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Labadie KP, Melstrom LG, Lewis AG. Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience. J Surg Oncol 2023; 128:1347-1352. [PMID: 37781938 DOI: 10.1002/jso.27455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023]
Abstract
Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.
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Affiliation(s)
- Kevin P Labadie
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Aaron G Lewis
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
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Boggi U, Donisi G, Napoli N, Partelli S, Esposito A, Ferrari G, Butturini G, Morelli L, Abu Hilal M, Viola M, Di Benedetto F, Troisi R, Vivarelli M, Jovine E, Ferrero A, Bracale U, Alfieri S, Casadei R, Ercolani G, Moraldi L, Molino C, Dalla Valle R, Ettorre G, Memeo R, Zanus G, Belli A, Gruttadauria S, Brolese A, Coratti A, Garulli G, Romagnoli R, Massani M, Borghi F, Belli G, Coppola R, Falconi M, Salvia R, Zerbi A. Prospective minimally invasive pancreatic resections from the IGOMIPS registry: a snapshot of daily practice in Italy on 1191 between 2019 and 2022. Updates Surg 2023; 75:1439-1456. [PMID: 37470915 PMCID: PMC10435655 DOI: 10.1007/s13304-023-01592-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
This retrospective analysis of the prospective IGOMIPS registry reports on 1191 minimally invasive pancreatic resections (MIPR) performed in Italy between 2019 and 2022, including 668 distal pancreatectomies (DP) (55.7%), 435 pancreatoduodenectomies (PD) (36.3%), 44 total pancreatectomies (3.7%), 36 tumor enucleations (3.0%), and 8 central pancreatectomies (0.7%). Spleen-preserving DP was performed in 109 patients (16.3%). Overall incidence of severe complications (Clavien-Dindo ≥ 3) was 17.6% with a 90-day mortality of 1.9%. This registry analysis provided some important information. First, robotic assistance was preferred for all MIPR but DP with splenectomy. Second, robotic assistance reduced conversion to open surgery and blood loss in comparison to laparoscopy. Robotic PD was also associated with lower incidence of severe postoperative complications and a trend toward lower mortality. Fourth, the annual cut-off of ≥ 20 MIPR and ≥ 20 MIPD improved selected outcome measures. Fifth, most MIPR were performed by a single surgeon. Sixth, only two-thirds of the centers performed spleen-preserving DP. Seventh, DP with splenectomy was associated with higher conversion rate when compared to spleen-preserving DP. Eighth, the use of pancreatojejunostomy was the prevalent reconstruction in PD. Ninth, final histology was similar for MIPR performed at high- and low-volume centers, but neoadjuvant chemotherapy was used more frequently at high-volume centers. Finally, this registry analysis raises important concerns about the reliability of R1 assessment underscoring the importance of standardized pathology of pancreatic specimens. In conclusion, MIPR can be safely implemented on a national scale. Further analyses are required to understand nuances of implementation of MIPR in Italy.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
| | - Greta Donisi
- Pancreatic Surgery Unit, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, OSR ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Luca Morelli
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Massimo Viola
- Department of Surgery, Ospedale Card. G. Panico, Tricase, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Troisi
- Division of HPB Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Elio Jovine
- Department of General Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, "Umberto I" Mauriziano Hospital, Turin, Italy
| | - Umberto Bracale
- Department Clinical Medicine and Surgery, Federico II University of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Sergio Alfieri
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, Department of Internal Medicine and Surgery (DIMEC), IRCCS, Azienda Ospedaliero Universitaria di Bologna Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- General and Oncology Surgery, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Luca Moraldi
- Division of Oncologic Surgery and Robotics, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Carlo Molino
- Department of Oncological Surgery Team 1, "Antonio Cardarelli" Hospital, Naples, Italy
| | - Raffaele Dalla Valle
- Hepatobiliary Surgery Unit Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuseppe Ettorre
- Transplantation Department, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva Delle Fonti, Bari, Italy
| | - Giacomo Zanus
- 4th Surgery Unit, Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | - Andrea Belli
- Division of Hepatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, Naples, Italy
| | | | - Alberto Brolese
- Department of General Surgery and HPB Unit, Santa Chiara Hospital, Trento, Italy
| | - Andrea Coratti
- USL Toscana Sud Est, Misericordia Hospital, Grosseto, Italy
| | | | - Renato Romagnoli
- Liver Transplant Center-General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Massani
- Department of Surgery, Regional Hospital of Treviso, Treviso, Italy
| | | | | | - Roberto Coppola
- Department of Surgery, University Campus Bio-Medico of Rome, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, OSR ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Kauffmann EF, Napoli N, Di Dato A, Salamone A, Ginesini M, Gianfaldoni C, Viti V, Amorese G, Cappelli C, Vistoli F, Boggi U. Practical implications of tumor proximity to landmark vessels in minimally invasive radical antegrade modular pancreatosplenectomy. Updates Surg 2023; 75:1533-1540. [PMID: 37458902 PMCID: PMC10435633 DOI: 10.1007/s13304-023-01584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/05/2023] [Indexed: 08/18/2023]
Abstract
Careful preoperative planning is key in minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS). This retrospective study aims to show the practical implications of computed tomography distance between the right margin of the tumor and either the left margin of the spleno-mesenteric confluence (d-SMC) or the gastroduodenal artery (d-GDA). Between January 2011 and June 2022, 48 minimally invasive RAMPS were performed for either pancreatic cancer or malignant intraductal mucinous papillary neoplasms. Two procedures were converted to open surgery (4.3%). Mean tumor size was 31.1 ± 14.7 mm. Mean d-SMC was 21.5 ± 18.5 mm. Mean d-GDA was 41.2 ± 23.2 mm. A vein resection was performed in 10 patients (20.8%) and the pancreatic neck could not be divided by an endoscopic stapler in 19 operations (43.1%). In patients requiring a vein resection, mean d-SMC was 10 mm (1.5-15.5) compared to 18 mm (10-37) in those without vein resection (p = 0.01). The cut-off of d-SMC to perform a vein resection was 17 mm (AUC 0.75). Mean d-GDA was 26 mm (19-39) mm when an endoscopic stapler could not be used to divide the pancreas, and 46 mm (30-65) when the neck of the pancreas was stapled (p = 0.01). The cut-off of d-GDA to safely pass an endoscopic stapler behind the neck of the pancreas was 43 mm (AUC 0.75). Computed tomography d-SMC and d-GDA are key measurements when planning for MI-RAMPS.
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Affiliation(s)
- Emanuele Federico Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Virginia Viti
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carla Cappelli
- Diagnostic and Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124 Pisa, Italy
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Peng F, He R, Wang H, Zhang H, Wang M, Qin T, Qin R. Development of a difficulty scoring system for laparoscopic pancreatoduodenectomy in the initial stage of the learning curve: a retrospective cohort study. Int J Surg 2023; 109:660-669. [PMID: 37010154 PMCID: PMC10389390 DOI: 10.1097/js9.0000000000000180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/29/2022] [Indexed: 04/04/2023]
Abstract
BACKGROUND It remains uncertain how surgeons can safely pass the learning curve of laparoscopic pancreatoduodenectomy (LPD) without potentially harming patients. We aimed to develop a difficulty scoring system (DSS) to select an appropriate patient for surgeons. MATERIALS AND METHODS A total of 773 elective pancreatoduodenectomy surgeries between July 2014 and December 2019, including 346 LPD and 427 open pancreatoduodenectomy cases, were included. A 10-level DSS for LPD was developed, and an additional 77 consecutive LPD surgeries which could provide information of the learning stage I of LPD externally validated its performance between December 2019 and December 2021. RESULTS The incidences of postoperative complications (Clavien-Dindo≥III) gradually decreased from the learning curve stage I-III (20.00, 10.94, 5.79%, P =0.008, respectively). The DSS consisted of the following independent risk factors: (1) tumor location, (2) vascular resection and reconstruction, (3) learning curve stage, (4) prognostic nutritional index, (5) tumor size, and (6) benign or malignant tumor. The weighted Cohen's κ statistic of concordance between the reviewer's and calculated difficulty score index was 0.873. The C -statistics of DSS for postoperative complication (Clavien-Dindo≥III) were 0.818 in the learning curve stage I. The patients with DSS<5 had lower postoperative complications (Clavien-Dindo≥III) than those with DSS≥5 (4.35-41.18%, P =0.004) in the training cohort and had a lower postoperative pancreatic fistula (19.23-57.14%, P =0.0352), delayed gastric emptying (19.23-71.43%, P =0.001), and bile leakage rate (0.00-21.43%, P =0.0368) in validation cohort in the learning curve stage I. CONCLUSION We developed and validated a difficulty score model for patient selection, which could facilitate the stepwise adoption of LPD for surgeons at different stages of the learning curve.
