Pancreatic Enucleation Research Articles

Minimally invasive versus open pancreatic enucleation. Systematic review and meta-analysis of surgical outcomes.

Parenchymal sparing procedures are gaining interest in pancreatic surgery and recent studies have reported that minimally invasive pancreatic enucleation may be associated with enhanced outcomes when compared with traditional surgery. By meta-analyzing the available data from the literature, minimally invasive surgery is not at higher risk of pancreatic fistula and offers a number of advantages over conventional surgery for pancreatic enucleation.

A single-team experience with robotic pancreatic surgery in 1010 cases

To assess the safety and advantages of robotic pancreatic surgery (RPS) based on the single-team experience with 1010 cases. The clinical data of 1010 cases of RPS performed by a single team from November, 2011 to September, 2017 in our hospital were collected prospectively and analyzed. In most of cases the surgeries were performed using the third-generation da Vinci robotic surgical system. The 1010 cases receiving RPS included 417 cases of robotic pancreatoduodenectomy (RPD), 428 cases of robotic distal pancreatectomy, 60 cases of robotic central pancreatectomy, 53 cases of robotic pancreatic tumor enucleation, 3 cases of Appleby procedure, and 49 cases of other operations (including 4 cases of innovative robotic retroperitoneal laparoscopic surgery, 4 cases of robotic pancreatic tumor enucleation combined with main pancreatic duct bridging repair, 1 case of single incision robotic pancreatic tumor enucleation, and 2 cases of robotic central pancreatectomy combined with end-to-end anastomosis reconstruction). The median operative time was 210 min (30-720 min) with a median intraoperative blood loss of 80 mL (10-2000 mL), a conversion rate of 4.06% (41/1010), a blood transfusion rate of 6.7% (68/1010), a mean post-operative stay of 10.87∓6.70 days, a complication rate (beyond grade III according to Clavien-Dindo scoring system) of 8.0% (81/1010), and a pancreatic fistula rate (beyond) grade B of 9.21% (93/1010). The mortality rate of the patients was 0.69% (7/1010) in 30 days and 1.31% (12//934) in 90 days. The application of RPS in total pancreatectomy increased steadily from the rate of 10.44% in 2012 to 72.06% in 2017. This represents to our knowledge the world largest series of robotic pancreatic resections. RPS is expected to gradually replace open procedure and laparoscopic procedure to become the primary choice of approach for pancreatectomy. After the learning curve, RPS procedure including distal pancreatectomy, robotic Appleby procedure and other operations can be safely performed, and the experiences from other centers can be beneficial to reduce severe complications in the early stage of learning.

Short-term outcomes and risk factors for pancreatic fistula after pancreatic enucleation: Single-center experience of 142 patients

Short-term outcomes and risk factors for pancreatic fistula after pancreatic enucleation: Single-center experience of 142 patients

The lesser omentum approach for laparoscopic pancreatic enucleation

Objective: To evaluate the feasibility and strategy of the lesser omentum approach for laparoscopic pancreatic enucleation. Methods: Between June 2011 and October 2013, 6 laparoscopic pancreatic enucleations were performed by lesser omentum approach.The average age was 42 years, including 1 male and 5 female.The preoperation diagnosis of 6 cases were pancreatic islet cell tumors determined by abdominal CT/MRI, ultrasound and digital subtraction angiography.The tumors of 3 cases located in pancreatic neck, 2 tumors located in neck and body of pancreas, and 1 tumor located in pancreatic body.Their biggest tumor diameter were 0.8-2.5 cm. Results: Among the 6 cases, all laparoscopic pancreatic enucleations were successfully performed.None of the patients were converted to open operation.Eestimated blood loss was (26.7±18.6)ml, operating time was (82.5±19.4)minutes, and postoperative length of stay was (5.17±1.17)days.Additionally, postoperative complication included grade A pancreatic fistula in 1 case.After 36-64 months followed-up, there was no tumor recurrence and clinical symptom disappeared. Conclusion: For the islet cell tumors located in pancreatic neck and body, the lesser omentumapproach may contribute to good surgical view and operative space, which can make pancreatectomy safer and easier for clinical application.

