Are major laparoscopic pancreatic resections worthwhile? A prospective study of 32 patients in a single institution

Revisiting the potential advantage of robotic surgical system in spleen-preserving distal pancreatectomy over conventional laparoscopic approach

BACKGROUND

This study aimed to compare success rate of spleen preservation between robotic and laparoscopic distal pancreatectomy (DP).

METHODS

Between November 2007 and March 2018, forty-one patients underwent the conventional laparoscopic DP (Lap group) and the other 37 patients underwent robotic DP (Robot group). The perioperative clinicopathologic variables were compared.

RESULTS

The robotic procedure was chosen by younger patients compared to conventional laparoscopic surgery (42.9±14.0 vs. 51.3±14.6 years, P=0.016). The mean operation time was longer (313 vs. 246 min, P=0.000), but the mean tumor size was smaller in Robot group (2.7±1.2 vs. 4.2±3.3 cm, P=0.018). The overall spleen-preserving rate was higher in the Robot group (91.9% vs. 68.3%, P=0.012). However, with accumulating laparoscopic experiences (after 16th case), the statistical differences in spleen preservation rate between the Robot and Lap groups had diminished (P=0.428).

CONCLUSIONS

The present results suggest a robot can be helpful to save the spleen during DP for benign and borderline malignancy. However, a surgeon highly experienced in the laparoscopic approach can also produce a high success rate of spleen preservation, similar to that shown with the robotic approach.

Matched Case-Control Comparative Study of Laparoscopic Versus Open Pancreaticoduodenectomy for Malignant Lesions

INTRODUCTION

Advances in surgical technologies allowed safe laparoscopic pancreaticoduodenectomy (LPD). The aim of this study is to compare the oncologic outcomes of LPD to open pancreaticoduodenectomy (OPD) in terms of safety and recurrence rate.

MATERIALS AND METHODS

A cohort of 30 patients were matched for age, sex, American Society of Anaesthesiologists, tumor size, pancreatic duct diameter, and histopathologic diagnosis on a 1:1 basis (15 LPD, 15 OPD). Comparison between groups was performed on intention-to-treat basis. Survival following resection was compared using the Kaplan-Meier survival analysis.

RESULTS

The median operating time for LPD group was longer than for OPD group (470 vs. 310 min; P=0.184). However, estimated blood loss (300 vs. 620 mL; P=0.023), high dependency unit stay (2.0 vs. 6.0 d; P=0.013) and postoperative hospital stay (9.0 vs. 17.4 d; P=0.017) were significantly lower in the LPD group. There was no significant difference in postoperative rates of morbidity (40% vs. 67%; P=0.431) and mortality (0% vs. 6.7%; P=0.99). The surgical resection margins R0 status (87% vs. 73%; P=0.79) and the number of lymph nodes (18 vs. 20; P=0.99) in the resected specimens were comparable between the 2 groups. There was no significant difference in overall survival outcomes.

CONCLUSIONS

In selected patients, the laparoscopic approach to pancreaticoduodenectomy in the hands of the experienced offers advantages over open surgery without compromising the oncologic resection.

Laparoscopic pancreaticoduodenectomy in pancreatic cancer: Our initial experience

Pancreas cancer is an important cause of mortality worldwide. It has no particular symptoms, and may cause different complaints according to tumor diameter and localization. Local invasion may develop in the short term and distant metastasis may occur in vascular structures in its neighborhood. That's why, resectability rates are low at the time of diagnosis with a negative effect on survival rates. Minimally invasive surgery is being increasingly implemented in pancreas lesions owing to the positive short-term oncologic results of the technique in many other procedures. Traditionally, conventional open surgery is performed in pancreatic head tumors. As laparoscopic resection of pancreatic head cancer has serious technical difficulties and requires advanced laparoscopic experience, minimal invasive attempts in this field have not yet reached sufficient acceptance worldwide. Besides the fact that laparoscopic pancreaticoduodenectomy may provide sufficient short-term oncologic results that are comparative with open surgery, it can be implemented in selected patients in centers with advanced laparoscopic resection capacity. In this case series, we aimed to present our experience of laparoscopic pancreaticoduodenectomy in pancreatic head cancer patients.

Minimally invasive pancreaticoduodenectomy for periampullary disease: a comprehensive review of literature and meta-analysis of outcomes compared with open surgery

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear.

METHODS

Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis.

RESULTS

One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes.

CONCLUSION

Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.

Laparoscopic distal resection of the pancreas. Can be all resections of body and tail of the pancreas called the same?

Introduction

Distal resection of the pancreas is a routine procedure in high-volume centres. However, the volume of this procedure can vary. This variation plays a very important role in laparoscopic approach of pancreatic surgery and can be a real challenge if the anatomical situation is underestimated.

Aim of the study

To present our experience in minimally invasive treatment of the pancreatic tumours and to discuss different approaches to different anatomical situations.

Material and methods

We performed a retrospective analysis of patients, who underwent laparoscopic pancreas resection for pancreatic cancer in our hospital since 2014 to 2016 February. According to extension of operation, patients were divided into two groups: distal pancreatectomy and left hemipancreatectomy for cases that required preparation of the portal vein. Demographic characteristics, and operative and postoperative data were compared between both groups.

Results

Out of 16 patients, distal pancreatectomy was performed for 7 (43.8%) and left hemipancreatectomy for 9 (56.2%) patients. For 1 (14.3%) laparoscopic distal pancreatectomy and for 2 (22.2%) laparoscopic left hemipancreatectomy patients surgical conversion to laparotomy was performed. The average operation time was 205 (195–245) min for distal pancreatectomy and 412.5 (280–520) min for left hemipancreatectomy group (p = 0.001), blood loss 125 (20–250) ml and 250 (50–1800) ml accordingly (p = 0.138). Totally postoperative fistula occurred in 7 (43.8%) cases; out of them, 5 (71.4%) patients were from the left hemipancreatectomy group.

Conclusions

Laparoscopic left hemipancreatectomy is more complicated than distal pancreatectomy. Extension and technique selection of distal resection of the pancreas depends on the Yonsei criteria and tumour relation to the portal vein.

