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
In contrast to DP, MI approaches for PD have been slow to develop despite being first reported nearly two decades ago [30–32]. 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 |
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 | – |
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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