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Affiliation(s)
| | | | | | | | | | - Tingting Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
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Xu Q, Li P, Zhang H, Wang M, Liu Q, Liu W, Dai M. Identifying the preoperative factors predicting the surgical difficulty of robotic distal pancreatectomy. Surg Endosc 2023; 37:3823-3831. [PMID: 36690891 DOI: 10.1007/s00464-023-09865-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/04/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Few studies have evaluated the preoperative factors predicting the surgical difficulty of robotic distal pancreatectomy (RDP). This study aims to explore such factors and provide guidance on the selection of suitable patients to aid surgeons lacking extensive experience in RDP. METHODS A retrospective study was conducted on consecutive patients who underwent RDP to identify preoperative factors predicting surgical difficulty. High surgical difficulty was defined by both operation time and intraoperative estimated blood loss exceeding their median, or by conversion to laparotomy. RESULTS A total of 161 patients were ultimately enrolled, including 51 patients with high levels of surgical difficulty. Multivariate analysis revealed that male sex [OR (95% CI): 4.07 (1.77,9.40), p = 0.001], body mass index (BMI) ≥ 25 kg/m2 OR (95% CI): 2.27 (1.03,5.00), p = 0.042], tumors located at the neck of the pancreas [OR (95% CI): 4.15 (1.49,11.56), p = 0.006] and splenic artery type B [OR (95% CI): 3.28 (1.09,9.91), p = 0.035] were independent risk factors for surgical difficulty. Regarding postoperative complications, high surgical difficulty was associated with the risk of overall complications and pancreatic fistula (grade B/C) (49.0% vs. 22.7%, p < 0.001; 39.2% vs. 19.1%, p = 0.006). CONCLUSION Male sex, body mass index ≥ 25 kg/m2, tumor located at the neck of the pancreas and splenic artery type B are associated with a high RDP difficulty level. These factors can be used preoperatively to assess the difficulty level of surgery, to help surgeons choose patients suitable for them and ensure surgical safety.
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Affiliation(s)
- Qiang Xu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Pengyu Li
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Hanyu Zhang
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Mengyi Wang
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Qiaofei Liu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Wenjing Liu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China.
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Honda M, Shimojima N, Maeda Y, Ito Y, Miyaguni K, Tsukizaki A, Abe K, Hashimoto M, Ishikawa M, Tomita H, Shimotakahara A, Hirobe S. Factors predicting surgical difficulties in congenital biliary dilatation in pediatric patients. Pediatr Surg Int 2023; 39:79. [PMID: 36629958 DOI: 10.1007/s00383-023-05363-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND The effects of disease classification and the patient's preoperative condition on the difficulty of performing a laparotomy for pediatric congenital biliary dilatation (CBD) have not been fully elucidated. METHODS The present study retrospectively analyzed 46 pediatric CBD laparotomies performed at the study center between March 2010 and December 2021 and predictors of operative time. The patients were separated into a short operative time group (SOT) (≤ 360 min, n = 27) and a long operative time group (LOT) (> 360 min, n = 19). RESULTS The preoperative AST and ALT values were higher, and the bile duct anastomosis diameter was larger, in the LOT. Correlation analysis demonstrated that the maximum cyst diameter, preoperative neutrophil-to-lymphocyte ratio, AST, ALT, AMY, and bile duct anastomosis diameter correlated positively with operative time. Multivariate analysis identified the maximal cyst diameter, preoperative AST, and bile duct anastomosis diameter as significant factors affecting surgical time. Postoperatively, intrapancreatic stones and paralytic ileus were observed in one patient each in the SOT, and mild bile leakage was observed in one patient in the LOT. CONCLUSIONS The maximum cyst diameter, preoperative AST, and bile duct anastomosis diameter have the potential to predict the difficulty of performing a pediatric CBD laparotomy.
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Affiliation(s)
- Masaki Honda
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.,Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Naoki Shimojima
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.
| | - Yutaro Maeda
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Yoshifumi Ito
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Kazuaki Miyaguni
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Ayano Tsukizaki
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Kiyotomo Abe
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Makoto Hashimoto
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Miki Ishikawa
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Hirofumi Tomita
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Akihiro Shimotakahara
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Seiichi Hirobe
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
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Robotic versus laparoscopic distal pancreatectomy on perioperative outcomes: a systematic review and meta-analysis. Updates Surg 2023; 75:7-21. [PMID: 36378464 PMCID: PMC9834369 DOI: 10.1007/s13304-022-01413-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Abstract
Robotic surgery has become a promising surgical method in minimally invasive pancreatic surgery due to its three-dimensional visualization, tremor filtration, motion scaling, and better ergonomics. Numerous studies have explored the benefits of RDP over LDP in terms of perioperative safety and feasibility, but no consensus has been achieved yet. This article aimed to evaluate the benefits and drawbacks of RDP and LDP for perioperative outcomes. By June 2022, all studies comparing RDP to LDP in the PubMed, the Embase, and the Cochrane Library database were systematically reviewed. According to the heterogeneity, fix or random-effects models were used for the meta-analysis of perioperative outcomes. Odds ratio (OR), weighted mean differences (WMD), and 95% confidence intervals (CI) were calculated. A sensitivity analysis was performed to explore potential sources of high heterogeneity and a trim and fill analysis was used to evaluate the impact of publication bias on the pooled results. Thirty-four studies met the inclusion criteria. RDP provides greater benefit than LDP for higher spleen preservation (OR 3.52 95% CI 2.62-4.73, p < 0.0001) and Kimura method (OR 1.93, 95% CI 1.42-2.62, p < 0.0001) in benign and low-grade malignant tumors. RDP is associated with lower conversion to laparotomy (OR 0.41, 95% CI 0.33-0.52, p < 0.00001), and shorter postoperative hospital stay (WMD - 0.57, 95% CI - 0.92 to - 0.21, p = 0.002), but it is more costly. In terms of postoperative complications, there was no difference between RDP and LDP except for 30-day mortality (RDP versus LDP, 0.1% versus 1.0%, p = 0.03). With the exception of its high cost, RDP appears to outperform LDP on perioperative outcomes and is technologically feasible and safe. High-quality prospective randomized controlled trials are advised for further confirmation as the quality of the evidence now is not high.
