A decade of pancreatoduodenectomy outcomes for pancreatic adenocarcinoma: 2014-2023 analysis of the N SQIP pancreatectomy PUF database: A decade of pancreatoduodenectomy in NSQIP.

166 Background: Training of general and thoracic surgeons continues to diverge, especially with the increasing role for minimally invasive surgical (MIS) approaches. Previous studies of esophagectomy outcomes by specialty do not adequately address malignancy or surgical approach. We sought to evaluate perioperative outcomes of esophagectomy for malignancy stratified by surgical specialty and approach using a national database. Methods: The National Surgical Quality Improvement Program (NSQIP) Targeted Esophagectomy Dataset was queried for esophagectomies for malignancy and grouped by surgeon specialty: thoracic surgery (TS) or general surgery (GS). Those with missing data were excluded (n = 6). To account for confounding due to specialty selection bias, we performed propensity score matching (PSM) by age, body mass index, ethnicity, American Society of Anesthesiologists class ³ 3, and surgical approach in a 1:1 ratio. An absolute standardized difference of ≤ 0.1 was considered an appropriate balance. The primary outcome was mortality and secondary outcomes were anastomotic leak, Clavien-Dindo grade ≥ 3 and positive margin rate. Univariate logistic regression analysis was performed for these outcomes on the matched cohort, with stratification by surgical approach (open vs. MIS). Results: A total of 1463 patients met inclusion criteria (512 GS, 951 TS). After PSM each group was comprised of 512 patients with similar demographics, neoadjuvant chemotherapy and radiation rates, and preoperative stage. The TS group consisted of 169 (33.0%) open and 343 (67.0%) MIS cases, while the GS group consisted of 177 (34.6%) open and 335 (65.4%) MIS cases. Postoperative complications, including surgical site infection, pneumonia, pulmonary embolism, stroke, and myocardial infarction were similar between matched groups, and remained similar when stratified by surgical approach. Mortality rates were similar between the TS and GS groups, both overall (14 (2.7%) vs. 10 (2.0%)) and when stratified by surgical approach (MIS: 11 (3.2%) vs. 10 (3.0%), open: 3 (1.8%) vs. 0 (0%)). By univariate analysis of the matched cohort stratified by surgical approach, TS patients had similar odds as GS patients of anastomotic leak (open: adjusted odds ratio (AOR) = 1.11, 95% confidence interval (95%CI) = 0.58 – 2.15, p = 0.75; MIS: AOR = 0.70, 95%CI = 0.47 – 1.04, p = 0.08), Clavien-Dindo grade ≥ 3 (open: AOR = 1.27, 95%CI = 0.79 – 2.06, p = 0.32; MIS: AOR = 1.01, 95%CI = 0.73 – 1.39, p = 0.97), positive surgical margins (open: AOR = 0.75, 95%CI = 0.33 – 1.68, p = 0.49; MIS: AOR = 0.62, 95%CI = 0.35 – 1.07, p = 0.09), and mortality (open: unable to be calculated due to 0 deaths in the GS group; MIS: AOR = 1.08, 95%CI = 0.45 – 2.62, p = 0.87). Conclusions: Esophagectomy for malignancy had a similar perioperative safety profile and positive margin rate among general and thoracic surgeons, regardless of surgical approach.

Establishing a new pancreatic surgery program in the community setting (our open and robotic experience)

A multi-institutional study of minimally invasive surgery compared to laparotomy for interval debulking after neoadjuvant chemotherapy in women with advanced ovarian cancer

Wednesday, September 26, 2018 1:00 PM – 2:00 PM What's New in MIS: 41. Complication risk in primary and revision minimally invasive lumbar interbody fusion: a comparable alternative to conventional open techniques?

