Andrew A Gumbs1, Elie Chouillard1, Mohamed Abu Hilal2, Roland Croner3, Brice Gayet4, Michel Gagner5,6. 1. Département de Chirurgie Digestive, Centre Hospitalier Intercommunal de POISSY/SAINT-GERMAIN-EN-LAYE, 10, Rue du Champ Gaillard, 78300, Poissy, France. 2. Unità Chirurgia Epatobiliopancreatica, Robotica e Mininvasiva, Fondazione Poliambulanza Istituto Ospedaliero, via Bissolati, 57, Brescia, 25124, Italia. 3. Department of General-, Visceral-, Vascular- and Transplantation Surgery, University of Magdeburg, Haus 60a, Leipziger Str. 44, 39120, Magdeburg, Germany. 4. Department of Digestive Diseases, Institut Mutaliste Montsouris, 42, Boulevard Jourdan, 75014, Paris, France. 5. Clinique Michel Ganger, Inc, 1 Carré Westmount Suite 801, Westmount, QC, H3Z 2P9, Canada. gagner.michel@gmail.com. 6. Department of Surgery, Hôpital du Sacre Coeur, Montréal, QC, H4J 1C5, Canada. gagner.michel@gmail.com.
Abstract
BACKGROUND: Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques. METHOD: We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery. RESULTS: From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03). CONCLUSION: FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.
BACKGROUND: Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques. METHOD: We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery. RESULTS: From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03). CONCLUSION: FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.
Authors: Ignasi Poves; Fernando Burdío; Olga Morató; Mar Iglesias; Aleksander Radosevic; Lucas Ilzarbe; Laura Visa; Luís Grande Journal: Ann Surg Date: 2018-11 Impact factor: 12.969
Authors: Jony van Hilst; Thijs de Rooij; Koop Bosscha; David J Brinkman; Susan van Dieren; Marcel G Dijkgraaf; Michael F Gerhards; Ignace H de Hingh; Tom M Karsten; Daniel J Lips; Misha D Luyer; Olivier R Busch; Sebastiaan Festen; Marc G Besselink Journal: Lancet Gastroenterol Hepatol Date: 2019-01-24
Authors: C Palanivelu; P Senthilnathan; S C Sabnis; N S Babu; S Srivatsan Gurumurthy; N Anand Vijai; V P Nalankilli; P Praveen Raj; R Parthasarathy; S Rajapandian Journal: Br J Surg Date: 2017-10 Impact factor: 6.939
Authors: Thijs de Rooij; Jony van Hilst; Hjalmar van Santvoort; Djamila Boerma; Peter van den Boezem; Freek Daams; Ronald van Dam; Cees Dejong; Eino van Duyn; Marcel Dijkgraaf; Casper van Eijck; Sebastiaan Festen; Michael Gerhards; Bas Groot Koerkamp; Ignace de Hingh; Geert Kazemier; Joost Klaase; Ruben de Kleine; Cornelis van Laarhoven; Misha Luyer; Gijs Patijn; Pascal Steenvoorde; Mustafa Suker; Moh'd Abu Hilal; Olivier Busch; Marc Besselink Journal: Ann Surg Date: 2019-01 Impact factor: 12.969
Authors: J van Hilst; E A Strating; T de Rooij; F Daams; S Festen; B Groot Koerkamp; J M Klaase; M Luyer; M G Dijkgraaf; M G Besselink Journal: Br J Surg Date: 2019-04-23 Impact factor: 6.939