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Feb 24, 2024, 11:20

Mark Lewis: Delayed gastric emptying is MISERABLE

Mark Lewis, the Director of Gastrointestinal Oncology at Intermountain Healthcare in Utah, shared an X post by Zhi Ven Fong, Pancreas and Liver surgeon at Mayo Clinic, adding:

“Delayed gastric emptying is MISERABLE.

From the patient perspective I would opt for open over robotic if the surgeon thought the former would substantially reduce the chances of DGE.

Just my two cents (lots of great nuance in the thread).

Quoting Zhi Ven Fong‘s post:

“The EUROPA trial randomizing patients open (n=29) vs robotic Whipple (n=33) just dropped.

Cumulative complications: 34%, 36%
Panc specific grade B/C rates:58%, 33%
DGE rates: 6%, 34%
Cost: $21,429,$33,503

A few thoughts in this thread

Superficially, although the authors concluded that both techniques are safe, most readers will view this as OPD being the winner.
However, technical RCTs have to be interpreted carefully. Authors specified that surgeons doing the RPD had to have done >40 RPDs. But, look closer..

There were 15 HPB surgeons and only 2 who did the PDs. The 2 had done >500, but req for was 40. Training a mid-career surgeon to do is diff vs someone who did in training. Conversions are never bad, but 23% indicates that the surgeons are still not over the learning curve.

In that same vein, DGE rates of 6% vs 34% in RPD single-handedly drove outcomes of this study.
GJs/DJs were performed very differently. It is more than just stapled vs hand sewn. They had 30 years and >1,000 OPD to figure out open GJs. Give em more time to figure out the RPD GJs.

IMO, the trial’s most important point — surgeons, do the operation you do best for your patients. If my mom needed a Whipple and is seeing Hackert/Buchler, I want them doing it open. But if she was seeing Herbert Zeh, Patricio Polanco or Melissa Hog, I want them doing it… and if you have no intentions of mastering, don’t do it for the sake of it and it is ok staying an OPD surgeon.

An OPD is still an extremely good operation and I tell every single one of my patients that the doesn’t change the actual operation.

And lastly, track your outcomes. Have an excel sheet and know your own or institution’s data. It cues you in to issues (like disproportionately higher DGE rates) and gives you the opportunity to fine tune it as you would any other operation.”

Source: Mark Lewis/X and Zhi Ven Fong/X

Mark A. Lewis is the Director of Gastrointestinal Oncology at Intermountain Healthcare in Utah, the Co-Chair of adolescent & young adult (AYA) oncology in the SWOG cooperative group and the Vice President of American Multiple Endocrine Neoplasia Support. Dr. Lewis is also a well-known patient advocate and social media influencer.