Ten years of experience with resection of left-sided pancreatic ductal adenocarcinoma: evolution and initial experience to a laparoscopic approach

A comprehensive analysis of robotic assisted vs. laparoscopic distal pancreatectomy using propensity score matching

Using the propensity-matched methodology, this meta-analysis and comprehensive review aimed to compare robotic distal pancreatectomy with laparoscopic distal pancreatectomy in terms of perioperative and short-term oncologic outcomes. Within the scope of this investigation, complete and total adherence to the PRISMA guidelines for Systematic Reviews and Meta-Analyses was established. The search we conducted in PubMed, Google Scholar, and EMBASE was automated to find relevant papers that matched the tendency up to July 1, 2024. The length of time spent while operating, the rate of conversion, and the collection of lymph nodes were the primary factors that were considered. Other metrics that were taken into consideration were the approximate amount of blood loss, the length of time spent in the hospital, the need for transfusions, and the occurrence of major adverse events. In the end, there were 8 studies that involved 1649 patients. Of those patients, 758 had robotic assisted distal pancreatectomy, whereas 891 underwent laparoscopic distal pancreatectomy. In comparison to laparoscopic distal pancreatectomy, the robotic assisted technique did result in higher anticipated blood loss and conversion rates; however, it also required longer durations of operation due to its lengthier duration. In terms of lymph node retrieval, the duration of hospital stay, the need for blood transfusions, and the incidence of postoperative pancreatic fistula, there were no distinctions that could be considered statistically significant between the two techniques. A realistic and risk-free surgical alternative is a distal pancreatectomy that is performed with the aid of robotic technology. When compared to laparoscopic surgery, the outcomes of robot-assisted surgery were superior in terms of conversion rates to laparotomy and less anticipated intraoperative blood loss. However, the operation took longer to complete than laparoscopic surgery.

A comparative analysis and survival analysis of open versus minimally invasive radical antegrade modular pancreatosplenectomy for pancreatic cancer: a systematic review and meta-analysis

Background

Pancreatic ductal adenocarcinoma (PDAC) is a major public health concern, ranking as the fourth leading cause of cancer-related mortality in the United States. Traditional surgical approaches often yield suboptimal outcomes, highlighting the need for innovative surgical strategies. Radical antegrade modular pancreatosplenectomy (RAMPS) has demonstrated improvements in surgical visualization and oncological outcomes. Recently, laparoscopic RAMPS (L-RAMPS) has been introduced as a minimally invasive alternative.

Objectives

This meta-analysis aims to compare the safety and efficacy of open RAMPS (O-RAMPS) versus L-RAMPS, focusing on operative outcomes, minimally invasive outcomes, intra-abdominal outcomes, overall postoperative outcomes, and oncologic outcomes.

Methods

A systematic review and meta-analysis were conducted following PRISMA guidelines. Eligible studies included prospective or retrospective cohort studies and randomized controlled trials comparing L-RAMPS with O-RAMPS. Data were extracted from EMBASE, PubMed, and the Cochrane Library databases through September 16, 2023. The ROBINS-I tool was used to assess the risk of bias. Statistical analyses included odds ratios (OR), risk differences (RD), mean differences (MD), and survival analyses.

Results

Eight studies involving 588 patients were included. O-RAMPS was associated with longer operative times (MD = 39.39 minutes, 95% CI = 22.93 to 55.84) and greater blood loss (MD = -231.84 mL, 95% CI = -312.00 to -151.69). No significant differences were observed in blood transfusion rates, pancreatic fistula rates, delayed gastric emptying, or length of hospital stay. L-RAMPS demonstrated a shorter time to oral feeding (MD = -0.79 days, 95% CI = -1.35 to -0.22). Survival analysis suggested a potentially improved long-term prognosis for L-RAMPS.

Conclusion

L-RAMPS offers advantages over O-RAMPS in terms of reduced blood loss, faster time to oral feeding, and potentially better long-term prognosis. Further research is warranted, particularly regarding the learning curve of L-RAMPS and its broader applicability.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42024498383.

Nationwide cost-effectiveness and quality of life analysis of minimally invasive distal pancreatectomy

BACKGROUND

This study analyzed the Quality of Life (QoL) and cost-effectiveness of laparoscopic (LDP) versus robotic distal pancreatectomy (RDP).

METHODS

Consecutive patients submitted to LDP or RDP from 2010 to 2020 in four high-volume Italian centers were included, with a minimum of 12 months of postoperative follow-up were included. QoL was evaluated using the EORTC QLQ-C30 and EQ-5D questionnaires, self-reported by patients. After a propensity score matching, which included BMI, gender, operation time, multiorgan and vascular resections, splenic preservation, and pancreatic stump management, the mean differential cost and Quality-Adjusted Life Years (QALY) were calculated and plotted on a cost-utility plane.

RESULTS

The study population consisted of 564 patients. Among these, 271 (49%) patients were submitted to LDP, while 293 (51%) patients to RDP. After propensity score matching, the study population was composed of 159 patients in each group, with a median follow-up of 59 months. As regards the QoL analysis, global health and emotional functioning domains showed better results in the RDP group (p = 0.037 and p = 0.026, respectively), whereas the other did not differ. As expected, the median crude costs analysis confirmed that RDP was more expensive than LDP (16,041 Euros vs. 10,335 Euros, p < 0.001). However, the robotic approach had a higher probability of being more cost-effective than the laparoscopic procedure when a willingness to pay more than 5697 Euros/QALY was accepted.

CONCLUSION

RDP was associated with better QoL as explored by specific domains. Crude costs were higher for RDP, and the cost-effectiveness threshold was set at 5697 euros/QALY.

Postoperative outcomes and costs of laparoscopic versus robotic distal pancreatectomy: a propensity-matched analysis

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) make the robotic approach controversial. We sought to compare outcomes and cost of LDP and RDP using propensity matching analysis at our institution.

METHODS

Patients undergoing LDP or RDP between 2000 and 2021 were retrospectively identified. Patients were optimally matched using age, gender, American Society of Anesthesiologists status, body mass index, and tumor size. Between-group differences were analyzed using the Wilcoxon signed-rank test for continuous data, and the McNemar's test for categorical data. Outcomes included operative duration, conversion to open surgery, postoperative length of stay, pancreatic fistula rate, pseudocyst requiring intervention, and costs.

RESULTS

298 patients underwent MIDP, 180 (60%) were laparoscopic and 118 (40%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10, except for tumor type (0.16). RDP had longer operative times (268 vs 178 min, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), fewer biochemical pancreatic leaks (11.9% vs 34.7%, p < 0.01), and fewer interventional radiological drainage (0% vs 5.9%, p = 0.01). The number of pancreatic fistulas (11.9% vs 5.1%, p = 0.12), collections requiring antibiotics or intervention (11.9% vs 5.1%, p = 0.12), and conversion rates (3.4% vs 5.1%, p = 0.72) were comparable between the two groups. The total direct index admission costs for RDP were 1.01 times higher than for LDP for FY16-19 (p = 0.372), and 1.33 times higher for FY20-22 (p = 0.031).

