Introduction
Robotic surgery has been increasingly utilized, yet its application for hepato–pancreato–biliary (HPB) procedures remains low due to technical complexity, perceived financial burden, and ...unproven clinical benefits. We hypothesized that the robotic approach would be associated with improved clinical outcomes following major hepatectomy compared with the laparoscopic approach among elderly patients who would benefit from the advantages of minimally invasive surgery.
Methods
A retrospective review of consecutive patients who underwent major hepatectomy between January 2010 and December 2021 at Carolinas Medical Center was performed. Inclusion criteria were age ≥ 65 years and major hepatectomy of three segments or more. Patients who underwent multiple liver resections, vascular/biliary reconstruction, or concomitant extrahepatic procedures (except cholecystectomy) were excluded. Categorical variables were compared using Chi-square or Fisher’s exact test when more than 20% of cells had expected frequencies less than five, and Wilcoxon two-sample or Kruskal–Wallis tests were used for continuous or ordinal variables. Results are described as median and interquartile range (IQR). Multivariate analyses were used on postoperative admission days.
Results
There were 399 major hepatectomies performed during this time period, of which 125 met the criteria and were included. There were no differences in perioperative demographics among patients who underwent robotic hepatectomy (RH,
n
= 39) and laparoscopic hepatectomy (LH,
n
= 32). There was no difference in operative time, blood loss, or major complication rates. However, RH had lower rates of conversion to an open procedure (2.6% versus 31.3%,
p
= 0.002), shorter length of hospital stay LOS, 4 (3–7) versus 6 (4–8.5) days,
p
≤ 0.0001, cumulative LOS 4 (3–7) versus 6 (4.5–9) days,
p
≤ 0.0001, and lower rates of intensive care unit (ICU) admission (7.7% versus 75%,
p
≤ 0.001), with a trend toward fewer rehabilitation requirements.
Conclusions
Robot major hepatectomy shows clinical advantages in elderly patients, including shorter hospital and ICU stays. These advantages, as well as reduced rehabilitation requirements associated with minimally invasive surgery, could overcome the current perceived financial disadvantages of robotic hepatectomy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Introduction
The Japanese difficulty score (JDS) categorizes laparoscopic hepatectomy into low, intermediate, and high complexity procedures, and correlates with operative and postoperative outcomes. ...We sought to perform a validation study to determine if the JDS correlates with operative and postoperative indicators of surgical complexity for patients undergoing robotic-assisted hepatectomy.
Methods
Retrospective review of 657 minimally invasive hepatectomy procedures was performed between January 2008 through March 2019. Outcomes included operative time, estimated blood loss (EBL), blood transfusion, complications, post-hepatectomy liver failure (PHLF), length of stay, 30-day readmission, and 30-day and 90-day mortality. Patients were grouped based on JDS defined as: low (< 4), intermediate (4–6), and high (7 +) complexity procedures. Statistical comparisons were analyzed by ANOVA or
χ
2
test.
Results
241 of 657 patients underwent robotic-assisted resection. Of these patients, 137 were included in the analysis based on JDS: 25 low, 58 intermediate, and 54 high. High JDS was associated with more major resections (≥ 4 contiguous segments) versus minor resections (median JDS 8 vs. 5,
P
< 0.0001). High JDS was associated with significantly longer operative times, higher EBL, and more blood transfusions. High JDS was associated with higher rates of PHLF at 16.7%, compared with 5.2% intermediate and 0.0% low, (
P
= 0.018). Complication rates, 30-day readmissions, and mortality rates were similar between groups. Median LOS was longer in patients with high JDS compared with intermediate and low (4 days vs. 3 days vs. 2 days;
P
= 0.0005).
Discussion
Higher JDS was associated with multiple indicators of operative complexity, including greater extent of resection, increased operative time, EBL, blood transfusion, PHLF, and LOS. This validation study supports the ability of the JDS to categorize patients undergoing robotic-assisted hepatectomy by complexity.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic ...techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma.
Methods
A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann–Whitney U test, log rank tests, and Kaplan–Meier methods.
Results
Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5;
p
= 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%;
p
= 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9;
p
= 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0 months;
p
= 0.1105) and longer time to recurrence (402 vs. 284 days;
p
= 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence.
Conclusions
While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The dissemination of robotic liver surgery is slow‐paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the ...current position of robotic liver surgery (RLS) worldwide and to identify if improved short‐term outcomes are observed, including secondary meta‐analyses for type of resection, etiology, and cost analysis.
Methods
A PRISMA‐based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle‐Ottawa score. Statistical analysis was performed after heterogeneity test and fixed‐ or random‐effect models were chosen accordingly.
Results
After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta‐analysis from the 38 comparative reports showed that RLS may offer improved short‐term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.
Conclusions
The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.
