Minimally Invasive Pancreaticoduodenectomy Research Articles

Improved outcomes with minimally invasive pancreaticoduodenectomy in patients with dilated pancreatic ducts: A prospective study

Presenter: Sanket Srinivasa MD, PhD | Washington University, St. Louis Background: There is little known about what factors predict better outcomes for patients who undergo minimally invasive pancreaticoduodenectomy (MIPD) versus open pancreaticoduodenectomy (OPD). Identifying such characteristics may guide patient selection in MIPD. We hypothesized that patients with dilated pancreatic ducts have improved postoperative outcomes with MIPD compared to OPD. Methods: All patients undergoing pancreaticoduodenectomy between April 2016 and July 2019 were prospectively followed, and perioperative and pathologic covariates and outcomes were compared. Patients with dilated pancreatic ducts (≥3mm) who underwent MIPD (Robotic/ Laparoscopic) were propensity score matched to patients with dilated ducts who underwent OPD and outcomes compared. Likewise, patients with non-dilated pancreatic ducts ( < 3mm) who underwent MIPD were 1:3 propensity score matched to patients with non-dilated ducts who underwent OPD and outcomes compared. Multivariate logistic regression analysis was used to control for potential confounders and the primary outcome was a composite measure termed the ideal outcome (IO) which required patients to achieve negative margins; experience no complications or readmission and be discharged within seven days. Results: 312 patients underwent PD– 51 (16.4%) MIPD and 212 (83.7%) OPD. Patients who underwent MIPD had significantly longer operative times, less intraoperative blood loss, less postoperative urinary retention, and a lower rate of 90-day readmission. After 1:3 propensity score matching, patients with dilated pancreatic ducts who underwent MIPD (n=30) had significantly increased intraoperative times, less intraoperative blood loss, less postoperative bleeding/anemia complications, lower overall complication rate, and were discharged from the hospital 3.5 days faster compared to matched OPD patients (n=90) with dilated ducts. Among propensity score matched patients with non-dilated pancreatic ducts, patients undergoing MIPD (n=21) had significantly less intraoperative blood loss compared to matched patients undergoing OPD (n=63) with non-dilated ducts, but there were no other significant differences in outcomes. In total, 39 (14.9%) patients had IO with OPD and 11 (21.6%) patients had IO with MIPD (p=0.276). With multivariate analysis, there was a significant interaction between operative approach (MIPD vs OPD) and pancreatic duct size (non-dilated [ < 3mm] vs dilated [≥ 3mm]) with respect to these variables’ association with IO (p=0.042). MIPD in patients with dilated pancreatic ducts was independently associated with increased IO (OR= 3.04, p=0.021) (Table 3). However, MIPD in patients with non-dilated pancreatic ducts was not associated with IO (OR=0.82, p=0.802). Conclusion: MIPD is safe with comparable perioperative and oncologic outcomes to OPD. Patients with pancreatic ducts ≥3mm appear to derive the most benefit from MIPD in terms of less complications and shorter hospital stay.

Vascular resection in minimally invasive vs open pancreaticoduodenectomy

Presenter: Roheena Panni MD, MPHS | Washington University, St. Louis Background: Pancreaticoduodenectomy is associated with high morbidity and the complexity of the procedure increases with vascular resection. Vascular resection during pancreaticoduodenectomy is associated with increased operative time, perioperative transfusion, DVT, septic shock, and length of stay, but the overall mortality is similar. With the advancement in minimally invasive surgical techniques, laparoscopic and robotic pancreatic surgery is becoming more common. A growing body of evidence exists demonstrating the equivalence or benefit of minimally invasive pancreaticoduodenectomy (MIPD) when compared to open pancreaticoduodenectomy (OPD) regarding the short term outcomes and safety. The purpose of this study is to determine the postoperative outcomes of patients undergoing vascular resection with OPD or MIPD approach using a large, multicenter cohort. Methods: All patients undergoing elective pancreaticoduodenectomy, including OPD and MIPD (robotic and laparoscopic, including open-assisted and unplanned open conversion), with vascular resection in the ACS NSQIP database were included in the study. Patients were stratified into those who underwent OPD vascular resection and those who underwent MIPD vascular resection. Patient covariates and outcomes were compared using standard statistical methods. Results: 2233 patients underwent OPD with vascular resection (17.8%) and 149 patients underwent MIPD with vascular resection (13.8%). The frequency of artery, vein, and combined artery and vein resection was (10.3%, 69.9%, and 19.6%) in OPD and (16.1%, 62.4%, and 21.47%) in MIPD, respectively. Patients undergoing MIPD vascular resection were more likely to have BMI < 25 (34.2% vs 42.5%, p-value 0.0143). The mean OR time was significantly longer in patients undergoing MIPD and vascular resection compared to OPD and vascular resection (485.4 ± 13.30 vs. 427 ± 152.90, p-value < 0.0001). We next compared postoperative complications and found that patients undergoing OPD vascular resection were more likely to have postoperative sepsis compared to MIPD vascular resection (10.17% vs. 4.70%, p-value= 0.0299). There was a trend towards a decrease in superficial surgical site infection, organ space infection and length of stay and an increase in 30-day readmission in the MIPD vascular resection group; however, these differences were not statistically significant. On multivariate analysis, postoperative sepsis was independently associated with OPD (p-value= 0.0446). Conclusion: MIPD with vascular resection is safe and feasible. Future studies are needed to determine the effect of MIPD with vascular resection on long term outcomes and survival.

