Laparoscopic distal pancreatectomy: results of a prospective non-randomized study from a tertiary center

The role of minimally invasive surgery in resectable distal pancreatic adenocarcinoma

BACKGROUND

In distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), we hypothesize that minimally invasive DP (MIDP) carries short-term benefits over ODP (ODP) in the absence of postoperative pancreatic fistula (POPF).

METHODS

NSQIP database was queried to select patients who underwent DP for PDAC with available report on POPF. The population was divided into No-POPF vs. POPF groups. In each group, propensity-score matching was applied to compare 30-day outcomes of ODP vs. MIDP.

RESULTS

There were 2,824 patients; 2,332 (82%) had No-POPF and 492 (21%) had POPF. In No-POPF patients, 921 pairs were matched between ODP and MIDP. MIDP patients had slightly longer operations (227 vs. 205 minutes; p < 0.001), but lower rates of surgical site complications (1% vs. 2.9%; p = 0.002), postoperative transfusion (7.1% vs. 11.0%; p = 0.003), overall morbidity (21.1% vs. 26.3%; p = 0.009), and one-day shorter median length of stay (LOS) (5 vs. 6 days; p = 0.001). In the POPF group, 172 pairs were matched. There was no difference in morbidity, mortality, reoperation, LOS, and home discharge. Similar conclusions were drawn in the intention-to-treat and per-protocol analyses.

CONCLUSION

POPF is common following DP for PDAC. In the absence of POPF, MIDP is associated with fewer postoperative morbidities and shorter LOS.

A Prognostic Impact of Splenectomy in Laparoscopic Distal Pancreatectomy on Benign/Borderline Pancreatic Tumors: A Change of the Era

PURPOSE

In the past, spleen preservation during distal pancreatectomy (DP) was preferred; however, more recent studies reported comparable results between splenectomy and spleen preserving. We retrospectively reviewed patients in a single center who underwent laparoscopic DP with/without splenectomy, and evaluated the chronologic changes of surgical outcomes of the two procedures.

MATERIALS AND METHODS

Patients who underwent laparoscopic DP with or without splenectomy due to benign/borderline tumor from 2005 to 2019 were included in this study. We divided this period into Era 1 (2005-2012) and Era 2 (2013-2019), and compared the chronological evolution of surgical outcomes of laparoscopic distal pancreatosplenectomy (LDPS) to those of laparoscopic spleen-preserving distal pancreatectomy (LSpDP), including the long-term postoperative immunologic profiles.

RESULTS

A total of 198 cases were included (LSpDP: 80 cases; LDPS: 118 cases). As the period changed from Era 1 to Era 2, the ratio of LSpDP decreased and the surgical outcomes of LDPS improved. In Era 1, LSpDP group showed superior results compared to LDPS group in terms of hospital days and postoperative pancreatic fistula ratio; however, in Era 2, the surgical outcomes showed no statistical differences. No significant differences were observed in all of the immunologic markers.

CONCLUSION

We carefully conclude that during laparoscopic DP, combined splenectomy can be equivalent to spleen preserving in surgical and immunological outcomes, and inevitable splenectomy can be safely conducted.

Comparison of Clinical Outcomes of Single-Incision Versus Conventional Multiport Laparoscopic Distal Pancreatectomy: A Single Institution Experience

Objectives:

Single-incision laparoscopic procedures have been gaining popularity in recent years due to their minimal incisional morbidity and improved cosmetic outcomes. Herein, we will compare the feasibility and outcomes of single-incision and conventional multiport laparoscopic distal pancreatectomy.

Methods:

This study involves consecutive patients who underwent either single-incision or conventional multiport laparoscopic distal pancreatectomy from March 2007 to February 2014. The patients were divided into two groups, based on the surgical approach: single-incision laparoscopic surgery (Group 1) and conventional multiport laparoscopic surgery (Group 2). The parameters evaluated included estimated blood loss, operative time, postoperative pain, duration of hospital stay, complications, conversion, and final pathology.

Results:

There were a total of 20 patients, 10 in each study group. Baseline characteristics were similar, and there was no mortality in either of the groups. The low-flow pancreatic fistula was the most commonly seen morbidity, but it was ceased spontaneously in each group by a ratio of 30%. The operative time was significantly shorter in Group 2, with a mean of 116 minutes versus a mean of 180 minutes for Group 1 (p<0.001). One of the procedures in Group 2 was converted to open surgery due to peroperative bleeding. The median follow-up periods of the patients were 22 months and 56 months. The spleen was preserved in only 1 patient from Group 1, whereas in Group 2, the spleen preservation was achieved in 5 patients.

