Robot-assisted Pancreaticoduodenectomy Research Articles

Short-term outcomes between robot-assisted and open pancreaticoduodenectomy in patients with high body mass index: A propensity score matched study.

High body mass index was considered as a risk factor for minimally invasive surgery. The short-term outcomes of robot-assisted pancreaticoduodenectomy (RPD) remain controversial. This study aims to investigate the feasibility and advantage of RPD in patients with high body mass index compared to open pancreaticoduodenectomy (OPD). Clinical data of 304 patients who underwent pancreaticoduodenectomy from January 2016 to December 2019 in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine was collected. Patients with BMI >25 kg/m2 were included and divided into RPD and OPD group. After PSM at a 1:1 ratio, 75 patients of OPD and 75 patients of RPD were recorded and analyzed. The RPD group showed advantages in the estimated blood loss (EBL) (323.3 mL vs. 480.7 mL, p = 0.010), the postoperative abdominal infection rate (24% vs. 44%, p = 0.010), the incidence of Clavien-Dindo III-V complications (14.7% vs. 28.0%, p = 0.042) over OPD group. RPD shows advantages in less EBL, lower incidence rate of Clavien-Dindo III-V complications over OPD in overweight and obese patients. RPD was confirmed as a safe and feasible surgical approach for overweight or obsess patients.

Robot-assisted pancreaticoduodenectomy in situs inversus totalis patient with pancreatic cancer

Pancreatic cancer (PC) combined with situs inversus totalis (SIT) is rare, and the treatment strategy is obscure. We report the first patient with PC and SIT who underwent robot-assisted pancreaticoduodenectomy. A 57-year-old male patient presented to our hospital with epigastric pain, nausea, and weight loss over 1 month. Preoperative diagnostic modalities revealed a resectable pancreatic ductal adenocarcinoma at the head and neck junction of the pancreas. The patient also had a rare condition called SIT. Then, the patient underwent Da Vinci robot-assisted pancreaticoduodenectomy (RPD) in our center. After the operation, the patient recovered well without complications. Until now, the patient was followed up 5 months, and the quality of life was well without tumor recurrence or metastasis. To the authors’ knowledge, this is the first RPD for PC in SIT patients.

Evolution Of Robot Assisted Pancreatico-Duodenectomy Over 7-years, Where Do We Stand?

Background: Robot-assisted laparoscopy was introduced more than 20 years ago and its adaptation in the field of pancreatic surgery is still evolving due to technical challenges. The aim of this study is to analyze the progress of robot-assisted pancreatico-duodenectomy (R-PD) in the U.S over 7 years to help optimize the development and adaptation of this challenging procedure.

An assessment of perioperative outcomes for open, laparoscopic, and robot-assisted pancreaticoduodenectomy in New York State.

Minimally invasive techniques for pancreaticoduodenectomy (PD) are increasing in practice, however, data remains limited regarding perioperative outcomes. Our study sought to compare patients undergoing open pancreaticoduodenectomy (OPD) with those undergoing laparoscopic (LPD) or robot-assisted pancreaticoduodenectomy (RPD). Patients who underwent PDduring 2016-2018 were identified from the New York State Planning and Research Cooperative System database. Of the 1954 patients identified, 1708 (87.4%) underwent OPD, 165 (8.4%) underwent LPD, and 81 (4.2%) underwent RPD. The majority of patients were White (63.8%), males (53.3%) with a mean age of 65.4 years. RPD patients had a lower median Charlson Comorbidity Index (2) than OPD (3) or LPD (3, p = 0.01) and had a lower 30-day rate of complications (35.8% vs. 48.3% vs. 43.6% respectively, p = 0.05). After propensity-score matching, however, there were no differences between the groups regarding overall complications, surgical site infections, anastomotic leaks, or mortality (p = NS for all). OPD demonstrated a longer length of stay (median 8 days) compared to LPD (7 days) or RPD (7 days, p < 0.01). Patients undergoing LPD and RPD have a shorter length of hospital stay compared to OPD and there was no difference in overall morbidity or mortality when matched to similar patients.