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Ramia JM. Invited Commentary: Structured Training Programs for Minimally Invasive Pancreatic Surgery Should Be Mandatory. J Am Coll Surg 2022; 235:390-391. [PMID: 35972157 DOI: 10.1097/xcs.0000000000000255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Korrel M, Lof S, Alseidi AA, Asbun HJ, Boggi U, Hogg ME, Jang JY, Nakamura M, Besselink MG, Abu Hilal M. Framework for Training in Minimally Invasive Pancreatic Surgery: An International Delphi Consensus Study. J Am Coll Surg 2022; 235:383-390. [PMID: 35972156 DOI: 10.1097/xcs.0000000000000278] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous reports suggest that structured training in minimally invasive pancreatic surgery (MIPS) can ensure a safe implementation into standard practice. Although some training programs have been constructed, worldwide consensus on fundamental items of these training programs is lacking. This study aimed to determine items for a structured MIPS training program using the Delphi consensus methodology. STUDY DESIGN The study process consisted of 2 Delphi rounds among international experts in MIPS, identified by a literature review. The study committee developed a list of items for 3 key domains of MIPS training: (1) framework, (2) centers and surgeons eligible for training, and (3) surgeons eligible as proctor. The experts rated these items on a scale from 1 (not important) to 5 (very important). A Cronbach's α of 0.70 or greater was defined as the cut-off value to achieve consensus. Each item that achieved 80% or greater of expert votes was considered as fundamental for a training program in MIPS. RESULTS Both Delphi study rounds were completed by all invited experts in MIPS, with a median experience of 20 years in MIPS. Experts included surgeons from 31 cities in 13 countries across 4 continents. Consensus was reached on 38 fundamental items for the framework of training (16 of 35 items, Cronbach's α = 0.72), centers and surgeons eligible for training (19 of 30 items, Cronbach's α = 0.87), and surgeons eligible as proctor (3 of 10 items, Cronbach's α = 0.89). Center eligibility for MIPS included a minimum annual volume of 10 distal pancreatectomies and 50 pancreatoduodenectomies. CONCLUSION Consensus among worldwide experts in MIPS was reached on fundamental items for the framework of training and criteria for participating surgeons and centers. These items act as a guideline and intend to improve training, proctoring, and safe worldwide dissemination of MIPS.
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Affiliation(s)
- Maarten Korrel
- From the Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands (Korrel, Lof, Besselink)
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Korrel, Lof, Abu Hilal)
| | - Sanne Lof
- From the Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands (Korrel, Lof, Besselink)
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Korrel, Lof, Abu Hilal)
| | - Adnan A Alseidi
- Division of Surgery, University of California, San Francisco, CA (Alseidi)
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL (Asbun)
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy (Boggi)
| | - Melissa E Hogg
- Department of Surgery, NorthShore University Health System, Evanston, IL (Hogg)
| | - Jin-Young Jang
- Departments of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea (Jang)
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (Nakamura)
| | - Marc G Besselink
- From the Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands (Korrel, Lof, Besselink)
| | - Mohammad Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Korrel, Lof, Abu Hilal)
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK (Abu Hilal)
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10
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Seo S, Uemura K, Sumiyoshi T, Kondo N, Okada K, Otsuka H, Murakami Y, Takahashi S. Optimal lymph-node dissection for pancreatic tail cancer. Surg Today 2022; 52:1307-1312. [PMID: 35182251 DOI: 10.1007/s00595-022-02463-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The optimal range of lymph-node dissection for pancreatic tail cancer remains unclear. We investigated the location and frequency of lymph-node metastases to identify the correct range of lymph-node dissection for pancreatic tail cancer. METHODS We analyzed clinical data retrospectively, on patients who underwent distal pancreatectomy for resectable left-sided pancreatic cancer, between February, 2006 and March, 2021. Eligible patients were divided into two groups according to the tumor location: those with pancreatic tail cancer (Pt group) and those with pancreatic body or body and tail cancer (non-Pt group). RESULTS Of the 96 patients analyzed, 61 (64%) were assigned to the Pt group and 35 (36%) were assigned to the non-Pt group. Metastases to stations 7, 8, 9, 10, 11, 14, and 18 were found in 0 (0%), 0 (0%), 0 (0%), 4 (7%), 18 (30%), 2 (4%), and 10 (17%) patients in the Pt group, and in 1 (3%), 4 (12%), 2 (6%), 1 (3%), 18 (51%), 3 (9%), and 6 (17%) patients in the non-Pt group, respectively. CONCLUSION Lymph-node dissection at stations 7, 8, and 9 might not be necessary in patients with resectable pancreatic cancer confined to the pancreatic tail.
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Affiliation(s)
- Shingo Seo
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kenichiro Uemura
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tatsuaki Sumiyoshi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Naru Kondo
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kenjiro Okada
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hiroyuki Otsuka
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yoshiaki Murakami
- Digestive Disease Center, Hiroshima Memorial Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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11
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Safety and Feasibility of Single-incision Laparoscopic Distal Pancreatectomy. Surg Laparosc Endosc Percutan Tech 2022; 32:488-493. [PMID: 35583583 DOI: 10.1097/sle.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Comparative studies regarding single-incision laparoscopic distal pancreatectomy (SILS-DP) are limited. This study aimed to compare the short-term outcomes of SILS-DP with conventional laparoscopic DP (C-LDP) under strict indication criteria. MATERIALS AND METHODS We retrospectively reviewed the patient characteristics and surgical outcomes of those who underwent either SILS-DP or C-LDP at National Taiwan University (NTU) and C-LDP at Nara Medical University (NMU) between 2009 and 2019. SILS-DP was indicated for benign or low-grade malignant pancreatic tail tumors and was performed along with splenectomy. RESULTS We compared 12 cases of SILS-DP with 31 of C-LDP from NTU and 17 of C-LDP from NMU. Patients in the SILS-DP group had significantly less blood loss than the C-LDP group at NTU (P=0.028). Postoperative outcomes, including the postoperative hospital stay and clinically relevant pancreatic fistula, were not significantly different between the 2 groups. Although SILS-DP was performed by a surgeon who was well-experienced with laparoscopic surgeries, the first few cases had a larger amount of blood loss, longer operation time, and a higher rate of complications. Such unfavorable outcomes were likely to be resolved shortly. No reoperations and deaths were noted. CONCLUSION SILS-DP is feasible when performed by an experienced surgeon and in carefully selected patients.
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12
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Müller PC, Kuemmerli C, Cizmic A, Sinz S, Probst P, de Santibanes M, Shrikhande SV, Tschuor C, Loos M, Mehrabi A, Z’graggen K, Müller-Stich BP, Hackert T, Büchler MW, Nickel F. Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization. ANNALS OF SURGERY OPEN 2022; 3:e111. [PMID: 37600094 PMCID: PMC10431463 DOI: 10.1097/as9.0000000000000111] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 10/30/2021] [Indexed: 12/31/2022] Open
Abstract
Objective To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP). Background Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized. Methods A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases. Results Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001). Conclusions This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.