The state of minimally invasive pancreaticoduodenectomy in Chinese mainland: A systematic literature review.

The development of Minimally invasive pancreaticoduodenectomy (MIPD) in Chinese mainland has been extremely quick. However, the safety and oncologic outcomes remain controversial. This review evaluates the current status of MIPD in Chinese mainland. A systematic literature search was performed using: Pubmed, Web of Sci, CNKI, Wanfang Data and Sinomed databases to filter all studies published up to and including June 2019 using key words "pancreaticoduodenectomy," or "Whipple operation" combined with "laparoscopy," or "laparoscopic," or "robotic," or "da Vinci," or "minimally invasive," or "hand-assisted". This systematic review included 39 articles that documented 2,653 MIPDs in Chinese mainland. The weighted average operative time was 370.6 min, and the weighted average blood loss was 278.0 mL. The overall morbidity was 31.9%, which Clavien-Dindo ≥ 3 complications accounted for 13.4%. Pancreatic fistula, delayed gastric emptying, bile leak and postoperative hemorrhage were reported in 20.9%, 5.5%, 3.5% and 6.0% of patients respectively. The average lengh of hospital stay was 16.1 days. The overall surgical mortality was 1.7%. The mean number of harvested lymph nodes was 13.5, and the rate of positive margin was 5.3%. Based on Chinese national condition, the operative volume of MIPD in Chinese mainland is the leading position in the world, and compared with some large international meta-analysis, no inferior perioperative and short-term oncological outcomes were observed in MIPD of Chinese mainland. However, research on survival analysis and phased learning curve outcomes is needed urgently before the innovative techniques are widely accepted.

How many cases are required to learn how to perform minimally invasive pancreaticoduodenectomy?

In this manuscript by Nagakawa and colleagues (1), the authors reported on their experience with 150 consecutive cases of laparoscopic pancreaticoduodenectomy. Specifically, the outcomes of three separate surgeons performing their first 50 cases were described. Their main finding was that there was a significant learning curve for minimally invasive pancreaticoduodenectomy (MIPD).

Predictors and outcomes of converted minimally invasive pancreaticoduodenectomy: a propensity score matched analysis.

Data-driven patient selection guidelines are not available to optimize outcomes in minimally invasive pancreaticoduodenectomy (MIPD). We aimed to define risk factors associated with conversion from MIPD to open PD and to determine the impact of conversion on post-operative outcomes. We conducted a retrospective review of MIPD using NSQIP from 2014 to 2015. Propensity score was used to match patients who underwent completed MIPD to converted MIPD. 467 patients were included: 375 (80.3%) MIPD and 92 (19.7%) converted. Converted patients were more often male (64% vs. 52%, p = 0.030), had higher rates of dyspnea (10% vs. 3%, p = 0.009), underwent more vascular (44% vs. 14%, p < 0.001) or multivisceral resection (19% vs. 6%, p = 0.0005), and were more likely attempted laparoscopically compared to robotically (76% vs. 51%, p < 0.001). Robotic approach was independently associated with reduced risk of conversion (OR 0.40, 95% CI 0.23-0.69), while male gender (OR 1.70, 95% CI 1.02-2.84), history of dyspnea (OR 3.85, 95% CI 1.49-9.96), vascular resection (OR 4.32, 95% CI 2.53-7.37), and multivisceral resection (OR 2.18, 95% CI 1.05-4.52) were associated with increased risk. Major complications were more common in converted patients (68% vs. 37%, p < 0.001). Converted patients had increased odds of non-home discharge (OR 3.25, 95% CI 1.06-9.97) and an associated increased length of stay of 3days (95% CI 0.1-6.7). Patients with a history of dyspnea or tumors requiring vascular or multivisceral resection were at increased risk of conversion, and the robotic platform was associated with a lower rate of conversion. Conversion was independently associated with increased overall complications, increased length of stay, and non-home discharge.

