Safe implementation of minimally invasive pancreas resection: a systematic review

Abstract

Background: Minimally invasive pancreas resection (MIPR) has been expanding in the past decade.Excellent outcomes have been reported, however, safety concerns exist. The aim of this study was to define prerequisites for performing MIPR with the objective to guide safe implementation of MIPR into clinical practice. Methods: This systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). PubMed, Embase and Cochrane databases were searched for literature concerning the implementation of MIPR between 1946 and November 2018. Quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN).Results: Overall, 1150 studies were screened, of which 32 studies with 8519 patients were included in this systematic review. Training programs for minimally invasive distal pancreatectomy, laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy have been described with acceptable outcomes during the learning curve and improved outcomes after training. Learning curve studies have revealed an association between growing experience and improving perioperative outcomes. In addition, the association between higher center volume and lower mortality and morbidity has been reported by several studies. Conclusion:When embarking on MIPR, it is recommended to participate in a dedicated training program, to assure a sufficient volume, especially when implementing minimally invasive pancreatoduodenectomy, (20 procedures recommended annually), and prospectively collect and closely monitor outcomes for continuous quality assessment, this can be achieved through institutional databases and participation in national or international registries.

Operationsindikationen bei zystischen Tumoren des Pankreas

“…Nach durchgeführter Punktion sind die Bestimmung von Muzin und des karzinoembryonalen Antigens (CEA) sowie eine zytologische Untersuchung sinnvoll [64 -66] Der Standardzugangsweg stellt auch in der Pankreaschirurgie zystischer Tumoren weiterhin die offene Chirurgie dar, wenngleich vor allem bei Pankreaslinksresektionen ein laparoskopisches Vorgehen sicher möglich ist und zunehmend eingesetzt wird. Zukünftig könnten minimalinvasive Operationsmethoden durch den Einsatz der robotischen Chirurgie auch im Bereich der Pankreaskopfchirurgie einen zunehmenden Stellenwert einnehmen [68,69].…”

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

“…A major obstacle to the widespread adoption of minimally invasive pancreatic surgery (MIPS)especially MIPD-is its steep learning curve. 46 In the literature, several authors have addressed the learning curve of LDP. Depending on the outcome measure, it was reported to be as low as from 10-15 procedures 47,48 for open conversion and up to 40 procedures for reduction in operating time.…”

“…Various factors can affect this "magic number", including the statistical method used (such as CUSUM), outcome measure (such as blood loss, operating time, morbidity and conversion rate), single surgeon vs institutional data, study cohort size and the surgeon's proficiency and experience in MIS and open surgery. 46 Consequently, it is almost impossible to determine the exact number of procedures that are required to complete the learning curve in order to achieve proficiency. It is also very unlikely that the personal learning curves of surgeons will be uniform across indivduals.…”

“…It is also very unlikely that the personal learning curves of surgeons will be uniform across indivduals. 46 The inverse association between institution volume and surgical outcomes is well documented in complex surgeries such as pancreatic surgery. 23,59,60 The volumeoutcome effect is seen in MIPS, especially MIPD.…”

Surgical Therapy of Chronic Alcoholic Pancreatitis: A Literature Review of Current Options

“…In a small series of patients with refractory CP and dilated main duct, Balduzzi et al [15] described a robotic lateral pancreaticojejunostomy as a feasible but complex operation which is limited to very few patients. Current data are not sufficient to estimate the role of minimal invasive surgery in CP [15][16][17][18]. It should be noted, however, that surgery in CP is challenging due to the chronically inflamed surrounding tissue.…”