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

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

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

MIPR Pancreas Cancer - Surgery

MIPR 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 4 IHPBA MIPR Conference São Paulo 2016

MIPR 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

MIPR 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?

MIPR

MIPR Lap Whipple (8/08 – 8/09) Patient, operative and peri-operative parameters 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) Zureikat and Hughes. J Gastrointest Surg. In press.

MIPR 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)

MIPR Lap Whipple Comparison across the learning curve Parameter Cases 1-7 Cases 8-14 Cases 30-38 Conversions, No. 2 0 1 Mortality, No. 0 0 1 Pancreatic Fistula,No. 2 3 3 Clavien I-II complications, No.* 3 3 2 Clavien III-IV complications, No.** 2 1 0 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 Zureikat and Hughes. J Gastrointest Surg. In press.

MIPR 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

MIPR Why Keep Going? Table 2. Operative and Oncologic Factors LPD (n = 52) OPD (n = 50) P Value 360 (9) ## Operative Time (min), mean (SE) 361 (7) .941 EBL (mL), mean (SE) 260 (36) 518 (54) <.001* Transfusion, % 4 (7.7) 4 (8.2) 1.00 Portal Vein Resection, % 0 0 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* 24 (47.1) # 24 (49.0) # Poor Differentiation, % .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 χ 2 coefficients for categorical variables. Significance was considered for P < 0.05. 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) 0 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 χ 2 coefficients for categorical variables and the unpaired t test for continuous variables. Abbreviations: d, days. Delitto, et al. J Gastrointest Surg , 2016 Jul;20(7):1343-9..

MIPR Perioperative outcomes of laparoscopic versus open pancreatoduodenectomy LOS Mortality Procedure Sample Conversion Op time EBL Major POPF Article DGE PPH Reoperation (days) Readmission (min.) (mL) morbidity B/C 30-day LPD 53 23% 541 195 25% 8% 9% 7% 4% 8 - 6%*** Asbun 2012 OPD 215 - 401 1032 25% 7% 10% 7% 7% 12 - 9%*** LPD 108 6% 379 492 6% 11% 9% 7% - 6 - 1% Croome 2014 OPD 214 - 387 867 14% 12% 18% 6% - 9 - 2% LPD 46 7% 342 368 28% 43% 17% 24% 24% 25 9% 2% Dokmak 2015* OPD 46 - 264 293 20% 33% 15% 7% 11% 23 9% 0% LPD 12 - - - 17% 17%^ - - - 15 - 0% Hakeem 2014* OPD 12 - - - 50% 8%^ - - - 15 - 8% LPD 11 - 474 1106 - - - - - 18 - 0% Lei 2013 OPD 75 - 251 1103 - - - - - 22 - 0% LPD 75 17% 551 - 31% 9% 13% - 4% 7 - - Mesleh 2013 OPD 48 - 355 - 31% 6% 8% - 2% 8 - - LPD 93 - 483 609 8% 7% 3% - 14 5% - Song 2015* OPD 93 - 348 570 5% 7% 8% - 19 3% - LPD 25 0% 381 200 - 16% - - 9% 9 30% 4% Speicher 2014 OPD 84 - 326 425 - 23% - - 11% 10 39% 6% LPD 30 6%** 513 - - 3% 7% - - 10 - 0% Tan 2015 OPD 30 - 372 - - 10% 10% - - 12 - 3% LPD 113 4% 365 345 10% 23% 24% 8% 3% 8 17% 4% Tee 2015 OPD 225 - 360 869 15% 25% 35% 8% 7% 9 17% 1% LPD 14 14% 456 300 20% 0% 7% 8 - 7% Zureikat 2011* OPD 14 - 373 400 7% 7% 7% 9 - 0% Underlined differences are statistically significant (p<0.05 ) Kendrick, et al. HPB , in press.

MIPR Perioperative outcomes of robotic versus open pancreatoduodenectomy Procedure Sample Conversion Operative EBL Major POPF LOS Article DGE PPH Reoperation (days) Readmission Mortality time (min) (mL) morbidity B/C RAPD 27 16%** 527 467 41%^ 7% 15% - - 10 22% 0% Baker 2015 OPD 49 - 391 867 67%^ 12% 31% - - 12 30% 4% RALPD 28 14% 431 100 - 21% 16% - 11% 7 25% 7% Bao 2014* OPD 28 - 410 300 - 21% 16% - 14% 8 25% 7% RAPD 44 5% 444 387 36%^ 9% 5% 7% 5% 13 - 5% Buchs 2011 OPD 39 - 549 827 49%^ 8% 3% 5% 13% 15 - 3% RALPD 30 10% 476 485 30%^ 7% 3% 3% 10% 10 - 4% Chalikonda 2012* OPD 30 - 366 775 43%^ 7% 3% 3% 23% 13 - 0% RALPD 60 2% 410 400 12% 8% 8% 7% 3% 20 - 2% Chen 2015* OPD 120 - 323 500 13% 15% 15% 8% 3% 25 - 3% RAPD 20 5% 492 247 50%^ 35%^ 5% 10% 10% 14 - 0% Lai 2012 OPD 67 - 265 775 49%^ 18%^ 12% 5% 5% 26 - 3% Kendrick, et al. HPB , in press. Underlined differences are statistically significant (p<0.05 )

MIPR LPD is Not Inferior to OPD with Respect to Oncologic Outcomes Delitto, et al. J Gastrointest Surg , 2016 Jul;20(7):1343-9..

MIPR Oncologic outcomes of minimally invasive versus open pancreatoduodenectomy for pancreatic adenocarcinoma Tumor Time to Major Sample Neoadj Survival OR time EBL LN’s R0 Adjuvant Local adjuvant Study Approach size Morbidity Mortality size therapy (min.) (mL) retrieved margin chemo Recurrence (months) (mm) (days) 6% 1% LPD 108 2=11% 379 492 33 21 78% 76% 48 15% 25 Croome 2014 14% 2% OPD 214 2=14% 387 867 33 20 77% 76% 59 27% 22 13% 0% LPD 15 - - - 24 20 60% - - - - Dokmak 2015 0% 0% OPD 14 - - - 28 25 50% - - - - - 5% Nussbaum MIPD 1191 2=13% - - 34 17.4 80% 55% 54 - - 2015 - 5% OPD 6776 2=13% - - 34 16.5 78% 53% 55 - - - 5% 1=7%, MIPD 384 - - 32 18 80% - - - - 2=11% Sharpe 2015 - 4% 1=8%, OPD 4037 - - 33 16 74% - - - - 2=12% 8% 0% Song MIPD 11 0% 483 609 28 15 73% - - - - 2015* 5% 0% OPD 261 0% 348 570 30 16 81% - - - - Underlined differences are statistically significant (p<0.05 ) Kendrick, et al. HPB , in press.

MIPR LPD is Cost Effective Total Cost OPD LPD Median $ 28,611 $ 28,464 Mean $ 36,759 $ 33,314 SD $ 17,381 $ 13,213 Laproscopic Electrosurgical OR Room Other Regional Block Staplers/Clips Suture Total Cost Supplies 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 .