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Iwanaga N, Takeda Y, Yoshioka R, Mise Y, Sugo H, Saiura A. Pancreaticoduodenectomy for octogenarians under postoperative rehabilitation enhanced ERAS protocol. BMC Surg 2024; 24:353. [PMID: 39533275 PMCID: PMC11556215 DOI: 10.1186/s12893-024-02656-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 11/05/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Although pancreaticoduodenectomy (PD) for pancreatic or periampullary cancer is the gold standard treatment regardless of patient age, patients aged 80 years or older have poor postoperative short-term outcomes because of their poor functional status and many medical comorbidities. Postoperative rehabilitation in octogenarians could improve postoperative outcomes; however, its effect remains unclear. METHODS This retrospective study included patients who underwent PD at two institutions between January 2019 and December 2022. All patients were managed using the enhanced recovery after surgery (ERAS) protocol, and elderly patients or those with loss of muscle mass or frailty underwent additional perioperative rehabilitation. Postoperative short-term outcomes were compared between the octogenarians and non-octogenarians. RESULTS We reviewed 251 patients including 44 octogenarians (17.5%). Octogenarians had higher rates of comorbidity (78.9% vs. 55.1%, P = 0.049) and sarcopenia (31.8% vs. 16.4%, P = 0.018) and a more impaired nutritional status than non-octogenarians and received postoperative rehabilitation more frequently (86.4% vs. 44.0%, P < 0.001, respectively). Under the rehabilitation-enhanced ERAS protocol, the postoperative major complication rate (25.0% vs. 24.6%, P = 0.960), the length of hospital stay (LOS) (P = 0.435), and the length of functional recovery (LOFR) (P = 0.110) did not differ between the two groups. In the multivariate analysis, age ≥ 80 years was not determined as a risk factor for major complications. CONCLUSIONS Despite the poor functional and nutritional status of octogenarians, their postoperative major complication rates, LOS, and LOFR after PD were comparable with those of non-octogenarians under the rehabilitation-enhanced ERAS protocol.
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Affiliation(s)
- Naoki Iwanaga
- Department of General Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Yoshinori Takeda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Ryuji Yoshioka
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroyuki Sugo
- Department of General Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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Farrarons SS, van Bodegraven EA, Sauvanet A, Hilal MA, Besselink MG, Dokmak S. Minimally invasive versus open central pancreatectomy: Systematic review and meta-analysis. Surgery 2022; 172:1490-1501. [PMID: 35987787 DOI: 10.1016/j.surg.2022.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/29/2022] [Accepted: 06/16/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to give an overview on the postoperative outcome after a minimally invasive (ie, laparoscopic and robot-assisted) central pancreatectomy and open central pancreatectomy with a specific emphasis on the postoperative pancreatic fistula. For benign and low-grade malignant lesions in the pancreatic neck and body, central pancreatectomy may be an alternative to distal pancreatectomy. Exocrine and endocrine insufficiency occur less often after central pancreatectomy, but the rate of postoperative pancreatic fistula is higher. METHODS An electronic search was performed for studies on elective minimally invasive central pancreatectomy and open central pancreatectomy, which reported on major morbidity and postoperative pancreatic fistula in PubMed, Cochrane Register, Embase, and Google Scholar until June 1, 2021. A review protocol was developed a priori and registered in PROSPERO as CRD42021259738. A meta-regression was performed by using a random effects model. RESULTS Overall, 41 studies were included involving 1,004 patients, consisting of 158 laparoscopic minimally invasive central pancreatectomies, 80 robot-assisted minimally invasive central pancreatectomies, and 766 open central pancreatectomies. The overall rate of postoperative pancreatic fistula was 14%, major morbidity 14%, and 30-day mortality 1%. The rates of postoperative pancreatic fistula (17% vs 24%, P = .194), major morbidity (17% vs 14%, P = .672), and new-onset diabetes (3% vs 6%, P = .353) did not differ significantly between minimally invasive central pancreatectomy and open central pancreatectomy, respectively. Minimally invasive central pancreatectomy was associated with significantly fewer blood transfusions, less exocrine pancreatic insufficiency, and fewer readmissions compared with open central pancreatectomy. A meta-regression was performed with a random effects model between minimally invasive central pancreatectomy and open central pancreatectomy and showed no significant difference for postoperative pancreatic fistula (random effects model 0.16 [0.10; 0.24] with P = .789), major morbidity (random effects model 0.20 [0.15; 0.25] with P = .410), and new-onset diabetes mellitus (random effects model 0.04 [0.02; 0.07] with P = .651). CONCLUSION In selected patients and in experienced hands, minimally invasive central pancreatectomy is a safe alternative to open central pancreatectomy for benign and low-grade malignant lesions of the neck and body. Ideally, further research should confirm this with the main focus on postoperative pancreatic fistula and endocrine and exocrine insufficiency.
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Affiliation(s)
- Sara Sentí Farrarons
- Department of HPB Surgery and Liver Transplantation, Hospital of Beaujon, Paris, France
| | - Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Alain Sauvanet
- Department of HPB Surgery and Liver Transplantation, Hospital of Beaujon, Paris, France
| | - Mohammed Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Hospital of Beaujon, Paris, France.
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Korrel M, Roelofs A, van Hilst J, Busch OR, Daams F, Festen S, Groot Koerkamp B, Klaase J, Luyer MD, van Oijen MG, Verdonck-de Leeuw IM, Besselink MG. Long-Term Quality of Life after Minimally Invasive vs Open Distal Pancreatectomy in the LEOPARD Randomized Trial. J Am Coll Surg 2021; 233:730-739.e9. [PMID: 34530127 DOI: 10.1016/j.jamcollsurg.2021.08.687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) shortens time to functional recovery and improves 30-day quality of life (QoL), as compared with open distal pancreatectomy (ODP) for nonmalignant disease. The impact of MIDP on QoL, cosmetic satisfaction, and overall major complications beyond 1-year follow-up is currently unknown. STUDY DESIGN The Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD) trial randomized 108 patients to MIDP (laparoscopic or robotic) or ODP in 14 Dutch centers (April 2015 to March 2017). The primary outcome measure of this study was quality-adjusted life years (QALYs), as assessed with the EQ-5D. QoL was assessed using subscales of the EORTC QLQ-C30, PAN-26, and a body image questionnaire. The latter included a cosmetic satisfaction score (range 3-24), and a body image score (range 5-20). Differences between MIDP and ODP for QALYs, generic, and disease-specific QoL and body image were analyzed. Missing QoL data were imputed using multiple imputation. RESULTS In total, 84 patients were alive, with a median follow-up of 44 months; 62 of these patients (74%) completed the questionnaires (27 MIDP, 35 ODP). There was no significant difference in QALYs between the 2 groups (mean score 2.34 vs 2.46 years, p = 0.63), nor on the QoL subscales. Significant overall change in EQ-5D health utilities were found for both groups over time (p < 0.001). Patients in the MIDP group scored higher on cosmetic satisfaction (21 vs 14, p = 0.049). No differences between the 2 groups were observed for clinical outcomes such as major complications, readmissions, and incisional hernias. CONCLUSIONS More than 3 years after distal pancreatectomy, no improvement in QALYs and overall QoL was seen after MIDP, whereas cosmetic satisfaction was higher after MIDP as compared with ODP.
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Affiliation(s)
- Maarten Korrel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Anne Roelofs
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands; Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | | | | | - Joost Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Martijn G van Oijen
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Irma M Verdonck-de Leeuw
- Department of Otolaryngology - Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands; Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands.
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de Ponthaud C, Menegaux F, Gaujoux S. Updated Principles of Surgical Management of Pancreatic Neuroendocrine Tumours (pNETs): What Every Surgeon Needs to Know. Cancers (Basel) 2021; 13:5969. [PMID: 34885079 PMCID: PMC8656761 DOI: 10.3390/cancers13235969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 02/07/2023] Open
Abstract
Pancreatic neuroendocrine tumours (pNETs) represent 1 to 2% of all pancreatic neoplasm with an increasing incidence. They have a varied clinical, biological and radiological presentation, depending on whether they are sporadic or genetic in origin, whether they are functional or non-functional, and whether there is a single or multiple lesions. These pNETs are often diagnosed at an advanced stage with locoregional lymph nodes invasion or distant metastases. In most cases, the gold standard curative treatment is surgical resection of the pancreatic tumour, but the postoperative complications and functional consequences are not negligible. Thus, these patients should be managed in specialised high-volume centres with multidisciplinary discussion involving surgeons, oncologists, radiologists and pathologists. Innovative managements such as "watch and wait" strategies, parenchymal sparing surgery and minimally invasive approach are emerging. The correct use of all these therapeutic options requires a good selection of patients but also a constant update of knowledge. The aim of this work is to update the surgical management of pNETs and to highlight key elements in view of the recent literature.
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Affiliation(s)
- Charles de Ponthaud
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France; (C.d.P.); (F.M.)
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France
- Paris-Sorbonne University, 21 rue de l’Ecole de Médecine, 75006 Paris, France
| | - Fabrice Menegaux
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France; (C.d.P.); (F.M.)
- Paris-Sorbonne University, 21 rue de l’Ecole de Médecine, 75006 Paris, France
| | - Sébastien Gaujoux
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France; (C.d.P.); (F.M.)
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France
- Paris-Sorbonne University, 21 rue de l’Ecole de Médecine, 75006 Paris, France
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van Hilst J, Korrel M, Lof S, de Rooij T, Vissers F, Al-Sarireh B, Alseidi A, Bateman AC, Björnsson B, Boggi U, Bratlie SO, Busch O, Butturini G, Casadei R, Dijk F, Dokmak S, Edwin B, van Eijck C, Esposito A, Fabre JM, Falconi M, Ferrari G, Fuks D, Groot Koerkamp B, Hackert T, Keck T, Khatkov I, de Kleine R, Kokkola A, Kooby DA, Lips D, Luyer M, Marudanayagam R, Menon K, Molenaar Q, de Pastena M, Pietrabissa A, Rajak R, Rosso E, Sanchez Velazquez P, Saint Marc O, Shah M, Soonawalla Z, Tomazic A, Verbeke C, Verheij J, White S, Wilmink HW, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma (DIPLOMA): study protocol for a randomized controlled trial. Trials 2021; 22:608. [PMID: 34503548 PMCID: PMC8427847 DOI: 10.1186/s13063-021-05506-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Recently, the first randomized trials comparing minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) for non-malignant and malignant disease showed a 2-day reduction in time to functional recovery after MIDP. However, for pancreatic ductal adenocarcinoma (PDAC), concerns have been raised regarding the oncologic safety (i.e., radical resection, lymph node retrieval, and survival) of MIDP, as compared to ODP. Therefore, a randomized controlled trial comparing MIDP and ODP in PDAC regarding oncological safety is warranted. We hypothesize that the microscopically radical resection (R0) rate is non-inferior for MIDP, as compared to ODP. METHODS/DESIGN DIPLOMA is an international randomized controlled, patient- and pathologist-blinded, non-inferiority trial performed in 38 pancreatic centers in Europe and the USA. A total of 258 patients with an indication for elective distal pancreatectomy with splenectomy because of proven or highly suspected PDAC of the pancreatic body or tail will be randomly allocated to MIDP (laparoscopic or robot-assisted) or ODP in a 1:1 ratio. The primary outcome is the microscopically radical resection margin (R0, distance tumor to pancreatic transection and posterior margin ≥ 1 mm), which is assessed using a standardized histopathology assessment protocol. The sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected R0 rate in the open group of 58%, expected R0 resection rate in the minimally invasive group of 67%, and a non-inferiority margin of 7%. Secondary outcomes include time to functional recovery, operative outcomes (e.g., blood loss, operative time, and conversion to open surgery), other histopathology findings (e.g., lymph node retrieval, perineural- and lymphovascular invasion), postoperative outcomes (e.g., clinically relevant complications, hospital stay, and administration of adjuvant treatment), time and site of disease recurrence, survival, quality of life, and costs. Follow-up will be performed at the outpatient clinic after 6, 12, 18, 24, and 36 months postoperatively. DISCUSSION The DIPLOMA trial is designed to investigate the non-inferiority of MIDP versus ODP regarding the microscopically radical resection rate of PDAC in an international setting. TRIAL REGISTRATION ISRCTN registry ISRCTN44897265 . Prospectively registered on 16 April 2018.
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Affiliation(s)
- Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Maarten Korrel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Sanne Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Frederique Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of 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 Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, Azienda Ospedaliero Universitaria Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Frederike Dijk
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Safi Dokmak
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France
| | - Bjorn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Casper van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, 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
| | - Giovanni Ferrari
- Department of Surgery, Niguarda Ca'Granda Hospital, Milan, Italy
| | - David Fuks
- Department of Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Keck
- Department of Surgery, UKSH campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | - Ruben de Kleine
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Arto Kokkola
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - David A Kooby
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Krishna Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | | | - Rushda Rajak
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Edoardo Rosso
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | - Olivier Saint Marc
- Department of Surgery, Centre Hospitalier Regional D'Orleans, Orleans, France
| | - Mihir Shah
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Steven White
- Department of Surgery, The Freeman Hospital Newcastle Upon Tyne, Newcastle, UK
| | - Hanneke W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI) and Humanitas University, Pieve Emanuele, MI, Italy
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
- Department of General Surgery, Fondazione Poliambulanza Instituto Ospedaliero, Brescia, Italy.
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Kauffmann EF, Napoli N, Genovese V, Ginesini M, Gianfaldoni C, Vistoli F, Amorese G, Boggi U. Feasibility and safety of robotic-assisted total pancreatectomy: a pilot western series. Updates Surg 2021; 73:955-966. [PMID: 34009627 PMCID: PMC8184722 DOI: 10.1007/s13304-021-01079-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 01/04/2023]
Abstract
This study was designed to demonstrate non-inferiority of robot-assisted total pancreatectomy (RATP) to open total pancreatectomy (OPT) based on an intention-to-treat analysis, having occurrence of severe post-operative complications (SPC) as primary study endpoint. The two groups were matched (2:1) by propensity scores. Assuming a rate of SPC of 22.5% (non-inferiority margin: 15%; α: 0.05; β: 0.20; power: 80%), a total of 25 patients were required per group. During the study period (October 2008–December 2019), 209 patients received a total pancreatectomy. After application of exclusion and inclusion criteria, matched groups were extracted from an overall cohort of 132 patients (OPT: 107; RATP: 25). Before matching, the two groups were different with respect to prevalence of cardiac disease (24.3% versus 4.0%; p = 0.03), presence of jaundice (45.8% versus 12.0%; p = 0.002), presence of a biliary drainage (23.4% versus 0; p = 0.004), history of weight loss (28.0% versus 8.0%; p = 0.04), and vein involvement (55.1% versus 28.0%) (p = 0.03). After matching, the two groups (OTP: 50; RATP: 25) were well balanced. Regarding primary study endpoint, SPC developed in 13 patients (26.0%) after OTP and in 6 patients (24.0%) after RATP (p = 0.85). Regarding secondary study endpoints, RATP was associated with longer median operating times [475 (408.8–582.5) versus 585 min (525–637.5) p = 0.003]. After a median follow-up time of 23.7 months (10.4–71), overall survival time [22.6 (11.2–81.2) versus NA (27.3–NA) p = 0.006] and cancer-specific survival [22.6 (11.2–NA) versus NA (27.3–NA) p = 0.02] were improved in patients undergoing RATP. In carefully selected patients, robot-assisted total pancreatectomy is non-inferior to open total pancreatectomy regarding occurrence of severe post-operative complications.
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Affiliation(s)
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Valerio Genovese
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
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7
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Korrel M, Vissers FL, van Hilst J, de Rooij T, Dijkgraaf MG, Festen S, Groot Koerkamp B, Busch OR, Luyer MD, Sandström P, Abu Hilal M, Besselink MG, Björnsson B. Minimally invasive versus open distal pancreatectomy: an individual patient data meta-analysis of two randomized controlled trials. HPB (Oxford) 2021; 23:323-330. [PMID: 33250330 DOI: 10.1016/j.hpb.2020.10.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) has been suggested to reduce postoperative outcomes as compared to open distal pancreatectomy (ODP). Recently, the first randomized controlled trials (RCTs) comparing MIDP to ODP were published. This individual patient data meta-analysis compared outcomes after MIDP versus ODP combining data from both RCTs. METHODS A systematic literature search was performed to identify RCTs on MIDP vs. ODP, and individual patient data were harmonized. Primary endpoint was the rate of major (Clavien-Dindo ≥ III) complications. Sensitivity analyses were performed in high-risk subgroups. RESULTS A total of 166 patients from the LEOPARD and LAPOP RCTs were included. The rate of major complications was 21% after MIDP vs. 35% after ODP (adjusted odds ratio 0.54; p = 0.148). MIDP significantly reduced length of hospital stay (6 vs. 8 days, p = 0.036), and delayed gastric emptying (4% vs. 16%, p = 0.049), as compared to ODP. A trend towards higher rates of postoperative pancreatic fistula was observed after MIDP (36% vs. 28%, p = 0.067). Outcomes were comparable in high-risk subgroups. CONCLUSION This individual patient data meta-analysis showed that MIDP, when performed by trained surgeons, may be regarded as the preferred approach for distal pancreatectomy. Outcomes are improved after MIDP as compared to ODP, without obvious downsides in high-risk subgroups.