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Affiliation(s)
- P. C. Müller
- From the Department of Surgery, Clinic Beau-Site, Bern, Switzerland
| | - C. Kuemmerli
- Clarunis, University Center for Gastrointestinal and Liver Disorders, University Hospital Basel, Basel, Switzerland
| | - A. Cizmic
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - S. Sinz
- Department of General Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - P. Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M. de Santibanes
- Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - S. V. Shrikhande
- Department of GI and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - C. Tschuor
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M. Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A. Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - K. Z’graggen
- From the Department of Surgery, Clinic Beau-Site, Bern, Switzerland
| | - B. P. Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - T. Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M. W. Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - F. Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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13
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Park Y, Hwang DW, Lee JH, Song KB, Jun E, Lee W, Hong S, Kim SC. Minimally invasive distal pancreatectomy: Chronologic changes in the trends and clinical outcomes through a 15-year, single-center experience with 2212 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:540-551. [PMID: 35112510 DOI: 10.1002/jhbp.1122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND We identified the chronologic changes in the clinical outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors in a single high-volume center over a period of 15 years. METHODS Between 2005 and 2019, 2212 patients underwent planned MIDP. Chronologic changes were analyzed according to 5-year intervals (P1, P2, P3). Furthermore, we assessed the prognostic factors of open conversion and postoperative complications. RESULTS MIDP has steadily increased during the last 15 years when compared to open distal pancreatectomy, from 10.8% to 84.9%. Also, MIDP for pancreatic ductal adenocarcinoma (PDAC) has been steadily increasing from 5.6% to 68.4%. According to the 5-year intervals, lengths of hospital stay decreased, but age and American Society of Anesthesiologists (ASA) ≥3 increased; conversely, the rates of Clavien-Dindo classification ≥grade 3 (9.5%) and postoperative pancreatic fistula (39.7%) showed no differences. The 90-day mortality and open conversion rates were 0.2% and 3.5%, respectively. Multivariate logistic regression analysis revealed malignancy and extended pancreatectomy were risk factors for open conversion. Furthermore, the poor prognostic factors for severe complications were malignancy, extended pancreatectomy, and ASA ≥3. CONCLUSION MIDP has become a popular procedure not only for benign cases but also for malignant ones. However, well-organized training, experience and skill are necessary, especially for poor-performance patients and extensively malignant conditions.
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Affiliation(s)
- Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Convergence Medicine, Asan Institute for Life Sciences, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea.,Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sarang Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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14
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Minagawa T, Sugiura T, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Sasaki K, Uesaka K. Clinical implications of lymphadenectomy for invasive ductal carcinoma of the body or tail of the pancreas. Ann Gastroenterol Surg 2022; 6:531-542. [PMID: 35847444 PMCID: PMC9271019 DOI: 10.1002/ags3.12551] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 01/05/2022] [Indexed: 01/23/2023] Open
Abstract
Aim The appropriate extent of lymphadenectomy for pancreatic cancer of the body/tail has not been standardized worldwide. The present study evaluated the optimal extent of harvesting lymph nodes. Methods Patients who underwent distal pancreatectomy for invasive ductal carcinoma of the pancreas between 2007 and 2018 were retrospectively reviewed. Patients were subclassified into three groups depending on the tumor location: pancreatic body (Pb), proximal pancreatic tail (Ptp), and distal pancreatic tail (Ptd). The pancreatic tail was further divided into even sections of Ptp and Ptd. Patterns of lymph node metastasis and the impact of lymph node metastasis on the prognosis were examined. Results A total of 120 patients were evaluated. Fifty‐eight patients had a tumor in the Pb, 38 in the Ptp, and 24 in the Ptd. No patients with a Ptd tumor had metastasis beyond the peripancreatic and splenic hilar lymph nodes (LN‐PSH). All patients with metastasis to the lymph nodes along the common hepatic artery (LN‐CHA) or along the left lateral superior mesenteric artery (LN‐SMA) also had metastasis to the LN‐PSH. Recurrence after surgery occurred significantly earlier in this population. In a multivariate analysis, metastasis to the LN‐CHA or LN‐SMA (hazard ratio [HR] 3.3; P = .04) was an independent risk factor for overall survival. Furthermore, high levels of preoperative serum CA19‐9 (HR 10.9; P = .013) were a predictive factor for metastasis to the LN‐CHA or LN‐SMA. Conclusions Metastasis to the LN‐CHA or LN‐SMA was rare but a significant prognostic factor in patients with pancreatic body/tail cancer.
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Affiliation(s)
- Takuya Minagawa
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Teiichi Sugiura
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Yukiyasu Okamura
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Takaaki Ito
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Yusuke Yamamoto
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Ryo Ashida
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Katsuhisa Ohgi
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Keiko Sasaki
- Division of Pathology Shizuoka Cancer Center Shizuoka Japan
| | - Katsuhiko Uesaka
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
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15
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Evaluation of factors predicting loss of benefit provided by laparoscopic distal pancreatectomy compared to open approach. Updates Surg 2021; 74:213-221. [PMID: 34687429 DOI: 10.1007/s13304-021-01194-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
Several studies showed safety and feasibility of laparoscopic distal pancreatectomy (LDP) as compared to open distal pancreatectomy (ODP). Patients who underwent LDP or ODP (2015-2019) were included. A 1:1 propensity score matching (PSM) was used to reduce the effect of treatment selection bias. Aim of this study was to identify those factors influencing the loss of benefit (defined as a significantly better outcome compared to ODP) after LDP. Overall, 387 patients underwent DP (n = 250 LDP, n = 137 ODP). After PSM, 274 patients (n = 137 LDP, n = 137 ODP) were selected. LDP was associated with reduced intraoperative blood loss (median: 200 mL vs. 250 mL, p < 0.001), decreased wound infection rate (1% vs. 9%, p = 0.044) and shorter time to functional recovery (TFR) (median: 4 days vs. 5 days, p = 0.002). Consequently, TFR > 5 days and blood loss > 250 mL were defined as loss of benefit after LDP. In the LDP group, age > 70 years [Odds Ratio (OR) 2.744, p = 0.022] and duration of surgery > 208 min (OR 2.957, p = 0.019) were predictors of TFR > 5 days and intraoperative blood loss > 250 mL, respectively. No differences in terms of TFR were found between ODP and LDP groups in patients > 70 years (p = 0.102). Intraoperative blood loss was significantly higher in the ODP group, also when the analysis was limited to surgical procedures with operative time > 208 min (p = 0.003). In conclusion, LDP seems comparable to ODP in terms of TFR in patients aged > 70 years. This finding could be helpful in the choice of the best surgical approach in elderly patients undergoing potentially challenging DPs.
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16
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Kosaka H, Satoi S, Kono Y, Yamamoto T, Hirooka S, Yamaki S, Hashimoto D, Sakaguchi T, Sekimoto M. Estimation of the degree of surgical difficulty anticipated for pancreatoduodenectomy: Preoperative and intraoperative factors. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:1166-1174. [PMID: 34596977 DOI: 10.1002/jhbp.1052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/29/2021] [Accepted: 09/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is a technically complex procedure. Preoperative anticipation of the degree of difficulty could contribute to patient safety during trainee surgical education. METHODS We prospectively administered a questionnaire to the chief surgeon after each PD performed between 2016 and 2018 at our institution (99 consecutive patients). The surgeon rated the difficulty of the procedure; we then analyzed this information against perioperative data. RESULTS The difficulty of PD was ranked as simple (29.3%), moderate (40.4%), or difficult (30.3%). The difficult procedures required an operative time of 2 h longer than the simple procedures and involved an additional 800 mL of intraoperative blood loss. Postoperative complications were similar in all groups. Multivariate analysis revealed that an unrecognized tissue plane for dissection was an independent determinant of a difficult PD (odds ratio [OR]: 89.2, 95% confidence interval [CI]: 9.2-861.2; P < .001). Independent predictors of a difficult PD were a pretreatment status of borderline resectable or unresectable (OR: 21.9, CI: 5.3-90.6; P < .001) and cholangitis during the preoperative period (OR: 4.1, CI: 1.3-13.0; P = .017). CONCLUSIONS Surgeons deem the PD procedure to be difficult when the proper tissue plane for dissection is unrecognized. Preoperative assessment of the anticipated difficulty could contribute to better operative management.