Conclusion:

The single-incision laparoscopic technique is a safe and effective alternative to standard laparoscopic distal pancreatectomy.

Predictive factors of endocrine and exocrine insufficiency after resection of a benign tumour of the pancreas

BACKGROUND

The aim of the present study is to evaluate the risk factors of endocrine and exocrine insufficiency occurring few years after pancreatic resections in a consecutive series of patients who underwent pancreatoduodenectomy (PD), left pancreatectomy (LP) or enucleation for benign neoplasms at a referral centre.

METHODS

Pancreatic exocrine insufficiency (PEI) was defined by the onset of steatorrhea associated with weight loss, and endocrine insufficiency was determinate by fasting plasma glucose. Association between pancreatic insufficiency and clinical, pathological, and perioperative features was studied using univariate and multivariate Cox regression analysis.

RESULTS

A prospective cohort of 92 patients underwent PD (48%), LP (44%) or enucleation (8%) for benign tumours, from 2005 to 2016 in the University Hospital in Poitiers (France). The median follow-up was 68.6±42.4months. During the following, 54 patients developed exocrine insufficiency whereas 32 patients presented endocrine insufficiency. In the Cox model, a BMI>28kg/m², being a man and presenting a metabolic syndrome were significantly associated with a higher risk to develop postoperative diabetes. The risks factors for the occurrence of PEI were preoperative chronic pancreatitis, a BMI<18.5kg/m², tumours located in the pancreatic head, biological markers of chronic obstruction and fibrotic pancreas. Undergoing LP or enucleation were protective factors of PEI. Histological categories such as neuroendocrine tumours and cystadenomas were also associated with a decreased incidence of PEI.

CONCLUSION

Men with metabolic syndrome and obesity should be closely followed-up for diabetes, and patients with obstructive tumours, pancreatic fibrosis or chronic pancreatitis require a vigilant follow up on their pancreatic exocrine function.

Splenic vessel patency: is it real menace to perform laparoscopic splenic vessel-preserving distal pancreatectomy

Purpose

This study compared the patency of the splenic vessels between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy.

Methods

We retrospectively reviewed a database of 137 patients who underwent laparoscopic (n = 91) or open (n = 46) spleen and splenic vessel-preserving distal pancreatectomy at a single institute from 2001 through 2015. Splenic vessel patency was assessed by abdominal computed tomography and classified into three grades according to the degree of stenosis.

Results

The splenic artery patency rate was similar in both groups (97.8 vs. 95.7%, P = 0.779). Also, the splenic vein patency rate was not significantly different between the 2 groups (74.7% vs. 82.6%, P = 0.521). Postoperative wound complication was significantly lower in the laparoscopic group (19.8% vs. 28.3%, P = 0.006), and hospital stay was significantly shorter in the laparoscopic group (7 days vs. 9 days, P = 0.001) than in the open group. Median follow-up periods were 22 months (3.7–96.2 months) and 31.7 months (4–104 months) in the laparoscopic and open groups, respectively.

Conclusion

Laparoscopic distal pancreatectomy showed good splenic vessel patency as well as open distal pancreatectomy. For this reason, splenic vessel patency is not an obstacle in performing laparoscopic splenic vessel-preserving distal pancreatectomy.

Experience-based surgical approach to pancreatic mucinous cystic neoplasms with ovarian-type stroma

The present study aimed to elucidate the clinicopathological characteristics of resected mucinous cystic neoplasm (MCN) with ovarian-type stroma and identify a surgical approach for MCN treatment, on the basis of Republic of Korean (Yonsei University College of Medicine, Seoul, South Korea) and Japanese (Nippon Medical School, Tokyo, Japan) bi-institutional collaboration. The present study retrospectively reviewed 55 MCNs with ovarian-type stroma using pathological re-examination. Clinicopathological features and preoperative clinical parameters were evaluated to predict malignant alterations in MCNs. The proportion of surgically treated MCNs has recently been increasing. All patients included in the present study were female, with a mean age of 47.9±13.3 years. Mural nodules were noted in 8 patients (14.5%) and the mean cyst size was 6.1±4.2 cm. A total of 9 patients (16.4%) were identified to exhibit non-invasive mucinous cystadenocarcinoma. The number of patients with small tumors (R²=-0.079, P=0.038) and asymptomatic pancreatic MCNs (P=0.022) was significantly increased (P<0.05), which resulted in the more frequent application of minimally invasive surgery (P<0.001). During the follow-up period (mean, 51.6 months; range, 1.1-242.8 months), no recurrence or tumor-associated mortality was identified. The presence of mural nodules (P=0.002) and a tumor size ≥4.5 cm (P=0.027) were identified as potential clinical parameters for predicting malignant transformation. The significance of mural nodules in predicting malignant transformation was increased in large MCNs (≥4.5 cm) of the pancreas compared with small MCNs (<4.5 cm) (P=0.002). Overall, non-invasive pancreatic MCNs are not aggressive, and minimally invasive pancreatectomy may be an effective approach for suitable patients.