CONCLUSIONS

Although RDP required longer operative times than LDP, postoperative stays were shorter. The procedure cost of RDP was modestly more expensive than LDP, though this was partially offset by reduced hospital stay and reintervention rate.

Port-site metastasis after laparoscopic radical pancreatosplenectomy in left-sided pancreatic cancer

Despite debates regarding the safety of well-selected left-sided pancreatic cancer, minimally invasive distal pancreatosplenectomy is considered safer and more effective than open distal pancreatosplenectomy in well-selected patients. Previous studies have shown that minimally invasive surgery yields comparable oncologic outcomes to open surgery. While patients who undergo minimally invasive distal pancreatosplenectomy also experience recurrences and metastases after surgery, port-site metastasis is particularly rare. In this report, we report an extremely rare case of port-site metastasis following minimally invasive distal pancreatosplenectomy for left-sided pancreatic cancer.

Minimally invasive radical antegrade modular pancreatosplenectomy: routine vs. modified

Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced in 2003 by Strasberg to improve survival outcomes in left-sided pancreatic ductal adenocarcinoma. Many investigators have shown the feasibility and safety of minimally invasive RAMPS (MI-RAMPS). However, the survival benefit of RAMPS is inconclusive, and possible risks following the procedure, such as exocrine and endocrine insufficiencies, cannot be ignored. Therefore, several modifications of RAMPS were designed. Modified RAMPS is not a specific technique but rather a reduced form of RAMPS that is undertaken without compromising oncologic principles. In this literature review, the surgical technique and strategies of MI-RAMPS were examined.

A comparison of robotic versus laparoscopic distal pancreatectomy: a single surgeon's robotic experience in a high-volume center

BACKGROUND

Robotic surgery is the most recent advanced minimally invasive approach for distal pancreatectomy. However, its benefits over laparoscopic distal pancreatectomy (LDP) remain undetermined. Previous studies were limited by their small sample size or variations in surgeon skills. This study aimed to compare robotic distal pancreatectomy (RDP) performed by a single surgeon with LDP performed by skilled laparoscopic surgeons in a high-volume center.

METHODS

We retrospectively analyzed consecutive RDP performed by a single surgeon between December 2020 and November 2021 with LDP performed by experienced surgeons during the same period in a high-volume center. Patient characteristics and perioperative variables were compared.

RESULTS

The analysis included 55 RDP and 146 LDP procedures. The operative time in the RDP group was significantly shorter than the LDP group (171 vs. 222 min, P < 0.001), both in spleen-preserved (154 vs. 212 min, P < 0.001) and spleen-removed (192 vs. 230 min, P = 0.005) procedures. The RDP group made more frequent use of the stapler technique for pancreas transection (87.3 vs. 68.5%, P = 0.007), and its estimated blood loss was lower (79 vs. 155 mL, P < 0.001) than the LDP group. The postoperative hospital stay in the RDP group was significantly shorter than the LDP group (8 vs. 12 days, P < 0.001). The groups were similar in their complication distributions.

CONCLUSION

RDP is as safe and feasible a minimally invasive approach as LDP. The advanced manipulation and visualization capabilities of the robotic approach in distal pancreatectomy could help reduce operative time and blood loss, and is related to shorter postoperative hospital stay.

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

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

Minimally invasive distal pancreatectomy: Chronologic changes in the trends and clinical outcomes through a 15-year, single-center experience with 2212 patients

BACKGROUND

We identified the chronologic changes in the clinical outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors in a single high-volume center over a period of 15 years.

METHODS

Between 2005 and 2019, 2212 patients underwent planned MIDP. Chronologic changes were analyzed according to 5-year intervals (P1, P2, P3). Furthermore, we assessed the prognostic factors of open conversion and postoperative complications.

RESULTS

MIDP has steadily increased during the last 15 years when compared to open distal pancreatectomy, from 10.8% to 84.9%. Also, MIDP for pancreatic ductal adenocarcinoma (PDAC) has been steadily increasing from 5.6% to 68.4%. According to the 5-year intervals, lengths of hospital stay decreased, but age and American Society of Anesthesiologists (ASA) ≥3 increased; conversely, the rates of Clavien-Dindo classification ≥grade 3 (9.5%) and postoperative pancreatic fistula (39.7%) showed no differences. The 90-day mortality and open conversion rates were 0.2% and 3.5%, respectively. Multivariate logistic regression analysis revealed malignancy and extended pancreatectomy were risk factors for open conversion. Furthermore, the poor prognostic factors for severe complications were malignancy, extended pancreatectomy, and ASA ≥3.

CONCLUSION

MIDP has become a popular procedure not only for benign cases but also for malignant ones. However, well-organized training, experience and skill are necessary, especially for poor-performance patients and extensively malignant conditions.

Cost-effectiveness and quality of life analysis of laparoscopic and robotic distal pancreatectomy: a propensity score-matched study

BACKGROUND

This study analyzed the Quality of Life (QoL) and cost-effectiveness of laparoscopic (LDP) versus robotic distal pancreatectomy (RDP).

METHOD

All patients who underwent LDP or RDP from 2011 to 2017 and with a minimum postoperative follow-up of 12 months were included in the study. To minimize bias, a propensity score-matched analysis (1:2) was performed. Two different questionnaires (EORTC QLQ-C30 and EQ-5D) were completed by the patients. The mean differential cost and mean differential Quality Adjusted Life Years (QALY) were calculated and plotted on a cost-utility plane.

RESULTS

The study population consisted of 152 patients. After having applied the propensity score matching, the final population included 103 patients divided into RDP group (n = 37, 36%) and LDP (n = 66, 64%). No differences were found between groups regarding the baseline, intraoperative, postoperative, and pathological variables (p > 0.05). The QoL analysis showed a significant improvement in the RDP group on the postoperative social function, nausea, vomiting, and financial status (p = 0.010, p = 0.050, and p = 0.030, respectively). As expected, the crude costs analysis confirmed that RDP was more expensive than LDP (12,053 Euros vs. 5519 Euros, p < 0.001). However, the robotic approach had a higher probability of being more cost-effective than the laparoscopic procedure when a willingness to pay of more than 4800 Euros/QALY was accepted.

CONCLUSION

RDP was associated with QoL improvement in specific domains. Crude costs were higher relative to LDP. Cost-effectiveness threshold resulted to be 4800 euros/QALY. The increasing worldwide diffusion of the robotic technology, with easier access and possible cost reduction, could increase the sustainability of this procedure.

Laparoscopic radical antegrade modular pancreatosplenectomy: preliminary experience with 10 cases

BACKGROUND

The radical antegrade modular pancreatosplenectomy (RAMPS) which is a reasonable surgical approach for left-sided pancreatic cancer is emphasis on the complete resection of regional lymph nodes and tumor-free margin resection. Laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS) has been rarely performed, with only 49 cases indexed on PubMed. In this study, we present our experience of LRAMPS.

