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

Minimally Invasive Pancreatectomy: Robotic and Laparoscopic Developments

Minimally invasive pancreatectomy is increasingly used. Although offering potential advantages over open approaches, minimally invasive pancreatectomy has many challenges to maintain high-quality of oncologic resection. Multiple patient and surgical factors should be considered in planning laparoscopic or robotic resection, including the learning curve required to produce proficiency. For pancreaticoduodenectomy, distal pancreatectomy, and other pancreatic resections, a safe, margin-negative resection remains the goal. National and societal guidelines for the adoption of minimally invasive pancreatectomy are ongoing and will continue to be important as these techniques are further adopted.

Hand-Assisted Versus Pure Minimally-Invasive Distal Pancreatectomy: Is There a Downside to Lending a Hand?

BACKGROUND

Hand-assisted laparoscopic distal pancreatectomy (HALDP) is suggested to offer similar outcomes to pure laparoscopic distal pancreatectomy (LDP). However, given the longer midline incision, it is unclear whether HALDP increases the risk of postoperative hernia. Our aim was to determine the risk of postoperative incisional hernia development after HALDP.

METHODS

We retrospectively collected data from patients undergoing HALDP or LDP at a single center (2012-2020). Primary endpoints were postoperative incisional hernia and operative time. All patients had at minimum six months of follow-up. Outcomes were compared using unadjusted and multivariable regression analyses.

RESULTS

Ninety-five patients who underwent laparoscopic distal pancreatectomy were retrospectively identified. Forty-one patients (43%) underwent HALDP. Patients with HALDP were older (median, 67 vs. 61 years, p = 0.02). Sex, race, Body Mass Index (median, 27 vs. 26), receipt of neoadjuvant chemotherapy, gland texture, wound infection rates, postoperative pancreatic fistula, overall complications, and hospital length-of-stay were similar between HALDP and LDP (all p > 0.05). In unadjusted analysis, operative times were shorter for HALDP (164 vs. 276 min, p < 0.001), but after adjustment, did not differ significantly (MR 0.73; 0.49-1.07, p = 0.1). Unadjusted incidence of hernia was higher in HALDP versus LDP (60% vs. 24%, p = 0.004). After adjustment, HALDP was associated with an increased odds of developing hernia (OR 7.52; 95% CI 1.54-36.8, p = 0.014). After propensity score matching, odds of hernia development remained higher for HALDP (OR 4.62; 95% CI 1.28-16.65, p = 0.031) p = 0.03).

CONCLUSIONS

Compared with LDP, HALDP was associated with increased likelihood of postoperative hernia with insufficient evidence that HALDP shortens operative times. Our results suggest that HALDP may not be equivalent to LDP.

Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula

BACKGROUND

Risk factors for postoperative pancreatic fistula (POPF) following pancreatic enucleation by the open approach (OpenEN) are well known. However, ENs are more frequently performed laparoscopically (LapEN). The aim of this study was to analyze the risk factors of POPF following LapEN.

METHODS AND PATIENTS

All patients in our prospective database who underwent LapEN were evaluated. We report the demographics, surgical, early and long-term outcomes. Numerous variables were analyzed to identify the risk factors of POPF.

RESULTS

From 2008 to 2020, 650 laparoscopic pancreatic resections were performed including 64 EN (10%). The median age was 51 years old (17-79), median BMI was 24 (19-48), and 44 patients were women (69%). The main presentation was an incidental diagnosis (n = 40; 62%), pain (n= 10;16%), and hypoglycemia (n = 8;12%). The main indications were neuroendocrine tumors (40; 63%), mucinous cystadenomas (15; 23%), intraductal papillary mucinous neoplasie (3; 5%), and other benign cysts (6; 9%). Lesions were located on the distal pancreas (43; 67%), head (n = 17; 27%), and neck (4; 6%). The median size was 20 mm (9-110); 30 mm (20-110) for mucinous cystadenoma and 18 mm (8-33) for NET. The median operative time was 90 mn (30-330), median blood loss was 20 ml (0-800) ml, and there were no transfusions and one conversion. There were no mortalities and overall morbidity (n = 22; 34%) included grades B and C POPF (10;16%) and post-pancreatectomy hemorrhage (4; 6%). The median hospital stay was 7 days (3-42). There were no invaded lymph nodes and all cystic lesions were nonmalignant. After a mean follow-up of 24 months, there was no recurrence. The risk factors for grades B/C POPF were mucinous cystadenoma and proximity to the Wirsung duct < 3 mm.

CONCLUSION

In this series, the outcome of LapEN was excellent with no mortality and a low rate of morbidity. However, the risk of POPF is increased with cystic lesions and those close to the Wirsung duct.

Central pancreatectomy for benign or low-grade malignant pancreatic tumors in the neck and body of the pancreas

BACKGROUND

For tumors in the neck and body of the pancreas, distal pancreatectomy (DP) has been the standard surgical procedure for the last few decades and central pancreatectomy (CP) is an alternative surgical option. Whether CP better preserves remnant pancreatic endocrine and exocrine functions after surgery remains a subject of debate.

AIM

To evaluate the safety and efficacy of CP compared with DP for benign or low-grade malignant pancreatic tumors in the neck and body of the pancreas.

METHODS

This retrospective study enrolled 296 patients who underwent CP or DP for benign and low-malignant neoplasms at the same hospital between January 2016 and March 2020. Perioperative outcomes and long-term morbidity of endocrine/exocrine function were prospectively evaluated.

RESULTS

No significant difference was observed in overall morbidity or clinically relevant postoperative pancreatic fistula between the two groups (P = 0.055). Delayed gastric emptying occurred more frequently in the CP group than in the DP group (29.4% vs 15.3%; P < 0.005). None of the patients in the CP group had new-onset or aggravated distal metastasis, whereas 40 patients in the DP group had endocrine function deficiency after surgery (P < 0.05). There was no significant difference in the incidence of diarrhea immediately after surgery, but at postoperative 12 mo, a significantly higher number of patients had diarrhea in the DP group than in the CP group (0% vs 9.5%; P < 0.05).

CONCLUSION

CP is a generally safe procedure and is better than DP in preserving long-term pancreatic endocrine and exocrine functions. Therefore, CP might be a better option for treating benign or low-grade malignant neoplasms in suitable patients.

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.

Usefulness of Inflammation-Based Prognostic Scores in Patients with Surgically Treated Pancreatic Ductal Adenocarcinoma

In this study, we evaluated the prognostic value of inflammation-based prognostic scores in patients undergoing curative surgery for pancreatic ductal adenocarcinoma (PDAC). A retrospective analysis was conducted for 914 patients undergoing curative surgical resection for PDAC between January 2011 and April 2016. Inflammation-based scores of modified Glasgow Prognostic Score (mGPS), neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio were assessed. mGPS was classified as high (1 or 2) or low (0). Median age was 63 (range, 33–88) years; 538 patients (58.9%) were male. A high mGPS was independently associated with poor overall survival (OS) and disease-free survival (DFS) (median OS: 25.4 months vs. 20.4 months, p = 0.001; median DFS: 11.6 months vs. 9.3 months, p = 0.002), poor OS in patients with TNM stage I PDAC (44 months vs. 24.8 months, p = 0.001), and poor OS and DFS in patients with tumors located at the pancreatic head or uncinate process (OS: 25.4 months vs. 20.4 months; p = 0.007, DFS: 11.4 months vs. 8.87 months; p = 0.005). Preoperative mGPS was a significant prognostic factor for PDAC after curative resection; thus, mGPS can be a useful prognostic predictive factor in patients with TNM stage I PDAC, especially for tumors located at the head and uncinate.

