Minimally Invasive Pancreaticoduodenectomy Research Articles

Analysis of factors influencing pancreatic fistula after minimally invasive pancreaticoduodenectomy and establishment of a new prediction model for clinically relevant pancreatic fistula

BackgroundPostoperative pancreatic fistula (POPF) is the most prevalent complications following minimally invasive pancreaticoduodenectomy (MIPD). Only one model related to MIPD exists, and previous POPF scoring prediction methods are based on open pancreaticoduodenectomy patients. Our objectives are to determine the variables that may increase the probability of pancreatic fistula following MIPD and to develop and validate a POPF predictive risk model.MethodsData from 432 patients who underwent MIPD between July 2015 and May 2022 were retrospectively collected. A nomogram prediction model was created using multivariate logistic regression analysis to evaluate independent factors for POPF in patients undergoing MIPD in the modeling cohort. The area under the curve (AUC) of the receiver operating characteristic curve (ROC) and the calibration curve were used to verify the nomogram prediction model internally and externally within the modeling cohort and the verification cohort.ResultsMultivariate logistic regression analysis showed that body mass index (BMI), albumin, triglycerides, pancreatic duct diameter, pathological diagnosis and intraoperative bleeding were independent variables for POPF. On the basis of this information, a model for the prediction of risks associated with POPF was developed. In accordance with the ROC analysis, the modeling cohort's AUC was 0.819 (95% CI 0.747–0.891), the internal validation cohort's AUC was 0.830 (95% CI 0.747–0.912), and the external validation cohort's AUC was 0.793 (95% CI 0.671–0.915). Based on the calibration curve, the estimated values of POPF have a high degree of concordance with the actual values that were measured.ConclusionsThis model for predicting the probability of pancreatic fistula following MIPD has strong predictive capacity and can provide a trustworthy predictive method for the early screening of high-risk patients with pancreatic fistula after MIPD and timely clinical intervention.

Minimally Invasive Pancreaticoduodenectomy in Elderly versus Younger Patients: A Meta-Analysis.

(1) Background: With ageing, the number of pancreaticoduodenectomies (PD) for benign or malignant disease is expected to increase in elderly patients. However, whether minimally invasive pancreaticoduodenectomy (MIPD) should be performed in the elderly is not clear yet and it is still debated. (2) Materials and Methods: A systematic review and meta-analysis was conducted including seven published articles comparing the technical and post-operative outcomes of MIPD in elderly versus younger patients up to December 2022. (3) Results: In total, 1378 patients were included in the meta-analysis. In term of overall and Clavien-Dindo I/II complication rates, post-operative pancreatic fistula (POPF) grade > A rates and biliary leakage, abdominal collection, post-operative bleeding and delayed gastric emptying rates, no differences emerged between the two groups. However, this study showed slightly higher intraoperative blood loss [MD 43.41, (95%CI 14.45, 72.38) p = 0.003], Clavien-Dindo ≥ III complication rates [OR 1.87, (95%CI 1.13, 3.11) p = 0.02] and mortality rates [OR 2.61, (95%CI 1.20, 5.68) p = 0.02] in the elderly compared with the younger group. Interestingly, as a minor endpoint, no differences in terms of the mean number of harvested lymphnode and of R0 resection rates were found. (4) Conclusion: MIPD seems to be relatively safe; however, there are slightly higher major morbidity, lung complication and mortality rates in elderly patients, who potentially represent the individuals that may benefit the most from the minimally invasive approach.

Comparison of the modified Blumgart mattress vs. interrupted suture pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy

Aim: The modified Blumgart mattress (BM) and conventional interrupted suture (IS) methods are currently the most widely adopted pancreaticojejunostomy (PJ) techniques utilized during minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the postoperative outcomes between the two PJ techniques using robotic and laparoscopic approaches. Methods: This was a retrospective study involving patients who underwent robotic or laparoscopic pancreaticoduodenectomy (PD) performed by two surgeons from two institutions. Surgical outcomes of the patients were compared according to the PJ techniques of robotic BM (Rob-BM), robotic IS (Rob-IS), and laparoscopic IS (Lap-IS), which were further analyzed among patients who had a soft pancreas and small pancreatic duct, while those with pancreatic ductal adenocarcinoma were excluded from the study. Results: A total of 230 patients underwent MIPD with 63 Rob-BM, 48 Rob-IS, and 119 Lap-IS for PJ. Within the study population, clinically relevant-postoperative pancreatic fistula (CR-POPF) rates were comparable between Rob-BM and Rob-IS (6.3% vs. 10.4%, P = 0.283) and between Rob-IS and Lap-IS (10.4% vs. 7.6%, P = 0.661). Comparing patients with soft pancreas and small pancreatic duct, CR-POPF rates were not statistically different among the groups [16.0% (Rob-BM) vs. 10.5% (Rob-IS), P = 0.055, and 10.5% (Rob-IS) vs. 10.1% (Lap-IS), P = 0.543]. In the multivariable analysis for risk factors of POPF, soft pancreatic textures and periampullary pathology other than pancreatic cancer were found to be risk factors. Conclusion: POPF rates after MIPD were not different according to the PJ methods of BM and IS when performed by skilled surgeons.

Risk stratification of clinically relevant delayed gastric emptying after pancreaticoduodenectomy

BackgroundDelayed gastric emptying (DGE) remains one of the major complications after pancreaticoduodenectomy (PD), with discrepant reports of its contributing factors. This study aimed to develop a nomogram to identify potential predictors and predict the probability of DGE after PD.MethodsThis retrospective study enrolled 422 consecutive patients who underwent PD from January 2019 to December 2021 at our institution. The LASSO algorithm and multivariate logistic regression were performed to identify independent risk and protective factors associated with clinically relevant delayed gastric emptying (CR-DGE). A nomogram was established based on the selected variables. Then, the calibration curve, ROC curve, decision curve analysis (DCA), and clinical impact curve (CIC) were applied to evaluate the predictive performance of our model. Finally, an independent cohort of 45 consecutive patients from January 2022 to March 2022 was enrolled to further validate the nomogram.ResultsAmong 422 patients, CR-DGE occurred in 94 patients (22.2%). A previous history of chronic gastropathy, intraoperative plasma transfusion ≥ 400 ml, end-to-side gastrointestinal anastomosis, intra-abdominal infection, incisional infection, and clinically relevant postoperative pancreatic fistula (CR-POPF) were identified as risk predictors. Minimally invasive pancreaticoduodenectomy (MIPD) was demonstrated to be a protective predictor of CR-DGE. The areas under the curve (AUCs) were 0.768 (95% CI, 0.706–0.830) in the development cohort, 0.766 (95% CI, 0.671–0.861) in the validation cohort, and 0.787 (95% CI, 0.633–0.940) in the independent cohort. Then, we built a simplified scale based on our nomogram for risk stratification.ConclusionsOur study identified seven predictors and constructed a validated nomogram that effectively predicted CR-DGE for patients who underwent PD.

Laparoscopic pancreaticoduodenectomy and laparoscopic pancreaticoduodenectomy with robotic reconstruction: single-surgeon experience and technical notes

Despite the increasing number of robotic pancreaticoduodenectomies, laparoscopic pancreaticoduodenectomy (LPD) and LPD with robotic reconstruction (LPD-RR) are still valuable surgical options for minimally invasive pancreaticoduodenectomy (MIPD). This study introduces the surgical techniques, tips, and outcomes of our experience with LPD and LPD-RR.Between March 2014 and July 2021, 122 and 48 patients underwent LPD and LPD-RR respectively, at CHA Bundang Medical Center in Korea. The operative settings, procedures, and trocar placements were identical in both approaches; however, different trocars were used. We introduced our techniques of retraction methods for Kocherization and uncinate process dissection, pancreatic reconstruction, pancreatic division, and protection using the round ligament. The perioperative surgical outcomes of LPD and LPD-RR were compared.Baseline demographics of patients in the LPD and LPD-RR groups were comparable, but the LPD group had older age (65.5 ± 11.6 years vs. 60.0 ± 14.1 years, p = 0.009) and lesser preoperative chemotherapy (15.6% vs. 35.4%, p = 0.008). The proportion of malignant disease was similar (LPD group, 86.1% vs. LPD-RR group, 83.3%; p = 0.759). Perioperative outcomes were also comparable, including operative time, estimated blood loss, clinically relevant postoperative pancreatic fistula (LPD group, 9.0% vs. LPD-RR group, 10.4%; p = 0.684), and major postoperative complication rates (LPD group, 14.8% vs. LPD-RR group, 6.2%; p = 0.082).Both LPD and LPR-RR can be safely performed by experienced surgeons with acceptable surgical outcomes. Further investigations are required to evaluate the objective benefits of robotic surgical systems in MIPD and establish widely acceptable standardized MIPD techniques.