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Affiliation(s)
- Maarten Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Frederique L Vissers
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, OLVG Oost, Amsterdam, the Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Per Sandström
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Mohammad Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom; Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - Bergthor Björnsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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8
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Probst P, Schuh F, Dörr-Harim C, Sander A, Bruckner T, Klose C, Rossion I, Nickel F, Müller-Stich BP, Mehrabi A, Hackert T, Büchler MW, Diener MK. Protocol for a randomised controlled trial to compare postoperative complications between minimally invasive and open DIStal PAnCreaTectomy (DISPACT-2 trial). BMJ Open 2021; 11:e047867. [PMID: 33619204 PMCID: PMC7903091 DOI: 10.1136/bmjopen-2020-047867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION In recent years, minimally invasive distal pancreatectomy (MIDP) has been used with increasing frequency to accelerate patient recovery. Distal pancreatectomy has an overall morbidity rate of 30%-40%. The known advantages of minimally invasive techniques must be rigorously compared with those of open surgery before they can be completely implemented into clinical practice. METHODS AND ANALYSIS DISPACT-2 is a multicentre randomised controlled trial comparing minimally invasive (conventional laparoscopic or robotic assisted) with open distal pancreatic resection in patients undergoing elective surgery for benign as well as malign diseases of the pancreatic body and tail. After screening for eligibility and obtaining informed consent, a total of 294 adult patients will be preoperatively randomised in a 1:1 ratio. The primary hypothesis is that MIDP is non-inferior to open distal pancreatectomy in terms of postoperative mortality and morbidity expressed as the Comprehensive Complication Index (CCI) within 3 months after index operation, with a non-inferiority margin of 7.5 CCI points. Secondary endpoints include pancreas-specific complications, oncological safety and patient reported outcomes. Follow-up for each individual patient will be 2 years. ETHICS AND DISSEMINATION The DISPACT-2 trial has been approved by the Ethics Committee of the medical faculty of Heidelberg University (S-693/2017). Results of the primary endpoint will be available in 2024 and will be published at national and international meetings. Full results will be made available in an open access, peer-reviewed journal. The website www.dispact.de contains up-to-date information regarding the trial. TRIAL REGISTRATION NUMBER DRKS00014011.
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Affiliation(s)
- Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Society of Surgery (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Fabian Schuh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Society of Surgery (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Colette Dörr-Harim
- The Study Center of the German Society of Surgery (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Anja Sander
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Inga Rossion
- The Study Center of the German Society of Surgery (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Beat Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- The Study Center of the German Society of Surgery (SDGC), University of Heidelberg, Heidelberg, Germany
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9
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Klotz R, Dörr-Harim C, Bruckner T, Knebel P, Diener MK, Hackert T, Mihaljevic AL. Evaluation of robotic versus open partial pancreatoduodenectomy-study protocol for a randomised controlled pilot trial (EUROPA, DRKS00020407). Trials 2021; 22:40. [PMID: 33419452 PMCID: PMC7796523 DOI: 10.1186/s13063-020-04933-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/25/2020] [Indexed: 12/25/2022] Open
Abstract
Background Partial pancreatoduodenectomy (PD) is the indicated surgical procedure for a wide range of benign and malignant diseases of the pancreatic head and distal bile duct and offers the only potential cure for pancreatic head cancer. The current gold standard, open PD (OPD) performed via laparotomy, is associated with morbidity in around 40% of cases, even at specialised centres. Robotic PD (RPD) might offer a viable alternative to OPD and has been shown to be feasible. Encouraging perioperative results have been reported for RPD in a number of small, non-randomised studies. However, since those studies showed a considerable risk of bias, a thorough comparison of RPD with OPD is warranted. Methods The EUROPA (EvalUation of RObotic partial PAncreatoduodenectomy) trial is designed as a randomised controlled unblinded exploratory surgical trial with two parallel study groups. A total of 80 patients scheduled for elective PD will be randomised after giving written informed consent. Patients with borderline or non-resectable carcinoma of the pancreatic head as defined by the National Comprehensive Cancer Network guidelines, distant metastases or an American Society of Anaesthesiologists (ASA) score > III will be excluded. The experimental intervention, RPD, will be compared with the control intervention, OPD. An intraoperative dropout of approximately eight patients per group is expected because they may receive another type of surgical procedure than planned. Overall, 64 patients need to be analysed. The primary endpoint of the trial is overall postoperative morbidity within 90 days after index operation, measured using the Comprehensive Complication Index (CCI). The secondary endpoints include the feasibility of recruitment and assessment of clinical, oncological and safety parameters and quality of life and cost-effectiveness. Discussion The EUROPA trial is the first randomised controlled trial comparing RPD with OPD. Differences in postoperative morbidity will be evaluated to design a future multicentre confirmatory efficacy trial. Trial registration German Clinical Trial Register DRKS00020407. Registered on 9 March 2020
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Affiliation(s)
- Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Colette Dörr-Harim
- The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Philipp Knebel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany. .,The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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10
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Nagai K, Kiguchi G, Yogo A, Anazawa T, Yagi S, Taura K, Takaori K, Masui T. Left-posterior approach for artery-first en bloc resection in laparoscopic distal pancreatectomy for left-sided pancreatic cancer. Langenbecks Arch Surg 2020; 405:1251-1258. [PMID: 33155070 DOI: 10.1007/s00423-020-02021-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/28/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE We describe a "left-posterior approach" in which the important steps in laparoscopic distal pancreatectomy (LDP) for left-sided pancreatic cancer are accomplished in the direction caudal and dorsal to the pancreas. METHODS The patients who underwent LDP with a left-posterior approach at our hospital from January 2016 to April 2020 were reviewed to evaluate the short-term postoperative outcomes. In LDP, we first dissected retroperitoneal tissues above the left renal vein and superior mesenteric artery, yielding the mobilization of the pancreatic body widely. Then, the splenic artery was divided behind the ventrally lifted pancreas as an artery-first approach. The regional lymphadenectomy was performed in an en bloc manner consecutively in the same operative field. The neck of the pancreas was transected with a linear stapler after mobilization of the spleen. RESULTS In nine patients (five men and four women) aged 76 years (range: 64-82 years), the operative time was 398 min (276-482 min) with the estimated blood loss of 40 ml (0-80 ml). No patients developed grade B/C pancreatic fistula or delayed gastric emptying. Postoperative complications classified as grade III in the Clavien-Dindo classification occurred in one patient (abdominal abscess). The pathology confirmed R0 resection in all patients who had pancreatic cancer (n = 5), IPMNs (n = 3), and high-grade pancreatic intraepithelial neoplasia (PanIN) (n = 1). The number of retrieved lymph nodes was 35 (11-49). CONCLUSION The procedure with a left-posterior approach is a rational surgical technique in LDP for left-sided pancreatic cancer.
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Affiliation(s)
- Kazuyuki Nagai
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Gozo Kiguchi
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akitada Yogo
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takayuki Anazawa
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shintaro Yagi
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kojiro Taura
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshihiko Masui
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine Kyoto University, 54 Shogoin Kawarahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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11
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Surgical Management of Neuroendocrine Tumours of the Pancreas. J Clin Med 2020; 9:jcm9092993. [PMID: 32947997 PMCID: PMC7565036 DOI: 10.3390/jcm9092993] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023] Open
Abstract
Neuroendocrine tumours of the pancreas (pNET) are rare, accounting for 1-2% of all pancreatic neoplasms. They develop from pancreatic islet cells and cover a wide range of heterogeneous neoplasms. While most pNETs are sporadic, some are associated with genetic syndromes. Furthermore, some pNETs are 'functioning' when there is clinical hypersecretion of metabolically active peptides, whereas others are 'non-functioning'. pNET can be diagnosed at a localised stage or a more advanced stage, including regional or distant metastasis (in 50% of cases) mainly located in the liver. While surgical resection is the cornerstone of the curative treatment of those patients, pNET management requires a multidisciplinary discussion between the oncologist, radiologist, pathologist, and surgeon. However, the scarcity of pNET patients constrains centralised management in high-volume centres to provide the best patient-tailored approach. Nonetheless, no treatment should be initiated without precise diagnosis and staging. In this review, the steps from the essential comprehensive preoperative evaluation of the best surgical approach (open versus laparoscopic, standard versus sparing parenchymal pancreatectomy, lymphadenectomy) according to pNET staging are analysed. Strategies to enhance the short- and long-term benefit/risk ratio in these particular patients are discussed.
