Improving Patient Centered Outcomes in Pancreatic Cancer (Text Version)

On September 19, 2011, A.J Moser and Herbert Zeh made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (9 MB). Plugin Software Help.

Slide 1

Improving Patient Centered Outcomes in Pancreatic Cancer

A. James Moser, MD
Herbert J. Zeh, III, MD

Co-Directors, UPMC Pancreatic Cancer Center
Division of Surgical Oncology
University of Pittsburgh School of Medicine (UPMC)

Slide 2

Improving Patient Centered Outcomes in Pancreatic Surgery

• Develop "personalized" surgical treatment:
  • Modeling of outcomes.
  • Theranostics.
• Re-thinking clinical trial design.
• Explore minimally invasive approach to pancreatic surgery program.

Slide 3

Patient Centered Outcomes in Pancreatic Surgery

• Reduced perioperative morbidity.
• Maintain quality of life.
• Decreased peri-operative blood loss and transfusion.
• Increased rate of adjuvant therapy.

Slide 4

Why develop a minimally invasive approach to Pancreas?

• Pancreatic cancer remains dormant for 10-12 years before clinically detectable?
  • Early detection may allow less invasive surgery to be curative?

Image of a journal article title and a figure from the article.

Slide 5

Why develop a minimally invasive approach to Pancreas?

• "Prophylactic" pancreatectomy:
  • IPMN = polyp of the pancreas.

Images: Polyps of the pancreas are shown.

Slide 6

Laparoscopic PD

• Adequate for ablative surgery.
• For procedures requiring extensive reconstruction the technique is modified to meet the technological limitations.

• Poor ergonomics for the surgeon.
• Limited range of motion of instruments.
• Two dimensional!
  • Wouldn't do open surgery with one eye.

Slide 7

Robotic Pancreas Resections

• Advantages of Robotic Surgery:
  • Magnification 20x-30x.
  • Near 360 degrees range of motion in instruments.
  • Elimination of tremor / improved dexterity.
  • Stereotactic binocular vision—it's 3D like Avatar!

Slide 8

Goals of Robotic Pancreas Program at UPMC

• Major objectives:
  • Reproduce open technique and outcomes.
  • Widely applicable.
  • Quality Assurance.
• Rule out Disadvantages:
  • Equivalent safety?
  • Learning curve and time investment.
• Explore Potential Advantages:
  • Decrease peri-operative morbidity/blood transfusions.
  • Earlier adjuvant chemotherapy.

Slide 9

UPMC Robotic Pancreas Program
9/17/2011

Flowchart showing breakdown of studies.

N=195

• RAPD N=85.
• RACP N=43.
• RATP  N=5.
• RADP N=60.
• RAF N=2.

Slide 10

Robot-Assisted Minimally-Invasive Distal Pancreatectomy Is Superior to the Laparoscopic Technique

Slide 11

Methods

• Retrospective analysis of all minimally-invasive distal pancreatectomies at UPMC between January 2004 and February 2011.
• Compared the peri-operative outcomes of our first 30 RADP to 94 consecutive historical control LDP.

Slide 12

Table 1. Outcomes Following Laparoscopic and Robotic-assisted Distal Pancreatectomy

Values represent mean ±SD, or n (%)

Slide 13

Table 2. Pathologic Indications for Distal Pancreatectomy

§ Includes autoimmune pancreatitis (n=2), chronic pancreatitis (n=1), serous cystadenoma (n=3), pseudocyst (n=1), mucinous cystadenocarcinoma (n=1), spindle cell lesion, (n=1), benign epithelial cyst (n=2) and oligocystic adenoma (n=1).
†† Includes lymphoepithelial cyst (n=1)

Slide 14

Table 3. Perioperative Outcomes Following Laparoscopic and Robotic-assisted Distal Pancreatectomy

Normally-distributed values are expressed as mean ± SD or n (%); otherwise median (25th, 75th percentile) as interquartile range (IQ).

¥Clavien classification of surgical complications.¹⁶

Slide 15

Table 5. Effects of Conversion During LDP on Perioperative Outcome

Normally-distributed values are expressed as mean ± SD or n (%); otherwise median (25th, 75th percentile) as interquartile range (IQ).

