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Life (Basel, Switzerland) Jun 2023Pancreatectomy, including pancreaticoduodenectomy (PD), as well as central pancreatectomy (CP), distal pancreatectomy (DP) and total/subtotal pancreatectomy, is a major,...
Pancreatectomy, including pancreaticoduodenectomy (PD), as well as central pancreatectomy (CP), distal pancreatectomy (DP) and total/subtotal pancreatectomy, is a major, complex and difficult surgical procedure performed for various benign and malignant pancreatic diseases: from chronic pancreatitis, through benign cystic tumors and neuroendocrine neoplasms to malignant neoplasms, including pancreatic ductal adenocarcinoma (PDAC) [...].
PubMed: 37374182
DOI: 10.3390/life13061400 -
Cancers Sep 2023Parenchymal-sparing approaches to pancreatectomy are technically challenging procedures but allow for preserving a normal pancreas and decreasing the rate of... (Review)
Review
BACKGROUND
Parenchymal-sparing approaches to pancreatectomy are technically challenging procedures but allow for preserving a normal pancreas and decreasing the rate of postoperative pancreatic insufficiency. The robotic platform is increasingly being used for these procedures. We sought to evaluate robotic parenchymal-sparing pancreatectomy and assess its complication profile and efficacy.
METHODS
This systematic review consisted of all studies on robotic parenchymal-sparing pancreatectomy (central pancreatectomy, duodenum-preserving partial pancreatic head resection, enucleation, and uncinate resection) published between January 2001 and December 2022 in PubMed and Embase.
RESULTS
A total of 23 studies were included in this review ( = 788). Robotic parenchymal-sparing pancreatectomy is being performed worldwide for benign or indolent pancreatic lesions. When compared to the open approach, robotic parenchymal-sparing pancreatectomies led to a longer average operative time, shorter length of stay, and higher estimated intraoperative blood loss. Postoperative pancreatic fistula is common, but severe complications requiring intervention are exceedingly rare. Long-term complications such as endocrine and exocrine insufficiency are nearly nonexistent.
CONCLUSIONS
Robotic parenchymal-sparing pancreatectomy appears to have a higher risk of postoperative pancreatic fistula but is rarely associated with severe or long-term complications. Careful patient selection is required to maximize benefits and minimize morbidity.
PubMed: 37686648
DOI: 10.3390/cancers15174369 -
International Journal of Surgery... Jul 2023The aim of this study was to perform a systematic review and meta-analysis on the safety and effectiveness regarding outcomes of minimally invasive total pancreatectomy... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of this study was to perform a systematic review and meta-analysis on the safety and effectiveness regarding outcomes of minimally invasive total pancreatectomy (MITP) versus open total pancreatectomy (OTP).
BACKGROUND
Total pancreatectomy is a complicated operation in abdominal surgery. The flexibility of minimally invasive surgery offers a new surgical approach to this technology. At present, there is little research on MITP, and its advantages over OTP remain uncertain.
METHODS
A systematic literature review and meta-analysis was conducted basing on comparative studies between MITP and OTP from January 1943 to November 2022. Intraoperative outcomes and postoperative outcomes were assessed. Pooled odds ratios (ORs) and mean differences with a 95% CI were calculated using fixed-effect or random-effect models under heterogeneity.
RESULTS
Seven studies with a total of 4275 patients were included. The major morbidity in the MITP group was significant lower (OR 0.50, 95% CI: 0.30-0.84, P=0.008, I²= 0%) than OTP group. At the same time, comparing with OTP, the MITP group had lower estimated blood loss (MD -362.50, 95% CI -641.34 to -83.66, P=0.01, I²=96%) and lower intraoperative transfusion rate (OR 0.36, 95% CI 0.16-0.84, P=0.02, I²=0%). There were no significant differences between the MITP and OTP groups for other outcomes.
CONCLUSIONS
The results suggested that MITP was associated with lower major morbidity, estimated blood loss, and intraoperative transfusion rate comparing with OTP. However, the further evidence with a better design is required.
