[PPT] - Minimally Invasive Pancreatoduodenectomy Steven J. Hughes, MD PowerPoint Presentation

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Minimally Invasive Pancreatoduodenectomy

Steven J. Hughes, MD Cracchiolo Family Professor and Chief, General Surgery Vice-Chair, Quality University of Florida

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Disclosure slide

I, Steven J. Hughes, MD, FACS, DO NOT have a financial interest/arrangement or affiliation with one or more

rganisations which could be perceived as a real or apparent

conflict of interest in the context of the subject of this presentation

IHPBA MIPR Conference São Paulo 2016

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Pancreas Cancer - Surgery

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Why Start? 2007

Pancreatic surgery passion, fraction of practice
Majority of practice – MIS
Foregut
Antireflux procedures
Gastrectomies –including Roux en Y reconstruction
Intestinal surgery, particularly colon resections
Distal pancreatectomy/splenectomy
Biliary reconstructions
LDP is superior to Open DP (2001 - 2007)
Blood loss, transfusion, wound morbidity = ↓ LOS
Equivalent oncologic procedure

IHPBA MIPR Conference São Paulo 2016

4

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Preparation

> 400 laparoscopic procedures (excluding hernia

and cholecystectomy)

> 150 radical pancreaticoduodenectomies
Uncinate dissection and PJ
Cadaver X 4
Lap Dissection X 4 with intentional conversion for

reconstruction

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Contraindications

Locally advanced disease
High Risk for positive margin
UPMC image-based model
CT - Any vessel involvement
EUS
EUS N1
T > 2.6 cm
Malignancy?

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Lap Whipple (8/08 – 8/09)

Characteristic Value (range) Patient, No. 14 Age, mean, (SD) 65.2 (20.3) Sex, Male / Female, % 78.6 / 21.4 ASA, II/III, % 43 / 57 BMI, median (IQR) 27.3 (7.8) Operative time, min, median (IQR) 456 (109.5) Estimated blood loss, mean, (IQR) 300 (225) Patients transfused, No. (%) 4 (29%) Patients needing ICU care, No. (%) 5 (36%) Length of stay, days, median (IQR) 8 (8.5)

Patient, operative and peri-operative parameters Zureikat and Hughes. J Gastrointest Surg. In press.

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Lap Whipple (8/08 – 8/09)

Diagnosis

No. (%)

Pancreatic adenocarcinoma 8 (58) Cholangiocarcinoma 2(14) Duodenal adenocarcinoma 1(7) Duodenal GIST 1(7) IPMN 1(7) Chronic pancreatitis 1(7)

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Lap Whipple

Parameter Cases 1-7 Cases 8-14 Cases 30-38 Conversions, No. 2 1 Mortality, No. 1 Pancreatic Fistula,No. 2 3 3 Clavien I-II complications, No.* 3 3 2 Clavien III-IV complications, No.** 2 1 Operative time, min, median 474 445 385 Estimated blood loss, ml, mean 325 250 285 Length of stay, days, median 9 7 6.5 * Complications not requiring radiologic, endoscopic or operative intervention and not causing organ failure ** Complications requiring radiologic, endoscopic or operative intervention and /or causing organ failure

Comparison across the learning curve Zureikat and Hughes. J Gastrointest Surg. In press.

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Why not Quit? 2008 - 2011

Brutal Learning Curve
Early ( n = 1 - 40)
Surgeon stress and subsequent fatigue
Fundamental issues - trocar placement, sequence of steps
Changes in dissection and reconstruction techniques
Late (n = 40 – 80)
Expansion of inclusion criteria
Minimal resuscitation + ABL → shock = poor outcomes
Value to palpation & digital control
Post-pancreatectomy hemorrhage
Energy devices
Staplers

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Why Keep Going?

Table 3. Postoperative Complications

LPD (n = 52) OPD (n = 50) P Value Length of Stay (d), mean (SE) 9.0 (0.7) 11.9 (1.1) .025* Wound Infection (%) 8 (16) 17 (34) .038* Pancreatic Leak, % 9 (17) 18 (36) .032* Grade B/C Leak, % 6 (12) 13 (26) .061 Postpancreatectomy Hemorrhage (%) 5 (10) 3 (6) .716 Major Morbidity (Clavien III/IV) 13 (25) 16 (32) .433 30-Day Mortality, % 1 (2) 1.00 Pancreatic fistulas are graded according to the International Study Group on Pancreatic Fistula (ISGPF) criteria.19 Morbidity is defined by Clavien-Dindo classification, as previously described.18 P values were calculated using χ2 coefficients for categorical variables and the unpaired t test for continuous variables. Abbreviations: d, days.