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12
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Morató O, Poves I, Burdío F, Sánchez-Velázquez P, Duran X, Grande L. Evaluation of the learning curve for laparoscopic pancreatoduodenectomy by CUSUM analyses. Cohort study. Int J Surg 2020; 80:61-67. [PMID: 32650295 DOI: 10.1016/j.ijsu.2020.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/27/2020] [Accepted: 05/05/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Laparoscopic pancreatoduodenectomy (LPD) remains an extremely demanding surgery. The purpose of this study was to describe the learning curve required for its safe implementation. METHODS Fifty consecutive patients undergoing LPD were retrospectively reviewed. The learning curve was clustered into 4 groups: A, B and C (initial phase, n = 10 each) and D (consolidation phase, n = 20). Cumulative Sum (CUSUM) analysis was applied to operative time, conversion rate and severe postoperative complications. RESULTS No significant differences were observed among groups and phases concerning specific and general postoperative complications, oncological outcomes or mortality. The conversion rate significantly reduced from 90% (9) in Group A to 40% (4) in Group C (p < 0.01). Operative time was longer in the consolidation phase (median of 506 vs 437 min, p < 0.01). Conversely, hospital stays were shorter during the consolidation phase (8 vs 15 days, p < 0.01). CUSUM analysis identified 20-25cases as being enough to complete the learning curve if operative time and severe complications are analysed, while 40 cases would be needed for considering the conversion rate. CONCLUSIONS The learning curve in LPD can be completed after 20-25 procedures. This information will help to design programmes for introducing new surgeons to this technique.
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Affiliation(s)
- O Morató
- Department of Surgery, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| | | | - F Burdío
- Department of Surgery, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| | - P Sánchez-Velázquez
- Department of Surgery, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| | - X Duran
- Department of Statistics, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| | - L Grande
- Department of Surgery, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
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13
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An outcome analysis of predictive factors for portal or splenic vein thrombosis after distal pancreatectomy. Surg Today 2020; 50:1282-1289. [PMID: 32346760 DOI: 10.1007/s00595-020-02004-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/05/2020] [Indexed: 02/07/2023]
Abstract
PURPOSES The aim of this study was to explore predictive factors for portal or splenic vein thrombosis (VT) that might cause serious problems after distal pancreatectomy (DP). METHODS A total of 230 patients who underwent DP between 2008 and 2017 were retrospectively reviewed to identify predictive factors for portal or splenic VT. RESULTS Ultimately, 164 patients were analyzed. Portal or splenic VT was significantly correlated with age < 65 years old, benign tumor, laparoscopic surgery, preservation of the inferior mesenteric vein (IMV) and left gastric vein (LGV), preservation of the IMV only, no drainage vein, length of the residual splenic vein (RSV) ≥ 26 mm, vessel dissection with a linear stapler, and intra-abdominal abscess (all P < 0.05). Furthermore, a multivariate analysis indicated that the length of the RSV (odds ratio [OR]: 9.15, P = 0.03) was an independent predictive factor for portal VT and that the length of the RSV (OR: 37.9, P < 0.01), vessel dissection with a linear stapler (OR: 6.49, P = 0.03), and intra-abdominal abscess (OR: 23.0, P = 0.02) were independent predictive factors for splenic VT. CONCLUSION As the length of the RSV was significantly associated with portal or splenic VT, a follow-up imaging diagnosis might be recommended for such cases.
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14
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Morelli L, Di Franco G, Guadagni S, Palmeri M, Furbetta N, Funel N, Gianardi D, Palma AD, Pollina L, Moglia A, Pietrabissa A, Candio GD, Mosca F, Cuschieri A. Robotic-assisted versus open left pancreatectomy for cystic tumours: A single-centre experience. J Minim Access Surg 2020; 16:66-70. [PMID: 30178768 PMCID: PMC6945332 DOI: 10.4103/jmas.jmas_158_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 07/27/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cystic pancreatic lesions (CPLs) are being identified increasingly, and some benefit from surgical treatment. With the increasing use of robotic-assisted surgery (RAS) for neoplasms of the pancreas, the aim of the present comparative study is to establish whether the RAS offered any advantages over conventional open surgery (OS) in the management of CPLs. PATIENTS AND METHODS Twenty-seven out of 37 robot-assisted left-sided pancreatectomy (LSP) performed between January 2010 and April 2017 were carried out for CPLs. The surgical outcome and histopathology were compared retrospectively with a control group of 27 patients who had undergone open LSP for CPLs, selected using a one-to-one case-matched methodology (OS-Group) from the prospectively collected institutional database. RESULTS The spleen was preserved in a significantly higher percentage of patients in the RAS-group (63% vs. 33.3%,P < 0.05). There was no difference in the post-operative course (pancreatic fistula and morbidity) between the two groups. The median post-operative hospital stay was significantly shorter in the RAS-group: 8 days (range 3-25) versus 12 days (range 7-26) in the OS-group (P < 0.01). No conversion to open approach was reported in the RAS-group. CONCLUSIONS Robotically assisted LSP is a safe and effective procedure. It is accompanied by a significantly higher spleen preservation rate compared to the open approach. In addition, because of the reduced trauma, RAS incurred a shorter post-operative hospital stay and faster return to full recovery, particularly important in patients undergoing surgery for relative indications. However, these benefits of RAS for LSP require confirmation by prospective randomised controlled studies.
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Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
| | - Niccola Funel
- Division of Surgical Pathology, University of Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
| | - Andrea De Palma
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
| | - Luca Pollina
- Division of Surgical Pathology, University of Pisa, Italy
| | - Andrea Moglia
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Italy
| | | | - Giulio Di Candio
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
| | - Franco Mosca
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Italy
| | - Alfred Cuschieri
- Institute for Medical Science and Technology, University of Dundee, Scotland, UK
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International Validation of Reduced Major Morbidity After Minimally Invasive Distal Pancreatectomy Compared With Open Pancreatectomy. Ann Surg 2019; 274:e966-e973. [PMID: 31756173 DOI: 10.1097/sla.0000000000003659] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To quantify the nationwide impact of minimally invasive distal pancreatectomy (MIDP) on major morbidity as compared with open distal pancreatectomy (ODP). BACKGROUND A recent randomized controlled trial (RCT) demonstrated significant reduction in time to functional recovery after MIDP compared with ODP, but was not powered to assess potential risk reductions in major morbidity. METHODS International cohort study using the American College of Surgeons' National Quality Improvement Program (ACS-NSQIP) (88 centers; 2014-2016) to evaluate the association between surgical approach (MIDP vs ODP) and 30-day composite major morbidity (CMM; death or severe complications) with external model validation using Dutch Pancreatic Cancer Group data (17 centers; 2005-2016). Multivariable logistic regression assessed the impact of nationwide MIDP rates between 0% and 100% on postoperative CMM at conversion rates between 0% and 25%, using estimated marginal effects. A sensitivity analysis tested the impact at various scenarios and patient populations. RESULTS Of 2921 ACS-NSQIP patients, 1562 (53%) underwent MIDP with 18% conversion, and 1359 (47%) underwent ODP. MIDP was independently associated with reduced CMM [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.42-0.60, P < 0.001], confirmed by external model validation (n = 637, P < 0.003). The association between rising MIDP implementation rates and falling postoperative morbidity was linear between 0% (all ODP) and 100% (all MIDP). The absolute risk reduction for CMM was 11% (95% CI 7.3%-15%) at observed conversion rates and improved to 14% (95% CI 11%-18%) as conversion approached 0%. Similar effects were seen across subgroups. CONCLUSION This international study predicted a nationwide 11% risk reduction for CMM after MIDP versus ODP, which is likely to improve as conversion rates decrease. These findings confirm secondary outcomes of the recent LEOPARD RCT.
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16
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Response to Comment on "Letter to the Editor Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD)". Ann Surg 2019; 270:e136-e137. [PMID: 31425333 DOI: 10.1097/sla.0000000000003541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10-20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.