Laparoscopic management of solid pseudo papillary neoplasm of pancreas in tertiary care center from south India

BACKGROUND

Solid pseudo papillary neoplasm (SPN) of the pancreas which predominantly affects young women is a relatively indolent entity with favorable prognosis. Resection through minimal access approach helps to achieve better short term benefits. The aim of this study is to describe our experience in laparoscopic management of this disease.

METHODS

A retrospective review of our prospectively maintained database revealed that 17 patients with SPN were managed with surgical resection between March 2009 and October 2016. The clinical data of these patients were then analyzed.

RESULTS

Among the 17 cases of SPN, 14 were females and 3 were males. The mean age at presentation was 26.1 years (11-46 years). The most common presenting symptom was an abdominal pain (n = 10; 58.8%). A tumor was incidentally detected in 5 patients. The neoplasm was localized in the pancreatic head/neck in 6 patients and in the body/tail in 11. The median diameter of the tumors was 7.5 cm (2-13 cm). Five patients underwent pancreaticoduodenectomy, 10 had distal pancreatectomy, while median pancreatectomy or enucleation was performed in one each. All the patients were offered laparoscopic surgery; one distal pancreatectomy was converted to open in view of bleeding. The median length of stay was 7 days (5-28 days). The patients were followed up for a median period of 31 months (3-62 months).

CONCLUSION

SPN is a rare neoplasm with low malignant potential and has an excellent prognosis. In our experience, laparoscopic surgical resection is safe and feasible, even for larger lesions.

Pancreatic resection in the era of laparoscopy: State of Art. A systematic review

BACKGROUND

Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature.

DATA SOURCE

A systematic review of literature was performed regarding laparoscopic pancreatic resection.

RESULTS

Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported.

CONCLUSIONS

Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.

Efficacy of laparoscopic ultrasonography in laparoscopic resection of insulinoma

Insulinoma is the most common functioning islet cell tumor of the pancreas, with an annual incidence of 4 cases/1 million individuals. It is treated by surgical methods. Open surgery was once considered the standard approach for the treatment of insulinoma. However, the procedure is traumatic and requires a large incision, which does not satisfy the growing expectations of minimally invasive management of small-sized tumors. Insulinomas are usually benign solitary tumors and mostly occur sporadically, which makes them suitable candidates for laparoscopic management. The potential advantages of laparoscopic management of insulinoma over open surgery include shorter duration of hospitalization, quicker recovery, and better cosmetic effect. However, because of the small tumor size as well as the depth and uncertainty of the location of the tumor, laparoscopic localization of the lesion without tactile sensation is difficult. Laparoscopic ultrasonography can detect about 90% of insulinomas, and its sensitivity is comparable to that of manual palpation along with intraoperative ultrasonography during open surgery; thus, it ensures the feasibility of laparoscopic management of insulinoma and reinforces its advantage as a minimally invasive procedure. Laparoscopic ultrasonography is vital for the localization of insulinomas and characterization of the surrounding pancreatic structure and should, therefore, be considered an integral part of the laparoscopic management of insulinoma.

Case-matched study of lesser versus greater curvature approach in laparoscopic Warshaw pancreatectomy

BACKGROUND

In laparoscopic distal pancreatectomy (LapDP), the pancreas is accessed in a greater curvature approach (GCA). The lesser curvature approach (LCA) has been proposed in underweight patients. The study investigated the feasibility of LCA irrespective of the body mass index (BMI).

METHODS

This retrospective study included consecutive patients scheduled to undergo LapDP with the LCA. A matched cohort (1:1) underwent GCA. Spleen preservation was performed using the Warshaw technique. Splenic perfusion was intraoperatively assessed by indocyanine green (ICG) angiography.

