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Klotz R, Mihaljevic AL, Kulu Y, Sander A, Klose C, Behnisch R, Joos MC, Kalkum E, Nickel F, Knebel P, Pianka F, Diener MK, Büchler MW, Hackert T. Robotic versus open partial pancreatoduodenectomy (EUROPA): a randomised controlled stage 2b trial. Lancet Reg Health Eur 2024; 39:100864. [PMID: 38420108 PMCID: PMC10899052 DOI: 10.1016/j.lanepe.2024.100864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
Background Open partial pancreatoduodenectomy (OPD) represents the current gold standard of surgical treatment of a wide range of diseases of the pancreatic head but is associated with morbidity in around 40% of cases. Robotic partial pancreatoduodenectomy (RPD) is being used increasingly, yet, no randomised controlled trials (RCTs) of RPD versus OPD have been published, leaving a low level of evidence to support this practice. Methods This investigator-initiated, exploratory RCT with two parallel study arms was conducted at a high-volume pancreatic centre in line with IDEAL recommendations (stage 2b). Patients scheduled for elective partial pancreatoduodenectomy (PD) for any indication were randomised (1:1) to RPD or OPD with a centralised web-based tool. The primary endpoint was postoperative cumulative morbidity within 90 days, assessed via the Comprehensive Complication Index (CCI). Biometricians were blinded to the intervention, but patients and surgeons were not. The trial was registered prospectively (DRKS00020407). Findings Between June 3, 2020 and February 14, 2022, 81 patients were randomly assigned to RPD (n = 41) or OPD (n = 40), of whom 62 patients (RPD: n = 29, OPD: n = 33) were analysed in the modified intention to treat analysis. Four patients in the OPD group were randomised, but did not undergo surgery in our department and one patient was excluded in the RPD group due to other reason. Nine patients in the RPD group and 3 patients in the OPD were excluded from the primary analysis because they did not undergo PD, but rather underwent other types of surgery. The CCI after 90 days was comparable between groups (RPD: 34.02 ± 23.48 versus OPD: 36.45 ± 27.65, difference in means [95% CI]: -2.42 [-15.55; 10.71], p = 0.713). The RPD group had a higher incidence of grade B/C pancreas-specific complications compared to the OPD group (17 (58.6%) versus 11 (33.3%); difference in rates [95% CI]: 25.3% [1.2%; 49.4%], p = 0.046). The only complication that occurred significantly more often in the RPD than in the OPD group was clinically relevant delayed gastric emptying. Procedure-related and overall hospital costs were significantly higher and duration of surgery was longer in the RPD group. Blood loss did not differ significantly between groups. The intraoperative conversion rate of RPD was 23%. Overall 90-day mortality was 4.8% without significant differences between RPD and OPD. Interpretation In the setting of a very high-volume centre, both RPD and OPD can be considered safe techniques. Further confirmatory multicentre RCTs are warranted to uncover potential advantages of RPD in terms of perioperative and long-term outcomes. Funding Federal Ministry of Education and Research (BMBF: 01KG2010).
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Affiliation(s)
- Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Sander
- Institute of Medical Biometry (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Rouven Behnisch
- Institute of Medical Biometry (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Maximilian C Joos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Eva Kalkum
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Frank Pianka
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Nickel F, Studier-Fischer A, Hackert T. [Robotic pancreatic surgery]. Chirurgie (Heidelb) 2024; 95:165-174. [PMID: 38095648 DOI: 10.1007/s00104-023-02001-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 02/02/2024]
Abstract
Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2-3 years.
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Affiliation(s)
- Felix Nickel
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Alexander Studier-Fischer
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Thilo Hackert
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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Abstract
BACKGROUND Endoscopically unresectable adenomas and carcinomas of the greater duodenal papilla and ampulla of the bile duct necessitate surgical resection. The surgical techniques need to be adapted to local tumor expansion and patterns of infiltrative growth. OBJECTIVE Based on the current scientific data and developments this article provides an overview of indications for surgical resection, surgical strategies and dissection techniques for ampullary tumors. MATERIAL AND METHODS A review of the literature addressing surgical management of ampullary neoplasms was performed. Current evidence and recommendations were summarized. RESULTS AND CONCLUSION Ampullary neoplasms can originate from intestinal or pancreatobiliary epithelial cells. Differentiating these histopathological subtypes is of crucial relevance concerning therapeutic strategy and prognosis in ampullary adenocarcinoma. All ampullary adenomas carry a risk of malignant transformation and therefore justify resection. Endoscopic papillectomy, surgical transduodenal ampullectomy and partial pancreatoduodenectomy are suitable resection techniques for ampullary adenoma. The selection of the procedure depends on intraductal tumor extension, tumor size and degree of dysplasia. Ampullary carcinoma is managed by upfront pancreatoduodenectomy comprising systematic lymph node dissection and level II dissection of the mesopancreas. Lymph node status and perineural sheath invasion are key prognostic factors concerning overall survival.