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Affiliation(s)
- Hisashi Kosaka
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata, Japan.,Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Yumiko Kono
- Department of Radiology, Kansai Medical University, Hirakata, Japan
| | | | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | | | | | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, Hirakata, Japan
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17
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Hirashita T, Iwashita Y, Fujinaga A, Nakanuma H, Tada K, Masuda T, Endo Y, Ohta M, Inomata M. Surgical and oncological outcomes of laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma. Surg Today 2021; 52:224-230. [PMID: 34173053 DOI: 10.1007/s00595-021-02326-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the outcomes of laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) with those of open RAMPS (O-RAMPS) in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS We reviewed, retrospectively, the medical records of 50 patients who underwent RAMPS for PDAC without resection of major vessels and adjacent organs between 2007 and 2019, and analyzed the relationship between the operative method and surgical and oncological outcomes. RESULTS Nineteen of the 50 patients underwent L-RAMPS and 31 patients underwent O-RAMPS. L-RAMPS was associated with significantly less blood loss (P = 0.034) but a longer operative time (P = 0.001) than O-RAMPS. There were no significant differences in patient characteristics, tumor factors, or postoperative course; or in the rates of recurrence-free survival (P = 0.084) or overall survival (P = 0.402) between the L-RAMPS and O-RAMPS groups. CONCLUSION L-RAMPS for PDAC resulted in less blood loss but a longer operative time than O-RAMPS. Although L-RAMPS may be feasible, the operative time needs to be reduced by standardizing the procedure.
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Affiliation(s)
- Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan.
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Hiroaki Nakanuma
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Kazuhiro Tada
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Masayuki Ohta
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, 1-1 Hasama-machi, Yufu, Oita, 879-5593, Japan
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18
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Deiro G, De Pastena M, Paiella S, Balduzzi A, Montagnini G, Andreotti E, Casetti L, Landoni L, Salvia R, Esposito A. Assessment of difficulty in laparoscopic distal pancreatectomy: A modification of the Japanese difficulty scoring system - A single-center high-volume experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:770-777. [PMID: 34114743 PMCID: PMC8518381 DOI: 10.1002/jhbp.1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/22/2021] [Accepted: 05/29/2021] [Indexed: 11/13/2022]
Abstract
Background The Japanese difficulty scoring system (DSS) was developed to assess the difficulty of laparoscopic distal pancreatectomy (LDP). The study aimed to validate a modified DSS (mDSS) in a European high‐volume center. Methods Patients' clinical data underwent LDP for benign and malignant pancreatic lesion between September 2013 and February 2020 were reviewed. Expert laparoscopic surgeons performed the procedures. The mDSS consisted of seven variables, such as type of operation, malignancy, neoadjuvant therapy, pancreatic resection line, tumor close to major vessels, tumor extension to peripancreatic tissue, and left‐sided portal hypertension and/or splenomegaly. According to the difficulty level and previous score, the mDSS was subdivided into three classes: low, intermediate, and high. Surrogates of case complexity (operative time, intraoperative blood loss and blood transfusion requirements, conversion rate) were used to validate the new scoring system. Results The study population included 140 LDP. Ninety‐five (68%), 35 (25%) and 10 (7%) patients belonged to low, intermediate, and high difficulty groups. The mDSS identified the complexity of the surgical case of the series for all the surrogates of complexity considered, namely conversion rate (P = .004), operative time (P = .033) and intraoperative blood loss (P = .009). No differences were recorded in the postoperative outcomes (P > .05). Conclusion The mDSS for LDP better stratified the pancreatic procedures according to their complexity. The new scoring system may allow an appropriate preoperative evaluation of surgical difficulty, facilitating LDP's training program. Future prospective studies are needed to validate the mDSS.
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Affiliation(s)
- Giacomo Deiro
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alberto Balduzzi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Greta Montagnini
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Elena Andreotti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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19
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Evaluation of relationship between splenic artery and pancreatic parenchyma using three-dimensional computed tomography for laparoscopic distal pancreatectomy. Langenbecks Arch Surg 2021; 406:1885-1892. [PMID: 33721087 DOI: 10.1007/s00423-021-02101-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/21/2021] [Indexed: 01/06/2023]
Abstract
AIM Isolating the root of the splenic artery (SPA) is a challenging procedure in laparoscopic distal pancreatectomy (LDP). We investigated the usefulness of evaluation of the relationship between the SPA and pancreatic parenchyma using three-dimensional computed tomography (3D-CT). METHODS In total, 104 patients were evaluated. The relationship between the SPA and pancreatic parenchyma was classified into two types: buried and non-buried. Video clips of 50 patients who underwent LDP requiring isolation of the SPA root were reviewed to determine whether the classification is related to difficulty of LDP. RESULTS Of the 50 assessed patients who underwent LDP, the relationship between the SPA and pancreatic parenchyma was the buried type in 30 (60.0%) and non-buried type in 20 (40.0%). The buried type was associated with a significantly longer median operative time than the non-buried type (285.0 vs. 235.5 min, respectively; P < 0.01). The median time required to isolate the SPA in the buried type (25.8 min; range, 4.0-101 min) was significantly longer than that in the non-buried type (7.0 min; range, 1.0-27.0 min) (P < 0.001). CONCLUSION Preoperative 3D-CT around the pancreas is practical for predicting the difficulty of SPA isolation and determining the safety of the procedure.
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Nakata K, Higuchi R, Ikenaga N, Sakuma L, Ban D, Nagakawa Y, Ohtsuka T, Asbun HJ, Boggi U, Tang CN, Wolfgang CL, Nishino H, Endo I, Tsuchida A, Nakamura M. Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:99-113. [PMID: 33533158 DOI: 10.1002/jhbp.901] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/19/2020] [Accepted: 01/18/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive pancreatoduodenectomy (MIPD) has recently gained popularity. Several international meetings focusing on the existing literature on MIPD were held; however, the precise surgical anatomy of the pancreas for the safe use of MIPD has not yet been fully discussed. The aim of this study was to carry out a systematic review of available articles and to show the importance of identifying the anatomical variation in pancreatoduodenectomy. METHODS In this review, we described variations in surgical anatomy related to MIPD. A systematic search of PubMed (MEDLINE) was conducted, and the references were identified manually. RESULTS The search strategy yielded 272 articles, with 77 retained for analysis. The important anatomy to be considered during MIPD includes the aberrant right hepatic artery, first jejunal vein, first jejunal artery, and dorsal pancreatic artery. Celiac artery stenosis and a circumportal pancreas are also important to recognize. CONCLUSIONS We conclude that only certain anatomical variations are associated directly with perioperative outcomes and that identification of these particular variations is important for safe performance of MIPD.
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Affiliation(s)
- Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Leon Sakuma
- Professor with Special Assistant, Kawasaki Medical School, Okayama, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Chung-Ngai Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | | | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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21
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Ban D, Garbarino GM, Ishikawa Y, Honda G, Jang JY, Kang CM, Maekawa A, Murase Y, Nagakawa Y, Nishino H, Ohtsuka T, Yiengpruksawan A, Endo I, Tsuchida A, Nakamura M. Surgical approaches for minimally invasive distal pancreatectomy: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:151-160. [PMID: 33527758 DOI: 10.1002/jhbp.902] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/23/2020] [Accepted: 01/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking. METHODS A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP. RESULTS All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed. CONCLUSIONS In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP.
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Affiliation(s)
- Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Giovanni Maria Garbarino
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Aya Maekawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiki Murase
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Anusak Yiengpruksawan
- Minimally Invasive Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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22
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Nishino H, Zimmitti G, Ohtsuka T, Abu Hilal M, Goh BKP, Kooby DA, Nakamura Y, Shrikhande SV, Yoon YS, Ban D, Nagakawa Y, Nakata K, Endo I, Tsuchida A, Nakamura M. Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:136-150. [PMID: 33527704 DOI: 10.1002/jhbp.903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/23/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP. METHODS A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology. RESULTS Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found. CONCLUSIONS The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.