Minimally Invasive Versus Open Pancreatoduodenectomy: Systematic Review and Meta-analysis of Comparative Cohort and Registry Studies

OBJECTIVE

This study aimed to appraise and to evaluate the current evidence on minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy only in comparative cohort and registry studies.

BACKGROUND

Outcomes after MIPD seem promising, but most data come from single-center, noncomparative series.

METHODS

Comparative cohort and registry studies on MIPD versus open pancreatoduodenectomy published before August 23, 2015 were identified systematically and meta-analyses were performed. Primary endpoints were mortality and International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula (POPF).

RESULTS

After screening 2293 studies, 19 comparative cohort studies (1833 patients) with moderate methodological quality and 2 original registry studies (19,996 patients) were included. For cohort studies, the median annual hospital MIPD volume was 14. Selection bias was present for cancer diagnosis. No differences were found in mortality [odds ratio (OR) = 1.1, 95% confidence interval (CI) = 0.6-1.9] or POPF [(OR) = 1.0, 95% CI = 0.8 to 1.3]. Publication bias was present for POPF. MIPD was associated with prolonged operative times [weighted mean difference (WMD) = 74 minutes, 95% CI = 29-118], but lower intraoperative blood loss (WMD = -385 mL, 95% CI = -616 to -154), less delayed gastric emptying (OR = 0.6, 95% = CI 0.5-0.8), and shorter hospital stay (WMD = -3 days, 95% CI = -5 to -2). For registry studies, the median annual hospital MIPD volume was 2.5. Mortality after MIPD was increased in low-volume hospitals (7.5% vs 3.4%; P = 0.003).

CONCLUSIONS

Outcomes after MIPD seem promising in comparative cohort studies, despite the presence of bias, whereas registry studies report higher mortality in low-volume centers. The introduction of MIPD should be closely monitored and probably done only within structured training programs in high-volume centers.

Modified Hand-Sewn Closure With Retroperitoneal Tissue-covering Method Prevents Pancreatic Fistula in Laparoscopic Distal Pancreatectomy

BACKGROUND

In laparoscopic distal pancreatectomy, the stapler transection of the pancreas remains the preferred method; however, pancreatic fistula continues to be a critical unsolved problem. The aim of this study was to compare complications associated with distal pancreatectomy, especially regarding the formation of pancreatic fistula, with particular attention to the stapler and hand-sewn closure technique.

PATIENTS AND METHODS

Between January 2004 and June 2012, 47 patients underwent laparoscopic distal pancreatectomy. These patient's pancreatic bodies were similar, and they were subjected to closure of the pancreatic stump either by stapler (Staple group, n=21) or by a modified hand-sewn technique (Sewn group, n=26), and were subsequently retrospectively reviewed.

RESULTS

The incidence of PF was significantly higher in the "Staple group" compared with the "Sewn group." Likewise, the amylase levels in the drainage fluid, were significantly higher in the "Staple group" compared with the "Sewn group." Patients in the Sewn group had shorter median hospital stay compared with those in the Sewn group (5 vs. 8 d, P<0.001).

CONCLUSIONS

The 2-layer hand-sewn technique is a simple method, and it significantly decreased the incidence of PF and hospital stay compared with the use of staples in laparoscopy.

Minimally invasive pancreaticoduodenectomy: A comprehensive review

BACKGROUND

While an increasing number of open procedures are now routinely performed laparoscopically or robotically, minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging operations in abdomen. The aim of this study is to evaluate the current status and development of MIPD.

METHODS

Embase, Medline, and PubMed databases were searched to identify studies up to and including Feb 2016 using the keywords "laparoscopic", or "laparoscopy", or "hand-assisted", or "minimally invasive", or "robotic", or "da vinci" combined with "pancreaticoduodenectomy", or "duodenopancreatectomy", "Whipple", or "pancreatic resection". Articles written in English with more than 10 cases were included for review.

RESULTS

Thirty-two articles representing 2209 patients were included for review. The weighted average operative time and intraoperative blood loss was 427.3 min and 289.4 mL respectively. A total of 375 patients required conversion to open pancreaticoduodenectomy (OPD), with an overall conversion rate of 17.8%. The postoperative severe complications (the Clavien-Dindo Classification ≥ III) occurred in 3.8%-33.0% patients, with an overall severe morbidity of 14.3%. Particularly, the overall incidence of clinically significant postoperative pancreatic fistula (POPF) was 8.0%. There were 26 perioperative death cases in total, with an overall postoperative mortality rate of 2.3%. The weighted average number of collected lymph nodes was 17.9, and R0 resection ranged from 60.0% to 100.0%. Comparisons between MIPD and OPD showed that MIPD increased operative time, decreased intraoperative blood loss and shortened the length of hospital stay, but the overall morbidity and mortality were comparable.

CONCLUSIONS

MIPD is technically feasible and safe in highly selected patients and can offer acceptable oncological outcomes. But concerns such as long-term outcomes, cost-effectiveness analysis, and learning curve analysis should be fully demonstrated before the popularization of this challenging procedure.

Getting Started with Minimally Invasive Pancreaticoduodenectomy: Is It Worth It?

BACKGROUND

This study evaluates the safety and cost of introducing minimally invasive pancreaticoduodenectomy (MIPD) to a surgeon's practice.

SUBJECTS AND METHODS

All MIPDs performed between December 2011 and July 2013 were compared with open pancreaticoduodenectomy (OPD) cases by the same surgeon. The primary outcomes were mortality, major morbidity, and re-operation. Secondary outcomes were perioperative and oncologic outcomes and cost. MIPD include total laparoscopic pancreaticoduodenectomy (TLPD) and laparoscopic-assisted pancreaticoduodenectomy (LAPD), where a small incision is used for reconstruction. Bivariate comparisons of outcomes were performed using nonparametric tests.