P-P37 Robot assisted pancreaticojejunostomy may be associated with lower risk of post-operative pancreatic fistula in high-risk cases: Initial experience

Abstract Background Robot assisted pancreaticoduodenectomy has increased in popularity over recent years. There is evidence from high volume centers which suggests that it is associated with lower risk of post-operative pancreatic fistula than open surgery. The aims of this study were to evaluate our initial experience after robotic assisted pancreaticoduodenectomy and compare if a low volume center can produce similar positive outcomes. Methods The initial 12 patients who were listed for a robot assisted pancreaticoduodenectomy were included in the study in a consecutive manner. A standardised method of anastomosis was used in all surgeries, this being a duct-to-mucosa two-layer modified Blumgart pancreato-jejunostomy. Data was collected prospectively and stored in an encrypted database. Surgical outcomes were then analysed. Results The study included first 12 consecutive patients who underwent robotic pancreaticoduodenectomy between August 2019 and January 2020. None of the patients had clinically relevant postoperative pancreatic fistula despite 75% of the patients falling into moderate to high-risk group for fistula development. Median operative time and length of stay was 547 minutes and 8 days respectively with three Clavien Dindo grade III complications and three Clavien-Dindo grade II complications. Conclusions Robotic assisted pancreaticoduodenectomy maybe associated with lower risk of post-operative pancreatic fistula in high-risk cases.

Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers.

The objective of the study is to compare the safety and efficacy of robot-assisted pancreaticoduodenectomy (PD) with open PD. The PubMed, EMBASE and Cochrane Library databases were searched for the literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio (RR) and weighted mean difference (WMD) and their 95% confidence intervals (CIs) were calculated using fixed-effect or random effect models. 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) (WMD = - 175.65, 95% CI (- 251.85, - 99.44), P < 0.00001), wound infection rate (RR = 0.60, 95% CI (0.44, 0.81), P = 0.001), reoperation rate (RR = 0.61, 95% CI (0.41, 0.91), P = 0.02), hospital day (WMD = - 2.95, 95% CI (- 5.33, - 0.56), P = 0.02), intraoperative blood transfusion (RR = 0.56, 95% CI (0.42, 0.76), P = 0.0001), overall complications (RR = 0.78, 95% CI (0.64, 0.95), P = 0.01), and clinical postoperative pancreatic fistula (POPF) (RR = 0.54, 95% CI (0.41, 0.70), P < 0.0001). In terms of lymph node clearance (WMD = 0.48, 95% CI (- 2.05, 3.02), P = 0.71), R0 rate (RR = 1.05, 95% CI (1.00, 1.11), P = 0.05), postoperative pancreatic fistula (RR = 1, 95% CI (0.85, 1.19), P = 0.97), bile leakage (RR = 0.99, 95% CI (0.54, 1.83), P = 0.98), delayed gastric emptying (DGE) (RR = 0.79, 95% CI (0.60, 1.03), P = 0.08), 90-day mortality (RR = 0.82, 95% CI (0.62, 1.10), P = 0.19), and severe complications (RR = 0.98, 95% CI (0.71, 1.36), P = 0.91), and there were no significant differences between the two groups. Robotic surgery was inferior to open surgery in terms of operational time (WMD = 80.85, 95% CI (16.09, 145.61), P = 0.01). RPD is not inferior to OPD, and it is even more advantageous for EBL, wound infection rate, reoperation rate, hospital stay, intraoperative transfusion, overall complications and clinical POPF. However, these findings need to be further verified by high-quality randomized controlled trials.

