Initial experiences using robot-assisted central pancreatectomy with pancreaticogastrostomy: a potential way to advanced laparoscopic pancreatectomy. Surg Endosc. 2011;25:1101-1106. [PMID: 20835724 DOI: 10.1007/s00464-010-1324-3]

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic Parenchymal-Sparing Pancreatectomy: A Systematic Review

BACKGROUND

Parenchymal-sparing approaches to pancreatectomy are technically challenging procedures but allow for preserving a normal pancreas and decreasing the rate of postoperative pancreatic insufficiency. The robotic platform is increasingly being used for these procedures. We sought to evaluate robotic parenchymal-sparing pancreatectomy and assess its complication profile and efficacy.

METHODS

This systematic review consisted of all studies on robotic parenchymal-sparing pancreatectomy (central pancreatectomy, duodenum-preserving partial pancreatic head resection, enucleation, and uncinate resection) published between January 2001 and December 2022 in PubMed and Embase.

RESULTS

A total of 23 studies were included in this review (n = 788). Robotic parenchymal-sparing pancreatectomy is being performed worldwide for benign or indolent pancreatic lesions. When compared to the open approach, robotic parenchymal-sparing pancreatectomies led to a longer average operative time, shorter length of stay, and higher estimated intraoperative blood loss. Postoperative pancreatic fistula is common, but severe complications requiring intervention are exceedingly rare. Long-term complications such as endocrine and exocrine insufficiency are nearly nonexistent.

CONCLUSIONS

Robotic parenchymal-sparing pancreatectomy appears to have a higher risk of postoperative pancreatic fistula but is rarely associated with severe or long-term complications. Careful patient selection is required to maximize benefits and minimize morbidity.

Short and long-term outcomes of minimally invasive central pancreatectomy: Comparison with minimally invasive spleen-preserving subtotal distal pancreatectomy

BACKGROUND

Central pancreatectomy(CP) is more complex surgery and higher complication rate than distal pancreatectomy(DP). However, with the development of minimally invasive surgery, CP has become a safer surgery technique. In this study, we compare minimally invasive CP(MI-CP) and Minimally invasive spleen-preserving subtotal DP(MI-SpSTDP) to figure out the short-term and long-term outcomes of MI-CP.

METHODS

From March 2007 to June 2020, 36 cases of MI-SpSTDP and 23 cases of MI-CP were performed for benign and borderline malignant pancreatic tumors in Severance hospital. The occurrence of postoperative pancreatic fistula(POPF) and Clavian-Dindo classification grade 3 or more in the two group was investigated, and the Controlling nutritional status scores(CONUT score) before and 1-year after surgery were compared to determine the long-term outcomes of exocrine function.

RESULTS

There was no difference in postoperative complications including POPF between the two groups(17.4% vs 5.1%, p = 0.294). And there were no statistical differences in either the MI-CP group (0.74 ± 0.75 vs. 0.78 ± 0.99, p = 0.803) or the MI-SpSTDP group (0.86 ± 0.83 to 0.61 ± 0.59, p = 0.071).

CONCLUSIONS

MI-CP had longer operation time and hospital stay and is safe and effective in preserving endocrine and exocrine functions in treatment of benign or borderline tumors located at the neck or proximal body of the pancreas.

Figures do matter: A literature review of 4587 robotic pancreatic resections and their implications on training

BACKGROUND

The use of robotic assistance in minimally invasive pancreatic resection is quickly growing.

METHODS

We present a systematic review of the literature regarding all types of robotic pancreatic resection (RPR). Our aim is to show for which procedures there is enough experience to permit safe training and provide an estimation of how many centers could serve as teaching institutions.

RESULTS

Sixty-four studies reporting on 4587 RPRs were analyzed. A total of 2598 pancreatoduodenectomies (PD) were reported by 28 centers from Europe (6/28; 21.4%), the Americas (11/28; 39.3%), and Asia (11/28; 39.3%). Six studies reported >100 robot PD (1694/2598; 65.2%). A total of 1618 distal pancreatectomies (DP) were reported by 29 centers from Europe (10/29; 34.5%), the Americas (10/29; 34.5%), and Asia (9/29; 31%). Five studies reported >100 robotic DP (748/1618; 46.2%). A total of 154 central pancreatectomies were reported by six centers from Europe (1/6; 16.7%), the Americas (2/6; 33.3%), and Asia (3/6; 50%). Only 49 total pancreatectomies were reported. Finally, 168 enucleations were reported in seven studies (with a mean of 15.4 cases per study). A single center reported on 60 enucleations (35.7%). Results of each type of robotic procedure are also presented.

CONCLUSIONS

Experience with RPR is still quite limited. Despite high case volume not being sufficient to warrant optimal training opportunities, it is certainly a key component of every successful training program and is a major criterion for fellowship accreditation. From this review, it appears that only PD and DP can currently be taught at few institutions worldwide.

Minimally invasive versus open central pancreatectomy: Systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to give an overview on the postoperative outcome after a minimally invasive (ie, laparoscopic and robot-assisted) central pancreatectomy and open central pancreatectomy with a specific emphasis on the postoperative pancreatic fistula. For benign and low-grade malignant lesions in the pancreatic neck and body, central pancreatectomy may be an alternative to distal pancreatectomy. Exocrine and endocrine insufficiency occur less often after central pancreatectomy, but the rate of postoperative pancreatic fistula is higher.

METHODS

An electronic search was performed for studies on elective minimally invasive central pancreatectomy and open central pancreatectomy, which reported on major morbidity and postoperative pancreatic fistula in PubMed, Cochrane Register, Embase, and Google Scholar until June 1, 2021. A review protocol was developed a priori and registered in PROSPERO as CRD42021259738. A meta-regression was performed by using a random effects model.