Enhanced recovery after surgery: operation-related factors

Background: The enhanced recovery after surgery (ERAS) program, which has been recently introduced in the field of perioperative care, represents a multimodal strategy to attenuate the loss, and improve the restoration, of functional capacity after surgery. This program aims to reduce morbidity and enhance recovery by reducing surgical stress, optimizing pain control, and facilitating early resumption of an oral diet and early mobilization. Considering this perspective, protocols for enhanced recovery should include comprehensive and evidence-based guidelines for best perioperative care. Appropriate protocol implementation may reduce complication rates and enhance functional recovery and thereby reduce the duration of hospitalization.Current Concepts: In major abdominal surgeries, the recommended ERAS protocols involve common items such as preoperative counseling, preoperative optimization, prehabilitation, preoperative nutrition, fasting and carbohydrate loading, bowel preparation, thromboprophylaxis, antimicrobial prophylaxis, surgical access, drainage, nasogastric intubation, urinary drainage, early mobilization and prevention of postoperative ileus, postoperative glycemic control, and postoperative nutritional care. These items have been briefly reviewed with the relevant evidence.Discussion and Conclusion: ERAS is a comprehensive and evidence-based guideline for optimal perioperative care. Although a number of ERAS items still require high-level evidence through well-designed randomized controlled trials, the ERAS guidelines can serve as adequate recommendations for our practice. Thus, these items can be introduced and adopted with evidence. In addition, it is important to remove items that are not supported by evidence from routine procedures.

Laparoscopic pancreatectomy for benign or low-grade malignant pancreatic tumors: outcomes in a single high-volume institution

OBJECTIVE

To investigate the perioperative and long-term outcomes of laparoscopic pancreatectomy for benign and low-grade malignant pancreatic tumors, and further compare the outcomes between different surgical techniques.

METHODS

We retrospectively collected clinical data of consecutive patients with benign or low-grade malignant pancreatic tumors underwent surgery from February 2014 to February 2019. Patients were grouped and compared according to different surgical operations they accepted.

RESULTS

Totally 164 patients were reviewed and 83 patients underwent laparoscopic pylorus-preserving pancreaticoduodenectomy (LPPPD), 41 patients underwent laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and 20 patients underwent laparoscopic central pancreatectomy (LCP) were included in this study, the rest 20 patients underwent laparoscopic enucleation were excluded. There were 53 male patients and 91 female patients. The median age of these patients was 53.0 years (IQR 39.3-63.0 years). The median BMI was 21.5 kg/m² (IQR 19.7-24.0 kg/m²). The postoperative severe complication was 4.2% and the 90-days mortality was 0. Compare with LCP group, the LPPPD and LSPDP group had longer operation time (300.4 ± 89.7 vs. 197.5 ± 30.5 min, P < 0.001) while LSPDP group had shorter operation time (174.8 ± 46.4 vs. 197.5 ± 30.5 min, P = 0.027), more blood loss [140.0 (50.0-1000.0) vs. 50.0 (20.0-200.0) ml P < 0.001 and 100.0 (20.0-300.0) vs. 50.0 (20.0-200.0 ml, P = 0.039, respectively), lower rate of clinically relevant postoperative pancreatic fistula [3 (3.6%) vs. 8 (40.0%), P < 0.001 and 3 (7.3%) vs. 8 (40.0%), P = 0.006, respectively], lower rate of postpancreatectomy hemorrhage [0 (0%) vs. 2 (10.0%), P = 0.036 and (0%) vs. 2 (10.0%) P = 0.104, respectively] and lower rate of postoperative severe complications [2 (2.4%) vs.4 (20.0%), P = 0.012 and 0 (0%) vs. 4 (20.0%), P = 0.009, respectively], higher proportion of postoperative pancreatin and insulin treatment (pancreatin: 39.8% vs., 15% P = 0.037 and 24.4%vs. 15%, P = 0.390; insulin: 0 vs. 18.1%, P = 0.040 and 0 vs. 12.2%, P = 0.041).

CONCLUSIONS

Overall, laparoscopic pancreatectomy could be safely performed for benign and low-grade malignant pancreatic tumors while the decision to perform laparoscopic central pancreatectomy should be made carefully for fit patients who can sustain a significant postoperative morbidity and could benefit from the excellent long-term results even in a high-volume center.

Surgical outcomes are hampered after endoscopic ultrasonography-guided ethanol lavage and/or Taxol injection in cystic lesions of the pancreas

Backgrounds/Aims

Endoscopic ultrasonography-guided ethanol lavage and Taxol injection (EUS-ELTI) for pancreatic cystic lesions have been recently performed in some medical centers. The aim of this study was to optimize patient selection and analyze outcomes of patients who underwent surgeries after EUS-ELTI for pancreatic cystic lesions.

Methods

Among 310 patients who underwent EUS-ELTI between January 2007 and December 2014, 23 underwent surgeries after EUS-ELTI owing to incomplete treatment and/or adverse events. Surgical outcomes of patients who underwent surgeries after EUSELTI were evaluated. Clinical outcomes of patients who underwent surgeries after EUS-ELTI were then retrospectively compared with those of patients who underwent upfront surgery for left-sided pancreatic lesions without an EUS-ELTI procedure.

Results

The pathology revealed degenerated cysts in 12 patients, mucinous cyst neoplasms in five, neuroendocrine tumors in two, intraductal papillary mucinous neoplasm (IPMN) in one, solid pseudopapillary tumor in one, pancreatic ductal adenocarcinoma arising from an IPMN in one, and hepatoid carcinoma in one. Twelve patients underwent laparoscopic distal pancreatectomy and five patients underwent open distal pancreatectomy. When clinical outcomes were retrospectively compared between patients who underwent laparoscopic distal pancreatectomy after EUS-ELTI and those who did not receive an EUS-ELTI procedure, the spleen-preserving rate was 0% in the EUS-ELTI group and 61.7% (365/592) in the control group (p < 0.001).

Conclusions

Surgical outcomes are compromised after EUS-ELTI for cystic tumor of the pancreas. Further studies are needed to investigate the efficacy and safety of the EUS-ELTI procedure.

Assessment of difficulty in laparoscopic distal pancreatectomy: A modification of the Japanese difficulty scoring system - A single-center high-volume experience

Background

The Japanese difficulty scoring system (DSS) was developed to assess the difficulty of laparoscopic distal pancreatectomy (LDP). The study aimed to validate a modified DSS (mDSS) in a European high‐volume center.

Methods

Patients' clinical data underwent LDP for benign and malignant pancreatic lesion between September 2013 and February 2020 were reviewed. Expert laparoscopic surgeons performed the procedures. The mDSS consisted of seven variables, such as type of operation, malignancy, neoadjuvant therapy, pancreatic resection line, tumor close to major vessels, tumor extension to peripancreatic tissue, and left‐sided portal hypertension and/or splenomegaly. According to the difficulty level and previous score, the mDSS was subdivided into three classes: low, intermediate, and high. Surrogates of case complexity (operative time, intraoperative blood loss and blood transfusion requirements, conversion rate) were used to validate the new scoring system.

Results

The study population included 140 LDP. Ninety‐five (68%), 35 (25%) and 10 (7%) patients belonged to low, intermediate, and high difficulty groups. The mDSS identified the complexity of the surgical case of the series for all the surrogates of complexity considered, namely conversion rate (P = .004), operative time (P = .033) and intraoperative blood loss (P = .009). No differences were recorded in the postoperative outcomes (P > .05).

Conclusion

The mDSS for LDP better stratified the pancreatic procedures according to their complexity. The new scoring system may allow an appropriate preoperative evaluation of surgical difficulty, facilitating LDP's training program. Future prospective studies are needed to validate the mDSS.

A comparison of minimally invasive vs open distal pancreatectomy for resectable pancreatic ductal adenocarcinoma: Propensity score matching analysis

BACKGROUND

Owing to concerns regarding adequate oncological outcomes and perioperative complications, minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC) has limited generalizability. The aim of this study was to assess the perioperative and oncologic outcomes of MIDP compared with open distal pancreatectomy (ODP) for resectable PDAC after propensity score matching (PSM).

METHODS

The patients who underwent MIDP and ODP for PDAC between January 2010 and December 2017 were retrospectively reviewed. Demographics, perioperative outcomes, pathological outcomes, and overall and disease-free survival data were collected to compare MIDP and ODP. After PSM, perioperative and oncologic outcomes were analyzed.

RESULTS

A total of 156 MIDP patients were compared with 156 ODP patients for resectable PDAC after PSM. Tumor size, TNM stage, differentiation, harvested lymph nodes, and positive lymph nodes were not different except for R1 resection and lymphovascular invasion between the MIDP and ODP groups. Operation times, overall complications, POPF, and adjuvant treatment were also not different between the two groups. The MIDP group had shorter hospital stays (10.0 vs 13.4 days, P < 0.001) and shorter interval times from surgery to adjuvant treatment (37.6 days vs 46.0 days, P = 0.002) than the ODP group. The MIDP group had better overall survival (34.9 vs 24.5 months, P = 0.012) and disease-free survival (16.2 vs 10.3 months, P = 0.001).