RESULTS

In total, 44 pancreaticoduodenectomies were performed: 15 MIPDs (2 TLPDs and 13 LAPDs) and 29 OPDs. One death occurred in each group. Major complication rates were not significantly different (33% for MIPD versus 17% for OPD); however, there was a trend toward more re-operation after MIPD compared with OPD (20% versus 3%; P = .07). The incidence of pancreatic leak (20% for MIPD versus 14% for OPD), biliary leak (0% versus 7%, respectively), abscess formation (27% versus 14%, respectively), and intraabdominal hemorrhage (13% versus 3%, respectively) were not significantly different. MIPD achieved equivalent oncologic outcomes as OPD with 100% R0 margin and adequate lymph node retrieval. There was no statistical difference in median operative time (342 minutes for MIPD versus 358 minutes for OPD), length of stay (8 versus 9 days, respectively), operating room expenses (Canadian) ($7246.0 versus $6912.0, respectively), or total cost (Canadian) per case ($15,034.0 versus $18,926.0, respectively).

CONCLUSIONS

MIPD and OPD had similar safety and cost in this introductory series. However, a trend toward a higher rate of re-operation for pancreatic leak suggests the need for caution in introducing this novel technique.

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.

The first total laparoscopic pancreatoduodenectomy in Poland

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

Laparoscopic 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.

Does minimally-invasive pancreaticoduodenectomy have advantages over its open method? A meta-analysis of retrospective studies

Background

While more and more open procedures now routinely performed using laparoscopy, minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging abdominal procedures. Therefore, we carried out this meta-analysis to evaluate whether MIPD is safe, feasible and worthwhile.

Methods

PubMed, EMBASE, and Cochrane Library were searched to identify studies published between January 1994 and November 2013 comparing MIPD with open pancreaticoduodenectomy (OPD). Intraoperative outcomes, oncologic safety, postoperative complications, and postoperative recovery were evaluated.

Results

11 retrospective studies representing 869 patients (327 MIPDs, 542 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (MD −361.93 ml, 95% CI −519.22 to −204.63 ml, p<0.001, I² = 94%), wound infection (OR 0.41, 95% CI 0.22 to 0.78, p = 0.007, I² = 0%), and hospital stay (MD −2.64 d, 95% CI −4.23 to −1.05 d, p = 0.001, I² = 78%). However, it brings longer operative time (MD 105 min, 95% CI 49.73 to 160.26 min, p<0.001, I² = 93%). There were no significant differences between the two procedures in likelihood of overall complications (p = 0.05), pancreatic fistula (PF) (p = 0.86), delayed gastric empting (DGE) (p = 0.96), positive surgical margins (p = 0.07), retrieval of lymph nodes (p = 0.48), reoperation (p = 0.16) and mortality (p = 0.64).

Conclusions

Our results suggest that MIPD is currently safe, feasible and worthwhile. But considering the selection bias, complexity of MIPD and lack of long-term oncologic outcomes, we suggest it be performed in a high-volume pancreatic surgery center in selected patients.

Clinical comparison of distal pancreatectomy with or without splenectomy: a meta-analysis

Objective

A distal pancreatectomy has routinely been used for removing benign/borderline malignant tumors of the body and tail of the pancreas; however, controversy exists whether or not the spleen should be saved. Therefore, we conducted this meta-analysis for comparing the clinical outcomes of patients who underwent distal pancreatectomy with or without splenectomy.

Methods

A literature research from the databases of Medline, Embase, and Cochrane library was performed to evaluate and compare the clinical outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). Pooled odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (95% CI) were calculated using fixed-effects or random-effects models.

Results

Eleven non-randomized controlled studies involving 897 patients were selected to satisfy the inclusion criteria; 355 patients underwent SPDP and 542 patients underwent DPS. Compared with DPS, SPDP required a shorter hospital stay (WMD = 1.16, 95% CI = −2.00 to −0.31, P = 0.007), and had a lower incidence of intra-abdominal abscesses (OR = 0.48, 95% CI = 0.27 to 0.83, P = 0.009). In addition, spleen infarctions occurred in SPDP, most of which involved use of the Warshaw method for preserving the spleen. There were no differences between the SPDP and DPS groups with respect to operative time, operative blood loss, requirement for blood transfusion, pancreatic fistulas, thromboses, post-operative bleeding, wound infections and re-operation rates.

Conclusion

SPDP should be performed due to the benefits of the immune system and quick post-operative recovery. It is also essential to preserve the splenic artery and vein. Large randomized controlled trials are further needed to verify the results of this meta-analysis.

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.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

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.

200 consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder

INTRODUCTION

Because of the potential benefit of robotics in pancreatic surgery, we review our experience at two minimally invasive pancreatic surgery centers that utilize a robotically controlled laparoscope holder to see if smaller robots that enable the operating surgeon to maintain contact with the patient may have a role in the treatment of pancreatic disease.

METHODS

From March 1994 to June 2011, a total of 200 laparoscopic pancreatic procedures utilizing a robotically controlled laparoscope holder were performed.

RESULTS

A total of 72 duodenopancreatectomies, 67 distal pancreatectomies, 23 enucleations, 20 pancreatic cyst drainage procedures, 5 necrosectomies, 5 atypical pancreatic resections, 4 total pancreatectomies, and 4 central pancreatectomies were performed. Fourteen patients required conversion to an open approach and eight a hand-assisted one. A total of 24 patients suffered a major complication. Sixteen patients developed a pancreatic leak and 19 patients required reoperation. Major complications occurred in 14 patients and pancreatic leaks occurred in 13 patients. Ten patients required conversion to a lap-assisted or open approach and six patients required reoperation.

CONCLUSIONS

Currently, a robotically assisted approach using a camera holder seems the only way to incorporate some of the benefits of robotics in pancreatic surgery while maintaining haptics and contact with the patient.

Total laparoscopic pancreaticoduodenectomy

INTRODUCTION

Total laparoscopic pancreaticoduodenectomy (TLPD) remains one of the most advanced laparoscopic procedures. Owing to the evolution in laparoscopic technology and instrumentation within the past decade, laparoscopic pancreaticoduodenectomy is beginning to gain wider acceptance.