Delayed gastric emptying (DGE) is common in patients undergoing pancreaticoduodenectomy (PD). The effect of DGE on mortality is less clear. We sought to identify predictors of mortality in patients undergoing PD for pancreatic adenocarcinoma hypothesizing DGE to independently increase risk of 30-day mortality. The ACS-NSQIP targeted pancreatectomy database (2014–2017) was queried for patients with pancreatic adenocarcinoma undergoing PD. A multivariable logistic regression analysis was performed. Separate sensitivity analyses were performed adjusting for postoperative pancreatic fistula (POPF) grades A–C. Out of 8011 patients undergoing PD, 1246 had DGE (15.6%). About 8.5% of patients with DGE had no oral intake by postoperative day-14. The DGE group had a longer median operative duration (373 vs. 362 min, p = 0.019), and a longer hospital length of stay (16.5 vs. 8 days, p < 0.001). After adjusting for age, gender, comorbidities, preoperative chemotherapy, preoperative radiation, open versus laparoscopic approach, vascular resection, deep surgical space infection (DSSI), postoperative percutaneous drain placement, and development of a POPF, DGE was associated with an increased risk for 30-day mortality (OR 3.25, 2.16–4.88, p < 0.001). On sub-analysis, grades A and B POPF were not associated with risk of mortality while grade C POPF was associated with increased risk of mortality (OR 5.64, 2.24–14.17, p < 0.001). The rate of DGE in patients undergoing PD in this large database was over 15%. DGE is associated with greater than three times the increased associated risk of mortality, even when controlling for POPF, DSSI, and other known predictors of mortality.

Minimally invasive hepatopancreatobiliary surgery in North America: an ACS-NSQIP analysis of predictors of conversion for laparoscopic and robotic pancreatectomy and hepatectomy

Objective:To compare perioperative outcomes of minimally invasive pancreatoduodenectomy (MIPD) to open pancreatoduodenectomy (OPD) using evidence from randomized controlled trials (RCTs).Background:The wider adoption of MIPD has largely been fueled by observational studies rather than high-level evidence.Methods:We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Web of Science for RCTs comparing MIPD with OPD in adult patients with benign or malignant conditions requiring elective pancreatoduodenectomy. The primary outcomes were 90-day mortality, the comprehensive complication index, Clavien-Dindo grade ≥III complications, and hospital length of stay (LOS). Secondary outcomes included postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood loss, reoperation, operative time, and oncologic outcomes. Data were pooled as odds ratios or mean differences using a random-effects model. Risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation approach (PROSPERO ID: CRD42024592919).Results:Ten RCTs with a total of 1794 patients were included. Meta-analysis showed there were no significant differences regarding 90-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, reoperation, readmission, or oncologic outcomes between MIPD and OPD. LOS was reduced for MIPD. No clinically relevant differences were found in the subgroup analyses of laparoscopic and robotic pancreatoduodenectomy. Certainty of evidence was moderate to low.Conclusions:MIPD showed no clinically relevant advantages over OPD. These findings were consistent both for the robotic and laparoscopic approach.

Impact of Neoadjuvant Therapy on Postoperative Pancreatic Fistula: A Systematic Review and Meta-analysis

The use of neoadjuvant therapy (NAT) for pancreatic cancer is increasing, although its impact on post-operative pancreatic fistula (POPF) is variably reported. This systematic review and meta-analysis aimed to assess the impact of NAT on POPF. A systematic literature search until October 2019 identified studies reporting POPF following NAT (radiotherapy, chemotherapy or chemoradiotherapy) versus upfront resection. The primary outcome was overall POPF. Secondary outcomes included grade B/C POPF, delayed gastric emptying (DGE), post-operative pancreatic haemorrhage (PPH) and overall and major complications. The search identified 24 studies: pancreatoduodenectomy (PD), 19 studies (n = 19 416) and distal pancreatectomy (DP), five studies (n = 477). Local staging was reported in 17 studies, with borderline resectable and locally advanced disease comprising 6% (0-100%) and 1% (0-33%) of the population, respectively. For PD, any NAT was significantly associated with lower rates of overall POPF (OR: 0.57, P < 0.001) and grade B/C POPF (OR: 0.55, P < 0.001). In DP, NAT was not associated with significantly lower rates of overall or grade B/C POPF. NAT is associated with significantly lower rates of POPF after PD but not after DP. Further studies are required to determine whether NAT should be added to POPF risk calculators.

