Open Pancreatectomy Research Articles

Effect of surgical approach on early return to intended oncologic therapy after resection for pancreatic ductal adenocarcinoma.

Although robotic pancreatectomy may facilitate an earlier functional recovery, the impact of a robotic pancreatectomy program during its early experience on the timing of return to intended oncologic therapy (RIOT) after surgery is unknown. In this retrospective cohort study, we used propensity score matching with a 1:2 ratio to compare patients who underwent robotic or open surgery (distal pancreatectomy or pancreatoduodenectomy) for pancreatic ductal adenocarcinoma (PDAC) during the first 3years of our robotic pancreatectomy experience (January 2018-December 2021). Generalized estimating equations modeling was used to evaluate the effect of surgical approach on early RIOT, defined as adjuvant chemotherapy initiation within 8weeks after surgery, and late RIOT, defined as initiation within 12weeks after surgery. The matched cohort included 26 patients who underwent robotic pancreatectomy and 52 patients who underwent open pancreatectomy. Rates of receipt of adjuvant chemotherapy were 96.2% and 78.9%, respectively. Rate of early RIOT in the robotic group (73.1% was higher than that in the open group (44.2%; P = 0.018). In multivariable analysis, a robotic approach was associated with early RIOT (odds ratio, 3.54; 95% confidence interval 1.08-11.62; P = 0.038). Surgical approach did not impact late RIOT (odds ratio, 3.21; 95% confidence interval 0.71-14.38; P = 0.128). Compared with open pancreatectomy, robotic pancreatectomy did not delay RIOT. In fact, odds of early RIOT were increased, which supports the oncological safety of our robotic pancreatectomy program during its implementation.

Outcome and survival were similar with laparoscopic and open pancreatectomy in 102 solid pseudopapillary neoplasms.

Solid pseudopapillary neoplasms of the pancreas (SPNP) are rare tumors predominantly in young women. We report the largest single-center cohort study comparing resection of SPNP by laparoscopic approach (LA) and the open approach (OA). Between 2001 and 2021, 102 patients (84% women, median age: 30) underwent pancreatectomy for SPNP and were retrospectively studied. Demographic, perioperative, pathological, early and the long-term results were evaluated between patients operated by LA and those by OA. Population included 40 LA and 62 OA. There were no significant differences in demographics data between the groups. A preoperative biopsy by endoscopic ultrasound was performed in 45 patients (44%) with no difference between the groups. Pancreatoduodenectomy (PD) was less frequently performed by LA (25 vs 53%, p = 0.004) and distal pancreatectomy (DP) was more frequently performed by LA (40 vs 16%, p = 0.003). In the subgroup analysis by surgical procedure, LA-PD was associated with one mortality, less median blood loss (180 vs 200ml, p = 0.034) and fewer harvested lymph nodes (11 vs 15, p = 0.02). LA-DP was associated with smaller median tumor size on imaging (40 vs 80mm, p = 0.048), shorter surgery (135 vs 190 min, p = 0.028), and fewer complications according to the median comprehensive complication index score (0 vs 8.7, p = 0.048). LA-Central pancreatectomy was associated with shorter surgery (160 vs 240, p = 0.037), less median blood loss (60 vs 200, p = 0.043), and less harvested lymph nodes (5 vs 2, p = 0.025). After a median follow-up of 60months, two recurrences (2%) were observed and were unrelated to the approach. The LA for SPNP appears to be safe, should be applied cautiously in case of PD for large lesion, and was not associated with recurrence.

Endoscopic ultrasound-guided perivascular pancreatic radiofrequency ablation using a hydroxyethyl starch solution prior to pancreatectomy