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Affiliation(s)
- Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Giuseppe Zimmitti
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Mohammed Abu Hilal
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore City, Singapore
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | | | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, Seoul, Korea
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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23
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Partelli S, Ricci C, Rancoita PMV, Montorsi R, Andreasi V, Ingaldi C, Arru G, Pecorelli N, Crippa S, Alberici L, Di Serio C, Casadei R, Falconi M. Preoperative predictive factors of laparoscopic distal pancreatectomy difficulty. HPB (Oxford) 2020; 22:1766-1774. [PMID: 32340858 DOI: 10.1016/j.hpb.2020.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is a challenging operation due to technical complexity and tumor-related factors. Aim of this study was to identify preoperative risk factors affecting LDP difficulty. METHODS Consecutive patients who underwent LDP between 2015 and 2018 at San Raffaele Hospital and Policlinico S.Orsola-Malpighi Hospital were enrolled retrospectively. Three variables were used to define surgical difficulty: conversion to open, duration of surgery >3rd quartile and intraoperative blood loss >3rd quartile. The presence of ≥1 of these 3 variables was considered as another measure of difficulty. RESULTS Overall, 191 patients were included. Conversion to open was required in 25 patients (13%). At multiple regression analysis, tumor proximity to major vessels was the only independent predictor of conversion from laparoscopic to open (p < 0.001). No variables independently predicted an excessive duration of surgery. Male gender (p = 0.033) and increasing parenchymal thickness at resection line (p = 0.018) were independent predictors of excessive blood loss. Increasing parenchymal thickness at resection line (p = 0.014) and tumor proximity to major vessels (p = 0.002) were significant risk factors for the presence of ≥1 outcome of surgical difficulty. CONCLUSION Male gender, increasing parenchymal thickness at resection line and tumor proximity to major vessels represent preoperative risk factors of LDP difficulty.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Paola M V Rancoita
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Roberto Montorsi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Carlo Ingaldi
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Giaime Arru
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Laura Alberici
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Clelia Di Serio
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy.
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24
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Laparoscopic distal pancreatectomy with regional lymphadenectomy through retroperitoneal-first laparoscopic approach (Retlap) for locally advanced pancreatic body cancer. Surg Oncol 2020; 35:301-302. [DOI: 10.1016/j.suronc.2020.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 05/05/2020] [Accepted: 07/21/2020] [Indexed: 01/06/2023]
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25
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Casadei R, Ricci C, Ingaldi C, Alberici L, Vaccaro MC, Galasso E, Minni F. The Usefulness of a Preoperative Nomogram for Predicting the Probability of Conversion from Laparoscopic to Open Distal Pancreatectomy: A Single-Center Experience. World J Surg 2020; 45:252-260. [PMID: 33063199 PMCID: PMC7752782 DOI: 10.1007/s00268-020-05806-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2020] [Indexed: 11/29/2022]
Abstract
Background Laparoscopic distal pancreatectomy (LDP) represents a challenging procedure with a high conversion rate. A nomogram is a simple statistical predictive tool which is superior to risk groups. The aim of this study was to develop and validate a preoperative nomogram for predicting the probability of conversion from laparoscopic to open distal pancreatectomy. Methods This is a retrospective study of 100 consecutive patients who underwent LDP. For each patient demographic, pre-intra- and postoperative data were collected. Univariate and multivariate analyses were carried out to identify the factors significantly influencing the conversion rate. The effect of each factor was weighted using the beta coefficient (β), and a nomogram was built. Finally, a logistic regression between the score and the conversion rate was carried out to calibrate the nomogram. Results The conversion rate was 19.0%. At multivariate analysis, female (β = − 1.8 ± 0.9; P = 0.047) and tail location of the tumor (β = − 2.1 ± 1.1; P = 0.050) were significantly related to a low probability of conversion. Body mass index (BMI) (β = 0.2 ± 0.1; P = 0.011) and subtotal pancreatectomy (β = 2.4 ± 0.9; P = 0.006) were factors independently related to a high probability of conversion. The nomogram constructed had a minimum value of 4 and a maximum value of 18 points. The probability of conversion increased significantly starting from a minimum score of 6 points (P = 0.029; conversion probability 14.4%; 95%CI, 1.5–27.3%) up to 16 (P = 0.048; 27.8%; 95%CI, 0.2–48.7%). Conclusion The nomogram proposed could serve as an effective preoperative tool capable of assessing the probability of conversion, allowing to take reliable decisions regarding indications and adequate stepwise training program of LDP.
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Affiliation(s)
- Riccardo Casadei
- Department of Internal Medicine and Surgery (DIMEC), S.Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy.
| | - Claudio Ricci
- Department of Internal Medicine and Surgery (DIMEC), S.Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Carlo Ingaldi
- Department of Internal Medicine and Surgery (DIMEC), S.Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Laura Alberici
- Department of Internal Medicine and Surgery (DIMEC), S.Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Maria Chiara Vaccaro
- Department of Internal Medicine and Surgery (DIMEC), S.Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Elisa Galasso
- Department of Internal Medicine and Surgery (DIMEC), S.Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Francesco Minni
- Department of Internal Medicine and Surgery (DIMEC), S.Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
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26
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Kazaryan AM, Solberg I, Aghayan DL, Sahakyan MA, Reiertsen O, Semikov VI, Shulutko AM, Edwin B. Does tumor size influence the outcome of laparoscopic distal pancreatectomy? HPB (Oxford) 2020; 22:1280-1287. [PMID: 31843445 DOI: 10.1016/j.hpb.2019.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/09/2019] [Accepted: 11/24/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned. METHODS Patients who underwent LDP for pancreatic solitary tumors in 1997-2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5 cm (group I); from 3.5 cm to 7.0 cm (group II), and ≥7 cm (group III). RESULTS 218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5 mm (p < 0.001). Nine procedures (2.1%) were converted including 1(0.5%), 5(3.4%) and 3(5.2%) in the groups I, II and III (p = 0.036). Median operative time was longer in the group III compared with the groups I and II - 195 vs 158 and 159 min (p = 0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R = 0.103; P = 0.035) and no correlation between tumor size and blood loss (R = 0.075; P = 0.125). Hospital stay was 5 days, similar in all groups.Postoperative morbidity was similar - 38.5, 32 and 34% in the group I, II and III. CONCLUSION LDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.
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Affiliation(s)
- Airazat M Kazaryan
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, Grålum, Norway; Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Department of Faculty Surgery N2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia; Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | | | - Davit L Aghayan
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mushegh A Sahakyan
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia; Department of General and Laparoscopic Surgery, Central Clinical Military Hospital, Yerevan, Armenia
| | - Ola Reiertsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Vasiliy I Semikov
- Department of Faculty Surgery N2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexander M Shulutko
- Department of Faculty Surgery N2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Bjørn Edwin
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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27
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Lee SQ, Kabir T, Koh YX, Teo JY, Lee SY, Kam JH, Cheow PC, Jeyaraj PR, Chow PKH, Ooi LL, Chung AYF, Chan CY, Goh BKP. A single institution experience with robotic and laparoscopic distal pancreatectomies. Ann Hepatobiliary Pancreat Surg 2020; 24:283-291. [PMID: 32843593 PMCID: PMC7452804 DOI: 10.14701/ahbps.2020.24.3.283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/18/2020] [Accepted: 04/29/2020] [Indexed: 01/08/2023] Open
Abstract
Backgrounds/Aims This study aims to describe our experience with minimally-invasive distal pancreatectomies, with emphasis on the comparison between robotic distal pancreatectomy (RDP) and laparoscopic distal pancreatectomy (LDP). Methods Retrospective review of 102 consecutive RDP and LDP from 2006 to 2019 was performed. Results There were 27 and 75 patients who underwent RDP and LDP, respectively. There were 12 (11.8%) open conversions and 16 (15.7%) patients had major (>grade 2) morbidities. Patients who underwent RDP had significantly higher rates of splenic preservation (44.4% vs. 13.3%, p=0.002), higher rates of splenic-vessel preservation (40.7% vs. 9.3%, p=0.001), higher median difficulty score (5 vs. 3, p=0.002) but longer operation time (385 vs. 245 minutes, p<0.001). The rate of open conversion tended to be lower with RDP (3.7% vs. 14.7%, p=0.175). Conclusions In our institution practice, both RDP and LDP were safe and effective. The use of RDP appeared to be complementary to LDP, allowing us to perform more difficult procedures with comparable postoperative outcomes.
