Laparoscopic distal pancreatectomy

Safety and effectiveness of minimally invasive central pancreatectomy versus open central pancreatectomy: a systematic review and meta-analysis

BACKGROUND

Central pancreatectomy is a surgical procedure for benign and low-grade malignant tumors which located in the neck and proximal body of the pancreas that facilitates the preservation of pancreatic endocrine and exocrine functions but has a high morbidity rate, especially postoperative pancreatic fistula (POPF). The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness between minimally invasive central pancreatectomy (MICP) and open central pancreatectomy (OCP) basing on perioperative outcomes.

METHODS

An extensive literature search to compare MICP and OCP was conducted from October 2003 to October 2023 on PubMed, Medline, Embase, Web of Science, and the Cochrane Library. Fixed-effect models or random effects were selected based on heterogeneity, and pooled odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 10 studies with a total of 510 patients were included. There was no significant difference in POPF between MICP and OCP (OR = 0.95; 95% CI [0.64, 1.43]; P = 0.82), whereas intraoperative blood loss (MD = - 125.13; 95% CI [- 194.77, -55.49]; P < 0.001) and length of hospital stay (MD = - 2.86; 95% CI [- 5.00, - 0.72]; P = 0.009) were in favor of MICP compared to OCP, and there was a strong trend toward a lower intraoperative transfusion rate in MICP than in OCP (MD = 0.34; 95% CI [0.11, 1.00]; P = 0.05). There was no significant difference in other outcomes between the two groups.

CONCLUSION

MICP was as safe and effective as OCP and had less intraoperative blood loss and a shorter length of hospital stay. However, further studies are needed to confirm the results.

Mapping global new-onset, worsening, and resolution of diabetes following partial pancreatectomy: a systematic review and meta-analysis

BACKGROUND AND AIMS

Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to determine the global prevalence of new-onset, worsening, and resolution of diabetes following partial pancreatectomy.

METHODS

The authors searched PubMed, Embase, Web of Science, and Cochrane Library from inception to October, 2023. DerSimonian-Laird random-effects model with Logit transformation was used. Sensitivity analysis, meta-regression, and subgroup analysis were employed to investigate determinants of the prevalence of new-onset diabetes.

RESULTS

A total of 82 studies involving 13 257 patients were included. The overall prevalence of new-onset diabetes after partial pancreatectomy was 17.1%. Univariate meta-regression indicated that study size was the cause of heterogeneity. Multivariable analysis suggested that income of country or area had the highest predictor importance (49.7%). For subgroup analysis, the prevalence of new-onset diabetes varied from 7.6% (France, 95% CI: 4.3-13.0) to 38.0% (UK, 95% CI: 28.2-48.8, P <0.01) across different countries. Patients with surgical indications for chronic pancreatitis exhibited a higher prevalence (30.7%, 95% CI: 21.8-41.3) than those with pancreatic lesions (16.4%, 95% CI: 14.3-18.7, P <0.01). The type of surgical procedure also influenced the prevalence, with distal pancreatectomy having the highest prevalence (23.7%, 95% CI: 22.2-25.3, P <0.01). Moreover, the prevalence of worsening and resolution of preoperative diabetes was 41.1 and 25.8%, respectively.

CONCLUSIONS

Postoperative diabetes has a relatively high prevalence in patients undergoing partial pancreatectomy, which calls for attention and dedicated action from primary care physicians, specialists, and health policy makers alike.

Role and Efficacy of Robotic-assisted Radical Antegrade Modular Pancreatosplenectomy (RAMPS) in Left-sided Pancreatic Cancer

Distal pancreatectomy with splenectomy is the gold-standard surgery for the treatment of left-sided pancreatic cancer. Margin negative resection accompanied by effective lymphadenectomy are the deciding factors affecting the outcome of tail-body pancreatic adenocarcinoma. Radical antegrade modular pancreatosplenectomy (RAMPS) is considered as a reasonable approach for margin-negative and systemic lymph node clearance. Herein, we aim to present all existing data regarding this novel approach including surgical technique and comparison with standardized procedures. RAMPS has shown oncological superiority comparing to distal pancreatectomy with splenectomy due to radical lymphadenectomy and improved dissection of the posterior pancreatic aspects. Robotic-assisted RAMPS has recently been described as a valuable alternative to open RAMPS. With this novel technique, anterior, posterior or modified approaches can be achieved; favorable clinical and oncological outcomes have been reported in the current literature, with reduced conversion rates compared to other minimally invasive approaches, as well as vastly improved maneuverability, accuracy and vision. Robotic-assisted RAMPS is not only technically feasible but also oncologically safe in cases of well-selected, left-sided pancreatic cancer.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

Laparoscopic distal pancreatectomy

After technological advances and increased experiences, more complicated surgeries including distal pancreatectomy can be easily performed with acceptable oncologic results, and decreased mortality and morbidity. Laparoscopic distal pancreatectomy (LDP) has been shown to have several advantages including less blood loss, less hospital stay, less pain. Several studies comparing open distal pancreatectomy (ODP) and LDP resulted that both techniques have similar results according to pancreas fistulas, oncological results, costs and operation indications. Morbidity is very low in high volume centers, for this reason at least ten cases should be performed for the learning curve. Several authors remarked important technical points in LDP in order to perform safe and acceptable LDP in several studies. Here in this review, we aimed to overview the results of previous studies about LDP and discuss the technical points of LDP.

Laparoscopic versus open distal pancreatectomy in pancreatic tumours: a case-control study

Laparoscopic distal pancreatectomy has become an increasingly used procedure in the surgical treatment of benign or borderline cystic and endocrine tumours. The feasibility and safety of this technique is well known but its results when compared with open distal pancreatectomy were rarely reported in literature. Data from 22 consecutive patients who underwent laparoscopic distal pancreatectomy were recorded in a prospective database from January 2006 to January 2010. These patients were matched with 22 patients who underwent open distal pancreatectomy from January 2000 to December 2005, regarding age, gender, American Society of Anesthesiologists score, pancreatic pathology. Intraoperative parameters and postoperative outcome were compared between the two groups. Blood loss, amount of analgesic drugs administered, postoperative mortality and morbidity and pancreatic fistula rate were similar in laparoscopic and open groups. Tumour size was significantly smaller in laparoscopic group (2.0 ± 3.3 vs. 5.0 ± 4.2 cm; P = 0.038). Operative time was significantly shorter in open group (145 ± 49 vs. 225 ± 83 min, P = 0.045). Time to adequate oral intake and length of postoperative hospital stay were significantly better in laparoscopic group than in open group (3.0 ± 0.8 vs. 4.0 ± 0.7 days; P = 0.030 and 8.0 ± 1.3 vs. 11.0 ± 3.0 days; P = 0.011, respectively). Laparoscopic distal pancreatectomy is a feasible and safe surgical approach as well as open distal pancreatectomy.

Preservation of splenic vessels during laparoscopic spleen-preserving distal pancreatectomy via lateral approach

Introduction

Preserving splenic vessels during laparoscopic distal pancreatectomy (SPDP-LA) is feasible and avoids unnecessary splenectomy.

Aim

To present our outcomes for this unique technique.

Material and methods

Between January 1998 and January 2012, 6 patients who underwent SPDP-LA for benign or low malignancy tumors in the pancreatic tail were included. Clinical characteristics as well as perioperative data were retrospectively recorded.

Results

All procedures were successful, with an average operative time of 184 min (range: 88–277 min) and average blood loss of 401.7 ml (range: 10–900 ml). The mean hospital stay was 7 days. Pancreatic fistula occurred in 2 patients but was then cured by external drainage. There was no mortality. Follow-ups were available for all patients.

Conclusions

Our experience was characterized by a lack of conversions and by acceptable rates of postoperative fistula and morbidity. The lateral approach showed beneficial results in patients without complications and short post-operative hospital stays.

Laparoscopic Distal Pancreatectomy with or without Preservation of the Spleen for Solid Pseudopapillary Neoplasm

Solid pseudopapillary neoplasm (SPN) is a rare tumor of the pancreas. Laparoscopic distal pancreatectomy (DP) is a feasible and safe procedure, and successful spleen preservation rates are higher using a laparoscopic approach. We hypothesized that certain patients with SPN would be good candidates for laparoscopic surgery; however, few surgeons have reported laparoscopic DP for SPN. We discuss the preoperative assessment and surgical simulation for two SPN cases. A simulation was designed because we consider that a thorough preoperative understanding of the procedure based on three-dimensional image analysis is important for successful laparoscopic DP. We also discuss the details of the actual laparoscopic DP with or without splenic preservation that we performed for our two SPN cases. It is critical to use appropriate instruments at appropriate points in the procedure; surgical instruments are numerous and varied, and surgeons should maximize the use of each instrument. Finally, we discuss the key techniques and surgical pitfalls in laparoscopic DP with or without splenic preservation. We conclude that experience alone is inadequate for successful laparoscopic surgery.

New-onset diabetes after distal pancreatectomy: a systematic review

OBJECTIVE

The true rate of new-onset diabetes (NODM) after distal pancreatectomy (DP) is not known. This systematic review was carried out to obtain exact percentages regarding the incidence of NODM after DP for different indications.

BACKGROUND

Distal pancreatectomy is the standard procedure for removal of benign or (potentially) malignant lesions from the pancreatic body or tail and increasingly used for removal of often benign lesions. It is associated with low mortality rates, though postoperative diabetes remains a serious problem.

METHODS

Embase, PubMed, Medline, Web of Science, the Cochrane Library, and Google Scholar were searched for articles reporting incidence of NODM after DP. Methodological quality of the included studies was assessed by means of the Newcastle-Ottawa scale for cohort studies and the Moga scale for case series. Mean weighted overall percentages of NODM after DP for different indications were calculated with 95% confidence intervals (CI) and corresponding P values.

RESULTS

Twenty-six studies were included, comprising 1.731 patients undergoing DP. The average cumulative incidence of NODM after DP performed for chronic pancreatitis was 39% and for benign or (potentially) malignant lesions it was 14%. Comparing the proportions of these 2 groups showed a significant difference (95% CI: 0.351-0.434 and 0.110-0.172, respectively, P < 0.000). The average percentage of insulin-dependent diabetes among patients with NODM after DP was 77%.

CONCLUSIONS

This review is the largest of its kind to assess the cumulative incidence of NODM after DP and shows that NODM is a frequently occurring complication, with incidence depending on the preexisting disease and follow-up time. Because NODM can affect quality of life, patients undergoing DP should be preoperatively provided with this information as specific as possible.

Lateral approach in laparoscopic distal pancreatectomy is safe and potentially beneficial compared to the traditional medial approach

INTRODUCTION

Laparoscopic distal pancreatectomy has become widely accepted for the treatment of left-sided pancreatic lesions. Traditionally, a medial laparoscopic distal pancreatectomy (MDLP) has been employed, with division of the gland followed by medial to lateral mobilization. Recent technical reports of lateral laparoscopic distal pancreatectomy (LLDP) suggest that it offers easier access and more precise dissection. Data on this technique remain sparse and inconclusive, with no formal comparison with MLDP. We sought to compare outcomes of LLDP to MLDP.

METHODS

We reviewed the charts of patients undergoing laparoscopic distal pancreatectomy at two academic institutions, from July 2009 to June 2013. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of sacrificed pancreas parenchyma, margins status, 30-day major morbidity (Clavien grade 3-5 complications), and length of stay. We reported data as proportions and medians. We performed comparative analysis using Chi square test or Fisher's exact test for categorical variables, and Mann-Whitney U test for continuous variables.

RESULTS

We retrieved 43 cases (19 LLDP, 24 MLDP). Median operative time was shorter (166 vs 190 min; p = 0.03) and estimated blood loss lower (50 vs 250 mL; p < 0.01) with LLDP. No margin was positive with LLDP compared to 2 (8.3%) with MLDP. Major morbidity did not differ (LLDP 21.0% vs MLDP 25.0%; p = 0.76). Trends toward lower conversion rate (16.7 vs 5.3%; p = 0.36) and shorter length of stay (5 vs 4 days; p = 0.35) were not significant.

CONCLUSION

LLDP is a feasible and safe approach for distal lesions of the pancreatic tail, associated with shorter operative time and decreased blood loss compared to traditional MLDP. Potential of decreased conversion rate and length of stay exists. These hypotheses need to be confirmed in larger prospective studies.

Lateral approach in laparoscopic distal pancreatectomy is safe and potentially beneficial compared to the traditional medial approach

INTRODUCTION

Laparoscopic distal pancreatectomy has become widely accepted for the treatment of left-sided pancreatic lesions. Traditionally, a medial laparoscopic distal pancreatectomy (MDLP) has been employed, with division of the gland followed by medial to lateral mobilization. Recent technical reports of lateral laparoscopic distal pancreatectomy (LLDP) suggest that it offers easier access and more precise dissection. Data on this technique remain sparse and inconclusive, with no formal comparison with MLDP. We sought to compare outcomes of LLDP to MLDP.

METHODS

We reviewed the charts of patients undergoing laparoscopic distal pancreatectomy at two academic institutions, from July 2009 to June 2013. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of sacrificed pancreas parenchyma, margins status, 30-day major morbidity (Clavien grade 3-5 complications), and length of stay. We reported data as proportions and medians. We performed comparative analysis using Chi square test or Fisher's exact test for categorical variables, and Mann-Whitney U test for continuous variables.

RESULTS

We retrieved 43 cases (19 LLDP, 24 MLDP). Median operative time was shorter (166 vs 190 min; p = 0.03) and estimated blood loss lower (50 vs 250 mL; p < 0.01) with LLDP. No margin was positive with LLDP compared to 2 (8.3%) with MLDP. Major morbidity did not differ (LLDP 21.0% vs MLDP 25.0%; p = 0.76). Trends toward lower conversion rate (16.7 vs 5.3%; p = 0.36) and shorter length of stay (5 vs 4 days; p = 0.35) were not significant.

CONCLUSION

LLDP is a feasible and safe approach for distal lesions of the pancreatic tail, associated with shorter operative time and decreased blood loss compared to traditional MLDP. Potential of decreased conversion rate and length of stay exists. These hypotheses need to be confirmed in larger prospective studies.

Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.