RESULTS

Overall, 41 studies were included involving 1,004 patients, consisting of 158 laparoscopic minimally invasive central pancreatectomies, 80 robot-assisted minimally invasive central pancreatectomies, and 766 open central pancreatectomies. The overall rate of postoperative pancreatic fistula was 14%, major morbidity 14%, and 30-day mortality 1%. The rates of postoperative pancreatic fistula (17% vs 24%, P = .194), major morbidity (17% vs 14%, P = .672), and new-onset diabetes (3% vs 6%, P = .353) did not differ significantly between minimally invasive central pancreatectomy and open central pancreatectomy, respectively. Minimally invasive central pancreatectomy was associated with significantly fewer blood transfusions, less exocrine pancreatic insufficiency, and fewer readmissions compared with open central pancreatectomy. A meta-regression was performed with a random effects model between minimally invasive central pancreatectomy and open central pancreatectomy and showed no significant difference for postoperative pancreatic fistula (random effects model 0.16 [0.10; 0.24] with P = .789), major morbidity (random effects model 0.20 [0.15; 0.25] with P = .410), and new-onset diabetes mellitus (random effects model 0.04 [0.02; 0.07] with P = .651).

CONCLUSION

In selected patients and in experienced hands, minimally invasive central pancreatectomy is a safe alternative to open central pancreatectomy for benign and low-grade malignant lesions of the neck and body. Ideally, further research should confirm this with the main focus on postoperative pancreatic fistula and endocrine and exocrine insufficiency.

Resection of the splenic vessels during laparoscopic central pancreatectomy is safe and does not compromise preservation of the distal pancreas

BACKGROUND

The diagnosis of low potential malignant diseases is increasingly frequent, and laparoscopic central pancreatectomy can be indicated in these patients. Laparoscopic central pancreatectomy that usually preserves the splenic vessels results in a low risk of new-onset diabetes but high morbidity, mainly due to postoperative pancreatic fistula and postpancreatectomy hemorrhage. In this study, we evaluated the short and long-term complications after laparoscopic central pancreatectomy with splenic vessel resection.

METHODS

This retrospective single-center cohort study included 650 laparoscopic pancreatic resections from 2008 to 2020 with 84 laparoscopic central pancreatectomy; 15 laparoscopic central pancreatectomy with splenic vessel resection; and 69 laparoscopic central pancreatectomy with preservation of the splenic vessels. Pancreaticogastrostomy was routinely performed, and the patients were discharged after complications had been treated. The 15 laparoscopic central pancreatectomy with splenic vessel resection were matched for age, sex, body mass index, and tumor characteristics [1:2] and compared with 30 laparoscopic central pancreatectomy with the preservation of the splenic vessels.

RESULTS

In the laparoscopic central pancreatectomy with splenic vessel resection group, resection of splenic vessels was performed due to tumoral or inflammatory adhesions (n = 11) or accidental vascular injury (n = 4). The demographic characteristics of the groups were similar. Tumors were larger in the laparoscopic central pancreatectomy with splenic vessel resection group (40 vs 21 mm; P = .008), and right transection on the body of the pancreas (53% vs 13%; P = .01) was more frequent. There were no differences in the characteristics of the pancreas (Wirsung duct size or consistency). The median operative time (minutes) was longer in the laparoscopic central pancreatectomy with splenic vessel resection group than in the laparoscopic central pancreatectomy with preservation of the splenic vessels group (210 vs 180, respectively; P = .15) with more blood loss (100 mL vs 50 mL, respectively; P = .012). The lengths (mm) of the resected pancreas and remnant distal pancreas in the 2 groups were 65 vs 50 (P = .053) and 40 vs 65 (P = .006), respectively. There were no differences in postoperative mortality (0% vs 3%; P = .47), grade B-C postoperative pancreatic fistula (27% vs 27%; P = 1), reintervention (7% vs 13%; P = .50), grade B-C postpancreatectomy hemorrhage (0% vs 13%; P = .13), length of hospital stay (20 days vs 22 days; P = .15), or new-onset diabetes (7% vs 10%; P = .67) between the 2 groups.

CONCLUSION

Laparoscopic central pancreatectomy with splenic vessel resection is a safe technical modification of central pancreatectomy that does not prevent preservation of the distal pancreas and does not influence postoperative pancreatic fistula or endocrine insufficiency. Furthermore, it could reduce the risk of postpancreatectomy hemorrhage.

Robotic central pancreatectomy: a systematic review and meta-analysis

BACKGROUND

Central pancreatectomy is usually performed to excise lesions of the neck or proximal body of the pancreas. In the last decade, thanks to the advent of novel technologies, surgeons have started to perform this procedure robotically. This review aims to appraise the results and outcomes of robotic central pancreatectomies (RCP) through a systematic review and meta-analysis.

METHODS

A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of RCP. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modelling.

RESULTS

Thirteen series involving 265 patients were included. In all cases but one, RCP was performed to excise benign or low-grade tumours. Clinically relevant post-operative pancreatic fistula (POPF) occurred in 42.3% of patients. While overall complications were reported in 57.5% of patients, only 9.4% had a Clavien-Dindo score ≥ III. Re-operation was necessary in 0.7% of the patients. New-onset diabetes occurred postoperatively in 0.3% of patients and negligible mortality and open conversion rates were observed.

CONCLUSION

RCP is safe and associated with low perioperative mortality and well preserved postoperative pancreatic function, although burdened by high overall morbidity and POPF rates.

Minimally invasive (laparoscopic and robot-assisted) versus open approach for central pancreatectomies: a single-center experience

BACKGROUND

There continues to be an interest in minimally invasive approaches to pancreatic surgery. At our institution, there has been a progressive change from an open to minimally invasive surgery (MIS) (laparoscopic, robotic, or laparoscopic-robotic) approach for central pancreatectomies (CP). The aim of this study was to evaluate surgical outcomes with open CP (O-CP) versus minimally invasive CP (MI-CP).

METHODS

A retrospective medical review of patients who underwent CP between 1993 and 2018 at Yonsei University Health System, Seoul, Korea was performed. Short-term perioperative outcomes were compared between O-CP and MI-CP.

RESULTS

Thirty-one CPs (11 open, 20 MIS) were identified during the study period. No difference was observed in admission days between O-CP and MI-CP (21.2 vs. 16.7 days, p = 0.340), although operating time was significantly increased in the MI-CP group (296.8 vs. 374.8 min, p = 0.036). Blood loss was significantly less in MI-CP vs. O-CP (807.1 vs. 214.0 mls, p = 0.001), with no difference in post-operative new-onset diabetes (9% vs. 5%). The overall post-operative pancreatic fistula rate was 25.8%, and no significant difference between O-CP and MI-CP or complication rates (45% vs. 40%) was observed.