METHODS

Data were collected for all patients who underwent a TLPD at our institution. Preoperative evaluation consisted of computed tomography scan with pancreatic protocol and selective use of magnetic resonance imaging and/or endoscopic ultrasonography. The TLPD was done with 6 ports on 3 patients and 5 ports in 2 patients and included a celiac, periportal, peripancreatic, and periduodenal lymphadenectomy. Pancreatic stents were used in all 5 cases, and intestinal continuity was re-established by intracorporeal anastomoses.

RESULTS

Five patients underwent a TLPD for suspicion of a periampullary tumor. There were 3 women and 2 men with a mean age of 60 years and a mean body mass index of 32.8. Intraoperatively, the mean operative time was 9 hours 48 minutes, with a mean blood loss of 136 mL. Postoperatively, there were no complications and a mean length of stay of 6.6 days. There was no lymph node involvement in 4 out of 5 specimens. The pathological results included intraductal papillary mucinous neoplasm in 2 patients, pancreatic adenocarcinoma in 1 patient (R0 resection), benign 4-cm periampullary adenoma in 1 patient, and a somatostatin neuroendocrine carcinoma in 1 patient (R0, N1).

CONCLUSION

TLPD is a viable alternative to the standard Whipple procedure. Our early experience suggests decreased length of stay, quicker recovery, and improved quality of life. Complication rates appear to be improved or equivalent.

Total laparoscopic pancreaticoduodenectomy

INTRODUCTION

Total laparoscopic pancreaticoduodenectomy (TLPD) remains one of the most advanced laparoscopic procedures. Owing to the evolution in laparoscopic technology and instrumentation within the past decade, laparoscopic pancreaticoduodenectomy is beginning to gain wider acceptance.

METHODS

Data were collected for all patients who underwent a TLPD at our institution. Preoperative evaluation consisted of computed tomography scan with pancreatic protocol and selective use of magnetic resonance imaging and/or endoscopic ultrasonography. The TLPD was done with 6 ports on 3 patients and 5 ports in 2 patients and included a celiac, periportal, peripancreatic, and periduodenal lymphadenectomy. Pancreatic stents were used in all 5 cases, and intestinal continuity was re-established by intracorporeal anastomoses.

RESULTS

Five patients underwent a TLPD for suspicion of a periampullary tumor. There were 3 women and 2 men with a mean age of 60 years and a mean body mass index of 32.8. Intraoperatively, the mean operative time was 9 hours 48 minutes, with a mean blood loss of 136 mL. Postoperatively, there were no complications and a mean length of stay of 6.6 days. There was no lymph node involvement in 4 out of 5 specimens. The pathological results included intraductal papillary mucinous neoplasm in 2 patients, pancreatic adenocarcinoma in 1 patient (R0 resection), benign 4-cm periampullary adenoma in 1 patient, and a somatostatin neuroendocrine carcinoma in 1 patient (R0, N1).

CONCLUSION

TLPD is a viable alternative to the standard Whipple procedure. Our early experience suggests decreased length of stay, quicker recovery, and improved quality of life. Complication rates appear to be improved or equivalent.

Current status of robotic distal pancreatectomy: a systematic review

OBJECTIVE

The aim of this systematic review is to determine the potential advantages of robotic distal pancreatectomy (RDP).

STUDY SELECTION

Both randomized and non-randomized studies.

DATA EXTRACTION

Two investigators independently selected studies for inclusion by article abstraction and full text reviewing.

DATA SYNTHESIS

Five non-RCTs were included in the review. The feasibility of RDP (95.4%) and spleen-preserving rate is between 50% and 100%. Mean OT varied between 298 min and 398 min with only completely robotic procedures, whereas mean OT was 293 in "laparoscopic/robotic" technique. Postoperative length of hospital stay ranged from 7 days to 13.7 days. The 30-day postoperative overall morbidity resulted between 0 and 18% of patients.

CONCLUSIONS

RDP is an emergent technology for which there are not yet sufficient data to draw definitive conclusions with respect to conventional or laparoscopic surgery. The mean duration of RDP is longer with Da Vinci robot, but hospital stay is shorter even if it is influenced by hospital protocols. We cannot make any conclusions comparing the outcomes to laparoscopic or open procedures here, since none of these studies are randomized, and we all know that most of these surgeons selected the easier cases for robotic procedures. For these reasons randomized controlled trials are recommended to better evaluate RDP cost-effectiveness.

Feasibility of robotic pancreaticoduodenectomy

BACKGROUND

Laparoscopic pancreaticoduodenectomy is feasible, but requires adaptations to established surgical techniques. The improved dexterity offered by robotic assistance provides the opportunity to see whether laparoscopic pancreaticoduodenectomy can be performed safely when faithfully reproducing the open operation.

METHODS

Patients were selected for robotic pancreaticoduodenectomy when generally suitable for laparoscopy. Obese patients were excluded, and those with pancreatic cancer were highly selected. A prospectively designed database was used for data collection and analysis.

RESULTS

Of 238 patients undergoing pancreaticoduodenectomy, 34 (14·3 per cent) were operated on robotically. No procedure was converted to conventional laparoscopy or open surgery, despite three patients requiring segmental resection of the superior mesenteric/portal vein and reconstruction. The mean duration of operation was 597 (range 420-960) min. The mean number of lymph nodes retrieved and analysed from patients with neoplasia was 32 (range 15-76). Four patients required blood transfusions and five developed postoperative complications exceeding Clavien-Dindo grade II. There were four grade B pancreatic fistulas. One patient died on postoperative day 40. Excess mean operative cost compared with open resection was €6193.

CONCLUSION

Selected patients can safely undergo robotic pancreaticoduodenectomy. The main downsides are high costs and prolonged operating times compared with open resection.

Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review

BACKGROUND

Splenic preservation during a distal pancreatectomy (SPDP) may be performed with splenic vessel ligation, known as Warshaw's Technique (WT) or splenic vessel preservation (SVP). The consensus on which approach is best is divided. A systematic review of evidence in the literature was undertaken with the aim of analysing the merits and disadvantages of both WT and SVP.