METHODS

From December 2018 to February 2020, 10 patients underwent LRAMPS for pancreatic cancer at our department. The data of the patient demographics, intraoperative variables, postoperative hospital stay, morbidity, mortality, pathologic findings and follow-up were collected.

RESULTS

LRAMPS was performed successfully in all the patients. The median operative time was 235 min (range 212-270 min), with an EBL of 120 ml (range 100-200 ml). Postoperative complications occurred in 5 (50.0%) patients. Three patients developed a grade B pancreatic fistula. There was no postoperative 30-day mortality and reoperation. The median postoperative hospital stay was 14 days (range 9-24 days).The median count of retrieved lymph nodes was 15 (range 13-21), and four patients (40%) had malignant-positive lymph nodes. All cases achieved a negative tangential margin and R0 resection. Median follow-up time was 11 months (range 3-14 m). Two patients developed disease recurrence (pancreatic bed recurrence and liver metastasis) 9 months, 10 months after surgery, respectively. Others survived without tumor recurrence or metastasis.

CONCLUSIONS

LRAMPS is technically safe and feasible procedure in well-selected patients with pancreatic cancer in the distal pancreas. The oncologically outcomes need to be further validated based on additional large-volume studies.

Comparison of minimal invasive versus open radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic ductal adenocarcinoma: a single center retrospective study

INTRODUCTION

Radical antegrade modular pancreatosplenectomy (RAMPS) was proposed a decade ago with the aim to achieve higher R0 tangential margin and radical N1 lymph node resection for left-sided pancreatic adenocarcinoma (PDAC), which has been widely accepted worldwide at present. Laparoscopic RAMPS (Lap-RAMPS) has been attempted for PDAC during last several years, however, no outcomes evaluation by comparison between laparoscopic vs open RAMPS has been reported yet.

MATERIALS AND METHODS

From August, 2012 to March, 2018, patients undergoing open or lap-RAMPS for the diagnosis of left-sided PDAC were reviewed from a prospective database. Patients excluded if they were related with combined organs or vessels resection, systematic metastasis as well as conversion from open RAMPS to lap RAMPS. The surgical and oncologic outcomes were compared.

RESULTS

A total of 48 PDAC patients were enrolled (25 underwent lap-RAMPS and 23 underwent open-RAMPS). There were no significant differences in demographic or perioperative morbidity. In the lap-RAMPS group, R0 transection margin and retroperitoneal margin were both achieved in 23 of 25 patients (92%). In the open RAMPS group, R0 transection margin was achieved in 21 of 23 patients (91.3%), R0 retroperitoneal margin was 22 of 23 patients (95.65%). There were no differences in pathological examinations. The number of lymph node (LN) retrieved between lap-RAMPS and open- RAMPS group was not significant difference (15.84 vs 18.22; P = 0.268). Median disease-free survival (DFS) was analogous in two groups (18.11 m vs 20.00 m, P = 0.999). Median overall survival (OS) was 24.53 m in lap-RAMPS group and 28.73 m in the open-RAMPS group (P = 0.633).

CONCLUSIONS

Lap-RAMPS is technically feasible, and has comparable long-term oncological outcome with open-RMAPS.

100 Robotic Distal Pancreatectomies: The Future at Hand

INTRODUCTION

This study was undertaken to examine 100 consecutive robotic distal pancreatectomies with splenectomies, and to compare our outcomes to predicted outcomes as calculated using the American college of surgeons national surgical quality improvement program (ACS NSQIP) Surgical Risk Calculator and to the outcomes contained within NSQIP.

METHODS

Outcomes were compared with predicted outcomes, calculated using the ACS NSQIP Surgical Risk Calculator, and with outcomes documented in NSQIP for distal pancreatectomy. For illustrative purposes, data are presented as median (mean ± SD).

RESULTS

Patients who underwent robotic distal pancreatectomy were of age 67 (63 ± 13.4) years with a BMI of 29 (29 ± 6.3) kg/m², with 49% being women. Operative duration was 242 (265 ± 112.2) minutes and estimated blood loss was 110 (211 ± 233.9) mL. Predicted outcomes were similar to those reported in NSQIP. Our actual outcomes were significantly superior to the predicted outcomes for serious complication, any complication, surgical site infection, sepsis, and length of stay. Compared to NSQIP outcomes, our actual outcomes for serious complication, any complication, surgical site infection, sepsis, and delayed gastric emptying were significantly superior. Twelve percent of operations were converted to "open." There were 3 deaths within 30 days, similar to predicted outcomes. Deaths were due to sepsis (2) and respiratory failure (1).

CONCLUSION

Our patients' predicted outcomes were the same as national outcomes; our patients were not a select group. However, their actual outcomes were like or significantly superior than those predicted by NSQIP or reported in NSQIP. We believe that the robot has the future of distal pancreatectomy with or without splenectomy.

Full Robotic Distal Pancreatectomy: Safety and Feasibility Analysis of a Multicenter Cohort of 236 Patients

Introduction. Despite the widespread use of the robotic technology, only a few studies with small sample sizes report its application to pancreatic diseases treatment. Our aim is to present the results of a multicenter study on the safety and feasibility of robot-assisted distal pancreatectomy (RDP). Materials and Methods. All RDPs for benign, borderline, and malignant diseases performed in 5 referral centers from 2008 to 2016 were included. Perioperative outcomes were evaluated. Results. Two hundred thirty-six patients were included. Spleen preservation was performed in 114 cases (48.3%). Operative time was 277.8 ± 93.6 minutes. Progressive improvement in operative time was observed over the study period. Conversion rate was 6.3%. Morbidity occurred in 102 cases (43.2%), mainly due to grade A fistulas. Reoperation was required in 10 patients. Postoperatively, 2 patients died of sepsis due to a grade C fistula. Hospital readmission was necessary in 11 cases. A R0 resection was always achieved, with a mean number of 16.2 ± 15 harvested lymph nodes. Conclusion. To our knowledge, this is one of the largest RDP series. Safety and feasibility including the low conversion rate, the high spleen preservation rate, the adequate operative time, and the acceptable morbidity and mortality rates confirm the validity of this technique. Appropriate oncological outcomes have been also obtained.

Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center

Background

The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery.

Methods

A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy.

Results

A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case.

Conclusions

The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Laparoscopic approach of the left side of the pancreas

INTRODUCTION

Laparoscopic left-sided pancreatectomy (LLP) is an increasingly used surgical technique for the treatment of benign and malignant lesions of the left side of the pancreas. The results of LLP as a treatment for primary pancreatic lesions of the head and tail of the pancreas were evaluated.

METHODS

From November 2011 to November 2017, 18 patients underwent surgery for primary lesions of the pancreas by means of a laparoscopic distal pancreatectomy. An intra-abdominal drain tube was used in all cases, and the recommendations of the International Study Group for Pancreatic Fistula (ISGPF) were followed.