RESULTS

The LCA with LapDP was successful in 12/15 patients. In 2 cases, LCA had to be converted to GCA and in 1 patient to open surgery. The cohorts were well matched in sex (P = 1.0), age (P = .67), indication (P = 1.0), and median BMI (23.4 kg/m² vs 24.8 kg/m², P = .41). Splenic preservation was achieved in 14/15 patients with LCA and 4/15 patients with GCA (P = .33). In all LCA cases, ICG angiography indicated sufficient spleen perfusion. The groups had similar morbidity (P = 1.0) and hospital stay (P = .74).

CONCLUSIONS

LCA was feasible in 80% irrespective of BMI and provided an excellent field of exposure. ICG angiography was feasible in the Warshaw technique. Its reliability should be evaluated in prospective studies.

Thirty-day outcomes underestimate endocrine and exocrine insufficiency after pancreatic resection

BACKGROUND

Long-term incidence of endocrine and exocrine insufficiency after pancreatectomy is poorly described. We analyze the long-term risks of pancreatic insufficiency after pancreatectomy.

METHODS

Subjects who underwent pancreatectomy from 2002 to 2012 were identified from a prospective database (n = 227). Subjects who underwent total pancreatectomy or pancreatitis surgery were excluded. New post-operative endocrine and exocrine insufficiency was defined as the need for new pharmacologic intervention within 1000 days from resection.

RESULTS

28 (16%) of 178 subjects without pre-existing endocrine insufficiency developed post-operative endocrine insufficiency: 7 (25%) did so within 30 days, 8 (29%) between 30 and 90 days, and 13 (46%) after 90 days. 94 (43%) of 214 subjects without pre-operative exocrine insufficiency developed exocrine insufficiency: 20 (21%) did so within 30 days, 29 (31%) between 30 and 90 days, and 45 (48%) after 90 days. Adjuvant radiation was associated with new endocrine insufficiency. On multivariate regression, pancreaticoduodenectomy and chemotherapy were associated with a greater risk of exocrine insufficiency.

CONCLUSION

Reporting 30-day functional outcomes for pancreatic resection is insufficient, as nearly 45% of subjects who develop disease do so after 90 days. Reporting of at least 90-day outcomes may more reliably assess risk for post-operative endocrine and exocrine insufficiency.

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

OBJECTIVES

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

BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness and feasibility of laparoscopic distal pancreatectomy on patients at high anesthetic risk

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is the most acceptable procedure in laparoscopic pancreatic surgery. Nevertheless, knowledge regarding patients at a high anesthetic risk during lengthy and technically demanding LDP is controversial. This study aims to assess the feasibility and safety of LDP in patients with high anesthetic risk.

PATIENTS AND METHODS

We conducted a prospective collection retrospective review of patients underwent LDP and open distal pancreatectomy (ODP) from January 2011 until December 2013. By the American Society of Anesthesiologists score, patients were divided into low- and high-risk patients. We compared the clinical, perioperative, and postoperative results in these patients.

RESULTS

The cohort included 77 patients: 20 underwent LDP, and 57 underwent ODP. There were 30 patients in the low-risk group and 47 patients in the high-risk group. In high-risk patients, LDP, compared with ODP, presented a shorter operating time (mean, 220.8±101.1 minutes versus 299.4±124.3 minutes; P=.038), less blood loss (409.3±569.9 mL versus 1083.1±1583.0 mL; P=.039), higher rate of spleen preservation (73.3% versus 43.8%, P=.037), and shorter length of postoperative hospital stay (LOS) (9.5±3.0 days versus 15.7±9.4 days; P=.044).

CONCLUSIONS

In conclusion, LDP provides early recovery and better cosmetic appearance. In high anesthetic risk patients, LDP shows less operative time, less perioperative blood loss, a higher rate of spleen preservation, slighter complication, and shorter LOS, which might explain why LDP is a feasible and effective procedure.

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.

Robotic distal pancreatectomy

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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.

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.

