Indirect comparison of perioperative outcomes between open, laparoscopic, and robotic pancreaticoduodenectomy: Systematic review and network meta-analysis.

Open vs robotic-assisted pancreaticoduodenectomy, cost-effectiveness and long-term oncologic outcomes: a systematic review and meta-analysis

To evaluate real-world clinical outcomes of robotic pancreaticoduodenectomy (PD) versus open and laparoscopic PD in a nationwide cohort. While robotic PD has gained popularity as a minimally invasive approach to pancreatic surgery, its clinical effectiveness remains uncertain owing to the limited generalizability of existing evidence. Data from the Japanese National Clinical Database, which captures over 95% of surgical procedures conducted nationwide, were analyzed. Patients who underwent PD between January 2019 and December 2023 were included. Propensity score matching was used to compare robotic PD with open and laparoscopic PD. Among 46,166 eligible PD cases, 1,371 were robotic. To ensure consistent surgical proficiency, the analysis included cases performed at institutions conducting ≥20 PDs annually (n=23,613). Following 1:1 matching, 1,248 robotic-open and 1,066 robotic-laparoscopic pairs were identified. Robotic PD was associated with a lower severe complication incidence than that with open (22.2% vs. 25.9%; odds ratio, 0.82; 95% confidence interval, 0.68-0.98; P=0.031) and laparoscopic PD (23.0% vs. 27.6%; odds ratio, 0.78; 95% confidence interval, 0.64-0.95; P=0.015). Robotic PD was also associated with a lower incidence of pancreatic fistula and shorter hospital stay, despite extended operative time. An increased incidence of deep venous thrombosis was observed in the robotic PD group. In this nationwide, Japanese credentialed setting, robotic PD was associated with improved short‑term outcomes compared with those of open and laparoscopic PD. As PD outcomes are influenced by surgeon/institutional experience and case complexity (tumor factors), these aspects should be carefully considered when selecting robotic PD.

Pancreatic ductal adenocarcinoma is a common malignancy. Despite all advancements, the prognosis remains, poor with an overall 5-year survival of only 10.8%. Recently, a robotic platform has become an attractive tool for treating pancreatic cancer (PC). While recent studies indicated improved lymph node (LN) harvest during robotic pancreaticoduodenectomy (PD), data on long-term outcomes are insufficient. To evaluate absolute LN harvest during PD. Secondary outcomes included evaluating the association between LN harvest and short- and long-term oncological outcomes for three different surgical approaches. We conducted an analysis of the National Cancer Database, including patients diagnosed with PC who underwent open, laparoscopic, or robotic PD in 2010-2018. One-way analysis of variance was used to compare continuous variables, chi-square test - for categorical. Overall survival was defined as the time between surgery and death. Median survival time was estimated with the Kaplan-Meier method, and groups were compared with the Wilcoxon test. A Cox proportional hazards model was used to assess the association of covariates with survival after controlling for patient characteristics and procedure type. 17169 patients were included, 8859 (52%) males; mean age 65; 14509 (85%) white. 13816 (80.5%) patients had an open PD, 2677 (15.6%) and 676 (3.9%) - laparoscopic and robotic PD respectively. Mean comorbidity index (Charlson-Deyo Score) 0.50. On average, 18.84 LNs were harvested. Mean LN harvest during open, laparoscopic and robotic PD was 18.59, 19.65 and 20.70 respectively (P < 0.001). On average 2.49 LNs were positive for cancer and did not differ by the procedure type (P = 0.26). Vascular invasion was noted in 42.6% of LNs and did differ by the approach: 42.1% for open, 44.0% for laparoscopic and 47.2% for robotic PD (P = 0.015). Median survival for open PD was 26.1 mo, laparoscopic - 27.2 mo, robotic - 29.1 mo (P = 0.064). Survival was associated with higher LN harvest, while higher number of positive LNs was associated with higher mortality. Our study suggests that robotic PD is associated with increased intraoperative LN harvest and has comparable short-term oncological outcomes and survival compared to open and laparoscopic approaches.