The impact of unplanned conversion to an open procedure during minimally invasive pancreatectomy

Background: Delayed gastric emptying (DGE) is the most common postoperative complication following any pancreatic resection. The incidence and risk factors of DGE in patients undergoing distal pancreatic resection (DPR) is not well defined. We aimed to determine the incidence of DGE not associated with postoperative pancreatic fistula (POPF) in patients undergoing DPR and to identify predictors of DGE. Methods: ACS-NSQIP pancreatectomy database (2014-2017) was queried for patients with pancreatic adenocarcinoma undergoing DPR, excluding patients with POPF. A classification and regression tree (CART) analysis was performed to identify risk for DGE, defined by nasogastric/gastrostomy tube placed after postoperative day (POD) 7 or no oral intake by POD 14. Results: A total of 1626 patients underwent DPR without POPF; 59 had DGE (3.6%). Patients with DGE had a longer length of stay vs patients without DGE (median 15 vs 6 days, P &lt; .001). CART analysis showed vascular resection and open surgery were predictors of DGE with a specificity of 98.3%. Patients requiring vascular resection had a 7.8% rate of DGE. Patients who did not undergo open surgery or vascular resection had a 1.8% rate of DGE. Conclusions: The rate of DGE in patients undergoing DPR without postoperative pancreatic fistula is low. Predictors of DGE include open surgical approach and vascular resection. These findings may be utilized to counsel patients and take precautions in those at greater risk of developing DGE. Further research can involve implementation of a scoring tool to help stratify patients at risk for DGE after DPR.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM What's New in MIS: 42. Diminishing clinical returns of multilevel minimally invasive lumbar interbody fusion

BackgroundAlthough minimally invasive pancreaticoduodenectomy has gained worldwide interest, there are limited comparative studies between two minimally invasive pancreaticoduodenectomy techniques. This meta-analysis aimed to compare the safety and efficacy of robotic and laparoscopic pancreaticoduodenectomy (LPD), especially the difference in the perioperative and short-term oncological outcomes.MethodsPubMed, China National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before July 2021. Data on operative times, blood loss, overall morbidity, major complications, vascular resection, blood transfusion, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), conversion rate, reoperation, length of hospital stay (LOS), and lymph node dissection were subjected to meta-analysis.ResultsOverall, the final analysis included 9 retrospective studies comprising 3,732 patients; 1,149 (30.79%) underwent robotic pancreaticoduodenectomy (RPD), and 2,583 (69.21%) underwent LPD. The present meta-analysis revealed nonsignificant differences in operative times, overall morbidity, major complications, blood transfusion, POPF, DGE, reoperation, and LOS. Alternatively, compared with LPD, RPD was associated with less blood loss (p = 0.002), less conversion rate (p < 0.00001), less vascular resection (p = 0.0006), and more retrieved lymph nodes (p = 0.01).ConclusionRPD is at least equivalent to LPD with respect to the incidence of complication, incidence and severity of DGE, and reoperation and length of hospital stay. Compared with LPD, RPD seems to be associated with less blood loss, lower conversion rate, less vascular resection, and more retrieved lymph nodes.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD2021274057

Cost-utility analysis of posterior minimally invasive fusion compared with conventional open fusion for lumbar spondylolisthesis

While multiple studies have demonstrated that minimally invasive surgical (MIS) techniques are a safe and efficacious approach to adrenalectomy for pheochromocytomas (PC), these studies have only been small comparative studies. The aim of this multi-institutional study is to compare perioperative outcomes between open and MIS, stratified by robotic and conventional laparoscopic, techniques in the surgical management of PC. We retrospectively evaluated patients who underwent adrenalectomy for PCs from 2000 to 2017 at three different institutions. Clinical, perioperative, and pathologic parameters were analyzed using t test, Chi square, and Fisher exact statistical measures. Of the 156 adrenalectomy cases performed, 26 (16.7%) were with an open approach and 130 (83.3%) using MIS techniques. Of the MIS procedures, 41 (31.5%) were performed robotically and 89 (68.5%) performed laparoscopically without robotic assistance. Demographic and clinical parameters were similar between the open and MIS groups. Patients, who underwent MIS procedure had a lower complication rate (p = 0.04), shorter hospitalization (p = 0.02), shorter operative time (p < 0.001), and less blood loss (p = 0.002) than those who underwent open surgical resection. Conventional laparoscopic and robotic operative approaches resulted in similar complication rates, length of hospitalization, and blood loss. Our study is one of the largest cohorts comparing the perioperative outcomes between conventional laparoscopic and robotic adrenalectomies in patients with PC. Our results support that MIS techniques have potentially lower morbidity compared to open techniques, while laparoscopic and robotic approaches have similar perioperative outcomes.