RESULTS

The mean age was 66.5years (IQR 46-74). Among the 18 left pancreatectomies performed, four were with splenic preservation, and one was a central pancreatectomy. There were two conversions. The median surgical time was 247.5minutes (IQR 242-275). The median postoperative hospital stay was 7days (IQR 6-8). After 90days, complications were detected in five patients: three gradeII, one gradeIII and one gradeV according to the modified Clavien-Dindo classification. There was one gradeB pancreatic fistula, and four patients had to be readmitted to hospital because of peripancreatic collections. The anatomic pathology diagnosis was malignant neoplasm in 38.9% of cases, all of them with negative resection margins.

CONCLUSIONS

LLP can be considered the technique of choice in the treatment of primary benign pancreatic lesions and an alternative to the open approach in selected patients diagnosed with malignant pancreatic lesions.

Radical antegrade modular pancreatosplenectomy for all pancreatic body and tail tumors: rationale and results

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS) has been propagated as the standard of care for pancreatic cancers involving the body and tail of the pancreas. This procedure has been shown to have promising results in enhancing the microscopically negative tangential resection margins as well as the lymph node yield.

METHODS

This is a retrospective analysis of prospectively maintained database on the resections performed for all pancreatic body and tail tumors at Tata Memorial Centre.

RESULTS

Sixty-five patients underwent RAMPS without any perioperative mortality. The various pathologies comprised of adenocarcinoma (41.5%), neuroendocrine tumors (12.3%), solid pseudopapillary epithelial neoplasm (15.3%), cystic neoplasms (15.2%), etc. The R0 resection rate was 87.7%. Among this cohort, 27 patients had pancreatic adenocarcinoma. The 3-year OS and DFS for distal pancreatic cancers were 56% and 38%, respectively, but 3-year OS and DFS for other distal pancreatic tumors were 97% and 73%, respectively. On multivariate analysis, R0 resection significantly improved disease-free survival (p = 0.023) for pancreatic cancer.

CONCLUSION

RAMPS procedure aids to achieve high negative tangential margins for all tumors involving the body and tail of the pancreas and not just pancreatic cancer in isolation. Since preoperative histologic diagnosis is not routinely indicated and also a number of other distal pancreatic tumors carry a relatively better prognosis compared with pancreatic cancer, our results provide further evidence that RAMPS should be considered as the procedure of choice for all operable tumors involving body and tail of the pancreas.

Laparoscopic distal pancreatectomy: better than open?

Distal pancreatectomy is well suited to the laparoscopic approach. Laparoscopic distal pancreatectomy (LDP) provides the same postoperative recovery advantages reputed to minimal access surgery. However, there have been fears as to the safety of LDP in terms of life-threatening intra-operative events and post-operative complications, adequate carcinological outcomes as compared to traditional (open) distal pancreatectomy (ODP) when performed for cancer, as well as to whether the laparoscopic approach is well adapted to the variety of diseases that may affect the pancreas (ranging from trauma to benign or malignant disease) and whether the minimal access approach is well adapted to perform pancreatic surgery safely in the obese, the elderly or the frail. In this review of the literature, we sought to determine whether LDP was as safe, provided the same oncological outcomes and was applicable to all diseases involving the body and tail of the pancreas, and to particular patient characteristics, compared to the traditional open approach. Last we looked at cost issues. We concluded that this review of the literature allowed to state that laparoscopic distal pancreatectomy is feasible and safe for a wide range of diseases, both benign and malignant. Morbidity, mortality, and probably, also, carcinological outcomes are comparable to open surgery. The overall costs are similar but the advantages of minimal access surgery make it the preferred approach, once the surgical expertise is acquired and present.

Robotic versus laparoscopic distal pancreatectomy: a French prospective single-center experience and cost-effectiveness analysis

BACKGROUND

Benefits and cost-effectiveness of robotic approach for distal pancreatectomy (DP) remain debated. In this prospective study, we aim to compare the short-term results and real costs of robotic (RDP) and laparoscopic distal pancreatectomy (LDP).

METHODS

From 2011 until 2016, all consecutive patients underwent minimally invasive DP were included and data were prospectively collected. Patients were assigned in two groups, RDP and LDP, according to the availability of the Da Vinci® Surgical System for our Surgical Unit.

RESULTS

A minimally invasive DP was performed in 38 patients with a median age of 61 years old (44-83 years old) and a BMI of 26 kg/m² (20-31 kg/m²). RDP group (n = 15) and LDP group (n = 23) were comparable concerning demographic data, BMI, ASA score, comorbidities, malignant lesions, lesion size, and indication of spleen preservation. Median operative time was longer in RDP (207 min) compared to LDP (187 min) (p = 0.047). Conversion rate, spleen preservation failure, and perioperative transfusion rates were nil in both groups. Pancreatic fistula was diagnosed in 40 and 43% (p = 0.832) of patients and was grade A in 83 and 80% (p = 1.000) in RDP and LDP groups, respectively. Median postoperative hospital stay was similar in both groups (RDP: 8 days vs. LDP: 9 days, p = 0.310). Major complication occurred in 7% in RDP group and 13% in LDP group (p = 1.000). Ninety-days mortality was nil in both groups. No difference was found concerning R0 resection rate and median number of retrieved lymph nodes. Total cost of RDP was higher than LDP (13611 vs. 12509 €, p < 0.001). The difference between mean hospital incomes and costs was negative in RDP group contrary to LDP group (- 1269 vs. 1395 €, p = 0.040).

CONCLUSION

Short-term results of RDP seem to be similar to LDP but the high cost of RDP makes this approach not cost-effective actually.

Improved perioperative outcomes of laparoscopic distal pancreatosplenectomy: modified lasso technique

BACKGROUND

Simultaneous division of the splenic artery, splenic vein and pancreatic parenchyma during laparoscopic distal pancreatosplenectomy (LDPS) is known as the lasso technique, which is considered to be simple to perform. However, the original lasso technique carries a risk of post-operative bleeding from the splenic artery. We modified the original lasso technique to improve its technical safety and compared the perioperative outcomes of LDPS performed with the modified lasso technique (ml-LDPS) with those of conventional LDPS (c-LDPS).

METHODS

From August 2006 to July 2016, 30 patients underwent c-LDPS and 31 patients underwent ml-LDPS for distal pancreatectomy involving <50% of the pancreas. The perioperative outcomes of the two groups were compared.

RESULTS

The ml-LDPS technique resulted in a shorter operation time (201 min versus 162 min, P < 0.01), less intraoperative blood loss (20 mL versus 200 mL, P < 0.01), a shorter post-operative hospital stay (8.0 days versus 12.5 days, P < 0.01), and a lower incidence of clinically relevant post-operative pancreatic fistulas (6.5% versus 26.7%, P = 0.04) compared with c-LDPS. The surgical approach (c-LDPS or ml-LDPS) was identified as an independent predictor of the development of clinically relevant post-operative pancreatic fistulas via multivariate analysis.