CONCLUSION

Minimally invasive distal pancreatectomy has advantages with respect to postoperative hospital stay, interval between surgery, and adjuvant treatment. MIDP is associated with the possibility of improved survival rate for resectable PDAC.

Effect of Flowable Thrombin-Containing Collagen-Based Hemostatic Matrix for Preventing Pancreatic Fistula after Pancreatectomy: A Randomized Clinical Trial

Background: The aim of this study was to evaluate the safety and efficacy of a flowable hemostatic matrix, and their effects for postoperative pancreatic fistula (POPF) after pancreatectomy. Methods: This was a randomized, clinical, single-center, single-blind (participant), non-inferiority, phase IV, and parallel-group trial. The primary endpoint was the incidence of POPF. The secondary endpoints were risk factors for POPF, drain removal days, incidence of complication, 90-day mortality, and length of hospital stay. Results: This study evaluated a total of 53 patients, of whom 26 patients were in the intervention group (flowable hemostatic matrix) and 27 patients were in the control group (thrombin-coated collagen patch). POPF was more common in the control group than in the intervention group (59.3% vs. 30.8%, p = 0.037). Among participants who underwent distal pancreatectomy, POPF (33.3% vs. 92.3%, p = 0.004), and clinically relevant POPF (8.3% vs. 46.2%, p = 0.027) was more common in the control group. A multivariate logistic regression model identified flowable hemostatic matrix use as an independent negative risk factor for POPF, especially in cases of distal pancreatectomy (DP) (odds ratio 17.379, 95% confidential interval 1.453–207.870, p = 0.024). Conclusion: Flowable hemostatic matrix application is a simple, feasible, and effective method of preventing POPF after pancreatectomy, especially for patients with DP. Non-inferiority was demonstrated in the efficacy of preventing POPF in the intervention group compared to the control group.

Predictive Factors Associated with Complications after Laparoscopic Distal Pancreatectomy

Although laparoscopic distal pancreatectomy (LDP) has become more popular, the postoperative complication rate remains high. We sought to identify the risk factors for post-LDP complications. We examined 1227 patients who underwent LDP between March 2005 and December 2015 at a single large-volume center. We used logistic regression for the analysis. The overall (13.2%) and major (3.3%) complication rates were determined. Postoperative pancreatic fistula was the most frequent complication, and 58 patients (4.7%) had clinically significant (grade B) pancreatic fistulas. No 90-day mortality was recorded. Long operative time (≥200 min), large estimated blood loss (≥320 mL), LDP performed by an inexperienced surgeon (<50 cases), and concomitant splenectomy were identified as risk factors for overall complications using a logistic regression model. For major complications, male sex (p = 0.020), long operative time (p = 0.005), and LDP performed by an inexperienced surgeon (p = 0.026) were significant predictive factors. Using logistic regression analysis, surgery-related factors, including long operative time and LDP performed by an inexperienced surgeon, were correlated with overall and major complications of LDP. As LDP is a technically challenging procedure, surgery-related variables emerged as the main risk factors for postoperative complications. Appropriate patient selection and sufficient surgeon experience may be essential to reduce the complications of LDP.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection

OBJECTIVE

The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).

SUMMARY BACKGROUND DATA

MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking.

METHODS

The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.

RESULTS

After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.

CONCLUSION

The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

How to train and evaluate minimally invasive pancreas surgery

Training for minimally invasive pancreas surgery is critical as an evolving body of literature supports its use with acceptable outcomes during training and improved short term outcomes following completion. Although case volume needed to achieve mastery remains unclear, improved outcomes for both laparoscopic and robotic pancreatectomy are demonstrated following a learning curve and inflection point. Therefore, dedicated training curricula for both laparoscopic and robotic pancreatectomy have been developed to mitigate this learning curve and improve outcomes.

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

Background

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

Methods

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

Results

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

Conclusions

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

Robotic versus laparoscopic distal pancreatectomy for left-sided pancreatic tumors: a single surgeon's experience of 228 consecutive cases

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) has gained popularity for the treatment of left-sided pancreatic tumors. Robotic systems represent the most recent advancement in minimally invasive surgical treatment for such tumors. Theoretically, robotic systems are considered to have several advantages over laparoscopic systems. However, there have been few studies comparing both systems in the treatment of distal pancreatectomy. We compared perioperative and oncological outcomes between the two treatment modalities.

