Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg. 2008;248:438-446. [PMID: 18791364 DOI: 10.1097/sla.0b013e318185a990]

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Laparoscopic radical 'no-touch' left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results

Background

Laparoscopic left pancreatectomy has been well described for benign pancreatic lesions, but its role in pancreatic adenocarcinoma remains open to debate. We report our results adopting a laparoscopic technique that obeys established oncologic principles of open distal pancreatosplenectomy.

Methods

This is a post hoc analysis of a prospectively kept database of 135 consecutive patients undergoing laparoscopic left pancreatectomy, performed across two sites in the UK and the Netherlands (07/2007–07/2015 Southampton and 10/2013–07/2015 Amsterdam). Primary outcomes were resection margin and lymph node retrieval. Secondary endpoints were other perioperative outcomes, including post-operative pancreatic fistula. Definition of radical resection was distance tumour to resection margin >1 mm. All patients underwent ‘laparoscopic radical left pancreatosplenectomy’ (LRLP) which involves ‘hanging’ the pancreas including Gerota’s fascia, followed by clockwise dissection, including formal lymphadenectomy.

Results

LRLP for pancreatic adenocarcinoma was performed in 25 patients. Seven of the 25 patients (28 %) had extended resections, including the adrenal gland (n = 3), duodenojejunal flexure (n = 2) or transverse mesocolon (n = 3). Mean age was 68 years (54–81). Conversion rate was 0 %, mean operative time 240 min and mean blood loss 340 ml. Median intensive/high care and hospital stay were 1 and 5 days, respectively. Clavien–Dindo score 3+ complication rate was 12 % and ISGPF grade B/C pancreatic fistula rate 28 %; 90-day (or in-hospital) mortality was 0 %. The pancreatic resection margin was clear in all patients, and the posterior margin was involved (<1 mm) in 6 patients, meaning an overall R0 resection rate of 76 %. No resection margin was microscopically involved. Median nodal sample was 15 nodes (3–26). With an average follow-up of 17.2 months, 1-year survival was 88 %.

Conclusions

A standardised laparoscopic approach to pancreatic adenocarcinoma in the left pancreas can be adopted safely. Our study shows that these results can be reproduced across multiple sites using the same technique.

Minimally invasive surgical approach to pancreatic malignancies

Pancreatic surgery for malignancy is recognized as challenging for the surgeons and risky for the patients due to consistent perioperative morbidity and mortality. Furthermore, the oncological long-term results are largely disappointing, even for those patients who experience an uneventfully hospital stay. Nevertheless, surgery still remains the cornerstone of a multidisciplinary treatment for pancreatic cancer. In order to maximize the benefits of surgery, the advent of both laparoscopy and robotics has led many surgeons to treat pancreatic cancers with these new methodologies. The reduction of postoperative complications, length of hospital stay and pain, together with a shorter interval between surgery and the beginning of adjuvant chemotherapy, represent the potential advantages over conventional surgery. Lastly, a better cosmetic result, although not crucial in any cancerous patient, could also play a role by improving overall well-being and patient self-perception. The laparoscopic approach to pancreatic surgery is, however, difficult in inexperienced hands and requires a dedicated training in both advanced laparoscopy and pancreatic surgery. The recent large diffusion of the da Vinci(®) robotic platform seems to facilitate many of the technical maneuvers, such as anastomotic biliary and pancreatic reconstructions, accurate lymphadenectomy, and vascular sutures. The two main pancreatic operations, distal pancreatectomy and pancreaticoduodenectomy, are approachable by a minimally invasive path, but more limited interventions such as enucleation are also feasible. Nevertheless, a word of caution should be taken into account when considering the increasing costs of these newest technologies because the main concerns regarding these are the maintenance of all oncological standards and the lack of long-term follow-up. The purpose of this review is to examine the evidence for the use of minimally invasive surgery in pancreatic cancer (and less aggressive tumors), with particular attention to the oncological results and widespread reproducibility of each technique.

The detail of the en bloc technique and prognosis of spleen-preserving laparoscopic distal pancreatectomy for pancreatic cancer

BACKGROUND

Although laparoscopic spleen-preserving distal pancreatectomy surgery is more and more popular, the reports about the en bloc technique used for pancreatic cancer were still rare. The aim of our study was to illustrate the detail of the spleen-preserving en bloc technique as well as the short-term and long-term outcomes.

METHODS

The detail of the en bloc technique with pictures was described. The prognosis of the successive 23 cases that underwent the laparoscopic distal pancreatectomy (LDP) surgery was evaluated.

RESULTS

There were 17 cases that underwent spleen-preserving LDP while six cases underwent spleen-resecting LDP. The average surgery time was 203 ± 54 min, and the average blood loss volume was 208 ± 264 ml; one case transferred to open surgery because of severe adhesion. The complication rate was 47 % (n = 8) shortly after surgery. Pancreatic fistula rate was 41 % (n = 7). No lethal case occurred. The average diameter of the tumor was 32 ± 12 mm. The average number of the lymph nodes obtained was 19.8 ± 9.3. All the cutting edges were negative. Survival rates of the patient after 1, 3, and 5 years are 64.7, 52.9, and 41.2 %, respectively. These records showed no statistical significance compared with spleen-resecting LDP and open distal pancreatectomy (ODP) surgeries.

CONCLUSIONS

The en bloc spleen-preserving LDP can be performed by experienced surgeons. This surgery has good short-term and long-term outcomes.

Pancreatic mucinous cystoadenomas and cystoadenocarcinomas: differential diagnosis by means of MRI

OBJECTIVE

To determine the accuracy of MRI in differentiating mucinous cystoadenomas (MCAs) from mucinous cystoadenocarcinomas (MCACs) of the pancreas, with histopathological analysis as the reference standard, for better surgical planning.

METHODS

A total of 65 patients with histopathologically proven mucinous cystic neoplasms (MCNs) underwent MRI and surgery. Quantitative image analysis included size, septa and wall thickness and number of loculations. Qualitative image analysis included nodules; hyperintensity of the cystic content on T1 weighted images; compression and/or infiltration of adjacent vessels or organs; and metastases. A comparison between MCAs and MCACs was performed with Student's t-test for quantitative variables and with Fisher test for qualitative variables. Receiver operating characteristic analysis was performed to determine the accuracy in the differential diagnosis between MCAs and MCACs on the basis of a score system obtained by giving 1 point for each quantitative and qualitative variable observed in each patient.