Abstract Background and study aims Pancreatic surgery remains complex, particularly for borderline resectable and locally advanced tumors. Vascular invasion compromises resectability, and vascular resection entails increased morbidity and mortality. Following a feasibility and safety demonstration of augmented endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) using hydroxyethyl starch (HES) in porcine pancreatic parenchyma, the present study assesses whether this approach (EUS-sugar-RFA) in the pancreatic perivascular space is safe and creates a controllable margin of necrosis to enable a vessel-sparing resection. Methods EUS-sugar-RFA in the pancreatic parenchyma adjacent to the splenic artery and vein was performed in a live animal model. Following different survival periods (0–4 days) in the interventional group (n = 3), open pancreatectomy was carried out. The control group (n = 4) included open pancreatectomies in two pigs with non-treated pancreases and in two with pancreatic RFA alone on the same day. Results All procedures were completed successfully, without intraoperative or postoperative complications. Survival periods were uncomplicated. Histopathological examination showed local necrosis and inflammatory reaction at the ablation sites. Vascular wall integrity was preserved in all specimens. The untreated pancreatic zones in the interventional group were no different from the normal pancreases in the control group. Conclusions Preoperative perivascular augmented RFA using HES was safe, and in the pancreatic animal model, the best timeframe was within 24 hours before pancreatic surgery. This technique might improve resectability in selected borderline and locally advanced pancreatic cancers.

Minimally invasive distal pancreatectomy for adenocarcinoma of the pancreas

IntroductionMinimally invasive (MI) surgery has been widely adopted to treat left-sided pancreatic cancer. However, outcomes are not clearly defined. MaterialsRetrospective cohort study utilizing NCDB and NSQIP data. ResultsPatients undergoing distal pancreatectomy for pancreatic adenocarcinoma from 2004 to 2016 were included (n = 7347). Utilizing NSQIP (n = 2406), patients were divided into two groups: intention-to-treat (ITT) MI (including MI converted to open, n = 929) and open (n = 1477). Patients undergoing open pancreatectomy were more likely to have longer length of stay (6 vs. 5 days, p=<0.001). On multivariate analysis, open procedures were not associated with mortality (OR 1.24; CI 0.51–3.30, p = 0.64), serious complications (OR 1.03; CI 0.90–1.37, p = 0.79), and any complications (OR 1.07; CI 0.86–1.32, p = 0.56). NCDB patients (n = 4941) were also divided into two groups, ITT MI (n = 1,769, 36%) and open group (n = 3,172, 64%). The median survival was lower in open procedure patients, 23 vs. 27.1 months (p < 0.001). This finding was maintained on multivariable analysis (HR 1.16; CI 1.03–1.32, p = 0.017). ConclusionBased on these data, MI distal pancreatectomy could be considered a standard of care for pancreatic cancer when technically feasible. Although morbidity and mortality were similar, the laparoscopic approach had a shorter length of stay and could hasten recovery.

Implementation of an opioid reduction toolkit in pancreatectomy patients significantly increases patient awareness of safe practice and decreases amount prescribed and consumed

BackgroundPostoperative opioid abuse following surgery is a major concern. This study sought to create an opioid reduction toolkit to reduce the number of narcotics prescribed and consumed while increasing awareness of safe disposal in pancreatectomy patients. MethodsPrescription, consumption, and refill request data for postoperative opioids were collected from patients receiving an open pancreatectomy before and after the implementation of an opioid reduction toolkit. Outcomes included safe disposal practice awareness for unused medication. Results159 patients were included in the study: 24 in the pre-intervention and 135 in the post-intervention group. No significant demographic or clinical differences existed between groups. Median morphine milliequivalents (MMEs) prescribed were significantly reduced from 225 (225–310) to 75 (75–113) in the post-intervention group (p < 0.0001). Median MMEs consumed were significantly reduced from 109 (111–207) to 15 (0–75), p < 0.0001), as well. Refill request rates remained equivalent during the study (Pre: 17% v Post: 13%, p = 0.9) while patient awareness of safe disposal increased (Pre: 25% v Post: 62%, p < 0.0001). DiscussionAn opioid reduction toolkit significantly reduced the number of postoperative opioids prescribed and consumed after open pancreatectomy, while refill request rates remained the same and patients’ awareness of safe disposal increased.

Robotic pancreaticoduodenectomy does not mitigate the impact of frailty on post-operative outcomes

Background: The modified frailty index (mFI) has been shown to predict morbidity and mortality following open pancreatectomies. While mFI correlates with outcomes after open pancreaticoduodenectomy, the correlation between frailty and robotic pancreaticoduodenectomy outcomes has not been explored. We hypothesized that the robotic approach would mitigate the impact of frailty in post-operative recovery.