Single-stage laparoscopic adrenalectomy for pheochromocytoma and enucleation of a pancreatic neuroendocrine tumor in Von Hippel-Lindau disease: A case report.

Von Hippel-Lindau (VHL) disease is an inherited syndrome with autosomal-dominant transmission, characterized by central nervous system and retinal hemangioblastomas, visceral cysts and tumors. Optimal surgical treatment, including its timing, remains a controversial topic. The present study reports the case of a 67-year-old female patient with adrenal and pancreatic manifestations of VHL. A laparoscopic cortex-sparing left adrenalectomy for a 4-cm pheochromocytoma and pancreatic enucleation for pancreatic polypeptidoma of the pancreas tail were performed during the same operative procedure. The total operative time was 240 min. There were no operative complications, and the surgery was completed laparoscopically with minimal blood loss. A prolonged hospital stay was necessary to treat a grade C postoperative pancreatic fistula. The histopathological result was an adrenal pheochromocytoma and a well-differentiated neuroendocrine tumor, secreting pancreatic polypeptides. In conclusion, organ-sparing laparoscopic surgery is an important option for treating simultaneous lesions in several abdominal solid viscera, such as VHL disease, and the present case study represents, to the best of the authors' knowledge, the first report of single-stage laparoscopic adrenalectomy and pancreatic tumor enucleation.

Robotic vs open pancreatectomy. Case matched study

Objective: Robotic surgery is gaining worldwide acceptance among surgeons. However, in the pancreatic field, its advantages are still under investigation. The aim of this study is to reports our early experience with robotic pancreatectomies and compare with the conventional open approach. Methods: Our robotic pancreatectomies experience was compared to a case-matched series of open pancreatectomies patients at the same center. Matching was according to benign/malignant diagnosis and main preoperative data. Patient data were obtained retrospectively. The main outcomes and measures were operative time, estimated blood loss, conversion rate (robotic to open), resection margin size, complication rates, stay length, ICU stay length, readmission rate, and 90-day mortality rate. Results: Forty-six robotic pancreatectomies were performed in 2011–2016 at the Sanchinarro Hospital. There were 15 duodenal pancreatectomies (DP), 21 distal pancreatectomies (DP) and 9 pancreatic enucleations (PE). Compared to 47 matched patients who underwent open pancreatectomies (17 DP, 21 PD, 9 PE), there was a higher mean operative of time in the robotic group (Robotic: 378 min, Open: 192 min, p=0.02), a lower median estimated blood loss (Robotic: 300 ml, Open: 525 ml, p=0.03) and a slight shorter mean hospital stay in the robotic group. There was a 15.2 % conversion rate in the robotic group. Post-operative complication rate and margin status, as well, were similar in both groups. Conclusion: Robotic pancreatectomy is safe and effective. Increasing experience will allow definition of which patient and type of tumor can be performed robotically, and will enable optimization of outcomes. Further studies are needed to confirm our early results.

Laparoscopic Enucleation of Benign Pancreatic Tumors

Benign pancreatic tumor enucleations have been performed since 1996. Endocrine tumors (ET) are rare yet they represent about 2/3 of the laparoscopic enucleations, a topic still in debate. Preoperative imaging routinely comprises a CT scan but endoscopic ultrasound is mandatory for localizing the tumor and guided biopsy-aspiration. Trocars have to be positioned to avoid “fencing” with the instruments. A Kocher maneuver may be necessary for accessing deep or posterior tumors. Bipolar electrocautery and harmonic scalpel ensure better hemostasis than the monopolar cautery hook. The raw surface can be covered with hemostatics or fibrin glue. The mean operating time is 2 hours. Forced conversions, due mainly to hemorrhage or insufficient exposure, are rare (9%). Pancreatic fistula, the main postoperative complication, affects up to one third of the patients and does not depend on the choice of dissection instruments, management of the remaining cavity or somatostatin use. A risk factor is the location of the tumor at less than 2mm from the main pancreatic duct. Necrotic pancreatitis, pancreatic pseudocyst and duodenal fistula contribute to a surgical morbidity of 60%. Although safe and technically feasible enucleation still has to be considered a low mortality but high morbidity procedure.

