250 Robotic Pancreatic Resections: Safety and Feasibility
TL;DR: 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.
Abstract: Background and Objectives: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
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TL;DR: TLPD is not only feasible in the setting of pancreatic ductal adenocarcinoma but also has advantages such as shorter hospital stay and faster recovery, allowing patients to recover in a timelier manner and pursue adjuvant treatment options.
Abstract: Objective:To directly compare the oncologic outcomes of TLPD and OPD in the setting of pancreatic ductal adenocarcinoma.Background:Total laparoscopic pancreaticoduodenectomy (TLPD) has been demonstrated to be feasible and may have several potential advantages over open pancreaticoduodenectomy (OPD),
376 citations
TL;DR: Continuous assessment of quality metrics allows for safe implementation of RPD and identified several inflexion points corresponding to optimization of performance metrics for RPD that can be used as benchmarks for surgeons who are adopting this technology.
Abstract: Importance Quality assessment is an important instrument to ensure optimal surgical outcomes, particularly during the adoption of new surgical technology. The use of the robotic platform for complex pancreatic resections, such as the pancreaticoduodenectomy, requires close monitoring of outcomes during its implementation phase to ensure patient safety is maintained and the learning curve identified. Objective To report the results of a quality analysis and learning curve during the implementation of robotic pancreaticoduodenectomy (RPD). Design, Setting, and Participants A retrospective review of a prospectively maintained database of 200 consecutive patients who underwent RPD in a large academic center from October 3, 2008, through March 1, 2014, was evaluated for important metrics of quality. Patients were analyzed in groups of 20 to minimize demographic differences and optimize the ability to detect statistically meaningful changes in performance. Exposures Robotic pancreaticoduodenectomy. Main Outcomes and Measures Optimization of perioperative outcome parameters. Results No statistical differences in mortality rates or major morbidity were noted during the study. Statistical improvements in estimated blood loss and conversions to open surgery occurred after 20 cases (600 mL vs 250 mL [ P = .002] and 35.0% vs 3.3% [ P P = .04), and operative time after 80 cases (581 minutes vs 417 minutes [ P Conclusions and Relevance Continuous assessment of quality metrics allows for safe implementation of RPD. We identified several inflexion points corresponding to optimization of performance metrics for RPD that can be used as benchmarks for surgeons who are adopting this technology.
270 citations
TL;DR: It is suggested that MIPD is a complex procedure for which comprehensive protocols outlining criteria for implementation might be warranted to optimize patient safety, and its use is associated with increased 30-day mortality.
Abstract: Objectives:To describe national practice patterns regarding utilization of minimally invasive pancreaticoduodenectomy (MIPD) and compare short-term outcomes with those following open pancreaticoduodenectomy for cancer.Background:There is increasing interest in use of MIPD; however, published data ar
199 citations
TL;DR: Postlearning curve RPD can be performed with similar perioperative outcomes achieved with open PD, and operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (<12 lymph nodes harvested).
Abstract: Objectives:Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD).Methods:Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011–
180 citations
TL;DR: At current level of evidence, LPD shows no advantage over OPD and further studies should focus on patient safety during LPD learning curves and the potential role of robotic surgery.
Abstract: Objective:To compare perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to open pancreaticoduodenectomy (OPD) using evidence from randomized controlled trials (RCTs).Background:LPD is used more commonly, but this surge is mostly based on observational data.Methods:We searched CENTR
177 citations
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TL;DR: The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4
Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature.
The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification.
Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.
23,435 citations
Additional excerpts
...Operative time (min) Mean ± SD 413 ± 164 527 ± 103 256 ± 93 394 ± 92 206 ± 67 503 ± 114 371 ± 62 441 ± 227 Conversion, n (%) 16 (6) 11 (8) 2 (2) 2 (15) 0 (0) 1 (20) 0 (0) 0 (0) Reoperation, n (%) 6 (2) 4 (3) 1 (1) 1 (8) 0 (0) 0 (0) 0 (0) 0 (0) LOS∗, d (range) 8 (3–87) 10 (4–87) 6 (4–12) 8 (6–19) 5 (3–12) 10 (7–18) 9 (6–14) 6 (5–9)...
