Identifying key outcome metrics in pancreatic surgery, and how to optimally achieve them

Background: Pancreaticoduodenectomy is the only possible choice of treatment for peri-ampoullar neoplasms. Morbidity in pancreatic surgery is mainly related to the development of a postoperative pancreatic fistula (POPF). According to International Study Group on Pancreatic Fistula it is possible to grade POPF based on clinical variables. Three main different surgical strategies have been proposed to deal with the pancreatic stump following pancreaticoduodenectomy: pancreatojejunostomy, pancreatogastrostomy and pancreatic duct occlusion, but none of them has been clearly demonstrated to be superior to the others. The aim of our study is to evaluate the feasibility of duct occlusion and its correlations with postoperative pancreatic fistula, “brittle diabetes” and overall survival in a low volume centre. We decided to review our previous experience in the light of the recent Covid pandemic where, in our country, it has been forced in many regions to displace treatment of oncological patients in low volume hospitals with limited experienceMethods: We retrospectively reviewed 56 consecutive patients, from a prospective maintained database, who underwent Whipple’s procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit with a low volume of pancreatic resections. The mean follow-up was 24.5 months. Results: The overall incidence of postoperative pancreatic fistula was 66.6%: 15 patients had a Grade A (31.25%), 13 a Grade B fistula (27.03%), and 4 (8.3%) suffered from a life-threatening Grade C fistula. At the last follow-up, 24 of the 28 patients who were alive (85.6%) habitually used substitutive pancreatic enzyme. Conclusion: Duct occlusion can be a safe alternative to pancreatic anastomosis especially in low volume centres and for those patients (age >75 years, obese, hard pancreatic texture, small pancreatic duct) at higher risk of clinically relevant POPF.Trial registration: 'retrospectively registered'

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“…Evidences support a strong correlation between surgical outcomes and hospital volume in pancreatic surgery [23][24][25][26].…”

Section: Discussionmentioning

confidence: 99%

Pancreatic Duct Occlusion: A Safe and Valid Alternative to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre

Giuliani

Rocca

Segreto³

et al. 2020

Preprint

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“…One of the most common postoperative complications of pancreas surgery is a pancreatic fistula. A reduction in the incidence of postoperative fistulas is a major factor to improve overall morbidity associated with pancreas surgery [56]. McMillan and colleagues conducted a noninferiority study comparing robotic PD to open PD to determine the rate of clinically relevant pancreatic fistula occurrence [57].…”

Section: Robotic Surgery Of the Pancreasmentioning

confidence: 99%

Robotic and laparoscopic surgery of the pancreas: an historical review

Lefor

2019

BMC biomed eng

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Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas including distal pancreatectomy and pancreatoduodenectomy. The progression from open surgery to laparoscopy to robotic surgery has occurred for many operations including adrenalectomy, thyroidectomy, colon resection, prostatectomy, gastrectomy and others. Data to show a benefit to the patient are scarce for robotic surgery, although both laparoscopic and robotic surgery of the pancreas have been shown not to be inferior with regard to major operative and oncologic outcomes. While there were serious concerns when laparoscopy was first used in patients with malignancies, robotic surgery has been used in many benign and malignant conditions with no obvious deterioration of outcomes. Robotic surgery for malignancies of the pancreas is well accepted and expanding to more centers. The importance of centers of excellence, surgeon experience supported by a codified mastery-based training program and international registries is widely accepted. Robotic pancreatic surgery is associated with slightly decreased blood loss and decreased length of stay compared to open surgery. Major oncologic outcomes appear to have been preserved, with some studies showing higher rates of R0 resection and tumor-free margins. Patients with lesions of the pancreas should find a surgeon they trust and do not need to be concerned with the operative approach used for their resection. The step-wise approach that has characterized the growth in robotic surgery of the pancreas, in contradistinction to the frenzy that accompanied the introduction of laparoscopic cholecystectomy, has allowed the identification of areas for improvement, many of which lie at the junction of engineering and medical practice. Refinements in robotic surgery depend on a partnership between engineers and clinicians.

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“…In conclusion, although the outcomes both for minimally invasive and open pancreatic surgery are dependent on the technical skills of the single surgeon, the optimal clinical environment and a dedicated pancreatic team plays a greater role in managing patient selection, safe surgery, and overcoming postoperative complications [68]. To facilitate further development of MIPS, it has to integrate effectively with the outcome-improving effect of a dedicated pancreatic team.…”

Section: Future Perspectivesmentioning

confidence: 99%

Minimally invasive pancreatic surgery—where are we going?

et al. 2019

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Background Introduced in the mid-1990s, minimally invasive pancreatic surgery (MIPS) developed slowly over the next two decades, and its real-life benefits remained unclear. Methods In this review, the current status and evidence on the most common types of MIPS, such as minimally invasive pancreatoduodenectomy (MIPD), distal pancreatectomy, enucleation, and central pancreatectomy are presented. Results Minimally invasive distal pancreatectomy (MIDP) is the most frequently used procedure among

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Identifying key outcome metrics in pancreatic surgery, and how to optimally achieve them

Abstract: Only by integrating MIPR with the outcome-improving effect of a dedicated pancreatic team will it be possible to assess more precisely the putative benefits of this minimally-invasive approach.

Cited by 22 publications

References 26 publications

Pancreatic Duct Occlusion: A Safe and Valid Alternative to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre

Pancreatic Duct Occlusion: A Safe and Valid Alternative to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre

Robotic and laparoscopic surgery of the pancreas: an historical review

Minimally invasive pancreatic surgery—where are we going?

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Identifying key outcome metrics in pancreatic surgery, and how to optimally achieve them

Abstract: Only by integrating MIPR with the outcome-improving effect of a dedicated pancreatic team will it be possible to assess more precisely the putative benefits of this minimally-invasive approach.

Cited by 22 publications

References 26 publications

Pancreatic Duct Occlusion: A Safe and Valid Alternative&nbsp;to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre

Pancreatic Duct Occlusion: A Safe and Valid Alternative&nbsp;to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre

Robotic and laparoscopic surgery of the pancreas: an historical review

Minimally invasive pancreatic surgery—where are we going?

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Product

Resources

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Pancreatic Duct Occlusion: A Safe and Valid Alternative to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre

Pancreatic Duct Occlusion: A Safe and Valid Alternative to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre