Pancreaticoduodenectomy: minimizing the learning curve

Abstract

Background: Pancreaticoduodenectomy outcomes improve as surgeon experience increases. We analyzed the outcomes of pancreaticoduodenectomy for any improvements over time to assess the learning curve.Methods: A retrospective study of patients undergoing consecutive pancreaticoduodenectomy by a single surgeon at the beginning of practice was performed. Operative factors and 90-day outcomes were examined and trends over the course of the 4-year time period were analyzed.Results: Between July 2011 and June 2015, 124 patients underwent pancreaticoduodenectomy (including total pancreatectomy, n=17) by open (n=93) or a laparoscopic (n=31) approach. The median operative time was 305 minutes which significantly improved over time. The median blood loss and length of stay were 250 mL and 6 days respectively which did not change over time. The pancreatic fistula rate, total morbidity, major morbidity, and mortality, and readmission rate was 7.5%, 41.1%, 14.5%, 1.6%, and 15.3% respectively and did not change over time. Pancreaticoduodenectomy was performed most commonly for pancreatic adenocarcinoma (51.6%) with a negative margin rate of 91.1% which significantly improved over time. Conclusions:The performance of pancreaticoduodenectomy improves as surgical experience is gained.However, a learning curve that impacts patient outcomes can be considerably diminished by appropriate training, high-volume practice/institution, proficient mentorship and experienced multidisciplinary team.

Total laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy (TJDBPS01): study protocol for a multicentre, randomised controlled clinical trial

“…Randomisation will be performed in a 1:1 allocation. The patients will be randomised into two groups:1 patients who will undergo TLPD and2 patients who will undergo OPD. This study is structured after the Standard Protocol Item Recommendations for Interventional Trials (SPIRIT) 2013 guideline defining standard protocol items for clinical trials (figure 1).…”

“…Inclusion criteria include1 age between 18 and 75 years;2 histologically proven periampullary cancer, including pancreatic cancer, bile duct cancer and duodenal cancer;3 cStage I pancreatic cancer;4 an indication for elective PD surgery;5 feasibility for both TLPD and OPD (the subject can also undergo surgery according to the MDT);6 patients understand the nature of this trial and are willing to comply;7 patients are able to provide written informed consent and8 patients are treated with curative intent in accordance with international guidelines 17…”

“…Exclusion factors include1 distant metastases including peritoneal carcinomatosis, liver metastases, distant lymph node metastases and involvement of other organs;2 patients may undergo left, central or total pancreatectomy or palliative surgery other than PD;3 patients with high operative risk, as defined by the American Society of Anesthesiologists (ASA), with a score ≥4;4 synchronous malignancy in other organs or second cancer requiring resection during the same procedure;5 pregnancy; or6 patients underwent or needed neo-adjuvant therapy including medication or radiotherapy.…”

“…Amylase determination of the drains is measured on the third postoperative day (POD) or when a fistula is suspected following the International Study Group on Pancreatic Fistula (ISGPF) criteria. Patients are willing to be discharged home when reached criteria as follow:1 do not need any intravenous infusion,2 can orally take solid or semisolid food,3 do not need analgesics or fully comfort by orally analgesics,4 incision fully recovered without infection,5 could get off bed without assistance,6 walking at least 250 m in plain road,7 major organ functioning well and nearly normal haematological parameters. The surgeons operating are not involved in the postoperative management hence cannot influence the discharge of the patients.…”

“…Pancreaticoduodenectomy (PD) is one of the most complex abdominal operations to perform, involving removal of the head of the pancreas, the duodenum and the common bile duct, and it is usually performed for the treatment of pancreatic cancer and the relief pain in chronic pancreatitis 1 2. Introduced by Gagner and Pomp, who performed the first total laparoscopic PD (TLPD) procedures in 1994, the use of laparoscopy in pancreas surgery has continued to grow rapidly because of its potential technical advantages, such as the precision of movements achieved using laparoscopic instruments and a three-dimensional view provided by the unique vision system 3.…”