Setting the Standard in Robotic Whipple Surgery: International Multicenter Benchmark Analysis.

Background Robotic Whipple holds the promise to overcome safety concerns associated with laparoscopy, paving the way for widespread implementation of minimal-invasive surgery in this complex procedure. However, randomized data comparing robot vs. open Whipple demonstrate more pancreas-specific complications and R1-resections in the robotic arm. Recent international consensus identified establishing benchmarks as critical to ensure safe adoption of the robot. Benchmarking is a validated quality improvement tool, enabling comparison of surgical performance. Aims The aim was to define benchmarks for outcome parameters in robotic Whipple. Methods We analyzed consecutive patients undergoing robotic Whipple from January 2020 until December 2023 in 11 centers across 4 continents, with a minimum one-year follow-up. Centers had to perform ≥15 cases/year and have mounted their learning curve. Benchmark criteria included benign or resectable malignant disease without neoadjuvant therapy, arterial resection, major co-morbidities, or significant previous abdominal surgery. Medians across centers represented benchmark cutoffs. Results Eleven centers performed 1’037 Whipple procedures, of which 603 (58%) were benchmark cases. One third (n=192) were pancreatic ductal adenocarcinoma (PDAC) patients. Key benchmarks at 6 months included ≤1.2% mortality, ≤24.2% major complications, and ≤ 8.7 points Comprehensive Complication Index®. Pancreas-specific cutoffs included ≤13.0% postoperative pancreatic fistula (POPF) B/C and ≤3.4% post-pancreatectomy hemorrhage B/C, with 100% R0-resection and ≥19 harvested lymph nodes in PDAC patients. One-year actuarial overall and recurrence-free survival was 87% and 77%. In the entire cohort POPF B/C occurred in 16% (n=195). Independent POPF predictors included duct diameter ≤4mm (OR 1.79 95%CI [1.27-2.55]), anticoagulation (OR 3.68 95%CI [2.14-6.24]), and indication other than PDAC (OR 3.17, 95%CI [2.13-4.85]). Conclusion This study establishes benchmarks for key outcomes in robotic Whipple, demonstrating oncologic adequacy and morbidity comparable to open surgery. Risk factors for POPF in open surgery also hold true in the robotic approach.

BackgroundVentilator-associated pneumonia (VAP) is a common nosocomial infection in critically ill patients in intensive care units (ICUs) worldwide. Despite the huge healthcare economic burden and the significant negative morbidity and mortality impact of VAP, its incidence and outcomes in the trauma ICU (TICU) population were poorly documented in South Africa (SA).ObjectivesTo determine the incidence of VAP in a level I trauma centre at Inkosi Albert Luthuli Central Hospital in Durban, SA, compared with international benchmarks. Determining mortality rates, the average length and cost of ICU stay, ventilator days and antibiotic consumption was a secondary objective.MethodsThis retrospective chart review of the trauma registry at the centre examined the incidence of VAP and secondary outcomes over the period January 2017 - December 2019. A data pro forma was used with VAP diagnoses as per the 2015 Centers for Disease Control and Prevention definitions. The comparator was international literature-based benchmark VAP rates in TICUs.ResultsThe study included 395 patients, of whom 143 (36.2%) were diagnosed with VAP. The VAP rate was calculated to be 35.6 per 1 000 ventilator days. Thirty-one patients with VAP (21.7%) died in the ICU, a similar figure to that for the non-VAP group (22.6%). There were no statistically significant differences in age, sex, mechanism of injury or Injury Severity Score between the VAP and non-VAP groups (p>0.05). There were statistically significant differences between the two groups in number of days on mechanical ventilation, ICU length of stay and ICU cost. The VAP group had a median of 12 ventilation days v. 5 days for the non-VAP group (p<0.001), and spent a median of 7 days longer in the ICU (p<0.001). The median cost of ICU stay for VAP patients was almost double that for non-VAP patients (p<0.001).ConclusionVAP rates in this local TICU were similar to international rates. Trauma patients, especially those with traumatic brain injury, are at higher risk of VAP than general ICU patients, so strict adherence to evidence-based VAP prevention bundles is necessary among TICU staff.Contribution of the studyThis study is the first to assess ventilator-associated pneumonia rates in a South African trauma-specific intensive care unit compared with national and international benchmarks, and sets the standard for local morbidity and mortality norms.