Topics: Humans; Pancreatectomy; Blood Loss, Surgical; Minimally Invasive Surgical Procedures; Length of Stay; Blood Transfusion; Postoperative Complications
PubMed: 37485920
DOI: 10.1097/JS9.0000000000000392 -
Annals of Surgery Oct 2023Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula... (Meta-Analysis)
Meta-Analysis
Systematic Review and Meta-analysis of the Role of Total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula: Is it a Justifiable Indication?
OBJECTIVE
Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula (POPF).
SUMMARY BACKGROUND DATA
TP is mentioned as an alternative to PD in patients at high risk for POPF, but a systematic review is lacking.
METHODS
Systematic review and meta-analyses using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published up to October 2022, comparing elective single-stage TP for any indication versus PD in patients at high risk for POPF. The primary endpoint was short-term mortality. Secondary endpoints were major morbidity (i.e., Clavien-Dindo grade ≥IIIa) on the short-term and quality of life.
RESULTS
After screening 1212 unique records, five studies with 707 patients (334 TP and 373 high-risk PD) met the eligibility criteria, comprising one randomized controlled trial and four observational studies. The 90-day mortality after TP and PD did not differ (6.3% vs. 6.2%; RR=1.04 [95%CI 0.56-1.93]). Major morbidity rate was lower after TP compared to PD (26.7% vs. 38.3%; RR=0.65 [95%CI 0.48-0.89]), but no significance was seen in matched/randomized studies (29.0% vs. 36.9%; RR = 0.73 [95%CI 0.48-1.10]). Two studies investigated quality of life (EORTC QLQ-C30) at a median of 30-52 months, demonstrating comparable global health status after TP and PD (77% [±15] vs. 76% [±20]; P =0.857).
CONCLUSIONS
This systematic review and meta-analysis found no reduction in short-term mortality and major morbidity after TP as compared to PD in patients at high risk for POPF. However, if TP is used as a bail-out procedure, the comparable long-term quality of life is reassuring.
Topics: Humans; Pancreatectomy; Pancreaticoduodenectomy; Pancreatic Fistula; Quality of Life; Pancreas; Postoperative Complications
PubMed: 37161977
DOI: 10.1097/SLA.0000000000005895 -
Islets Dec 2023Patients with chronic pancreatitis (CP) often have severe and intractable abdominal pain, leading to decreased quality of life (QOL), inability to work or attend school,...
BACKGROUND
Patients with chronic pancreatitis (CP) often have severe and intractable abdominal pain, leading to decreased quality of life (QOL), inability to work or attend school, and increased health care costs due to repeated emergency room visits and hospitalizations.
METHODS
We evaluated the efficacy of total pancreatectomy and islet autotransplantation (TPIAT) in terms of pain control and QOL in CP patients treated at our center in Japan. To evaluate QOL, we used the Short-Form 36 Health Survey version 2 (SF-36v2 Standard, Japanese), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), and Quality of Life Questionnaire-Pancreatic Modification (QLQ-PAN28).
RESULTS
Between August 2016 and June 2019, we performed this procedure in 5 patients. All patients were followed up for 12 months and all transplanted islets were still functioning at the 1-year follow-up. The major adverse events were abdominal wall hemorrhage, intestinal obstruction, intra-abdominal abscess, and abdominal pain requiring hospitalization; no case had sequelae. No major complications were due to islet transplantation. Pain scores improved postoperatively in all patients. Three QOL item dimensions role-physical ( = 0.03125), general health perception ( = 0.03125) and vitality ( = 0.03125) in the SF-36 were significantly improved 12 months after TPIAT. Mean values of many other QOL items improved, though not significantly.
CONCLUSION
The QOL improvement after TPIAT for CP suggests its effectiveness in the Japanese population.
Topics: Humans; Pancreatectomy; Transplantation, Autologous; Quality of Life; Japan; Treatment Outcome; Pancreatitis, Chronic; Islets of Langerhans Transplantation; Abdominal Pain
PubMed: 37087752
DOI: 10.1080/19382014.2023.2202092 -
Hepatobiliary Surgery and Nutrition Aug 2023
PubMed: 37600989
DOI: 10.21037/hbsn-23-193 -
Surgical Endoscopy Jun 2023Robot-assisted distal pancreatectomy (RDP) has been suggested to hold some benefits over laparoscopic distal pancreatectomy (LDP) but consensus and data on specific... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Robot-assisted distal pancreatectomy (RDP) has been suggested to hold some benefits over laparoscopic distal pancreatectomy (LDP) but consensus and data on specific subgroups are lacking. This systematic review and meta-analysis reports the surgical and oncological outcome and costs between RDP and LDP including subgroups with intended spleen preservation and pancreatic ductal adenocarcinoma (PDAC).