Enucleation: A treatment alternative for branch duct intraductal papillary mucinous neoplasms

Small, asymptomatic, branch-duct intraductal papillary mucinous neoplasms of the pancreas are often kept under surveillance despite their malignant potential. The management of branch-duct intraductal papillary mucinous neoplasm is controversial with regard to indications and extent of any operative intervention. The present study aimed to evaluate enucleation as an alternative operative approach for branch-duct intraductal papillary mucinous neoplasms to exclude and prevent malignancy. For branch-duct intraductal papillary mucinous neoplasms of <30mm in diameter and an acceptable distance from the main pancreatic duct, enucleation was considered as the operative approach of choice. All patients scheduled for enucleation of branch-duct intraductal papillary mucinous neoplasm on the basis of these features between January 2004 and September 2014 were analyzed. Among these, patients with successful enucleation were compared with those who were scheduled for enucleation but converted intraoperatively to pancreatic resection (intention-to-treat analysis). End points were hospital morbidity and mortality as well as histopathology and functional outcome at a mean follow-up of 32months. In the study, 115 patients with presumed branch-duct intraductal papillary mucinous neoplasm and the intention to perform pancreatic enucleation were included; 87 enucleations were performed in 74 patients. In 41 patients, enucleation was converted to a pancreatic resection (procedure-specific success rate 64%); indications for conversion included location or size (46%), presence of multicystic lesions (39%), or involvement of the main pancreatic duct (15%). Of the 74 patients with enucleation, 64 branch-duct intraductal papillary mucinous neoplasms revealed low- (85%), 11% moderate dysplasia-, and 4% high-grade dysplasia on histology. Among converted resections, 6 intraductal papillary mucinous neoplasms revealed high-grade dysplasia or invasive carcinoma (15%). Intention-to-treat analysis with patients converted to pancreatic resection showed that enucleations resulted in less blood loss (100 vs 400mL) and a shorter operation time (146 vs 255minutes; P<.001 each). Postoperative morbidity including postoperative pancreatic fistula was similar in both groups. No mortality occurred after enucleation; after formal resection, 1 patient died due to multiorgan failure. Both hospital stay (10 vs 14days) and rates of postoperative endocrine and exocrine dysfunction rates were less after enucleation (P<.02 each). Intraductal papillary mucinous neoplasm-specific recurrence rates (3% vs 6%) were similar in both groups. Enucleation is a safe procedure that can be performed successfully in a high proportion of branch-duct intraductal papillary mucinous neoplasms and should be considered instead of standard resections as an important function-preserving alternative. Limitations may occur due to malignancy, size, localization, multilocularity, or main-duct involvement requiring conversion to a formal, anatomic resection. Beside the advantages in the short-term course, functional outcome seems to be superior after enucleation, and intraductal papillary mucinous neoplasm-specific recurrence rates are not increased compared with standard resections, at least at a mean follow-up of 32months.

Role of laparoscopic enucleation in the treatment of pancreatic lesions: case series and case-matched analysis.