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Affiliation(s)
- Shi Qing Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Juinn-Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Prema Raj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Pierce K H Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - London L Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
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28
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Matsumoto I, Kamei K, Satoi S, Murase T, Matsumoto M, Kawaguchi K, Yoshida Y, Lee D, Takebe A, Nakai T, Takeyama Y. Conversion to open laparotomy during laparoscopic distal pancreatectomy: lessons from a single-center experience in 70 consecutive patients. Surg Today 2020; 51:70-78. [PMID: 32577881 DOI: 10.1007/s00595-020-02056-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to determine the factors influencing conversion from laparoscopic distal pancreatectomy (LDP) to open surgery, and the effect of such conversion on the outcome. METHODS This retrospective single-center study included 70 consecutive patients undergoing LDP. The primary endpoint was the rate of conversion to open surgery during LDP. The secondary endpoints were determining the reasons for conversion to open surgery, with detailed analyses of these cases and a comparison of the surgical outcome with and without conversion. RESULTS Seven patients (10%) required conversion to open surgery during LDP. Pancreatic ductal adenocarcinoma (PDAC) was identified as a risk factor for conversion (p = 0.010). The reasons for conversion included technical difficulty (two bleeding, one severe adhesion) and pancreatic stump-related issues (two margin-positive, two stapling failures). Although the overall morbidity rate (29 vs. 11%, p = 0.48) and the rate of clinically relevant postoperative pancreatic fistula (14 vs. 5%, p = 0.82) were no different for the patients with or without open conversion, the postoperative hospital stay was significantly longer in the former (median 15 vs. 10 days, p = 0.03). CONCLUSIONS Careful preoperative assessment is required when planning LDP for PDAC. Although conversion to open surgery does not result in failure of LDP, efforts to reduce the duration of postoperative hospital stay and the occurrence of complications are desirable to improve the outcome of LDP.
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Affiliation(s)
- Ippei Matsumoto
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Keiko Kamei
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Shumpei Satoi
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Takaaki Murase
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Masataka Matsumoto
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Kohei Kawaguchi
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yuta Yoshida
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Dongha Lee
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Atsushi Takebe
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Takuya Nakai
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Faculty of Medicine, Kindai University, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
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Takagi K, Kimenai HJAN, Terkivatan T, Tran KTC, Ijzermans JNM, Minnee RC. A novel difficulty grading system for laparoscopic living donor nephrectomy. Surg Endosc 2020; 35:2889-2895. [PMID: 32556762 PMCID: PMC8116223 DOI: 10.1007/s00464-020-07727-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/09/2020] [Indexed: 11/28/2022]
Abstract
Background Several difficulty grading systems have been developed as a useful tool for selecting patients and training surgeons in laparoscopic procedures. However, there is little information on predicting the difficulty of laparoscopic donor nephrectomy (LDN). The aim of this study was to develop a grading system to predict the difficulty of LDN. Methods Data of 1741 living donors, who underwent pure or hand-assisted LDN between 1994 and 2018 were analyzed. Multivariable analyses were performed to identify factors associated with prolonged operative time, defined as a difficulty index with 0 to 8. The difficulty of LDN was classified into three levels based on the difficulty index. Results Multivariable analyses identified that male (odds ratio [OR] 1.69, 95% CI 1.37–2.09, P < 0.001), BMI > 28 (OR 1.36, 95% CI 1.08–1.72, P = 0.009), pure LDN (OR 1.99, 95% CI 1.53–2.60, P < 0.001), multiple renal arteries (OR 2.38, 95% CI 1.83–3.10, P < 0.001) and multiple renal veins (OR 2.18, 95% CI 1.52–3.16, P < 0.001) were independent risk factors influencing prolonged operative time. The difficulty index based on these factors was calculated and categorized into three levels: low (0–2), intermediate (3–5), and high (6–8) difficulty. Operative time was significantly longer in the high difficulty group (225 min) than in the low (169 min, P < 0.001) and intermediate difficulty group (194 min, P < 0.001). The conversion rate was higher in the high difficulty group (4.4%) than in the low (2.1%, P = 0.04) and the intermediate difficulty group (3.0%, P = 0.27). No significant difference in major complications was found between the groups. Conclusion We developed a novel grading system with simple preoperative donor factors to predict the difficulty of LDN. This grading system may help surgeons in patient selection to advance their experiences and/or teach fellows from simple to difficult LDN.
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Affiliation(s)
- Kosei Takagi
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD, Rotterdam, The Netherlands. .,Department of Gastroenterological Surgery, Dentistry, and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan.
| | - Hendrikus J A N Kimenai
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD, Rotterdam, The Netherlands
| | - Turkan Terkivatan
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD, Rotterdam, The Netherlands
| | - Khe T C Tran
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD, Rotterdam, The Netherlands
| | - Jan N M Ijzermans
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD, Rotterdam, The Netherlands
| | - Robert C Minnee
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD, Rotterdam, The Netherlands
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Critical Appraisal of the Impact of Individual Surgeon Experience on the Outcomes of Minimally Invasive Distal Pancreatectomies: Collective Experience of Multiple Surgeons at a Single Institution. Surg Laparosc Endosc Percutan Tech 2020; 30:361-366. [PMID: 32398450 DOI: 10.1097/sle.0000000000000800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Presently, there are limited studies analyzing the learning experience of minimally invasive distal pancreatectomies (MIDPs) and these frequently focused on a single surgeon or institution learning curve. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of MIDP based on the collective experiences of multiple surgeons at a single institution. METHODS A retrospective review of 90 consecutive MIDP from 2006 to 2018 was performed. These cases were performed by 13 surgeons over various time periods. The cohort was stratified into 4 groups according to individual surgeon experience. The case experience of these surgeons was as follows: <5 cases (n=8), 6 to 10 cases (n=2), 11 to 15 cases (n=2), and 30 cases (n=1). RESULTS The distribution of the 90 cases were as follows: experience <5 cases (n=44), 6 to 10 cases (n=20), 11 to 15 cases (n=11), and 15 cases (n=15). As individual surgeons gained increasing experience, this was significantly associated with increasingly difficult resections performed, increased frequency of the use of robotic assistance and decreasing open conversion rates (20.5% vs. 100% vs. 9.1% vs. 0%, P=0.038). There was no significant difference in other perioperative outcomes. These findings suggest that the outcomes of MIDP in terms of open conversion rate could be optimized after 15 cases. Subset analyses suggested that the learning curve for MIDP of low difficulty was only 5 cases. CONCLUSION MIDP can be safely adopted today and the individual surgeon learning curve for MIDP of all difficulties in terms of open conversion rate can be overcome after 15 cases.