Type 4 vein resection during robot-assisted pancreaticoduodenectomy

Type 4 vein resection during robot-assisted pancreaticoduodenectomy

Robot-assisted pancreaticoduodenectomy with vascular resection: technical details and results from a high-volume center

Background: Pancreaticoduodenectomy with vein resection (PD-VR) is widely accepted as a standard procedure to achieve a higher rate of R0 resections in borderline resectable pancreatic tumors. Thanks to the availability of newer technologies, such as the da Vinci Surgical System, several high-volume centers are reporting small series of minimally invasive PD-VR.

Type 3 vein resection during robot-assisted pancreaticoduodenectomy

Type 3 vein resection during robot-assisted pancreaticoduodenectomy

Outcome of robot-assisted pancreaticoduodenectomy during initial learning curve versus laparotomy

To analyze the initial learning curve (LC) for robot-assisted pancreaticoduodenectomy (RAPD) and compare RAPD during the initial LC with open pancreaticoduodenectomy (OPD) in terms of outcome. This study is a retrospective review of patients who consecutively underwent RAPD and OPD between October 2015 and January 2020 in our hospital. 41 consecutive RAPD cases and 53 consecutive open cases were enrolled for review. Compared with OPD, RAPD required a significantly longer operative time (401.1 ± 127.5 vs. 230.8 ± 44.5 min, P < 0.001) and higher cost (194621 ± 78342 vs. 121874 ± 39973 CNY, P < 0.001). Moreover, compared with the OPD group, the RAPD group revealed a significantly smaller mean number of lymph nodes harvested in malignant cases (15.6 ± 5.9 vs 18.9 ± 7.3, P = 0.025). No statistically significant differences were observed between the two groups in terms of incidence of Clavien–Dindo grade III–V morbidities and 90-day mortality and readmission (P>0.05). In the CUSUM graph, one peak point was observed at the 8th case, after which the operation time began to decrease. LC for RAPD may be less than 30 cases, and RAPD is safe and feasible during the initial LC.

Modified Transperitoneal Ports Configuration Technique and Docking with the da Vinci Surgical System Xi for Combined Pancreaticoduodenectomy and Right Partial Nephrectomy

A 68-year-old man with ampullary cancer and clear cell renal cell carcinoma of the kidney underwent a combined robot-assisted laparoscopic pancreaticoduodenectomy and right partial nephrectomy. We report a combined robot assisted surgery for both procedures done at the same setting.

Short-term Outcomes After Robot-Assisted vs Open Pancreaticoduodenectomy After the Learning Curve

Robot-assisted pancreaticoduodenectomy (RPD) has been reported to be safe and feasible. As a new technique, RPD has a learning curve similar to that of other types of minimally invasive pancreatic surgery such as laparoscopic pancreaticoduodenectomy. To our knowledge, no reports exist on the outcomes of open pancreaticoduodenectomy (OPD) and RPD after the learning curve. To analyze and evaluate the actual advantages of RPD. Between May 2010 and December 2018, 450 patients underwent RPD in the Shanghai Ruijin Hospital affiliated with Shanghai Jiaotong University in Shanghai, China, a high-volume pancreatic disease center. According to our previous study, an important flexion point in the learning curve is 250 cases. Data on the last 200 RPD cases were collected from January 2017 to December 2018. During that period, 634 patients underwent OPD. These patients were divided into 2 groups, and propensity score matching was used to minimize bias. The demographic data and operative outcomes were collected and analyzed. Analysis began May 2019. Robot-assisted pancreaticoduodenectomy and OPD. The short-term operative outcomes of RPD and OPD. After 1:1 matching, 187 cases of RPD and OPD were recorded. In the RPD group, 78 patients (41.7%) were women, and the mean (SD) age was 60.9 (11.4) years. In the OPD group, 80 patients (42.8%) were women, and the mean (SD) age was 60.1 (10.8) years. Robot-assisted pancreaticoduodenectomy had advantages in operative time (mean [SD], 279.7 [76.3] minutes vs 298.2 [78.3] minutes; P = .02), estimated blood loss (mean [SD], 297.3 [246.8] mL vs 415.2 [497.9] mL; P = .002), and postoperative length of hospital stay (mean [SD], 22.4 [16.7] days vs 26.1 [16.3] days; P = .03). However, there was no significant difference in the R0 resection rate and incidence rate of postoperative complications, such as postoperative pancreatic fistula, bile leak, and delayed gastric emptying. The incidence rates of postoperative bleeding and reoperation in the RPD group were similar to those in the OPD group, with no statistically significant difference. After passing the learning curve, RPD had advantages in operative time and blood loss compared with OPD. There were no differences in postoperative complications such as postoperative pancreatic fistula, bile leak, and delayed gastric emptying. However, patients recovered more quickly after RPD than after OPD. A prospective randomized clinical trial is needed in the future to verify these results.

