SAN ANTONIO – Early data suggest that robotic-assisted technology may be the vehicle that helps drive pancreatic cancer surgery into the mainstream, thanks in large part to the improved dexterity and visualization capabilities the technology provides, according to Dr. A. James Moser.
After performing 50 robotic pancreaticoduodenectomies, he and his colleagues at the University of Pittsburgh Medical Center believe robotic hepatobiliary-pancreatic (HPB) surgery is a reasonable and feasible approach for management of pancreatic cancer, Dr. Moser said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
"The majority of patients [mean age 67 years] had had prior surgery, more than half had major medical comorbidities, and a quarter of them had multiple major comorbidities," said Dr. Moser. The first 34 patients underwent classic pancreaticoduodenectomy, and the rest had pylorus-preserving surgery, he said. The mean operative time was 576 minutes, and the median estimated blood loss was 400 mL.
"The rates of transfusion and conversion to open procedures were both acceptable at approximately 20%, and the lymph node harvest was a median of 18, which exceeds the standard of 12 established in most papers," he said. Additionally, "of 25 adenocarcinomas, 22 had clearly negative margins, giving us an R0 resection rate of 88%."
With respect to postoperative outcomes, he said, "half of the pancreatic fistulae were clinically insignificant grade A, while 12% were more significant. The rates of major and minor complications are essentially identical to open procedures, and the reoperation rate, all the way out to 90 days was only 3%."
The investigators also compared their robotic results with those of contemporaneous laparoscopic procedures, looking specifically at the outcomes of 76 minimally invasive distal pancreatectomies performed within the past 2½ years, said Dr. Moser. Although patients were equivalent in age, body mass index, and American Society of Anesthesiologists (ASA) scores, the investigators found that there was less risk of the need for blood transfusions and conversion to open surgery, and better lymph node harvest with the robotic approach vs. laparoscopy, whereas fistula and complication rates were the same in robotic vs. laparoscopic procedures.
Dr. Moser offered the following observations about four important keys to success:
• Safety. "There is a fallacy of learning curves," Dr. Moser stated. "In the 21st century, you don’t get one. You have to get beyond it before you even start."
• Teamwork. "The idea of collaboration between two experienced surgeons is often overlooked," he said. "The use of robotic surgery has enabled us to get beyond the idea of the surgeon/assistant paradigm to enable four-hand surgery to be done minimally invasively."
• Comparative effectiveness research. "It’s essential that the technical outcomes and approaches of the minimally invasive procedure mirror precisely what we do in open procedures, because relative efficacy has to be determined based on the outcomes of two operations that are exactly equivalent except for the minimally invasive approach," he said. "The procedures also have to be approached without case selection bias and using a widely applicable strategy. It should be the rule, not the exception, that we be able to apply this technology to all patients who come to us for primary surgical therapy." Toward this end, the investigators use a validated prediction model based on preoperative imaging to maximize the R0 resection rate (HPB [Oxford] 2009;11:606-11).
• Transparency. "Effectiveness in this domain requires a commitment to quality assurance and quality improvement, and it has to be transparent. [At UPMC] we have a vast volume of complex HPB surgery that has led to individual and institutional competence. We have a robotic selection committee, and all patients are signed up for the IRB registry. We have an outcomes program that tracks 34 variables in real time. We established early on the idea of a ‘drop dead’ time of 6 hours, after which, if the resection is not complete, we convert to an open procedure so patients will not be harmed by excessively long operating times. The idea is outcomes, outcomes, outcomes."
"We will either find a way to make pancreatic cancer surgery less fearsome to people or we will make one," Dr. Moser said, borrowing from the Latin proverb "I’ll either find a way or make one" commonly attributed to Hannibal.
"If you look at recent studies on national failure to operate on early-stage pancreatic cancer, approximately 71% of people who were clinically stage I with the disease never underwent an operation in the U.S. as of 2007, which shows that the operation is at least as fearsome as the disease," he observed (Ann. Surg. 2007;246:173-80). "Any method that can potentially reduce the morbidity of this operation is going to be beneficial in patients with early-stage disease, at least in the absence of more efficacious chemotherapeutic agents."