National minimally invasive pancreaticoduodenectomy outcomes are improving with time: a propensity score matched NSQIP analysis

Background: There is a steep learning curve associated with minimally invasive pancreaticoduodenectomy (MIPD), and some past studies have suggested MIPD could be associated with increased rates of pancreatic fistula and mortality. NSQIP is a methodically rigorous and robust method of complication gathering in surgery and is ideal to study MIPD outcomes over time. We sought to compare the outcomes of patients undergoing MIPD in previous years of pancreatectomy targeted NSQIP (2014–2015) to the most recent year (2016). We hypothesized that the national MIPD outcomes would significantly improve with time. Methods: All patients undergoing elective MIPD (robotic and laparoscopic, including open-assisted and unplanned open conversion) in the ACS NSQIP pancreatectomy specific database were included in the study. Patients were stratified into those who underwent MIPD during 2014 and 2015 (MIPD1415) and those who underwent MIPD in 2016 (MIPD16). Patient covariates and outcomes were compared using standard statistical methods. 1:1 propensity score matching was also performed and outcomes compared. Results: 766 patients (7.8%) of 9069 pancreaticoduodenectomy (PD) patients underwent MIPD between 2014–2016. 48.7% of MIPD were robotic-assisted. Compared to MIPD1415, MIPD16 patients were significantly more likely to have a drain left at the time of surgery (97.5% vs 94.5%, p = 0.04) and less likely to have a vascular resection (10.2% vs 17.3%, p = 0.01). There is also a difference regarding the distribution of gland texture between the two groups. MIPD16 patients had a significantly decreased rate of pancreatic fistula (14.9% vs 21.1%, p = 0.03), mortality (0.3% vs 2.4%, p = 0.02), and length of stay (8.2 vs 10.4 days, p = 0.02) compared to MIPD1415 patients. However, there was no difference in these outcomes between patients in the two different time periods undergoing open PD. Among 279 propensity score matched pairs (n = 558), MIPD16 patients had significantly decreased rates of pancreatic fistula (15.8% vs 23.0%, p = 0.03), clinically relevant pancreatic fistula (9.0% vs 16.1%, p = 0.01), postoperative length of stay (8.0 vs 10.5 days, p = 0.02), and mortality (0.4% vs 2.9%, p = 0.02) compared to matched MIPD1415 patients. In a subanalysis excluding patients with pancreas ducts <3mm (n = 564), MIPD16 patients had a significantly decreased 30-day mortality rate (0.5% vs 2.9%, p<0.05) and postoperative length of stay (8.2 vs 10.2 days, p = 0.04) along with a strong trend towards a decreased rate of clinically relevant pancreatic fistula (8.5% vs 13.0%, p = 0.05), shown in Figure 1. However, there was no difference in these outcomes between MIPD1415 and MIPD16 patients with <3mm pancreas ducts. Conclusion: National MIPD outcomes are improving with time. A major contributing factor for this finding is improved MIPD outcomes in patients with larger pancreas ducts.

National Pancreatic Fistula Rates after Minimally Invasive Pancreaticoduodenectomy: A NSQIP Analysis

There is a substantial learning curve associated with minimally invasive pancreaticoduodenectomy (MIPD). We sought to determine if national MIPD pancreatic fistula rates are decreasing with time. All patients undergoing elective MIPD and accrued into the pancreatectomy-targeted NSQIP database between 2014 and 2017 were included in the study. Trends in MIPD outcomes by year were examined using Cochran-Armitage and Mann-Kendall tests for trend. Multivariable logistic regression was used to assess for an independent association between increasing year of operation and pancreatic fistula. There were 1,096 patients who underwent MIPD between 2014 and 2017. There was a significant trend toward decreasing pancreatic fistula rates (23.6% vs 19.2% vs 14.9% vs 12.7%, p<0.01) and clinically relevant pancreatic fistula rates (18.3% vs 15.4% vs 11.1% vs 9.1%, p < 0.01) by increasing year. In multivariable analysis, increasing year of operation was independently protective against pancreatic fistula (odds ratio [OR] 0.76 per year, p < 0.01) and clinically relevant pancreatic fistula (OR 0.73 per year, p < 0.01). Patients without pancreas ducts <3 mm or soft pancreas gland texture experienced a significant decreasing trend in pancreatic fistula rates (23.7% vs 13.2% vs 10.3% vs 8.0%, p < 0.01) and clinically relevant pancreatic fistula rates (18.3% vs 9.1% vs 5.2% vs 6.0%, p < 0.01), respectively, by increasing year. However, there was not a significant trend in pancreatic fistula rate or clinically relevant fistula rate among patients having either pancreas ducts < 3 mm or soft gland texture. National MIPD pancreatic fistula rates are improving with time. A major contributing factor for this finding is better outcomes in patients who are at lower risk of pancreatic fistula, which could be a reflection of evolving minimally invasive anastomotic techniques.