RESULTS

At histopathology, 43 lesions were MCAs and 22 lesions were MCACs. A statistically significant difference was observed for size >7cm (<0.001), septa and wall thickness >3 mm (<0.0001), number of loculations >4 (<0.0001), nodules (<0.0001), hyperintensity of the cystic content on T1 weighted images (<0.0001), compression (<0.01) and/or infiltration (<0.01) of adjacent vessels or organs and metastases (<0.05). The best cut-off value to discriminate MCAs from MCACs was the presence of three features (p < 0.001), with an accuracy of 91%.

CONCLUSION

MRI has an accuracy of 91% in the differential diagnosis between MCA and MCAC, helping in identifying forms that could undergo parenchyma-sparing surgery (MCAs), reducing post-surgical morbidity and mortality.

ADVANCES IN KNOWLEDGE

In this study, the differentiation between MCAs and MCACs of the pancreas by means of MRI is addressed. The differential diagnosis allows selecting benign forms, susceptible of parenchyma-sparing surgery, with the advantage of reducing post-surgical morbidity and stratifying prognosis of MCNs.

Laparoscopic Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma: Time for a Randomized Controlled Trial? Results of an All-inclusive National Observational Study

OBJECTIVES

The aim of this study is to compare at a national level, the early and long-term outcome of distal pancreatectomy (DP) performed by laparoscopy (LapDP) or open surgery (OpenDP) for pancreatic ductal adenocarcinoma (PDAC).

BACKGROUND DATA

LapDP is feasible and safe for benign conditions but its use for PDAC is controversial.

METHODS

French healthcare databases were screened to identify all patients who had undergone LapDP or OpenDP for PDAC between 2007 and 2012. Endpoints were (i) 90-day mortality, (ii) morbidity, (iii) transfusion rate, (iv) length of hospital stay (LOS), and (v) long-term survival. Logistic regression and adjusted Cox models were used to compare LapDP and OpenDP with regard to these outcomes. Confounders included (i) patients' characteristics; (ii) associated surgical procedures; and (iii) characteristics of the hospital. Performance of the resulting models was determined by the area under the receiver operating characteristic (ROC) curve.

RESULTS

Over the 6-year period, there were 2753 operations for PDAC: 2406 OpenDP and 347 LapDP (12.6%). The overall 90-day mortality rate was 5.2%; median LOS was 15 days, and median survival was 38 months. LapDP was not correlated with 90-day mortality but was associated with reduced pleuropulmonary morbidity (odds ratio (OR) 0.73, P = 0.028), blood transfusion (OR 0.44, P = 0.001), and LOS (P = 0.042), and was associated with increased survival (P = 0.0007).

CONCLUSIONS

LapDP has not been adopted widely for PDAC. The early and long-term results of LapDP as currently practiced are as good as those of OpenDP. The next step in the evaluation of LapDP should be a randomized controlled trial (RCT), but such a trial is likely to suffer from insufficient recruitment.

Laparoscopic Pylorus- and Spleen-Preserving Duodenopancreatectomy for a Multifocal Neuroendocrine Tumor

Background

In contrast to laparoscopic left pancreatic resection, laparoscopic total duodenopancreatectomy is a procedure that has not been standardized until now. It is not only the complexity that limits such a procedure but also its rare indication. The following article demonstrates the technical aspects of laparoscopic pylorus- and spleen-preserving duodenopancreatectomy.

Case Report

The indication for intervention in the underlying case was a patient diagnosed with a multiple endocrine neoplasia (MEN) I syndrome and a multifocal neuroendocrine tumor (NET) infiltrating the duodenum and the pancreas. The patient was post median laparotomy which was necessary after jejunal perforation due to a peptic ulcer. The resection was carried out entirely laparoscopically, and the reconstruction, which included a biliodigestive anastomosis and a gastroenterostomy, was carried out by means of a median upper abdomen laparotomy of 7 cm in length through which the resected specimen was also removed. The total operative time was 391 min. The blood loss accounted for 250 ml. The postoperative course was uneventful, and the patient was discharged on the eighth postoperative day.

Conclusion

Laparoscopic pancreatectomy is a treatment option in carefully selected indications. The complexity of the operation demands a high level of expertise in the surgical team.

The impact of recent hospitalization on surgical site infection after a pancreatectomy

BACKGROUND

Surgical site infections (SSI) are a major cause of increased morbidity and cost after a pancreatectomy. Patients undergoing a pancreatectomy frequently have had recent inpatient hospital admissions prior to their surgical admission (recent pre-surgical admission, RPSA), which could increase the risk of SSI.

METHODS

The 2009-2011 Healthcare Cost Utilization Project California State Inpatient Database was used. Chi-square tests, Student's t-tests and multivariable logistic regression were used.

RESULTS

Three thousand three hundred and seventy-six patients underwent a pancreatectomy, and 444 (13.2%) had RPSA. One hundred and eighty (40.5%) RPSAs were to different hospitals other than where patients' pancreatectomy took place. In univariate analysis, patients with RPSA had a significantly higher rate of post-operative SSIs, and this was associated with a longer length of post-operative stay, higher post-operative hospital costs and increased postoperative 30-day readmission rates (Table 1). In Multivariate analysis, RPSA was an independent predictor of post-operative SSI [odds ratio (OR) = 1.68, P = 0.013], and the risk of SSI increased with increasing RPSA length of stay (OR = 1.07 per day, P = 0.001).

CONCLUSIONS

Recent pre-surgical admission is an important risk factor for SSI after a pancreatectomy. Many patients with RPSA are not admitted pre-operatively to the same hospital where the pancreatectomy occurs; in such circumstances, SSI rates may not be a sole reflection of the care provided by operating hospitals.

Laparoscopic distal pancreatectomy for adenocarcinoma: safe and reasonable?