Highlight
Ciria and colleagues analyzed the impact of robotics in liver surgery. The largest systematic review and short‐term outcomes meta‐analysis performed to date was done on 2728 cases. Few initial advantages were observed for the robotic approach compared with laparoscopy, contrary to significant higher costs. However, a high potential was highlighted.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Debate exists regarding outcomes of robot-assisted versus laparoscopic hepatectomy. We reviewed and analyzed major hepatectomies (resection of ≥3 Couinaud liver segments) performed in a minimally ...invasive fashion at a single institution.
From 2011 to 2016, 473 major hepatectomy procedures were performed, of which 173 (37%) were performed in a minimally invasive fashion (57 robot-assisted and 116 laparoscopic). Patient demographics, operating statistics and outcomes were analyzed retrospectively.
Patients undergoing robot-assisted versus laparoscopic hepatectomy were older (58.1 vs 53.2 years, respectively; p = 0.030), admitted to ICU postoperatively less frequently (43.9% vs 61.2%, respectively; p = 0.043), and readmitted less often within 90 days (7.0% vs 28.5%, respectively; p = 0.001). No significant differences were identified in relation to complications, blood loss, operative times, and length of stay.
Robot-assisted is an effective alternative to laparoscopic major hepatectomy for resection of malignant and benign liver lesions. Robotic-assisted offers technical advantages compared to laparoscopic surgery including improved optic visualization, operative dexterity, and ease of dissection and suturing. This experience suggested that the robotic platform was associated with improved outcomes including reduced postoperative ICU admission and 90-day readmission.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Introduction
While minimally invasive left pancreatectomy has become more widespread and generally accepted over the last decade, opinions on modality of minimally invasive approach (robotic or ...laparoscopic) remain mixed with few institutions performing a significant portion of both operative approaches simultaneously.
Methods
247 minimally invasive left pancreatectomies were retrospectively identified in a prospectively maintained institutional REDCap™ database, 135 laparoscopic left pancreatectomy (LLP) and 108 robotic-assisted left pancreatectomy (RLP). Demographics, intraoperative variables, postoperative outcomes, and OR costs were compared between LLP and RLP with an additional subgroup analysis for procedures performed specifically for pancreatic adenocarcinoma (35 LLP and 23 RLP) focusing on pathologic outcomes and 2-year actuarial survival.
Results
There were no significant differences in preoperative demographics or indications between LLP and RLP with 34% performed for chronic pancreatitis and 23% performed for pancreatic adenocarcinoma. While laparoscopic cases were faster (
p
< 0.001) robotic cases had a higher rate of splenic preservation (
p
< 0.001). Median length of stay was 5 days for RLP and LLP, and rate of clinically significant grade B/C pancreatic fistula was approximately 20% for both groups. Conversion rates to laparotomy were 4.3% and 1.8% for LLP and RLP approaches respectively. RLP had a higher rate of readmission (
p
= 0.035). Pathologic outcomes and 2-year actuarial survival were similar between LLP and RLP. LLP on average saved $206.67 in OR costs over RLP.
Conclusions
This study demonstrates that at a high-volume center with significant minimally invasive experience, both LLP and RLP can be equally effective when used at the discretion of the operating surgeon. We view the laparoscopic and robotic platforms as tools for the modern surgeon, and at our institution, given the technical success of both operative approaches, we will continue to encourage our surgeons to approach a difficult operation with their tool of choice.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Objective
Robotic liver surgery (RLS) has emerged as a feasible alternative to laparoscopic or open resections with comparable perioperative outcomes. Little is known about the oncologic adequacy of ...RLS. The purpose of this study was to investigate the long-term oncologic outcomes for patients undergoing RLS for primary hepatobiliary malignancies.
Methods
We performed an international, multicenter, retrospective study of patients who underwent RLS for hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), or gallbladder cancer (GBC) between 2006 and 2016. Age, gender, histology, resection margin status, extent of surgical resection, disease-free survival (DFS), and overall survival (OS) were retrospectively collected and analyzed.
Results
Of the 61 included patients, 34 (56%) had RLS performed for HCC, 16 (26%) for CC, and 11 (18%) for GBC. The majority of resections were nonanatomical or segmental resections (39.3%), followed by central hepatectomy (18%), left-lateral sectionectomy (14.8%), left hepatectomy (13.1%), right hepatectomy (13.1%), and right posterior segmentectomy (1.6%). R0 resection was achieved in 94% of HCC, 68% of CC, and 81.8% of GBC patients. Median hospital stay was 5 days, and conversion to open surgery was needed in seven patients (11.5%). Grade III–IV Dindo–Clavien complications occurred in seven patients with no perioperative mortality. Median follow-up was 75 months (95% confidence interval 36–113), and 5-year OS and DFS were 56 and 38%, respectively. When stratified by tumor type, 3-year OS was 90% for HCC, 65% for GBC, and 49% for CC (
p
= 0.01).