Laparoscopic versus Open Pancreatectomy in 102 Solid Pseudopapillary Neoplasm Showed Similar Outcome and Survival

Laparoscopic versus Open Pancreatectomy in 102 Solid Pseudopapillary Neoplasm Showed Similar Outcome and Survival

Association of robotic approach with patient-reported outcomes after pancreatectomy: a prospective cohort study.

Robotic-assisted pancreatectomy continues to proliferate despite limited evidence supporting its benefits from the patient's perspective. We compared patient-reported outcomes (PROs) between patients undergoing robotic and open pancreatectomies. PROs, measured with the FACT-Hep, FACT-G, and HCS, were assessed in the immediate postoperative (i.e., preoperative to discharge) and recovery (i.e., discharge to three months postoperative) periods. Linear mixed models estimated the association of operative approach on PROs. Minimally important differences (MIDs) were also considered. Among 139 patients, 105 (75.5%) underwent robotic pancreatectomies. Compared to those who underwent open operations, those who underwent robotic operations experienced worse FACT-Hep scores that were both statistically and clinically significant (mean difference [MD] 8.6 points, 95% CI 1.0-16.3). Declines in FACT-G (MD 4.3, 95% CI -1.0 to 9.6) and HCS (MD 4.3, 95% CI 0.8-7.9) scores appeared to contribute equally in both operative approaches to the decline in total FACT-Hep score. Patients who underwent robotic versus open operations both statistically and clinically significantly improved due to improvements in HCS (MD 6.1, 95% CI 2.3-9.9) but not in FACT-G (MD 1.2, 95% CI - 5.1-7.4). The robotic approach to pancreas surgery might offer, from the patient's perspective, greater improvement in symptoms over the open approach by three months postoperatively.

Oncological outcomes of robotic pancreatectomy in patients with pancreatic cancer who receive adjuvant chemotherapy: A propensity score-matched retrospective cohort study

BackgroundLimited data are available regarding long-term oncological outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo robotic pancreatectomy (RP). MethodAll patients who underwent RP and open pancreatectomy (OP) for resectable PDAC between January 2011 and December 2019 were included. The RP group was matched 1:1 with OP group by propensity score matching (PSM). The oncological outcomes were collected and analyzed. ResultsOverall, 1606 patients were included in this study. After PSM, a well-balanced cohort of 335 patients in each group was selected for further analysis. The RP group had shorter operative time (210 min vs. 240 min, P < 0.001), lower estimated blood loss (200 ml vs. 300 ml, P = 0.011), lower wound infection rates (4.5% vs. 10.1%, P = 0.005) and shorter length of postoperative hospital stay (15 days vs. 17 days, P = 0.001) compared to the OP group, with no significant differences in other perioperative outcomes. OS was comparable between the two groups (31 months vs. 28 months, P = 0.077); however, RFS was improved in the RP group (17 months vs. 14 months, P = 0.015). Subgroup analysis showed that patients who received adjuvant chemotherapy (AC) in the RP group had better RFS than the similar patient cohort in the OP group (17 months vs. 14 months, P = 0.024). ConclusionRobotic pancreatectomy is safe and oncologically effective for resectable PDAC. OS was comparable between RP and OP, and RFS was improved in the RP group, especially in patients who receive AC.

Association of Patient Controlled Analgesia and Total Inpatient Opioid Use After Pancreatectomy.

