Optimal hepatic surgery: Are we making progress in North America?

Beane, Joal D.; Hyer, Madison; Mehta, Rittal; Onuma, Amblessed E.; Gleeson, Elizabeth M.; Thompson, Vanessa; Pawlik, Timothy M.; Pitt, Henry A.

doi:10.1016/j.surg.2021.06.028

Cited by 23 publications

(35 citation statements)

References 46 publications

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“…27 The aim of the current study is different considering that robotic DP is already performed routinely in many centers, and the "gold standard" is no longer the open but rather the minimally invasive approach including both laparoscopic and robotic approaches. 21 Therefore, we aimed to provide convincing reference values for robotic DP to enable conclusive comparisons with both open and laparoscopic DP, and higher risk groups.…”

Section: Discussionmentioning

confidence: 99%

“…[17][18][19][20] With this knowledge, robotic DP is nowadays implemented as the preferred approach in many centers. 21,22 The available information on robotic DP, however, suffers from inherent bias related to the retrospective nature of the analyses and comparisons, and the lack of high-level evidence high-level evidence studies. A major obstacle in designing a conclusive RCT in the future will rely on the lack of equipoise.…”

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confidence: 99%

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Robotic Distal Pancreatectomy

Müller¹,

Breuer²,

Nickel

et al. 2022

Annals of Surgery

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Background and Objective: Robotic distal pancreatectomy (DP) is an emerging attractive approach, but its role compared with laparoscopic or open surgery remains unclear. Benchmark values are novel and objective tools for such comparisons. The aim of this study was to identify benchmark cutoffs for many outcome parameters for DP with or without splenectomy beyond the learning curve. Methods: This study analyzed outcomes from international expert centers from patients undergoing robotic DP for malignant or benign lesions. After excluding the first 10 cases in each center to reduce the effect of the learning curve, consecutive patients were included from the start of robotic DP up to June 2020. Benchmark patients had no significant comorbidities. Benchmark cutoff values were derived from the 75th or the 25th percentile of the median values of all benchmark centers. Benchmark values were compared with a laparoscopic control group from 4 high-volume centers and published open DP landmark series. Results: Sixteen centers contributed 755 cases, whereof 345 benchmark patients (46%) were included the analysis. Benchmark cutoffs included: operation time ≤300 minutes, conversion rate ≤3%, clinically relevant postoperative pancreatic fistula ≤32%, 3 months major complication rate ≤26.7%, and lymph node retrieval ≥9. The comprehensive complication index at 3 months was ≤8.7 without deterioration thereafter. Compared with robotic DP, laparoscopy had significantly higher conversion rates (5×) and overall complications, while open DP was associated with more blood loss and longer hospital stay. Conclusion: This first benchmark study demonstrates that robotic DP provides superior postoperative outcomes compared with laparoscopic and open DP. Robotic DP may be expected to become the approach of choice in minimally invasive DP.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Robotic Distal Pancreatectomy

Müller¹,

Breuer²,

Nickel

et al. 2022

Annals of Surgery

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“…Length of stay ≤7 days was selected as the cutoff for optimal duration as described previously. 10 Achievement of negative resection margins has been consistently associated with decreased recurrence and improved survival and was therefore included in the definition of OOS. Inclusion of optimal lymph node harvest, defined as ≥12 lymph nodes retrieved during oncologic resection, was based upon current College of American Pathologists and eighth edition American Joint Committee on Cancer staging guidelines.…”

Section: Definitionsmentioning

confidence: 99%

A National Assessment of Optimal Oncologic Surgery for Distal Pancreatic Adenocarcinomas

Hrebinko

Tohme²,

Hoehn³

et al. 2021

Pancreas

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Objectives:The objective of this study was to create a composite measure, optimal oncologic surgery (OOS), for patients undergoing distal pancreatectomy for pancreatic adenocarcinoma and identify factors associated with OOS.Methods: Adult patients undergoing distal pancreatectomy were identified from the National Cancer Database between 2010 and 2016. Patients were stratified based on receipt of OOS. Criteria for OOS included 90-day survival, no 30-day readmission, length of stay ≤7 days, negative resection margins, ≥12 lymph nodes harvested, and receipt of chemotherapy. Multivariate logistic regression was performed to identify predictors of OOS. Survival curves and a Cox proportional hazards model were created to compare survival and identify risk factors for mortality.Results: Three thousand five hundred forty-six patients were identified.The rate of OOS was 22.3%. Diagnosis after 2012, treatment at an academic medical center, and a minimally invasive surgical approach (MIS) were associated with OOS. Survival was superior for patients undergoing OOS. Decreasing age at diagnosis, fewer comorbidities, surgery at an academic medical center, MIS, and lower pathologic stage were also associated with improved survival on multivariate analysis. Conclusions:Rates of OOS for distal pancreatectomy are low. Time trends show increasing rates of OOS that may be related to increasing MIS, adjuvant chemotherapy, and referrals to academic medical centers.

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“…This is of particular importance because perioperative complications negatively affect quality of life, limit receipt of adjuvant therapeutics, and have been associated with reduced overall survival . The most common sources of severe perioperative morbidity are surgical site infection (SSI) and postoperative pancreatic fistula, which, combined, occur in more than 30% of patients …”

Section: Introductionmentioning

confidence: 99%

Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy

D’Angelica

Ellis

Liu

et al. 2023

JAMA

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ImportanceDespite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood.ObjectiveTo define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics.Design, Setting, and ParticipantsPragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment.InterventionThe intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care).Main Outcomes and MeasuresThe primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program.ResultsThe trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, −13.0% [95% CI, −19.1% to −6.9%]; P &lt; .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, −3.3% [95% CI, −6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, −6.3% [95% CI, −11.4% to −1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, −1.2% [95% CI, −3.1% to 0.7%]; P = .32).Conclusions and RelevanceIn participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy.Trial RegistrationClinicalTrials.gov Identifier: NCT03269994

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Optimal hepatic surgery: Are we making progress in North America?

Cited by 23 publications

References 46 publications

Robotic Distal Pancreatectomy

Robotic Distal Pancreatectomy

A National Assessment of Optimal Oncologic Surgery for Distal Pancreatic Adenocarcinomas

Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy

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