Lesser curvature approach in laparoscopic distal pancreatectomy

Laparoscopic distal pancreatectomy (LDP) has entailed ventrally retracting the stomach to afford adequate visualization. The retracted stomach commonly droops over the pancreas and obstructs the surgical field, thus forcing the assistant surgeon to repeatedly lift the stomach out of the way ventrally and cranially. We herein reported LDP using the "lesser curvature approach" in which the pancreas was approached cephalad to the lesser curvature of the stomach in underweight patients with a coincidental low hanging stomach. An excellent view of both the distal pancreas and the spleen could be afforded, enabling complete mobilization of these organs from the retroperitoneum and easy ligation of the splenic vessels, without needing to retract the stomach ventrally and cranially. The lesser curvature approach in LDP could be performed safely and efficiently as an alternative to the conventional greater curvature approach in underweight patients with a low hanging stomach.

Comparison of open with laparoscopic distal pancreatectomy: a single institution's transition over a 7-year period

OBJECTIVES

Many studies have shown laparoscopic distal pancreatectomy (LDP) to have benefits over open distal pancreatectomy (ODP). This institution made a unique abrupt transition from an exclusively open approach to a preference for the laparoscopic technique. This study aimed to compare outcomes in patients undergoing LDP and ODP, respectively, over the period of transition.

METHODS

A retrospective review of all patients undergoing LDP (n = 82) or ODP (n = 90) was performed. Surrogate oncologic markers for the subgroup of patients with malignant disease were also studied.

RESULTS

The ODP and LDP groups were well matched with regard to demographics, comorbidities and tumour characteristics. Significant differences were noted in favour of the LDP group in which decreases were seen in estimated blood loss (<0.001), need for packed red blood cell transfusions (<0.001), length of hospital stay (<0.001) and intensive care unit stay (<0.001). No other significant differences in the occurrence of complications or oncologic outcomes were seen. Rates of Grade B and C fistulae were 10% and 6% in the ODP and LDP groups, respectively. Grade III-V complications occurred in 20% and 13% of the ODP and LDP groups, respectively.

CONCLUSIONS

Laparoscopic distal pancreatectomy continues to compare favourably with ODP when well-matched patient series are reviewed. The results show a decreased need for blood transfusions and hospital resources in LDP. Additionally, there may be oncologic advantages associated with LDP compared with ODP in pancreatic malignancies.

Predictive factors of morbidity in distal pancreatic resections

OBJECTIVE

To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors.

METHODS

The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity.

RESULTS

Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations.

CONCLUSION

The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

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.

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.

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 distal pancreatectomy: does splenic preservation affect outcomes?

Although the spleen is often routinely resected during both open and laparoscopic distal pancreatectomies, a splenectomy can increase the risk of postoperative and life-long infectious complications. Spleen-preserving laparoscopic pancreatectomies can technically be more difficult because of the delicate dissection of the splenic vessels. We performed a retrospective review of 34 laparoscopic pancreatectomies done at our institution. All procedures were done laparoscopically without hand assistance. Attempts were made in all patients to conserve the spleen, which was successful in 10 patients (29%). In the splenectomy group, 9 patients had 12 surgical complications (26%), which was statistically significant compared with the spleen-preserving group, in which there were no complications. This included 7 patients with a pancreatic leak (20%) and 3 with postoperative hemorrhage requiring reexploration (9%). Patients with spleen-preserving pancreatectomies had significantly less blood loss and shorter operative time compared with patients who underwent concomitant splenectomy. Splenic preservation should be attempted in all patients undergoing laparoscopic distal pancreatectomy unless there are overriding oncological or anatomic concerns.

Laparoscopic resection of exocrine carcinoma in central and distal pancreas results in a high rate of radical resections and long postoperative survival

BACKGROUND

The role of laparoscopic resection in patients with pancreatic cancer remains to be clarified, because previous reports have not clearly defined oncologic outcomes. The objective of the present study was to investigate this question with the rate of R0 resection and long-term survival as endpoints.

METHODS

This retrospective observational study included prospectively collected data from 40 patients operated laparoscopically with curative intent for exocrine pancreatic malignancies identified among 250 consecutive patients undergoing laparoscopic pancreatic operations since 1997. All 40 patients had histologically verified exocrine pancreatic carcinoma.

RESULTS

Ten patients (25%) with typical ductal adenocarcinoma of the pancreas were deemed nonresectable by laparoscopic staging. Laparoscopic distal pancreatectomy was performed in 29 patients; 8 resections were combined with resections of adjacent organs and 1 removal of a malignant intraductal papillary mucinous neoplasm what appeared to be ectopic pancreatic tissue. In 1 patient, the resection was completed by hand-assisted technique, and 1 procedure was converted to open resection. Postoperative morbidity was 23% (n = 7). The median hospital stay was 5 days (range, 1-30). The rate of R0 resections was 93%. Postoperative 3-year survivals rates were 36% for the entire cohort (n = 30) and 30% in typical ductal adenocarcinoma (n = 21).