The initial settings on an intravenous patient-controlled analgesia (IV-PCA) pump can represent a significant source of postoperative opioid exposure. The primary aim of this study was to evaluate the impact of first day IV-PCA use on total inpatient opioid use after open pancreatectomy, before and after standardization of initial dosing. Inpatient oral morphine equivalents (OMEs) were reviewed for pancreatectomy patients treated with IV-PCA at a single institution before and after (3/2016-8/2017 versus 3/2019-11/2020) implementation of a standardized initial IV-PCA dosing regimen (initial limit 0.1mg hydromorphone, or 1mg OME, every 10min as needed). IV-PCA OME in the first 24h and the total inpatient OME were compared between cohorts. Of 220 total patients, 132 were in the prestandardization (PRE) historical cohort. A first-24-h IV-PCA use was different (PRE median 95mg versus poststandardization [POST] 15mg, P<0.001). The median total inpatient OME was different (P<0.001) between PRE (525mg, interquartile range [IQR] 239-951mg) and POST patients (129mg, IQR 65-204mg) with 77% (median 373mg) of total inpatient OMEs contributed by IV-PCA in the PRE and 56% (median 64mg) in the POST cohorts. There were similar patient-reported pain scores between groups. Standardizing initial IV-PCA settings was associated with a reduced first-24-h opioid exposure, proportional and absolute total IV-PCA use, and total inpatient OMEs. Because of the contribution of an IV-PCA to the total inpatient opioid exposure, purposeful reduction or omission of an IV-PCA is critical to perioperative opioid reduction strategies.

Minimally Invasive versus Open Pancreatectomy for Pancreatic Neuroendocrine Tumors: A Multi-Institutional Ten-Year Experience on 1023 Patients

Introduction: Pancreatectomy for pancreatic neuroendocrine tumors (PNETs) may be associated with worse perioperative outcomes compared to pancreatic adenocarcinoma given the high-risk nature of soft glands with small pancreatic ducts. We aimed to investigate the outcomes of minimally invasive (MIS) vs open pancreatectomy in four high-volume institutions.

Impact of Conversion at the Time of Minimally Invasive Pancreaticoduodenectomy: A Review of the National Cancer Database

Introduction: Current literature presents limited outcomes following conversion at the time of minimally invasive pancreaticoduodenectomy (MI-PD). We aim to compare perioperative, oncologic outcomes and survival between patients who required conversion from MI-PD to open pancreaticoduodenectomy (CO-PD) with patients who underwent open pancreatectomy (O-PD) on a national level.

Laparoscopic versus open central pancreatectomy: A propensity score-matched analysis in a single center

Laparoscopic versus open central pancreatectomy: A propensity score-matched analysis in a single center

Laparoscopic Pancreatectomy in Rats: The Development of an Experimental Model

Introduction several pancreatectomy techniques in rats have been described and utilized for research concerning the pancreas endocrine and exocrine functions. However, we did not find a description of any kind of laparoscopic pancreatectomy in rats in the consulted databases. The objective of this study is to describe a laparoscopic splenic lobe pancreatectomy in rats. Methods ten Wistars rats weighting more then 300 g were operated for standardizing the laparoscopic pancreatosplenectomy technique, aided by previous descriptions of laparoscopic splenectomy and open pancreatectomy in rats. Adjustments have been progressively adopted for technical refinement. Results In five animals a low-cost rat laparoscopic set was used. In other five animals we used a standard laparoscopic set. Three rats died early due to different causes: transection of the gastroesophageal junction, hemorrhagic shock and inadvertent colonic injury. The postoperative period of the other seven rats was uneventful until the seventh postoperative day. Discussion laparoscopic distal pancreatectomy and splenectomy in rats is feasible and safe, even with a low-cost set, in which the results were alike the standard laparoscopic set.

Minimally Invasive Versus Open Pancreatectomy for Right-Sided and Left-Sided G1/G2 Nonfunctioning Pancreatic Neuroendocrine Tumors: A Multicenter Matched Analysis with an Inverse Probability of Treatment-Weighting Method.