As a result of technological advances during the past two decades, surgeons now use minimally invasive surgery (MIS) approaches to pancreatic resection more frequently, yet the role of these approaches for pancreatic ductal adenocarcinoma resections remains uncertain, given the aggressive nature of this malignancy. Although there are no controlled trials comparing MIS technique to open surgical technique, laparoscopic distal pancreatectomy for pancreatic adenocarcinoma is performed with increasing frequency. Data from retrospective studies suggest that perioperative complication profiles between open and laparoscopic distal pancreatectomy are similar, with perhaps lower blood loss and fewer wound infections in the MIS group. Concerning oncologic outcomes, there appear to be no differences in the rate of achieving negative margins or in the number of lymph nodes (LNs) resected when compared to open surgery. There are limited recurrence and survival data on laparoscopic compared to open distal pancreatectomy for pancreatic adenocarcinoma, but in the few studies that assess long term outcomes, recurrence rates and survival outcomes appear similar. Recent studies show that though laparoscopic distal pancreatectomy entails a greater operative cost, the associated shorter length of hospital stay leads to decreased overall cost compared to open procedures. Multiple new technologies are emerging to improve resection of pancreatic cancer. Robotic pancreatectomy is feasible, but there are limited data on robotic resection of pancreatic adenocarcinoma, and outcomes appear similar to laparoscopic approaches. Additionally fluorescence-guided surgery represents a new technology on the horizon that could improve oncologic outcomes after resection of pancreatic adenocarcinoma, though published data thus far are limited to animal models. Overall, MIS distal pancreatectomy appears to be a safe and reasonable approach to treating selected patients with pancreatic ductal adenocarcinoma, though additional studies of long-term oncologic outcomes are merited. We review existing data on MIS distal pancreatectomy for pancreatic ductal adenocarcinoma.

Minimally invasive spleen-preserving distal pancreatectomy: Does splenic vessel preservation have better postoperative outcomes? A systematic review and meta-analysis

BACKGROUND

Minimally invasive spleen-preserving distal pancreatectomy (SPDP) can be performed with either splenic vessel preservation (SVP) or resection [Warshaw procedure (WP)]. The aim of this study was to evaluate the postoperative clinical outcomes of patients undergoing both methods.

DATA SOURCES

Database search of PubMed, Embase, Scopus, Cochrane, and Google Scholar was performed (2000-2014); key bibliographies were reviewed. Qualified studies comparing patients undergoing SPDP with either SVP or WP, and assessing postoperative complications were included. Calculated pooled risk ratio (RR) with the corresponding 95% confidence interval (CI) by random effects methods were used in the meta-analyses.

RESULTS

The search yielded 215 studies, of which only 14 observational studies met our selection criteria. The studies included 943 patients in total; 652 (69%) underwent SVP and 291 (31%) underwent WP. Overall, there was a lower incidence of splenic infarction (RR=0.17; 95% CI: 0.09-0.33; P<0.001), gastric varices (RR=0.16; 95% CI: 0.05-0.51; P=0.002), and intra/postoperative splenectomy (RR=0.20; 95% CI: 0.08-0.49; P<0.001) in the SVP group. There was no difference in incidence of pancreatic fistula (WP vs SVP, 23.6% vs 22.9%; P=0.37), length of hospital stay, operative time or blood loss. There was moderate cross-study heterogeneity.

CONCLUSIONS

SVP is a safe, efficient and feasible technique that may be used to preserve the spleen. WP may be more suitable for large tumors close to the splenic hilum or those associated with splenomegaly. Randomized clinical trials are justified to examine the long-term benefits of SVP-SPDP.

Robotic surgery of the pancreas: The current state of the art

Pancreatic surgery is one of the most technically challenging and complex types of surgery. Most pancreatic surgery is performed with the open technique, yet minimally invasive surgery has become the standard of care for many other intra-abdominal operations. The unique qualities of the robotic platform have made this approach to pancreatic surgery safe and feasible with at least equivalent if not better results than the open platform in terms of surgical and oncological outcomes.

Technical Aspects of Laparoscopic Distal Pancreatectomy for Benign and Malignant Disease: Review of the Literature

Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. The most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Spleen preservation can be achieved preferably by preserving the splenic vessels (Kimura technique), but also by resecting the splenic vessels and maintaining vascularity through the short gastric vessels and left gastroepiploic artery (Warshaw technique). Several studies have suggested a higher rate of spleen preservation with laparoscopy. The radical antegrade modular pancreatosplenectomy has become mainstay for treating pancreatic cancer and can be performed laparoscopically as well. Evidence on the feasibility and safety of laparoscopic distal pancreatectomy for cancer is scarce. Despite the obvious advantages of laparoscopic surgery, postoperative morbidity remains relatively high, mainly because of the high incidence of pancreatic fistula. For decades, surgeons have tried to prevent these fistulas but to date no strategy has been confirmed to be effective in 2 consecutive randomized studies. Pragmatic multicenter studies focusing on technical aspects of laparoscopic distal pancreatectomy are lacking and should be encouraged.

Laparoscopic perspectives for distal biliary obstruction

BACKGROUND

In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions.

METHODS

We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected.

RESULTS

In the six-years period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred.

CONCLUSIONS

Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life.

Predictive factors associated with postoperative pancreatic fistula after laparoscopic distal pancreatectomy: a 10-year single-institution experience

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is a treatment option for benign and borderline pancreatic tumors. However, pancreatic fistula (PF) remains a significant morbidity, contributing to the length of hospital stay and overall costs. In a consecutive series of 143 patients at a single institution, the predictive factors associated with PF after LDP were identified.

METHODS

A retrospective study of patients who had undergone LDP between January 2003 and December 2013 was conducted. Patient demographic data and clinicopathological parameters were analyzed to evaluate their correlation with the incidence of PF.

RESULTS

Among the 143 patients, the indications for surgery were benign disease in 117 (82%) and malignant tumors in 26 (18%). PF occurred in 25 (17%) patients, 10 (40%) of whom had clinically significant (grade B) PF. No grade C PF was observed. Multivariable analysis showed that pancreatic thickness was a significant predictive factor for PF (P < 0.001). A 12-mm cutoff value was based on the median pancreatic thickness in this series. Pancreatic texture alone was not a significant risk factor (P = 0.30); however, it became significant in patients with pancreatic thickness exceeding 12 mm (P = 0.005).

CONCLUSIONS

Pancreatic thickness exceeding 12 mm significantly increases the likelihood of PF after LDP. Pancreatic texture alone is not an independent risk factor for PF, but when combined with a thick parenchyma (>12 mm), a soft pancreas is predictive of PF.

A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: it's time to randomize

BACKGROUND

Laparoscopic distal pancreatectomy is regarded as a feasible and safe surgical alternative to open distal pancreatectomy for lesions of the pancreatic tail and body. The aim of the present systematic review was to provide recommendations for clinical practice and research on the basis of surgical morbidity, such as pancreas fistula, delayed gastric empting, safety, and clinical significance of laparoscopic versus open distal pancreatectomy for malignant and nonmalignant diseases of the pancreas.

METHODS

A systematic literature search (MEDLINE) was performed to identify all types of studies comparing laparoscopic distal pancreatectomy and open distal pancreatectomy. Random effects meta-analyses were calculated after critical appraisal of the included studies and presented as odds ratios or mean differences each with corresponding 95% confidence intervals.