CONCLUSION

Despite increased operative time, MI-CP is feasible and comparable to conventional O-CP with regard to surgical outcomes in well-selected patients.

A comparative study of end-to-end pancreatic anastomosis versus pancreaticojejunostomy after robotic central pancreatectomy

Robotic central pancreatectomy has been applied for 20 years with the advantage of minimally invasive surgery. The general pancreatic reconstruction approaches include pancreaticojejunostomy and pancreaticogastrostomy. Recently, our group reported a few preliminary cases of application of end-to-end pancreatic anastomosis in robotic central pancreatectomy. This novel approach has not been compared with the conventional approach on a large scale. The objective of this study is to compare end-to-end pancreatic anastomosis with pancreaticojejunostomy after robotic central pancreatectomy based on the perioperative and long-term outcomes. Clinical data consist of demographics, clinicopathologic characteristics, perioperative and long-term outcomes of patients who underwent robotic central pancreatectomy from March 2015 to December 2019 were collected and analyzed. Seventy-four patients received a robotic central pancreatectomy with either end-to-end pancreatic anastomosis (n = 52) or pancreaticojejunostomy (n = 22). End-to-end pancreatic anastomosis was associated with shorter operative time and reduced blood loss. Despite a higher incidence of clinically relevant postoperative pancreatic fistula (69.2% vs. 36.4%, p = 0.009), the newer anastomotic technique was also associated with earlier removal of nasogastric tube and resumption of oral intake. Long-term results, in terms of either endocrine or exocrine function, were not affected by the anastomotic technique. We have shown the feasibility of robotic central pancreatectomy with end-to-end pancreatic anastomosis. Despite streamlined technique, the newer anastomosis appears to improve early post-operative results while preserving endocrine and exocrine functions in the long-term period. Evaluation of the true potential of robotic central pancreatectomy with end-to-end pancreatic anastomosis requires a prospective and randomized study enrolling a large number of patients.

Revo-i assisted robotic central pancreatectomy

Central pncreatectomy (CP) can be one of procedures for function-preserving pancreatectomy for patients with benign or low grade malignant pancreatic tumors. Surgeons have to deal with two cut surface of the pancreas when performing CP, which can be associated with severe complication, such as postoperative pancreatic fistula. Fine and delicate surgical skill is highly required for safe CP. With the advance of minimally invasive surgery, CP is now thought to be one of appropriate procedures for function-preserving minimally invasive pancreatectomy. Robotic surgery is thought to make complicated surgical procedure easy and effective. Recently, Korean robotic surgical system, Revo-i, was successfully developed by Meeraecompany and have been proved its safety and feasibility in several recent reports. A 56-year old woman was referred for a body of pancreatic lesion. Contrast abdominopelvic CT revealed a pancreatic body tumor measuring around 1.2 cm in diameter. The patient underwent a robot-assisted central pancreatectomy using Revo-i. The patient endured the procedure well and was discharged to home at postoperative day 9. This report showed a successful case of central pancreatectomy performed with the Korean robotic surgical system Revo-i.

A single institution experience with robotic and laparoscopic distal pancreatectomies

BACKGROUNDS/AIMS

This study aims to describe our experience with minimally-invasive distal pancreatectomies, with emphasis on the comparison between robotic distal pancreatectomy (RDP) and laparoscopic distal pancreatectomy (LDP).

METHODS

Retrospective review of 102 consecutive RDP and LDP from 2006 to 2019 was performed.

RESULTS

There were 27 and 75 patients who underwent RDP and LDP, respectively. There were 12 (11.8%) open conversions and 16 (15.7%) patients had major (＞grade 2) morbidities. Patients who underwent RDP had significantly higher rates of splenic preservation (44.4% vs. 13.3%, p=0.002), higher rates of splenic-vessel preservation (40.7% vs. 9.3%, p=0.001), higher median difficulty score (5 vs. 3, p=0.002) but longer operation time (385 vs. 245 minutes, p＜0.001). The rate of open conversion tended to be lower with RDP (3.7% vs. 14.7%, p=0.175).

CONCLUSIONS

In our institution practice, both RDP and LDP were safe and effective. The use of RDP appeared to be complementary to LDP, allowing us to perform more difficult procedures with comparable postoperative outcomes.

Pre- and intraoperative diagnostic requirements, benefits and risks of minimally invasive and robotic surgery for neuroendocrine tumors of the pancreas

Pancreatic neuroendocrine tumours (PanNET) are rare tumours, accounting for 1%-2% of all pancreatic neoplasms. These tumors are classified as functioning neuroendocrine tumours (F-PanNETs) or non-functioning (NF-PanNETs) depends on whether the tumour is associated with clinical hormonal hypersecretion syndrome or not. In the last decades, diagnosis of PanNETs has increased significantly due to the widespread of cross-sectional imaging. Whenever possible, surgery is the cornerstone of PanNETs management and the only curative option for these patients. Indeed, after R0 resection, the 5-year overall survival rate is around 90-100% for low grade lesions but significantly drops after incomplete resections. Compared to standard resections, pancreatic sparing surgery, i.e. enucleation and central pancreatectomy, significantly decreased the risk of pancreatic insufficiency. It should be performed in patients with good general condition and normal pancreatic function to limit the operative risk and enhance the benefit of surgery. Nowadays, due to many known advantages of minimally invasive surgery, there is an ongoing trend towards laparoscopic and robotic pancreatic surgery. The aim of this study is to describe the pre- and intraoperative diagnostic requirements for the management of PanNETs and the benefits and risks of minimally invasive surgery including laparoscopic and robotic approach in view of the recent literature.

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.

Systematic Review and Meta-analysis of Minimally Invasive Pancreatectomies for Solid Pseudopapillary Neoplasms of the Pancreas

OBJECTIVES

We report the first systematic review and meta-analysis on minimally invasive pancreatectomy (MIP) for solid pseudopapillary neoplasms (SPPN) of the pancreas.

METHODS

A systematic review of all studies reporting patient characteristics and outcomes of MIP for SPPN was conducted.