Pancreatic head cancer: Open or minimally invasive pancreaticoduodenectomy?

Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons. Pancreaticoduodenectomy (PD) continues to be the operative standard of care and potentially curative procedure for pancreatic head cancer. Despite the rapid development of minimally invasive techniques, whether the efficacy of minimally invasive pancreaticoduodenectomy (MIPD) is noninferior or superior to open pancreaticoduodenectomy (OPD) remains unclear. In this review, we summarized the history of OPD and MIPD and the latest staging and classification information for pancreatic head cancer as well as the proposed recommendations for MIPD indications for patients with pancreatic head cancer. By reviewing the MIPD- vs. OPD-related literature, we found that MIPD shows noninferiority or superiority to OPD in terms of safety, feasibility, enhanced recovery after surgery (ERAS) and several short-term and long-term outcomes. In addition, we analyzed and summarized the different MIPD outcomes in the USA, Europe and China. Certain debates over MIPD have continued, however, selection bias, the large number of low-volume centers, the steep MIPD learning curve, high conversion rate and administration of neoadjuvant therapy may limit the application of MIPD for pancreatic head cancer.

Case Matched Comparison of Peri-Operative and Pathological Outcomes Between Laparoscopic and Robotic Pancreaticoduodenectomy

Introduction: Minimally invasive pancreaticoduodenectomy (MIPD) is being performed with increasing frequency for pancreatic cancer, but the most preferred and oncologically radical surgical platform, whether robotic or laparoscopic, is yet to be determined. This study aims to assess the surgical outcomes of robotic pancreaticoduodenectomy relative to its laparoscopic counterpart. Currently, there are no studies in India comparing the peri-operative outcomes and pathological radicality between robotic (RPD) and laparoscopic (LPD) pancreaticoduodenectomy Method: This was a retrospective study done between 2017 Jan to 2018 Jan, where patients who underwent robotic pancreaticoduodenectomy (RPD) were compared with case matched controls from the LPD arm. Perioperative data including operative time, estimated blood loss, complications, morbidity, mortality, postoperative length of stay, margin status and lymph node yield were analyzed. Result: 15 cases of RPD were case matched with LPD on 1:1 basis; based on tumour location, tumour size and ASA grade. Though operative time was slightly longer in the RPD arm, compared to the LPD , it was not statistically significant(p value-0.7).No statistical difference was observed between the two groups in terms of complication rate, mortality rate, R0 resection rate, number of harvested lymph nodes, median length of stay, 90-day mortality and 30-day readmission rate Conclusion: 15 cases of RPD were case matched with LPD on 1:1 basis; based on tumour location, tumour size and ASA grade. Though operative time was slightly longer in the RPD arm, compared to the LPD , it was not statistically significant(p value-0.7).No statistical difference was observed between the two groups in terms of complication rate, mortality rate, R0 resection rate, number of harvested lymph nodes, median length of stay, 90-day mortality and 30-day readmission rate

Robotic-assisted versus laparoscopic pancreaticoduodenectomy: oncological outcomes.

Minimally invasive pancreaticoduodenectomy (MIPD) is being performed with increasing frequency for pancreatic cancer, but the most oncologically efficacious surgical platform, whether robotic or laparoscopic, is yet to be determined. Currently, there are no national studies comparing the oncological outcomes between robotic (RPD) and laparoscopic (LPD) pancreaticoduodenectomy. This was a retrospective study using the National Cancer Database between 2010 and 2013. We compared the perioperative, pathological, and mid-term oncological outcomes between RPD and LPD. There were 1623 MIPD cases, of which 90% were LPD and 10% were RPD. Most LPD (63%) and RPD (51%) cases were performed at institutions with a volume of ≤ 5 MIPDs per year. There were no differences in patient- and tumor-related factors between the groups. The majority of treated tumors were adenocarcinoma (90.1% for RPD and 89.1% for LPD). RPDs were more likely to be performed at academic centers (89.1%) compared to LPDs (68.1%, P < 0.001) and at higher-volume centers (median MIPD/year of 4.7 for RPD vs 3.6 for LPD, P < 0.001). There was no difference in the median number of examined lymph nodes, margin status, median length of stay, 90-day mortality, or 30-day readmission between groups. There was no difference in median overall survival for pancreatic adenocarcinoma between LPD (20.7months) and RPD (22.7 months; log-rank P = 0.445). The 1- and 3-year overall survival rates were 74 and 31% for LPD and 71 and 33% for RPD. In this national cohort of patients, LPD and RPD were associated with equivalent perioperative, pathological, and mid-term oncological outcomes.