Slide 16

Table 4. Pathologic Outcomes Following Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

Normally-distributed values are expressed as mean ± SD or n (%); otherwise median (25th, 75th percentile) as interquartile range (IQ).

Slide 17

Comparison of Robotic (RADP) and Laparoscopic (LDP) Approach to Distal Pancreatectomy

• Robotic assisted minimally invasive distal pancreatic resection appears comparable to laparoscopic approach in safety and feasibility.
• RADP was associated with decreased frequency of conversion to open, increased number of total Lymph node harvested, higher rate of R0 resections and decreased significant blood loss.
• These data suggest that use of the Robotic Platform may allow more patients to successfully undergo minimally invasive distal pancreatectomy.
• Larger multicenter studies are needed to validate these findings.

Slide 18

UPMC Robotic Pancreas Program
9/17/2011

Repeat of Slide 9.

Slide 19

Image: Titles and authors for two articles on robot-assisted pancreative resection and reconstruction are shown.

Slide 20

Table 1: Demographics of Entire RAPD Cohort

Data are presented as mean ±SD, or n (%).

Slide 21

Table 2: Pathologic Indications for RAPD

Slide 22

Table 3: Perioperative Outcomes of RAPD Cohort

Slide 23

Table 4: Pathologic Outcomes Following RAPD for Invasive Periampullary Adenocarcinoma

Data presented as median (IQR) or n (%) for PDA, AMP, and CCA only.

Slide 24

Table 5: Postoperative Complications Following RAPD

Slide 25

Conclusions:

• Robotic assisted Pancreatic resections are currently feasible and safe.
• Evolution of the technique will likely continue making comparative studies difficult.
• Multicenter collaborations necessary to study comparative effectiveness.

Slide 26

Minimally Invasive Pancreatic Surgery Consortium (MIPSC)

• Contributing Members:
  • University of Pittsburgh.
  • Mayo Clinic.
  • Cleveland Clinic.
  • Pisa Italy.
• Second Annual meeting November 2011.
• Goals:
  • Multicenter prospective database.
  • Standardization of procedures.
  • Comparative effectiveness studies.

Slide 27

UPMC Pancreatic Cancer Program

zehh@upmc.edu

moseraj@upmc.edu

Slide 28

RAPD Set Up

Images: Photographs of the RAPD equipment are shown.

Slide 29

Tying It All Together...

Slide 30

Case Presentation

• 76 y/o female symptomatic found to have elevated amylase and lipase after abdominal pain.
• CT main duct IPMN.
• Followed for several years.
• Recent EUS demonstrated increased in disease in head of gland.

Slide 31

Case Presentation

Image: MRI of a patient's abdomen are shown.

Slide 32

Case Presentation

Image: A photograph of the removed pancreas section is shown.

Slide 33

Case Presentation (continued)

IMPN of main duct:

• Uncomplicated Robotic Assisted Pancreaticoduoenectomy.
• Discharged POD #10.
• Final Pathology:
  • IPMN with dysplasia.

Slide 34

Case Presentation: #2

• 72 y/o male abdominal pain three months, followed by jaundice.
• CT Large mass in the HOP:
  • Loss of fat plane between mass and PV/SMV.
• EUS –:
  • Loss of fat plane PV/SMV.
• ERCP:
  • Double duct.
  • Short metal stent.
• Cytology:
  • Acinar Cell Carcinoma.

Slide 35

Image: An MRI of a patient's abdomen is shown.

Slide 36

Case Presentation : #2 (continued)

• Received six cycles of modified FOLFOX.
• Repeat Staging demonstrated partial response in tumor and no metastatic disease.

Slide 37

Image: An MRI of a patient's abdomen is shown.

Slide 38

Case Presentation: #2 (continued)

• Uncomplicated Robotic Assisted Pancreaticoduoenectomy.
• Discharged POD 5.
• Final Pathology:
  • Acinar Cell Carcinoma with significant Rx effect.
  • Negative margins.

Slide 39

Case Presentation: #2 (continued)

• Received additional three cycles of modified FOLFOX.
• Alive and disease free at 24 months.