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Søreide K, Olsen F, Nymo LS, Kleive D, Lassen K. A nationwide cohort study of resection rates and short-term outcomes in open and laparoscopic distal pancreatectomy. HPB (Oxford) 2019; 21:669-678. [PMID: 30391219 DOI: 10.1016/j.hpb.2018.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/10/2018] [Accepted: 10/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Distal pancreatectomy (DP) is increasingly done by laparoscopy but data from routine practise are scarce. We describe practise in a national cohort. METHODS Data from the Norwegian Patient Register of all patients undergoing DP from 2012 to 2016. National resection rates were analysed. Short-term outcomes include length of stay, reoperation, readmissions and 90-day mortality. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). RESULTS Of 554 procedures, 327 (59%) were laparoscopic. Median age was 66 years (iqr 55-72) and 52% were women. Resection rates increased during the period for all DP (from 1.76 to 2.39 per 100.000/yr), and significantly for laparoscopic DP (adjusted R-square 0.858; P = 0.015). Elderly patients had more resection (r2 = 0.11; P = 0.019). Splenectomy (n = 427; 77%) was less likely with laparoscopy (laparoscopy 72% vs open 84%, respectively; OR 0.64, 95% c.i. 0.42-0.97; P = 0.035). Multivisceral resections occurred more often in open DP (5.3% vs 1.2% for laparoscopy, OR 4.51, 1.44-14.2; P = 0.008). Reoperation occurred in 34 (6%), readmission in 109 (20%), and mortality in 8 (1.4%). Hospital stay was shorter for laparoscopic DP. CONCLUSION Use of DP increases in the population, particularly in the elderly, with use of laparoscopic access and an association with a reduced hospital stay.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Frank Olsen
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Tromsø, Norway
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Dyre Kleive
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway; Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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van Hilst J, Strating EA, de Rooij T, Daams F, Festen S, Groot Koerkamp B, Klaase JM, Luyer M, Dijkgraaf MG, Besselink MG. Costs and quality of life in a randomized trial comparing minimally invasive and open distal pancreatectomy (LEOPARD trial). Br J Surg 2019; 106:910-921. [PMID: 31012498 PMCID: PMC6594097 DOI: 10.1002/bjs.11147] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/05/2019] [Accepted: 02/01/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy decreases time to functional recovery compared with open distal pancreatectomy, but the cost-effectiveness and impact on disease-specific quality of life have yet to be established. METHODS The LEOPARD trial randomized patients to minimally invasive (robot-assisted or laparoscopic) or open distal pancreatectomy in 14 Dutch centres between April 2015 and March 2017. Use of hospital healthcare resources, complications and disease-specific quality of life were recorded up to 1 year after surgery. Unit costs of hospital healthcare resources were determined, and cost-effectiveness and cost-utility analyses were performed. Primary outcomes were the costs per day earlier functional recovery and per quality-adjusted life-year. RESULTS All 104 patients who had a distal pancreatectomy (48 minimally invasive and 56 open) in the trial were included in this study. Patients who underwent a robot-assisted procedure were excluded from the cost analysis. Total medical costs were comparable after laparoscopic and open distal pancreatectomy (mean difference €-427 (95 per cent bias-corrected and accelerated confidence interval €-4700 to 3613; P = 0·839). Laparoscopic distal pancreatectomy was shown to have a probability of at least 0·566 of being more cost-effective than the open approach at a willingness-to-pay threshold of €0 per day of earlier recovery, and a probability of 0·676 per additional quality-adjusted life-year at a willingness-to-pay threshold of €80 000. There were no significant differences in cosmetic satisfaction scores (median 9 (i.q.r. 5·75-10) versus 7 (4-8·75); P = 0·056) and disease-specific quality of life after minimally invasive (laparoscopic and robot-assisted procedures) versus open distal pancreatectomy. CONCLUSION Laparoscopic distal pancreatectomy was at least as cost-effective as open distal pancreatectomy in terms of time to functional recovery and quality-adjusted life-years. Cosmesis and quality of life were similar in the two groups 1 year after surgery.
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Affiliation(s)
- J. van Hilst
- Department of SurgeryCancer Center AmsterdamAmsterdamThe Netherlands
| | - E. A. Strating
- Department of SurgeryCancer Center AmsterdamAmsterdamThe Netherlands
| | - T. de Rooij
- Department of SurgeryCancer Center AmsterdamAmsterdamThe Netherlands
| | - F. Daams
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMCVU UniversityAmsterdamThe Netherlands
| | - S. Festen
- Department of SurgeryOLVGAmsterdamThe Netherlands
| | | | - J. M. Klaase
- Department of SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - M. Luyer
- Department of SurgeryCatharina HospitalEindhovenThe Netherlands
| | - M. G. Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - M. G. Besselink
- Department of SurgeryCancer Center AmsterdamAmsterdamThe Netherlands
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20
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Eguia E, Kuo PC, Sweigert P, Nelson M, Aranha GV, Abood G, Godellas CV, Baker MS. The laparoscopic approach to distal pancreatectomy is a value-added proposition for patients undergoing care in moderate-volume and high-volume centers. Surgery 2019; 166:166-171. [PMID: 31160061 DOI: 10.1016/j.surg.2019.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Little is known regarding the impact of the minimally invasive approach to distal pancreatectomy on the aggregate costs of care for patients undergoing distal pancreatectomy. METHODS We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic distal pancreatectomy or open distal pancreatectomy between 2012 and 2014. Multivariable regression was used to evaluate postoperative outcomes including readmissions to 90 days after distal pancreatectomy. RESULTS A total of 267 (11%) patients underwent laparoscopic distal pancreatectomy, and a total of 2,214 (89%) underwent open distal pancreatectomy. On multivariable regression, patients undergoing laparoscopic distal pancreatectomy had a decreased odds risk of having any severe adverse outcome (odds ratio 0.73, 95% confidence interval [0.54-0.97]), prolonged length of stay (odds ratio 0.49, 95% confidence interval [0.30-0.79]), and of being in the highest quartile for aggregate costs of care (odds ratio 0.46, 95% confidence interval [0.32-0.66]) relative to those undergoing open distal pancreatectomy. Patients undergoing laparoscopic distal pancreatectomy had a lower average 90-day aggregate cost of care than those undergoing open distal pancreatectomy when procedures were performed in high-volume (-$16,153, 95% CI: [-$23,342 to -$8,964]) centers. CONCLUSION Patients undergoing laparoscopic distal pancreatectomy have a lower risk of severe adverse outcomes, prolonged overall length of stay, and lower associated costs of care relative to those undergoing open distal pancreatectomy. This association is independent of hospital volume.
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Affiliation(s)
- Emanuel Eguia
- Department of Surgery, Loyola University Medical Center, Maywood, IL.
| | - Paul C Kuo
- Department of Surgery, University of South Florida, Tampa, FL
| | - Patrick Sweigert
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Marc Nelson
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Gerard V Aranha
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Gerard Abood
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | | | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL
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21
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Sham JG, Gage MM, He J. Contemporary issues in the surgical management of pancreatic neuroendocrine tumours. SURGICAL PRACTICE 2019. [DOI: 10.1111/1744-1633.12349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jonathan G. Sham
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
| | - Michele M. Gage
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
| | - Jin He
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
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22
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Tan JKH, Ng JJ, Yeo M, Koh FHX, Bonney GK, Ganpathi IS, Madhavan K, Kow AWC. Propensity score-matched analysis of early outcomes after laparoscopic-assisted versus open pancreaticoduodenectomy. ANZ J Surg 2019; 89:E190-E194. [PMID: 30968539 DOI: 10.1111/ans.15124] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy (PD) is a feasible option for periampullary tumours. However, it remains a complex procedure with no proven advantages over open PD (OPD). The aim of the study was to compare the outcomes between laparoscopic-assisted PD (LAPD) and OPD using a propensity score-matched analysis. METHODS Retrospective review of 40 patients who underwent PD for periampullary tumours between January 2014 and December 2016 was conducted. The patients were matched 1:1 for age, gender, body mass index, Charlson comorbidty index, tumour size and haematological indices. Peri-operative outcomes were evaluated. RESULTS LAPD appeared to have a longer median operative time as compared to OPD (LAPD, 425 min (285-597) versus OPD, 369 min (260-500)) (P = 0.066). Intra-operative blood loss was comparable between both groups. Respiratory complications were five times higher in the OPD group (LAPD, 5% versus OPD, 25%) (P = 0.077), while LAPD patients required less time to start ambulating post-operatively (LAPD, 2 days versus OPD, 2 days) (P = 0.021). Pancreas-specific complications and morbidity/mortality rates were similar. CONCLUSION LAPD is a safe alternative to OPD in a select group of patients for an institution starting out with minimally invasive PD, and can be used to bridge the learning curve required for total laparoscopic PD.
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Affiliation(s)
- Jarrod K H Tan
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore
| | - Jun Jie Ng
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore
| | - Melissa Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Frederick H X Koh
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore
| | - Glenn K Bonney
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore
| | - Iyer S Ganpathi
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore
| | - Krishnakumar Madhavan
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore
| | - Alfred W C Kow
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore
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Abstract
In pancreatic cancer, resection combined with neoadjuvant and/or adjuvant therapy remains the only chance for cure and/or prolonged survival. A minimally invasive approach to pancreatic cancer has gained increased acceptance and popularity. The aim of minimally invasive surgery of the pancreas includes limiting trauma, decreasing length of hospitalization, lessening cost, decreasing blood loss, and allowing for a more meticulous oncologic dissection. New advances and routine use in practice have helped progress the field making the minimally invasive approach more feasible. In this article, the minimally invasive surgical approaches to proximal, central, and distal pancreatic cancer are described and literature reviewed.