METHODS

A systematic search of medical literature from 1985-2011 was undertaken to identify all comparative studies and case series on SPDP. Non-English papers, series with < 5 patients, technical reports and reviews were excluded. The remaining articles were reviewed considering the study design, surgical technique, outcomes and complications.

RESULTS

In 23 relevant studies, 356 patients underwent WT and 572 underwent SVP. In WT patients, the mean operating time (160 versus 215 min, P < 0.001), mean estimated blood loss (301 versus 390 ml, P < 0.001) and length of stay (8 versus 11 days, P < 0.001) was significantly less than the SVP patients, respectively. Considering complications, splenic infarction and splenectomy occurred more frequently in WT patients (P < 0.05).

DISCUSSION

WT is technically easier to perform than SVP but has a higher incidence of subsequent splenectomies. Surgeons should be able to perform both procedures and tailor the technique according to the patient.

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.

Robot-assisted spleen-preserving distal pancreatectomy: a single surgeon's experiences and proposal of clinical application

BACKGROUND

Advanced and delicate laparoscopic techniques are usually required for safe and successful laparoscopic spleen-preserving distal pancreatectomy. The unique characteristics of robotic surgical system are thought to be useful for this minimally invasive procedure.

METHODS

From September 2007 to May 2011, patients who underwent robot-assisted, spleen-preserving, distal pancreatectomy for benign and borderline malignant tumors of the pancreas were retrospectively reviewed. Perioperative clinicopathologic surgical outcomes were evaluated.

RESULTS

Twenty-two patients were attempted for robot-assisted, spleen-preserving, distal pancreatectomy, and in 21 patients (95.5 %), the spleen was saved either by splenic vessels conservation (SVC; n = 17, 81 %) or by splenic vessels sacrifice (SVS; n = 4, 19 %). Seven patients were male and 15 were female with a mean age of 43.2 ± 15.2 years. Pathologic diagnosis included MCT in five patients, SCT in five, SPT in four, IPMT in three, NET in three, and other benign conditions in two. The mean operation time was 398.9 ± 166.3 min, but it gradually decreased as experiences were accumulated (Rsq = 0.223, p = 0.023). Intraoperative blood loss was 361.3 ± 360.1 ml, and intraoperative transfusion was required in four patients (18.1 %). A soft diet was given for 1.2 ± 0.4 days, and the length of hospital stay was 7.0 ± 2.4 days postoperatively. Clinically relevant pancreatic fistula was noted in two patients (9.1 %) but was successfully managed conservatively. Most patients (87.5 %) showed patency in conserved both splenic vessels, and only two patients (12.5 %) had partially or completely obliterated in splenic veins in the SVC-SpDP group. Partially impaired splenic perfusion was observed in one patient in the SVS-SpDP group. The perfusion defect area decreased without any clinical symptom after 4 months.

CONCLUSIONS

The robotic surgical system is thought to be beneficial for improving the spleen-preservation rate in laparoscopic distal pancreatectomy. Robot-assisted approach can be chosen for patients who require spleen-preserving distal pancreatectomy.

Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Pankreas - Kontra-Position

<b><i>Hintergrund: </i></b>Für eine Vielzahl von Erkrankungen der Bauchspeicheldrüse gilt die chirurgische Resektion als die Therapie der Wahl. In den vergangenen Jahren wurden die offenen Operationsmethoden für Pankreaserkrankungen zunehmend standardisiert und können mittlerweile mit hoher Sicherheit durchgeführt werden. Unabhängig davon wird zunehmend über laparoskopische Pankreasresektionen berichtet. <b><i>Methode: </i></b>In diesem Artikel stellen wir die aktuelle Literatur zur minimalinvasiven Chirurgie der Bauchspeicheldrüse vor, um sie mit offenen Operationsverfahren zu vergleichen. Besondere Berücksichtigung finden laparoskopische und roboterassistierte Duodenopankreatektomien sowie laparoskopische Pankreasschwanzresektionen bei Patienten mit chronischer Pankreatitis sowie mit gutartigen und bösartigen Tumoren. <b><i>Ergebnisse: </i></b>Laparoskopische und roboterassistierte Pankreaskopfresektionen sollten nur in ausgewählten Fällen angewandt werden und gelten als technisch äußerst anspruchsvoll - mit einer erhöhten Inzidenz von Pankreasfisteln. Laparoskopische Pankreasschwanzresektionen sind sichere Verfahren mit einem Trend zu einer kürzeren Krankenhausaufenthaltsdauer, sollten jedoch nur für gutartige Tumoren in Betracht gezogen werden. Im Rahmen der onkologischen Chirurgie sollte die offene Pankreasresektion bevorzugt werden. Werden onkologische Eingriffe laparoskopisch durchgeführt, ist eine ausgezeichnete präoperative Diagnostik und gegebenenfalls der Einsatz eines intraoperativen laparoskopischen Ultraschalls notwendig. <b><i>Schlussfolgerungen: </i></b>Obwohl laparoskopische Pankreasresektionen in ausgewählten Fällen von Nutzen sein können, werden sie zukünftig wohl eher die Ausnahme darstellen. Eine allgemeine Umstellung auf laparoskopische Pankreasschwanzresektionen wird aufgrund des Mangels an eindeutigen Vorteilen gegenüber dem offenen Verfahren höchstwahrscheinlich nicht stattfinden.

Laparoscopic distal pancreatectomy with or without splenectomy: spleen-preservation does not increase morbidity

BACKGROUND

The indications for laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and its morbidity compared with laparoscopic distal pancreatectomy with splenectomy (LDPS) are ill-defined. This study aimed to share the indications for spleen-preservation and investigate the safety and outcome of LSPDP at our institution.

METHODS

A retrospective review of patients who were scheduled to receive laparoscopic surgery for distal pancreatic lesions was conducted. The indications, surgical procedures, intra-operative data, and outcomes of the two procedures were collected and compared by statistical analysis.