Patient-controlled analgesia with continuous perioperative lidocaine and s-ketamine is non-inferior to epidural analgesia after robot-assisted pancreaticoduodenectomy

Patient-controlled analgesia with continuous perioperative lidocaine and s-ketamine is non-inferior to epidural analgesia after robot-assisted pancreaticoduodenectomy

The Safety and Feasibility of&amp;nbsp;Robot-Assisted Pancreatic Surgery at&amp;nbsp;a High-Volume Center: A Nine-Year Retrospective Single-Center Analysis of 1396 Patients

Objective: We aimed to share our experience with 1396 cases of robot-assisted pancreatic surgery (RAPS) over nine years. Methods:The medical records of 1396 patients who underwent RAPS between May 2010 and December 2018 at Shanghai Ruijin Hospital were retrospectively analyzed. Operative outcomes, including the operative duration, estimated blood loss (EBL), and incidence of morbidities, especially postoperative pancreatic fistula (POPF), are discussed. We also recorded and illustrate our progress along the learning curve for RAPS in this large cohort. Results: During the study period, 1396 patients underwent RAPS at our center. Among them, 450 patients underwent robot-assisted pancreaticoduodenectomy (RPD), 605 patients underwent robot-assisted distal pancreatectomy (RDP), 144 patients underwent robot-assisted middle pancreatectomy (RMP), 119 patients underwent robot-assisted enucleation (REn), 40 patients underwent robot-assisted duodenum-preserving pancreatic head resection (R-DPPHR), 12 patients underwent robot-assisted total pancreatectomy (R-TP) and 26 patients underwent other types of surgery with a robot-assisted platform. A total of 442 patients (31.7%) suffered malignant tumors, while 357 (25.6%) patients had pancreatic ductal adenocarcinoma (PDAC). The mean operative duration was 195.3±107.4 min. The mean EBL was 197.5±107.4 ml. There were a total of 13 cases (0.9%) of conversion to open surgery due to adhesion and vascular invasion by the tumor. The total incidence rate of complications was 39.1% (546/1396). The incidence rate of clinically related (CR)-POPF of the total cohort was 16.5% (230 patients). The mean postoperative length of hospital stay (LOS) of the total cohort was 20.0±12.9 days. Conclusions: To the best of our knowledge, this is the largest sample size of RAPS cases ever reported. In conclusion, for benign and low-grade malignant pancreatic tumors, minimally invasive pancreatic surgery is safe and feasible and might be a good choice. Operative outcomes improve with accumulated experience. Further prospective analyses of RAPS should be designed to verify the advantages of RAPS. Funding Statement: The study was funded by National Natural Science Foundation of China (NSFC) directly to Baiyong Shen. Serial number: 81871906. It was also sponsored bu the Interdisciplinary Program of Shanghai Jiao Tong University directly to Jiabin Jin. Serial number: YG2019QNB26. Declaration of Interests: All the authors, Dr Yusheng Shi, Dr Jiabin Jin, Dr Junjie Xie, Dr Yuanchi Weng, Dr Mengmin Chen, Dr Kai Qin, Dr Hao Chen, Dr Xiaxing Deng, Dr Baiyong Shen and Dr Chenghong Peng have no conflicts or financial ties to disclose. Ethics Approval Statement: This retrospective study was approved by the institutional review board of Shanghai Ruijin Hospital. Every patient provided written informed consent to undergo the operation and for the use of the data we collected before and after the surgery.

