Is There a Role for Laparoscopic and/or Robotic Techniques for Borderline Resectable Tumors?

 

N

Malignancy (%)

Operative time (min)

EBL (mL)

LOS (days)

Overall morbidity (%)

30-day mortality (%)

R0 resection (%)

Lymph node harvest (mean)

Author

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

DiNorcia [18]

71

192

13

39

250

270

150

900

5

6

28

44

0

1

97

87

6

8

Jayaraman [20]

100

100

17

47

195

160

175

300

5

6

26

33

0

0

97

98

6

5

Kim [21]

93

35

0

0

195

190

NR

NR

10

16

25

29

NR

NR

NR

NR

NR

NR

Vijan [26]

100

100

23

23

214

208

171

519

6

9

34

29

3

1

NR

NR

NR

NR

Kooby [27]

142

200

38

42

230

216

357

588

6

9

40

57

0

1

92

93

NR

NR

Kooby [29]

23

70

100

100

238

216

422

751

7

9

NR

NR

0

2

74

66

14

12


Lap laparoscopic, NR not reported

Bold p < 0.05



In contrast to DP, MI approaches for PD have been slow to develop despite being first reported nearly two decades ago [3032]. The past 5 years, however, have witnessed renewed interest in MI PD, fueled by reports of feasibility and the prospect of reducing the substantial morbidity (up to 50 %) associated with OPD [33, 34]. Croome et al. recently published the largest comparative series between LPD and open PD (OPD) for patients with PDA [35]. Over a 5-year period, a total of 108 patients underwent LPD and 214 underwent OPD. The authors found that LPD was associated with a lower EBL (492 vs. 867 mL; p < 0.001), lower rates of delayed gastric emptying (11 % vs. 26 %; p = 0.03), and a shorter LOS (6 vs. 9 days; p < 0.001), with no difference in R0 resection rates, overall complication rates, or postoperative pancreatic fistulae. Importantly, LPD was associated with a significantly shorter time period from surgery to the initiation of adjuvant chemotherapy (48 days vs. 59 days; p = 0.001); fewer long delays (>8 weeks) between time of surgery and initiation of chemotherapy (27 % vs. 41 %; p = 0.01); and lower rates of patients failing to receive chemotherapy altogether or within 90 days of surgery (5 % vs. 12 %; p = 0.04). There was no difference in overall survival, but LPD was associated with a longer progression-free survival. Although limited by its retrospective nature and small numbers, this comparison offers important insights into the potential benefits of MI pancreatectomy. PD is associated with significant morbidity and prolonged convalescence that may preclude the receipt of any adjuvant chemotherapy or its full scheduled dose [36]. The potential for MI surgery to reduce the morbidity associated with PD is important since this would increase the number of patients that could derive potential benefit from postoperative chemotherapy, particularly as potentially effective regimens such as FOLFIRINOX and gemcitabine/nab-paclitaxel are being evaluated in the adjuvant setting [37, 38]. To date, only three studies have compared LPD to OPD [35, 39, 40], and these are summarized in Table 12.2. Although some of these series are not exclusive to PDA patients, their outcomes suggest that the LPD can be performed with equivalent short-term oncologic outcomes, less EBL, and shorter LOS (at the expense of slightly longer operative times) compared to OPD in select patient cohorts.


Table 12.2
Summary of studies comparing laparoscopic to open pancreaticoduodenectomy





























































































Author

N

Malignancy (%)

Operative time (min)

EBL (mL)

LOS (days)

R0 resection (%)

Lymph node harvest (mean)
 
Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Lap

Open

Asbun [39]

53

215

75

67

541

401

195

1032

8

12

95

83

23

17

Kuroki [40]

20

31

70

74

657

555

377

1510

NR

NR

NR

NR

14

26

Croome [35]

108

214

100

100

379

388

492

 867

6

9

78

77

21

20


Lap laparoscopic, NR not reported

Bold p < 0.05



Robotic-Assisted Pancreatectomy for Resectable PDA


The inherent visual and ergonomic limitations of laparoscopy have played a major role in the development of robotic surgery, which allows surgeons to perform advanced laparoscopic procedures with greater ease. Advantages include articulating instruments that re-create the seven-degrees of freedom of the human wrist, three-dimensional high-definition view of the operative field, and complex algorithms that minimize physiologic tremor. These features allow for precise dissection and intracorporeal suturing, thus expanding the scope and complexity of procedures that can be performed in MI fashion. Disadvantages include high cost, loss of haptic feedback, the inability to operate in multiple fields, and the need for a skilled bedside assistant. The lack of haptic feedback is generally overcome by the enhanced, three-dimensional visualization, which allows the operating surgeon to use visual cues as a compensatory mechanism [41]. The platform has controls and ergonomics that closely mimic the movements of open surgery, and appears to shorten the learning curve for complex cases compared to conventional laparoscopy. This should allow a greater number of surgeons to perform complex pancreatic resections, and—by extension—increase the number of patients treated by MI pancreatectomy.