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Affiliation(s)
- Martin Schneider
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Markus W Büchler
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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Kulu Y, Büchler MW, Hackert T. [Evidence for robotics in oncological pancreatic surgery]. Chirurg 2021; 92:102-6. [PMID: 33064158 DOI: 10.1007/s00104-020-01299-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Robotic surgical procedures have been implemented and have become an important development in pancreatic surgery with an increasing acceptance worldwide. Nearly all types of pancreatic surgery have now been performed robotically and especially standardized resections, such as distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) have gained importance despite a potentially long learning curve and high associated procedural costs. The present review article summarizes the available literature and evidence on the respective procedures focused on their use for indications of malignancy.
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Klaiber U, Probst P, Hüttner FJ, Bruckner T, Strobel O, Diener MK, Mihaljevic AL, Büchler MW, Hackert T. Randomized Trial of Pylorus-Preserving vs. Pylorus-Resecting Pancreatoduodenectomy: Long-Term Morbidity and Quality of Life. J Gastrointest Surg 2020; 24:341-352. [PMID: 30671796 DOI: 10.1007/s11605-018-04102-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/29/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The randomized controlled PROPP trial (DKRS00004191) showed that pylorus-resecting pancreatoduodenectomy (PR) is not superior to the pylorus-preserving procedure (PP) in terms of perioperative outcome, specifically in reduction of delayed gastric emptying. Non-superiority of PR was also confirmed in a recent meta-analysis of randomized controlled trials. However, long-term data on morbidity and quality of life after PP compared to PR are sparse. The aim of this study was to investigate long-term outcomes of patients included in the PROPP trial. METHODS Between February 2013 and June 2016, a total of 188 patients underwent PD and were intraoperatively randomized to either preservation or resection of the pylorus (95 vs. 93 patients). For long-term follow-up, morbidity and quality of life (EORTC QLQ-C30/PAN26) were monitored until January 1, 2018. Statistical analysis was performed on an intention-to-treat basis. RESULTS The mean duration of follow-up was 34.3 (± 11.3) months. Sixty-three of the 188 patients had died (PP n = 33, PR n = 30), 29 patients were lost to follow-up (PP n = 17, PR n = 12), and the remaining 96 patients were included in long-term follow-up (PP n = 45, PR n = 51). There was no difference between PP and PR patients regarding endocrine and exocrine pancreatic function, receipt of adjuvant/palliative chemotherapy, cancer recurrence, and other relevant characteristics. Late cholangitis occurred significantly more often in patients following pylorus resection (P = 0.042). Reoperations, readmissions to hospital, and quality of life scores except pain were comparable between the two study groups. CONCLUSIONS Similar to short-term results, long-term follow-up showed no significant differences between pylorus resection compared to pylorus preservation.
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Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Felix J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Nanashima A, Imamura N, Tsuchimochi Y, Hamada T, Yano K, Hiyoshi M, Fujii Y, Kawano F, MitsuruTamura. Horizontal traumatic laceration of the pancreas head: A rare case report. Int J Surg Case Rep 2017; 31:119-123. [PMID: 28135676 PMCID: PMC5279907 DOI: 10.1016/j.ijscr.2017.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This case report is intended to inform acute care surgeons about treating rare horizontal laceration of the pancreas head caused by blunt trauma. CASE PRESENTATION A 57-year-old woman who sustained blunt abdominal trauma during a car crash was transported to the emergency center of our hospital with unstable vital signs due to hemorrhagic shock. Computed tomography showed transection of the pancreas head and massive intra-abdominal hemorrhage. She was referred for emergency surgery because of a transient response. Laparotomy at five hours after the accident initially revealed consistent massive bleeding from branches of the superior mesenteric artery and vein, which we resolved by suturing the vessels without damaging the main trunks. A horizontal laceration and complete transection of the pancreatic head were then confirmed but the main pancreatic duct remained intact. The lower part of the pancreatic head including the uncus with the attached part of the duodenum was resected, and the pancreatic stump remaining after transection was fixed by suturing. The jejunal limb was attached to the remnant duodenum by side-to-side functional anastomosis. Although gastric emptying was delayed for one month after surgery, the postoperative course was good and the patient recovered at three months thereafter. The embryonic border of pancreas head accompanied with pancreatic divisum was considered for this laceration without disruption of the main pancreatic duct. DISCUSSION Blunt pancreatic trauma usually causes vertical transection and thus, horizontal transection is considered rare. The embryological anatomical border between the ventral and dorsal pancreas due to pancreatic divisum was supposed to be transected and therefore the main pancreatic duct was not damaged. CONCLUSION Hemorrhagic shock and rare pancreatic head trauma were treated by appropriate intraoperative management.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan.
| | - Naoya Imamura
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Yuki Tsuchimochi
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Takeomi Hamada
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Kouichi Yano
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Masahide Hiyoshi
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Yoshiro Fujii
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Fumiaki Kawano
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - MitsuruTamura
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
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