Multidimensional Nomogram to Predict Postoperative Pancreatic Fistula after Minimally Invasive Pancreaticoduodenectomy.

Clinically relevant postoperative pancreatic fistula (CR-POPF) is an inherently severe risk of pancreatic resection. Previous research has proposed models that identify risk factors and predict CR-POPF, although these are rarely applicable to minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the individual risks of CR-POPF and to propose a nomogram for predicting POPF in MIPD. We retrospectively reviewed the medical records of 429 patients who underwent MIPD. In the multivariate analysis, the Akaike information criterion stepwise logistic regression method was used to select the final model to develop the nomogram. Of 429 patients, 53 (12.4%) experienced CR-POPF. On multivariate analysis, pancreatic texture (p = 0.001), open conversion (p = 0.008), intraoperative transfusion (p = 0.011), and pathology (p = 0.048) were identified as independent predictors of CR-POPF. The nomogram was developed based on patient, pancreatic, operative, and surgeon factors by using the following four additional clinical factors as variables: American Society of Anesthesiologists class ≥ III, size of pancreatic duct, type of surgical approach, and < 40 cases of MIPD experience. A multidimensional nomogram was developed to predict CR-POPF after MIPD. This nomogram and calculator can help surgeons anticipate, select, and manage critical complications.

Impact of conversion at time of minimally invasive pancreaticoduodenectomy on perioperative and long-term outcomes: Review of the National Cancer Database.

Current literature presents limited data regarding outcomes following conversion at the time of minimally invasive pancreaticoduodenectomy (MI-PD). The National Cancer Database was queried for patients who underwent pancreaticoduodenectomy. Patients were stratified into three groups: MI-PD, converted to open pancreaticoduodenectomy (CO-PD), and open pancreaticoduodenectomy (O-PD). Multivariable modeling was applied to compare outcomes of MI-PD and CO-PD to those of O-PD. Of 17,570 patients identified, 12.5%, 4.2%, and 83.4% underwent MI-PD, CO-PD, and O-PD, respectively. Robotic pancreaticoduodenectomy (R-PD) resulted in a higher lymph node yield (n = 23.2 ± 12.2) even when requiring conversion (n = 22.4 ± 13.2, p < 0.001). Margin positivity was higher in the CO-PD group (26.6%) than in the MI-PD group (21.3%) and the O-PD (22.6%) group (p = 0.017). Length of stay was shorter in the MI-PD group (laparoscopic pancreaticoduodenectomy 10.4 ± 8.6, R-PD 10.6 ± 8.8) and the robotic converted to open group (10.7 ± 6.4) than in the laparoscopic converted to open group (11.2 ± 9) and the O-PD group (11.5 ± 8.9) (p < 0.001). After adjusting for patient and tumor characteristics, both MI-PD (odds ratio = 1.40; p < 0.001) and CO-PD (odds ratio = 1.24; p = 0.020) were significantly associated with an increased likelihood of long-term survival. CO-PD does not negatively impact perioperative or oncologic outcomes.

Feasibility of simultaneous development of laparoscopic and robotic pancreaticoduodenectomy

Laparoscopic (LPD) and robotic pancreaticoduodenectomy (RPD) are both challenging procedures. The feasibility and safety of simultaneously developing LPD and RPD remain unreported. We retrospectively reviewed the data of patients undergoing LPD or RPD between 2014 and 2021. A total of 114 patients underwent minimally invasive pancreaticoduodenectomy (MIPD): 39 LPDs and 75 RPDs. The learning process of LPD and RPD were similar. The cutoff points of the learning curve were LPD, 13th patient (the 27th patient of MIPD), and RPD, 18th patient (the 31st patient of MIPD) according the cumulative sum analysis of operative time. A decrease in the operative time was associated with the case sequence (p < 0.001) but not with the surgical approach (p = 0.36). The overall surgical outcomes were comparable between both the LPD and RPD groups. When evaluating the learning curve impact on MIPD, LPD had higher major complication (≧ Clavien–Dindo grade III), bile leak and wound infection rates in the pre-learning curve phase than those in the after-learning curve phase, while RPD had similar surgical outcomes between two phases. Simultaneous development of LPD and RPD is feasible and safe for experienced surgeons, with similar learning process and comparable surgical outcomes.

