Laparoscopic pancreatoduodenectomy training program outcomes
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outcome of a multi-center training program in laparoscopic pancreatoduodenectomy
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Laparoscopic pancreatoduodenectomy training program outcomes
- 2. Laparoscopic pancreatoduodenectomy ↓ delayed gastric emptying ↓ intraoperative blood loss ↓ hospital stay, without increasing overall costs ↑ operative time 2X postoperative mortality in low volume centers (<10 LPDs annually) May ↑ rates of postoperative pancreatic fistula (POPF) and readmission rates
- 3. LAELAPS Longitudinal Assessment and Realization of Laparoscopic Pancreatic Surgery Nationwide Dutch Pancreatic Cancer Group (DPCG) 7X ↑ in the use of laparoscopic distal pancreatectomy ↓ conversion rates (38%→8%) and hospital stay (9 → 7 days )
- 4. LAELAPS-2 multicenter training Program in LPD : April 2014 - September 2015. Data of all LPDs were collected prospectively: April 2014-September 2016
- 5. Selection criteria were used for LPD Body mass index (BMI) <35 kg/m2 No signs of vascular tumor involvement celiac trunk hepatic artery superior mesenteric artery portal vein superior mesenteric vein No previous chronic pancreatitis or pancreatic radiotherapy
- 6. •8 pancreatic surgeons from 4 centers • Completed the LAELAPS-2 multicenter training program in LPD. • >5 years of experience with open pancreatic surgery and (advanced, including stapled and hand-sewn intracorporeal anastomoses) laparoscopic gastrointestinal surgery • All completed the LAELAPS-1 training program in laparoscopic distal pancreatectomy
- 7. median score 3.5/5 3 median score 3/5 4
- 8. Completing all training phases by a single surgeon took around 35hours median score 4.5/5 1 median score 4/5 2
- 12. 20% to 29% 5%
- 13. • This LPD training program was feasible and ensured acceptable outcomes during the learning curve in all centers. • Future studies should determine whether such a training program is applicable in other settings and assess the added value of LPD.
Editor's Notes
- 3. de Rooij T, Lu MZ, Steen MW, et al., Dutch Pancreatic Cancer Group. Minimally invasive versus open pancreatoduodenectomy: systematic review and meta-analysis of comparative cohort and registry studies. Ann Surg. 2016;264:257–267. 4. Conlon KC, de Rooij T, van Hilst J, et al., Minimally Invasive Pancreatic Resection Organizing Committee. Minimally invasive pancreatic resections: cost and value perspectives. HPB (Oxford). 2017;19:225–233. 5. de Rooij T, Klompmaker S, Abu Hilal M, et al. Laparoscopic pancreatic surgery for benign and malignant disease. Nat Rev Gastroenterol Hepatol. 2016;13:227–238. 6. Nassour I, Wang SC, Christie A, et al. Minimally invasive versus open pancreaticoduodenectomy: a propensity-matched study from a national cohort of patients. Ann Surg. 2017. May 8. [Epub ahead of print]. 7. Dokmak S, Fte´riche FS, Aussilhou B, et al. Laparoscopic pancreaticoduodenectomy should not be routine for resection of periampullary tumors. J Am Coll Surg. 2015;220:831–838.
- In 2014, the Dutch Pancreatic Cancer Group (DPCG) initiated the nationwide LAELAPS (Longitudinal Assessment and Realization of Laparoscopic Pancreatic Surgery) program to implement pancreatic surgery safely according to the IDEAL framework.8–11 LAELAPS-1 resulted in a 7-fold increase in the use of laparoscopic distal pancreatectomy in the Netherlands and was followed by decreased conversion rates (from 38% to 8%) and hospital stay (from 9 to 7 days).11 to assess the feasibility and outcomes of the LAELAPS-2 multicenter LPD training program in the Dutch healthcare setting.
- (Fig. 1). The participating surgeons considered proctoring on-site as the most important step (median score 4.5/ 5), followed by proctoring off-site (median score 4/5), detailed technique description (median score 3.5/5) and video training (median score 3/5). All surgeons (100%) considered the training program sufficient to start performing LPD by themselves and would advise colleagues to complete the training program before starting with LPD. After training, participating surgeons aimed to perform 20% to 60% of pancreatoduodenectomies laparoscopically.
- pancreatic ductal adenocarcinoma
- Patient selected for LPD were at relatively higher risk for POPF due to a small pancreatic duct diameter and soft pancreatic texture in the vast majority of cases. With 22% of patients undergoing radiological drainage and 2% a reoperation because of a POPF, the overall POPF rate (34%) was high. This 34% is however close to the upper range of the 20% to 29% POPF rate seen in European multicenter randomized controlled trials on open pancreatoduodenectomy .Keck T, Wellner UF, Bahra M, et al. Pancreatogastrostomy versus pancreatojejunostomy for RECOnstruction after PANCreatoduodenectomy (RECOPANC, DRKS 00000767): perioperative and long-term results of a multicenter randomized controlled trial. Ann Surg. 2016;263:440–449. . Perinel J, Mariette C, Dousset B, et al. Early enteral versus total parenteral nutrition in patients undergoing pancreaticoduodenectomy: a randomized multicenter controlled trial (Nutri-DPC). Ann Surg. 2016;264:731–737. The rate of grade B/C bile leakage in our series was high (11%) compared with open procedures in the Netherlands.(5%) This could perhaps be explained by the fact that the hepatic duct was only dilated in a minority of patients but also by technical problems.