Table 2. Operative and Oncologic Factors

LPD (n = 52) OPD (n = 50) P Value Operative Time (min), mean (SE) 361 (7) 360 (9)## .941 EBL (mL), mean (SE) 260 (36) 518 (54) <.001* Transfusion, % 4 (7.7) 4 (8.2) 1.00 Portal Vein Resection, % 1.00 Nodal Metastasis, % 34 (65.4) 40 (80.0) .098 Total Lymph Nodes, mean (SE) 23.0 (1.2) 20.8 (1.2) .178 Positive Lymph Nodes, mean (SE) 3.1 (0.5) 3.1 (0.4) .994 Tumor Size (cm), mean (SE) 2.5 (0.1) 3.1 (0.2) .046* R1 Resection, % 5 (9.6) 13 (26.0) .030* Poor Differentiation, % 24 (47.1)# 24 (49.0)# .848

R0 resection is defined as a margin-negative resection. #One adenosquamous tumor was excluded from analysis of tumor differentiation in each indicated cohort. ##Operative times were available for 42 of 50 OPD patients. P values represent significant levels calculated using the unpaired t test for continuous variables and χ2 coefficients for categorical variables. Significance was considered for P < 0.05.

Delitto, et al. J Gastrointest Surg, 2016 Jul;20(7):1343-9..

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MIPR Perioperative outcomes of laparoscopic versus open pancreatoduodenectomy

Article Procedure Sample Conversion Op time (min.) EBL (mL) Major morbidity POPF B/C DGE PPH Reoperation LOS (days) Readmission Mortality 30-day Asbun 2012 LPD 53 23% 541 195 25% 8% 9% 7% 4% 8

6%***

OPD 215

401

1032 25% 7% 10% 7% 7% 12

9%***

Croome 2014 LPD 108 6% 379 492 6% 11% 9% 7%

6
1%

OPD 214

387

867 14% 12% 18% 6%

9
2%

Dokmak 2015* LPD 46 7% 342 368 28% 43% 17% 24% 24% 25 9% 2% OPD 46

264

293 20% 33% 15% 7% 11% 23 9% 0% Hakeem 2014* LPD 12

17%

17%^

15
0%

OPD 12

50%

8%^

15
8%

Lei 2013 LPD 11

474

1106

18
0%

OPD 75

251

1103

22
0%

Mesleh 2013 LPD 75 17% 551

31%

9% 13%

4%

7

OPD

48

355
31%

6% 8%

2%

8

Song

2015* LPD 93

483

609 8% 7% 3%

14

5%

OPD

93

348

570 5% 7% 8%

19

3%

Speicher

2014 LPD 25 0% 381 200

16%
9%

9 30% 4% OPD 84

326

425

23%
11%

10 39% 6% Tan 2015 LPD 30 6%** 513

3%

7%

10
0%

OPD 30

372
10%

10%

12
3%

Tee 2015 LPD 113 4% 365 345 10% 23% 24% 8% 3% 8 17% 4% OPD 225

360

869 15% 25% 35% 8% 7% 9 17% 1% Zureikat 2011* LPD 14 14% 456 300 20% 0% 7% 8

7%

OPD 14

373

400 7% 7% 7% 9

0%

Underlined differences are statistically significant (p<0.05)

Kendrick, et al. HPB, in press.

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Perioperative outcomes of robotic versus open pancreatoduodenectomy

Article Procedure Sample Conversion Operative time (min) EBL (mL) Major morbidity POPF B/C DGE PPH Reoperation LOS (days) Readmission Mortality Baker 2015 RAPD 27 16%** 527 467 41%^ 7% 15%

10

22% 0% OPD 49

391

867 67%^ 12% 31%

12

30% 4% Bao 2014* RALPD 28 14% 431 100

21%

16%

11%

7 25% 7% OPD 28

410

300

21%

16%

14%

8 25% 7% Buchs 2011 RAPD 44 5% 444 387 36%^ 9% 5% 7% 5% 13

5%

OPD 39

549

827 49%^ 8% 3% 5% 13% 15

3%

Chalikonda 2012* RALPD 30 10% 476 485 30%^ 7% 3% 3% 10% 10

4%

OPD 30

366

775 43%^ 7% 3% 3% 23% 13

0%

Chen 2015* RALPD 60 2% 410 400 12% 8% 8% 7% 3% 20

2%

OPD 120

323

500 13% 15% 15% 8% 3% 25

3%

Lai 2012 RAPD 20 5% 492 247 50%^ 35%^ 5% 10% 10% 14

0%

OPD 67

265

775 49%^ 18%^ 12% 5% 5% 26

3%

Underlined differences are statistically significant (p<0.05)

Kendrick, et al. HPB, in press.