Arterial resections in pancreatic cancer – Systematic review and meta-analysis

A limited amount of data exists from developing and underdeveloped nations related to patient safety culture among diverse healthcare employees. This study aimed to identify baseline perceptions and attitudes towards patient safety across healthcare disciplines at two Egyptian hospitals using a validated survey tool to allow for comparison with international benchmarks. We conducted a cross- sectional study of 250 employees, who voluntarily completed the survey over a 14-day period. Results revealed that job satisfaction scored highest among the safety domains assessed and was significantly greater than the international benchmark. Job satisfaction was followed by teamwork climate, working conditions, safety climate, and perceptions of unit management and hospital management. All mean scores for these domains were significantly greater than the international benchmarks. In contrast, the mean score of stress recognition was significantly less than the international benchmark. Respondent demographics did not influence overall safety perception measured by the six domains; however, resident physicians perceived greater collaboration and communication among team members than other position types reported. Egyptian healthcare providers reported an overall positive perception of the culture of safety. However, recognition of the negative implications of stress on patient safety among Egyptians was lower than the international benchmark. Clinical Relevance: Our study provides insight into patient safety perceptions among diverse healthcare employees in a developing nation, establishes baseline data on safety culture at two hospitals, and offers a comparison between Egyptian healthcare workers’ patient safety attitudes and international benchmarks.

Robotic pancreaticoduodenectomy (RPD) is an emerging alternative to open pancreaticoduodenectomy (OPD). Although RPD offers various theoretical advantages, it is used in less than 10% of all pancreaticoduodenectomies. The aim of this study was to report our 10-year experience and compare RPD outcomes with international benchmarks for OPD. A retrospective review of a prospectively maintained institutional database was performed of consecutive patients who underwent RPD between January 2011 and December 2021. Patients were categorized into low-risk and high-risk groups according to the selection criteria set by the benchmark study. Their outcomes were compared to the international benchmark cut off values. Outcomes were then evaluated over time to identify improvements in practice and establish a learning curve. Of 201 RPDs, 36 were low-risk and 165 high-risk patients. Compared to the OPD benchmarks, outcomes of low-risk patients were within the cutoff values. High-risk patients were outside the cutoff for blood transfusions (26% vs. ≤ 23%), overall complications (78% vs. ≤ 73%), grade I-II complications (68% vs. ≤ 62%), and readmissions (22% vs ≤ 21%). Oncologic outcomes for high-risk patients were within benchmark cutoffs. Cases at the end of the learning curve included more pancreatic cancer (42% from 17%) and fewer low-risk patients (10% from 24%) than those at the beginning. After 41 RPD there was a decline in conversion rates and operative time. Between 95 and 143 cases operative time, transfusion rates, and LOS declined significantly. Complications did not differ over time. RPD yields results comparable to the established benchmarks in OPD in both low- and high-risk patients. Along the learning curve, RPD evolved with the inclusion of more high-risk cases while outcomes remained within benchmarks. Addition of a robotic HPB surgery fellowship did not compromise outcomes. These results suggest that RPD may be an option for high-risk patients at specialized centers.

Correspondence on “Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers”

Periarterial divestment following neoadjuvant therapy in patients with locally advanced pancreatic cancer with celiac axis invasion: Asafe and effective surgical procedure.

Perioperative and long-term outcome of en-bloc arterial resection in pancreatic surgery.

To examine the prognostic significance of postoperative morbidities in patients with ovarian cancer treated with neoadjuvant chemotherapy and interval surgical debulking. Retrospective chart reviews of all patients treated with neoadjuvant chemotherapy and interval debulking were performed from 1999 to 2002. Descriptive statistics were used to summarize the distributions of important clinical variables. Logistic regression was used to identify statistically significant predictors of postoperative morbidities. Cox regression was used to model time to first clinical progression. Survivals were estimated by the Kaplan-Meier method and compared with the log rank test. P < .05 was considered to be statistically significant. Fifty-eight patients were treated with neoadjuvant platinum-taxane combination chemotherapy. Major surgical complications were observed in four patients (6.8%). There were no perioperative deaths. The presence of concurrent medical comorbidities was associated with the development of significant postoperative morbidities (P = .038). Cox regression showed any macroscopic residual disease (P = .04) and the presence of significant postoperative morbidities (odds ratio, 4.7, 95% confidence interval, 1.8-12.7, P = .002) to be predictive of a shorter progression-free interval. Neoadjuvant chemotherapy followed by interval surgical debulking carried a low risk for postoperative morbidity. The adverse influence of marked postoperative morbidity on progression-free survival needs further study.