Comparison of robotic versus open pancreaticoduodenectomy: achieving a textbook oncologic operation for pancreatic ductal adenocarcinoma

Pancreaticoduodenectomy is the first choice surgical intervention for the radical treatment of pancreatic tumors. However, an anastomotic fistula is a common complication after pancreaticoduodenectomy with a high mortality rate. With the development of minimally invasive surgery, open pancreaticoduodenectomy (OPD), laparoscopic pancreaticoduodenectomy (LPD), and robotic pancreaticoduodenectomy (RPD) are gaining interest. But the impact of these surgical methods on the risk of anastomosis has not been confirmed. Therefore, we aimed to integrate relevant clinical studies and explore the effects of these three surgical methods on the occurrence of anastomotic fistula after pancreaticoduodenectomy. A systematic literature search was conducted for studies reporting the RPD, LPD, and OPD. Network meta-analysis of postoperative anastomotic fistula (Pancreatic fistula, biliary leakage, gastrointestinal fistula) was performed. Sixty-five studies including 10,026 patients were included in the network meta-analysis. The rank of risk probability of pancreatic fistula for RPD (0.00) was better than LPD (0.37) and OPD (0.62). Thus, the analysis suggests the rank of risk of the postoperative pancreatic fistula for RPD, LPD, and OPD. The rank of risk probability for biliary leakage was similar for RPD (0.15) and LPD (0.15), and both were better than OPD (0.68). This network meta-analysis provided ranking for three different types of pancreaticoduodenectomy. The RPD and LPD can effectively improve the quality of surgery and are safe as well as feasible for OPD.

Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD). Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011-1/2015) were assessed. Univariate analyses of clinicopathologic and treatment factors were performed, and multivariable models were constructed to determine associations of operative approach (RPD or OPD) with perioperative outcomes. Of the 1028 patients, 211 (20.5%) underwent RPD (4.7% conversions) and 817 (79.5%) underwent OPD. As compared with OPD, RPD patients had higher body mass index, rates of prior abdominal surgery, and softer pancreatic remnants, whereas OPD patients had a higher percentage of pancreatic ductal adenocarcinoma cases, and greater proportion of nondilated (<3 mm) pancreatic ducts. On multivariable analysis, as compared with OPD, RPD was associated with longer operative times [mean difference = 75.4 minutes, 95% confidence interval (CI) 17.5-133.3, P = 0.01], reduced blood loss (mean difference = -181 mL, 95% CI -355-(-7.7), P = 0.04) and reductions in major complications (odds ratio = 0.64, 95% CI 0.47-0.85, P = 0.003). No associations were demonstrated between operative approach and 90-day mortality, clinically relevant postoperative pancreatic fistula and wound infection, length of stay, or 90-day readmission. In the subset of 522 (51%) pancreatic ductal adenocarcinomas, operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (<12 lymph nodes harvested). Postlearning curve RPD can be performed with similar perioperative outcomes achieved with OPD. Further studies of cost, quality of life, and long-term oncologic outcomes are needed.

Perioperative Outcomes of Robotic Pancreaticoduodenectomy: a Propensity-Matched Analysis to Open and Laparoscopic Pancreaticoduodenectomy

Though open pancreatoduodenectomy (OPD) is the gold standard, robotic pancreatoduodenectomy (RPD) is on the rise due to its technical ease with robotic armamentarium and claim to decrease morbidity in the perioperative period. This study compares the perioperative and oncologic outcomes of RPD performed for periampullary neoplasms (PANs) with OPD. This is a retrospective study conducted from January 2018 to December 2023 for all the patients who underwent either OPD or RPD for PANs. Demographic, peri-operative outcomes and oncological parameters [disease-free survival (DFS) and overall survival (OS)] were analysed and compared. The two groups were matched using 1:1 propensity score matching (PSM) to reduce the risk of confounding. A hundred patients were analysed (30 in RPD and 70 in OPD), and both groups were similar in demographic characteristics. Post-operative morbidity in terms of clinically relevant pancreatic fistula, post-pancreatectomy haemorrhage, delayed gastric emptying and overall Clavien-Dindo ≥ Grade 3 complications were similar in both groups. Surgical site infection (SSI) was significantly higher in the OPD group compared to RPD (31.4% vs. 6.7, p = 0.008); however, the median postoperative hospital stay was similar in both groups. After PSM (26 patients in each group), the RPD group had significantly more operative time (480min vs. 360min, p = 0.007) less blood loss (250ml vs. 400ml, p = 0.004), and similar SSI [2(7.7%) vs. 6(23.1%), p = 0.178). The R0 resection rate, lymph nodal yield, lymph nodal positivity, DFS and OS were similar in both groups. The robotic approach for PD is technically safe and feasible with equivalent resection quality and oncological outcomes compared to the open approach. RPD has equivalent postoperative morbidity, DFS and OS.