Previous studies report successful application of laparoscopic pancreatic enucleation (LPE). However, the evidence is limited to small series. This study aimed to evaluate the indications, technique and outcome of LPE at a tertiary care institution. Between February 1998 and April 2016, 45 consecutive LPEs were performed at Oslo University Hospital-Rikshospitalet. Twenty-four (53.3%) patients subjected to right-sided LPE (RLPE) were compared with 21 (46.7%) patients who had undergone left-sided LPE (LLPE). A case-matched analysis (1:2) was performed to compare the outcomes following LLPE and laparoscopic distal pancreatectomy (LDP). Patient demographics, BMI, ASA score and pathological characteristics were similar between the RLPE and LLPE groups. Operative time was slightly longer for RLPE [123 (53-320) vs 102 (50-373) min, P=0.09]. The rates of severe morbidity (≥Accordion grade III) and clinically relevant pancreatic fistula (grades B/C) were comparable, although with a trend for higher rate of complications following LLPE (16.7 vs 33.3%; P=0.19 and 20.8 vs 33.3%, P=0.34, respectively). The hospital stay was similar between RLPE and LLPE [5 (2-80) vs 7 (2-52), P=0.49]. A case-matched analysis demonstrated shorter operating time [145 (90-350) vs 103 (50-233) min, P=0.02], but higher readmission rate following LLPE (25 vs 3.1%, P=0.037). LLPE seems to be associated with a higher risk of postoperative morbidity and readmission rates than LDP. RLPE is a feasible, safe approach and a reasonable alternative to pancreatoduodenectomy in selected patients with pancreatic lesions.

A systematic review and meta-analysis of surgical outcome after pancreatic enucleation versus standard resection

A systematic review and meta-analysis of surgical outcome after pancreatic enucleation versus standard resection

Evaluation of central pancreatectomy and pancreatic enucleation as pancreatic resections – A comparison

IntroductionFor minor pancreatic resection such as enucleation (PE) and central pancreatectomy (CP) comparative data are rare. These techniques provide parenchyma-sparing alternatives to major resections (e.g. pancreaticoduodenectomy) for neuroendocrine tumors, cystic tumors or metastases. This study retrospectively compares the morbidity and mortality of both techniques, with special regard to the formation of postoperative pancreatic fistulas (POPF). MethodsBetween December 1996 and November 2013 the postoperative events and clinical outcomes of 17 patients after pancreatic enucleation and 26 patients after central pancreatectomy were retrospectively analyzed from a prospectively collected database. ResultsPerioperative mortality was 0% in both groups. There was no significant difference in the overall peri-operative morbidity (CP 80.8% vs. PE 82.4%). The major cause of the high morbidity was the formation of a POPF with 26.9% of the patients after CP and 35.3% after PE. Univariate analysis showed a BMI over 30 kg/m2 in the CP group to be an independent risk factor. Additional minor complications, e.g. urinary tract infection, pleural effusion, etc. furthermore contributed to the perioperative morbidity. ConclusionPE and central CP are feasible techniques for selected patients, but the indications are limited. Morbidity after these resections is high with the major cause being the development of a POPF.

Laparoscopic Hand-Assisted Parenchymal-Sparing Resections for Presumed Side-Branch Intraductal Papillary Mucinous Neoplasms.

The diagnosis of side-branch intraductal papillary mucinous neoplasms (IMPNs) is increasingly more common, but their appropriate management is still evolving. We recently began performing laparoscopic hand-assisted enucleation or duodenal-sparing pancreatic head resection for these lesions with vigilant postoperative imaging. Seventeen patients with pancreatic cystic lesions were included in this single-center retrospective review from January 1, 2008 to March 30, 2013. Indication for surgical intervention was growth in size of the cyst, symptoms, cyst size >3 cm, and/or presence of a mural nodule. Twelve patients underwent laparoscopic hand-assisted enucleation, and 5 patients underwent laparoscopic hand-assisted pancreatic head resection. The mean age of patients was 64 years old. The most common presenting symptom was abdominal pain. The indication for surgical intervention was growth in the cyst or symptoms in the majority of patients. Fourteen lesions were in the head/uncinate, two were in the pancreatic body, and one was in the tail. Final pathology was consistent with side-branch IPMN in 13 patients (1 with focal adenocarcinoma). Three patients had serous cysts, and 1 had a mucinous cyst. Three patients developed pancreatic leaks, which were controlled with intraoperative placed drains, whereas 1 patient required additional drain placement. Median time from surgery to latest follow-up imaging is over 2 years. No patients have developed recurrent cysts or adenocarcinoma. Duodenal-sparing pancreatic head resection or pancreatic enucleation for patients with presumed side-branch IPMN is a safe and efficacious option, in terms of both operative outcomes and postoperative recurrence risk.