METHODS

A retrospective analysis was conducted of all consecutive minimally invasive distal pancreatectomy cases performed by a single surgeon at a high-volume center between January 2015 and December 2017.

RESULTS

The analysis included 228 consecutive patients (LDP, n = 182; Robotic-assisted laparoscopic distal pancreatectomy [R-LDP], n = 46). Operative time was significantly longer in the R-LDP group than in the LDP group (166.4 vs. 140.7 min; p = 0.001). In a subgroup analysis of patients who underwent the spleen-preserving approach, the spleen preservation rate associated with R-LDP was significantly higher than that associated with LDP (96.8% vs. 82.5%; p = 0.02). In another subgroup analysis of patients with pancreatic cancer, there were no significant differences in median overall and disease-free survival between the two groups.

CONCLUSIONS

R-LDP is a safe and feasible approach with perioperative and oncological outcomes comparable to those of LDP. R-LDP offers an added technical advantage that enables the surgeon to perform a complex procedure with good ergonomic comfort.

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Laparoscopic Distal Pancreatectomy: Our Experience in a Tertiary Referral Center

BACKGROUND

Despite an increase in the number of laparoscopic distal pancreatectomy (LDP) procedures being performed, the long-term oncology and operative results are still unclear. The aim of this study was to present the surgical and long-term results of patients undergoing LDP for the treatment of distal pancreatic tumors.

MATERIALS AND METHODS

A retrospective review was made of patients who underwent LDP in our clinic, between 2006 and 2018, and who were diagnosed with pancreas tail, neck, and corpus tumors. For the purposes of this study, the data related to the preoperative, operative, and postoperative characteristics of the patients were determined.

RESULTS

A total of 46 patients were identified as suitable for inclusion in the study. Of these, 52.1% were female individuals, and the average age of the whole group was 63 years. Previous surgery for malignant diseases was recorded for 54.3% of the patients, due to premalignant diseases in 13% and benign diseases in 32.7%. On average, 10 lymph nodes were removed from patients diagnosed with malignant tumors. The conversion rate was found to be 2.1%. The postoperative pancreatic fistula rate was 26%, and there was 1 complication each of grades III and IV according to the Clavien-Dindo classification. The mortality rate was 0%.

CONCLUSIONS

It was concluded that LDP of distal pancreas tumors seems to be both safe and effective in respect of the long-term results in addition to the early results of the operation.

True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is generally the treatment of choice for diseases of the pancreatic body and tail. Most surgeons prefer the spleen- and splenic vessel-preserving technique (SPVP-LDP) in benign/borderline pancreatic disease because complications of splenic infarction and gastric varices can arise after Warshaw technique. This study was aimed to determine the true learning curve of the SPVP-LDP procedure not LDP including Warshaw technique.

METHODS

Data were collected retrospectively from all patients who underwent a LDP between June 2007 and April 2017 at Gangnam Severance Hospital. We used cumulative sum control chart (CUSUM) analysis to assess the learning curve for the SPVP-LDP technique.

RESULTS

Eight-three patients were performed LDP and we excluded patients who underwent robotic approach (N = 10) and open conversion DP (N = 8). Patients who underwent SPVP-LDP procedures were categorized into Group 1 (primary end-point). Those who underwent LDP procedures with splenectomy and the Warshaw technique were categorized into Group 2. We found that the 16th case was the cutoff point and the mean length of hospital stay was 13.0 days in the first period and 8.7 days in the second period (p = < 0.001).

CONCLUSIONS

These results indicated that the frequency of SPVP-LDPs had increased and that technological progress had been made over time. The true learning curve for SPVP-LDP was indicated as 16 cases in a group of surgeons with no experience of laparoscopic pancreatic surgery.

The treatment indication and optimal management of fluid collection after laparoscopic distal pancreatectomy

BACKGROUND

Recently, laparoscopic distal pancreatectomy (LDP) has become the standard procedure for resection of left-sided pancreatic tumors. Fluid collection (FC) at the resection margin of the pancreatic stump after LDP is a frequent radiological finding. However, there have been few treatment guidelines and the optimal management for this clinical finding is unclear. The aim of present study is to define the incidence of FC and suggest the optimal management for FC after LDP.