Objective To explore the short-term outcome of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for pancreatic head cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 108 patients with pancreatic head cancer who were admitted to the Affiliated Tongji Hospital of Huazhong University of Science and Technology between July 2014 and July 2015 were collected. Among 108 patients, 47 and 61 who respectively underwent LPD and OPD were allocated into LPD and OPD groups. Observation indicators: (1) intraoperative situations; (2) postoperative situations; (3) postoperative pathological situations; (4) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect chemotherapy and postoperative survival situations at 1 and 3 years postoperatively up to June 2018. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Comparison between groups of count data was analyzed using the chi-square test. Results (1) Intraoperative situations: operation time in the LPD and OPD groups was respectively (288±24)minutes and (265±29)minutes, with no statistically significant difference between groups (t=5.138, P>0.05). Volume of intraoperative blood loss in the LPD and OPD groups was respectively (136±14)mL and (388±21)mL, with a statistically significant difference between groups (t=-7.297, P 0.05). (2) Postoperative situations: of 47 patients in the LPD group, 16 with postoperative complications were improved by conservative treatment, including 7 with pancreatic fistula (5 with biochemical pancreatic fistula and 2 with grading B and C of pancreatic fistula); 4 with delayed gastric emptying were cured by gastrointestinal decompression and gastric motility promoting treatment; 2 with postoperative bleeding were improved by conservative treatment; 2 with intra-abdominal infection were improved by enhanced antibiotic therapy and transabdominal percutaneous drainage; 1 with biliary fistula was improved by transabdominal percutaneous drainage; there was no wound infection and perioperative death. Of 61 patients in the OPD group, 28 with postoperative complications were improved by conservative treatment, including 12 with pancreatic fistula (9 with biochemical pancreatic fistula and 3 with grading B and C of pancreatic fistula); 8 with delayed gastric emptying were cured by gastrointestinal decompression and gastric motility promoting treatment; 3 with intra-abdominal infection were improved by enhanced antibiotic therapy and transabdominal percutaneous drainage; 2 with postoperative bleeding were improved by conservative treatment; 2 with wound infection were cured by conservative treatment; 1 with biliary fistula was improved by transabdominal percutaneous drainage; there was no perioperative death. There was no statistically significant difference in the cases with postoperative complications between groups (χ2=1.546, P>0.05). Duration of hospital stay in the LPD and OPD groups was (13.6±2.1)days and (19.3±4.4)days, respectively, with a statistically significant difference (t=-4.354, P 0.05), and there was 1 patient with R1 resection in the OPD group. The total number of lymph node dissected in the LPD and OPD groups was respectively 19±4 and 13±4, with a statistically significant difference (t=-4.126, P 0.05). (4) Follow-up and survival situations: 44 and 55 patients in the LPD and OPD group respectively underwent postoperative adjuvant therapy during the follow-up, with no statistically significant difference (χ2=0, P>0.05). The postoperative 1-year follow-up: 47 patients in the LPD group were followed up, 37 survived and 10 died; of 61 patients in the OPD group, 3 lost to follow-up, and 58 were followed up (43 survived and 15 died); there was no statistically significant difference in survival between groups (χ2=0.301, P>0.05). The postoperative 3-year follow-up: of 47 patients in the LPD group, 3 lost to follow-up, and 44 were followed up (21 survived and 23 died); of 61 patients in the OPD group, 6 lost to follow-up, and 55 were followed up (23 survived and 32 died); there was no statistically significant difference in survival between groups (χ2=0.346, P>0.05). Conclusion LPD is safe and feasible for pancreatic head cancer, with advantages of less bleeding, shorter duration of hospital stay and more total number of lymph node dissected, and its survival effect is equivalent to that of OPD. Key words: Pancreatic neoplasms; Pancreatic head cancer; Pancreaticoduodenectomy; Short-term outcomes; Laparoscopy

Effect of Operative Time on Outcomes of Minimally Invasive Versus Open Pancreatoduodenectomy

The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.