Minimally invasive approaches increase postoperative complications in obese patients undergoing pancreaticoduodenectomy during the initial development period: a propensity score matching study.

Obesity increases surgical risks in various abdominal surgeries and its impact on open pancreaticoduodenectomy (OPD) and minimally invasive pancreaticoduodenectomy (MIPD) remains unknown. This study aimed to compare the surgical outcomes of OPD and MIPD in obese and non-obese patients by propensity score matching (PSM) analysis during the implementation of MIPD. We retrospectively reviewed all pancreaticoduodenectomies from December 2014 to May 2021. Obesity was defined as body mass index > 25kg/m2 according to World Health Organization International Obesity Task Force. PSM was used to minimize the selection bias of MIPD. Among 462 pancreaticoduodenectomies (339 OPDs, 123 MIPDs), there were 313 patients in the non-obese group (MIPD: 78, OPD: 235) and 149 patients in the obese group (MIPD: 45, OPD: 104). After PSM, there were 70 MIPD/106 OPD patients in the non-obese group and 38 MIPD/54 OPD patients in the obese group. The obese MIPD patients had more fluid collection (36.8% vs 9.8%, p = 0.002), a higher Clavien-Dindo (CD) grade (p = 0.007), more major complications (42.1% vs 14.8%, p = 0.004), and longer operative times (306min vs 264min, p < 0.001) than the obese OPD patients. The non-obese MIPD patients had lower CD grades (p = 0.02), longer operative times (294 vs 264min, p < 0.001), and less blood loss (100mL vs 200mL) than the non-obese OPD patients. MIPD was a strong predictor of major complication (CD ≥ 3) in obese patients (odds ratio 3.11, 95% CI: 1.40-6.95, p = 0.005). Minimally invasive approaches deteriorate the CD grade, fluid collection, and major complications in obese patients undergoing pancreaticoduodenectomy during the initial development period. Non-obese patients may benefit from MIPD over OPD in terms of less blood loss and lower CD grades. The impact of BMI on MIPD should be considered when assessing the surgical risks.

HPB P48 Minimally invasive HPB surgery in the UK from consultant and trainee perspectives

Abstract Background This survey took a ‘'snapshot’’ of prevailing attitudes towards minimally invasive HPB surgery from a consultant and trainee perspective. Methods Between November 2020 and January 2021, two google surveys were emailed to all HPB tertiary centres in the UK. The questionnaire contained 33 and 31 questions respectively regarding minimally invasive practice and training. Results Thirty-five HPB consultants completed the survey. The most common indications for conversion were failure to progress (91.4%), excessive blood loss (85.7%), access issues (85.7%). The majority (78.8%) of HPB surgeons undertook minimally invasive distal pancreatectomy (MIDP). One consultant undertook minimally invasive pancreaticoduodenectomy (MIPD), 48.4% declared not performing MIPDs due to uncertainty of its superiority. Eighty-five-point seven percent performed minimally invasive minor liver resection and segementectomy (MImLRS), 70.6% reported better outcomes with this approach; 28.6% of consultants performed minimally invasive major liver resection (MIMLR), 23.3% reported better outcomes with MIMLR. Half of HPB trainees did not have access to complex laparoscopic HPB procedures; 72.2% desired fellowship training. Conclusions MImLRS and MIDP are accepted approaches by most HPB consultants correlating with a perception that outcomes are better/comparable to open approaches, in contrast to MIPD and MIMLR. HPB trainees lack laparoscopic HPB exposure leading them to seek further experience with fellowships.