METHODS

A total of 1227 patients who underwent LDP between March 2005 and December 2015 were collected. FC was considered present when the longest diameter of the lesion on CT scan was > 3 cm.

RESULTS

A follow-up with at least two CT image was available for 1102 patients. Of these, 689 (62.5%) patients showed initial fluid collection (IFC) at the pancreas resection site in immediate postoperative CT. IFC (+) group had higher proportion of men, BMI, and higher rate of concomitant splenectomy than IFC (-) group. Among patients with FC after LDP, the treatment group had more frequent leukocytosis and accompanying symptoms than the observation group. Seventy-seven patients underwent therapeutic interventions for FC after LDP. Among them, 55 (71.4%) patients underwent endoscopic ultrasonography-guided gastrocystostomy (EUS-GC). EUS-GC group had a higher success rate (85.6 vs. 63.6%, p < 0.033) and shorter hospital stay after the intervention (5.2 vs. 13.3 days, p < 0.001) than those who underwent other procedures.

CONCLUSIONS

High BMI, male, and concomitant splenectomy contribute to the occurrence of FC after LDP. In most cases, FC after LDP resolved spontaneously over time with observation. The patients with symptomatic FC ultimately required treatment. EUS-GC is the optimal intervention therapy for FC after LDP.

A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population

INTRODUCTION

Minimally invasive surgery (MIS) has become standard of care for many gastrointestinal surgical procedures. Despite possible clinical benefits, MIS may be underutilized in some populations. The aim of this study was to access the utilization of MIS among Medicare patients undergoing hepatopancreatic procedures and define clinical outcomes, as well as costs, of minimally invasive techniques compared with the conventional open approach.

METHODS

The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. Primary outcomes of the analysis included perioperative clinical outcomes such as rates of complications, index hospitalization length-of-stay (LOS), failure-to-rescue, rates, and causes of 90-day readmission, as well as 90-day mortality. Secondary outcomes were Medicare payments for index hospitalization and readmission. Multivariable logistic regression was used to investigate the impact of MIS on clinical outcomes and health expenditures.

RESULTS

A total of 13,716 (90.6%) patients underwent open resection, while MIS was performed in 1424 (9.4%) patients. LOS was shorter among patients undergoing MIS (mean 7.3 ± SD 7.3) versus open (mean 9.3 ± SD 9.1) surgery (p < 0.001). The incidence of perioperative complications was lower following MIS (open 25.5%, n = 3492 vs. MIS 17.2%, n = 245) (p < 0.001). Rates of failure-to-rescue were similar among patients undergoing an open versus MIS pancreatic procedure (open 19.4%, n = 271 vs. MIS 13.4%, n = 17) (p = 0.09). In contrast, 90-day readmission (open 31.1%, n = 1630 vs. MIS 24.1%, n = 201, p < 0.001), as well as 90-day mortality (open 7.7%, n = 404 vs. MIS 4.2%, n = 35, p < 0.001) were lower among patients undergoing pancreatic resections via an MIS approach. In contrast, failure-to-rescue and readmission, as well as mortality, were all comparable among patients undergoing a liver resection, regardless as to whether the operation was performed open or via an MIS approach (all p > 0.05). Mean total payments for open pancreatic surgery were on average $1421 higher in the open versus MIS pancreatic group (p = 0.01); in contrast, there was no difference in the overall payment for hepatic resection (p > 0.05).

CONCLUSION

The MIS approach was underutilized among patients undergoing liver and pancreatic procedures. MIS was associated with lower complication and readmission and shorter LOS, as well as comparable/slightly lower Medicare payments, compared with the open approach. The MIS approach should strongly be considered among older patients undergoing liver and pancreatic procedures.

The Indications for Laparoscopic Pancreatectomy

BACKGROUND

Laparoscopic pancreatectomy is not yet established as a routine procedure everywhere in Germany or in other countries. Few data are available on its short- and long-term outcomes.

METHODS

From 2008 onward, a working group initiated by 10 centers and currently comprising 34 centers has gathered data on all cases of laparoscopic pancreatectomy. Procedures in which laparoscopy was converted to open surgery are also included.