RESULTS

A total of 4,148 citations were retrieved initially; available data of 29 observational studies (3,701 patients overall) were included in the meta-analyses. Five systematic reviews on the same topic were found and critically appraised. Meta-analyses showed superiority of laparoscopic distal pancreatectomy in terms of blood loss, time to first oral intake, and hospital stay. All other parameters of operative morbidity and safety showed no difference. Data on oncologic radicality and effectiveness are limited.

CONCLUSION

Laparoscopic distal pancreatectomy seems to be a safe and effective alternative to open distal pancreatectomy. No more nonrandomized trials are needed within this context. A large, randomized trial is warranted and should focus on oncologic effectiveness, defined end points, and cost-effectiveness.

Ductal pancreatic adenocarcinoma

BACKGROUND

Ductal adenocarcinoma of the pancreas is the fourth most common cause of death from cancer in men and women in Germany: about 15 000 persons die of this disease each year.

METHOD

The S3 guideline on exocrine pancreatic carcinoma was updated with the aid of systematic literature reviews on the surgical, neoadjuvant, and adjuvant treatment of ductal pancreatic carcinoma, and on treatment in the metastatic stage. These reviews covered the periods 2002 to February 2012 (for radiotherapy) and 2006 to August 2011 (for all other topics).

RESULTS

The criteria for borderline resectable pancreatic tumors are the same as those of the guidelines of the National Comprehensive Cancer Network. Preoperative biliary drainage with a stent is recommended only if cholangitis is present or if a planned operation cannot be performed soon after the diagnosis is made. When a pancreatic carcinoma is resected, at least 10 regional lymph nodes should be excised, and the ratio of affected to excised nodes should be documented in the pathology report. Gemcitabine and 5-fluorouracil are recommended for adjuvant therapy. Neither of these drugs is preferred over the other; if the one initially given is poorly tolerated, the other one should be given instead. When gemcitabine and erlotinib are given for palliative treatment, erlotinib should be given for no longer than 8 weeks if no skin rash develops. In selected patients, the folfirinox protocol yields markedly better results than gemcitabin. Moreover, the new combination of nab-paclitaxel and gemcitabine can be used as first-line treatment. In the event of disease progression under first-line treatment, second-line treatment should be initiated.

CONCLUSION

In recent years, new chemotherapeutic protocols have brought about marked improvement in palliative care. Further trials are needed to determine whether the perioperative or adjuvant use of these protocols might also improve the outcome of surgical treatment with curative intent.

State of the art of robotic pancreatic surgery

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.

Robotic approach improves spleen-preserving rate and shortens postoperative hospital stay of laparoscopic distal pancreatectomy: a matched cohort study

BACKGROUND

Spleen preservation (SP) is beneficial for patients undergoing distal pancreatectomy of benign and borderline tumors; however, the conventional laparoscopy approach (C-LDP) is less effective in controlling splenic vessel bleeding. The benefits of the robotic-assisted approach (RA-LDP) in SP have not been clearly described. This study aimed to evaluate whether a robotic approach could improve SP rate and effectiveness/safety profile of laparoscopic distal pancreatectomy (LDP).

METHODS

Matched for scheduled SP, age, sex, ASA classification, tumor size, tumor location, and pathological type, 69 patients undergoing RA-LDP and 50 undergoing C-LDP between January 2005 and May 2014 were included. Main outcome measures included SP rate, operative time (OT), blood loss, transfusion frequency, morbidity, postoperative hospital stay (PHS), and oncologic safety.

RESULTS

Among matched patients scheduled for SP, RA-LDP was associated with significantly higher overall (95.7 vs. 39.4%) and Kimura SP rates (72.3 vs. 21.2%), shorter OT (median 120 vs. 200 min), less blood loss (median 100 vs. 300 mL), lower transfusion frequency (2.1 vs. 18.2%), and shorter mean PHS (10.2 vs. 14.5 days). Among matched patients scheduled for splenectomy, RA-LDP was associated with similar OT, blood loss, transfusion frequency, and PHS. The two approaches were similar in overall morbidity, frequency of pancreatic fistula, and oncologic outcome among patients undergoing splenectomy for malignant tumors.

CONCLUSIONS

RA-LDP was associated with a significantly better SP rate and reduced OT, blood loss, transfusion requirement, and PHS for patients undergoing SP compared to C-LDP, but offered less benefits for patients undergoing splenectomy.

The influence of transection site on the development of pancreatic fistula in patients undergoing distal pancreatectomy: A review of 294 consecutive cases

BACKGROUND

Pancreatic fistula (PF) is a significant cause of morbidity in patients undergoing distal pancreatectomy (DP), with an incidence of 15-40%. It remains unclear if the location of pancreatic transection affects the rate of PF occurrence. This study examines the correlation between the transection site of the pancreas during DP and the incidence of PF.

METHODS

All cases of DP from October 2005 to January 2012 were reviewed retrospectively from an institutional review board-approved database at the Thomas Jefferson University Hospital. Patient demographics and perioperative outcomes were analyzed. The pancreatic transection location was determined by review of operative reports, and then dichotomized into 2 groups: neck/body or tail. PF were graded following the International Study Group on Pancreatic Fistula guidelines.

RESULTS

During the study period, 294 DP were performed with 244 pancreas transections at the neck/body and 50 at the tail. Of the 294 patients, 52 (17.7%) developed a postoperative PF. The incidence of PF after transection at the tail of the pancreas was higher (28%) when compared with transection at the neck/body (15.6%; P = .04). When stratified by PF grade, grade A PF occurred more commonly when transection of the gland was at the tail (22% tail vs 8.2% neck/body; P = .007); however, no difference was found for grade B/C PF (6% tail vs 7.4% neck/body; P = 1).

CONCLUSION

Our data suggest that PF occurs more often when the tail is transected during DP, although the majority are low grade and of minimal clinical significance. More severe PF occurred equally between the transection sites.

Laparoscopic middle pancreatectomy: how do I do it?

BACKGROUND

Although laparoscopic surgery is now extensively used, laparoscopic middle pancreatectomy (LMP) has rarely been described.

STUDY DESIGN AND METHODS

A 45-year-old woman was diagnosed with branch duct intraductal papillary mucinous neoplasia (IPMN) at the pancreatic neck, which was discovered after numerous attacks of acute pancreatitis. LMP was decided on for treatment.