Equal Access for Minimally Invasive Pancreaticoduodenectomy

INTRODUCTION: Minimally invasive pancreaticoduodenectomy (MIPD) is more frequently employed in the management of pancreatic malignancies and offers potential advantages over open pancreatoduodenectomy (OPD) in length of stay, time to adjuvant therapy, and margin status. Whether disparities in access to MIPD exist is less clear. METHODS: The National Cancer Database (NCDB) was queried (2010 to 2017) for patients who underwent pancreatoduodenectomy (PD) for pancreatic malignancy. Cochran-Armitage tests were employed to assess for trends over time. Social determinants of health were compared between OPD and MIPD, including insurance status, region, race, income, and education. Multivariable logistic models identified predictors of MIPD. RESULTS: We identified 12,639 patients, of which 81.3% (n = 10,274) were OPD and 18.7% (n = 2,365) were MIPD (18.4% robotic/81.6% laparoscopic). For all patients, the proportion of cases that were robotic (1.7% vs 5.5%) and laparoscopic (11.4% vs 16.8%) increased over time (p < 0.0001). Patients with pancreatic adenocarcinoma were less likely to have MIPD if they were Black (vs White; odds ratio [OR] 0.75; 95% CI 0.62 to 0.90) or if they had ≥21% no high school degree (vs <7% no high school degree OR 0.70; 95% CI 0.57 to 0.87). Over time, MIPD increased as a proportion of all PD performed for White patients (p < 0.0001), and the proportion for Black patients was unchanged (p = 0.125). CONCLUSION: Patients who are Black or have lower educational status are less likely to undergo MIPD compared with OPD. Proportion of MIPD is increasing over time for White patients, but not for Black patients. These data may suggest that the racial gap in access to MIPD could continue to widen.

Minimally invasive versus open pancreaticoduodenectomy for distal bile duct cancer: an inverse probability of treatment weighting analysis of outcomes.

Minimally invasive pancreaticoduodenectomy (MIPD) has been extended to periampullary cancers, but the oncologic outcome of MIPD for distal bile duct cancer (DBDC) has not been confirmed yet. Patients who underwent pancreaticoduodenectomy (PD) for DBDC of stage I-IIb from 2015 to 2019 at a tertiary referral center were identified and divided into open PD (OPD) and MIPD groups, the latter including laparoscopic and robotic procedures. Survival was compared between the two groups after inverse probability of treatment weighting (IPTW) using predetermined factors, and exploratory mediation analysis was performed using surgery-derived outcomes. MIPD (n = 81) group had more female patients (46.9% vs 31.6%, p = 0.011) and longer operation time (366.2min vs. 279.1min, p < 0.001) than the OPD (n = 288) group before IPTW. Otherwise, intraoperative and immediate postoperative outcomes were comparable between the two groups. In oncologic outcomes, MIPD group showed comparable 3-year overall survival (78.2% vs 75.0%, p = 0.062) and recurrence-free survival (51.2% vs 53.4%, p = 0.871) rates with OPD group before IPTW, and MIPD was not related with survival (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.29-1.26, p = 0.18) and recurrence (HR 1.01, 95% CI 0.67-1.53, p = 0.949) after IPTW with consideration of potential mediators. Sensitivity analysis using propensity score matching also showed similar results for survival (HR 0.68, 95% CI 0.32-1.44, p = 0.312) and recurrence (HR 1.12, 95% CI 0.67-1.88, p = 0.653). MIPD and OPD groups showed similar postoperative and oncologic outcomes. MIPD could be a considerable treatment option without oncological compromise in high-volume centers.

Robotic Pancreaticoduodenectomy: Increased Adoption and Improved Outcomes: Is Laparoscopy Still Justified?

To compare the rate of postoperative 30-day complications between laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD). Previous studies suggest that minimally invasive pancreaticoduodenectomy (MI-PD)-either LPD or RPD-is noninferior to open pancreaticoduodenectomy in terms of operative outcomes. However, a direct comparison of the two minimally invasive approaches has not been rigorously performed. Patients who underwent MI-PD were abstracted from the 2014 to 2019 pancreas-targeted American College of Surgeons National Sample Quality Improvement Program (ACS NSQIP) dataset. Optimal outcome was defined as absence of postoperative mortality, serious complication, percutaneous drainage, reoperation, and prolonged length of stay (75th percentile, 11 days) with no readmission. Multivariable logistic regression models were used to compare optimal outcome of RPD and LPD. A total of 1540 MI-PDs were identified between 2014 and 2019, of which 885 (57%) were RPD and 655 (43%) were LPD. The rate of RPD cases/year significantly increased from 2.4% to 8.4% ( P =0.008) from 2014 to 2019, while LPD remained unchanged. Similarly, the rate of optimal outcome for RPD increased during the study period from 48.2% to 57.8% ( P <0.001) but significantly decreased for LPD (53.5% to 44.9%, P <0.001). During 2018-2019, RPD outcomes surpassed LPD for any complication [odds ratio (OR)=0.58, P =0.004], serious complications (OR=0.61, P =0.011), and optimal outcome (OR=1.78, P =0.001). RPD adoption increased compared with LPD and was associated with decreased overall complications, serious complications, and increased optimal outcome compared with LPD in 2018-2019.

