Costs of complications following distal pancreatectomy: a systematic review.

BACKGROUND: Postoperative complications following distal pancreatectomy (DP) are common, especially postoperative pancreatic fistula (POPF). In order to design adequate prophylactic strategies, it is of relevance to determine the costs of these complications. An overview of the literature on the costs of complications following DP is lacking. METHODS: A systematic literature search was performed in PubMed, Embase, and Cochrane Library (inception until 1 August 2022). The primary outcome was the costs (i.e. cost differential) of major morbidity, individual complications and prolonged hospital stay. Quality of non-RCTs were assessed using the Newcastle-Ottawa scale. Costs were compared with the use of Purchasing Power parity. This systematic review was registered with PROSPERO (CRD42021223019). RESULTS: Overall, seven studies were included with 854 patients after DP. The rate POPF grade B/C varied between 13% and 27% (based on five studies) with a corresponding cost differential of EUR 18,389 (based on two studies). The rate of severe morbidity varied between 13% and 38% (based on five studies) with a corresponding cost differential of EUR 19,281 (based on five studies). CONCLUSION: This systematic review reported considerable costs for POPF grade B/C and severe morbidity after DP. Prospective databases and studies should report on all complications in a uniform matter to better display the economic burden of complications of DP.

Procedure-specific Training for Robot-assisted Distal Pancreatectomy.

OBJECTIVE: To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality. BACKGROUND: RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce. METHODS: A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy. RESULTS: After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP. CONCLUSION: Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

Short-term outcomes of laparoscopic versus open hepatectomy in the elderly patient: systematic review and meta-analysis.

BACKGROUND AND AIM: Favorable outcomes of laparoscopic hepatectomy (LH) over open hepatectomy (OH) have been demonstrated. LH offers less postoperative morbidity, less blood loss, and shorter hospital stay, while maintaining oncological safety. Only limited evidence about outcomes of LH in elderly is currently available. Therefore, this study aimed to compare short term outcomes of LH to OH for patients >65 years. METHODS: A systematic review and meta-analysis were performed according to Cochrane guidelines. Embase, PubMed, Cochrane Library, and Google Scholar were searched to identify eligible studies. Studies were included if they compared LH to OH, and focused on an elderly population, or had a majority of patients >65 years. Perioperative and postoperative outcomes were analyzed. RESULTS: Thirteen studies with 1174 patients (LH:532, OH:642) were included for analysis. When compared to OH, elderly undergoing LH had significantly less postoperative complications (risk ratio [RR]0.52; 95% confidence interval (CI):0.43-0.63), less blood loss (mean difference [MD]-198.58; 95% CI:-299.88 to -97.28), and shorter length of stay (MD-4.83; 95%CI:-7.91 to -1.84), while oncological safety was non-inferior (RR1.04; 95%CI:1.00-1.08). CONCLUSIONS: Within the elderly population LH seems to be superior to OH, concerning short-term outcomes. However, for broader applicability more trials are needed including more difficult and major resections.

Transversus abdominis plane block reduces pain and narcotic consumption after robot-assisted distal pancreatectomy.

BACKGROUND: Minimizing pain and disability are key postoperative objectives of robot-assisted distal pancreatectomy (RADP). This study tested effects of bupivacaine transversus abdominis plane (TAP) block on opioid consumption and pain after RADP. METHODS: Retrospective case-control study (June 2012 -Oct 2017) evaluating bilateral intraoperative bupivacaine TAP block as an interrupted time series. Linear regression evaluated opioid consumption in terms of intravenous (IV) morphine milligram equivalents (MME) and controlled for preoperative morbidity. Secondary outcomes included numerical rating scale (NRS) pain scores. RESULTS: 81 RADP patients met eligibility, 48 before and 33 after implementation of TAP. Baseline characteristics were equivalent with a trend toward higher age, Charlson comorbidity, and ASA score among the TAP cohort. TAP patients consumed on average 4.52 fewer IV MME than controls during the first six postoperative hours (p = 0.032) and reported lower mean NRS scores at six (p = 0.009) and 12 h (p = 0.006) but not at 24 h (p = 0.129). Postoperative morbidity and lengths of stay (LOS) were equivalent (5 vs. 6 days, p = 0.428). CONCLUSION: Bupivacaine TAP block was associated with significant reductions in opioid consumption and pain after RADP but did not shorten hospital LOS consistent with bupivacaine's limited half-life.