RESULTS

The patient underwent pure LMP with right to left dissection and one-layer pancreatogastric anastomosis. Surgery lasted 160 minutes, with 20 mL of blood loss. A frozen section showed negative margins on both sides. The postoperative course was uneventful with 15 days in the hospital. Histology confirmed the diagnosis of branch duct IPMN with moderate dysplasia and negative margins. The patient is symptom free 6 months after surgery.

CONCLUSIONS

Our results and the data in the literature suggest that the laparoscopic approach is indicated for middle pancreatectomy because there are no technical or oncological contraindications and the outcome is similar to that with the open approach.

Laparoscopic pancreaticoduodenectomy via a reverse-''V'' approach with four ports: Initial experience and perioperative outcomes

AIM: To evaluate the feasibility, safety, and efficacy of laparoscopic pancreaticoduodenectomy (LPD) using a reverse-“V” approach with four ports.

METHODS: This is a retrospective study of selected patients who underwent LPD at our center between April 2011 and April 2012. The following data were collected and reviewed: patient characteristics, tumor histology, surgical outcome, resection margins, morbidity, and mortality. All patients were thoroughly evaluated preoperatively by complete hematologic investigations, triple-phase helical computed tomography, upper gastrointestinal endoscopy, and biopsy of ampullary lesions (when present). Magnetic resonance cholangiopancreatography was performed for doubtful cases of lower common bile duct lesions.

RESULTS: There was no perioperative mortality. LPD was performed with tumor-free margins in all patients, including patients with pancreatic ductal adenocarcinoma (n = 6), ampullary carcinoma (n = 6), intra-ductal papillary mucinous neoplasm (n = 2), pancreatic cystadenocarcinoma (n = 2), pancreatic head adenocarcinoma (n = 3), and bile duct cancer (n = 2). The mean patient age was 65 years (range, 42-75 years). The median blood loss was 240 mL, and the mean operative time was 368 min.

CONCLUSION: LPD using a reverse-“V” approach can be performed safely and yields good results in elective patients. Our preliminary experience showed that LDP can be performed via a reverse-“V” approach. This approach can be used to treat localized malignant lesions irrespective of histopathology.

Minimally invasive pancreatectomy for cancer: a critical review of the current literature

Minimally invasive surgery (MIS) has transformed operative practices by offering patients procedures with reduced hospital stay and recovery compared to that of open operations. In spite of the advantages of a MIS approach, the application to pancreatectomy has only recently emerged. This review aims to analyze and discuss available comparative studies as they relate to resection techniques for treatment of malignant disease. A PubMed search was used to obtain original studies and meta-analyses relating to MIS pancreatectomy from 2008 to 2013. Several studies were identified that reported on the application of MIS specifically to the treatment of cancer, many of which were retrospective, single-institution studies. Notwithstanding an inherent selection bias, several studies suggest that MIS can provide equivalent R0 resection rates, number of lymph nodes harvested, and survival to that of open resection. Furthermore, parameters such as blood loss and length of stay are significantly reduced in patients treated with MIS. The current literature supports the conclusion that MIS is safe and effective as a treatment for cancer in well-selected patients in the hands of experienced surgeons. However, the published studies to date are observational in nature and therefore higher quality studies will be needed to support the application and generalizability of MIS in the treatment of pancreatic malignancies.

The laparoscopic approach to distal pancreatectomy for ductal adenocarcinoma results in shorter lengths of stay without compromising oncologic outcomes

BACKGROUND

The oncologic equivalence of laparoscopic distal pancreatectomy (LDP) to open pancreatectomy (ODP) for ductal adenocarcinoma (DAC) is not established.

METHODS

The National Cancer Data Base was used to compare perioperative outcomes following LDP and ODP for DAC between 2010 and 2011.

RESULTS

One hundred forty-five patients underwent LDP; 625 underwent ODP. Compared with ODP, patients undergoing LDP were older (68 ± 10.1 vs 66 ± 10.5 years, P = .027), more likely treated in academic centers (70% vs 59%, P = .01), and had shorter hospital stays (6.8 ± 4.6 vs 8.9 ± 7.5 days, P < .001). Demographic data, lymph node count, 30-day unplanned readmission, and 30-day mortality were identical between groups. Multivariable regression identified a lower probability of prolonged length of stay with LDP (odds ratio .51, 95% confidence interval .327 to .785, P = .0023). There was no association between surgical approach and node count, readmission, or mortality.

CONCLUSION

LDP for DAC provides shorter postoperative lengths of stay and rates of readmission and 30-day mortality similar to OPD without compromising perioperative oncologic outcomes.

Transumbilical single-incision laparoscopic distal pancreatectomy: preliminary experience and comparison to conventional multi-port laparoscopic surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS), which has been demonstrated to be safely applied on kinds of surgeries, may represent an improvement over conventional multi-port laparoscopic surgery. However, there are still few clinical experiences of SILS in pancreatic surgery until now. In this study, we will summarize our experience of transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP), and compare its related parameters with conventional multi-port laparoscopic distal pancreatectomy (C-LDP).

METHODS

A retrospective analysis was conducted for the patients who underwent C-LDP or TUSI-LDP in our department. The demographic data, operative parameters, and postoperative complications in the two groups were summarized and compared.

RESULTS

Laparoscopic distal pancreatectomy was performed in a total of 21 cases, among which TUSI-LDP was performed in 14 cases. As far as the demographical results concerned, there were no significant differences between the two groups. The conversion to open surgery was conducted in one case in the TUSI-LDP group because of severe adhesion between pancreatic cyst and surrounding tissues, while in the C-LDP group the only one conversion was for the difficult detection of small lesion. The mean operating time and intraoperative blood loss in TUSI-LDP group was a little shorter (166.4 ± 57.4 versus 202.1 ± 122.5 minutes, p > 0.05, and 157.1 ± 162.4 versus 168.6 ± 157.4 ml, p > 0.05). The postoperative pain and post-operation lengths of hospital stay in the TUSI-LDP group were also less, though there was no significant statistical difference between the two groups. For the post-operation complications, in TUSI-LDP group the pancreatic leakage occurred in only one case, and ceased spontaneously with only a drain for 61 days. There were no other complications including postoperative hemorrhage, venous thrombosis, infections and so on in both groups.

CONCLUSION

For the experienced laparoscopic surgeons, in selected patients, TUSI-LDP is a feasible technique, with excellent cosmetic effect, less postoperative pain and post-operation lengths of hospital stay. With the experience accumulated, the operating time and intraoperative blood loss of TUSI-LDP could also gradually reduce.

