Impact of a nationwide training program in minimally invasive distal pancreatectomy (LAELAPS)

de Rooij and colleagues from the Dutch Pancreatic Cancer Group (DPCG) report on their experience disseminating a nationwide training program for minimally invasive distal pancreatectomy (MIDP) called LAELAPS (1). This effort included 32 surgeons at 17 medical centers in the Netherlands. The perioperative results prior to and following LAELAPS are compared, and conversion rate (38% vs. 8%, P<0.001), blood loss (350 vs. 200 cc, P=0.03) and length of hospital (9 vs. 7 days, mean, P<0.001) were all improved significantly presumably as a result of the training and experience. The assessment was made according to STROBE guidelines (2). Robotic and laparoscopic procedures were included, as performed using the same techniques, and patient selection was according to the criteria of Yonsei (3).

I congratulate the DPCG for their systematic approach and clear reporting of results with what appear to be direct cause and effect improvements. Innovation in surgery is both crucial and complex. Acceptance of innovation is a process, which takes time. Innovators and early adopters are often ridiculed and condemned as heretics and showmen by non-adaptors. Moving the process forward requires dedication and careful introspection to ensure that said innovation is not inferior to the original way of doing things, and that it may add additional value. Innovation may also raise concern, as innovators and early adopters may have abilities and access beyond what the general population can achieve, such as unusual skill and/or use of limited available technology. As we move along the innovation curve and more surgeons perform the newer technique, risks rises that inadequate training will lead to poor outcomes, increased patient risk, and loss of progress.

Laparoscopic colectomy is a commonly performed operation. In 2004, the results of the COST trial were presented and the concerns of surgeons who perform colon surgery were assuaged (COST), as the trial demonstrated non-inferiority of the laparoscopic approach to right, left, and sigmoid colectomy as compared with their open counterparts for the surgical removal of colon cancer (4). Industry supported training courses to increase technology sales and minimally invasive colectomy is a standard approach for appropriate patients with colon cancer.

Distal pancreatectomy is a less-commonly performed procedure than is partial colectomy, and the pancreas is a deep-seated retroperitoneal organ adjacent to foreboding vasculature. Merging experience in pancreatic resection with advanced laparoscopic technique for a relatively uncommonly performed procedure made systematic dissemination of MIDP slower than for colectomy. Coordinated efforts like LAELAPS are necessary to achieve this endpoint.

What we do not gain from this study is a true appreciation for the actual contribution of the training program. It could be that the “tipping point” was reached and more surgeons in the Netherlands gained comfort with MIDP, and that some of the post-LAELAPS improvement are circumstance. This is probably unlikely as the number of cases performed doubled in the 22 months after training as compared with the previous 9 years. The DPCG is unique in that it is a nationwide organization which demonstrates unusual collaborative spirit, as has been demonstrated in the Netherlands through various collaborative randomized studies. Problem with comparing longitudinally is that the surgeons already have increased experience, which can affect the significance. The B/C fistula rate of 30% seems higher than reported in other studies, but did not change following LAELAPS (5,6). I would not have included robotic procedures in this report, as robotic experience is even more reliant on a team approach and some important differences exist between robotic and laparoscopic distal pancreatectomy (7).

Overall, this study represents an important step in patient safety and collaboration. Current practice in the United States is to learn technique as a trainee during fellowship, or as faculty from course, mentorship, and/or trial and error. Systematic training programs for surgical innovation are crucial to achieve these results. LAELAPS and the collaborative effort from the Netherlands is a great example of this.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by the Editorial Board Member Marc Besselink (Department of Surgery, Academic Medical Center, AZ, Amsterdam, The Netherlands).

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales.2016.10.07). Kooby DA serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from Jul 2016 to Jun 2018.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. de Rooij T, van Hilst J, Boerma D, et al. Impact of a Nationwide Training Program in Minimally Invasive Distal Pancreatectomy (LAELAPS). Ann Surg 2016;264:754-62. [Crossref] [PubMed]
2. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 2007;4:e296 [Crossref] [PubMed]
3. Lee SH, Kang CM, Hwang HK, et al. Minimally invasive RAMPS in well-selected left-sided pancreatic cancer within Yonsei criteria: long-term (&gt;median 3 years) oncologic outcomes. Surg Endosc 2014;28:2848-55. [Crossref] [PubMed]
4. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-9. [Crossref] [PubMed]
5. Diener MK, Knaebel HP, Witte ST, et al. DISPACT trial: a randomized controlled trial to compare two different surgical techniques of DIStal PAnCreaTectomy - study rationale and design. Clin Trials 2008;5:534-45. [Crossref] [PubMed]
6. Subhedar PD, Patel SH, Kneuertz PJ, et al. Risk factors for pancreatic fistula after stapled gland transection. Am Surg 2011;77:965-70. [PubMed]
7. Daouadi M, Zureikat AH, Zenati MS, et al. Robot-assisted minimally invasive distal pancreatectomy is superior to the laparoscopic technique. Ann Surg 2013;257:128-32. [Crossref] [PubMed]