CONCLUSION

Laparoscopic distal pancreatectomy for exocrine pancreatic carcinoma is comparable with outcomes after open surgery and supports the concept that laparoscopic distal pancreatectomy is a safe, oncologic procedure.

Revisiting vascular patency after spleen-preserving laparoscopic distal pancreatectomy with conservation of splenic vessels

Background

We evaluated vascular patency and potential changes in preserved spleens after laparoscopic spleen-preserving distal pancreatectomy (SPDP) with conservation of both splenic vessels.

Methods

We retrospectively analyzed the patency of conserved splenic vessels in patients who underwent laparoscopic or robotic splenic vessel-conserving SPDP from January 2006 to August 2010. The patency of the conserved splenic vessels was evaluated by abdominal computed tomography and classified into three grades according to the degree of severity.

Results

Among 30 patients with splenic vessel-conserving laparoscopic SPDP, 29 patients with complete follow-up data were included in this study. During the follow-up period (median: 13.2 months), grades 1 and 2 splenic arterial obliteration were observed in one patient each. A total of five patients (17.2%) showed grade 1 or 2 obliteration in conserved splenic veins. Most patients (82.8%) had patent conserved splenic vein. Four patients (13.8%) eventually developed collateral venous vessels around gastric fundus and reserved spleen, but no spleen infarction was found, and none presented clinical relevant symptoms, such as variceal bleeding. There was no statistical difference in vascular patency between the laparoscopic and robotic groups (P > 0.05).

Conclusions

Most patients showed intact vascular patency in conserved splenic vessels and no secondary changes in the preserved spleen after laparoscopic splenic vessel-conserving SPDP.

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.

Minimally invasive (laparoscopic and robot-assisted) approach for solid pseudopapillary tumor of the distal pancreas: a single-center experience

BACKGROUND/PURPOSE

A single-institutional experiences of solid pseudopapillary tumor (SPT) in the distal pancreas were retrospectively reviewed with special reference to a minimally invasive approach.

METHODS

Thirty-five patients with SPT of the distal pancreas treated during the past 20 years were retrospectively evaluated. We divided the patients into 2 groups based on the surgical approach: the laparoscopic/robot-assisted surgery (LR) group and the conventional open surgery (O) group. We reviewed the chronological changes and characteristics of SPT. A comparative analysis of the two groups (LR vs. O) was conducted in terms of perioperative surgical outcomes.

RESULTS

The discovery of relatively small SPTs without symptoms seemed to be increasing (p < 0.05). Eleven of the 35 patients were assigned to the LR group. Ten patients were female and 1 was male, and they had a median age of 32 years (range 24-62 years) and a median tumor size of 3.6 cm (range 1-8.5 cm). Eight patients underwent laparoscopic distal pancreatectomy with or without splenectomy, and the remaining 3 underwent robot-assisted central pancreatectomy with pancreaticogastrostomy. In the comparative analysis of the LR and O groups, smaller tumor size, earlier oral intake, and shorter hospital stay, without increasing morbidity, were noted in the LR group (p < 0.05).

CONCLUSIONS

A minimally invasive (laparoscopic/robot-assisted) approach for SPT of the distal pancreas is thought to be more appropriate than and preferable to conventional open surgery in well-selected 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 approach to distal and subtotal pancreatectomy: a clockwise technique

BACKGROUND

Laparoscopic surgery is becoming a more widely used approach for benign and malignant lesions in the neck, body, and tail of the pancreas. Recent literature reports appear to demonstrate that laparoscopic distal pancreatectomy (LDP) has clear benefits compared with open distal pancreatectomy (ODP). However, the procedure is relatively new and in some patients may remain a technically demanding operation.

METHODS

Twenty-nine LDPs were performed by a single surgeon during the course of 12 months by using a multistep clockwise technique described in detail below. The technique appears to simplify and standardize the approach for both the simpler and the more difficult procedure. Retrospective analysis was performed regarding perioperative outcomes.

RESULTS

Twenty-three procedures were performed for a neoplastic process with five patients having pancreatic adenocarcinoma. There was no conversion to ODP, but one patient required a hand-assist method. Splenectomy was performed in 26 patients. Median operative time, estimated blood loss, and length of stay was 182 min, 50 ml, and 4 days respectively. Overall morbidity and pancreatic fistula rate was 17.2% and 10.3%, respectively. Median number of lymph nodes was 14, concomitant left adrenalectomy was performed in 3 patients, and margins were negative in 28 patients.