Minimally invasive radical pancreatectomy for left-sided pancreatic cancer: current status and future perspectives

Minimally invasive distal pancreatectomy with splenectomy has been regarded as a safe and effective treatment for benign and borderline malignant pancreatic lesions. However, its application for left-sided pancreatic cancer is still being debated. The clinical evidence for radical antegrade modular pancreatosplenectomy (RAMPS)-based minimally invasive approaches for left-sided pancreatic cancer was reviewed. Potential indications and surgical concepts for minimally invasive RAMPS were suggested. Despite the limited clinical evidence for minimally invasive distal pancreatectomy in left-sided pancreatic cancer, the currently available clinical evidence supports the use of laparoscopic distal pancreatectomy under oncologic principles in well-selected left sided pancreatic cancers. A pancreas-confined tumor with an intact fascia layer between the pancreas and left adrenal gland/kidney positioned more than 1 or 2 cm away from the celiac axis is thought to constitute a good condition for the use of margin-negative minimally invasive RAMPS. The use of minimally invasive (laparoscopic or robotic) anterior RAMPS is feasible and safe for margin-negative resection in well-selected left-sided pancreatic cancer. The oncologic feasibility of the procedure remains to be determined; however, the currently available interim results indicate that even oncologic outcomes will not be inferior to those of open radical distal pancreatosplenectomy.

Successful interventional radiological management of postoperative complications of laparoscopic distal pancreatectomy

During the past decade, laparoscopic distal pancreatectomy (LDP) has gained increasing acceptance in the surgical community as a viable treatment option for distal pancreatic lesions. However, the possible complication of post-LDP pancreatic leakage remains a challenge, because it may lead to a series of events resulting in intraperitoneal abscess formation, sepsis, pseudoaneurysm formation, and occasional fatal hemorrhage. Dealing with these complications is extremely difficult and not much experience has been reported to date. We report a case involving the aforementioned post-LDP complications successfully managed by interventional radiological techniques while avoiding reoperation. We conclude that these management options are attractive, safe and minimally invasive alternatives to standard protocols.

Laparoscopic left pancreatectomy: current concepts

The minimally invasive approach has been slow to gain acceptance in the field of pancreatic surgery even though its advantages over the open approach have been extensively documented in the medical literature. The reasons for the reluctant use of the technique are manifold. Laparoscopic distal or left sided pancreatic resections have slowly become the standard approach to lesions of the pancreatic body and tail as a result of evolution in technology and experience. A number of studies have shown the potential advantages of the technique in terms of safety, blood loss, oncological and economic feasibility, hospital stay and time to recovery from surgery. This review aims to provide an overview of the recent advances in the field of laparoscopic left pancreatectomy (LLP) and discuss potential future developments.

Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis

OBJECTIVE

To compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) by using meta-analytical techniques.

BACKGROUND

LDP is increasingly performed as an alternative approach for distal pancreatectomy in selected patients. Multiple studies have tried to assess the safety and efficacy of LDP compared with ODP.

METHODS

A systematic review of the literature was performed to identify studies comparing LDP and ODP. Intraoperative outcomes, postoperative recovery, oncologic safety, and postoperative complications were evaluated. Meta-analysis was performed using a random-effects model.

RESULTS

Eighteen studies matched the selection criteria, including 1814 patients (43% laparoscopic, 57% open). LDP had lower blood loss by 355 mL (P < 0.001) and hospital length of stay by 4.0 days (P < 0.001). Overall complications were significantly lower in the laparoscopic group (33.9% vs 44.2%; odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.57-0.95), as was surgical site infection (2.9% vs 8.1%; OR = 0.45, 95% CI 0.24-0.82). There was no difference in operative time, margin positivity, incidence of postoperative pancreatic fistula, and mortality.

CONCLUSIONS

LDP has lower blood loss and reduced length of hospital stay. There was a lower risk of overall postoperative complications and wound infection, without a substantial increase in the operative time. Although a thorough evaluation of oncological outcomes was not possible, the rate of margin positivity was comparable to the open technique. The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients.

Perioperative outcomes of laparoscopic and open distal pancreatectomy: our institution's 5-year experience

BACKGROUND

Application of minimally invasive techniques in the surgical management of distal pancreatic lesions is increasing. Despite this, numbers of laparoscopic distal pancreatectomy remain low and limited to treatment of benign and premalignant lesions.

METHODS

Retrospective analysis of 31 patients who underwent distal pancreatectomy from 2005 to 2010. Patients were grouped according to mode of surgical access: open (ODP) or laparoscopic (LDP). Perioperative parameters were compared.

RESULTS

Twenty-one (67.7%) patients underwent ODP and 10 (32.3%) LDP (median age 61; 80.0% females in LDP group, p = 0.030). Postoperative morbidity rate were comparable between the two groups. In the LDP group, there were significantly lower estimated blood loss (p < 0.001) and amount of blood transfusion (p = 0.001), smaller tumor size (p = 0.010) and fewer lymph nodes harvested (p = 0.020), shorter postoperative length of stay (p = 0.020), and shorter length of stay in surgical high dependency (p = 0.001).

CONCLUSION

LDP is a safe, efficient technique for resection of benign and premalignant pancreatic lesions. Indices reflecting perioperative outcomes in this study are highly competitive with those in other major centers.

Laparoscopic distal pancreatectomy is as safe and feasible as open procedure: A meta-analysis

AIM: To evaluate the feasibility and safety of laparoscopic distal pancreatectomy (LDP) compared with open distal pancreatectomy (ODP).

METHODS: Meta-analysis was performed using the databases, including PubMed, the Cochrane Central Register of Controlled Trials, Web of Science and BIOSIS Previews. Articles should contain quantitative data of the comparison of LDP and ODP. Each article was reviewed by two authors. Indices of operative time, spleen-preserving rate, time to fluid intake, ratio of malignant tumors, postoperative hospital stay, incidence rate of pancreatic fistula and overall morbidity rate were analyzed.

RESULTS: Nine articles with 1341 patients who underwent pancreatectomy met the inclusion criteria. LDP was performed in 501 (37.4%) patients, while ODP was performed in 840 (62.6%) patients. There were significant differences in the operative time, time to fluid intake, postoperative hospital stay and spleen-preserving rate between LDP and ODP. There was no difference between the two groups in pancreatic fistula rate [random effects model, risk ratio (RR) 0.996 (0.663, 1.494), P = 0.983, I² = 28.4%] and overall morbidity rate [random effects model, RR 0.81 (0.596, 1.101), P = 0.178, I² = 55.6%].

CONCLUSION: LDP has the advantages of shorter hospital stay and operative time, more rapid recovery and higher spleen-preserving rate as compared with ODP.

Laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a UK experience and a systematic review of the literature

BACKGROUND

Advances in operative techniques and technology have facilitated laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD).

METHODS

All distal pancreatectomies were attempted laparoscopically, while selected patients underwent LPD. The literature was systematically reviewed.

RESULTS

Between 2002 and 2008, 21 patients underwent LDP (n=14) or LPD (n = 7). The mean operating time, blood loss, and hospital stay after LDP were 265 min, 262 ml, and 7.7 days, respectively, and after LPD they were 628 min, 350 ml, and 11.1 days, respectively. The conversion, morbidity, pancreatic fistula, readmission, reoperation, and mortality after LDP were 7.1, 35.7, 28.4, 28.4, 0, and 7.1% respectively, and after LPD they were 0, 28.6, 14.3, 28.6, 0, and 0% respectively. The literature review identified 987 LDP and 126 LPD. Most LDP were for benign disease (83.9%) while most LPD were for malignancy (91.5%). The mean operating time, morbidity, pancreatic fistula, mortality, and hospital stay after LDP were 221.5 min, 24.7%, 16.4%, 0.4%, and 7.7 days, respectively, and after LPD they were 448.3 min, 28.6%, 11.6%, 2.1%, and 16 days, respectively.

CONCLUSION

LDP, particularly for benign disease and low-grade malignancy, is increasingly becoming the gold standard approach in experienced hands. In selected patients, LPD is feasible and safe. Long-term follow-up data are needed.

Laparoscopic distal pancreatectomy for solid and cystic pancreatic neoplasms: outpatient postoperative management

BACKGROUND

Laparoscopic distal pancreatectomy is a challenging procedure that has been reported in the last decade. The aim of this study is to describe our experience with laparoscopic distal pancreatectomy and an outpatient postoperative management after an early hospital discharge.

METHODS

Retrospective study of 11 laparoscopic distal pancreatectomies carried out at our institution between November 2005 and June 2007 for cystic and solid pancreatic neoplasms. Mean age was 55.5 years and 10 patients were females. A splenopancreatectomy was carried out in 9 cases, and a spleen-preserving resection was carried out in 2 cases.

RESULTS

Mean blood loss was 73.6 mL and mean operative time was 238.3 minutes. Patients were able to tolerate regular diet after a mean of 1.2 days and were discharged with a drain after a mean of 2.3 days. Two patients developed a mild pancreatic fistula that resolved with conservative management. One patient developed a pancreatic pseudocyst that was followed up with an MRI.

CONCLUSIONS

Laparoscopic distal pancreatectomy is feasible with a fast postoperative recovery. We recommend close follow-up of the patient in the outpatient clinic and maintaining the intraabdominal drain until a pancreatic fistula can be ruled out based on biochemical analysis of the fluid.

Tumors of the Pancreatic Body and Tail

Tumors of the pancreatic body and tail are uncommon. They have a propensity to present late and often attain a large size with local invasion before they produce any clinical symptoms. The current review aims at comprehensively analysing these tumors with respect to their pathology, presentation, the investigation of these tumors, and finally the latest trends in their surgical and medical management.

Laparoscopic distal pancreatic resection: our own experience in the treatment of solid tumors

A laparoscopic resection is a new treatment for pancreatic tumors. Articles by surgeons who are writing about their first experience in carrying out this treatment have appeared in the literature, reporting that laparoscopic surgery can be used for the treatment of pancreatitis, benign lesions, and solid tumors. This is a study of three patients with pancreatic tumors who were treated by means of a laparoscopic distal pancreatic resection with preservation of the spleen and splenic vessels. In three cases a laparoscopic distal resection was performed for the tumor. The histologic examinations showed one insulinoma and two mucinous cystadenomas. No patient suffered from intra- or postoperative complications. A laparoscopic resection of the distal pancreas is a new alternative for the treatment of pancreatic tumors. This method takes advantage of the benefits of minimally invasive surgery.

Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.

Laparoscopic distal pancreatectomy: critical analysis of preliminary experience from a tertiary referral centre

BACKGROUND

Laparoscopic pancreatic surgery has been slow to gain wide acceptance due to the complex pancreatic anatomy and physiology. The aim of this study was to analyze our preliminary results and highlight the impact of centralization on surgeon workload and pancreatic surgical innovation.

METHODS

A retrospective analysis was performed on all patients who underwent laparoscopic distal pancreatectomy from May 2007 to October 2008.

RESULTS

Laparoscopic distal pancreatectomy was performed in 17 patients during that period. Median operative time was 180 min (range 120-300 min). Median blood loss was 100 ml (range 50-500 ml). Splenectomy was performed in 12 patients. None of the patients was converted to open operation. All patients were kept in high-dependency unit for median duration of 1 day (range 0-1 day). One patient with previous cardiac disease was kept in intensive therapy unit for one night, but discharged home on 7th postoperative day without any complications. Postoperative recovery was uneventful in 13 patients, while four patients had pancreatic leak. One pancreatic leak was observed in the last 11 patients, in which pancreatic stump was oversewn. In three patients, pancreatic leaks (PL) were minor and settled with conservative management, while one patient needed a computed tomography (CT)-guided drainage and subsequent minilaparotomy for wash out of the intra abdominal collection. None of the patients died in this series. Median hospital stay was 5 days (range 4-7 days).

CONCLUSIONS

Laparoscopic distal pancreatic resection is feasible, safe, and efficient. However, this surgery should only be performed in specialized centres with extensive experience in pancreatic and laparoscopic surgery. Oversewing the pancreatic stump after transaction with Endostapler may reduce the incidence of pancreatic leak. Centralization of pancreatic surgery has a positive impact on building up surgical expertise, resulting in obvious benefits for both patients and institutions.

Laparoscopic pancreatic resection for cancer

Laparoscopic (lap) organ resection is now commonly performed for the management of solid tumors of the kidney, colon, adrenal glands and prostate. Surgeons have been slower to adopt minimally invasive approaches to the pancreas owing to operative complexity and complication potential. The majority of existing reports concerning lap pancreatectomy are single-center studies that describe experience with fewer than 20 cases. Only recently have larger experiences surfaced demonstrating the safety and efficacy of lap tumor enucleation and lap left pancreatectomy. As neoplastic disease is the most common indication for pancreatic resection, understanding the effects of the lap approach to pancreatectomy on cancer outcome is crucial. In addition to concerns of port-site tumor recurrence and tumor dissemination due to lap manipulation in the setting of pneumoperitoneum, adequacy of resection as defined by margin status and nodal assessment must be considered. This review covers the development and current state-of-the-art of lap pancreatic surgery for cancer. Existing data are reviewed for both open and lap pancreatic resections, with particular attention to pancreatic ductal adenocarcinoma. Projections of future advances in the field of lap pancreatic surgery are provided.

Clinical outcome of laparoscopic distal pancreatectomy

BACKGROUND

Few studies have compared laparoscopic distal pancreatectomy (Lap-DP) and open distal pancreatectomy (open-DP). The aim of this study was to evaluate the clinical outcome of Lap-DP and compare it to that of open-DP.

METHODS

A total of 37 patients who underwent distal pancreatectomy (Lap-DP, 21 patients; open-DP, 16 patients) between January 2000 and March 2007 were enrolled in this study. Prior to January 2004, open-DP was the standard procedure for patients with a lesion in the distal pancreas without invasive ductal cancer; thereafter, Lap-DP was also an approved procedure. All 16 open-DP procedures were performed prior to January 2004.