Multicenter outcomes of robotic reconstruction during the early learning curve for minimally-invasive pancreaticoduodenectomy

BackgroundPerceived excess morbidity during the early learning curve of minimally-invasive pancreaticoduodenectomy (MIPD) has limited widespread adoption. It was hypothesized that robot-assisted reconstruction (RA) after MIPD allows anastomotic outcomes equivalent to open pancreaticoduodenectomy (PD). MethodsIntent to treat analysis of centrally audited data accrued during early adoption of RA-MIPD at five centers. ResultsCUSUM analysis of operating times at each center identified 92 RA-MIPD during the early learning curve. Mean age was 65 ± 12 years with body mass index 25.8 ± 5.0. Surgical indications included malignant (60%) and premalignant (38%) lesions. Median operating time was 504 min (interquartile range 133) with 242 ml median estimated blood loss (IQR 398) and twelve (13%) conversions to open PD. Major complication rate (Clavien-Dindo III/IV) was 24% with 2 (2.2%) deaths and ten (10.9%) reoperations. Nine (9.9%) clinically significant pancreatic fistulae were observed (4 grade B; 5 grade C). Margin negative resection rate for malignancy was 90% (75% for PDA) with mean harvest of 16 ± 8 lymph nodes. ConclusionsThese multicenter data during the early learning curve for RA-MIPD do not demonstrate excess anastomotic morbidity compared to open. Further studies are required to determine whether surgeon proficiency and evolving technique improve anastomotic outcomes compared to open.

A systemic review and an updated meta-analysis: minimally invasive vs open pancreaticoduodenectomy

The feasible of minimally invasive pancreaticoduodenectomy (MIPD) remains controversial when compared with open pancreaticoduodenectomy (OPD). We conducted a systemic review and meta-analysis to summarise the available evidence to compare MIPD vs OPD. We systemically searched PubMed, EMBASE and Web of Science for studies published through February 2016. The primary endpoint was postoperative pancreatic fistula (POPF, grade B/C). A total of 27 studies involving 14,231 patients (2,377 MIPD and 11,854 OPD) were included. MIPD was associated with longer operative times (P < 0.01) and increased mortality (P < 0.01), but decreased estimated blood loss (P < 0.01), decreased delayed gastric emptying (P < 0.01), increased R0 resection rate (P < 0.01), decreased wound infection (P = 0.03) and shorter hospital stays (P < 0.01). There were no significant differences in BMI (P = 0.43), tumor size (P = 0.17), lymph nodes harvest (P = 0.57), POPF (P = 0.84), reoperation (P = 0.25) and 5-year survival rates (P = 0.82) for MIPD compared with OPD. Although there was an increased operative cost (P < 0.01) for MIPD compared with OPD, the postoperative cost was less (P < 0.01) with the similar total costs (P = 0.28). MIPD can be a reasonable alternative to OPD with the potential advantage of being minimally invasive. However, MIPD should be performed in high-volume centers and more randomized-controlled trials are needed to evaluate the appropriate indications of MIPD.

Defining a Hospital Volume Threshold for Minimally Invasive Pancreaticoduodenectomy in the United States