Learning Curve From 450 Cases of Robot-Assisted Pancreaticoduocectomy in a High-Volume Pancreatic Center: Optimization of Operative Procedure and a Retrospective Study.

We aimed to describe our experience and the learning curve of 450 cases of robot-assisted pancreaticoduodenectomy (RPD) and optimize the surgical process so that our findings can be useful for surgeons starting to perform RPD. Robotic surgical systems were first introduced 20 years ago. Pancreaticoduodenectomy (PD) is a challenging surgery because of its technical difficulty. RPD may overcome some of these difficulties. The medical records of 450 patients who underwent RPD between May 2010 and December 2018 at the Shanghai Ruijin Hospital were retrospectively analyzed. Operative times and estimated blood loss (EBL) were analyzed and the learning curve was determined. A cumulative sum (CUSUM) analysis was used to identify the inflexion points. Other postoperative outcomes, postoperative complications, and long-term follow-up were also analyzed. Operative time improved graduallyovertimefrom405.4 ± 112.9 minutes (case 1-50) to 273.6 ± 70 minutes (case 301-350) (P < 0.001). EBL improved from 410 ± 563.5 mL (case 1-50) to 149.0 ± 103.3 mL (case 351-400) (P< 0.001). According to the CUSUM curve, there were 3 phases in the RPD learning curve. The inflexion points were around cases 100 and 250. The incidence of pancreatic leak in the last 350 cases was significantly lower than that in the first 100 cases (30.0% vs 15.1%, P = 0.003). RPD is safe and feasible for selected patients. Operative and oncologic outcomes were much improved after experience of 250 cases. Our optimization of the surgical process may have also contributed to this. Future prospective and randomized studies are needed to confirm our results.

Surgical and oncological outcomes of our first 59 cases of robotic pancreaticoduodenectomy.

Robotics has shown encouraging results for a number of technically demanding abdominal surgeries including pancreaticoduodenectomy, which has originally represented a relative contraindication to the application of the minimally-invasive technique. We aimed to investigate the perioperative, clinicopathologic, and oncological outcomes of robot-assisted pancreaticoduodenectomy by assessing a consecutive series of totally robotic procedures. All consecutive patients who underwent robotic pancreaticoduodenectomy were included in the present analysis. Perioperative, clinicopathologic and oncological outcomes were examined. In order to investigate the role of the learning curve, surgical outcomes were also used to compare the early and the late phase of our experience. A total of 59 patients underwent surgery. Median hospital stay was 9 days (5 - 110), with an overall morbidity and mortality of 37% and 3%, respectively. Of note, the rate of clinically relevant pancreatic fistula was 11.8%. R0 resections were achieved in 96% of patients and the 3-year disease-free and overall survivals were 37.2 and 61.9%, respectively. Overall, surgical outcomes did not vary significantly between the first and the late phase of the series. Robotic pancreaticoduodenectomy can be performed competently. It satisfies all features of oncological adequacy and may offer a number of advantages over standard procedures in terms of surgical results.