Laparoscopic distal pancreatectomy: Educating surgeons about advanced laparoscopic surgery

INTRODUCTION

Laparoscopic distal pancreatectomy (Lap-DP) has been recognized worldwide as a feasible and highly beneficial procedure. The aim of this study is to investigate whether Lap-DP techniques are being implemented safely by surgeons training to perform this procedure.

METHODS

We retrospectively compared the perioperative outcomes of Lap-DP in patients operated on by the surgeon originating this procedure at our hospital (expert surgeon group [E group], n = 47) and patients operated on by surgeons training to perform this procedure (training surgeons group [T group], n = 53).

RESULTS

The median operating times for the E group and T group were 321 min (range, 150-653 min) and 314 min (range, 173-629 min), respectively; these times were not significantly different (P = 0.4769). The median blood loss in the T group (100 mL; range, 0-1950 mL) was significantly smaller than in the E group (280 mL; range, 0-1920 mL) (P = 0.0003). There were no significant intergroup differences in other operative results: combined operation ratio, spleen- and splenic vessels-preserving ratio, hand-assisted procedure ratio, and the ratio of transition to open. The frequency of pancreatic fistulas in the E group and T group was 12.8% and 16.9%, respectively; these rates were not significantly different (P = 0.5886). There were no significant differences between the two groups in terms of other complications and reoperation rates. The median hospital stay for the E group was significantly shorter than for the T group (10 vs 13 days; P = 0.0307).

CONCLUSION

This retrospective analysis shows that teaching safe Lap-DP techniques to surgeons is reflected in stable perioperative outcomes.

Robotic surgery of the pancreas

Pancreatic surgery is one of the most challenging and complex fields in general surgery. While minimally invasive surgery has become the standard of care for many intra-abdominal pathologies the overwhelming majority of pancreatic surgery is performed in an open fashion. This is attributed to the retroperitoneal location of the pancreas, its intimate relationship to major vasculature and the complexity of reconstruction in the case of pancreatoduodenectomy. Herein, we describe the application of robotic technology to minimally invasive pancreatic surgery. The unique capabilities of the robotic platform have made the minimally invasive approach feasible and safe with equivalent if not better outcomes (e.g., decreased length of stay, less surgical site infections) to conventional open surgery. However, it is unclear whether the robotic approach is truly superior to traditional laparoscopy; this is a key point given the substantial costs associated with procuring and maintaining robotic capabilities.

The first total laparoscopic pancreatoduodenectomy in Poland

We present a case of a 55-year-old female patient with pancreatic head cancer who was treated with total laparoscopic pylorus-preserving pancreatoduodenectomy (TLPD) on 13.12.2013. The procedure as well as the postoperative course was uncomplicated. The patient was mobilized on the day of surgery; a liquid diet was introduced on day 1 and a full hospital diet on day 2 postoperatively. Drains were removed on the 3^rd day after the procedure. Length of hospital stay was 6 days. The final pathology report confirmed the diagnosis of cancer. According to our knowledge this is the first report on total laparoscopic pancreatoduodenectomy in Poland performed by an entirely Polish team of surgeons. In our opinion, TLPD is feasible and similarly to other laparoscopic operations may improve postoperative recovery.

Laparoscopic resection of pancreatic adenocarcinoma: Dream or reality?

Laparoscopic pancreatic surgery is in its infancy despite initial procedures reported two decades ago. Both laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD) can be performed competently; however when minimally invasive surgical (MIS) approaches are implemented the indication is often benign or low-grade malignant pathologies. Nonetheless, LDP and LPD afford improved perioperative outcomes, similar to those observed when MIS is utilized for other purposes. This includes decreased blood loss, shorter length of hospital stay, reduced post-operative pain, and expedited time to functional recovery. What then is its role for resection of pancreatic adenocarcinoma? The biology of this aggressive cancer and the inherent challenge of pancreatic surgery have slowed MIS progress in this field. In general, the overall quality of evidence is low with a lack of randomized control trials, a preponderance of uncontrolled series, short follow-up intervals, and small sample sizes in the studies available. Available evidence compiles heterogeneous pathologic diagnoses and is limited by case-by-case follow-up, which makes extrapolation of results difficult. Nonetheless, short-term surrogate markers of oncologic success, such as margin status and lymph node harvest, are comparable to open procedures. Unfortunately disease recurrence and long-term survival data are lacking. In this review we explore the evidence available regarding laparoscopic resection of pancreatic adenocarcinoma, a promising approach for future widespread application.

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms: A retrospective study

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.

METHODS: The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively. Surgical techniques for LSPDP included preservation of the splenic artery and vein (Kimura’s technique) and ligation of the splenic pedicle with preservation of the short gastric vessels (Warshaw’s technique).

RESULTS: There were no conversions to open surgery in the 38 patients. Splenic vessels were conserved during spleen-preserving pancreatectomy, except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels. The mean operation time was 123.2 ± 52.4 min, the mean intraoperative blood loss was 78.2 ± 39.5 mL, and the mean postoperative hospital stay was 7.6 ± 2.9 d. The overall rate of postoperative complications was 18.4% (7/38), and the rate of clinical pancreatic fistula was 13.2% (5/38). All postoperative complications were treated conservatively. The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions. During a median follow-up of 38 mo (range: 5-133 mo), no recurrence was observed.

CONCLUSION: LSPDP is a safe, feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.

Results of 100 consecutive laparoscopic distal pancreatectomies: postoperative outcome, cost-benefit analysis, and quality of life assessment

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) has been recently proposed as the procedure of choice for lesions of the pancreatic body and tail in experienced centres. The purpose of this study is to assess the potential advantages of LDP in a consecutive series of 100 patients.

METHODS

Propensity score matching was used to identify patients for comparison between LDP and control open group. Match criteria were: age, gender, ASA score, BMI, lesion site and size, and malignancy. All patients were treated according to an early feeding recovery policy. Primary endpoint was postoperative morbidity rate. Secondary endpoints were operative time, blood transfusion, length of hospital stay (LOS), hospital costs, and quality of life.

RESULTS

Thirty patients of the LDP group had pancreatic adenocarcinoma. Conversion to open surgery was necessary in 23 patients. Mean operative time was 29 min shorter in the open group (p = 0.002). No significant difference between groups was found in blood transfusion rate and postoperative morbidity rate. LDP was associated with an early postoperative rehabilitation and a shorter LOS in uneventful patients. Economic analysis showed <euro> 775 extra cost per patient of the LDP group. General health perception and vitality were better in the LDP group one month after surgery.