CONCLUSION

The ml-LDPS method had beneficial effects on the operation time, intraoperative bleeding, the post-operative morbidity rate and the length of the post-operative hospital stay. The ml-LDPS procedure is a simple, safe and effective way of performing planned LDPS.

Yonsei criteria: a clinical reflection of stage I left-sided pancreatic cancer

In this study, we examined associations between pancreatic cancer that met the Yonsei criteria (YC) and classifications from the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. Clinicopathological and survival data were collected from132 patients who underwent distal pancreatectomy for left-sided pancreatic ductal adenocarcinoma between January 2000 and December 2015, and the utility of the YC for selecting treatment and predicting survival was evaluated using the 8th AJCC staging manual. Of the 102 patients who ultimately qualified for the study, 45 patients were reclassified as stage I based on the 8th AJCC cancer staging system. Disease-free survival and disease-specific survival periods were longer in stage I patients who met the YC than in those who did not. Clinicopathological characteristics did not differ between stage I patients who did and did not meet the YC. These results suggest that meeting the YC criteria may be a clinical indicator that left-sided pancreatic cancer patients who are candidates for resection have early-stage disease according to the 8th edition of the AJCC staging manual.

The Yonsei criteria as a clinically detectable parameter for excellent prognosis in resected left-sided pancreatic cancer: outcomes of a propensity score-matched analysis

BACKGROUND

This study aimed to identify that Yonsei criteria (YC) can be regarded as a preoperative clinical parameter to predict biological behavior of the left-sided pancreatic cancer.

METHODS

Between June 2007 and December 2014, 135 patients who underwent minimally invasive (MIS) or open distal pancreatectomy for left-sided pancreatic cancer were enrolled in this study consecutively. Perioperative short-term and long-term oncologic outcomes were analyzed according to the YC retrospectively.

RESULTS

Fifty-four and 81 patients did and did not meet the YC, respectively. Short-term oncologic outcomes were favorable among those meeting the YC even after propensity score matching. Patients within the YC also had better disease-free and disease-specific overall survival (p < 0.05). In analysis for receiver operating characteristic curve, area under curve of CA19-9 was satisfactory only within YC group. Multivariate analysis for disease-free survival identified the YC as a strong independent prognostic factor (p < 0.05). In preoperative clinical setting, patients' survival was clearly different based on following clinical groups, such as within YC, beyond YC, and unresectable.

CONCLUSIONS

Preoperative CT-based determined YC can predict excellent short-term and long-term oncologic outcomes. YC might have a potential role as a preoperative clinical staging for left-sided pancreatic cancer. External validations of YC based on multicenter cohorts are mandatory to confirm this oncologic significance of YC.

Robotic versus open pancreatoduodenectomy: a propensity score-matched analysis based on factors predictive of postoperative pancreatic fistula

BACKGROUND

Improvement in morbidity of pancreatoduodenectomy (PD) largely depends on the reduction in the incidence of clinically relevant (CR) postoperative pancreatic fistula (POPF).

METHODS

After internal validation of the clinical risk score (CRS) of POPF, and identification of other predictive factors for POPF, robotic (RPD), and open (OPD) PDs were stratified into risk categories and matched by propensity scores. The primary endpoint of this study was incidence of CR-POPF. Secondary endpoints were 90-day morbidity and mortality, and sample size calculation for randomized controlled trials (RCT).

RESULTS

No patient undergoing RPD was classified at negligible risk for POPF, and no CR-POPF occurred in 7 RPD at low risk. The matching process identified 48 and 11 pairs at intermediate and high risk for POPF, respectively. In the intermediate-risk group, RPD was associated with higher rates of CR-POPF (31.3% vs 12.5%) (p = 0.0026), with equivalent incidence of grade C POPF. In the high-risk group, CR-POPF occurred frequently, but in similar percentages, after either procedures. Starting from an unadjusted point estimate of the effect size of 1.71 (0.91-3.21), the pair-matched odds ratio for CR-POPF after RPD was 2.80 (1.01-7.78) for the intermediate-risk group, and 0.20 (0.01-4.17) for the high-risk group. Overall morbidity and mortality were equivalent in matched study groups. Sample size calculation for a non-inferiority RCT demonstrated that a total of 31,669 PDs would be required to randomize 682 patients at intermediate risk and 1852 patients at high risk.

CONCLUSIONS

In patients at intermediate risk, RPD is associated with higher rates of CR-POPF. Incidence of grade C POPF is similar in RPD and OPD, making overall morbidity and mortality also equivalent. A RCT, with risk stratification for POPF, would require an enormous number of patients. Implementation of an international registry could be the next step in the assessment of RPD.

Robotic versus laparoscopic distal pancreatectomy: A propensity score-matched study

BACKGROUND

Robotic distal pancreatectomy (RDP) is considered a safe and feasible alternative to laparoscopic distal pancreatectomy (LDP). However, previous studies have some limitations including small sample size and selection bias. This study aimed to evaluate whether the robotic approach has advantages over laparoscopic surgery in distal pancreatectomy.

METHODS

Demographics and perioperative outcomes among patients undergoing RDP (n = 102) and LDP (n = 102) between January 2011 and December 2015 were reviewed. A 1:1 propensity score matched analysis was performed between both groups.

RESULTS

Both groups displayed no significant differences in perioperative outcomes including operative time, blood loss, transfusion rate, and rates of overall morbidities and pancreatic fistula. Robotic approach reduced the rate of conversion to laparotomy (2.9% vs 9.8%, P = 0.045), especially in patients with large tumors (0% vs 22.2%, P = 0.042). RDP improved spleen (SP) and splenic vessels preservation (SVP) rates in patients with moderate tumors (60.0% vs 35.5%, P = 0.047; 37.1% vs 12.9%, P = 0.025), especially in patients without malignancy (95.5% vs 52.4%, P = 0.001; 59.1% vs 19.0%, P = 0.007). RDP also reduced postoperative hospital stay (PHS) significantly (7.67% vs 8.58, P = 0.032).

CONCLUSIONS

RDP is associated with less rate of conversion to laparotomy, shorter PHS, and improved SP and SVP rates in selected patients than LDP.

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS), first reported by Strasberg in 2003, has attracted increasing attention in the treatment of left-sided pancreatic cancer. The limited number of cases eligible for RAMPS makes it difficult to perform any prospective randomized trial of RAMPS versus the standard procedure. Therefore, we performed this systemic review and meta-analysis of the current data to clarify the role of the RAMPS procedure.

METHODS

A literature search was performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing RAMPS with the standard procedure were included in this meta-analysis. R0 resection rate, recurrence rate at the end of the follow-up, overall survival (OS) and disease-free survival (DFS) were measured as primary outcomes. Revman 5.3 was used to perform the analysis.