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Kovid N, Han HS, Yoon YS, Cho JY. Advanced laparoscopic HPB surgery: Experience in Seoul National University Bundang Hospital. Ann Gastroenterol Surg 2020; 4:224-228. [PMID: 32490336 PMCID: PMC7240149 DOI: 10.1002/ags3.12323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/04/2020] [Accepted: 02/17/2020] [Indexed: 12/16/2022] Open
Abstract
The worldwide trend in surgery has moved from open surgery to minimally invasive surgery. Likewise, the application of minimally invasive surgery in the hepato-pancreato-biliary (HBP) field is also rapidly expanding. The field of HBP surgery can be divided into liver, pancreas and biliary fields. Minimally invasive liver surgery is recently developed. However, laparoscopic liver resection in difficult areas is challenging. However, with the accumulation of experiences, laparoscopic liver resection for difficult areas is performed more than before. With more propagation, more and more liver resection will be performed by laparoscopic approach. In minimally surgery for the pancreas, distal pancreatectomy has become a well-recommended procedure in benign and borderline malignancy. There have been several systemic reviews that show advantages of laparoscopic distal pancreatectomy. The reports on laparoscopic pancreaticoduodenectomy (PD) are slowly increasing in spite of technical difficulty, with several systemic reviews showing advantages of the procedure. However, more PD will be performed as robotic-assisted procedures in the future. The laparoscopic surgery for biliary tract malignancy is still in early stages. The laparoscopic surgery for gallbladder cancer has been contraindicated, although there have been encouraging reports from expert centers. The laparoscopic surgery for Klatskin tumor is still an experimental procedure. Robotic-assisted procedures for the surgery of cholangiocarcinoma will be the future. Robotic-assisted surgery for the HBP field is still not well-developed. However, with the necessity of more precise manipulation like intracorporeal suturing, robotic-assisted surgery will be used more often in the field of HBP surgery.
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Affiliation(s)
| | - Ho-Seong Han
- Seoul National University Bundang Hospital Gyeonggi-do Korea
| | - Yoo-Seok Yoon
- Seoul National University Bundang Hospital Gyeonggi-do Korea
| | - Jai Young Cho
- Seoul National University Bundang Hospital Gyeonggi-do Korea
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Ohtsuka T, Nagakawa Y, Toyama H, Takeda Y, Maeda A, Kumamoto Y, Nakamura Y, Hashida K, Honda G, Fukuzawa K, Toyoda E, Tanabe M, Gotohda N, Matsumoto I, Ryu T, Uyama I, Kojima T, Unno M, Ichikawa D, Inoue Y, Matsukawa H, Sudo T, Takaori K, Yamaue H, Eguchi S, Tahara M, Shinzeki M, Eguchi H, Kurata M, Morimoto M, Hayashi H, Marubashi S, Inomata M, Kimura K, Amaya K, Sho M, Yoshida R, Murata A, Yoshitomi H, Hakamada K, Yasunaga M, Abe N, Hioki M, Tsuchiya M, Misawa T, Seyama Y, Noshiro H, Sakamoto E, Hasegawa K, Kawabata Y, Uchida Y, Kameyama S, Ko S, Takao T, Kitahara K, Nakahira S, Baba H, Watanabe M, Yamamoto M, Nakamura M. A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 27:47-55. [PMID: 31665567 DOI: 10.1002/jhbp.695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system. METHODS Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836. RESULTS Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD. CONCLUSION LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.
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Affiliation(s)
- Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yutaka Takeda
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Yusuke Kumamoto
- Department of General, Pediatric and Hepato-Biliary-Pancreatic Surgery, Kitasato University Hospital, Sagamihara, Kanagawa, Japan
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kazuki Hashida
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kengo Fukuzawa
- Department of Surgery, Oita Red Cross Hospital, Oita, Japan
| | - Eiji Toyoda
- Department of Surgery, Otsu Red Cross Hospital, Otsu, Shiga, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naoto Gotohda
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Tomoki Ryu
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Ichiro Uyama
- Department of Surgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Toru Kojima
- Department of Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Kofu, Yamanashi, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroyoshi Matsukawa
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Takeshi Sudo
- Department of Surgery National Hospital Organization Kure Medical Center Chugoku Cancer Center, Kure, Hiroshima, Japan
| | - Kyoichi Takaori
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Munenori Tahara
- Department of Surgery, Hokkaido P.W.F.A.C Sapporo Kosei General Hospital, Sapporo, Hokkaido, Japan
| | - Makoto Shinzeki
- Department of Surgery, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masanao Kurata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mamoru Morimoto
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | | | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University, Fukushima, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Kenjiro Kimura
- Department of Surgical Oncology, Osaka City University School of Medicine, Osaka, Japan
| | - Koji Amaya
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Ryuichi Yoshida
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Akihiro Murata
- Department of Hepatobiliary Pancreatic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Masafumi Yasunaga
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Masayoshi Hioki
- Department of Gastroenterological Surgery, Fukuyama City Hospital, Fukuyama, Hiroshima, Japan
| | - Masaru Tsuchiya
- Division of General and Gastroenterological Surgery, Department of Surgery, Toho University School of Medicine, Omori, Tokyo, Japan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Yasuji Seyama
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Eiji Sakamoto
- Department of Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yoichiro Uchida
- Department of Gastroenterological Surgery and Oncology, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Shinichiro Kameyama
- Department of Surgery, Center for Gastroenterology, Urasoe General Hospital, Urasoe, Okinawa, Japan
| | - Saiho Ko
- Department of Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Takashi Takao
- Department of Surgery, Shin Koga Hospital, Kurume, Fukuoka, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga Medical Center Koseikan, Saga, Japan
| | - Shin Nakahira
- Department of Surgery, Sakai City Medical Center, Sakai, Osaka, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masahiko Watanabe
- Kitasato University Kitasato Institutional Hospital, Sagamihara, Kanagawa, Japan.,Japan Society for Endoscopic Surgery, Tokyo, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.,Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Japanese Society for Endoscopic and Robotic Pancreatic Surgery, Tokyo, Japan
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Outcomes of Elective and Emergency Conversion in Minimally Invasive Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma: An International Multicenter Propensity Score-matched Study. Ann Surg 2019; 274:e1001-e1007. [PMID: 31850984 DOI: 10.1097/sla.0000000000003717] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the impact of conversion during minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC) on outcome by a propensity-matched comparison with open distal pancreatectomy (ODP). BACKGROUND MIDP is associated with faster recovery as compared with ODP. The high conversion rate (15%-25%) in patients with PDAC, however, is worrisome and may negatively influence outcome. METHODS A post hoc analysis of a retrospective cohort including distal pancreatectomies for PDAC from 34 centers in 11 countries. Patients requiring conversion were matched, using propensity scores, to ODP procedures (1:2 ratio). Indications for conversion were classified as elective conversions (eg, vascular involvement) or emergency conversions (eg, bleeding). RESULTS Among 1212 distal pancreatectomies for PDAC, 345 patients underwent MIDP, with 68 (19.7%) conversions, mostly elective (n = 46, 67.6%). Vascular resection (other than splenic vessels) was required in 19.1% of the converted procedures. After matching (61 MIDP-converted vs 122 ODP), conversion did not affect R-status, recurrence of cancer, nor overall survival. However, emergency conversion was associated with increased overall morbidity (61.9% vs 31.1%, P= 0.007) and a trend to worse oncological outcome compared with ODP. Elective conversion was associated with comparable overall morbidity. CONCLUSIONS Elective conversion in MIDP for PDAC was associated with comparable short-term and oncological outcomes in comparison with ODP. However, emergency conversions were associated with worse both short- and long-term outcomes, and should be prevented by careful patient selection, awareness of surgeons' learning curve, and consideration of early conversion when unexpected intraoperative findings are encountered.
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Goh BK, Kabir T, Koh YX, Teo JY, Lee SY, Kam JH, Cheow PC, Jeyaraj PR, Chow PK, Ooi LL, Chung AY, Chan CY. External validation of the Japanese difficulty scoring system for minimally-invasive distal pancreatectomies. Am J Surg 2019; 218:967-971. [DOI: 10.1016/j.amjsurg.2019.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/06/2019] [Accepted: 03/13/2019] [Indexed: 01/08/2023]
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