Background:Pancreatic cancer frequently involves the surrounding major arteries, preventing surgeons from making a radical excision. Neoadjuvant therapy (NAT) can lessen the size of local tumors and eliminate potential micrommetastases. However, systematic and evidence-based recommendations for the treatment of arterial resection (AR) after NAT in pancreatic cancer are scarce.Method:A computerized search of the Medline, Embase, Cochrane Library databases, and Clinicaltrials was performed to identify studies reporting the outcomes of patients who underwent pancreatectomy with AR and NAT for pancreatic cancer. Studies that reported perioperative and/or long-term results after pancreatectomy with AR and NAT were eligible for inclusion. The quality of the evidence was assessed with Newcastle–Ottawa Quality Assessment Form of bias tool. Data were pooled and analyzed by Stata 14.0 software.Result:Nine studies with an overall sample size of 215 met our eligibility criteria and were included in the meta-analysis. All studies were retrospective studies, and the methodological quality was moderate. The pooled morbidity and mortality rates were 51% (95% CI: 41–61%; I²= 0.0%) and 2% (95% CI: 0–0.08; I²=33.3%), respectively. Meta-analysis showed that the overall R0 resection rate was 79% (CI: 70–86%, I²=15.5%). Comparative data on R0 rates of patients who underwent pancreatectomy with and without NAT showed a significant difference in favor of the former group with moderate statistical heterogeneity (Relative risk=1.21; 95% CI: 0.776–1.915; I²=48.0%). The median 1-, 2-, 3-, and 5-year survival rates of patients who had AR were 92.3% (range: 72.7–100%), 64.8% (range: 25–78.8%), 51.6% (range: 16.7–63.6%), and 14% (range: 0–41.1%), respectively. Data on median progression-free survival ranged from 5.25 to 36.3 months, and the median overall survival ranged from 17 to 44.9 months.Conclusions:Pancreatectomy with major AR following NAT has the potential to enhance the survival rate of patients with unresectable pancreatic cancer involving the arteries by achieving R0 resection, despite a significant risk of postoperative complications. However, to validate the feasibility and effectiveness of this procedure, prospective controlled studies are necessary to address limitations arising from small sample sizes and potential biases inherent in retrospective studies.

LBA5505 Background: Lion trial demonstrated the lack of benefit of retroperitoneal pelvic and paraaortic lymphadenectomy (RPPL) in primary surgery in advanced epithelial ovarian cancer (AEOC) with clinically negative lymph nodes. As a consequence, the question of RPPL during interval cytoreductive surgery after neoadjuvant chemotherapy remains open. Methods: CARACO was a prospective multi-institutional phase III trial including patients with newly diagnosed AEOC FIGO III-IV, with no pre- and intra-operative suspicious lymph nodes, randomized intra-operatively to RPPL versus no-RPPL, stratified by surgical strategy (primary surgery, surgery after neoadjuvant chemotherapy). The primary endpoint was progression free survival (PFS). The target sample size was 450 evaluable patients, providing 80% power at 5% alpha based on the hypothesis of a 5 years PFS of 41%. Results: Between December 2008 and March 2020, 379 patients were randomly assigned to RPPL (n=181) or no-RPPL (n=187), 11 patients were excluded. Our required sample size was not reached because of a stop of inclusion after the publication of the Lion trial. The median number of removed lymph nodes in patients randomized to RPPL was 27 [IQR=19-36]. 75% of the patients were treated with neoadjuvant chemotherapy (244 patients treated with 3 or 4 cycles before interval surgery and 41 patients treated with 6 cycles before delayed surgery) and 83 patients treated with primary surgery followed with adjuvant platinum-based chemotherapy. The rate of surgery with no residual was 86% and 88% respectively in the No RPPL and the RPPL arm. Lymph node metastases were diagnosed in 49% of the patients in the RPPL arm, with a median of 3 involved lymph nodes [IQR=2-7]. After a median follow up of 9 years, median PFS in the no-RPPL arm and in the RPPL arm was 14.8 months and 18.5 months respectively (HR 0.98, 95%CI 0.78-1.22, p=0.86). Median OS was not significantly different: 48.9 months and 58.0 months in the No RPPL and RPPL arm respectively (HR 0.96, 95%CI 0.75-1.22 p=0.72). Results considering progression free and overall survival were not different in the subgroup of patients with a complete surgery or a neoadjuvant chemotherapy. Serious post-operative complications occurred more frequently in the RPPL arm: re-laparotomies 8.3% vs 3.2% [p=0.03], transfusion rate (34% vs 25%, p=0.05). Mortality within 60 days after surgery was similar between arms (1.1 vs 0.5% [p=0.54]) respectively. Conclusions: CARACO trial is the first randomized trial showing that systematic lymphadenectomy should be omitted in AEOC with clinically negative lymph nodes also in patients undergoing neoadjuvant chemotherapy and interval complete surgery. This surgical de-escalation allows to significantly reduce serious post operative morbidity. Clinical trial information: NCT01218490 .