RESULTS

Six retrospective cohort studies with a total number of 378 patients were included in our analysis. Meta-analysis revealed that RAMPS was correlated with higher R0 resection rates [Odds Ratio (OR) 95% confidence interval (CI), 2.19 (1.16 ~ 4.13); P = 0.02] and successful harvest of more lymph nodes [weighted mean difference (WMD) 95% CI, 7.06 (4.52 ~ 9.60); P < 0.01] compared with the standard procedure. However, no statistically significant difference was found between the procedures with respect to recurrence rates [OR 95% CI, 0.66 (0.40 ~ 1.09); P = 0.10], OS [Hazard ratio (HR) 95% CI, 0.65 (0.42 ~ 1.00); P = 0.05] or DFS [HR 95% CI, 1.02 (0.62 ~ 1.68); P = 0.93].

CONCLUSIONS

RAMPS is safe and oncologically superior to the standard procedure for the treatment of left-sided pancreatic cancer. However, high-grade evidence will be necessary to confirm the potential survival benefits of RAMPS.

Minimally invasive distal pancreatectomy

BACKGROUND

The first International conference on Minimally Invasive Pancreas Resection was arranged in conjunction with the annual meeting of the International Hepato-Pancreato-Biliary Association (IHPBA), in Sao Paulo, Brazil on April 19th 2016. The presented evidence and outcomes resulting from the session for minimally invasive distal pancreatectomy (MIDP) is summarized and addressed perioperative outcome, the outcome for cancer and patient selection for the procedure.

METHODS

A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to compare MIDP and open distal pancreatectomy. Patient selection was discussed based on plenary talks, panel discussions and a worldwide survey on MIDP.

RESULTS

Of 582 studies, 52 (40 observational and 12 case-matched) were included in the assessment for outcome for LDP (n = 5023) vs. ODP (n = 16,306) whereas 16 observational comparative studies were identified for cancer outcome. No randomized trials were identified. MIDP resulted in similar outcome to ODP with a tendency for lower blood loss and shorter hospital stay in the MIDP group.

DISCUSSION

Available evidence for comparison of MIDP to ODP is weak, although the number of studies is high. Observed outcomes of MIDP are promising. In the absence of randomized control trials, an international registry should be established.

Laparoscopic resection of retroperitoneal benign neurilemmoma

Purpose

The aim of this study was to verify that laparoscopic resection for treating retroperitoneal benign neurilemmoma (NL) is expected to be favorable for complete resection of tumor with technical feasibility and safety.

Methods

We retrospectively analyzed 47 operations for retroperitoneal neurogenic tumor at Yonsei University College of Medicine, Severance Hospital and Gangnam Severance Hospital between January 2005 and September 2015. After excluding 21 patients, the remaining 26 were divided into 2 groups: those who underwent open surgery (OS) and those who underwent laparoscopic surgery (LS). We compared clinicopathological features between the 2 groups.

Results

There was no significant difference in operation time, estimated blood loss, transfusion, complication, recurrence, or follow-up period between 2 groups. Postoperative hospital stay was significantly shorter in the LS group versus the OS group (OS vs. LS, 7.00 ± 3.43 days vs. 4.50 ± 2.16 days; P = 0.031).

Conclusion

We suggest that laparoscopic resection of retroperitoneal benign NL is feasible and safe by obtaining complete resection of the tumor. LS for treating retroperitoneal benign NL could be useful with appropriate laparoscopic technique and proper patient selection.

Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference

BACKGROUND

Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients.

METHODS

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey.

RESULTS

LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case-control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe.

CONCLUSIONS

LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.

Initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer in a single institution: technical aspects and oncological outcomes

Background

Laparoscopic surgery has been performed less frequently in the era of pancreatic cancer due to technical difficulties and concerns about oncological safety. Radical antegrade modular pancreatosplenectomy (RAMPS) is expected to be helpful to obtain a negative margin during radical lymph node dissection. We hypothesized that it would also be favorable as a laparoscopic application due to unique features.

Methods

Fifteen laparoscopic RAMPS for well-selected patients with left-sided pancreatic cancer were performed from July 2011 to April 2016. Five trocars were usually used, and the operative procedures and range of dissection were similar to or the same as those of open RAMPS described by Strasberg. All medical records and follow-up data were reviewed and analyzed.

Results

All patients had pancreatic ductal adenocarcinoma. Mean operative time was 219.3 ± 53.8 min, and estimated blood loss was 250 ± 70 ml. The length of postoperative hospital stay was 6.1 ± 1.2 days, and postoperative morbidities developed in two patients (13.3%) with urinary retention. The median number of retrieved lymph nodes was 18.1 ± 6.2 and all had negative margins. Median follow-up time was 46.0 months, and the 3-year disease free survival and overall survival rates were 56.3% and 74.1%, respectively.

Conclusion

Our early experience with laparoscopic RAMPS achieved feasible perioperative results accompanied by acceptable survival outcomes. Laparoscopic RAMPS could be a safe and oncologically feasible procedure in well-selected patients with left-sided pancreatic cancer.

Adverse oncologic effects of intraoperative transfusion during pancreatectomy for left-sided pancreatic cancer: the need for strict transfusion policy

BACKGROUND

The aim of the present study was to investigate the prognostic impact of transfusion following distal pancreatectomy (DP) for left-sided pancreatic ductal adenocarcinoma (PDAC).

METHODS

Retrospective analysis was performed to identify prognostic factors in patients who underwent DP from July 1992 to October 2012.

RESULTS

Forty-eight patients were male, and 35 were female with a mean age of 62 ± 9 years. Twenty-three (27.7%) of the patients received intraoperative blood transfusion. In univariate analysis, combined organ resection (P = 0.046), intraoperative transfusion (P < 0.001), pathologic tumor size (≥3 cm, P = 0.051), clinical tumor size (≥3 cm, P = 0.008), lymph node metastasis (P = 0.021), lymph node ratio (LNR ≥ 0.017, P < 0.001), and tumor differentiation (P = 0.013) were analyzed to predict tumor recurrence. Multivariate analysis showed that lymph node metastasis (Exp(β) = 2.136, P = 0.016), LNR (Exp(β) = 2.003, P = 0.049), and intraoperative transfusion (Exp(β) = 2.793, P = 0.001) were independent prognostic factor predicting tumor recurrence. The amount of estimated blood loss was closely associated with intraoperative transfusion (P < 0.001).

CONCLUSION

Intraoperative transfusion should be avoided by gentle operative handling to minimize intraoperative bleeding, and the appropriate transfusion policy should be followed to increase the survival outcome.

Laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: results of a multicenter cohort study on 196 patients

BACKGROUND

Laparoscopy is widely accepted as a feasible option for distal pancreatectomy. However, the experience in laparoscopic distal pancreatectomy (LDP) for pancreatic ductal adenocarcinoma (PDAC) is limited to a small number of studies, reported by expert centers. The present study aimed to evaluate perioperative and oncological outcomes after LDP for PDAC in a large, multicenter cohort of patients.