RESULTS

We reviewed 27 studies comprising 149 patients with SPPN managed via MIP. Five were comparative retrospective cohort studies, comprising 46 and 60 patients in the minimally-invasive and open groups, respectively. Tumor size was smaller in the minimally-invasive group (mean difference, -2.20; 95% confidence interval (CI), -3.09 to -1.32; P < 0.001). The MI group had lower intraoperative blood loss (mean difference, -180.19; 95% CI, -344.28 to -16.09; P = 0.03) and transfusion requirement (relative risk, 0.24; 95% CI, 0.06-0.94; P = 0.04), and a shorter time to diet (mean difference, -2.99; 95% CI, -3.96 to -2.03; P < 0.001) and length of stay (mean difference, -3.61; 95% CI, -6.98 to -0.24; P = 0.04). There was no significant difference in operating time, margin positivity, postoperative morbidity, and postoperative pancreatic fistula rates.

CONCLUSIONS

Minimally invasive pancreatectomy for SPPN is associated with decreased intraoperative blood loss and transfusion requirements and a shorter postoperative time to diet and hospital stay.

Different biological behaviors in left-sided pancreatic cancer according to Yonsei criteria: Proposal of a modified Yonsei criteria score

BACKGROUND/OBJECTIVES

Our institutional experience has demonstrated that bloodless and margin-negative resection is the most potent prognostic factor in treating left-sided pancreatic cancer and we developed selection guideline. The Yonsei criteria (YC) is selection criteria for oncologically safe and effective resection of left-sided pancreatic cancer by a minimally invasive approach. In this study, we investigated whether left-sided pancreatic cancer with YC can be more individualized to predict long-term survival by using clinically and pathologically detectable parameters.

METHODS

From January 2000 to December 2015, 105 patients underwent distal pancreatectomy for left-sided pancreatic cancer. The medical records of the patients were retrospectively reviewed.

RESULTS

Among clinically and pathologically detectable parameters to predict tumor conditions, radiologically determined tumor size (p = 0.080) and SUVmax (p = 0.086) were identified as predictors of early tumor recurrence with marginal significance. Among them, 20% of the patients with YC were identified as having the most favoring tumor condition, with an modified YC score of 3. The patient group with the lowest mYC score was found to have a very long disease-free survival time, with a mean of 108 months, which was statistically different from those with other mYC scores (mYC score = 4, mean 47.1 months [95% CI: 27.8-69.5] vs. mYC score = 5, mean 36.7 months [95% CI: 12.7-60.7], vs. mYC score = 6, mean 10.7 months [95% CI: 3.9-17.4]).

CONCLUSIONS

Modified Yonsei criteria score can predict long-term survival in resected left-sided pancreatic cancer. And patients within YC with a mYC score = 3 could have a favorable survival outcome.

The role of central pancreatectomy in pancreatic surgery: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP) and pancreaticoduodenectomy (PD).

METHODS

A systematic literature research in PubMed/Medline, Embase and Cochrane Library was performed to identify articles reporting CP from January 1983 to November 2017.

RESULTS

Fifty studies with 1305 patients undergoing CP were identified. The overall morbidity, mortality, pancreatic fistula (PF) rate and reoperation rate was 51%, 0.5%, 35% and 4% respectively. Endocrine and exocrine insufficiency were occurred in 4% and 5% of patients after CP. Meta-analysis of CP versus DP favored CP with regard to less blood loss (WMD = -143.4, P = 0.001), lower rates of endocrine (OR = 0.13, P < 0.001) and exocrine insufficiency (OR = 0.38, P < 0.001). CP was associated with higher morbidity and PF rate. In comparison with PD, CP had a lower risk of endocrine (OR = 0.14, P < 0.001) and exocrine insufficiency (OR = 0.14, P < 0.001), but a higher PF rate (OR = 1.6, P = 0.015).

CONCLUSIONS

CP maintains pancreatic endocrine and exocrine function better than DP and PD, but is associated with a higher PF rate.

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

Minimally invasive distal pancreatectomy for PNETs: laparoscopic or robotic approach?

Background

The most effective and radical treatment for pancreatic neuroendocrine tumors (PNETs) is surgical resection. Minimally invasive surgery has been increasingly used in pancreatectomy. Initial results in robotic distal pancreatectomy (RDP) have been encouraging. Nonetheless, data comparing outcomes of RDP with those of laparoscopic distal pancreatectomy (LDP) in treating PNETs are rare. The aim of this study was to compare the safety and efficacy of RDP and LDP for PNETs.

Methods

From September 2010 to January 2017, operative parameters and perioperative outcomes in an initial experience with 43 consecutive patients undergoing RDP were collected and compared with those in 31 patients undergoing LDP.

Results

Patients undergoing RDP and LDP demonstrated equivalent age, sex, ASA score, tumor location and tumor size. Operating time, length of resected pancreas, postoperative length of hospital stay and rates of conversion to open, pancreatic fistula, transfusion and reoperation were not statistically different. Patients in the RDP group were associated with significantly higher overall (79.1 vs. 48.4 %, P = 0.006) and Kimura spleen preservation rates (72.1 vs. 16.1%, P < 0.001) and had reduced risk of excessive blood loss (50 vs. 200mL, P < 0.001). Oncological outcomes in this series were superior for the RDP group with more lymph node harvest for G2 and G3 PNETs (3.5 vs. 2, P = 0.034).

Conclusions

Both RDP and LDP are efficacious and safe methods in treating PNETs located in the body or tail of pancreas. Robotic approach offers advantages with less intraoperative blood loss, higher spleen preservation rate and more lymph node harvest. It may be sensible to choose RDP for patients who fit indications for scheduled spleen preservation.

Surgical resection of neuroendocrine tumors of the pancreas (pNETs) by minimally invasive surgery: the laparoscopic approach

Neuroendocrine tumors of the pancreas (pNETs) are a rare group of neoplasms that originate from the endocrine portion of the pancreas. Tumors that either secrete or do not secrete compounds, resulting in symptoms, can be classified as functioning and non-functioning pNETs, respectively. The prevalence of such tumors has recently increased due to the use of more sensitive imaging techniques, such as multidetector computed tomography, magnetic resonance imaging and endoscopic ultrasound. The biological behavior of pNETs varies widely from indolent, well-differentiated tumors to those that are far more aggressive. The most effective and radical treatment for pNETs is surgical resection. Over the last decade, minimally invasive surgery has been increasingly used in pancreatectomy, with laparoscopic pancreatic surgery (LPS) emerging as an alternative to open pancreatic surgery (OPS) in patients with pNETs. Non-comparative studies have shown that LPS is safe and effective. In well-selected groups of patients with pancreatic lesions, LPS was found to results in good perioperative outcomes, including reduced intraoperative blood loss, postoperative pain, time to recovery, and length of hospital stay. Despite the encouraging results of studies from highly specialized centers with extensive experience, no randomized trials to date have conclusively validated these findings. Indications for minimally invasive LPS for patients with pNETs remain unclear. This review presents the current state of LPS for pNETs.

