Can laparoscopic pancreaticoduodenectomy be safely implemented?

INTRODUCTION: The implementation of laparoscopic pancreaticoduodenectomy (LPD) has been appropriately met with apprehension, and concerns exist regarding outcomes early in a program's experience. We reviewed our early experience and outcomes of LPD. METHODS: A retrospective review of patients undergoing LPD was compared to a matched cohort of open pancreaticoduodenectomy (OPD) patients. The endpoints are as follows: age, gender, ASA score, BMI, operative time, estimated blood loss, perioperative transfusion requirement, intensive care unit stay, margin status, lymph node count, 90 day morbidity and mortality, length of stay, and adjuvant therapy treatment. RESULTS: Fourteen patients underwent an attempted LPD. The median operative time was 456 min (interquartile range (IQR), 109.5), median estimated blood loss was 300 ml (IQR, 225), and 29% of the patients required a perioperative blood transfusion. A conversion was necessary in two patients (14%). A malignancy was present in 12 patients. The mean tumor size was 2.2 cm (standard deviation (SD), 1.1), the mean lymph node count was 18.5 (SD 6.2), and an R0 resection was achieved in all 12 cases. Clavien grade I/II complications occurred in 42% of the patients, and Clavien grade III/IV complications occurred in three (20%). There was one late postoperative death. The median length of stay was 8 days. Compared to OPD, LPD took longer to perform, but no differences were noted with respect to blood loss, morbidity, mortality, R0 resection rate, and LN harvest. CONCLUSIONS: LPD can be implemented in a high-volume pancreatic surgery center with acceptable oncologic and patient outcomes.

Effect of natural disaster on routine surgery.

BACKGROUND: We undertook this study to learn about the effect of Hurricane Katrina on routine surgery, using laparoscopic cholecystectomy (LC) as an index case. STUDY DESIGN: All inpatients with (LC) (DRG 493 and 494) and outpatients with principal procedure code 51.23 LC were included in the study. The time periods used were for the 7 months before Katrina compared with 7 months post-Katrina, starting 3 months after the storm when operating room volumes had returned to normal. Data points collected were operative time, length of stay, operating room turnover time, cost, revenue, surgery staff levels pre- and poststorm, and payer mix pre- and poststorm. RESULTS: Total cases were 196 prestorm and 167 poststorm for outpatient LC, and 62 prestorm and 64 poststorm for inpatient LC. Operative time, length of stay, and turnover time did not change significantly, despite staffing difficulties in the operative area. Poststorm cost decreased for both inpatient and outpatient LC. Revenue was down for inpatient LC and up slightly for outpatient. Decreased costs were largely from the loss of staff because of the storm, which meant that we were performing procedures with fewer staff. Our better payers decreased by 10.5% and Medicare, Medicaid, and private pay noninsured patients increased by 1%, 3.5%, and 6%, respectively. Change in profit was not significant. CONCLUSIONS: Hurricane Katrina opened the door to cost efficiencies for LC. But revenue went down because of increases in uninsured patients and fewer outpatient LCs. Efficiency remained stable despite the loss of staff. In planning for this type of disaster, be ready for large staff turnovers, a potential increase in uninsured patients, a diminished employment pool, and decreases in outpatient surgery.

Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The reported learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGB) is 20-100 cases. Our aim was to investigate whether advanced laparoscopic skills could decrease the learning curve for LRYGB with regard to major morbidity. METHODS: The senior author performed all operations in this series. His training included a laparoscopic fellowship without bariatric surgery, six years in surgical practice focusing on upper abdominal laparoscopic surgery, two courses on bariatric surgery at national meetings, one week of observing a bariatric program, and two mentored LRGBY cases. A comprehensive obesity program was put in place before the program began. Data were collected prospectively and reviewed at the series' end. Results are presented as mean +/- standard deviation and standard statistical analysis was applied. RESULTS: Between December 2003 and February 2005, 107 LRYGB operations were performed. Mean operative time decreased significantly with experience (p < 0.0001) and was 154 +/- 29, 132 +/- 40, 127 +/- 29, and 114 +/- 30 min by quartile. Mean length of stay was 2.9 +/- 1.6 days. Mean excess weight loss was 45.3% (n = 41) at six months. There were no conversions to an open procedure, no anastomotic leaks, no pulmonary embolisms, and no bowel obstructions. The five major complications (3 in the first 50 and 2 in the last 57 cases, p = NS) were two cases of biliopancreatic limb obstruction, two cases of significant gastrointestinal bleeding from anastomotic ulcer, and one case of gastric volvulus of the remnant stomach. CONCLUSIONS: A bariatric fellowship and/or extended mentoring are not required to safely initiate a bariatric program for surgeons with advanced laparoscopic skills. Operative time decreases significantly with experience, but morbidity and mortality remain low even early in the learning curve. A comprehensive obesity program seems necessary for success.