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24
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Yang DJ, Xiong JJ, Lu HM, Wei Y, Zhang L, Lu S, Hu WM. The oncological safety in minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. Sci Rep 2019; 9:1159. [PMID: 30718559 PMCID: PMC6362067 DOI: 10.1038/s41598-018-37617-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 12/11/2018] [Indexed: 02/08/2023] Open
Abstract
The safety of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) regarding oncological outcomes of pancreatic ductal adenocarcinoma (PDAC) remains inconclusive. Therefore, the aim of this study was to examine the oncological safety of MIDP and ODP for PDAC. Major databases including PubMed, Embase, Science Citation Index Expanded, and the Cochrane Library were searched for studies comparing outcomes in patients undergoing MIDP and ODP for PDAC from January 1994 to August 2018. In total, 11 retrospective comparative studies with 4829 patients (MIDP: 1076, ODP: 3753) were included. The primary outcome was long-term survival, including 3-year overall survival (OS) and 5-year OS. The 3-year OS (hazard ratio (HR): 1.03, 95% confidence interval (CI): 0.89, 1.21; P = 0.66) and 5-year OS (HR: 0.91, 95% CI: 0.65, 1.28; P = 0.59) showed no significant differences between the two groups. Furthermore, the positive surgical margin rate (weighted mean difference (WMD): 0.71, 95% CI: 0.56, 0.89, P = 0.003) was lower in the MIDP group. However, patients in the MIDP group had less intraoperative blood loss (WMD: -250.03, 95% CI: -359.68, -140.39; P < 0.00001), a shorter hospital stay (WMD: -2.76, 95% CI: -3.73, -1.78; P < 0.00001) and lower morbidity (OR: 0.57, 95% CI: 0.46, 0.71; P < 0.00001) and mortality (OR: 0.50, 95% CI: 0.31, 0.81, P = 0.005) than patients in the ODP group. The limited evidence suggested that MIDP might be safer with regard to oncological outcomes in PDAC patients. Therefore, future high-quality studies are needed to examine the oncological safety of MIDP.
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Affiliation(s)
- Du-Jiang Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Jun-Jie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Hui-Min Lu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yi Wei
- Department of Transportation Center, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Ling Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Shan Lu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Wei-Ming Hu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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25
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de Rooij T, van Hilst J, van Santvoort H, Boerma D, van den Boezem P, Daams F, van Dam R, Dejong C, van Duyn E, Dijkgraaf M, van Eijck C, Festen S, Gerhards M, Groot Koerkamp B, de Hingh I, Kazemier G, Klaase J, de Kleine R, van Laarhoven C, Luyer M, Patijn G, Steenvoorde P, Suker M, Abu Hilal M, Busch O, Besselink M. Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): A Multicenter Patient-blinded Randomized Controlled Trial. Ann Surg 2019; 269:2-9. [PMID: 30080726 DOI: 10.1097/sla.0000000000002979] [Citation(s) in RCA: 390] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This trial followed a structured nationwide training program in minimally invasive distal pancreatectomy (MIDP), according to the IDEAL framework for surgical innovation, and aimed to compare time to functional recovery after minimally invasive and open distal pancreatectomy (ODP). BACKGROUND MIDP is increasingly used and may enhance postoperative recovery as compared with ODP, but randomized studies are lacking. METHODS A multicenter patient-blinded randomized controlled superiority trial was performed in 14 centers between April 2015 and March 2017. Adult patients with left-sided pancreatic tumors confined to the pancreas without vascular involvement were randomly assigned (1:1) to undergo MIDP or ODP. Patients were blinded for type of surgery using a large abdominal dressing. The primary endpoint was time to functional recovery. Analysis was by intention to treat. This trial was registered with the Netherlands Trial Register (NTR5689). RESULTS Time to functional recovery was 4 days [interquartile range (IQR) 3-6) in 51 patients after MIDP versus 6 days (IQR 5-8) in 57 patients after ODP (P < 0.001). The conversion rate of MIDP was 8%. Operative blood loss was less after MIDP (150 vs 400 mL; P < 0.001), whereas operative time was longer (217 vs 179 minutes; P = 0.005). The Clavien-Dindo grade ≥III complication rate was 25% versus 38% (P = 0.21). Delayed gastric emptying grade B/C was seen less often after MIDP (6% vs 20%; P = 0.04). Postoperative pancreatic fistulas grade B/C were seen in 39% after MIDP versus 23% after ODP (P = 0.07), without difference in percutaneous catheter drainage (22% vs 20%; P = 0.77). Quality of life (day 3-30) was better after MIDP as compared with ODP, and overall costs were non-significantly less after MIDP. No 90-day mortality was seen after MIDP versus 2% (n = 1) after ODP. CONCLUSIONS In patients with left-sided pancreatic tumors confined to the pancreas, MIDP reduces time to functional recovery compared with ODP. Although the overall rate of complications was not reduced, MIDP was associated with less delayed gastric emptying and better quality of life without increasing costs.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Hjalmar van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht, the Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter van den Boezem
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Freek Daams
- Department of Surgery, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands, and Universitätsklinikum Aachen, Aachen, Germany
| | - Cees Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands, and Universitätsklinikum Aachen, Aachen, Germany
| | - Eino van Duyn
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marcel Dijkgraaf
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Surgery, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
| | - Joost Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Ruben de Kleine
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Gijs Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | | | - Mustafa Suker
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Moh'd Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
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26
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Buanes T, Edwin B. Long term oncological outcome of laparoscopic techniques in pancreatic cancer. World J Gastrointest Endosc 2018; 10:383-391. [PMID: 30631402 PMCID: PMC6323502 DOI: 10.4253/wjge.v10.i12.383] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/05/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023] Open
Abstract
The laparoscopic technique in distal pancreatic resection (LDP) has been widely accepted, and outcome data support the hypothesis that survival is improved, partly due to improved postoperative safety and recovery, thus optimizing treatment with adjuvant chemotherapy. But laparoscopic pancreaticoduodenectomy (LPD or Whipple-procedures) has spread more slowly, due to the complexity of the procedure. Surgical safety has been a problem in hospitals with low patient volume, resulting in raised postoperative mortality, requiring careful monitoring of outcome during the surgical learning curve. Robotic assistance is expected to improve surgical safety, but data on long term oncological outcome of laparoscopic Whipple procedures with or without robotic assistance is scarce. Future research should still focus surgical safety, but most importantly long term outcome, recorded as recurrence at maximal follow up or - at best - overall long term survival (OS). Available data show median survival above 2.5 years, five year OS more than 30% after LDP even in series with suboptimal adjuvant chemotherapy. Also after LPD, long term survival is reported equal to or longer than open resection. However, surgical safety during the learning curve of LPD is a problem, which hopefully can be facilitated by robotic assistance. Patient reported outcome should also be an endpoint in future trials, including patients with pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Trond Buanes
- Department of Gastroenterological Surgery, Division of Cancer, Surgery and Transplantation, Institute of Clinical Medicine, Faculty of Medicine, Oslo University Hospital, Oslo N-0424, Norway
| | - Bjørn Edwin
- the Intervention Centre and Department of Hepato-Pancreatico-Biliary Surgery, Institute of Clinical Medicine, Faculty of Medicine, Oslo University Hospital, Oslo N-0424, Norway
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27
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Rho SY, Yun M, Kang CM, Lee SH, Hwang HK, Lee WJ. Different biological behaviors in left-sided pancreatic cancer according to Yonsei criteria: Proposal of a modified Yonsei criteria score. Pancreatology 2018; 18:990-995. [PMID: 30201440 DOI: 10.1016/j.pan.2018.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/12/2018] [Accepted: 09/01/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Our institutional experience has demonstrated that bloodless and margin-negative resection is the most potent prognostic factor in treating left-sided pancreatic cancer and we developed selection guideline. The Yonsei criteria (YC) is selection criteria for oncologically safe and effective resection of left-sided pancreatic cancer by a minimally invasive approach. In this study, we investigated whether left-sided pancreatic cancer with YC can be more individualized to predict long-term survival by using clinically and pathologically detectable parameters. METHODS From January 2000 to December 2015, 105 patients underwent distal pancreatectomy for left-sided pancreatic cancer. The medical records of the patients were retrospectively reviewed. RESULTS Among clinically and pathologically detectable parameters to predict tumor conditions, radiologically determined tumor size (p = 0.080) and SUVmax (p = 0.086) were identified as predictors of early tumor recurrence with marginal significance. Among them, 20% of the patients with YC were identified as having the most favoring tumor condition, with an modified YC score of 3. The patient group with the lowest mYC score was found to have a very long disease-free survival time, with a mean of 108 months, which was statistically different from those with other mYC scores (mYC score = 4, mean 47.1 months [95% CI: 27.8-69.5] vs. mYC score = 5, mean 36.7 months [95% CI: 12.7-60.7], vs. mYC score = 6, mean 10.7 months [95% CI: 3.9-17.4]). CONCLUSIONS Modified Yonsei criteria score can predict long-term survival in resected left-sided pancreatic cancer. And patients within YC with a mYC score = 3 could have a favorable survival outcome.