Surgical resection of pancreatic neuroendocrine neoplasm by minimally invasive surgery-the robotic approach?

Over the past decade, there has been increasing adoption of minimally invasive pancreatic surgery world-wide and this has naturally expanded to the management of pancreatic neuroendocrine neoplasms (PNENs). More recently, robotic pancreatic surgery (RPS) was introduced to overcome the limitations during laparoscopic pancreatic surgery (LPS). Due to the relative rarity of PNEN and the novelty of minimally invasive pancreatic surgery in particular RPS today, the evidence for robotic surgery in PNENs remains extremely limited. Presently, the available evidence is limited to a few low level retrospective case-control studies. These studies suggest that RPS may be associated with a higher splenic preservation rates and lower open conversion rates compared to conventional laparoscopic surgery. Ideally a prospective randomized trial should be performed but this would be extremely challenging due to the rarity of PNEN, making it almost impossible to conduct a sufficiently powered trial.

Robotic central pancreatectomy

Central pancreatectomy (CP) is a parenchyma-sparing procedure that can be utilized in the resection of tumors of the neck or the proximal body of the pancreas. Among 872 open CP reported since 1993, the mean rate of morbidity was 43.2% and mean rate of mortality was 0.24%. The mean pancreatic fistula rate was 28%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 19%. The rate of development of post-operative diabetes mellitus was at 2% and the average incidence of exocrine insufficiency experienced by patients undergoing open CP was 4.4%. Also, the mean length of hospital stay was around 15 days. In comparison, a total of 100 patients underwent either laparoscopic or robotic CP with a mean rate of morbidity of 37.3% and mean rate of mortality of 0%. Also, the mean rate of development of pancreatic fistula was 36.6%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 17%. The rate of development of post-operative diabetes mellitus was at 1.5%. None of the patients included in these series developed any postoperative exocrine insufficiency. The mean length of hospital stay was around 13 days. Standard procedures such as DP and PD are associated with lower rates of short-term morbidity such as pancreatic fistula development but are also accompanied with a higher rate of long-term endocrine and exocrine insufficiency due to the significant loss of normal pancreatic parenchyma when compared to CP. It can be inferred, albeit from limited and small retrospective studies and case reports, that conventional and robotic-assisted laparoscopic approaches to CP are safe and feasible in highly specialized centers.

Minimally Invasive Approaches to Pancreatic Surgery

Minimally invasive techniques have the potential to revolutionize the surgical management of pancreatic disease in the setting of benign and malignant processes. Pancreatic surgery, in particular, may be aided significantly by minimal access surgery given the high morbidity associated with traditional open pancreatic procedures. This article presents a review of two minimally invasive techniques for distal pancreatectomy and pancreaticoduodenectomy, focusing on metrics of technique, safety, morbidity, and oncologic outcomes and potential benefits.

Minimally invasive central pancreatectomy and pancreatogastrostomy: current surgical technique and outcomes

Recent improvements in imaging techniques and more frequent use of cross-sectional imaging have led to an increase in the identification of benign and low-grade lesions of the pancreas. Patients with resectable cancers are commonly treated by either a Whipple procedure or distal pancreatectomy (DP) based on the location of the tumor. Central pancreatectomy (CP) is a less commonly performed operation that has recently been utilized for resection of these now more frequently diagnosed low-grade and benign lesions located in the mid pancreas. Lesions that may have a relatively more indolent nature include branch-type intraductal papillary mucinous neoplasm (IPMNs), mucinous cystic neoplasms, neuroendocrine tumors, and solid pseudopapillary tumors. The goal of a CP is complete extirpation of the lesion, while preserving pancreatic parenchyma to reduce the risks of developing diabetes and exocrine insufficiency (EI). Although open CP has been shown to be safe and efficacious, the outcomes of a minimally invasive approach are still relatively underreported and therefore unknown. In this paper, we describe our surgical approach to performing a CP with an accompanying video demonstration of the key portions of the operation.

Robotic pancreatectomies

Pancreatic surgery represents one of the most challenging fields in general surgery. Its complexity is related to the severity of the disease and the technical skills required for surgical approach. Given this, most pancreatic resections are performed through classic open surgery. Minimally invasive approaches are gradually gaining widespread popularity also in this specific setting, as for distal resections and enucleations. The robotic platform, due to its 3-dimensional vision and articulated movements, represents the natural progress of laparoscopic surgery overcoming the technical defaults and opening up the possibility to perform major pancreatic resections as pancreaticoduodenectomies. This review focuses on the impact of robotic platform in pancreatic surgery in terms of surgical and oncological outcome.

Laparoscopic long sleeve pancreaticogastrostomy (LPG): a novel pancreatic anastomosis following central pancreatectomy

BACKGROUND

Central pancreatectomy (CP) is preferred to distal pancreatectomy (DP) for the excision of benign tumours at the neck or body of the pancreas, in order to preserve pancreatic function and the spleen. However, the pancreaticoenterostomy is technically difficult to perform laparoscopically and the postoperative pancreatic fistula (POPF) rate is high.

METHODS

A novel laparoscopic reconstruction of the pancreatic stump during CP is described, the laparoscopic long sleeve pancreaticogastrostomy (LPG).

RESULTS

Two males and two females with a median age of 49 years had a laparoscopic CP with LPG. After a median follow-up of 27.5 months, there was no mortality. One patient had a grade A POPF, managed conservatively.

CONCLUSIONS

The LPG is a safe and technically less demanding method to reconstruct pancreatic drainage laparoscopically.