There is increasing interest in expanding use of minimally invasive pancreaticoduodenectomy (MIPD). This procedure is complex, with data suggesting a significant association between hospital volume and outcomes. To determine whether there is an MIPD hospital volume threshold for which patient outcomes could be optimized. Adult patients undergoing MIPD were identified from the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2012. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting annual hospital volume against the adjusted odds of postoperative complications. The current analysis was conducted on August 16, 2016. Incidence of any complication. Of the 865 patients who underwent MIPD, 474 (55%) were male and the median patient age was 67 years (interquartile range, 59-74 years). Among the patients, 747 (86%) had cancer and 91 (11%) had benign conditions/pancreatitis. Overall, 410 patients (47%) had postoperative complications and 31 (4%) died in-hospital. After adjustment for demographic and clinical characteristics, increasing hospital volume was associated with reduced complications (overall association P < .001); the likelihood of experiencing a complication declined as hospital volume increased up to 22 cases per year (95% CI, 21-23). Median hospital volume was 6 cases per year (range, 1-60). Most patients (n = 717; 83%) underwent the procedure at low-volume (≤22 cases per year) hospitals. After adjustment for patient mix, undergoing MIPD at low- vs high-volume hospitals was significantly associated with increased odds for postoperative complications (odds ratio, 1.74; 95% CI, 1.03-2.94; P = .04). Hospital volume is significantly associated with improved outcomes from MIPD, with a threshold of 22 cases per year. Most patients undergo MIPD at low-volume hospitals. Protocols outlining minimum procedural volume thresholds should be considered to facilitate safer dissemination of MIPD.

Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy.

The technique of minimally invasive pancreatic surgeries has evolved rapidly, including minimally invasive pancreaticoduodenectomy (MIPD). However, controversy on safety and feasibility remains when comparing the MIPD with the open pancreaticoduodenectomy (OPD); therefore, we aimed to compare MIPD and OPD with a systemic review and meta-analysis. Multiple electronic databases were systematically searched to identify studies (up to February 2016) comparing MIPD with OPD. Intra-operative outcomes, oncologic data, postoperative complications and postoperative recovery were evaluated. Twenty-two retrospective studies including 6120 patients (1018 MIPDs and 5102 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (WMD -312.00ml, 95% CI -436.30 to -187.70ml, p<0.001), transfusion rate (OR 0.41, 95% CI 0.30-0.55, p<0.001), wound infection (OR 0.37, 95% CI 0.20-0.66, p<0.001) and length of hospital stay (WMD -3.57days, 95% CI -5.17 to -1.98days, p<0.001). Meanwhile, MIPD group has a higher R0 resection rate (OR 1.47, 95% CI 1.18-1.82, p<0.001) and more lymph nodes harvest (WMD 1.74, 95% CI 1.03-2.45, p<0.001). However, it had longer operation time (WMD 83.91min, 95% CI 36.60-131.21min, p<0.001). There were no significant differences between the two procedures in morbidities (p=0.86), postoperative pancreatic fistula (p=0.17), delayed gastric empting (p=0.65), vascular resection (p=0.68), reoperation (p=0.33) and mortality (p=0.90). MIPD can be a reasonable alternative to OPD with potential advantages. However, further large-volume, well-designed RCTs with extensive follow-ups are suggested to confirm and update the findings of our analysis.

Systemic Review of the Feasibility and Advantage of Minimally Invasive Pancreaticoduodenectomy.

Minimally invasive pancreaticoduodenectomy (MIPD), which includes laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is a complex procedure that needs to be performed by experienced surgeons. However, the safety and oncologic performance have not yet been conclusively determined. A systematic literature search was performed using the Embase, Medline, and PubMed databases to identify all studies published up to March 2015. Articles written in English containing the keywords: "pancreaticoduodenectomy" or "Whipple operation" combined with "laparoscopy," "laparoscopic," "robotic," "da vinci," or "minimally invasive surgery" were selected. Furthermore, to increase the power of evidence, articles describing more than ten MIPDs were selected for this review. Twenty-six articles matched the review criteria. A total of 780 LPDs and 248 RPDs were included in the current review. The overall conversion rate to open surgery was 9.1 %. The weighted average operative time was 422.6 min, and the weighted average blood loss was 321.1 mL. The weighted average number of harvested lymph nodes was 17.1, and the rate of microscopically positive tumor margins was 8.4 %. The cumulative morbidity was 35.9 %, and a pancreatic fistula was reported in 17.0 % of cases. The average length of hospital stay was 12.4 days, and the mortality rate was 2.2 %. In conclusion, after reviewing one-thousand cases in the current literature, we conclude that MIPD offers a good perioperative, postoperative, and oncologic outcome. MIPD is feasible and safe in well-selected patients.

Pancreatic cancer: Open or minimally invasive surgery?