Surgical Approach does not Affect Return to Intended Oncologic Therapy Following Pancreaticoduodenectomy for Pancreatic Adenocarcinoma: A Propensity-Matched Study.

The effect of minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic pancreaticoduodenectomy (LPD and RPD, respectively), on compliance and time to return to intended oncologic therapy (RIOT) for pancreatic ductal adenocarcinoma (PDAC) remains unknown. Patients with nonmetastatic PDAC were analyzed in the National Cancer Database (NCDB). Three groups were matched per propensity score: open pancreaticoduodenectomy (OPD) and MIPD, LPD and RPD, and converted and nonconverted patients. RIOT rates and time to RIOT were examined. A total of 14,135 patients were included: 11,834 (83.7%) underwent OPD and 2301 (16.3%) underwent MIPD. After score matching, RIOT rates (67.2 vs. 65.3%; p = 0.112) and RIOT within 8 weeks (57.7 vs. 56.4%; p = 0.276) were similar among MIPD and OPD groups, and approach was not a significant predictor of RIOT on multivariable regression. Neither RIOT nor time to RIOT were different among LPD and RPD groups (63.9 vs. 67.0%, and 58.4 vs. 56.9%, respectively). Compared with LPD, RPD was associated with lower conversion rates (HR 0.519; p < 0.001), and conversion was associated with longer median time to RIOT (10 vs. 8 weeks; p = 0.041). In this national cohort, approach did not impact RIOT rates or time to RIOT for patients with PDAC. While conversion was associated with longer median time to RIOT, readiness to commence adjuvant therapy was similar for LPD and RPD.

Postoperative Pancreatic Fistula: Is Minimally Invasive Surgery Better than Open? A Systematic Review and Meta-analysis.

Minimally invasive pancreaticoduodenectomy (PD) is gaining popularity. The aim of this study was to compare the incidence of postoperative pancreatic fistula (POPF) after minimally invasive versus open procedures. Following the PRISMA statement, literature research was conducted focusing on papers comparing the incidence of POPF after open pancreaticoduodenectomy (OPD) versus minimally invasive pancreaticoduodenectomy (MIPD). Twenty-one papers were included in this meta-analysis, for a total of 4,448 patients. A total of 2,456 patients (55.2%) underwent OPD, while 1,992 (44.8%) underwent MIPD. Age, ASA score III patients, incidence of pancreatic ductal adenocarcinoma and duct diameter were significantly lower in the MIPD group. No statistically significant differences were found between the OPD and MIPD regarding the incidence of major complications (15.6% vs. 17.0%, respectively, p=0.55), mortality (3.7% vs. 2.4%, p=0.81), and POPF rate (14.3% vs. 12.9%, p=0.25). MIPD and OPD had comparable rates of postoperative complications, postoperative mortality, and POPF.

Comparing Minimally Invasive and Open Pancreaticoduodenectomy for the Treatment of Pancreatic Cancer: a Win Ratio Analysis

IntroductionDespite its rising adoption, the use of minimally invasive (MIS) pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer remains controversial. We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel statistical approach. MethodsPatients undergoing PD for pancreatic adenocarcinoma 2010–2016 were identified from the National Cancer Database (NCDB). Patients were paired based on age, sex, race, tumor size, Charlson-Deyo score, and receipt of neoadjuvant chemotherapy. The win ratio was calculated based on 30-day and 3-year mortality, receipt of adjuvant chemotherapy, surgical margin status, examination of at least 11 lymph nodes, extended length of stay, and 30-day readmission. ResultsAmong 18,936 patients, median age was 67 (IQR: 60–74); most patients had stage II disease at diagnosis (n = 16,530, 87.3%) and tumor size ≥ 2 cm (n = 15,880, 83.9%). The majority of patients underwent open PD (n = 16,409, 86.7%) versus MIS PD (n = 2527, 13.3%). For every matched patient-patient pair, the odds of the patient undergoing MIS PD “winning” were 1.14 (95%CI 1.13–1.15) higher versus open PD. The benefits of MIS PD were most pronounced among patients with tumor size < 2 cm (WR 1.21, 95%CI 1.13–1.30 versus ≥ 2 cm, WR 1.13, 95%CI 1.12–1.14) and patients who received neoadjuvant chemotherapy prior to resection (WR 1.28, 95%CI 1.23–1.32 versus no neoadjuvant chemotherapy, WR 1.13, 95%CI 1.11–1.14). ConclusionsMIS PD may be preferable to open PD based on a hierarchical composite outcome that considered short-term, long-term, and oncologic outcomes.