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Affiliation(s)
- Seoung Yoon Rho
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Mijin Yun
- Department of Nuclear Medicine, Yonsei University College of Medicine, South Korea
| | - Chang Moo Kang
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea.
| | - Sung Hwan Lee
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Woo Jung Lee
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, South Korea; Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
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28
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Nota CLMA, Smits FJ, Woo Y, Borel Rinkes IHM, Molenaar IQ, Hagendoorn J, Fong Y. Robotic Developments in Cancer Surgery. Surg Oncol Clin N Am 2018; 28:89-100. [PMID: 30414684 DOI: 10.1016/j.soc.2018.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Indications for robotic surgery have been rapidly expanding since the first introduction of the robotic surgical system in the US market in 2000. As the robotic systems have become more sophisticated over the past decades, there has been an expansion in indications. Many new tools have been added with the aim of optimizing outcomes after oncologic surgery. Complex abdominal cancers are increasingly operated on using robot-assisted laparoscopy and with acceptable outcomes. In this article, the authors discuss robotic developments, from the past and the future, with an emphasis on cancer surgery.
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Affiliation(s)
- Carolijn L M A Nota
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA; Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Francina Jasmijn Smits
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Yanghee Woo
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Inne H M Borel Rinkes
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Izaak Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA.
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Fingerhut A, Uranues S, Khatkov I, Boni L. Laparoscopic distal pancreatectomy: better than open? Transl Gastroenterol Hepatol 2018; 3:49. [PMID: 30225383 PMCID: PMC6131158 DOI: 10.21037/tgh.2018.07.04] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/27/2018] [Indexed: 12/14/2022] Open
Abstract
Distal pancreatectomy is well suited to the laparoscopic approach. Laparoscopic distal pancreatectomy (LDP) provides the same postoperative recovery advantages reputed to minimal access surgery. However, there have been fears as to the safety of LDP in terms of life-threatening intra-operative events and post-operative complications, adequate carcinological outcomes as compared to traditional (open) distal pancreatectomy (ODP) when performed for cancer, as well as to whether the laparoscopic approach is well adapted to the variety of diseases that may affect the pancreas (ranging from trauma to benign or malignant disease) and whether the minimal access approach is well adapted to perform pancreatic surgery safely in the obese, the elderly or the frail. In this review of the literature, we sought to determine whether LDP was as safe, provided the same oncological outcomes and was applicable to all diseases involving the body and tail of the pancreas, and to particular patient characteristics, compared to the traditional open approach. Last we looked at cost issues. We concluded that this review of the literature allowed to state that laparoscopic distal pancreatectomy is feasible and safe for a wide range of diseases, both benign and malignant. Morbidity, mortality, and probably, also, carcinological outcomes are comparable to open surgery. The overall costs are similar but the advantages of minimal access surgery make it the preferred approach, once the surgical expertise is acquired and present.
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Affiliation(s)
- Abe Fingerhut
- Section for Surgical Research, Department of Surgery, University of Graz, Graz, Austria
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, University of Graz, Graz, Austria
| | - Igor Khatkov
- Department of Surgical Oncology Moscow Clinical Scientific Center, Moscow, Russia
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Raoof M, Ituarte PHG, Woo Y, Warner SG, Singh G, Fong Y, Melstrom L. Propensity score-matched comparison of oncological outcomes between laparoscopic and open distal pancreatic resection. Br J Surg 2018; 105:578-586. [PMID: 29493784 DOI: 10.1002/bjs.10747] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/23/2017] [Accepted: 10/09/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Selected studies have reported improved outcomes in laparoscopic compared with open distal pancreatic resection. Concerns regarding failure to achieve proper oncological resection and compromised long-term outcomes remain. This study investigated whether postoperative outcomes and long-term survival after laparoscopic distal pancreatectomy are comparable to those after an open procedure. METHODS This retrospective case-control study included patients who underwent distal pancreatectomy for resectable pancreatic adenocarcinoma between 2010 and 2013, identified from the National Cancer Database. Propensity score nearest-neighbour 1 : 1 matching was performed between patients undergoing laparoscopic or open distal pancreatectomy based on all relevant co-variables. The primary outcome was overall survival. RESULTS Of 1947 eligible patients, 605 (31·1 per cent) underwent laparoscopic distal pancreatectomy. After propensity score matching, two well balanced groups of 563 patients each were analysed. There was no difference in overall survival at 3 years after laparoscopic versus open distal pancreatectomy (41·6 versus 36·0 per cent; hazard ratio 0·93, 95 per cent c.i. 0·77 to 1·12; P = 0·457). The overall conversion rate was 27·3 per cent (165 of 605). Patients who underwent laparoscopic distal pancreatectomy had outcomes comparable to those of patients who had an open procedure with regard to median time to chemotherapy (50 versus 50 days; P = 0·342), median number of nodes examined (12 versus 12; P = 0·759); 30-day mortality (1·2 versus 0·9 per cent; P = 0·562); 90-day mortality (2·8 versus 3·7 per cent; P = 0·403), 30-day readmission rate (9·6 versus 9·2 per cent; P = 0·838) and positive margin rate (14·9 versus 18·5 per cent; P = 0·110). However, median duration of hospital stay was shorter in the laparoscopic group (6 versus 7 days; P < 0·001). CONCLUSION Laparoscopic distal pancreatectomy is an acceptable alternative to open distal pancreatectomy with no detriment to survival.
