Learning Curve of a Laparoscopic Pancreaticoduodenectomy Program at a Second Institution.

BACKGROUND: Historically, pancreaticoduodenectomy (PD) has been performed via a laparotomy, but increasingly, laparoscopic and robotic platforms are being employed for PD. Laparoscopic PD has a steep surgeon specific learning curve and programmatic elements that must be optimized. These factors may limit a surgeon who is proficient at laparoscopic PD to develop a program at another institution. We hypothesize that the learning curve for a surgeon transferring a program to a second institution is shorter than the initial laparoscopic PD learning curve for the same surgeon. METHODS: A retrospective review of patients who underwent laparoscopic PD for any indication at the first institution (FI) from 2012 to 2017 and the second institution (SI) from 2018 to 2021 was conducted. Standard statistical analysis was performed. The learning curve was identified using one-sided CUSUM analysis of operative times. RESULT: We identified 110 participants, 90 from the FI and 20 from the SI. More patients at the FI were diagnosed with periampullary adenocarcinoma on final pathology compared to the SI (65.6% vs 40.0%, P = .0132). FI operative times stabilized after the 25th laparoscopic PD and SI operative times stabilized after the 5th operation. No statistically significant difference was identified in postoperative complications. CONCLUSIONS: The learning curve and average operative time of an SI laparoscopic PD program was shorter than the initial learning curve for a single surgeon with comparable outcomes. This suggests that complex minimally invasive surgical programs can be safely transferred to another high-volume institution without significant loss of progress.

Minimally Invasive Approaches to Pancreatic Cancer.

In pancreatic cancer, resection combined with neoadjuvant and/or adjuvant therapy remains the only chance for cure and/or prolonged survival. A minimally invasive approach to pancreatic cancer has gained increased acceptance and popularity. The aim of minimally invasive surgery of the pancreas includes limiting trauma, decreasing length of hospitalization, lessening cost, decreasing blood loss, and allowing for a more meticulous oncologic dissection. New advances and routine use in practice have helped progress the field making the minimally invasive approach more feasible. In this article, the minimally invasive surgical approaches to proximal, central, and distal pancreatic cancer are described and literature reviewed.

Comparable long-term oncologic outcomes of laparoscopic versus open pancreaticoduodenectomy for adenocarcinoma: a propensity score weighting analysis.

BACKGROUND: To date, no study has reported long-term oncologic outcome for patients undergoing laparoscopic pancreaticoduodenectomy (LPD) compared to open surgery (OPD). The aim of this study is assess long-term oncologic outcomes for patients with adenocarcinoma undergoing LPD versus OPD using propensity score weighting modeling to minimize selection bias. PATIENTS AND METHODS: All patients undergoing PD at Institut Mutualiste Montsouris between January 2000 and April 2010 were included. Propensity scores were calculated using multivariate logistic regression, relating preoperative covariates to surgical approach. Logistic regression was performed, and Cox proportional hazards models for postoperative outcomes were constructed, with and without adjustment for propensity scores weights. RESULTS: Among 87 patients who underwent PD, 40 underwent LPD and 25 OPD for confirmed adenocarcinoma. Preoperative covariates across both groups were comparable. The median follow-up time was 34.5 months. During follow-up, metastasis was identified in 16 (40%) LPD and 7 (28%) OPD patients. After propensity score adjustment, the median overall survival (OS) was 35.5 versus 29.6 months, respectively. The 1-, 3-, and 5-year OS rates were 80.5, 49.2, 39.7% and 77.8, 46.4, 30% in the LP and OPD groups (P = 0.41, 0.42, 0.25), respectively. The median recurrence-free survival (RFS) was 21.5 versus 13.7 months (LPD vs. OPD), and the 1-, 3-, and 5-year RFS rates were 70.9, 33.3, 21.9% and 62.3, 37.9, 25.7% in the LP and OPD groups (P = 0.27, 0.37, 0.39), respectively. CONCLUSIONS: Due to the early adoption of LPD, this study is the first to report on long-term oncologic safety of LPD: LPD is non-inferior to OPD with respect to long-term outcomes for patients with adenocarcinoma.

Laparoscopic pancreatoduodenectomy: current status and future directions.

In recent years, laparoscopic pancreatoduodenectomy (LPD) has been gaining a favorable position in the field of pancreatic surgery. However, its role still remains unclear. This review investigates the current status of LPD in high-volume centers. A literature search was conducted in PubMed, and only papers written in English containing more than 30 cases of LPD were selected. Papers with "hybrid" or robotic technique were not included in the analysis. Out of a total of 728 LPD publications, 7 publications matched the review criteria. The total number of patients analyzed was 516, and the largest series included 130 patients. Four of these studies come from the United States, 1 from France, 1 from South Korea, and 1 from India. In 6 reports, LPDs were performed only for malignant disease. The overall pancreatic fistula rate grades B-C were 12.7%. The overall conversion rate was 6.9%. LPD seems to be a valid alternative to the standard open approach with similar technical and oncological results. However, the lack of many large series, multi-institutional data, and randomized trials does not allow the clarification of the exact role of LPD.