Pancreatic duct adenocarcinoma is one of the most fatal malignancies, with R0 resection remaining the most important part of treatment of this malignancy. However, pancreatectomy is believed to be one of the most challenging procedures and R0 resection remains the only chance for patients with pancreatic cancer to have a good prognosis. Some surgeons have tried minimally invasive pancreatic surgery, but the short- and long-term outcomes of pancreatic malignancy remain controversial between open and minimally invasive procedures. We collected comparative data about minimally invasive and open pancreatic surgery. The available evidence suggests that minimally invasive pancreaticoduodenectomy (MIPD) is as safe and feasible as open PD (OPD), and shows some benefit, such as less intraoperative blood loss and shorter postoperative hospital stay. Despite the limited evidence for MIPD in pancreatic cancer, most of the available data show that the short-term oncological adequacy is similar between MIPD and OPD. Some surgical techniques, including superior mesenteric artery-first approach and laparoscopic pancreatoduodenectomy with major vein resection, are believed to improve the rate of R0 resection. Laparoscopic distal pancreatectomy is less technically demanding and is accepted in more pancreatic centers. It is technically safe and feasible and has similar short-term oncological prognosis compared with open distal pancreatectomy.

Open and minimally invasive pancreatic surgery—a review of the literature

Background: There is increasing evidence demonstrating the safety, feasibility and improved postoperative recovery of laparoscopic pancreas resections. The purpose of this study is to review recent advances in laparoscopic distal pancreatectomy (LDP) and minimally invasive pancreaticoduodenectomy (MIPD) with an emphasis on laparoscopic technique, intraoperative outcomes, perioperative outcomes, and oncologic outcomes. Methods: A systematic literature search was performed using MEDLINE, Web of Science, and Embase. Studies were included if they were an original series in adult patients comparing laparoscopic and open pancreatectomies between 2005 and 2015 with ten or more patients in the laparoscopic group. Patient demographics and intraoperative, postoperative, and oncologic variables were recorded. Odds ratios (ORs) were calculated from dichotomous data and the mean difference (MD) from the continuous data, both with 95% confidence intervals (CIs). Results: A total of 495 articles were reviewed, 42 of which were selected and included in the distal pancreatectomy group and 19 studies in the pancreaticoduodenectomy group. LDP was performed in 20.2% (n=3,759/18,587) of patients. MIPD was performed in 14.8% (n=3,692/24,923) of patients. Patients in the LDP group had longer operating times (P<0.001), lower estimated blood loss (P<0.001), reduced number of red blood cell transfusions (P<0.001), higher rate of spleen preservation (P<0.001), lower positive margin (P<0.001), lower overall complication rates (P<0.001), reduced 30-day mortality or in-hospital mortality (P=0.012), less post-operative bleeding (P=0.003), decreased wound infections (P<0.001), shorter length of hospital stay (P<0.001), earlier return of bowel function (P<0.001), quicker time to PO intake (P<0.001), and fewer days of IV narcotics (P=0.016). The LDP group had similar lymph node (LN) retrieval (P=0.325), number of patients with positive LN (P=0.734), pancreatic fistula rates (P=0.539), need for re-operation (P=0.354), readmission rates (P=0.898), and time to ambulation (P=0.081) as the open group. The MIPD group had longer operating room times (P<0.001), fewer intra-operative red blood cell transfusions (P=0.009), lower positive margin rate (P=0.022), increased post-operative bleeding (P=0.024), shorter length of hospital stay (P<0.001), lower readmission rate (P=0.048), earlier return of bowel function (P<0.001), and shorter time to PO intake (P<0.001) in comparison to the open group. However, both groups had similar LN retrieval (P=0.142), number of patients with positive LNs (P=0.099), overall morbidity (P=0.145), 30-day or in-hospital mortality (P=0.853), pancreatic fistula (P=0.685), delayed gastric emptying (DGE) (P=0.092), bile leak (P=0.617), wound infections (P=0.061), and similar reoperation rates (P=0.863). Conclusions: Analysis of the available literature suggests that laparoscopic pancreatectomies are feasible, safe, and potentially have improved perioperative recovery; while achieving equivalent oncologic outcomes when compared to open resection. Further investigation with randomized controlled trials is needed to avoid selection bias and control for confounding factors inherently found in the studies reviewed. However, this analysis does suggest a growing acceptance of laparoscopic pancreas surgery.

Minimally Invasive Pancreaticoduodenectomy Does Not Improve Use or Time to Initiation of Adjuvant Chemotherapy for Patients With Pancreatic Adenocarcinoma.