Minimally Invasive Surgery for Pancreatic Disease - Current Status

Laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. Although application in pancreatic surgery is hampered by the friable nature of the gland and the difficulty of its exposure, advanced technology and surgeons' experience are leading to an expansion of minimally invasive pancreatic surgery. Addressing the whole range of main operative procedures, this review analyzes the literature data so far to give an overview about the current status of minimally invasive pancreatic surgery, its indications and limitations. In acute pancreatitis, a step-up approach from percutaneous drainage to retroperitoneoscopic necrosectomy seems beneficial. Transgastric necrosectomy also preserves the retroperitoneal compartment in contrast to the laparoscopic approach, which has widely been abandoned. In tumor pathology, laparoscopic access is adequate for small benign lesions in the pancreatic tail and body. Oncological outcome shows to be at least equal to the open procedure. Concerning laparoscopic pancreaticoduodenectomy, there is no evidence for a patients' benefit currently although several studies prove that it can be done.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Minimally invasive surgical approach to pancreatic malignancies

Pancreatic surgery for malignancy is recognized as challenging for the surgeons and risky for the patients due to consistent perioperative morbidity and mortality. Furthermore, the oncological long-term results are largely disappointing, even for those patients who experience an uneventfully hospital stay. Nevertheless, surgery still remains the cornerstone of a multidisciplinary treatment for pancreatic cancer. In order to maximize the benefits of surgery, the advent of both laparoscopy and robotics has led many surgeons to treat pancreatic cancers with these new methodologies. The reduction of postoperative complications, length of hospital stay and pain, together with a shorter interval between surgery and the beginning of adjuvant chemotherapy, represent the potential advantages over conventional surgery. Lastly, a better cosmetic result, although not crucial in any cancerous patient, could also play a role by improving overall well-being and patient self-perception. The laparoscopic approach to pancreatic surgery is, however, difficult in inexperienced hands and requires a dedicated training in both advanced laparoscopy and pancreatic surgery. The recent large diffusion of the da Vinci(®) robotic platform seems to facilitate many of the technical maneuvers, such as anastomotic biliary and pancreatic reconstructions, accurate lymphadenectomy, and vascular sutures. The two main pancreatic operations, distal pancreatectomy and pancreaticoduodenectomy, are approachable by a minimally invasive path, but more limited interventions such as enucleation are also feasible. Nevertheless, a word of caution should be taken into account when considering the increasing costs of these newest technologies because the main concerns regarding these are the maintenance of all oncological standards and the lack of long-term follow-up. The purpose of this review is to examine the evidence for the use of minimally invasive surgery in pancreatic cancer (and less aggressive tumors), with particular attention to the oncological results and widespread reproducibility of each technique.

Minimally Invasive Techniques for Resection of Pancreatic Neuroendocrine Tumors

Surgical resection remains the treatment of choice for primary pancreatic neuroendocrine tumors (PNETs), because it is associated with increased survival. Minimally invasive procedures are a safe modality for the surgical treatment of PNETs. In malignant PNETs, laparoscopy is not associated with a compromise in terms of oncologic resection, and provides the benefits of decreased postoperative pain, better cosmetic results, shorter hospital stay, and a shorter postoperative recovery period. Further prospective, multicenter, randomized trials are required for the analysis of these minimally invasive surgical techniques for the treatment of PNETs and their comparison with traditional open pancreatic surgery.

Robotic spleen-preserving laparoscopic distal pancreatectomy: a single-centered Chinese experience

BACKGROUND

Spleen-preserving laparoscopic distal pancreatectomy is technically challenging. New surgical robotic systems are now available and show promising outcomes but were very recently implemented in China.

METHODS

Seven patients underwent laparoscopic distal pancreatectomy using the da Vinci Robotic System (RDP) for benign or borderline malignant pancreatic tumors. Spleen preservation rate, blood loss, and operative complications were assessed.

RESULTS

Mean age was 44.6 ± 13.7 years. Surgery was uneventful in all patients, without conversion to laparotomy. The surgical time (including anesthesia induction, robot docking, operation, and postoperative awaking time) was 460 ± 154 min, while the operation time was 368 ± 126 min. Blood losses were 200 ± 110 mL. The minor (Clavien I+II) complication rate was 14.3%, and the major (Clavien III+IV) complication rate was 14.3 %, including hemorrhage and pancreatic leakage. The spleen preservation rate was 100%. All complications were successfully managed and cured. Intraoperative laparoscopic ultrasound examination successfully identified the correct surgical resection margins. Mean postoperative hospitalization was 8.7 ± 6.6 days. No patient had to undergo a second pancreas surgery. Patients were followed up for a median of 6.8 months (range, 6 to 22 months). All patients survived and reported few discomforts.

CONCLUSIONS

RDP is feasible and allows the preservation of the splenic vessels.

Laparoscopic distal pancreatectomy for adenocarcinoma: safe and reasonable?

As a result of technological advances during the past two decades, surgeons now use minimally invasive surgery (MIS) approaches to pancreatic resection more frequently, yet the role of these approaches for pancreatic ductal adenocarcinoma resections remains uncertain, given the aggressive nature of this malignancy. Although there are no controlled trials comparing MIS technique to open surgical technique, laparoscopic distal pancreatectomy for pancreatic adenocarcinoma is performed with increasing frequency. Data from retrospective studies suggest that perioperative complication profiles between open and laparoscopic distal pancreatectomy are similar, with perhaps lower blood loss and fewer wound infections in the MIS group. Concerning oncologic outcomes, there appear to be no differences in the rate of achieving negative margins or in the number of lymph nodes (LNs) resected when compared to open surgery. There are limited recurrence and survival data on laparoscopic compared to open distal pancreatectomy for pancreatic adenocarcinoma, but in the few studies that assess long term outcomes, recurrence rates and survival outcomes appear similar. Recent studies show that though laparoscopic distal pancreatectomy entails a greater operative cost, the associated shorter length of hospital stay leads to decreased overall cost compared to open procedures. Multiple new technologies are emerging to improve resection of pancreatic cancer. Robotic pancreatectomy is feasible, but there are limited data on robotic resection of pancreatic adenocarcinoma, and outcomes appear similar to laparoscopic approaches. Additionally fluorescence-guided surgery represents a new technology on the horizon that could improve oncologic outcomes after resection of pancreatic adenocarcinoma, though published data thus far are limited to animal models. Overall, MIS distal pancreatectomy appears to be a safe and reasonable approach to treating selected patients with pancreatic ductal adenocarcinoma, though additional studies of long-term oncologic outcomes are merited. We review existing data on MIS distal pancreatectomy for pancreatic ductal adenocarcinoma.