METHODS
Studies comparing RDP and LDP were included from PubMed, Cochrane Central Register, and Embase (inception-July 2022). Primary outcomes were conversion and unplanned splenectomy. Secondary outcomes were R0 resection, lymph node yield, major morbidity, operative time, intraoperative blood loss, in-hospital mortality, operative costs, total costs and hospital stay.
RESULTS
Overall, 43 studies with 6757 patients were included, 2514 after RDP and 4243 after LDP. RDP was associated with a longer operative time (MD = 18.21, 95% CI 2.18-34.24), less blood loss (MD = 54.50, 95% CI - 84.49-24.50), and a lower conversion rate (OR = 0.44, 95% CI 0.36-0.55) compared to LDP. In spleen-preserving procedures, RDP was associated with more Kimura procedures (OR = 2.23, 95% CI 1.37-3.64) and a lower rate of unplanned splenectomies (OR = 0.32, 95% CI 0.24-0.42). In patients with PDAC, RDP was associated with a higher lymph node yield (MD = 3.95, 95% CI 1.67-6.23), but showed no difference in the rate of R0 resection (OR = 0.96, 95% CI 0.67-1.37). RDP was associated with higher total (MD = 3009.31, 95% CI 1776.37-4242.24) and operative costs (MD = 3390.40, 95% CI 1981.79-4799.00).
CONCLUSIONS
RDP was associated with a lower conversion rate, a higher spleen preservation rate and, in patients with PDAC, a higher lymph node yield and similar R0 resection rate, as compared to LDP. The potential benefits of RDP need to be weighed against the higher total and operative costs in future randomized trials.
Topics: Humans; Robotics; Robotic Surgical Procedures; Pancreatectomy; Treatment Outcome; Pancreatic Neoplasms; Carcinoma, Pancreatic Ductal; Laparoscopy; Operative Time; Length of Stay; Retrospective Studies
PubMed: 36781467
DOI: 10.1007/s00464-023-09894-y -
Asian Journal of Surgery Oct 2023Patients with locally advanced pancreatic body/tail tumors, gastric cancer, or colon cancer often have contiguous organ involvement requiring extensive pancreatic...
PURPOSE
Patients with locally advanced pancreatic body/tail tumors, gastric cancer, or colon cancer often have contiguous organ involvement requiring extensive pancreatic resection. This study was performed to compare surgical complications and the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between distal pancreatectomy (DP) with extended organ resection and standard DP.
METHODS
In total, 128 patients who underwent DP from January 2012 to January 2021 were retrospectively reviewed. Extended DP was defined according to the International Study Group of Pancreatic Surgery definition.
RESULTS
Of the 128 patients, 62 (48.4%) underwent extended DP and 66 (51.6%) underwent DP. Blood loss was greater (p < 0.001), the incidence of major complications was higher (p = 0.032), and the hospital stay was longer (p = 0.002) in the extended DP group than in the DP group. There were no differences in the incidence of CR-POPF, the readmission rate, or the need for postoperative intervention drainage. Univariate and multivariate analyses showed that extended DP was not a risk factor for CR-POPF or major complications.
CONCLUSION
Extended DP can be performed with comparable CR-POPF occurrence and mortality but increased morbidity when compared with standard DP.
Topics: Humans; Pancreatectomy; Retrospective Studies; Pancreas; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications; Risk Factors
PubMed: 36575100
DOI: 10.1016/j.asjsur.2022.12.044 -
The British Journal of Surgery May 2024Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of...
BACKGROUND
Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of individual hospitals using national averages. This study aimed to evaluate the use of quality indicators for benchmarking hepato-pancreato-biliary (HPB) surgery and when outlier hospitals could be identified.