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LPD is Not Inferior to OPD with Respect to Oncologic Outcomes

Delitto, et al. J Gastrointest Surg, 2016 Jul;20(7):1343-9..

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MIPR Oncologic outcomes of minimally invasive versus open pancreatoduodenectomy for pancreatic adenocarcinoma

Study Approach Sample size Neoadj therapy OR time (min.) EBL (mL) Tumor size (mm) LN’s retrieved R0 margin Major Morbidity Mortality Adjuvant chemo Time to adjuvant (days) Local Recurrence Survival (months) Croome 2014 LPD 108 2=11% 379 492 33 21 78% 6% 1% 76% 48 15% 25 OPD 214 2=14% 387 867 33 20 77% 14% 2% 76% 59 27% 22 Dokmak 2015 LPD 15

24

20 60% 13% 0%

OPD

14

28

25 50% 0% 0%

Nussbaum

2015 MIPD 1191 2=13%

34

17.4 80%

5%

55% 54

OPD

6776 2=13%

34

16.5 78%

5%

53% 55

Sharpe

2015 MIPD 384 1=7%, 2=11%

32

18 80%

5%
OPD

4037 1=8%, 2=12%

33

16 74%

4%
Song

2015* MIPD 11 0% 483 609 28 15 73% 8% 0%

OPD

261 0% 348 570 30 16 81% 5% 0%

Underlined differences are statistically significant (p<0.05)

Kendrick, et al. HPB, in press.

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LPD is Cost Effective

Total Cost OPD LPD Median $ 28,611 $ 28,464 Mean $ 36,759 $ 33,314 SD $ 17,381 $ 13,213

Electrosurgical Laproscopic Supplies OR Room Other Regional Block Staplers/Clips Suture Total Cost LPD OPD LPD OPD LPD OPD LPD OPD LPD OPD LPD OPD LPD OPD LPD OPD Diff Mean $ 662 $ 587 $ 450 $ 47 $ 7,571 $ 7,381 $ 364 $ 544 $ 1,450 $ 820 $ 1,829 $ 1,835 $ 305 $ 311 $12,631 $11,523 $ 1,107 Median $ 640 $ 503 $ 446 $ - $ 7,315 $ 7,164 $ 348 $ 192 $ 1,510 $ 718 $ 1,591 $ 1,886 $ 244 $ 212 $12,290 $11,299 $ 991 SD $ 303 $ 358 $ 225 $ 125 $ 1,321 $ 1,617 $ 170 $ 2,159 $ 1,040 $ 744 $ 794 $ 1,351 $ 318 $ 373 $ 1,804 $ 3,587

Hughes Sj, et al. J Gastrointest Surg. In review.

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Disposition

LPD OPD P value (n=52) (n=50) Expired 1 (2%) 1 (2%) 1 To home (with or without HHC) 46 (88%) 36 (72%) 0.047* To home with HHC 23 (44%) 23 (46%) 1 To home without HHC 23 (44%) 13 (26%) 0.064 To facility 5 (10%) 13 (26%) 0.038* To long term acute care 0 (0%) 2 (4%) 0.24 To rehabilitation center 0 (0%) 4 (8%) 0.054 To skilled nursing facility 5 (10%) 7 (14%) 0.55

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Open approach Minimally invasive approach

Advantage Disadvantage

“gold standard”, “time tested” outcomes newer approach, needs additional investigation

perative time

increased operative time during learning curve

perative cost

increased operative/equipment cost established training paradigms limited supervised training opportunities tactile feedback reduced tactile feed back

Disadvantage Advantage

blood loss reduced blood loss incisional pain reduced incisional pain wound morbidity (infection/hernia) reduced wound morbidity hospital stay reduced hospital stay recovery time reduced recovery time Failure to receive adjuvant therapy magnified view computer enhanced surgical skills

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Summation

Initiating a program is daunting
High volume necessary for iterative improvement
No
CPT code
Training program
Credentialing criteria
Selection criteria

IHPBA MIPR Conference São Paulo 2016

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Questions?

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Why not the robot?

Additional skill
MIS skills are intrinsic to current practice and training
Thus, robot skills presently build on MIS skills
Logistics
Access
Costs
Capitol and consumables costs
Team costs