RESULTS

The operating times for the Lap-DP and open-DP patients were 308.4 +/- 124.6 and 281.5 +/- 83.3 min, respectively, and these were not significantly different (P = 0.4635). Blood loss for the Lap-DP group (249.0 +/- 239.8 ml) was significantly smaller than that for the open-DP group (714.1 +/- 650.4 ml) (P = 0.0055), and none of the patients in the Lap-DP group received transfusions. The frequency of complications for the Lap-DP and open-DP groups was 0 and 18.8%, respectively, which is not significantly different (P = 0.0784). The average hospital stay for the Lap-DP group was significantly shorter than that for the open-DP group (10.0 +/- 2.6 vs. 25.8 +/- 8.8 days; P < 0.0001).

CONCLUSION

In pancreatic diseases, other than invasive ductal cancer, arising in the distal pancreas, Lap-DP might be a more feasible and safer than open-DP.

Laparoscopic distal pancreatectomy: a retrospective review of 14 cases

Although the role of minimally invasive techniques in pancreatic surgery remains controversial, resection of the left pancreas for benign or endocrine lesions has been universally adopted as a routine technique over the last few years. This study was undertaken to assess feasibility and safety of minimal access resections of distal pancreas in benign, endocrine, and malignant diseases. Operative time, conversion rate, adequacy of dissection, respect for oncologic principles, morbidity rate, and short-term outcomes were analyzed. From the years 2002 to 2007, 14 patients affected by pancreatic neoplasm of body/tail region were approached by minimally invasive technique. Nine patients were affected by malignant neoplasms and distal splenopancreatectomy was successfully achieved by laparoscopy in 6. Five patients were affected by endocrine neoplasms; distal pancreatectomy with preservation of spleen and splenic vessels was achieved laparoscopically in 3, whereas 2 needed conversion to laparotomy. Four patients developed pancreatic leak after transection by linear cutting stapler plus oversewing, whereas no leak was observed within 30 days from surgery after transection by linear stapler with Seamguard reinforcement of the staple line (P<0.05 with Fisher exact test).

Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches

OBJECTIVES

To compare perioperative outcomes of laparoscopic left-sided pancreatectomy (LLP) with traditional open left-sided pancreatectomy (OLP) in a multicenter experience.

SUMMARY AND BACKGROUND DATA

LLP is being performed more commonly with limited data comparing results with outcomes from OLP.

METHODS

Data from 8 centers were combined for all cases performed between 2002-2006. OLP and LLP cohorts were matched by age, American Society of Anesthesiologists, resected pancreas length, tumor size, and diagnosis. Multivariate analysis was performed using binary logistic regression.

RESULTS

Six hundred sixty-seven LPs were performed, with 159 (24%) attempted laparoscopically. Indications were solid lesion in 307 (46%), cystic in 295 (44%), and pancreatitis in 65 (10%) cases. Positive margins occurred in 51 (8%) cases, 335 (50%) had complications, and significant leaks occurred in 108 (16%). Conversion to OLP occurred in 20 (13%) of the LLPs. In the matched comparison, 200 OLPs were compared with 142 LLPs. There were no differences in positive margin rates (8% vs. 7%, P = 0.8), operative times (216 vs. 230 minutes, P = 0.3), or leak rates (18% vs. 11%, P = 0.1). LLP patients had lower average blood loss (357 vs. 588 mL, P < 0.01), fewer complications (40% vs. 57%, P < 0.01), and shorter hospital stays (5.9 vs. 9.0 days, P < 0.01). By MVA, LLP was an independent factor for shorter hospital stay (P < 0.01, odds ratio 0.33, 95% confidence interval 0.19-0.56).

CONCLUSIONS

In selected patients, LLP is associated with less morbidity and shorter LOS than OLP. Pancreatic fistula rates are similar for OLP and LLP. LLP is appropriate for selected patients with left-sided pancreatic pathology.

Laparoscopic distal pancreatectomy: the Brisbane experience of forty-six cases

BACKGROUND AND AIMS

Laparoscopic distal pancreatectomy (LDP) is a safe alternative to conventional open distal pancreatectomy, with advantages that include smaller incisions, less pain, and shorter postoperative recovery. Despite these apparent advantages, however, uptake of the procedure has been slow, with only a handful of series published.

MATERIAL AND METHODS

All LDPs performed in Brisbane, Australia, over a 10-year period (May 1996 to June 2006) were retrospectively reviewed.

RESULTS

Forty-six consecutive LDPs were performed. A variety of lesions were resected, including nine cancers. Twelve patients were converted for oncological (6) or technical reasons (6). The spleen was retained in 14/29 patients, either by main splenic vessel preservation (9) or solely supported by the short gastric vessels (5), resulting in inferior pole infarction in 2 patients. Overall morbidity was 39%, including 15% pancreatic fistula. All fistulas resolved after a median of 6 weeks without re-operation. A non-significant trend toward fewer fistulas with stapled rather than sutured stump closure was observed (13% vs 19%; p=0.43). Median operative duration and hospital stay were 157 min and 7 days, respectively. There was no mortality.