CONCLUSIONS

LDP has been shown to be an acceptable approach to both benign and malignant disease of the distal pancreas. The technique used in this manuscript appears to facilitate a reliable and safe five-step method to perform this procedure and ensures that appropriate oncologic principles are followed through each step. Even though this is a small feasibility series focused on surgical technique, our results appear to demonstrate an acceptable pancreatic leak rate.

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.

Laparoscopic distal pancreatectomy with division of the pancreatic neck for benign and borderline malignant tumor in the proximal body of the pancreas

BACKGROUND

Conventional laparoscopic distal pancreatectomy (DP) is now regarded as a safe, effective treatment modality; however, pancreatic transections are mostly believed to be somewhere between the body and tail of the pancreas. Laparoscopic DP, with its division at the pancreatic neck (subtotal pancreatectomy [STP]), is more challenging because there are major vascular structures, such as the celiac axis, coronary vein, and superior mesenteric vein-splenic vein-portal vein (SMV-SV-PV) confluence around the pancreatic neck portion to be dissected.

PATIENTS AND METHODS

Ten patients underwent laparoscopic STP with pancreatic division at the level of SMV-SV-PV confluence for benign and borderline pancreatic disease.

RESULTS

Three patients were male and 7 were female, with a median age of 60 years (range, 28-73). All patients had benign or borderline malignant tumors in the body near the neck of the pancreas, with a median tumor size of 3 cm (range, 1-9.2). The operation time was a median of 287.5 minutes (range, 160-480). The intraopeative bleeding was a median of 300 mL (range, 100-700). Spleen preservation was carried out in 8 patients. Compared with open DP with the division of the pancreatic neck, a more frequent rate of spleen preservation (P = 0.004), longer operation time (P = 0.006), and early postoperative recovery presented by early intake of a soft diet (P = 0.001) and earlier discharge (P = 0.03) were significantly more frequent in the laparoscopic STP group. In a comparative study with laparoscopic DP, the longer segment of resected pancreas (P < 0.001), smaller amount of blood loss (P = 0.019), and high rate of spleen preservation (P = 0.019) were also noted in the laparoscopic STP group.

CONCLUSIONS

Laparoscopic DP with division of the pancreatic neck is considered feasible and safe.

Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies

BACKGROUND

The current literature suggests that minimally invasive distal pancreatectomy (MIDP) is associated with faster recovery and less morbidity than open surgery. However, most studies have been limited by a small sample size and a single-institution design. To overcome this problem, the first metaanalysis of studies comparing MIDP and open distal pancreatectomy (ODP) has been performed.

METHODS

A systematic literature review was conducted to identify studies comparing MIDP and ODP. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.

RESULTS

For the metaanalysis, 10 studies including 349 patients undergoing MIDP and 380 patients undergoing ODP were considered suitable. The patients in the two groups were similar with respect to age, body mass index (BMI), American Society of Anesthesiology (ASA) classification, and indication for surgery. The rate of conversion from full laparoscopy to hand-assisted procedure was 37%, and that from minimally invasive to open procedure was 11%. Patients undergoing MIDP had less blood loss, a shorter time to oral intake, and a shorter postoperative hospital stay. The mortality and reoperative rates did not differ between MIDP and ODP. The MIDP approach had fewer overall complications [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27-0.89], major complications (OR, 0.57; 95% CI, 0.34-0.96), surgical-site infections (OR, 0.32; 95% CI, 0.19-0.53), and pancreatic fistulas (OR, 0.68; 95% CI, 0.47-0.98).

CONCLUSIONS

The MIDP procedure is feasible, safe, and associated with less blood loss and overall complications, shorter time to oral intake, and shorter postoperative hospital stay. Furthermore, the minimally invasive approach reduces the rate of pancreatic leaks and surgical-site infections after ODP.

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.

A solid pseudopapillary tumor of the pancreas treated with laparoscopic distal pancreatectomy and splenectomy: a case report and review of the literature

Introduction

Laparoscopic distal pancreatectomy has been described for more than a decade now and has been considered technically feasible, safe, and with reproducible outcomes. It seems to exhibit several benefits of minimally invasive surgery and should be performed in carefully selected patients.