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...7) 10 (12) 9 (69) 2 (20) 0 (0) 3 (75) 1 (33) Grade C 10 (4) 5 (3....
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...Grade III 34 (14) 13 (10) 11 (13) 3 (23) 3 (30) 1 (20) 2 (50) 1 (33)...
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...Grade II 85 (34) 40 (30) 35 (42) 5 (38) 1 (10) 1 (20) 0 (0) 1 (33)...
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TL;DR: In this article, an international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easy-to-apply definition of postoperative pancreatic fistula, graded primarily on clinical impact.
3,622 citations
01 Jan 2005
TL;DR: The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed.
Abstract: Background. Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences. Methods. An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easyto-apply definition of POPF, graded primarily on clinical impact. Results. A POPF represents a failure of healing/sealing of a pancreatic-enteric anastomosis or a parenchymal leak not directly related to an anastomosis. An all-inclusive definition is a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity. Three different grades of POPF (grades A, B, C) are defined according to the clinical impact on the patient’s hospital course. Conclusions. The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed. (Surgery 2005;138:8-13.)
3,617 citations
TL;DR: Patients who have cancers with favorable pathological features have a statistically significant improved long-term survival, and pathological factors having a significant impact on survival included tumor diameter, resection margin status, lymph node status, and histologic grade.
1,358 citations
Additional excerpts
...Grade II 85 (34) 40 (30) 35 (42) 5 (38) 1 (10) 1 (20) 0 (0) 1 (33)...
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...7) 10 (12) 9 (69) 2 (20) 0 (0) 3 (75) 1 (33) Grade C 10 (4) 5 (3....
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...Grade III 34 (14) 13 (10) 11 (13) 3 (23) 3 (30) 1 (20) 2 (50) 1 (33)...
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...Grade I 39 (15) 15 (11) 14 (17) 5 (38) 1 (10) 3 (60) 0 (0) 1 (33)...
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...Pancreatic leak, n (%) 76 (30) 22 (17) 36 (43) 12 (92) 3 (30) 0 (0) 3 (75) 1 (33)...
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TL;DR: Pancreaticoduodenectomy has become an effective operation for pancreatic cancer in those patients in whom their tumor is margin negative and node negative, and Operative time, blood loss, and length of stay have dropped substantially.
Abstract: The first successful local resection of a periampullary tumor was performed by Dr. William Stewart Halsted in 1898.1 The patient was a 58-year-old woman with obstructive jaundice. Halsted resected a segment of the second portion of the duodenum, including the tumor, and anastomosed the duodenum end to end. He then reimplanted the bile and pancreatic ducts. The first successful regional resection for a periampullary tumor was performed by the German surgeon from Berlin, Kausch, in 1909, and reported in 1912.2 The regional operative procedure for periampullary tumors was popularized by Whipple in a paper published in 1935.3 In this paper, 3 patients were reported who underwent regional resection performed in 2 stages. Two of the 3 patients survived. Between 1912 and Whipple’s report in 1935, a small number of patients in Europe underwent a regional resection of a periampullary tumor successfully. Following Whipple’s report, the operative procedure became widely known but was still infrequently performed. By the end of Whipple’s career, he had only performed 37 such procedures.4
During the 1960s and 1970s, few pancreaticoduodenectomies were performed because of a hospital mortality in the range of 25%. However, during the 1980s and 1990s, experience performing pancreaticoduodenectomy increased, and large volume “centers of excellence” developed. These high-volume centers acquired a substantial experience, and mortality decreased to below 5%.5–8 In recent years at the Johns Hopkins Hospital, more than 200 pancreaticoduodenectomies have been performed annually. This has allowed individual surgeons to develop significant experiences. Between 1969 and 2003, 1000 consecutive pancreaticoduodenectomies were performed by a single surgeon (J.L.C.) at the Johns Hopkins Hospital. This report reviews that experience and documents the changes that have occurred with this operative procedure over 5 decades.
1,153 citations