Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its Adoption in Singapore.

Despite the potential clinical advantages offered by laparoscopic pancreatic surgery (LPS), the main obstacle to its widespread adoption is the technically demanding nature of the procedure and its steep learning curve. LPS and robotic pancreatic surgery (RPS) have been proven to result in superior short-term perioperative outcomes and equivalent long-term oncological outcomes compared to the conventional open approach, with the caveat that they are performed by expert surgeons who have been trained to perform such procedures. The primary challenge faced by most pancreatic surgeons is the steep learning curve associated with these complex procedures and the need to undergo surgical training, especially with regards to laparoscopic and robotic pancreaticoduodenectomy. Current evidence suggests that RPS may help to shorten the lengthy learning curve required for LPS. More robust evidence-in the form of large randomised controlled trials-is needed to determine whether LPS and RPS can be safely adopted universally.

Minimally Invasive Versus Open Pancreatectomies for Pancreatic Neuroendocrine Neoplasms: A Propensity-Score-Matched Study.

BACKGROUND: Pancreatic neuroendocrine neoplasms (PNENs) are increasingly prevalent with modern imaging, and surgical excision remains mainstay of treatment. This study aims to perform a propensity-score-matched (PSM) comparison of perioperative and oncologic outcomes following minimally invasive pancreatectomy (MIP) versus open pancreatectomy (OP) for PNEN. METHODS: A retrospective review was performed on patients who underwent curative-intent surgery for PNEN at Singapore General Hospital from 1997 to 2018. A 1:1 PSM was performed between MIP and OP, after which both groups were balanced for baseline variables. RESULTS: We studied 134 patients who underwent surgery (36 MIP and 98 OP) for PNEN. Propensity-score-matched comparison between 35 MIP and 35 OP patients revealed that the MIP group had a longer operating time (MD = 75.0, 95% CI 15.2 to 134.8, P = 0.015), lower intraoperative blood loss (MD = - 400.0, 95% CI - 630.5 to - 169.5, P = 0.001), shorter median postoperative stay (MD = - 1.0, 95% CI - 1.9 to - 0.1, P = 0.029) and shorter median time to diet (MD = - 1.0, 95% CI - 1.9 to - 0.1, P = 0.039). There were no differences between both groups for short-term adverse outcomes and oncologic clearance. Overall survival (HR = 0.84, 95% CI 0.28 to 2.51, P = 0.761) and disease-free survival (HR = 0.57, 95% CI 0.20 to 1.64, P = 0.296) were comparable. CONCLUSION: MIP is a safe and feasible approach for PNEN and is associated with a lower intraoperative blood loss, decreased postoperative stay and time to oral intake, at the expense of a longer operative time compared to OP.

Systematic review of current prognostication systems for pancreatic neuroendocrine neoplasms.

BACKGROUND: Pancreatic neuroendocrine neoplasms are a heterogenous group of rare tumors whose natural history remains poorly defined. Accurate prognostication of pancreatic neuroendocrine neoplasms is essential for guiding clinical decisions. This paper aims to summarize all the commonly utilized and recently proposed prognostication systems for pancreatic neuroendocrine neoplasms published in the literature to date. METHODS: A systematic review of Pubmed, Scopus, and Embase databases, of the period from January 1, 2000-November 29, 2016, was conducted to identify all published articles reporting on prognostication systems of pancreatic neuroendocrine neoplasms. RESULTS: A total of 23 articles were included in our review, and a total of 25 classification systems were identified. There were 2 modifications of the World Health Organization 2004 criteria, 4 modifications of the World Health Organization 2010 criteria, 2 modifications of the American Joint Committee on Cancer 2010 staging system, 3 modifications of the European Neuroendocrine Tumor Society 2006 tumor, node, metastasis staging system, 7 novel categorial classification systems, and 2 novel proposed continuous classifications. The most commonly included variables included age, size of tumor, presence of distant and lymph node metastases, Ki-67 index, and mitotic count. CONCLUSION: Numerous prognostication systems have been proposed for pancreatic neuroendocrine neoplasms, of which the most commonly used systems presently include the World Health Organization 2010 criteria and the two tumor, node, metastasis staging systems by the European Neuroendocrine Tumor Society and the American Joint Commission on Cancer. However, prognostication systems for pancreatic neuroendocrine neoplasms continue to evolve with time as more prognostication factors are identified. More validation and comparative studies are needed to identify the most effective prognostication system.

Surgical resection of pancreatic neuroendocrine neoplasm by minimally invasive surgery-the robotic approach?

Over the past decade, there has been increasing adoption of minimally invasive pancreatic surgery world-wide and this has naturally expanded to the management of pancreatic neuroendocrine neoplasms (PNENs). More recently, robotic pancreatic surgery (RPS) was introduced to overcome the limitations during laparoscopic pancreatic surgery (LPS). Due to the relative rarity of PNEN and the novelty of minimally invasive pancreatic surgery in particular RPS today, the evidence for robotic surgery in PNENs remains extremely limited. Presently, the available evidence is limited to a few low level retrospective case-control studies. These studies suggest that RPS may be associated with a higher splenic preservation rates and lower open conversion rates compared to conventional laparoscopic surgery. Ideally a prospective randomized trial should be performed but this would be extremely challenging due to the rarity of PNEN, making it almost impossible to conduct a sufficiently powered trial.

Validation and comparison between current prognostication systems for pancreatic neuroendocrine neoplasms: A single-institution experience with 176 patients.

BACKGROUND: This article aims to validate and compare the performance of 6 prognostication systems-the World Health Organization 2010 grading criteria, the European Neuroendocrine Tumour Society and the American Joint Committee for Cancer staging systems, the Memorial Sloan Kettering Cancer Center staging and grading systems, as well as the Bilimoria criteria in a cohort of patients with pancreatic neuroendocrine neoplasms at a single institution. METHODS: A retrospective review of 176 patients with histologically proven pancreatic neuroendocrine neoplasm was performed. The prognostic ability of the various prognostication systems for pancreatic neuroendocrine neoplasm was assessed by analyzing the homogeneity, discriminatory ability, monotonicity of gradient, and Akaike information criteria. RESULTS: The 5-year overall survival for the 176 patients was 69% and 5-year recurrence-free survival in 119 patients who underwent curative resection was 78%. Comparison between the 6 prognostication systems demonstrated that the World Health Organization 2010 system had the lowest Akaike information criteria score and was hence the best prognostication system in predicting overall survival and recurrence-free survival rates in our cohort of patients. The European Neuroendocrine Tumour Society was superior to the American Joint Committee for Cancer in prognosticating overall survival rates for pancreatic neuroendocrine neoplasms, as there was a statistically significant difference in overall survival across the different stages when stratified by the European Neuroendocrine Tumour Society, while the use of the American Joint Committee for Cancer was limited to distinguishing between patients in stages I and II versus stages III and IV only. CONCLUSION: All 6 prognostication systems were useful in the prognostication of pancreatic neuroendocrine neoplasm. The World Health Organization 2010 grading system was the best prognostication system in predicting both overall survival in our entire cohort of patients and recurrence-free survival in the subset of patients who underwent curative resection.