Case presentation

We report the case of a 55-year-old Greek woman with a solid pseudopapillary tumor of the tail of the pancreas. She underwent a laparoscopic distal pancreatectomy and splenectomy. The histopathologic examination finally revealed a cystic-solid pseudopapillary neoplasm of the pancreas. Solid pseudopapillary tumors of the pancreas are rare and affect predominantly young women. These tumors are of unclear pathogenesis and low malignancy, and surgical resection offers an excellent chance for long-term survival.

Conclusion

This case report indicates that in selected centers and for selected patients, laparoscopic distal pancreatectomy is feasible. The benign characteristics of these tumors make them ideal for laparoscopic excision.

Laparoscopic distal pancreatectomy offers shorter hospital stays with fewer complications

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. The aim of this study was to investigate short-term outcomes after LDP compared to open distal pancreatectomy (ODP) at a single, high-volume institution.

METHODS

We reviewed records of patients who underwent distal pancreatectomy (DP) and compared perioperative data between LDP and ODP. Continuous variables were compared using Student's t or Wilcoxon rank-sum tests. Categorical variables were compared using chi-square or Fisher's exact test.

RESULTS

A total of 360 patients underwent DP. Beginning in 2001, 95 were attempted, and 71 were completed laparoscopically with a 25.3% conversion rate. Compared to ODP, LDP had similar rates of splenic preservation, pancreatic fistula, and mortality. LDP had lower blood loss (150 vs. 900 mL, p < 0.01), smaller tumor size (2.5 vs. 3.6 cm, p < 0.01), and shorter length of resected pancreas (7.7 vs. 10.0 cm, p < 0.01). LDP had fewer complications (28.2% vs. 43.8%, p = 0.02) as well as shorter hospital stays (5 vs. 6 days, p < 0.01).

CONCLUSIONS

LDP can be performed safely and effectively in patients with benign or low-grade malignant neoplasms of the distal pancreas. When feasible in selected patients, LDP offers fewer complications and shorter hospital stays.

Comparative study of laparoscopic and open distal pancreatectomy

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) has been shown to be an effective surgical option for benign lesions in the body and tail of the pancreas. However, its advantages and disadvantages have not been well characterized. In this study, we compared the outcomes of LDP and open pancreatectomy performed in our clinic.

MATERIALS AND METHODS

Peri- and postoperative outcomes were retrospectively compared between patients with benign pancreatic disorders who underwent open distal pancreatectomy (ODP) (n = 35) and those who underwent LDP (n = 40). The peri- and postoperative factors analyzed included operative time, blood loss, hospital stay, postoperative recovery, biochemical findings, and complications.

RESULTS

LDP was associated with significantly less operative blood loss (363 versus 606 mL; P = 0.001) and shorter hospital stay (22 versus 27 day; P = 0.009), but longer operative time (342 versus 250 min; P = 0.000), compared with ODP. There were no significant differences between the two groups in complication rates or postoperative recovery, except for the significantly shorter duration of postoperative pain-killer intake and earlier improvement of the biochemical analysis in LDP than in ODP.

CONCLUSIONS

LDP appears to be a safe, desirable procedure for the management of benign pancreatic diseases, with outcomes similar to ODP.

Prolonged peri-firing compression with a linear stapler prevents pancreatic fistula in laparoscopic distal pancreatectomy

BACKGROUND

Laparoscopic distal pancreatectomy (Lap-DP) is one of the most accepted laparoscopic procedures in the field of pancreatic surgery. However, pancreatic fistula remains a major and frequent complication in Lap-DP, as in open surgery. The aim of this retrospective study is to clarify the advantages of prolonged peri-firing compression (PFC) with a linear stapler for prevention of pancreatic fistula after laparoscopic distal pancreatectomy.

PATIENTS AND METHODS

Incidence of pancreatic fistula in clinical levels (equivalent to grades B and C defined by the International Study Group of Pancreatic Fistula (ISGPF)) was retrospectively compared between patients who underwent Lap-DP with PFC (PFC group, n = 17) and those who underwent Lap-DP without PFC (no-PFC group, n = 25).

RESULTS

Incidence of clinical pancreatic fistula was significantly lower in the PFC group than in the no-PFC group. Consistent with the results for pancreatic fistula, peritoneal drainage period and postoperative hospital stay were shorter in the PFC group than in the no-PFC group.

CONCLUSIONS

Our data show that PFC effectively prevents pancreatic fistula and shortens postoperative hospital stay after Lap-DP.