The purpose of this study was to test the hypothesis that neoadjuvant chemotherapy (NACT) does not increase morbidity in patients undergoing radical hysterectomy with lymphadenectomy for locally advanced cervical cancer. MATERIALS AND METGODS: A retrospective study was undertaken of 140 patients with locally advanced cervical cancer (FIGO stage Ia to IIb) who underwent radical hysterectomy with lymphadenectomy by the same surgeon at the same hospital. Among the 140 patients, 39 received NACT followed by radical hysterectomy with pelvic lymphadenectomy (NACT group). This group received three cycles consisting of cisplatin 100 mg/m2/day on day 1 and 5-fluorouracil 1000 mg/m2/day from day 1 to 5. The NACT group was compared, in terms of intraoperative morbidity and postoperative morbidity, with the other 101 patients who underwent radical hysterectomy with lymphadenectomy but without chemotherapy (surgery-only group). There were no significant differences in mean age, body weight or height between the two groups. The only significant difference was that the NACT patients had higher stages of cancer. The incidence of intraoperative morbidity did not differ between the NACT and surgery only patients. We considered the operation duration, amount of blood loss and need for transfusion as indicators of intraoperative morbidity. We could not find any significant differences in the duration of suprapubic catheterization, days of hemovac drainage, amount of drained hemovac fluid, days of hospitalization or postoperative febrile morbidity between the NACT and surgery-only groups. Patients in the surgery-only group had more postoperative complications (ureteral obstruction, intestinal obstruction, lymphocyst, lymphedema, and death) than the NACT group, although not to a statistically significant degree (P>0.05). In this retrospective review, there was no evidence that NACT increased intraoperative or postoperative morbidity in patients with locally advanced cervical cancer. As this was a retrospective study, other prospective, randomized studies are needed to confirm these results.

South Africa (SA) is a resource-limited country that needs efficient operating theatres in order for surgical care to function cost-effectively. Regular assessment of theatre efficiency in our setting is therefore needed. To describe ophthalmology theatre efficiency at a central hospital in SA and compare this with international benchmarks. St John Eye Hospital is the ophthalmology section of Chris Hani Baragwanath Academic Hospital in Soweto, SA. It has three operating theatres. A cross-sectional study was done of the theatres' registry of surgical procedures over a 6-month period. Data analysed included the starting and finishing times of theatre lists, surgical cases that were cancelled on the day of surgery, and theatre utilisation rates. These data were compared with international benchmarks. A total of 1 482 surgical procedures in 229 theatre lists were included in the study. Sixty-five percent of these theatre lists started late, accounting for 4 236 minutes of lost theatre time, significantly more than the maximum of 10% recommended by the Royal College of Anaesthetists. Of theatre lists, 23% and 30% finished after 16h15 (theatre overrun) and before 16h00 (theatre underrun), respectively. This is more than double the 10% recommended by the Royal College of Anaesthetists. The theatre utilisation rate was 62%, which is significantly lower than the ideal utilisation rate of 80%. The cancellation rate was 16%, which is significantly higher than the international benchmark of 2% recommended by the New South Wales guidelines. The most common reasons for cancellations were medical unfitness of the patient and lack of operating theatre time. All theatre efficiency parameters at St John Eye Hospital were below international benchmarks.

Pancreatic adenocarcinoma: effects of neoadjuvant therapy on post-pancreatectomy outcomes – an American College of Surgeons National Surgical Quality Improvement Program targeted variable review

Aggressive preoperative and intraoperative management may improve the resectability rates and outcomes for locally advanced pancreatic adenocarcinoma with venous involvement. The efficacy and use of venous resection and especially arterial resection in the management of pancreatic adenocarcinoma remain controversial. Retrospective review of patients entered into prospective databases. Two tertiary referral centers. A retrospective review of 2 prospective databases of 593 consecutive pancreatic resections for pancreatic adenocarcinoma from January 1, 1999, through May 1, 2007. Of the 593 patients, 36 (6.1%) underwent vascular resection at the time of pancreatectomy. Thirty-one of the 36 (88%) underwent venous resection alone; 3 (8%), combined arterial and venous resection; and 2 (6%), arterial resection (superior mesenteric artery resection) alone. Patients included 18 men and 18 women, with a median age of 62 (range, 42-82) years. The 90-day perioperative mortality and morbidity rates were 0% and 35%, respectively, compared with 2% and 39%, respectively, for the group undergoing nonvascular pancreatic resection (P = .34). Median survival was 18 (range, 8-42) months in the vascular resection group compared with 19 months in the nonvascular resection group. Multivariate analysis demonstrated node-positive disease, tumor location (other than head), and no adjuvant therapy as adverse prognostic variables. In this combined experience, en bloc vascular resection consisting of venous resection alone, arterial resection alone, or combined vascular resection at the time of pancreatectomy for adenocarcinoma did not adversely affect postoperative mortality, morbidity, or overall survival. The need for vascular resection should not be a contraindication to surgical resection in the selected patient.