Limited evidence exists for the safety and oncologic efficacy of minimally invasive surgery (MIS) for nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) according to tumor location. This study aimed to compare the surgical outcomes of MIS and open surgery (OS) for right- or left-sided NF-PNETs. The study collected data on patients who underwent surgical resection (pancreatoduodenectomy, distal/total/central pancreatectomy, duodenum-preserving pancreas head resection, or enucleation) of a localized NF-PNET between January 2000 and July 2017 at 14 institutions. The inverse probability of treatment-weighting method with propensity scores was used for analysis. The study enrolled 859 patients: 478 OS and 381 MIS patients. A matched analysis by tumor location showed no differences in resection margin, intraoperative blood loss, or complications between MIS and OS. However, MIS was associated with a longer operation time for right-sided tumors (393.3 vs 316.7 min; P < 0.001) and a shorter postoperative hospital stay for left-sided tumors (8.9 vs 12.9 days; P < 0.01). The MIS group was associated with significantly higher survival rates than the OS group for right- and left-sided tumors, but survival did not differ for the patients divided by tumor grade and location. Multivariable analysis showed that MIS did not affect survival for any tumor location. The short-term outcomes offered by MIS were comparable with those of OS except for a longer operation time for right-sided NF-PNETs. The oncologic outcomes were not compromised by MIS regardless of tumor location or grade. These findings suggest that MIS can be performed safely for selected patients with localized NF-PNETs.

Impact of conversion at the time of minimally invasive pancreaticoduodenectomy: a review of the national cancer database

Presenter: Daisy Sanchez MD | Memorial Healthcare System Background: Current literature presents limited data regarding outcomes following conversion at the time of minimally invasive pancreaticoduodenectomy (MI-PD). We aim to compare perioperative, oncologic outcomes and survival between patients who required conversion from MI-PD to open pancreaticoduodenectomy (CO-PD) with patients who underwent open pancreatectomy (O-PD) on a national level. Methods: The National Cancer Database was queried for patients who underwent pancreaticoduodenectomy. Patients were stratified into three groups: minimally invasive (MI-PD), converted to open (CO-PD), and open pancreaticoduodenectomy (O-PD). Multivariable modeling was applied to compare outcomes to O-PD while adjusting for patient and tumor characteristics. Results: Among 17,570 patients identified, 2,191 (12.5%) underwent MI-PD (2.3% robotic and 10.2% laparoscopic), 734 (4.2%) CO-PD, and 14,645 (83.4%) O-PD. Baseline demographics and tumor characteristics were similar among cohorts. Robotic pancreaticoduodenectomy (R-PD) resulted in a significantly higher lymph node yield (n = 23.2 ± 12.2) even when requiring conversion (R-CO, n = 22.4 ± 13.2) when compared to O-PD (n = 17.6, ± 9.5) (p = 0.00). Margin positivity was higher in the CO-PD (robotic converted to open (R-CO) 36.6%, laparoscopic converted to open (L-CO) 25.4%) compared to the MI-PD (R-PD 22.7%, L-PD 21.3%) and O-PD (22.6%) group (p = 0.017). Length of stay (days) was shortest for MI-PD (L-PD 10.4 ± 8.6, R-PD 10.6 ± 8.8) and R-CO (10.7 ± 6.4), compared to the L-CO (11.2 ± 9) and O-PD (11.5 ± 8.9) group (p = 0.000). 30-day readmission, 30-day mortality and 90-day mortality were similar among the groups. After adjusting for patient and tumor characteristics, both MI-PD (OR = 1.40; p = 0.000) and CO-PD (OR = 1.24; P = 0.030) were both significantly associated with an increased likelihood of long-term survival. Conclusion: Minimally-invasive pancreaticoduodenectomy with conversion to an open approach (CO-PD) is not associated with poorer short-term outcomes. Despite the noted increase positive margin rate, CO-PD was still associated with an increased likelihood of long-term survival when compared to O-PD.

Minimally invasive versus open pancreatectomy for right-sided and left-sided non-functioning pancreatic neuroendocrine tumors; a multicenter, matched analysis with inverse probability of treatment weighting method

Minimally invasive versus open pancreatectomy for right-sided and left-sided non-functioning pancreatic neuroendocrine tumors; a multicenter, matched analysis with inverse probability of treatment weighting method

Is pathologic examination of excised preperitoneal fat, round ligament, or falciform ligament necessary after pancreatectomy for pancreatic cancer?