Mo1264 - The International Study Group of Pancreatic Surgery Grade B/C Delayed Gastric Emptying in Robot-Assisted Pancreaticoduodenectomy: Analysis of Predictive Factors and Impact of Learning Curve

Mo1264 - The International Study Group of Pancreatic Surgery Grade B/C Delayed Gastric Emptying in Robot-Assisted Pancreaticoduodenectomy: Analysis of Predictive Factors and Impact of Learning Curve

Technical Aspects and Results of Robot-Assisted Pancreatic Surgery

Aim. To improve the results of treatment of patients with pancreatic diseases. Materials and Methods. For the period from 2010 to 2014 it was performed 59 robot-assisted pancreatic operations. There were distal pancreatectomy in 30 cases and pancreaticoduodenectomy in 12 cases including total pancreatoduodenectomy (1), central resection (5), tumor enucleations (12). The study included 48 (81.4%) females and 11 (19.6%) males. Median age was 48.4 ± 14.5 years. Results. Average operation time in case of ancreaticoduodenectomy, distal pancreatectomy, central resection and tumor enucleation was 463.1 ± 111.1, 218.0 ± 68.2, 253.0 ± 37.7 and 150.0 ± 49.0 minutes respectively. Postoperative complications arose in 24 (40.7%) cases including external pancreatic fistula in 19 patients, delayed gastric empty in 3 and arrosive hemorrhage in 2 cases. There was one death after robot-assisted pancreaticoduodenectomy. Conclusion. Indications for robot-assisted pancreatic surgery are malignant tumors T1–T2, neuroendocrine neoplasms and benign tumors with size not more than 5–6 cm. The use of robotic complex doesn’t prevent from specific postoperative complications definitive for pancreatic surgery.

Totally laparoscopic or robot-assisted pancreaticoduodenectomy versus open surgery for periampullary neoplasms: separate systematic reviews and meta-analyses.

To compare perioperative and oncologic outcomes of pure (totally) laparoscopic pancreaticoduodenectomy (TLPD) or robot-assisted pancreaticoduodenectomy (RAPD) with those of conventional open pancreaticoduodenectomy (OPD). A systematic literature search was performed using PubMed, EMBASE, and Cochrane library databases. Studies comparing TLPD with OPD and RAPD with OPD were included; only original studies reporting more than 10 cases for each technique were included. Studies were combined using a random-effects model to report heterogeneous data, or a fixed-effects model was applied. TLPD involved longer operative time (weighted mean difference [WMD]: 116.85min; 95% confidence interval [CI] 54.53-179.17) and significantly shorter postoperative hospital stay (WMD: -3.68days; 95% CI -4.65 to -2.71). Overall morbidity and postoperative pancreatic fistula were not significantly different between TLPD and OPD. RAPD was associated with a longer operative time, less intraoperative blood loss, and shorter hospital stay. Oncologic outcomes were not significantly different among the procedure types. Compared to OPD, TLPD and RAPD were feasible and oncologically safe procedures. However, there are no prospective studies, and the majority of the studies on TLPD and RAPD have remained in the early training phase. In addition to randomized controlled trials or prospective studies, new data from the late training phase of learning experiences should also be analyzed.

The Learning Curve in Robotic Pancreaticoduodenectomy

Background/Purpose: Few data are available on the learning curve (LC) in robot-assisted pancreaticoduodenectomy (RAPD) and no study specifically addresses the LC of a single surgeon. Methods: The LC of a single surgeon in RAPD was determined using the cumulative sum method, based on operative time (OT). Data were extracted from a prospectively maintained database and analyzed retrospectively considering all events occurring within 90 days of index operation. Results: Seventy RAPD were analyzed. One operation was converted to open surgery (1.4%). One patient died within 30 days (1.4%) and one within 90 days (2.8%). Postoperative complications occurred in 53 patients (75.7%) and exceeded Clavien-Dindo grade IIIb in 7 patients (10%). OT dropped after 33 operations from a mean of 564 ± 101.7 min to a mean of 484.1 ± 77.9 min (p = 0.0005) and was associated to reduced incidence of delayed gastric emptying (72.7 vs. 48.7%; p = 0.039). The rate of hospital readmission improved after 40 operations from 20.0 (8 of 40) to 3.3% (1 of 30) (p = 0.04). Conclusions: RAPD was safely feasible in selected patients. OT dropped after the first 33 operations and was associated with reduced rate of delayed gastric emptying. Readmission rate improved after 40 operations.