CONCLUSION

Laparoscopic distal pancreatectomy improved short-term postoperative recovery and quality of life in a consecutive series of both cancer and non-cancer patients. Despite the extra cost, the laparoscopic approach should be considered the first option in patients undergoing distal pancreatectomy.

Cost comparison analysis of open versus laparoscopic distal pancreatectomy

BACKGROUND

In comparison with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) is associated with fewer complications and shorter hospital stays, but comparative cost data for the two approaches are limited.

METHODS

Records of all distal pancreatectomies carried out from January 2009 to June 2013 were reviewed and stratified according to operative complexity. Patient factors and outcomes were recorded. Total variable costs (TVCs) were tabulated for each patient, and stratified by category [e.g. 'floor', 'operating room' (OR), 'radiology']. Costs for index admissions and 30-day readmissions were compared between LDP and ODP groups.

RESULTS

Of 153 procedures, 115 (70 LDP, 45 ODP) were selected for analysis. The TVC of the index admission was US$3420 less per patient in the LDP group (US$10 480 versus US$13 900; P = 0.06). Although OR costs were significantly greater in the LDP cohort (US$5756 versus US$4900; P = 0.02), the shorter average hospitalization in the LDP group (5.2 days versus 7.7 days; P = 0.01) resulted in a lower overall cost. The total cost of index hospitalization combined with readmission was significantly lower in the LDP cohort (US$11 106 versus US$14 803; P = 0.05).

CONCLUSIONS

In appropriately selected patients, LDP is more cost-effective than ODP. The increased OR cost associated with LDP is offset by the shorter hospitalization. These data clarify targets for further cost reductions.

Minimally invasive RAMPS in well-selected left-sided pancreatic cancer within Yonsei criteria: long-term (>median 3 years) oncologic outcomes

BACKGROUND

Although minimally invasive techniques for distal pancreatectomy with or without splenectomy have been regarded as a feasible and safe treatment option for benign and borderline malignant lesions of the pancreas, the management of left-sided pancreatic cancer remains controversial.

METHODS

From June 2007 to November 2010, 12 patients underwent laparoscopic or robotic radical antegrade modular pancreatosplenectomy (RAMPS) for well-selected left-sided pancreatic cancer. The Yonsei criteria for patient selection included the following conditions: (1) tumor confined to the pancreas, (2) intact fascial layer between the distal pancreas and the left adrenal gland and kidney, and (3) tumor located more than 1-2 cm from the celiac axis. We compared the clinicopathologic factors and oncologic outcomes of the minimally invasive surgery (MIS) and the conventional open surgery groups for treating left-sided pancreatic cancer.

RESULTS

In the MIS group, the mean tumor size was 2.75 ± 1.32 cm, and the mean number of retrieved lymph nodes was 10.5 ± 7.14. The resection margins were confirmed to be negative for malignancy in all patients. The MIS group and open group (n = 78) were statistically different in terms of tumor size (2.8 ± 1.3 vs. 3.5 ± 1.9 cm, p = 0.05) and length of hospital stay (12.3 ± 6.8 vs. 22.4 ± 21.6 days, p = 0.002). On survival analysis, the MIS group had longer disease-free survival (DFS) and overall survival (OS) than the open group (DFS: 47.6 vs. 24.7 months, p = 0.027; OS: 60.0 vs. 30.7 months, p = 0.046). In order to overcome the heterogeneity of subjects between the MIS and the open group, we performed statically matched comparisons using the propensity score analysis and then divided the open group into two subgroups according to the Yonsei criteria. There were no significant differences in median overall survival between the MIS group and the open group that met the Yonsei criteria (60.00 vs. 60.72 months, p = 0.616).

CONCLUSIONS

Minimally invasive RAMPS is not only technically feasible but also oncologically safe in cases of well-selected left-sided pancreatic cancer. Our selection criteria for minimally invasive RAMPS needs to be further validated based on additional large-volume studies.

Robotic distal pancreatectomy

The authors found that robotic distal pancreatectomy, with or without splenic preservation, can be performed safely for patients with lesions of the distal pancreas.

Background:

A robotic-assisted minimal invasive approach has the potential to overcome the limitations of conventional laparoscopic pancreatectomies. We analyzed the outcomes of robotic-assisted distal pancreatectomies (RDPs) to demonstrate the safety and feasibility of robotic distal pancreas resection, including spleen preservation.

Methods:

We performed a descriptive retrospective analysis of 40 RDPs. Statistical comparisons were performed between two groups of patients undergoing robotic-assisted spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (SDP). Survival analysis was performed using the Kaplan-Meier method.

Results:

Of 49 attempted RDPs, 40 were completed with robotic assistance, with a conversion rate of 18.4%. Compared with the published reports of laparoscopic distal pancreatotomy (DP) and robotic DP, the spleen preservation rate (30%), operating time (203 minutes), major complications rate (5%), fistula rate (20%), and length of hospital stay (5 days) were similar in our RDP patients. Also, the perioperative outcomes of the SPDP and SDP groups did not differ significantly. The median survival was 12.5 months for the patients undergoing RDP for pancreatic ductal adenocarcinoma.

Conclusions:

Robotic-assisted distal pancreatectomy, with or without splenic preservation, can be safely performed for lesions of the distal pancreas, with appropriate indications.

Laparoscopic central pancreatectomy for benign or low-grade malignant lesions in the pancreatic neck and proximal body

INTRODUCTION

Laparoscopic central pancreatectomy (LCP) is a parenchyma-sparing minimally invasive surgical technique for removal of benign or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this study was to compare the short- and long-term clinical outcomes of LCP with those of other pancreatectomies.

METHODS

During the study period, January 2007 to December 2010 (median follow-up 40.6 months), 287 pancreatectomies were performed for lesions in the neck and proximal body of the pancreas. To compare the clinical outcomes of LCP and other pancreatectomies, 26 cases of LCP, 14 cases of open central pancreatectomy (OCP), and 96 cases of extended laparoscopic distal pancreatectomy (E-LDP) were selected.

RESULTS

Tumor sizes in the LCP (2.2 cm) and OCP (2.9 cm) groups were smaller than in the E-LDP (4.0 cm) group. Mean operation time in the LCP group (350.2 min) was longer than in the OCP (270.3 min) and E-LDP groups (210.6 min). There were more surgical complications in the LCP (38.5 %) and OCP groups (50 %) than in the E-LDP group (14.6 %). Mean duration of postoperative hospital stay was 13.8 days for the LCP group, which was significantly shorter than for the OCP group (22.4 days). New-onset diabetes was less frequent after LCP than after E-LDP (11.5 vs. 30.8 %).