RESULTS

LDPS and LSPDP were successfully performed in 16 and 21 patients respectively, whereas they were converted to open surgery in 9 patients. There were no significant differences in age, gender, operation time, blood loss, and conversion rate between the LDPS and LSPDP groups. The mean tumor size showed an inter-group difference (5.05 vs 2.53 cm, P<0.001). There were no significant differences in complication and morbidity rates between the two groups. All patients remained alive without recurrence during a follow-up of 9 to 67 months (median 35).

CONCLUSION

LSPDP has a morbidity and outcome comparable to LDPS.

Laparoscopic pancreatectomy for malignancy

Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.

A case report of an ampullary tumor presenting with spontaneous perforation of an aberrant bile duct and treated with total laparoscopic pancreaticoduodenectomy

BACKGROUND

This case report discusses a patient who presented with bile peritonitis due to spontaneous perforation of an aberrant bile duct that originated in the triangular ligament of the liver. It was associated with an ampullary tumor and treated with total laparoscopic pancreaticoduodenectomy (TLPD).

CASE REPORT

A 58-year-old male patient was admitted to the emergency department of Medical Park Gaziantep Hospital in September 2009 with acute abdominal findings. He underwent an urgent laparoscopy, and, interestingly, bile peritonitis due to the rupture of an aberrant bile duct in the triangular ligament was noted. After laparoscopic treatment of the acute conditions, the follow-up examinations of the patient showed the finding of obstructive jaundice. Endoscopic retrograde cholangio-pancreatography revealed a 1-cm polypoid mass located at the ampulla of Vater (duodenal papilla) with possible extension to the ampullary sphincter. A stent was inserted for temporary biliary drainage, and subsequent endoscopic biopsy showed the pathological finding of adenocarcinoma.After waiting for a 1-month period for the peritonitis to heal, the patient underwent pylorus-preserving TLPD and was discharged without any major complications on postoperative day 7.

CONCLUSION

In patients with bile peritonitis, it should be considered that the localization of the perforation may be in an aberrant bile duct localized at the triangular ligament and the etiology may be associated with an obstructing periampullary tumor. Laparoscopic pancreaticoduodenectomy is a feasible operative procedure in carefully selected patients. This technique can achieve adequate margins and follows oncological principles. Randomized comparative studies are needed to establish the superiority of minimally invasive surgery over traditional open surgery.

Laparoscopic distal pancreatectomy: trends and lessons learned through an 11-year experience

BACKGROUND

As compared with open distal pancreatectomy, laparoscopic distal pancreatectomy (LDP) is associated with lower morbidity and shorter hospital stays. Existing reports do not elucidate trends in patient selection, technique, and outcomes over time. We aimed to determine outcomes after LDP at a specialized center, analyze trends of patient selection and operative technique, and validate a complication risk score (CRS).

STUDY DESIGN

Patients undergoing LDP between January 2000 and January 2011 were identified and divided into 2 equal groups to represent our early and recent experiences. Demographics, tumor characteristics, operative technique, and perioperative outcomes were examined and compared between groups. A CRS was calculated for the entire cohort and examined against observed outcomes.

RESULTS

A total of 132 LDPs were attempted, of which 8 (6.1%) were converted to open procedures. Thirty-day overall and major complication rates were 43.2% and 12.9%, respectively, with mortality < 1%. Pancreatic fistulas occurred in 28 (21%) patients, of which 14 (11%) were clinically significant. Recent LDPs (n = 66) included patients with increasingly severe comorbidities (Charlson scores > 2, 40.9% vs 16.7%, p = 0.003), more proximal tumors (74.2% vs 26.2%, p < 0.001), more extended resections (10.6 vs 8.3 cm, p < 0.001), shorter operative times (141 vs 172 minutes, p = 0.007), and less frequent use of a hand port (25.8% vs 66.6%, p < 0.001). No significant differences were found in perioperative outcomes between the groups. As compared with the hand access technique, the total laparoscopic approach was associated with shorter hospital stays (5.3 vs 6.8 days, p = 0.032). Increasing CRS was associated with longer operative time, significant fistulas, wound infections, blood transfusions, major complications, ICU readmissions, and rehospitalizations.

CONCLUSIONS

This large, single-institution series demonstrates that despite a shift in patient selection to sicker patients with more proximal tumors, similar perioperative outcomes can be achieved with laparoscopic distal pancreatectomy. The CRS appears to be a reliable preoperative assessment tool for assessing other adverse perioperative outcomes in addition to predicting overall complications and fistulas as originally published.

The minimally invasive approach to surgical management of pancreatic diseases

Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.

Distal pancreatectomy with or without splenectomy: comparison of postoperative outcomes and surrogates of splenic function

OBJECTIVES

Published data on splenic preservation during distal pancreatectomy have been inconsistent. We hypothesized that patients undergoing spleen-preserving distal pancreatectomy (SPDP) would have fewer infectious and non-infectious complications than those undergoing en bloc distal pancreatectomy with splenectomy (DPS), and that their haematological parameters would be consistent with splenic function.

METHODS

Of 97 patients who underwent either SPDP using the Warshaw technique or en bloc DPS, 78 met our study inclusion criteria. Records were reviewed for data on age, gender, resection, indications for resection, operative time, blood loss, transfusion requirements, hospital stay, infectious complications, any other complications, postoperative white blood cell (WBC) and platelet counts. Data were analysed using the chi-squared test, the two-sided Mann-Whitney-Wilcoxon text, and simple and multiple logistic regression analyses. A P-value of <0.05 was considered significant.

RESULTS

Patients undergoing SPDP had a shorter length of stay and shorter operative time, were more likely to be completed laparoscopically, less likely to require re-operation, and had fewer infectious and non-infectious complications. However, these differences were not statistically significant. In multiple logistic regression analyses, patient age and length of hospital stay were both significant predictors of the occurrence of non-infectious complications (P= 0.04 and P= 0.006, respectively). Blood transfusion was a significant predictor of postoperative morbidity (P= 0.013 for infectious complications; P= 0.018 for non-infectious complications). White blood cell count was a statistically significant predictor of infectious (P= 0.02) and non-infectious (P= 0.04) complications, whereas platelet count was not. Patients who underwent DPS had statistically significantly higher WBC and platelet counts immediately postoperatively and at 6 months compared with SPDP patients. Postoperative mortality in both the SPDP and DPS groups was 0%. None of the 30 SPDP patients had evidence of splenic infarction. Pancreatic leaks occurred in 18% of patients in the SPDP group, compared with 8% in the DPS group (P < 0.05).