Presenter: Hassan Ahmed MD, MRCSI | Case Western Reserve University School of Medicine/University Hospitals Cleveland Medical Center Background: For patients with pancreatic ductal adenocarcinoma (PDAC), routine excision of the preperitoneal fat, falciform ligament, or round ligament are commonly performed during open pancreatectomy to aid in exposure and visualization. There is variation in clinical practice, but these specimens are commonly submitted for pathologic examination. As minimally invasive pancreatectomies have become more popular in recent years, routine excision of the preperitoneal fat, falciform ligament, or round ligament are not commonly performed. We aimed to evaluate the rate of metastases in these specimens to determine if routine pathologic examination is required and should be incorporated into minimally invasive pancreatectomies. Methods: A retrospective chart review was completed of 838 pancreatectomies performed at our institution between July 2004 and February 2021. All patients who underwent an open pancreatic resection with histologically confirmed invasive pancreatic cancer were included in the analysis, including patients with the pancreas as a site for metastasis. Pathology reports were reviewed to determine if a preperitoneal fat, falciform ligament, or round ligament excisional biopsy was submitted for pathologic examination. The aforementioned biopsies were classified as negative or positive for malignancy. Results: A total of 595 patients underwent a pancreatectomy for cancer and were included in the analysis. Approximately 21% of patients received neoadjuvant chemotherapy. Seventy patients (11.8%) had a preperitoneal fat, falciform ligament, or round ligament excisional biopsy available for review. None of the submitted specimens had evidence of malignancy or any significant pathological finding. Conclusion: Although the preperitoneal fat, round ligament, and falciform ligament are commonly excised for the sake of exposure during open pancreatic resection, our data does not seem to justify the time, cost, and resources required for formal pathologic examination. These data are important to consider for both open and minimally invasive pancreatectomies.

Minimally invasive vs open pancreatectomy for nonfunctioning pancreatic neuroendocrine tumors.

BACKGROUNDThe mainstay of treating nonfunctioning-pancreatic neuroendocrine tumors(NF-PNETs) is surgical resection. However, minimally invasive approaches to pancreatic resection for treating NF-PNETs are not widely accepted, and the long-term oncological outcomes of such approaches remain unknown.AIMTo determine the short- and long-term outcomes of minimally invasive pancreatic resection conducted in patients with NF-PNETs.METHODSProspective databases from Severance Hospital were searched for 110 patients who underwent curative resection for NF-PNETs between January 2003 and August 2018.RESULTSThe proportion of minimally invasive surgery (MIS) procedures performed for NF-PNET increased to more than 75% after 2013. There was no significant difference in post-operative complications (P = 0.654), including pancreatic fistula (P = 0.890) and delayed gastric emptying (P = 0.652), between MIS and open approaches. No statistically significant difference was found in disease-free survival between the open approach group and the MIS group (median follow-up period, 28.1 mo; P = 0.428). In addition, the surgical approach (MIS vs open) was not found to be an independent prognostic factor in treating NF-PNET patients [Exp(β) = 1.062; P = 0.929].CONCLUSIONRegardless of the type of surgery, a minimally invasive approach can be safe and feasible for select NF-PNET patients.

Long-term oncologic outcomes of robotic and open pancreatectomy in a national cohort of pancreatic adenocarcinoma.

Robotic pancreatectomy is gaining momentum; however, limited data exist on the long-term survival of this approach for pancreatic ductal adenocarcinoma (PDAC). The objective of this study is to compare the long-term oncologic outcomes of robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP) to open surgery in patients with PDAC. Robotic and open pancreatectomy for stages I-III PDAC were obtained from the 2010 to 2016 National Cancer Database. We identified 17 831 pancreaticoduodenectomies and 2718 distal pancreatectomies of which 626 (4%) and 332 (12%) were robotic, respectively. There was no difference in median overall survival between RPD (22.0 months) and open pancreatoduodenectomy (21.8 months; logrank P = .755). The adjusted hazard ratio [HR] was 1.014 (95% confidence interval [CI]: 0.903-1.139). The median overall survival for RDP (35.3 months) was higher than open distal pancreatectomy (ODP) (24.9 months; logrank P = .001). The adjusted HR suggests a benefit to RDP compared to ODP (HR, 0.744; 95% CI: 0.632-0.868) CONCLUSION: In a national cohort of resected pancreatic adenocarcinoma, the robotic platform was associated with similar long-term survival for pancreaticoduodenectomy, but improved survival for distal pancreatectomy.