A Combination of Robotic Approach and ERAS Pathway Optimizes Outcomes and Cost for Pancreatoduodenectomy

Kowalsky, Stacy J.; Zenati, Mazen S.; Steve, Jennifer; Esper, Stephen A.; Lee, Kenneth K.; Hogg, Melissa E.; Zeh, Herbert J.; Zureikat, Amer H.

doi:10.1097/sla.0000000000002707

Cited by 70 publications

(54 citation statements)

References 56 publications

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“…This network analysis showed statistically significant longer operative time for LapPD and RobPD, might be due to the learning curve and docking of the robot. Few articles reported the analysis of costs with a trend towards greater cost in minimally invasive techniques, mainly RobPD, probably due to the maintenance of instrument and equipment costs [77]. However, the reduced postoperative complications, hospital length of stay, and hospital readmissions may suggest a presumed ultimate cost-effectiveness [78].…”

Section: Discussionmentioning

confidence: 99%

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

et al. 2020

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The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.

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Section: Discussionmentioning

confidence: 99%

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

et al. 2020

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“…The medicoeconomic impact of ERAS for rectal surgery is difficult to demonstrate. However, recent publications have underlined the cost benefit of enhanced recovery after hepatectomy or pancreatectomy. For colorectal surgery, a systematic review underlined the poor quality data currently available, but showed that ERAS was less costly and more effective than proctectomy alone.…”

Section: Discussionmentioning

confidence: 99%

Combined robotic approach and enhanced recovery after surgery pathway for optimization of costs in patients undergoing proctectomy

et al. 2020

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Background: Enhanced recovery after surgery (ERAS) pathways are beneficial in proctocolectomy, but their impact on robotic low rectal proctectomy is not fully investigated. This study assessed the impact of an ERAS pathway on the outcomes and cost of robotic (RTME) versus laparoscopic (LTME) total mesorectal excision.Methods: A retrospective review was performed of patients with rectal cancer in a single French tertiary centre for three yearly periods: 2011, LTME; 2015, RTME; and 2018, RTME with ERAS. Patient characteristics, operative and postoperative data, and costs were compared among the groups.Results: A total of 220 consecutive proctectomies were analysed (71 LTME, 58 RTME and 91 RTME with ERAS). A prevalence of lower and locally advanced tumours was observed with RTME. The median duration of surgery increased with the introduction of RTME, but became shorter than that for LTME with greater robotic experience (226, 233 and 180 min for 2011, 2015 and 2018 respectively; P < 0⋅001). The median duration of hospital stay decreased significantly for RTME with ERAS (11, 10 and 8 days respectively; P = 0⋅011), as did the overall morbidity rate (39, 38 and 16 per cent; P = 0⋅002). Pathology results, conversion and defunctioning stoma rates remained stable. RTME alone increased the total cost by €2348 compared with LTME. The introduction of ERAS and improved robotic experience decreased costs by €1960, compared with RTME performed in 2015 without ERAS implementation. In patients with no co-morbidity, costs decreased by €596 for RTME with ERAS versus LTME alone. Conclusion: ERAS is associated with cost reductions in patients undergoing robotic proctectomy.

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“…The length of hospital stay is controversial and reported to be significantly shorter in RPD than in OPD and even laparoscopic PD (LPD), whereas other studies reported equal times between RPD and OPD [16,20,31,58,59,62,63].…”

Section: Robotic Pancreatoduodenectomymentioning

confidence: 99%

Minimally invasive pancreatic surgery—will robotic surgery be the future?

et al. 2021

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SummaryDue to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.

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A Combination of Robotic Approach and ERAS Pathway Optimizes Outcomes and Cost for Pancreatoduodenectomy

Abstract: ERAS implementation is independently associated with cost savings for pancreatoduodenectomy. A combination of ERAS and robotic approach synergistically decreases hospital stay and overall cost compared with other strategies.

Cited by 70 publications

References 56 publications

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

Combined robotic approach and enhanced recovery after surgery pathway for optimization of costs in patients undergoing proctectomy

Minimally invasive pancreatic surgery—will robotic surgery be the future?

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