CONCLUSIONS

Spleen-preserving distal pancreatectomy using the Warshaw technique is associated with lower postoperative morbidity than DPS. Lower WBC and platelet counts suggest better splenic function in SPDP patients.

Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. We analyzed the clinical characteristics of the largest series of patients to date who underwent LDP at a single center, as well as their outcomes, to reassess the surgical paradigm for left pancreatic resection.

METHODS

We retrospectively reviewed the records of 359 patients who underwent LDP at Asan Medical Center, Seoul, Korea, for pancreatic neoplasms between March 2005 and December 2010.

RESULTS

Of the 359 patients, 323 (90%) had benign or low-grade malignant neoplasms and 36 (10%) had malignancies. The most common diagnosis was intraductal papillary mucinous neoplasm (IPMN) in 72 patients (21.2%). There were 24 patients (6.7%) with pancreatic ductal adenocarcinoma (PDAC). We found that 178 patients (49.6%) underwent spleen-preserving LDP (SP-LDP): 150 (84.3%) by main splenic vessel preservation, and 28 (15.7%) supported by short gastric and gastroepiploic vessels (Warshaw technique). Postoperative complications occurred in 43 (12%) patients, including 25 (7%) with pancreatic fistula (ISGPF grade B, C), but there was no death. Median operative time was 195 (range, 78-480) min, and median postoperative hospital stay was 8 (range, 4-37) days. The proportion of patients with pancreatic lesions who underwent LDP increased from 8.6% in 2005 to 66.9% in 2010. Kaplan-Meier analysis showed that the 1- and 2-year overall survival rates in the 24 patients with PDAC were 85.2% each.

CONCLUSIONS

LDP is feasible, safe, and effective for the treatment of benign and low-grade malignant lesions of the pancreas. The increased use of LDP for left-sided pancreatic lesions, including malignant lesions, represents a paradigm shift from open distal pancreatectomy.

Laparoscopic versus open distal pancreatectomy: a single-institution case-control study

BACKGROUND

Laparoscopic distal pancreatic surgery has gained popularity in the last decade. However, well-designed studies comparing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP) are limited. We present a single-institution case-control study comparing outcomes of LDP to ODP.

METHODS

From a prospectively accruing database, 104 patients who underwent distal pancreatectomy for pancreatic pathologies were eligible. Of these, 30 LDPs were matched with 30 ODPs using a 1:1 case-match design. Matching criteria were final histopathologic diagnosis and lesion size. Twelve LDPs were excluded from analysis because of lack of adequate ODP controls. In all cases, an attempt was made at conservation of the spleen.

RESULTS

There were more females in the LDP group (p = 0.001). Other clinicopathologic characteristics of the LDP and ODP groups such mean age (52.4 ± 17.2 vs. 59 ± 12.8, p = 0.104), prior history of upper abdominal surgery (6.7% vs. 20.0%, p = 0.254) or pancreatitis (13.3% vs. 10.0%, p = 1.000), histopathologic diagnosis (p = 1.000), lesion size on imaging (3.7 ± 2.7 vs. 4.4 ± 2.4 cm, p = 0.170), and histopathology (3.8 ± 2.3 vs. 4.3 ± 2.3, p = 0.386) were comparable. There were no significant differences in postoperative complication rates (50.0% vs. 43.3%, p = 0.604), major complication rates (20% vs. 20%, p = 0.829), grade B/C pancreatic fistula rates (16.7% vs. 13.3%, p = 0.717), or reoperation rates (3.3% vs. 6.7%, p = 1.000) between LDP and ODP groups, respectively. There was a significantly higher rate of splenic conservation in the LDP group (70% vs. 30%, p = 0.002). The intraoperative blood loss (294 ± 245 vs. 726 ± 709 ml, p < 0.001) and mean duration of hospitalization (8.7 ± 4.2 vs. 12.6 ± 8.7 days, p = 0.009) were significantly lower in the LDP group compared to the ODP group.

CONCLUSION

LDP is a safe and feasible option for distal pancreatic resections in experienced centers. The postoperative complication rate is comparable to that of ODP. LDP is associated with lower operative blood loss, higher rate of splenic conservation, and shorter duration of hospitalization. These encouraging results demand further validation in prospective randomized trials.

Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have clinical advantages?

BACKGROUND

Function-preserving minimally invasive pancreatectomy is thought to be an ideal approach for pancreatic benign and borderline malignant lesions requiring pancreatectomy. However, it is not that easy to accomplish this goal with the conventional laparoscopic approach. It requires extensive surgeon experience and learned techniques. A robot surgical system was recently introduced to overcome these limitations and it may potentially provide precise and safe laparoscopic surgery.

METHODS

Between March 2006 and July 2010, a total of 45 patients underwent laparoscopic or robot-assisted pancreatectomy performed by a single pancreatic surgeon to preserve the spleen. Twenty-five patients underwent the conventional laparoscopic approach (Lap group) and the other 20 patients underwent robot-assisted surgery (Robot group). The perioperative clinicopathologic variables (age, gender, length of resected pancreas, tumor size, tumor location, amount of bleeding, operation time, length of hospital stay, complications, mortality, and cost) were compared between the two groups, as well as the spleen preservation rate.

RESULTS

Younger patients preferred robot-assisted surgery to conventional laparoscopic surgery (44.5±15.9 vs. 56.7±13.9 years, p=0.010), and the mean operation time was longer in the Robot group (258.2±118.6 vs. 348.7±121.8 min, p=0.016). The spleen-preserving rate of the Robot group was considerably superior to that of the Lap group (fail/success, 9/16 vs. 1/19, p=0.027). However, robot surgery cost the patients about USD 8,300 (USD 8,304.8±870.0), which was more than twice the amount for the Lap group (USD 3,861.7±1,724.3). There were no significant differences in other clinicopathologic variables.

