Implementation and outcome of minimally invasive pancreatoduodenectomy in Europe: a registry-based retrospective study - a critical appraisal of the first 3 years of the E-MIPS registry.

BACKGROUND: International multicenter audit-based studies focusing on the outcome of minimally invasive pancreatoduodenectomy (MIPD) are lacking. The European Registry for Minimally Invasive Pancreatic Surgery (E-MIPS) is the E-AHPBA endorsed registry aimed to monitor and safeguard the introduction of MIPD in Europe. MATERIALS AND METHODS: A planned analysis of outcomes among consecutive patients after MIPD from 45 centers in 14 European countries in the E-MIPS registry (2019-2021). The main outcomes of interest were major morbidity (Clavien-Dindo grade ≥3) and 30-day/in-hospital mortality. RESULTS: Overall, 1336 patients after MIPD were included [835 robot-assisted (R-MIPD) and 501 laparoscopic MIPD (L-MIPD)]. Overall, 20 centers performed R-MIPD, 15 centers L-MIPD, and 10 centers both. Between 2019 and 2021, the rate of centers performing L-MIPD decreased from 46.9 to 25%, whereas for R-MIPD this increased from 46.9 to 65.6%. Overall, the rate of major morbidity was 41.2%, 30-day/in-hospital mortality 4.5%, conversion rate 9.7%, postoperative pancreatic fistula grade B/C 22.7%, and postpancreatectomy hemorrhage grade B/C 10.8%. Median length of hospital stay was 12 days (IQR 8-21). A lower rate of major morbidity, postoperative pancreatic fistula grade B/C, postpancreatectomy hemorrhage grade B/C, delayed gastric emptying grade B/C, percutaneous drainage, and readmission was found after L-MIPD. The number of centers meeting the Miami Guidelines volume cut-off of ≥20 MIPDs annually increased from 9 (28.1%) in 2019 to 12 (37.5%) in 2021 ( P =0.424). Rates of conversion (7.4 vs. 14.8% P <0.001) and reoperation (8.9 vs. 15.1% P <0.001) were lower in centers, which fulfilled the Miami volume cut-off. CONCLUSION: During the first 3 years of the pan-European E-MIPS registry, morbidity and mortality rates after MIPD were acceptable. A shift is ongoing from L-MIPD to R-MIPD. Variations in outcomes between the two minimally invasive approaches and the impact of the volume cut-off should be further evaluated over a longer time period.

Robotic versus laparoscopic distal pancreatectomy: multicentre analysis.

BACKGROUND: The role of minimally invasive distal pancreatectomy is still unclear, and whether robotic distal pancreatectomy (RDP) offers benefits over laparoscopic distal pancreatectomy (LDP) is unknown because large multicentre studies are lacking. This study compared perioperative outcomes between RDP and LDP. METHODS: A multicentre international propensity score-matched study included patients who underwent RDP or LDP for any indication in 21 European centres from six countries that performed at least 15 distal pancreatectomies annually (January 2011 to June 2019). Propensity score matching was based on preoperative characteristics in a 1 : 1 ratio. The primary outcome was the major morbidity rate (Clavien-Dindo grade IIIa or above). RESULTS: A total of 1551 patients (407 RDP and 1144 LDP) were included in the study. Some 402 patients who had RDP were matched with 402 who underwent LDP. After matching, there was no difference between RDP and LDP groups in rates of major morbidity (14.2 versus 16.5 per cent respectively; P = 0.378), postoperative pancreatic fistula grade B/C (24.6 versus 26.5 per cent; P = 0.543) or 90-day mortality (0.5 versus 1.3 per cent; P = 0.268). RDP was associated with a longer duration of surgery than LDP (median 285 (i.q.r. 225-350) versus 240 (195-300) min respectively; P < 0.001), lower conversion rate (6.7 versus 15.2 per cent; P < 0.001), higher spleen preservation rate (81.4 versus 62.9 per cent; P = 0.001), longer hospital stay (median 8.5 (i.q.r. 7-12) versus 7 (6-10) days; P < 0.001) and lower readmission rate (11.0 versus 18.2 per cent; P = 0.004). CONCLUSION: The major morbidity rate was comparable between RDP and LDP. RDP was associated with improved rates of conversion, spleen preservation and readmission, to the detriment of longer duration of surgery and hospital stay.

Case report of a combined oncocytoma and type 1 papillary renal cell carcinoma: a rare entity.

An extremely rare renal hybrid tumor composed of papillary renal cell carcinoma (PRCC) and renal oncocytoma (RO) within the same tumor is described. Only eight previous cases are documented in the literature.A 44-year-old man showed a 3.5 cm renal mass composed by areas with tubulo-papillary structures made up with small cells with scanty cytoplasm adjacent to polygonal cells forming solid sheet and tubules with abundant eosinophilic cytoplasm and uniform, round central nuclei without mitoses. Complete immunohistochemical panel suggested a diagnosis of type 1 PRCC combined with RO. Contrary to previous cases of hybrid renal tumors reported in the literature, no pseudocapsule divided the two histotypes of tumors. Our patient is the youngest among the previous reports being 44.Collision tumours have previously been described, although mixed renal tumours composed of oncocytoma and PRCC is extremely rare. There is no evidence to suggest a relationship between oncocytoma and papillary RCC since they originate from different cells and have different prognoses.Given the possibility of oncocytomas to harbour other tumours, we suggest careful examination of the samples to exclude the presence of an associated malignant neoplasm, which might have a significantly worse prognosis than oncocytoma. Differential diagnosis is needed, and immunohistochemical stains are of great help in distinguishing between the two histological components.

The Learning Curve in Robotic Pancreaticoduodenectomy.

BACKGROUND/PURPOSE: Few data are available on the learning curve (LC) in robot-assisted pancreaticoduodenectomy (RAPD) and no study specifically addresses the LC of a single surgeon. METHODS: The LC of a single surgeon in RAPD was determined using the cumulative sum method, based on operative time (OT). Data were extracted from a prospectively maintained database and analyzed retrospectively considering all events occurring within 90 days of index operation. RESULTS: Seventy RAPD were analyzed. One operation was converted to open surgery (1.4%). One patient died within 30 days (1.4%) and one within 90 days (2.8%). Postoperative complications occurred in 53 patients (75.7%) and exceeded Clavien-Dindo grade IIIb in 7 patients (10%). OT dropped after 33 operations from a mean of 564 ± 101.7 min to a mean of 484.1 ± 77.9 min (p = 0.0005) and was associated to reduced incidence of delayed gastric emptying (72.7 vs. 48.7%; p = 0.039). The rate of hospital readmission improved after 40 operations from 20.0 (8 of 40) to 3.3% (1 of 30) (p = 0.04). CONCLUSIONS: RAPD was safely feasible in selected patients. OT dropped after the first 33 operations and was associated with reduced rate of delayed gastric emptying. Readmission rate improved after 40 operations.