ≥20 MIPDs annually increased from 9 (28.1%) in 2019 to 12 (37.5%) in 2021 ( P =0.424). Rates of conversion (7.4 vs. 14.8% P <0.001) and reoperation (8.9 vs. 15.1% P <0.001) were lower in centers, which fulfilled the Miami volume cut-off.

CONCLUSION

During the first 3 years of the pan-European E-MIPS registry, morbidity and mortality rates after MIPD were acceptable. A shift is ongoing from L-MIPD to R-MIPD. Variations in outcomes between the two minimally invasive approaches and the impact of the volume cut-off should be further evaluated over a longer time period.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Defining the learning curve for robotic pancreaticoduodenectomy for a single surgeon following experience with laparoscopic pancreaticoduodenectomy

Robotic pancreaticoduodenectomy (RPD) has a learning curve of approximately 30-250 cases to reach proficiency. The learning curve for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study describes the RPD learning curve for a single surgeon following experience with LPD. LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and learning curve were defined with respect to operative time using CUSUM analysis. Seventeen LPD and 69 RPD were analyzed LPD had an inverted learning curve possibly accounting for proficiency attained during the surgeon's fellowship and acquisition of new skills coinciding with more complex patient selection. The learning curve for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 479 min, p < 0.005), less EBL (250 vs 500, p < 0.02), and similar R0 resection. RPD also had improved LOS (7 vs 10 days, p < 0.007), and lower rates of surgical site infection (10% vs 47%, p < 0.002), DGE (19% vs 47%, p < 0.03), and readmission (13% vs 41%, p < 0.02). Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between LPD and RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.

Reappraisal of surgical and survival outcomes of 500 consecutive cases of robotic pancreaticoduodenectomy

BACKGROUND

The role of the robotic approach for pancreaticoduodenectomy has not been well established with robust data. This study aimed to reappraise feasibility and justification of robotic pancreaticoduodenectomy (RPD) over time.

METHODS

A total of 500 patients undergoing RPD were enrolled and divided into early (first 250 patients) and late (last 250 patients) groups for a comparative study.

RESULTS

The conversion rate was 8.8% overall and was significantly lower in the late group (5.6% vs. 12.0%; p = .012). The overall median intraoperative blood loss was 130 mL. Radicality of resection was similar between early and late groups. The overall surgical mortality after RPD was 1.3%. The overall surgical morbidity and major complication was 44.1% and 13.2%, respectively, and similar between early and late groups. Chyle leakage was the most common complication after RPD (25.0%), followed by postoperative pancreatic fistula (POPF). The POPF rate was 8.6% overall, with 5.9% in the early group and 11.0% in the late group, p = .051. The overall delayed gastric emptying rate was 3.5%. The late group had better survival outcomes than those of the early group after RPD for ampullary adenocarcinoma (p = .027) but not for pancreatic head adenocarcinoma.

CONCLUSIONS

Reappraisal of this study has confirmed that RPD is not only technically feasible without increasing surgical risks but also oncologically justified without compromising survival outcomes for both pancreatic head and other periampullary cancers over time. Moreover, RPD is associated with the benefits of low surgical mortality, blood loss, and delayed gastric emptying.

Advances in the management of pancreatic cancer

Pancreatic cancer remains among the malignancies with the worst outcomes. Survival has been improving, but at a slower rate than other cancers. Multimodal treatment, including chemotherapy, surgical resection, and radiotherapy, has been under investigation for many years. Because of the anatomical characteristics of the pancreas, more emphasis on treatment selection has been placed on local extension into major vessels. Recently, the development of more effective treatment regimens has opened up new treatment strategies, but urgent research questions have also become apparent. This review outlines the current management of pancreatic cancer, and the recent advances in its treatment. The review discusses future treatment pathways aimed at integrating novel findings of translational and clinical research.

Epidemiology of healthcare-associated infections and outcomes among open and robotic pancreatoduodenectomy: A retrospective study from 2013 to 2022

BACKGROUND AND AIM

Healthcare-associated infections (HAIs) after pancreaticoduodenectomy (PD) are one of the common postoperative complications. This study aims to investigate the epidemiology of postoperative HAIs in patients with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD).

METHODS

This retrospective cohort study described the trend of HAIs in patients undergoing PD from January 2013 to December 2022 at a tertiary hospital. Patients were divided into OPD and RPD, and the HAIs and outcomes were compared.

RESULTS

Among 2632 patients who underwent PD, 230 (8.7%, 95% confidence interval [CI] 7.7-9.9%) were diagnosed with HAIs, with a decreasing trend from 2013 to 2022 (P < 0.001 for trend). The incidence of postoperative HAIs was significantly higher in patients with OPD than RPD (9.6% vs 5.8%; P = 0.003). The incidence of HAIs for patients with OPD showed a decreasing trend (P = 0.001 for trend), and the trend for RPD was not significant (P = 0.554 for trend). Logistic regression showed that RPD was significantly associated with postoperative HAIs after adjusting for covariates (adjusted odds ratio = 0.654; 95% CI 0.443-0.965; P = 0.032), especially in the subgroup of patients without preoperative biliary drainage (adjusted odds ratio = 0.486; 95% CI 0.292-0.809; P = 0.006). Regarding clinical outcomes, RPD has a shorter length of stay and a more expensive charge than OPD (all P < 0.05).

