The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis.

BACKGROUND: Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity between these tumors. Therefore, this study aimed to evaluate the role of MIPD compared to open pancreatoduodenectomy (OPD) in patients with non-pancreatic periampullary cancer (NPPC). METHODS: A systematic review of Pubmed, Embase, and Cochrane databases was performed by two independent reviewers to identify studies comparing MIPD and OPD for NPPC (ampullary, distal cholangio, and duodenal adenocarcinoma) (01/2015-12/2021). Individual patient data were required from all identified studies. Primary outcomes were (90-day) mortality, and major morbidity (Clavien-Dindo 3a-5). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood-loss, length of hospital stay (LOS), and overall survival (OS). RESULTS: Overall, 16 studies with 1949 patients were included, combining 928 patients with ampullary, 526 with distal cholangio, and 461 with duodenal cancer. In total, 902 (46.3%) patients underwent MIPD, and 1047 (53.7%) patients underwent OPD. The rates of 90-day mortality, major morbidity, POPF, DGE, PPH, blood-loss, and length of hospital stay did not differ between MIPD and OPD. Operation time was 67 min longer in the MIPD group (P = 0.009). A decrease in DFS for ampullary (HR 2.27, P = 0.019) and distal cholangio (HR 1.84, P = 0.025) cancer, as well as a decrease in OS for distal cholangio (HR 1.71, P = 0.045) and duodenal cancer (HR 4.59, P < 0.001) was found in the MIPD group. CONCLUSIONS: This individual patient data meta-analysis of MIPD versus OPD in patients with NPPC suggests that MIPD is not inferior in terms of short-term morbidity and mortality. Several major limitations in long-term data highlight a research gap that should be studied in prospective maintained international registries or randomized studies for ampullary, distal cholangio, and duodenum cancer separately. PROTOCOL REGISTRATION: PROSPERO (CRD42021277495) on the 25th of October 2021.

Minimally invasive versus open pancreatoduodenectomy for pancreatic ductal adenocarcinoma: Individual patient data meta-analysis of randomized trials.

OBJECTIVE: Assessment of minimally invasive pancreatoduodenectomy (MIPD) in patients with pancreatic ductal adenocarcinoma (PDAC) is scarce and limited to non-randomized studies. This study aimed to compare oncological and surgical outcomes after MIPD compared to open pancreatoduodenectomy (OPD) for patients after resectable PDAC from published randomized controlled trials (RCTs). METHODS: A systematic review was performed to identify RCTs comparing MIPD and OPD including PDAC (Jan 2015-July 2021). Individual data of patients with PDAC were requested. Primary outcomes were R0 rate and lymph node yield. Secondary outcomes were blood-loss, operation time, major complications, hospital stay and 90-day mortality. RESULTS: Overall, 4 RCTs (all addressed laparoscopic MIPD) with 275 patients with PDAC were included. In total, 128 patients underwent laparoscopic MIPD and 147 patients underwent OPD. The R0 rate (risk difference(RD) -1%, P = 0.740) and lymph node yield (mean difference(MD) +1.55, P = 0.305) were comparable between laparoscopic MIPD and OPD. Laparoscopic MIPD was associated with less perioperative blood-loss (MD -91ml, P = 0.026), shorter length of hospital stay (MD -3.8 days, P = 0.044), while operation time was longer (MD +98.5 min, P = 0.003). Major complications (RD -11%, P = 0.302) and 90-day mortality (RD -2%, P = 0.328) were comparable between laparoscopic MIPD and OPD. CONCLUSIONS: This individual patient data meta-analysis of MIPD versus OPD in patients with resectable PDAC suggests that laparoscopic MIPD is non-inferior regarding radicality, lymph node yield, major complications and 90-day mortality and is associated with less blood loss, shorter hospital stay, and longer operation time. The impact on long-term survival and recurrence should be studied in RCTs including robotic MIPD.

Long-term Outcomes After Laparoscopic, Robotic, and Open Pancreatoduodenectomy for Distal Cholangiocarcinoma: An International Propensity Score-matched Cohort Study.

OBJECTIVE: This study aimed to compare surgical and oncological outcomes after minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) for distal cholangiocarcinoma (dCCA). BACKGROUND: A dCCA might be a good indication for MIPD, as it is often diagnosed as primary resectable disease. However, multicenter series on MIPD for dCCA are lacking. METHODS: This is an international multicenter propensity score-matched cohort study including patients after MIPD or OPD for dCCA in 8 centers from 5 countries (2010-2021). Primary outcomes included overall survival (OS) and disease-free interval (DFI). Secondary outcomes included perioperative and postoperative complications and predictors for OS or DFI. Subgroup analyses included robotic pancreatoduodenectomy (RPD) and laparoscopic pancreatoduodenectomy (LPD). RESULTS: Overall, 478 patients after pancreatoduodenectomy for dCCA were included of which 97 after MIPD (37 RPD, 60 LPD) and 381 after OPD. MIPD was associated with less blood loss (300 vs 420 mL, P =0.025), longer operation time (453 vs 340 min; P <0.001), and less surgical site infections (7.8% vs 19.3%; P =0.042) compared with OPD. The median OS (30 vs 25 mo) and DFI (29 vs 18) for MIPD did not differ significantly between MIPD and OPD. Tumor stage (Hazard ratio: 2.939, P <0.001) and administration of adjuvant chemotherapy (Hazard ratio: 0.640, P =0.033) were individual predictors for OS. RPD was associated with a higher lymph node yield (18.0 vs 13.5; P =0.008) and less major morbidity (Clavien-Dindo 3b-5; 8.1% vs 32.1%; P =0.005) compared with LPD. DISCUSSION: Both surgical and oncological outcomes of MIPD for dCCA are acceptable as compared with OPD. Surgical outcomes seem to favor RPD as compared with LPD but more data are needed. Randomized controlled trials should be performed to confirm these findings.

Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?

BACKGROUND: In mechanically ventilated acute respiratory distress syndrome (ARDS) patients infected with the novel coronavirus disease (COVID-19), we frequently recognised the development of pneumomediastinum and/or subcutaneous emphysema despite employing a protective mechanical ventilation strategy. The purpose of this study was to determine if the incidence of pneumomediastinum/subcutaneous emphysema in COVID-19 patients was higher than in ARDS patients without COVID-19 and if this difference could be attributed to barotrauma or to lung frailty. METHODS: We identified both a cohort of patients with ARDS and COVID-19 (CoV-ARDS), and a cohort of patients with ARDS from other causes (noCoV-ARDS).Patients with CoV-ARDS were admitted to an intensive care unit (ICU) during the COVID-19 pandemic and had microbiologically confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. NoCoV-ARDS was identified by an ARDS diagnosis in the 5 years before the COVID-19 pandemic period. RESULTS: Pneumomediastinum/subcutaneous emphysema occurred in 23 out of 169 (13.6%) patients with CoV-ARDS and in three out of 163 (1.9%) patients with noCoV-ARDS (p<0.001). Mortality was 56.5% in CoV-ARDS patients with pneumomediastinum/subcutaneous emphysema and 50% in patients without pneumomediastinum (p=0.46).CoV-ARDS patients had a high incidence of pneumomediastinum/subcutaneous emphysema despite the use of low tidal volume (5.9±0.8 mL·kg-1 ideal body weight) and low airway pressure (plateau pressure 23±4 cmH2O). CONCLUSIONS: We observed a seven-fold increase in pneumomediastinum/subcutaneous emphysema in CoV-ARDS. An increased lung frailty in CoV-ARDS could explain this finding more than barotrauma, which, according to its etymology, refers to high transpulmonary pressure.

Outcome of oncological patients admitted with COVID-19: experience of a hospital center in northern Italy.

BACKGROUND: Recent literature regarding the outcome of cancer patients infected with COVID-19 are not encouraging. Nevertheless, current evidence on the risk and benefits of continuing oncological treatment of cancer patients during the pandemic remains insufficient. We provide our experience in a center with high access for patients with COVID-19-associated pneumonia in Lombardy, Italy. We conducted a retrospective study using a prospectively maintained database of patients admitted to our hospital between 25 February 2020 and 9 April 2020 with a confirmed diagnosis of COVID-19 pneumonia. RESULTS: A total of 53 patients with a history or current oncological disease were included in this study. Sixteen oncological patients (30.2%) died during hospitalization. Multivariable logistic regression analysis found that age (Odds ratio [OR]: 1.17, p = 0.009), diabetes (OR: 15.05, p = 0.028) and active oncological disease (OR 13.60, p = 0.015) were independently associated with in-hospital mortality. The mortality rate of the total number of cancer patients is about twice as high as that of non-oncological patients admitted to our hospital with a diagnosis of COVID-19. CONCLUSION: The presence of active oncological disease is independently related to mortality as well as age and diabetes. The majority of patients who died were frail. Careful evaluation of the risks and benefits of treatment in frail patients is needed, considering that difficult access to intensive care may have affected the mortality rate.

Factors associated with adverse events after distal tibiofibular syndesmosis fixation.

PURPOSE AND HYPOTHESIS: Factors associated with adverse outcomes following surgery for syndesmotic instability with associated closed fibula fracture are incompletely understood. The purpose of this study was to determine the pathoetiology and incidence of adverse events after stabilization of syndesmotic instability. In addition, we aimed to identify any patient or surgeon related factors that might be associated with unanticipated outcomes. METHODS: Between January 2000 and May 2015, a total of 849 adult patients who were surgically treated with either screw or suture button fixation for syndesmotic instability with associated fibula fracture without open wound were identified and retrospectively evaluated. Multivariable logistic regression analyses were used to determine factors associated with any postoperative complication or unplanned reoperation. RESULTS: Within one year after surgery, 10.7% (91 patients) suffered an infectious complication and 22.0% (187 patients) underwent unplanned reoperation. Factors associated with infectious complications were increased duration of hospital admission (OR: 1.08, p = .014), use of an external fixator device before ORIF (OR: 5.19 p < .001), peripheral vascular disease (OR: 4.33, p = .008), and osteoporosis (OR: 2.71, p = .022). For unplanned hardware removal specifically, patients' BMI below 30 was an associated risk factor. (OR: 1.50, p = .010). CONCLUSION: Certain patient groups have an increased risk of adverse events following the use of current surgical fixation methods for stabilizing the syndesmosis. Patients undergoing surgery for syndesmotic instability with associated fibula fracture without open wound should be counseled that up to 1 in 10 suffer an infectious complication and that 1 in 5 require unplanned hardware removal.