Risk of pancreatic fistula after enucleation of pancreatic tumours.

Enucleation is used increasingly for small pancreatic tumours. Data on perioperative outcome after pancreatic enucleation, especially regarding the significance and risk factors associated with postoperative pancreatic fistula (POPF), are limited. This study aimed to assess risk-dependent perioperative outcome after pancreatic enucleation, with a focus on POPF. Patients undergoing enucleation for pancreatic lesions between October 2001 and February 2014 were identified from a prospective database. A detailed analysis of morbidity was performed. Risk factors for POPF were assessed by univariable and multivariable analyses. Of 166 enucleations, 94 (56.6 per cent) were performed for cystic and 72 (43.4 per cent) for solid lesions. Morbidity was observed in 91 patients (54.8 per cent). Severe complications occurred in 30 patients (18.1 per cent), and one patient (0.6 per cent) died. Reoperation was necessary in nine patients (5.4 per cent). POPF was the main determinant of outcome and occurred in 68 patients (41.0 per cent): grade A POPF, 34 (20.5 per cent); grade B, ten (6.0 per cent); and grade C, 24 (14.5 per cent). Risk factors independently associated with POPF were: cystic tumour, localization in the pancreatic tail, history of pancreatitis and cardiac co-morbidity. Only cystic morphology was independently associated with clinically relevant POPF (grade B or C), occurring after enucleation in 25 (27 per cent) of 94 patients with cystic tumours versus nine (13 per cent) of 72 patients with solid tumours. Tumour size and distance to the main duct were not associated with risk of POPF. Enucleation is a safe procedure in appropriately selected patients with a low rate of severe complications. POPF is the main determinant of outcome and is more frequent after the enucleation of cystic lesions.

Meta-analysis of surgical outcome after enucleation versus standard resection for pancreatic neoplasms.

Pancreatic enucleation is a tissue-sparing approach to pancreatic neoplasms and may result in better postoperative pancreatic function than standard pancreatic resection. The objective of this review was to compare the postoperative outcome after pancreatic enucleation versus standard resection. MEDLINE, Embase and the Cochrane Library were searched systematically until February 2015 to identify studies comparing the outcome of enucleation versus standard resection for pancreatic neoplasms. After critical appraisal, meta-analysis was performed and the findings were presented as odds ratios or weighted mean differences with corresponding 95 per cent c.i. Twenty-two observational studies (1148 patients) were included. Duration of surgery (P < 0.001), blood loss (P < 0.001), length of hospital stay (P = 0.04), and postoperative endocrine (P < 0.001) and exocrine (P = 0.01) insufficiency were lower after enucleation than after standard resection. Mortality (P = 0.44), overall complications (P = 0.74), reoperation rate (P = 0.93) and delayed gastric emptying (P = 0.15) were not significantly different between the two approaches. The overall rate of postoperative pancreatic fistula (POPF) was higher after enucleation than after standard resection (P < 0.001). However, the raised POPF rate did not result in higher mortality or overall morbidity. Sensitivity analysis of high-volume studies (total of more than 20 enucleations and more than 4 per year) showed that, in specialized centres, enucleation can be performed with no increased risk of POPF (P = 0.12). Compared with standard resection, pancreatic enucleation can be performed effectively and with comparable safety in high-volume institutions. Enucleation should be considered instead of standard resection for selected pancreatic neoplasms.