The first report of robotic-assisted pancreatectomy was by Guilianotti et al. in 2003 [42]. Since then, various reports have emerged to confirm the safety and feasibility of this platform. In the largest single-institutional experience of 250 consecutive robotic-assisted pancreatic resections [43], the authors at the University of Pittsburgh examined 132 patients that underwent robotic pancreaticoduodenectomy (RPD) (80 % were for malignancy of which 41 % were resectable PDA) and found the outcomes comparable to large historic retrospective series of OPD [3, 44]. For the malignant cohort, R0 resection was achieved in 88% of patients with a median of 19 resected lymph nodes. Similarly, for the 83 patients that underwent robotic distal pancreatectomy (RDP) (72 % for malignancy of which 37 % were resectable PDA), R0 resection was achieved in 97 % of patients with a median of 14 lymph nodes resected. No long-term survival data were available due to a short follow-up period. In a separate propensity score-matched analysis of 34 ODP and 28 MI DP (robotic and laparoscopic) for resectable PDA, the same group found short-term oncologic outcomes (R0 and lymph node harvest) and disease-specific survival to be equivalent [45]. Finally, in a retrospective comparison of 94 LDPs and 30 RDPs, the same group noted several advantages to the robotic approach including significantly reduced operative times, EBL, and conversion rates [46]. Furthermore, RDP was associated with superior short-term oncologic outcomes in patients with PDA, including a lower rate of microscopically positive margins and a greater lymph node harvest. Table 12.3 highlights some of the major series reporting on RPD to date. Similar to the LPD series, RPD seems to be associated with reduced EBL and LOS at the expense of longer operative times. These data must be viewed with caution since most of these series, particularly for PD, are limited by their retrospective nature, small numbers, and inherent selection bias. Conversely, many if not all of these series represent surgeons working through their initial learning curve. Future reports will focus on outcomes beyond this implementation phase, allowing for a more robust assessment of any benefits to this costly platform.


Table 12.3
Summary of selected studies reporting on robotic pancreaticoduodenectomy

























































































































































Author

N

Malignancy (%)

Operative time (min)

EBL (mL)

LOS (days)

Overall Morbidity (%)

30-day mortality (%)

R0 resection (%)

Lymph node harvest (mean)

Rob

Open

Rob

Open

Rob

Open

Rob

Open

Rob

Open

Rob

Open

Rob

Open

Rob

Open

Rob

Open

Buchs [58]

44

39

75

69

444

559

387

827

13

15

36

49

4.5

2.6

91

81

17

11

Lai [59]

20

67

75

79

492

265

247

775

14

26

50

50

0

3

73

64

10

10

Chalikonda [60]

30

30

46a

46a

476

366

485

775

10

13

30

43

4

0

100

87

13

12

Giulianotti [61]

60


75


421


394


22


NR

NR

3


92


18


Zureikat [43]

132


80


527


350


10


63


1.5


88


19



Rob robotic, NR not reported

aOnly reported for PDA

Bold p < 0.05



Minimally Invasive Approaches to Borderline Resectable Pancreatic Cancer



Challenges


Whereas the application of MI surgery to benign and resectable malignant disease is slowly expanding, its utility for borderline resectable and locally advanced tumors poses a unique set of challenges. The potential for catastrophic hemorrhage, coupled to oncologic concern for margin clearance, has contributed to a paucity of reported outcomes on this subset of patients. Moreover, borderline resectable tumors are usually larger in size and associated with increased rates of preoperative chemotherapy or chemo-radiotherapy administration—factors that potentially contribute to more difficult resections. Additionally, the lack of available data on the cost-benefit ratio for MI PD for benign disease and resectable cancers translates to reduced enthusiasm to apply the MI platforms to the more complex borderline resectable tumors.

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Jan 29, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Is There a Role for Laparoscopic and/or Robotic Techniques for Borderline Resectable Tumors?
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