The modifiable variable best proven to improve survival after resection of pancreatic adenocarcinoma is the addition of adjuvant chemotherapy. A theoretical advantage of minimally invasive pancreaticoduodenectomy (MI-PD) is the potential for greater use and earlier initiation of adjuvant therapy, but this benefit remains unproven. The 2010-2012 National Cancer Data Base (NCDB) was queried for patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. Subjects were classified as MI-PD versus open pancreaticoduodenectomy (O-PD). Baseline variables were compared between groups. The independent effect of surgical approach on the use and timing of adjuvant chemotherapy was estimated using multivariable regression analyses. For this study, 7967 subjects were identified: 1191 MI-PD (14.9%) and 6776 O-PD (85.1%) patients. Patients who underwent MI-PD were more likely to have been treated at academic hospitals. Otherwise, the groups had no baseline differences. In both the MI-PD and O-PD groups, approximately 50% of the patients received adjuvant chemotherapy, initiated at a median of 54 versus 55 days postoperatively (p = 0.08). After multivariable adjustment, surgical approach was not independently associated with use (odds ratio 1.00; p = 0.99) or time to initiation of adjuvant chemotherapy (-2.3 days; p = 0.07). Younger age, insured status, lower comorbidity score, higher tumor stage, and the presence of lymph node metastases were independently associated with the use of adjuvant chemotherapy. At a national level, MI-PD does not result in greater use or earlier initiation of adjuvant chemotherapy. As surgeons and institutions continue to gain experience with this complex procedure, it will be important to revisit this benchmark as a justification for its increasing use for patients with pancreatic cancer.

Getting Started with Minimally Invasive Pancreaticoduodenectomy: Is It Worth It?

This study evaluates the safety and cost of introducing minimally invasive pancreaticoduodenectomy (MIPD) to a surgeon's practice. All MIPDs performed between December 2011 and July 2013 were compared with open pancreaticoduodenectomy (OPD) cases by the same surgeon. The primary outcomes were mortality, major morbidity, and re-operation. Secondary outcomes were perioperative and oncologic outcomes and cost. MIPD include total laparoscopic pancreaticoduodenectomy (TLPD) and laparoscopic-assisted pancreaticoduodenectomy (LAPD), where a small incision is used for reconstruction. Bivariate comparisons of outcomes were performed using nonparametric tests. In total, 44 pancreaticoduodenectomies were performed: 15 MIPDs (2 TLPDs and 13 LAPDs) and 29 OPDs. One death occurred in each group. Major complication rates were not significantly different (33% for MIPD versus 17% for OPD); however, there was a trend toward more re-operation after MIPD compared with OPD (20% versus 3%; P = .07). The incidence of pancreatic leak (20% for MIPD versus 14% for OPD), biliary leak (0% versus 7%, respectively), abscess formation (27% versus 14%, respectively), and intraabdominal hemorrhage (13% versus 3%, respectively) were not significantly different. MIPD achieved equivalent oncologic outcomes as OPD with 100% R0 margin and adequate lymph node retrieval. There was no statistical difference in median operative time (342 minutes for MIPD versus 358 minutes for OPD), length of stay (8 versus 9 days, respectively), operating room expenses (Canadian) ($7246.0 versus $6912.0, respectively), or total cost (Canadian) per case ($15,034.0 versus $18,926.0, respectively). MIPD and OPD had similar safety and cost in this introductory series. However, a trend toward a higher rate of re-operation for pancreatic leak suggests the need for caution in introducing this novel technique.

Challenges of minimally invasive pancreas surgery growth with such a high learning curve.

Minimally invasive pancreaticoduodenectomy (MIPD), defined as laparoscopic or robotic surgery, has been slow to develop compared with operations on other organs.1 Approximately100yearsafter the first pancreaticoduodenectomy, MIPD is foundtobesafe,have potential oncologic advantages, andhasbeena large technical advance inour abilities.2,3 Despite continued skepticism, a select group of institutions, including our own, performMIPD routinely. Boone et al4 found that after 20, 40, and 80 cases, there was a statistical drop in the conversion rate, estimated blood loss, and operative time, respectively. These learning curve milestones were determined after analyzing 200 robotic pancreaticoduodenectomies and highlight the challenge in training future robotic pancreatic surgeons, particularly because trainees will not even reach these milestones for open pancreaticoduodenectomy. There are several unique aspects of this article that must be kept in context before applying its findings to all MIPDs. First, the authors’ early learning curve was spent in the development of robotic techniques. This development was a significant component of our own learning curve with laparoscopic pancreaticoduodenectomy. With proper mentorship, the learning curve should no longer be an issue. However, robotic surgery adds another layer to the learning curve. Using laparoscopic techniques, in which most surgical residents are proficient, may create a more efficient training environment. These milestones will be invaluable for comparison; however, to use robotic milestones to represent all MIPDs is premature. Boone et al highlight the large number of cases required to become a proficient robotic pancreatic surgeon. How to efficiently attain expertise will be a challenge and may limit robotic pancreas surgery growth.