METHODS

A retrospective analysis of the data on 196 patients with histologically verified PDAC, operated at Oslo University Hospital-Rikshospitalet (Oslo, Norway), Asan Medical Center (Seoul, Republic of Korea), Institut Mutualiste Montsouris (Paris, France) and University Hospital Southampton (Southampton, UK) between January 2002 and April 2015 was conducted. The patients with standard (SLDP) and extended (i.e., en bloc with adjacent organ, ELDP) resections were compared in terms of perioperative and oncological outcomes.

RESULTS

Out of 196 LDP procedures, 191 (97.4 %) were completed through laparoscopy, while five (2.6 %) were converted to open surgery. ELDP was performed in 30 (15.7 %) cases. Sixty-one (31.9 %) patients experienced postoperative complications, including 48 (25.1 %) with pancreatic fistula. The rate of clinically relevant fistula (grade B/C) was 15.7 %. Median postoperative hospital stay was 8 (2-63) days. Median follow-up was 16 months. Median survival was 31.3 months (95 % CI 22.9-39.6). Three- and 5-year actuarial survival rates were 42.4 and 30 %, respectively. SLDP was associated with significantly higher survival compared with ELDP (p = 0.032).

CONCLUSIONS

LDP seems to be a feasible and safe procedure, providing satisfactory oncological outcomes in patients with PDAC.

Single institution results of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of pancreas in 78 patients

BACKGROUND

The purpose of this report is to present results of the radical antegrade modular pancreatosplenectomy (RAMPS) procedure in 78 patients from a single center.

METHODS

Seventy-eight patients had RAMPS procedure over 13 years. A database dealing with RAMPS for adenocarcinoma of the pancreas was constructed so that it could be converted into a set of tables. Each table covered one element of the subject. The database was populated from clinical records of patients who had a RAMPS procedure from 1999 to 2013.

RESULTS

Fifty-six patients had anterior RAMPS and 22 had posterior RAMPS. Negative tangential margins were obtained in 94% of specimens. Overall the R0 rate was 85%. Mean lymph node count was 20. There were no 30-day or in-hospital mortalities but two patients died within 90 days. Pancreatic fistula and need for postoperative transfusion were the most common complications. Median survival was 24.6 months and 5-year overall actuarial survival was 25.1%.

CONCLUSIONS

The RAMPS technique resulted in high negative tangential margin rates and good lymph node retrieval. The long-term survival result in 78 patients is probably an accurate reflection of what is possible with this tumor using this technique at this time.

Laparoscopic Distal Pancreatectomy for Pancreatic Tumors: Does Size Matter?

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) for large pancreatic tumors may require prolonged dissection, and this could be associated with increased operative time and intraoperative complications.

METHODS

From a total cohort of 190 consecutive patients undergoing LDP, 18 patients were found to have pancreatic tumors >5 cm and were included in the retrospective study of prospectively collected data. Three techniques were used to approach the splenic vessels: the superior pancreatic, the inferior supracolic and post-pancreatic transection.

RESULTS

Of these 18 patients, 13 were women and 5 were men, the median age was 68 years and their median tumor size 7 cm. Exocrine pancreatic malignancy was diagnosed in 8 patients, 6 patients had neuroendocrine pancreatic tumors and 4 patients cystic neoplasm. The median number of resected nodes was 14. R1 resections for exocrine pancreatic malignancies were found in 50% of patients. Morbidity (grade >II) was found in 16.6% of patients and 30 days mortality in 1 patient. Overall median survival was 50 months and 29 months for patients with exocrine pancreatic malignancies.

CONCLUSIONS

LDP for large tumors, while technically demanding, is possible without additional morbidity and did not compromise short- and long-term oncological outcomes.

Minimally Invasive Distal Pancreatectomy: A Single-Center Analysis of Outcome With Experience and Systematic Review of the Literature

BACKGROUND

The aim of this study is to analyze the learning curve for laparoscopic distal pancreatectomy (LDP) in our series and review the literature on learning curves for LDP and robotic distal pancreatectomy (RDP).

METHODS

Learning curve analysis was performed by split group and cumulative sum (CUSUM) analysis of blood loss, operative time, and length of stay. The systematic review identified studies analyzing changes in outcome with experience.

RESULTS

A total of 25 resections were performed. CUSUM analysis of operative time found learning curves of 10 cases for LDP and splenectomy and 11 for LDP with splenic preservation. CUSUM analysis of blood loss showed approximately 6 cases. In the literature, values of 10 cases of LDP and approximately 7 RDP were found.

CONCLUSIONS

Low numbers of LDP are required to reach proficiency in the hands of expert laparoscopic surgeons. Our results correspond with numbers quoted in the literature.

Laparoscopic pancreatic resection-a review

Contrary to many other gastrointestinal operations, minimal access approaches in pancreatic surgery have gained ground slowly. Laparoscopic distal pancreatectomy has gained wide acceptance. It is associated with reduced blood loss and shorter duration of stay (DOS) while oncologic results and morbidity are similar to open surgery. In recent years the number of laparoscopic pancreatoduodenectomies has also increased. While oncological outcome seems comparable to the open approach, operative times are longer while DOS and blood loss are reduced. One added advantage of the laparoscopic approach to pancreatic cancer seems to be that adjuvant treatment can start earlier. Minimal access total pancreatectomy, only reported in small numbers (mostly robot assisted), has also been shown to be feasible and safe. Enucleation (EN) of small pancreatic lesions is the most common tissue sparing resection. Although no reconstruction is necessary, the risk of pancreatic fistula is high, related to excision margins equal or smaller than 2 mm to the main pancreatic duct. Compared to the open approach, laparoscopic EN has shown comparable results in terms of morbidity, pancreatic function and fistula rate, with shorter operation times and faster recovery. Experience in robot assisted pancreatic surgery is increasing. However reports are still small in numbers, lacking randomization and mostly limited to dedicated centers. The learning curve for minimal access pancreatic surgery is steep. Low patient volume leads to longer DOS, higher costs and negatively impacts outcome.

Laparoscopic versus open distal pancreatectomy for pancreatic cancer

BACKGROUND

Surgical resection is currently the only treatment with the potential for long-term survival and cure of pancreatic cancer. Surgical resection is provided as distal pancreatectomy for cancers of the body and tail of the pancreas. It can be performed by laparoscopic or open surgery. In operations on other organs, laparoscopic surgery has been shown to reduce complications and length of hospital stay as compared with open surgery. However, concerns remain about the safety of laparoscopic distal pancreatectomy compared with open distal pancreatectomy in terms of postoperative complications and oncological clearance.

OBJECTIVES

To assess the benefits and harms of laparoscopic distal pancreatectomy versus open distal pancreatectomy for people undergoing distal pancreatectomy for pancreatic ductal adenocarcinoma of the body or tail of the pancreas, or both.

SEARCH METHODS

We used search strategies to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded and trials registers until June 2015 to identify randomised controlled trials (RCTs) and non-randomised studies. We also searched the reference lists of included trials to identify additional studies.