CONCLUSION

LDP is a safe alternative to conventional resection for a wide range of lesions. As with open resection, pancreatic fistula is the dominant morbidity, but is generally indolent. While spleen preservation is often possible, care must be taken to avoid infarction of the inferior pole if the Warshaw technique is utilized.

Laparoscopic pancreatic resection: the past, present, and future

Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism, and neoplasms of the pancreas; e.g., insulinoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, etc. Laparoscopic pancreatic resections with an en bloc lymph node dissection have also been performed for invasive carcinomas. The long-term results after laparoscopic resections for invasive pancreatic cancer, however, are still not well defined. Laparoscopic distal pancreatectomies with or without spleen preservation may benefit patients with reduced postoperative pain, shorter hospital stay, a quicker recovery to normal activity, and better cosmetic appearances based on retrospective analyses of collective series and case reports. Prospective randomized controlled trials are needed to validate these benefits. In contrast, laparoscopic proximal pancreatectomies with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy and laparoscopic duodenum-preserving pancreatic head resection are technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences by highly skilled endoscopic surgeons. To justify the performance of laparoscopic proximal pancreatectomies, it is mandatory to demonstrate the potential clinical benefits and safety of these complicated procedures.

Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases

OBJECTIVE

The objective of this study was to identify potential risk factors for mortality and morbidity after distal pancreatectomy, with special focus on the formation of pancreatic fistula.

SUMMARY BACKGROUND DATA

Distal pancreatectomy can be performed with low mortality and acceptable morbidity rates. Pancreatic fistulas, occurring in 10% to 20% of cases, remain a problem that contributes significantly to morbidity, length of stay, and overall costs.

METHODS

From November 1993 to February 2006, perioperative and postoperative data of 302 consecutive patients were recorded. Univariate and multivariate analyses of potential risk factors for morbidity and for the formation of pancreatic fistula were performed. The surgical techniques used for closure were categorized into 4 groups: 1) anastomosis, 2) seromuscular patch, 3) closure by suture, and 4) closure using a stapling device.

RESULTS

Indications for resection were pancreatic tumors in 62% of patients, nonpancreatic tumors in 23%, chronic pancreatitis in 12%, and others in 3%. The spleen was preserved in 24% of patients. The morbidity and mortality rates for distal pancreatectomy in this series were 35% and 2%, respectively. The prevalence of pancreatic fistula was 12%. Univariate and multivariate analyses indicated that closure using a stapling device and an operating time >or=480 minutes were associated with a higher incidence of pancreatic fistula (odds ratio = 2.6 and 4.2, respectively). Overall morbidity was mainly influenced by the extent of resection (multivisceral vs. conventional; odds ratio = 1.7).

CONCLUSION

Pancreatic leak remains a common complication after distal pancreatectomy. Our series suggests that stapler closure of the pancreatic remnant is associated with a significantly higher fistula rate.

Laparoscopic distal pancreatectomy with splenic preservation for serous cystadenoma: a case report and literature review

A minimally invasive approach can be beneficial in a spleen-preserving distal pancreatectomy. This article reports a 71-year-old woman who presented to her internist with hypertension and persistent hypokalemia. A computed tomography scan to rule out a functional adrenal mass incidentally revealed a 4 cm x 3 cm x 2 cm serous cystadenoma of the distal pancreas and normal adrenal glands. The patient was referred to the general surgery service for resection of the distal pancreatic lesion. A laparoscopic spleen-preserving distal pancreatectomy was performed. The lesion was completely excised, and the pathology revealed serous cystadenoma with focal fibrosis and atrophic acini. The postoperative advantages of this approach were the early return of bowel function, minimal narcotic requirements, and early resumption of normal activities. This case illustrates the advantages of minimally invasive surgery in the performance of a spleen-preserving distal pancreatectomy.

Minimally invasive pancreatic surgery: the new frontier?

Recent advances in minimally invasive pancreatic surgery encompass laparoscopic, retroperitoneoscopic, endoscopic, thoracoscopic, and percutaneous approaches. Applications of endoscopic pancreatic surgery include laparoscopic resection, necrosectomy, drainage of pseudocysts, gastric and biliary bypass, and thoracoscopic splanchnotomy. This review provides an update on laparoscopic pancreatic resections. Over 400 cases of laparoscopic distal pancreatectomy (LDP) and enucleation (LEn) have been reported in the English literature, largely for benign disease. LDP and LEn have been associated with reductions in blood loss, morbidity, and hospital stay and a greater rate of splenic preservation compared with open surgery. Laparoscopic ultrasound is essential for intraoperative localization of insulinomas because failure of localization is the most common cause for conversion to laparotomy. The role of LDP with en bloc splenectomy and laparoscopic pancreaticoduodenectomy (LPD) for malignancy remains controversial. The majority of LPDs have been performed for malignancy. The short-term results of the limited world experience of 34 reported LPDs appear favorable.