Conclusions
RLS can be performed for primary hepatobiliary malignancies with long-term oncologic outcomes comparable to published open and laparoscopic data.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Neoadjuvant therapy may improve survival of patients with pancreatic adenocarcinoma; however, determining response to therapy is difficult. Artificial intelligence allows for novel ...analysis of images. We hypothesized that a deep learning model can predict tumor response to NAC.
Methods
Patients with pancreatic cancer receiving neoadjuvant therapy prior to pancreatoduodenectomy were identified between November 2009 and January 2018. The College of American Pathologists Tumor Regression Grades 0-2 were defined as pathologic response (PR) and grade 3 as no response (NR). Axial images from preoperative computed tomography scans were used to create a 5-layer convolutional neural network and LeNet deep learning model to predict PRs. The hybrid model incorporated decrease in carbohydrate antigen 19-9 (CA19-9) of 10%. Accuracy was determined by area under the curve.
Results
A total of 81 patients were included in the study. Patients were divided between PR (333 images) and NR (443 images). The pure model had an area under the curve (AUC) of .738 (P < .001), whereas the hybrid model had an AUC of .785 (P < .001). CA19-9 decrease alone was a poor predictor of response with an AUC of .564 (P = .096).
Conclusions
A deep learning model can predict pathologic tumor response to neoadjuvant therapy for patients with pancreatic adenocarcinoma and the model is improved with the incorporation of decreases in serum CA19-9. Further model development is needed before clinical application.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Background
Prehabilitation encompasses multidisciplinary interventions to improve health and lessen incidence of surgical deterioration by reducing physiologic stress and functional decline. This ...study presents an interim analysis to demonstrate prehabilitation for hepatopancreatobiliary (HPB) surgical patients.
Methods
In 2018, a structured prehabilitation pilot program was implemented. Eligibility required HPB malignancy, neoadjuvant chemotherapy, and residence within hour drive. Patients were enrolled into the 4-month program. The fitness component was composed of timed up and go test and grip strength with exercise recommendations. Nutrition involved evaluation of sarcopenic obesity, glucose management, and smoking and alcohol counseling. Psychological services included psychosocial assessments and advanced care planning, with social work referrals. Component were evaluated monthly by a physician using laboratory results, nutritional data and questionnaires, psychological assessments, and validated fitness tests. Nurse navigators spoke with patients weekly to monitor compliance.
Results
At 12 months, nineteen patients were enrolled. Ten completed prehabilitation, neoadjuvant chemotherapy and underwent their surgical procedure. There were no differences found after prehabilitation in functional status, physical performance, psychosocial assessments, or nutrition. Frailty, as assessed by Fried frailty criteria, improved significantly after prehabilitation (P < .0001). Symptom severity and laboratory values did not change. Length of stay was 6.5 days and all patients were discharged to home. There was 1 readmission for transient ischemic attack and 90-day mortality rate was 0%.
Discussion
Prehabilitation to improve recovery is a promising concept encompassing a wide array of multidisciplinary assessments and interventions. It may demonstrate a protective effect on physiologic decline from chemotherapy and may reverse frailty phenotypes.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Background
Treatment of hepatocellular carcinoma (HCC) in the setting of cirrhosis is limited by tumor size/location and underlying liver disease. Radiofrequency ablation is utilized in selected ...patients; however, local recurrence remains a concern. Microwave ablation (MWA) delivers energy to tissue in a unique fashion, reducing local recurrence. A minimally invasive operative approach allows for mobilization/protection of adjacent structures, intra-operative ultrasound, and assessment of ablation progress.
Study Design
Retrospective review of operative MWA performed for HCC in patients with cirrhosis over a 4-year period at a single center. Complications were stratified by Clavien–Dindo classification. Incomplete ablation and local, regional, and metastatic recurrence was assessed on follow-up imaging. Survival was assessed in months.
Results
Fifty-four patients with 73 tumors underwent MWA. Median tumor size was 2.6 cm (range 0.5–8.5 cm). Cirrhosis was present in 92.6 % of patients, with a Child–Pugh score of B/C in 27.8 % and hepatitis C present in 59.3 %. A minimally invasive approach was used in 94.5 % of patients. There were no deaths within 30 days. Thirty-day morbidity was 28.9 %, with grade III complications present in 11.5 %. Delayed complications occurred in 7.8 % of patients, with a 5.6 % 90-day mortality. Incomplete ablation was identified in 5.9 % of tumors with local recurrence of 2.9 % at 9 months median follow-up. Regional and metastatic recurrence occurred in 27.5 and 11.8 % at 9 months median follow-up. Median survival was not reached at 11 months median follow-up. One- and 2-year survival was 72.3 and 58.8 %.
Conclusion
Operative, preferably minimally invasive, MWA can be performed in cirrhotic patients with HCC with acceptable morbidity and low recurrence rates. High regional and metastatic recurrence rates in these patients underscore the need for minimally invasive, low morbidity approaches to liver-directed therapy.
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EMUNI, NUK, SBMB, SBNM, UL, UPUK
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