Minimally invasive pancreatic surgery - a review

During the past 20 years the application of a minimally invasive approach to pancreatic surgery has progressively increased. Distal pancreatectomy is the most frequently performed procedure, because of the absence of a reconstructive phase. However, middle pancreatectomy and pancreatoduodenectomy have been demonstrated to be safe and feasible as well. Laparoscopic distal pancreatectomy is recognized as the gold standard treatment for small tumors of the pancreatic body-tail, with several advantages over the traditional open approach in terms of patient recovery. The surgical treatment of lesions of the pancreatic head via a minimally invasive approach is still limited to a few highly experienced surgeons, due to the very challenging resection and complex anastomoses. Middle pancreatectomy and enucleation are indicated for small and benign tumors and offer the maximum preservation of the parenchyma. The introduction of a robotic platform more than ten years ago increased the interest of many surgeons in minimally invasive treatment of pancreatic diseases. This new technology overcomes all the limitations of laparoscopic surgery, but actual benefits for the patients are still under investigation. The increased costs associated with robotic surgery are under debate too. This article presents the state of the art of minimally invasive pancreatic surgery.

State of the art of robotic pancreatic surgery

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.

Laparoscopic middle pancreatectomy: how do I do it?

BACKGROUND

Although laparoscopic surgery is now extensively used, laparoscopic middle pancreatectomy (LMP) has rarely been described.

STUDY DESIGN AND METHODS

A 45-year-old woman was diagnosed with branch duct intraductal papillary mucinous neoplasia (IPMN) at the pancreatic neck, which was discovered after numerous attacks of acute pancreatitis. LMP was decided on for treatment.

RESULTS

The patient underwent pure LMP with right to left dissection and one-layer pancreatogastric anastomosis. Surgery lasted 160 minutes, with 20 mL of blood loss. A frozen section showed negative margins on both sides. The postoperative course was uneventful with 15 days in the hospital. Histology confirmed the diagnosis of branch duct IPMN with moderate dysplasia and negative margins. The patient is symptom free 6 months after surgery.

CONCLUSIONS

Our results and the data in the literature suggest that the laparoscopic approach is indicated for middle pancreatectomy because there are no technical or oncological contraindications and the outcome is similar to that with the open approach.

Laparoscopic pancreatic reconstruction technique following laparoscopic pancreaticoduodenectomy

With the advance of laparoscopic experiences and techniques, it is carefully regarded that laparoscopic pancreaticoduodenectomy (lap-PD) is feasible and safe in managing perimapullary pancreatic pathology. Especially, laparoscopic management of remnant pancreas can be a critical step toward completeness of minimally invasive PD. According to available published reports, there is a wide range of technical differences in choosing surgical options in managing remnant pancreas after lap-PD. For the evidence-based surgical approach, it would be ideal to test potential techniques by randomized controlled trials, but, currently, it is thought to be very difficult to expect those clinical trials to be successful because there are still a lack of expert surgeons with sound surgical techniques and experience. In addition, lap-PD is so complicated and technically demanding that many surgeons are still questioning whether this surgical approach could be standardized and popular like laparoscopic cholecystectomy. In general, surgical options are usually chosen based on following question: (1) Is it simple? (2) Is it easy and feasible? (3) Is it secure and safe? (4) Is there any supporting scientific evidence? It would be interesting to estimate which surgical technique would be appropriate in managing remnant pancreas under these considerations. It is hoped that a well standardized multicenter-based randomized control study would be successful to test this fundamental issues based on sound surgical techniques and scientific background.

Central pancreatectomy: the Dagradi Serio Iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach

Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure. The aims are to clarify the history and the development of CP and to give credits to those from whom it came. Ehrhardt, in 1908, described segmental neck resection (SNR) followed, in 1910, by Finney without reconstructive part. In 1950 Honjyo described two cases of SNR combined with gastrectomy for gastric cancer infiltrating the neck of the pancreas. Guillemin and Bessot (1957) and Letton and Wilson (1959) dealt only with the reconstructive aspect of CP. Dagradi and Serio, in 1982, performed the first CP including the resective and reconstructive aspects. Subsequently Iacono has validated it with functional endocrine and exocrine tests and popularized it worldwide. In 2003, Baca and Bokan performed laparoscopic CP and, In 2004, Giulianotti et al performed a robotic assisted CP. CP is performed worldwide either by open surgery or by using minimally-invasive or robotic approaches. This confirms that the operation does not belong to whom introduced it but to everyone who carries out it; however credit must be given to those from whom it came.

Prognostic markers in early-stage colorectal cancer: significance of TYMS mRNA expression

BACKGROUND

Several studies have recently indicated the prognostic or predictive role of several biomarkers in colorectal cancer. We sought to investigate the prognostic value of prostaglandin synthase 2 (PTGS2), cyclooxygenase 2 (COX2), thymidylate synthetase (TYMS), thymidine phosphorylase (TYMP), dihydropyrimidine dehydrogenase (DPYD) and topoisomerase I (TOPO1) in colorectal cancer patients treated with 5-FU-based regimens, such as De Gramont and FOLFOX in the adjuvant setting.

MATERIALS AND METHODS

In total, 96 formalin-fixed paraffin-embedded and 30 fresh-frozen tumor tissue samples were evaluated using immunohistochemistry, quantitative reverse transcription-polymerase chain reaction and microarray gene expression profiling, respectively.

RESULTS

The majority of tumors exhibited protein overexpression of COX2 (69%), TYMS (75%) and TOPO1 (75%). There was a significant association of TYMP protein expression with T classification, gender and stage (p=0.040, p=0.041 and p=0.011, respectively). TOPO1 protein expression was correlated with TOPO1 mRNA expression and was positively associated with stage (p=0.002) and lymph node infiltration (p=0.004). In univariate analysis, patients with high TYMS mRNA expression were shown to have a significantly lower risk for progression and death (Wald's p=0.030 and p=0.015, respectively). However, in multivariate analysis, only a trend for decreased risk for death was shown in patients with high TYMS mRNA expression (Wald's p=0.083), while patients with high PTGS2 mRNA expression had a trend for lower risk for progression (p=0.064). Using supervised hierarchical clustering, based on the expression in fresh-frozen tumor tissue of PTGS2, TYMS, TYMP and DPYD, our 30 patients were separated into two clusters. One of the clusters was enriched with patients with infiltrated lymph nodes (p<0.05), suggesting that these genes might have an impact on the tumor's ability to metastasize.