Total laparoscopic versus robotic-assisted laparoscopic pancreaticoduodenectomy: which one is better?

Minimally invasive pancreaticoduodenectomy (MIPD) is a challenging procedure. Laparoscopic pancreaticoduodenectomy (LPD) is feasible and safe. Since the development of robotic platforms, the number of reports on robot-assisted pancreatic surgery has increased. We compared the technical feasibility and safety between LPD and robot-assisted LPD (RALPD). From September 2012 to August 2020, 257 patients who underwent MIPD for periampullary tumors were enrolled. Of these, 207 underwent LPD and 50 underwent RALPD. We performed a 1:1 propensity score-matched (PSM) analysis and retrospectively analyzed the demographics and surgical outcomes. After PSM analysis, no difference was noted in demographics. Operation times and estimated blood loss were similar, as was the incidence of complications (p > 0.05). In subgroup analysis in patients with soft pancreas with pancreatic duct ≤ 2mm, no significant between-group difference was noted regarding short-term surgical outcomes, including clinically relevant POPF (CR-POPF) (p > 0.05). In multivariable analysis, the only soft pancreatic texture was a predictive factor (HR 3.887, 95% confidence interval 1.121-13.480, p = 0.032). RALPD and LPD are safe and effective for MIPD and can compensate each other to achieve the goal of minimally invasive surgery.

Quality of Life Associated with Open vs Minimally Invasive Pancreaticoduodenectomy: A Prospective Pilot Study.

This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies. From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted. Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being. Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.

Improved Outcomes with Minimally Invasive Pancreaticoduodenectomy in Patients with Dilated Pancreatic Ducts: A Prospective Study

Introduction: Little is known about what predicts better outcomes for minimally invasive pancreaticoduodenectomy (MIPD) versus open pancreaticoduodenectomy (OPD). We hypothesized that MIPD patients with dilated pancreatic ducts have improved outcomes compared to OPD. Methods: All patients undergoing pancreaticoduodenectomy were prospectively followed over 47 months; perioperative and pathologic covariates and outcomes were compared. Ideal outcome (IO) was defined as: having no complications, postoperative length of stay < 7 days and negative margins on pathology. Patients with dilated ducts (≥3mm) who underwent MIPD were 1:3 propensity score matched to patients with dilated ducts who underwent OPD. Likewise, patients with non-dilated ducts (<3mm) who underwent MIPD were 1:3 propensity score matched to patients with non-dilated ducts who underwent OPD, and outcomes compared. Results: 371 patients underwent PD– 74 (19.9%) MIPD and 297 (80.1%) OPD. Overall, MIPD patients had significantly less intraoperative blood loss. After 1:3 propensity score matching, MIPD patients with dilated pancreatic ducts (n=45) had significantly lower overall complication and 90-day readmission rates compared to matched OPD patients (n=135) with dilated ducts. MIPD patients with dilated duct were more likely to have IO than patients with OPD (29% vs 15%, p=0.035). There were no significant differences in postoperative outcomes among matched patients with non-dilated pancreatic ducts who underwent MIPD (n=29) compared to matched patients undergoing OPD (n=87) with non-dilated ducts. Conclusions: MIPD is safe with comparable outcomes to OPD. Patients with pancreatic ducts ≥3mm derive the most benefit from MIPD: fewer complications, lower readmission rates and higher likelihood of ideal outcome.

Multicenter Comparison of Totally Laparoscopic and Totally Robotic Pancreaticoduodenectomy: Propensity Score and Learning Curve-Matching Analyses

Introduction: Few studies to date have compared laparoscopic pancreaticoduodenectomy(LPD) and robotic pancreaticoduodenectomy(RPD) despite emerging use of minimally invasive pancreaticoduodenectomy(MIPD). The present study, therefore, compared perioperative outcomes in patients who underwent LPD and RPD.