Reappraisal of pancreatic enucleations: A single-center experience of 126 procedures

Parenchyma-sparing pancreatectomies, especially enucleations, could avoid disappointing functional results associated with standard resections for benign/low-grade pancreatic neoplasms. This study aimed to assess short- and long-term outcomes in a large, single-center series of enucleations. All 126 patients who underwent enucleation for benign/low-grade neoplasms between 1996 and 2011 were included retrospectively. Lesions were mainly incidentally diagnosed (71%), most often located in the head (46%), and with a median size of 20mm. Enucleations were mainly performed for branch-duct intraductal papillary mucinous neoplasm (30%), nonfunctioning pancreatic neuroendocrine tumors (29%), and mucinous cystadenoma (21%). Overall mortality was 0.8% and morbidity 63%, mainly owing to pancreatic fistula (57%). Most were significant clinically, that is, grade B or C (41%), but managed conservatively (85%). Reoperation rate was 3%, mainly owing to hemorrhage. Postoperative de novo diabetes was 0.8%, and exocrine insufficiency never observed. The 1-, 3-, and 5-year recurrence-free survival were 100%, 98%, and 93%, respectively. Enucleation is associated with substantial morbidity, especially pancreatic fistula. Enucleations as an alternative to standard resection are best indicated for small, benign, and low-grade lesions located far from the main pancreatic duct. Enucleations should be proposed to young and fit patients able to tolerate postoperative morbidity and who could benefit from the excellent long-term results.

Enucleation for benign or low-grade malignant lesions of the pancreas: Single-center experience with 65 consecutive patients

Standard resection for benign and borderline neoplasms of the pancreas is associated with a substantial risk of postoperative morbidity and long-term functional impairment, whereas enucleation leads to less morbidity and preserves healthy parenchyma as well as pancreatic function. The aim of this study was to evaluate the postoperative clinical outcomes and long-term functional and oncologic results after pancreatic enucleation, and to compare the clinical results of laparoscopic and open enucleation. From March 2005 to December 2013, 65 cases of enucleation of benign tumors in the pancreas were identified through a retrospective review of medical records. Most of the patients were women (73.8 %), and the median age was 52.7 years (interquartile range 43.1-60.9 years). Median tumor size was 2.5 cm (interquartile range 1.6-3.8 cm). The most common indication for enucleation was pancreatic neuroendocrine tumor (24, 36.9%). A clinically relevant pancreatic fistula (International Study Group on Pancreatic Fistula grade B, C) was reported in 6 patients (9.2%). The patients with tumors of the pancreatic neck had more complications after enucleation than those with tumors at other locations (3/4, 75%). There were no differences of clinical outcomes between open and laparoscopic enucleation groups. At a median follow-up of 58.7 months there was one case of new-onset diabetes, and there were no recurrences or deaths. Enucleation is a safe and effective procedure for the treatment of benign and borderline pancreatic neoplasms. It preserves pancreatic function and is not associated with recurrence. The incidence of postoperative complications, including pancreatic fistula, is acceptable. Laparoscopic enucleation seems to be a feasible and safe approach associated with favorable perioperative outcomes for the selected patients.

A Critical Appraisal of Laparoscopic Pancreatic Enucleations

Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few small-sized series show encouraging results, especially after enucleations performed for lesions located in the left part of the pancreas. The outcome of laparoscopic pancreatic enucleations was retrospectively evaluated by the analysis of prospectively collected parameters. Results of right-sided (head/uncus) and left-sided (neck/body/tail) enucleations were compared. From 1997 to 2010, 25 patients underwent laparoscopic pancreatic enucleation. The conversion rate was 12%, mean operating time was 158 minutes, and mean blood loss was 106 mL. Morbidity was 56% and the rate of pancreatic fistula 32%. Outcome differed between patients undergoing right-sided and left-sided enucleations, the operative time being 178 versus 132 minutes, morbidity 64% versus 45%, and median hospital stay 26 versus 9 days, respectively. Pancreatic enucleation is feasible by laparoscopy, with a high success rate and no mortality but significant morbidity. Laparoscopy seems to be of no use in right-sided procedures. Pancreatic fistula is still the main cause of long-lasting morbidity.