SELECTION CRITERIA

We considered for inclusion in the review RCTs and non-randomised studies comparing laparoscopic versus open distal pancreatectomy in patients with resectable pancreatic cancer, irrespective of language, blinding or publication status..

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and independently extracted data. We calculated odds ratios (ORs), mean differences (MDs) or hazard ratios (HRs) along with 95% confidence intervals (CIs) using both fixed-effect and random-effects models with RevMan 5 on the basis of intention-to-treat analysis when possible.

MAIN RESULTS

We found no RCTs on this topic. We included in this review 12 non-randomised studies that compared laparoscopic versus open distal pancreatectomy (1576 participants: 394 underwent laparoscopic distal pancreatectomy and 1182 underwent open distal pancreatectomy); 11 studies (1506 participants: 353 undergoing laparoscopic distal pancreatectomy and 1153 undergoing open distal pancreatectomy) provided information for one or more outcomes. All of these studies were retrospective cohort-like studies or case-control studies. Most were at unclear or high risk of bias, and the overall quality of evidence was very low for all reported outcomes.Differences in short-term mortality (laparoscopic group: 1/329 (adjusted proportion based on meta-analysis estimate: 0.5%) vs open group: 11/1122 (1%); OR 0.48, 95% CI 0.11 to 2.17; 1451 participants; nine studies; I(2) = 0%), long-term mortality (HR 0.96, 95% CI 0.82 to 1.12; 277 participants; three studies; I(2) = 0%), proportion of people with serious adverse events (laparoscopic group: 7/89 (adjusted proportion: 8.8%) vs open group: 6/117 (5.1%); OR 1.79, 95% CI 0.53 to 6.06; 206 participants; three studies; I(2) = 0%), proportion of people with a clinically significant pancreatic fistula (laparoscopic group: 9/109 (adjusted proportion: 7.7%) vs open group: 9/137 (6.6%); OR 1.19, 95% CI 0.47 to 3.02; 246 participants; four studies; I(2) = 61%) were imprecise. Differences in recurrence at maximal follow-up (laparoscopic group: 37/81 (adjusted proportion based on meta-analysis estimate: 36.3%) vs open group: 59/103 (49.5%); OR 0.58, 95% CI 0.32 to 1.05; 184 participants; two studies; I(2) = 13%), adverse events of any severity (laparoscopic group: 33/109 (adjusted proportion: 31.7%) vs open group: 45/137 (32.8%); OR 0.95, 95% CI 0.54 to 1.66; 246 participants; four studies; I(2) = 18%) and proportion of participants with positive resection margins (laparoscopic group: 49/333 (adjusted proportion based on meta-analysis estimate: 14.3%) vs open group: 208/1133 (18.4%); OR 0.74, 95% CI 0.49 to 1.10; 1466 participants; 10 studies; I(2) = 6%) were also imprecise. Mean length of hospital stay was shorter by 2.43 days in the laparoscopic group than in the open group (MD -2.43 days, 95% CI -3.13 to -1.73; 1068 participants; five studies; I(2) = 0%). None of the included studies reported quality of life at any point in time, recurrence within six months, time to return to normal activity and time to return to work or blood transfusion requirements.

AUTHORS' CONCLUSIONS

Currently, no randomised controlled trials have compared laparoscopic distal pancreatectomy versus open distal pancreatectomy for patients with pancreatic cancers. In observational studies, laparoscopic distal pancreatectomy has been associated with shorter hospital stay as compared with open distal pancreatectomy. Currently, no information is available to determine a causal association in the differences between laparoscopic versus open distal pancreatectomy. Observed differences may be a result of confounding due to laparoscopic operation on less extensive cancer and open surgery on more extensive cancer. In addition, differences in length of hospital stay are relevant only if laparoscopic and open surgery procedures are equivalent oncologically. This information is not available currently. Thus, randomised controlled trials are needed to compare laparoscopic distal pancreatectomy versus open distal pancreatectomy with at least two to three years of follow-up. Such studies should include patient-oriented outcomes such as short-term mortality and long-term mortality (at least two to three years); health-related quality of life; complications and the sequelae of complications; resection margins; measures of earlier postoperative recovery such as length of hospital stay, time to return to normal activity and time to return to work (in those who are employed); and recurrence of cancer.

The prognostic influence of intrapancreatic tumor location on survival after resection of pancreatic ductal adenocarcinoma

Background

The prognosis of pancreatic ductal adenocarcinoma (PDAC) is worse when the tumor is located in the pancreatic body or tail, compared to being located in the pancreatic head. However, for localized, resectable tumors survival seems to be at least similar.

Methods

We analyzed and compared the outcome after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) for PDAC at our institution. Clinical, pathological and survival data from patients undergoing pancreatic resection for PDAC 1994–2014 were explored retrospectively, accessing a prospective pancreatic database. Patients receiving primary total pancreatectomy were excluded.

Results

Four hundred and thirteen patients were treated for PDAC: 347 (84 %) underwent PD and 66 (16 %) DP. Tumors located in the pancreatic body and tail were significantly larger than their counterparts located in the head (30.6 mm vs. 41.2 mm; p < 0.001). However, distal tumors had significantly less nodal involvement (71 % vs. 57 %; p = 0.03). Portal-vein resection (PVR) was performed more often in PD, multivisceral resection (MVR) was more frequent in DP (37 % vs. 14 % and 4 % vs. 29 %; p < 0.001). Rates for negative resection margins and tumor grading were similar. Postoperative complication rates including morbidity, rates of re-operation and mortality were comparable. Long-term outcome revealed no significant difference between PD and DP with 5-year survival rates of 17.8 and 22 % respectively (p = 0.284). Multivariate analysis confirmed positive resection margin, positive nodal status, extended resection (PVR, MVR) and lack of adjuvant/additive chemotherapy as independent risk factors for poor survival after pancreatic resection.

Conclusion

Patients with resectable pancreatic ductal adenocarcinoma located in the body and tail of the pancreas display a similar postoperative oncological outcome despite larger tumors when compared to patients with resectable tumors located in the pancreatic head.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgery for Pancreatic and Periampullary Carcinoma

Surgical resection for pancreatic and periampullary cancer has evolved over several decades. The postoperative mortality for these resections has declined to less than 5 %. However, morbidity associated with these resections is still considerable. Various technical modifications like pylorus preservation, reconstruction techniques and methods to perform pancreaticoenteric anastomosis have been suggested to improve postoperative outcomes after pancreaticoduodenectomy. Surgical modifications to improve oncological clearance and decrease fistula rates after distal pancreatic resections have also been suggested. Dilemma still exists whether interventions like pancreatic duct stents, octreotide and drains help to improve postoperative outcomes. The role of extended lymph node dissection and extended resections for pancreatic and periampullary cancer is still controversial, as is the management of borderline resectable pancreatic cancer. In this review, we discuss the literature pertaining to various surgical aspects of pancreatic and periampullary carcinoma.

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

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

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.

METHODS

A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.

RESULTS

A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.

CONCLUSION

Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.