CONCLUSION

Postoperative HAIs in patients with PD showed a decreasing trend in recent years, especially in OPD. RPD was significantly associated with reduced postoperative HAIs and length of stay, although the charge is more expensive. Attention should be paid to postoperative HAIs in OPD, and it is imperative to continue reducing the costs of RPD.

Repeated robotic pancreatectomy for recurrent pancreatic metastasis of mesenchymal chondrosarcoma: A case report

Mesenchymal chondrosarcoma is a rare subset of sarcomas accounting for 3%-10% of all cases of chondrosarcomas. Radical resection is the only curative strategy, even in patients with metastatic tumors. However, data regarding treatment strategies remain limited owing to the small number of cases. Herein, we report a patient who underwent repeated robotic pancreatectomy for recurrent pancreatic metastasis originating from extraskeletal mesenchymal chondrosarcoma of the pelvis. First, robotic pancreaticoduodenectomy with a reconstruction of pancreaticogastrostomy was performed for synchronous pancreatic metastasis 5 months after the primary resection of mesenchymal chondrosarcoma. Ten months after robotic pancreaticoduodenectomy, tumor recurrence was observed at the tail end of the pancreas, which was removed by reperforming robotic distal pancreatectomy. Given the precise tissue manipulation that can be achieved with robotic articulated forceps, the peripheral splenic artery and pancreas were easily isolated and divided in close proximity to the tumor. The central part of the pancreas was preserved. Robotic surgery allowed safe and effective resection of the reconstructed remnant pancreas. The patient survived for 28 months after primary tumor resection. Repeated pancreatectomy with minimally invasive techniques is a feasible and curative treatment for metastatic mesenchymal chondrosarcoma.

Prospective minimally invasive pancreatic resections from the IGOMIPS registry: a snapshot of daily practice in Italy on 1191 between 2019 and 2022

This retrospective analysis of the prospective IGOMIPS registry reports on 1191 minimally invasive pancreatic resections (MIPR) performed in Italy between 2019 and 2022, including 668 distal pancreatectomies (DP) (55.7%), 435 pancreatoduodenectomies (PD) (36.3%), 44 total pancreatectomies (3.7%), 36 tumor enucleations (3.0%), and 8 central pancreatectomies (0.7%). Spleen-preserving DP was performed in 109 patients (16.3%). Overall incidence of severe complications (Clavien-Dindo ≥ 3) was 17.6% with a 90-day mortality of 1.9%. This registry analysis provided some important information. First, robotic assistance was preferred for all MIPR but DP with splenectomy. Second, robotic assistance reduced conversion to open surgery and blood loss in comparison to laparoscopy. Robotic PD was also associated with lower incidence of severe postoperative complications and a trend toward lower mortality. Fourth, the annual cut-off of ≥ 20 MIPR and ≥ 20 MIPD improved selected outcome measures. Fifth, most MIPR were performed by a single surgeon. Sixth, only two-thirds of the centers performed spleen-preserving DP. Seventh, DP with splenectomy was associated with higher conversion rate when compared to spleen-preserving DP. Eighth, the use of pancreatojejunostomy was the prevalent reconstruction in PD. Ninth, final histology was similar for MIPR performed at high- and low-volume centers, but neoadjuvant chemotherapy was used more frequently at high-volume centers. Finally, this registry analysis raises important concerns about the reliability of R1 assessment underscoring the importance of standardized pathology of pancreatic specimens. In conclusion, MIPR can be safely implemented on a national scale. Further analyses are required to understand nuances of implementation of MIPR in Italy.

A duct-to-mucosa pancreaticojejunostomy for small main pancreatic duct and soft pancreas in minimally invasive pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is often associated with significant morbidity and mortality after the Whipple operation. Patient-related factors associated with POPF include soft pancreatic texture and a small main pancreatic duct (MPD). The traditional duct-to-mucosa anastomosis was modified to be easily performed. The aim of the study was to evaluate the simplified pancreaticojejunostomy (PJ) method in the prevention of POPF after minimally invasive pancreaticoduodenectomy (PD).

METHODS

Ninety-eight patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) with a simplified PJ procedure containing only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer in our center were retrospectively studied. Demographics and clinical short-term safety were assessed.

RESULTS

All LPD and RPD procedures were successfully performed. The median time of PJ was 17 min, and the median blood loss was 60 mL, with only one patient requiring transfusion. Four patients (4.1%) suffered from clinically relevant POPF (CR-POPF), including four grade B cases and no grade C cases. For patients with an MPD diameter of 3 mm or less, POPF was noted in two (4%) of the fifty patients, with all cases being grade B. Of the patients with a soft pancreas, only two (4.5%) patients suffered from grade B POPF. One patient (1.0%) experienced a 90-day mortality. Neither the main pancreatic diameter nor pancreatic texture had an impact on postoperative outcomes.

CONCLUSIONS

Our technique is a simple, safe and efficient alternative to prevent POPF after LPD and RPD. This method is suitable for almost all pancreatic conditions, including cases with a small main pancreatic duct and soft pancreas, and has the potential to become the preferred procedure in low-volume pancreatic surgery centers. Our modified duct-to-mucosa PJ, which contains only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer, is ideal for small MPD and soft pancreas when performing minimally invasive PD and has a low rate of POPF. PJ pancreaticojejunostomy, MPD main pancreatic diameter, PD pancreaticoduodenectomy, POPF postoperative pancreatic fistula.