A Phantom Pig Abdomen as an Alternative for Testing Robotic Surgical Systems: Our Experience

The use of animals for testing and validating new medical devices and surgical techniques has raised ethical issues for a long time. Following the introduction of the Three Rs principle, significant efforts have been made to achieve a reduction in the numbers of animals used in testing. Nevertheless, the number of large animals used for testing purposes is still too high. This article describes a potential alternative to the use of large animals in the early phase of the development of surgical equipment -- a high-definition phantom pig abdomen. The phantom pig abdomen was developed from computed tomography scans by using affordable materials, and it was used with two different robotic platforms. It permitted the testing of minimally-invasive robotic pancreatic enucleation, with or without intraoperative ultrasound guidance. The phantom pig abdomen has proven to be a realistic tool, with the potential to reduce the cost and time-frame of the experiments.

Enucleation of Pancreatic Lesions: Indications, Outcomes, and Risk Factors for Clinical Pancreatic Fistula

BackgroundThere are few large samples and single-center series that focus on the outcomes of pancreatic enucleation and risk factors for clinical pancreatic fistula (PF). This study aimed to evaluate the indications, short- and long-term results, and risk factors for clinical PF after pancreatic enucleation. MethodsPatients who underwent pancreatic enucleation from January 2005 to April 2011 at the Peking Union Medical College Hospital in China were included. Clinical data were collected and analyzed. ResultsA total of 119 patients underwent enucleation. PF was the most common complication; the incidence of clinical PF (grades B and C) was 27.7 %. The most common indications were endocrine neoplasms (76.5 %). During a median follow-up of 41 months, no patient developed exocrine insufficiency. Three elderly patients developed non-insulin-dependent diabetes mellitus. One patient with VIPoma developed recurrence and liver metastasis. New York Heart Association (NYHA) class II or III (P = 0.009; hazard ratio (HR) 3.191; 95 % confidence interval (CI) 1.334–7.632), operative time ≥180 min (P = 0.025; HR 2.664; 95 % CI 1.112–6.386) were the independent risk factors for clinical PF. ConclusionEnucleation is a safe and effective treatment for benign and low malignant lesions of the pancreas. NYHA class II or III and operation time of ≥180 min are independent risk factors for clinical PF.

250 Robotic Pancreatic Resections

Computer-assisted robotic surgery allows complex resections and anastomotic reconstructions to be performed with nearly identical standards to open surgery. We applied this technology to a variety of pancreatic resections to assess the safety, feasibility, versatility, and reliability of this technology. A retrospective review of a prospective database of robotic pancreatic resections at a single institution between August 2008 and November 2012 was performed. Perioperative outcomes were analyzed. A total of 250 consecutive robotic pancreatic resections were analyzed; pancreaticoduodenectomy (132), distal pancreatectomy (83), central pancreatectomy (13), pancreatic enucleation (10), total pancreatectomy (5), Appleby resection (4), and Frey procedure (3). Thirty-day and 90-day mortality was 0.8% and 2.0%. Rate of Clavien 3 and 4 complications was 14% and 6%. The International Study Group on Pancreatic Fistula grade C fistula rate was 4%. Mean operative time for the 2 most common procedures was 529 ± 103 minutes for pancreaticoduodenectomy and 257 ± 93 minutes for distal pancreatectomy. Continuous improvement in operative times was observed over the course of the experience. Conversion to open procedure was required in 16 patients (6%) (11 with pancreaticoduodenectomy, 2 with distal pancreatectomy, 2 with central pancreatectomy, 1 with total pancreatectomy) for failure to progress (14) and bleeding (2). This represents to our knowledge the largest series of robotic pancreatic resections. Safety and feasibility metrics including the low incidence of conversion support the robustness of this platform and suggest no unanticipated risks inherent to this new technology. By defining these early outcome metrics, this report begins to establish a framework for comparative effectiveness studies of this platform.