METHODS
A population-based study used data from two nationwide Dutch HPB audits (DHBA and DPCA) from 2014 to 2021. Sample size calculations determined the threshold (in percentage points) to identify centres as statistical outliers, based on current volume requirements (annual minimum of 20 resections) on a two-year period (2020-2021), covering mortality rate, failure to rescue (FTR), major morbidity rate and textbook/ideal outcome (TO) for minor liver resection (LR), major LR, pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).
RESULTS
In total, 10 963 and 7365 patients who underwent liver and pancreatic resection respectively were included. Benchmark and corresponding range of mortality rates were 0.6% (0 -3.2%) and 3.3% (0-16.7%) for minor and major LR, and 2.7% (0-7.0%) and 0.6% (0-4.2%) for PD and DP respectively. FTR rates were 5.4% (0-33.3%), 14.2% (0-100%), 7.5% (1.6%-28.5%) and 3.1% (0-14.9%). For major morbidity rate, corresponding rates were 9.8% (0-20.5%), 28.1% (0-47.1%), 36% (15.8%-58.3%) and 22.3% (5.2%-46.1%). For TO, corresponding rates were 73.6% (61.3%-94.4%), 54.1% (35.3-100), 46.8% (25.3%-59.4%) and 63.3% (30.7%-84.6%). Mortality rate thresholds indicating a significant outlier were 8.6% and 15.4% for minor and major LR and 14.2% and 8.6% for PD and DP. For FTR, these thresholds were 17.9%, 31.6%, 22.9% and 15.0%. For major morbidity rate, these thresholds were 26.1%, 49.7%, 57.9% and 52.9% respectively. For TO, lower thresholds were 52.5%, 32.5%, 25.8% and 41.4% respectively. Higher hospital volumes decrease thresholds to detect outliers.
CONCLUSION
Current event rates and minimum volume requirements per hospital are too low to detect any meaningful between hospital differences in mortality rate and FTR. Major morbidity rate and TO are better candidates to use for benchmarking.
Topics: Humans; Benchmarking; Quality Indicators, Health Care; Netherlands; Pancreatectomy; Male; Pancreaticoduodenectomy; Hepatectomy; Female; Middle Aged; Aged; Hospital Mortality
PubMed: 38747683
DOI: 10.1093/bjs/znae119 -
Scandinavian Journal of Surgery : SJS :... Dec 2023Chronic pancreatitis may cause intractable abdominal pain, with total pancreatectomy sometimes being the last resort. To mitigate the subsequent diabetes, total...
BACKGROUND AND AIMS
Chronic pancreatitis may cause intractable abdominal pain, with total pancreatectomy sometimes being the last resort. To mitigate the subsequent diabetes, total pancreatectomy can be followed by islet autotransplantation (TP-IAT). The primary aim of this study was to assess the outcomes in patients undergoing TP-IAT at Karolinska University Hospital with respect to safety, postoperative complications, and islet graft function. A secondary aim was to compare liver to skeletal muscle as autotransplantation sites.
METHODS
Single-center observational cohort study on patients undergoing TP-IAT. Islets were transplanted either into the liver or skeletal muscle. Data on baseline characteristics and pretransplantory conditions were collected. Outcome measures included mortality and major postoperative complications as well as the glycemic measures: insulin use, fasting C-peptide, and HbA1c.
RESULTS
Between 2004 and 2020, 24 patients underwent TP-IAT. Islets were transplanted into the liver in 9 patients and into skeletal muscle in 15 patients. There was no 90-day mortality, and major complications (Clavien-Dindo ⩾IIIa) occurred in 26.7%, all related to the procedure of total pancreatectomy. Fasting C-peptide could be detected postoperatively, with higher levels in patients receiving islet autotransplantation into the liver (p = 0.006). Insulin independence was not achieved, although insulin doses at last follow-up were significantly lower in patients receiving islet autotransplantation into the liver compared to skeletal muscle (p = 0.036).
CONCLUSION
TP-IAT is safe and associated with tolerable risk, the component of islet autotransplantation being seemingly harmless. Although islet grafts maintain some endocrine function, insulin independence should not be expected. Regarding islet autotransplantation sites, the liver seems superior to skeletal muscle.
CLINICAL TRIAL REGISTRATION
Not applicable.
PubMed: 38145318
DOI: 10.1177/14574969231220176