CONCLUSION

These findings indicate a possible prognostic role of TYMS mRNA expression and highlight a cluster of genes associated with nodal metastases that warrant further investigation in a larger cohort of patients with colorectal cancer treated with 5-FU-based adjuvant chemotherapy.

The state of the art of robotic pancreatectomy

During the last decades an increasing number of minimally invasive pancreatic resections have been reported in the literature. With the development of robotic surgery a new enthusiasm has not only increased the number of centers approaching minimally invasive pancreatic surgery in general but also enabled the use of this technique for major pancreatic procedures, in particular in minimally invasive pancreatoduodenectomy. The aim of this review was to define the state of the art of pancreatic robotic surgery. No prospective randomized trials have been performed comparing robotic, laparoscopic, and open pancreatic procedures. From the literature one may conclude that robotic pancreatectomies seem to be as feasible and safe as open procedures. The general idea that the overall perioperative costs of robotic surgery would be higher than traditional procedures is not supported. With the current lack of evidence of any oncologic advantages, the cosmetic benefits offered by robotic surgery are not enough to justify extensive use in cancer patients. In contrast, the safety of these procedure can justify the use of the robotic technique in patient with benign/low grade malignant tumors of the pancreas.

Robotic pancreatic surgery is no substitute for experience and clinical judgment: an initial experience and literature review

Robotic pancreatic surgery offers technical advantages, and has been applied across many surgical specialties. We report an initial experience of 12 distal pancreatic resections for benign tumors from an established pancreatic center with previous general and biliary laparoscopic experience. Of a total of 12 patients, 7 were women; the mean age was 55.5 years, and the lesions included 8 distal intraductal papillary mucinous tumors, 1 insulinoma and in 3 a non-functioning neuroendocrine tumor. All operations were performed in between 90 and 180 minutes, and blood loss and hospital stay were minimal.

Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy

BACKGROUND

Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure that enables the removal of benign and/or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this review was to evaluate the short- and long-term surgical results of CP from all published studies, and the results of comparative studies of CP versus distal pancreatectomy (DP).

METHODS

Eligible studies published between 1988 and 2010 were reviewed systematically. Comparisons between CP and DP were pooled and analysed by meta-analytical techniques using random- or fixed-effects models, as appropriate.

RESULTS

Ninety-four studies, involving 963 patients undergoing CP, were identified. Postoperative morbidity and pancreatic fistula rates were 45·3 and 40·9 per cent respectively. Endocrine and exocrine pancreatic insufficiency was reported in 5·0 and 9·9 per cent of patients. The overall mortality rate was 0·8 per cent. Compared with DP, CP had a higher postoperative morbidity rate and a higher incidence of pancreatic fistula, but a lower risk of endocrine insufficiency (relative risk (RR) 0·22, 95 per cent confidence interval 0·14 to 0·35; P < 0·001). The risk of exocrine failure was also lower after CP, although this was not significant (RR 0·59, 0·32 to 1·07; P = 0·082).

CONCLUSION

CP is a safe procedure with good long-term functional reserve. In situations where DP represents an alternative, CP is associated with a slightly higher risk of early complications.

Robotic-assisted minimally invasive central pancreatectomy: technique and outcomes

BACKGROUND

Central pancreatectomy is a definitive treatment for low-grade tumors of the pancreatic neck that preserves pancreatic and splenic function at the potential expense of postoperative pancreatic fistula. We analyzed outcomes after robot-assisted central pancreatectomy (RACP) to reexamine the risk-benefit profile in the era of minimally invasive surgery.

METHODS

Retrospective analysis of nine RACP performed between August 2009 through June 2010 at a single institution.

RESULTS

The average age of the cohort was 64 (range 18-75 years) with six women (67 %). Indications for surgery included: five benign cystic neoplasm and four pancreatic neuroendocrine tumor. Median operative time was 425 min (range 305-506 min) with 190 ml median blood loss (range 50-350 ml) and one conversion to open due to poor visualization. Median tumor size was 3.0 cm (range 1.9-6.0 cm); all patients achieved R0 status. Pancreaticogastrostomy was performed in seven cases and pancreaticojejunostomy in two. The median length of hospital stay was 10 days (range 7-19). Two clinically significant pancreatic fistulae occurred with one requiring percutaneous drainage. No patients exhibited worsening diabetes or exocrine insufficiency at the 30-day postoperative visit.

CONCLUSIONS

RACP can be performed with safety and oncologic outcomes equivalent to published open series. Although the rate of pancreatic fistula was high, only 22 % had clinically significant events, and none developed worsening pancreatic endocrine or exocrine dysfunction.

Initial experiences in robot-assisted middle pancreatectomy

OBJECTIVES

Initial results in robot-assisted middle pancreatectomy (MP) have been encouraging. However, data comparing outcomes of robot-assisted MP with those of open MP are limited. The aim of this study was to compare outcomes in patients undergoing open and robot-assisted MP, respectively.

METHODS

Outcomes in an initial experience with seven consecutive patients undergoing robot-assisted MP were compared with those in 36 patients undergoing open MP.

RESULTS

The robot-assisted MP group included five women and two men with a median age of 55 years (range: 30-62 years). Median tumour size, operative time and blood loss were 3.0 cm (range: 0.5-5.0 cm), 210 min (range: 150-330 min) and 200 ml (range: 50-400 ml), respectively. Pancreaticogastrostomy was performed in all patients. No transfusion was given intraoperatively. Pathological examination revealed five serous cystic neoplasms, one mixed-type intraductal papillary mucinous neoplasm and one lipoma. Five patients experienced postoperative pancreatic fistula and one experienced post-pancreatectomy haemorrhage. No operative mortality was noted. Compared with the open MP group, the robot-assisted MP group demonstrated a shorter median length of postoperative gastrointestinal tract recovery [2 days (range: 2-3 days) versus 4 days (range: 2-11 days); P = 0.001].

CONCLUSIONS

Robot-assisted MP can be performed safely with satisfactory efficacy; patients experienced faster gastrointestinal tract recovery compared with patients undergoing open surgery.