CONCLUSION

Robot-assisted pancreatic surgery could provide an increased chance for spleen preservation in spite of higher cost and longer operation time. More experiences are needed to specifically address the role of robot surgery in the advanced laparoscopic era.

Laparoscopic pancreatoduodenectomy: a review of 285 published cases

BACKGROUND

Given the difficulty level of minimally invasive pancreatoduodenectomy (MIPD), limited data exist for a comparison to open pancreatoduodenectomies. As the technique becomes more diffuse, issues regarding the adequacy of oncologic margins and lymph node retrieval need to be addressed.

METHODS

All published cases of MIPD were examined. Variables analyzed included conversion rates, operating room time, estimated blood loss, length of stay, follow-up, complications, mortality, lymph node retrieval, and margins.

RESULTS

Twenty-seven articles describing outcomes after MIPD were found, and a total of 285 cases were described. Main malignancy treated was pancreatic adenocarcinoma, accounting for 32% of all cases. Eighty-seven percent were performed totally laparoscopically, and 13% were performed with a hand-assisted approach to facilitate the reconstruction step of the procedure. The rate of conversion to an open procedure was 9%. Estimated blood loss had a weighted average (WA) of 189 mL. Average length of stay had a WA of 12 days, and average follow-up had a WA of 14 months. The overall complication rate was 48%, and the overall mortality rate was 2%. Average lymph nodes retrieved ranged from 7 to 36 nodes, with a WA of 15 nodes, and positive margins of resection were reported to be positive in 0.4% of patients with malignant disease.

CONCLUSIONS

This review found similar outcomes with respect to perioperative morbidity and mortality rates compared to open pancreatoduodenectomies. The oncologic goals of pancreatic resection may be able to be achieved by MIPD, but longer follow-up and larger series are still needed.

Development of a pancreatic tumor animal model and evaluation of NOTES tumor enucleation

BACKGROUND

Laparoscopic distal pancreatectomy is associated with high morbidity and mortality. NOTES tumor enucleation may provide an alternative to laparoscopic distal pancreatectomy. The goal of this study was to determine the feasibility of NOTES tumor creation and enucleation as a multidisciplinary approach.

METHODS

A linear-array endoscopic ultrasound (EUS) endoscope was used to inject a thermosensitive ABA triblock polymer mixed with methylene blue through the stomach wall and into the distal pancreas using a 22-gauge EUS needle. Due to its thermosensitive character, the polymer solidifies in response to body temperature, creating an artificial tumor. Seventeen swine underwent NOTES transgastric pancreatic tumor enucleation. Nine nonsurvival animals were sacrificed immediately after the NOTES procedure, with subsequent necropsy. Eight survival animals were observed for up to 16 days after the procedure, subsequently sacrificed, followed by necropsy.

RESULTS

The procedure was performed successfully in all 17 pigs studied, 9/9 nonsurvival (100%) and 8/8 survival (100%) animals, using a pure NOTES approach without any laparoscopic ports. Complications included two esophageal dissections (1 in nonsurvival group, 1 in survival group) caused by the introduction of the endoscopic overtube (2/17, 12%), unrelated to the actual surgical procedure. In the survival animals, there were two small splenic lacerations caused during retraction with the endoscopic forceps, for which hemostasis was achieved prior to closure of the gastrotomy (2/7, 29%). At necropsy of the animals, there was sufficient closure of 15/17 gastrotomy sites (88%).

CONCLUSIONS

The creation of artificial pancreatic tumors via EUS guidance is feasible. Pancreatic tumor enucleation using a transgastric NOTES approach is technically feasible and could be an alternative to laparoscopic distal pancreatectomy with further development. Further adoption and adaptation of this technique will require the development of more sophisticated specialized tools to improve the safety profile of the procedure.

Perioperative and long-term results after left pancreatectomy: a single-institution, non-randomized, comparative study between open and laparoscopic approach

BACKGROUND

Laparoscopic left pancreatic resections are being increasingly performed. In this study, we provide a nonrandomized comparison between laparoscopic and open left pancreatectomy (OLP) for benign and borderline tumors, focusing on both perioperative and long-term results.

METHODS

Demographic, pathologic, and perioperative details from patients who underwent laparoscopic and OLP between 1999 and 2006 were retrieved from our database and analyzed. Long-term results, including resume to full-time work, occurrence of incisional hernias, and incidence of exocrine and endocrine insufficiency also were evaluated.

RESULTS

A total of 116 patients were included in the analysis; 43 (37.1%) were managed laparoscopically and 73 (62.9%) underwent the open procedure. There were no significant differences regarding clinical and pathological data. All of the resections attempted laparoscopically were completed. The rate of splenic preservation was significantly higher in the laparoscopic group (P = 0.0001). Postoperative outcomes were similar between the two groups. Longitudinal comparison between two time periods (1999-June 2004 vs. July 2004-2006) showed that pancreatic fistula and hospital stay significantly diminished over time in the laparoscopic group (P = 0.04 and P = 0.004, respectively). Median follow-up was 53 months. The incidence of exocrine insufficiency and incisional hernias was significantly higher after open resections (both P = 0.05). After hospital discharge, median time to resume full-time work was 6 weeks in the open group and 3 weeks after laparoscopic resections (P < 0.0001). Laparoscopy also resulted as an independent factor for an early resume to full-time activities in the multivariate analysis (P < 0.0001).

CONCLUSIONS

Laparoscopic left pancreatectomy is a safe procedure for benign and borderline tumors, with similar perioperative outcomes compared with the open procedure. In the long term, the laparoscopic approach is likely to be superior thanks to a more rapid resume of full-time activities and to the lower incidence of incisional hernias and exocrine insufficiency. Clearly, these results have yet to be confirmed in large, randomized trials.

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.