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Affiliation(s)
- M Raoof
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, MOB.L002, Duarte, California, 91016, USA
| | - P H G Ituarte
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, MOB.L002, Duarte, California, 91016, USA
| | - Y Woo
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, MOB.L002, Duarte, California, 91016, USA
| | - S G Warner
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, MOB.L002, Duarte, California, 91016, USA
| | - G Singh
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, MOB.L002, Duarte, California, 91016, USA
| | - Y Fong
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, MOB.L002, Duarte, California, 91016, USA
| | - L Melstrom
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, MOB.L002, Duarte, California, 91016, USA
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de Rooij T, van Hilst J, Bosscha K, Dijkgraaf MG, Gerhards MF, Groot Koerkamp B, Hagendoorn J, de Hingh IH, Karsten TM, Lips DJ, Luyer MD, Molenaar IQ, van Santvoort HC, Tran TCK, Busch OR, Festen S, Besselink MG, for the Dutch Pancreatic Cancer Group. Minimally invasive versus open pancreatoduodenectomy (LEOPARD-2): study protocol for a randomized controlled trial. Trials 2018; 19:1. [PMID: 29298706 PMCID: PMC5753506 DOI: 10.1186/s13063-017-2423-4] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/18/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Data from observational studies suggest that minimally invasive pancreatoduodenectomy (MIPD) is superior to open pancreatoduodenectomy regarding intraoperative blood loss, postoperative morbidity, and length of hospital stay, without increasing total costs. However, several case-matched studies failed to demonstrate superiority of MIPD, and large registry studies from the USA even suggested increased mortality for MIPDs performed in low-volume (<10 MIPDs annually) centers. Randomized controlled multicenter trials are lacking but clearly required. We hypothesize that time to functional recovery is shorter after MIPD compared with open pancreatoduodenectomy, even in an enhanced recovery setting. METHODS/DESIGN LEOPARD-2 is a randomized controlled, parallel-group, patient-blinded, multicenter, phase 2/3, superiority trial in centers that completed the Dutch Pancreatic Cancer Group LAELAPS-2 training program for laparoscopic pancreatoduodenectomy or LAELAPS-3 training program for robot-assisted pancreatoduodenectomy and have performed ≥ 20 MIPDs. A total of 136 patients with symptomatic benign, premalignant, or malignant disease will be randomly assigned to undergo minimally invasive or open pancreatoduodenectomy in an enhanced recovery setting. After the first 40 patients (phase 2), the data safety monitoring board will assess safety outcomes (not blinded for treatment allocation) and decide on continuation to phase 3. Patients from phase 2 will then be included in phase 3. The primary outcome measure is time (days) to functional recovery. All patients will be blinded for the surgical approach, at least until postoperative day 5, but preferably until functional recovery has been attained. Secondary outcome measures are operative and postoperative outcomes, including clinically relevant complications, mortality, quality of life, and costs. DISCUSSION The LEOPARD-2 trial is designed to assess whether MIPD reduces time to functional recovery, as compared with open pancreatoduodenectomy in an enhanced recovery setting. TRIAL REGISTRATION Netherlands Trial Register, NTR5689 . Registered on 2 March 2016.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, 5200 ME Den Bosch, The Netherlands
| | - Marcel G. Dijkgraaf
- Clinical Research Unit, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Michael F. Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, PO Box 85 500, 3508 GA Utrecht, The Netherlands
| | - Ignace H. de Hingh
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - Tom M. Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM Amsterdam, The Netherlands
| | - Daan J. Lips
- Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, 5200 ME Den Bosch, The Netherlands
| | - Misha D. Luyer
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, PO Box 85 500, 3508 GA Utrecht, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - T. C. Khé Tran
- Department of Surgery, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
- Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, 5200 ME Den Bosch, The Netherlands
- Clinical Research Unit, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM Amsterdam, The Netherlands
- Department of Surgery, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Surgery, University Medical Center Utrecht, PO Box 85 500, 3508 GA Utrecht, The Netherlands
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, The Netherlands
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32
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Klompmaker S, de Rooij T, van Hilst J, Besselink MG. Systematic Training for Safe Implementation of Minimally Invasive Pancreatic Surgery. MINIMALLY INVASIVE SURGERY OF THE PANCREAS 2018. [DOI: 10.1007/978-88-470-3958-2_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Chong JU, Kim SH, Hwang HK, Kang CM, Lee WJ. Yonsei criteria: a clinical reflection of stage I left-sided pancreatic cancer. Oncotarget 2017; 8:110830-110836. [PMID: 29340019 PMCID: PMC5762287 DOI: 10.18632/oncotarget.22734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/13/2017] [Indexed: 01/28/2023] Open
Abstract
In this study, we examined associations between pancreatic cancer that met the Yonsei criteria (YC) and classifications from the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. Clinicopathological and survival data were collected from132 patients who underwent distal pancreatectomy for left-sided pancreatic ductal adenocarcinoma between January 2000 and December 2015, and the utility of the YC for selecting treatment and predicting survival was evaluated using the 8th AJCC staging manual. Of the 102 patients who ultimately qualified for the study, 45 patients were reclassified as stage I based on the 8th AJCC cancer staging system. Disease-free survival and disease-specific survival periods were longer in stage I patients who met the YC than in those who did not. Clinicopathological characteristics did not differ between stage I patients who did and did not meet the YC. These results suggest that meeting the YC criteria may be a clinical indicator that left-sided pancreatic cancer patients who are candidates for resection have early-stage disease according to the 8th edition of the AJCC staging manual.
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Affiliation(s)
- Jae Uk Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Sung Hyun Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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Thomaschewski M, Neeff H, Keck T, Neumann HPH, Strate T, von Dobschuetz E. Is there any role for minimally invasive surgery in NET? Rev Endocr Metab Disord 2017; 18:443-457. [PMID: 29127554 DOI: 10.1007/s11154-017-9436-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neuroendocrine tumors (NET) represent the variability of almost benign lesions either secreting hormones occurring as a single lesion up to malignant lesions with metastatic potential. Treatment of NET is usually performed by surgical resection. Due to the rarity of NET, surgical treatment is mainly based on the experience and recommendations of experts and less on the basis of prospective randomized studies. In addition, the development and establishment of new surgical procedures is made more difficult by their rarity. The development of laparoscopic-assisted surgery has significantly improved the treatment of many diseases. Due to the well-known advantages of laparoscopic surgery, this method has also been increasingly used to treat NET. However, due to limited comparative data, the assumed superiority of laparoscopic surgery in the area NET remains often unclear or not yet proven. This review focuses on the present usage of laparoscopic techniques in the area of NET. Relating to the current literature, this review presents the evidence of various laparoscopic procedures for treatment of adrenal, pancreatic and intestine NET as well as extraadrenal pheochromocytoma and neuroendocrine liver metastases. Further, this review focuses on recent new developments of minimally invasive surgery in the area of NET. Here, robotic-assisted surgery and single-port surgery are promising approaches.
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Affiliation(s)
- M Thomaschewski
- Department of Surgery, University of Lübeck and University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - H Neeff
- Department of Visceral and General Surgery, University Medical Center Freiburg, Freiburg, Germany
| | - T Keck
- Department of Surgery, University of Lübeck and University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - H P H Neumann
- Section for Preventive Medicine, Department of Nephrology and General Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - T Strate
- Department of General, Visceral and Thoracic Surgery, Academic Teaching Hospital University of Hamburg, Reinbek, Germany
| | - E von Dobschuetz
- Section of Endocrine Surgery, Department of General, Visceral and Thoracic Surgery, Academic Teaching Hospital University of Hamburg, Reinbek, Germany.
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35
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Welsch T, Distler M, Weitz J. [Minimally invasive and robot-assisted surgery for pancreatic cystic tumors]. Chirurg 2017; 88:934-943. [PMID: 28842736 DOI: 10.1007/s00104-017-0496-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The indications for resection of pancreatic cystic lesions (PCL) are often complex and the operative risk has to be balanced against the risk of malignant transformation. The aim of the study was to provide a synopsis of the current treatment results of minimally invasive surgery for PCL. METHODS A systematic literature search was performed using the Medline database (PubMed). Subsequently, the retrieved literature was selectively reviewed. RESULTS No published prospective randomized controlled trials have yet addressed the comparison of open and minimally invasive surgery of PCL; however, retrospective case studies have demonstrated the feasibility, safety and a comparable morbidity after minimally invasive distal pancreatectomy (DP), pancreatoduodenectomy (PD), central (CP) or total pancreatectomy and enucleation. Whereas most DPs are performed laparoscopically, the experience of minimally invasive PD has been consolidated for the robot-assisted approach but is concentrated in only a few centers. The number of published reports on minimally invasive organ-sparing pancreas procedures (e. g. CP or enucleation) for PCL is scarce; however, the available (selected) results are promising. CONCLUSION Minimally invasive surgery for PCL has the potential to reduce the operative trauma to the patients, while at the same time causing comparable or less morbidity. This requires an increasing specialization of complex minimally invasive resections. The clinical use of robotic systems will grow for the latter cases. A prospective registry of the results should be mandatory for quality management.
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Affiliation(s)
- T Welsch
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie (VTG), Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Deutschland.
| | - M Distler
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie (VTG), Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Deutschland
| | - J Weitz
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie (VTG), Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Deutschland
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Nota CL, Zwart MJ, Fong Y, Hagendoorn J, Hogg ME, Koerkamp BG, Besselink MG, Molenaar IQ. Developing a robotic pancreas program: the Dutch experience. J Vis Surg 2017; 3:106. [PMID: 29078666 DOI: 10.21037/jovs.2017.07.02] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 06/28/2017] [Indexed: 12/19/2022]
Abstract
Robot-assisted surgery has been developed to overcome limitations of conventional laparoscopy aiming to further optimize minimally invasive surgery. Despite the fact that robotics already have been widely adopted in urology, gynecology, and several gastro-intestinal procedures, like colorectal surgery, pancreatic surgery lags behind. Due to the complex nature of the procedure, surgeons probably have been hesitant to apply minimally invasive techniques in pancreatic surgery. Nevertheless, the past few years pancreatic surgery has been catching up. An increasing number of procedures are being performed laparoscopically and robotically, despite it being a highly complex procedure with high morbidity and mortality rates. Since the complex nature and extensiveness of the procedure, the start of a robotic pancreatic program should be properly prepared and should comply with several conditions within high-volume centers. Robotic training plays a significant role in the preparation. In this review we discuss the different aspects of preparation when working towards the start of a robotic pancreas program against the background of our nationwide experience in the Netherlands.
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Affiliation(s)
- Carolijn L Nota
- Department of Surgery, University Medical Center Utrecht, CX Utrecht, The Netherlands.,Department of Surgery, City of Hope Medical Center, Duarte, California, USA
| | - Maurice J Zwart
- Department of Surgery, Academic Medical Center Amsterdam, AZ Amsterdam-Zuidoost, The Netherlands
| | - Yuman Fong
- Department of Surgery, City of Hope Medical Center, Duarte, California, USA
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, CX Utrecht, The Netherlands
| | - Melissa E Hogg
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, CE Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center Amsterdam, AZ Amsterdam-Zuidoost, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, CX Utrecht, The Netherlands
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