The authors aimed to assess the safety of an enhanced recovery after surgery (ERAS) and early discharge pathway in a robotic pancreatoduodenectomy (PD) program and compared outcomes with an open PD control cohort to identify the synergistic effects of robotic surgery and an ERAS pathway on lengths of stay (LOS). Consecutive patients undergoing open or robotic PD from a single surgeon between March 2020 and July 2022 were identified. Logistic regression models were used for adjusted analyses of postoperative outcomes. There were 134 consecutive PD patients, of which 40 (30%) were performed robotically. Pancreatic adenocarcinoma was the most common indication in both open (56%) and robotic (55%, p = 0.51) groups, with a similar proportion of them being borderline resectable or locally advanced tumors (78% vs 82% in robotic group, p = 0.82). The LOS was significantly shorter in the robotic PD group (median, 5 [IQR 4 to 7] days) when compared with the open PD group (median, 6 [IQR 5 to 8] days, p < 0.001). LOS of 4 days or fewer were observed in 40% of the robotic PD group compared with only 3% of patients in the open PD group (p < 0.001). There was no difference in the overall readmission rate (10% vs 12% in the robotic PD group, p = 0.61). On multivariable logistic regression, robotic PD was independently associated with higher odds of LOS of 4 days or fewer (odds ratio 22.4, p = 0.001) when compared with open PD. An ERAS and early discharge pathway could be safely implemented in a robotic PD program. Patients undergoing robotic PD have significantly shorter length of stay without increased complication or readmission rate compared with open PD, with 40% of patients undergoing robotic PD achieving a LOS of 4 days or fewer.

Standardized pancreaticojejunostomy by Double U-Stitch Technique in Open, Laparoscopic, and Robotic Pancreatoduodenectomies

This study is to clarify the feasibility and justification of robotic pancreaticoduodenectomy (RPD) by comparing the outcomes between RPD and open pancreaticoduodenectomy (OPD) groups. All perioperative data and outcomes were prospectively collected. There were 304 (63.9%) RPD and 172 (36.1%) OPD. The median operation time was longer in RPD group than OPD (7.5 vs 7.0h). The blood loss was much lower in RPD group, with a median of 130 vs. 400 c.c. in OPD group. Based on Clavien-Dindo classification, grade 0 (no complication) was 51.8% in RPD group, higher than 43.2% in OPD. Delayed gastric emptying was only 3.5% in RPD group, much lower than 13.6% in OPD. Wound infection rate was also lower in RPD group, 3.2% vs. 7.7% in OPD. The postoperative hospital stay was shorter in RPD group, with a median of 20days, vs. 24days in OPD. There was no significant difference regarding the lymph node yield, surgical mortality, postoperative pancreatic fistula, postpancreatectomy hemorrhage, chyle leakage and bile leakage between RPD and OPD groups. For pancreatic head adenocarcinoma, the survival outcome was better in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8% respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD. RPD is not only feasible but also justified without increasing the surgical risks and compromising the survival outcomes. Moreover, RPD might provide benefits of less blood loss, less delayed gastric emptying, lower wound infection rate and shorter length of postoperative stay, as compared with OPD.

Major complications (MCs) after pancreaticoduodenectomy (PD) are a known independent predictor of worse oncologic outcomes. There are limited data on the effect of major complications on long-term outcomes after robotic PD (RPD). The aim of this study is to compare the effect of MC on overall (OS) and disease-free survival (DFS) after RPD and open PD (OPD). This is a single-center, retrospective review of a prospectively maintained database of all patients undergoing PD for periampullary cancer including ampullary adenocarcinoma, distal cholangiocarcinoma, and duodenal carcinoma. Univariate analysis was performed on all clinical, pathologic, and treatment factors. MCs were defined as Clavien-Dindo ≥ grade 3. Kaplan-Maier survival analysis was performed with log-rank test for group comparison. Multivariable Cox regression analysis was used to identify factors associated with overall survival (OS) in both the OPD and RPD groups. A total of 190 patients with ampullary carcinoma (n = 98), cholangiocarcinoma (n = 55), and duodenal adenocarcinoma (n = 37) were examined over the study period with 61.1% (n = 116) undergoing RPD and 38.9% (n = 74) undergoing OPD. There was no significant difference in patient demographics between the RPD and OPD cohorts. Furthermore, R0 resection rates, tumor size, and lymph node involvement were similar between the RPD and OPD cohorts. OPD had higher rate of MC (40.5% vs 28.3% in RPD, p = 0.011) including clinically relevant pancreatic fistula (25.7% vs 8.6%, p = 0.001) and wound infection (34.5% vs 13.8%, p < 0.001). MCs were associated with a lower OS in the OPD cohort (HR = 2.18, 95%CI 1.0-4.55, p = 0.038). MCs were not associated with OS in the RPD cohort (HR = 1.55, 95%CI 0.87-2.76, p = 0.14). MCs are associated with worse patient outcomes after OPD but not after RPD. Robotic approach mitigates and possibly abrogates the negative effects of MCs on patient outcomes after PD for malignancy and is associated with improved adjuvant chemotherapy completion rates.