CONCLUSIONS

In selected patients with small and benign tumors in the pancreatic neck and proximal body LCP leads to increased postoperative morbidity but earlier postoperative recovery than OCP, and excellent postoperative pancreatic function (compared with E-LDP). LCP should, therefore, be considered a valid therapeutic option for selected patients.

Laparoscopic spleen-preserving distal pancreatectomy: the technique must suit the lesion

Splenic preservation is currently recommended during minimally invasive surgery for benign tumors of the distal pancreas. The aim of this study was to evaluate the outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy, with particular attention paid to the technique used for spleen preservation (splenic vessel ligation vs preservation). A review of consecutive patients who underwent laparoscopic distal pancreatectomy with the intention of splenic preservation was conducted. Patient demographics, operative data, and outcomes were collected and analyzed. Fifty-five consecutive patients underwent laparoscopic distal pancreatectomy with the intention of splenic preservation; 5 required splenectomy (9 %). Of the remaining 50 patients, 31 (62 %) had splenic vessel ligation, and 19 (38 %) had vessel preservation. Patient demographics and tumor size were similar. The vessel ligation group had significantly more pancreas removed (95 vs 52 mm, P < 0.001) and longer operative times (256 vs 201 min, P = 0.008). Postoperative outcomes, complication rates, and splenic viability were similar between groups. Laparoscopic spleen-preserving distal pancreatectomy is a safe operation with a high rate of success (91 %). Vessel ligation was the chosen technical strategy for lesions that required resection of a greater length of pancreas. We found no advantage to either technique with respect to outcomes and splenic preservation. Operative approach should reflect technical considerations including location in the pancreas.

Pancreatic cancer: advances in treatment

Pancreatic cancer is a leading cause of cancer mortality and the incidence of this disease is expected to continue increasing. While patients with pancreatic cancer have traditionally faced a dismal prognosis, over the past several years various advances in diagnosis and treatment have begun to positively impact this disease. Identification of effective combinations of existing chemotherapeutic agents, such as the FOLFIRINOX and the gemcitabine + nab-paclitaxel regimen, has improved survival for selected patients although concerns regarding their toxicity profiles remain. A better understanding of pancreatic carcinogenesis has identified several pre-malignant precursor lesions, such as pancreatic intraepithelial neoplasias, intraductal papillary mucinous neoplasms, and cystic neoplasms. Imaging technology has also evolved dramatically so as to allow early detection of these lesions and thereby facilitate earlier management. Surgery remains a cornerstone of treatment for patients with resectable pancreatic tumors, and advances in surgical technique have allowed patients to undergo resection with decreasing perioperative morbidity and mortality. Surgery has also become feasible in selected patients with borderline resectable tumors as a result of neoadjuvant therapy. Furthermore, pancreatectomy involving vascular reconstruction and pancreatectomy with minimally invasive techniques have demonstrated safety without significantly compromising oncologic outcomes. Lastly, a deeper understanding of molecular aberrations contributing to the development of pancreatic cancer shows promise for future development of more targeted and safe therapeutic agents.

Effects of laparoscopic versus open surgery on splenic vessel patency after spleen and splenic vessel-preserving distal pancreatectomy: a retrospective multicenter study

BACKGROUND

The aims of this study were to compare splenic vessel patency between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy (SSVpDP), and to identify possible risk factors for poor splenic vessel patency.

METHODS

This retrospective multicenter study included 116 patients who underwent laparoscopic (n = 70) or open (n = 46) SSVpDP at seven Korean tertiary medical institutions between 2004 and 2011. Clinical parameters and the splenic vessel patency assessed by abdominal computed tomography were compared between the two surgical procedures.

RESULTS

The clinical parameters were not significantly different between both groups, except for postoperative hospital stay, which was significantly shorter in the laparoscopic group (10.4 vs. 13.5 days, P = 0.024). The splenic artery patency rate was similar in both groups (90.0 vs. 97.8 %), but the splenic vein patency rate was significantly lower in the laparoscopic group (64.3 vs. 87.0 %, P = 0.022). Univariate and multivariate analyses revealed surgical procedure [odds ratio (OR) 3.085, P = 0.043] and intraoperative blood loss (OR 4.624, P = 0.002) as independent risk factors for compromised splenic vein patency (partial or total occlusion). The splenic vein patency rate was significantly better in the late group (n = 34) than in the early period (n = 35) (79.4 vs. 48.6 %, P = 0.008).

CONCLUSIONS

Although laparoscopic SSVpDP had an advantage of shorter hospital stay compared with open surgery, it was associated with greater risk of poor splenic vein patency. However, this risk could decrease with increasing surgical experience and with efforts to minimize blood loss.

Improved perioperative outcomes with minimally invasive distal pancreatectomy: results from a population-based analysis

IMPORTANCE

Interest in minimally invasive distal pancreatectomy (MIDP) has grown in recent years, but currently available data are limited. Greater insight into application patterns and outcomes may be gained from a national database inquiry.

OBJECTIVES

To study trends in the use of MIDP and compare the short-term outcomes of MIDP with those of open distal pancreatectomy.

DESIGN, SETTING, AND PARTICIPANTS

Population-based retrospective cohort study evaluating perioperative outcomes and hospital charge measures for distal pancreatectomy, comparing the surgical approaches and adjusting for patient- and hospital-level factors, among patients undergoing elective distal pancreatectomy from 1998 to 2009 in the Nationwide Inpatient Sample in a 20% stratified sample of all US hospitals.

MAIN OUTCOMES AND MEASURES

In-hospital mortality, rates of perioperative complications and splenectomy, total charges, and length of stay.

RESULTS

A total of 8957 distal pancreatectomies were included in this analysis, of which 382 (4.3%) were MIDPs. On a national level, this projected to 42,320 open distal pancreatectomies and 1908 MIDPs. The proportion of distal pancreatectomies performed via minimally invasive approaches tripled between 1998 and 2009, from 2.4% to 7.3%. The groups were comparable for sex and comorbidity profiles, while patients who underwent MIDP were 1.5 years older. On multivariate analysis, MIDP was associated with lower rates of overall predischarge complications, including lower incidences of postoperative infections and bleeding complications, as well as a shorter length of stay by 1.22 days. There were no differences in rates of in-hospital mortality, concomitant splenectomy, or total charges.

CONCLUSIONS AND RELEVANCE

This population-based study of MIDP reveals that the application of this approach has tripled in practice and provides strong evidence that MIDP has evolved into a safe option in the treatment of benign and malignant pancreatic diseases.