RESULTS

The registry now contains 550 data sets representing 267 cases of benign disease, 244 malignancies, and 39 borderline tumors. The most common procedure was laparoscopic left pancreatectomy, followed by resection of the head of the pancreas and tumor enucleation. The most common intraoperative complication was hemorrhage, with a frequency of 3%. The rate of conversion to open surgery was 35%; if minilaparotomies are excluded, the conversion rate was only 16%. 39% of patients developed a pancreatic fistula after surgery (usually grade A or B, with 1.5% grade C) and 3% underwent reoperation because of postoperative hemorrhage. The procedure-related mortality was 1.3%. 91% of the patients reported only very mild postoperative pain. 6.7% newly developed diabetes mellitus after the procedure.

CONCLUSION

The patient cohort in the registry consists of persons who were selected to undergo laparoscopic pancreatectomy by the participating hospital teams, and the data are thus inherently affected by selection bias. The operative procedures that they underwent reflect the current practice of laparoscopic pancreatectomy in Germany. The complication rates are similar to those of open surgery. Selection bias can be avoided only by a randomized trial.

True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is generally the treatment of choice for diseases of the pancreatic body and tail. Most surgeons prefer the spleen- and splenic vessel-preserving technique (SPVP-LDP) in benign/borderline pancreatic disease because complications of splenic infarction and gastric varices can arise after Warshaw technique. This study was aimed to determine the true learning curve of the SPVP-LDP procedure not LDP including Warshaw technique.

METHODS

Data were collected retrospectively from all patients who underwent a LDP between June 2007 and April 2017 at Gangnam Severance Hospital. We used cumulative sum control chart (CUSUM) analysis to assess the learning curve for the SPVP-LDP technique.

RESULTS

Eight-three patients were performed LDP and we excluded patients who underwent robotic approach (N = 10) and open conversion DP (N = 8). Patients who underwent SPVP-LDP procedures were categorized into Group 1 (primary end-point). Those who underwent LDP procedures with splenectomy and the Warshaw technique were categorized into Group 2. We found that the 16th case was the cutoff point and the mean length of hospital stay was 13.0 days in the first period and 8.7 days in the second period (p = < 0.001).

CONCLUSIONS

These results indicated that the frequency of SPVP-LDPs had increased and that technological progress had been made over time. The true learning curve for SPVP-LDP was indicated as 16 cases in a group of surgeons with no experience of laparoscopic pancreatic surgery.

Initial experience with robotic pancreatic surgery in Singapore: single institution experience with 30 consecutive cases

BACKGROUND

Presently, the worldwide experience with robotic pancreatic surgery (RPS) is increasing although widespread adoption remains limited. In this study, we report our initial experience with RPS.

METHODS

This is a retrospective review of a single institution prospective database of 72 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2017. Of these, 30 patients who underwent RPS were included in this study of which 25 were performed by a single surgeon.

RESULTS

The most common procedure was robotic distal pancreatectomy (RDP) which was performed in 20 patients. This included eight subtotal pancreatectomies, two extended pancreatecto-splenectomies (en bloc gastric resection) and 10 spleen-saving-RDP. Splenic preservation was successful in 10/11 attempted spleen-saving-RDP. Eight patients underwent pancreaticoduodenectomies (five hybrid with open reconstruction), one patient underwent a modified Puestow procedure and one enucleation of uncinate tumour. Four patients had extended resections including two RDP with gastric resection and two pancreaticoduodenectomies with vascular resection. There was one (3.3%) open conversion and seven (23.3%) major (>Grade II) morbidities. Overall, there were four (13.3%) clinically significant (Grade B) pancreatic fistulas of which three required percutaneous drainage. These occurred after three RDP and one robotic enucleation. There was one reoperation for port-site hernia and no 30-day/in-hospital mortalities. The median post-operative stay was 6.5 (range: 3-36) days and there were six (20%) 30-day readmissions.

CONCLUSION

Our initial experience showed that RPS can be adopted safely with a low open conversion rate for a wide variety of procedures including pancreaticoduodenectomy.

Short- and mid-term outcomes of robotic versus laparoscopic distal pancreatosplenectomy for pancreatic ductal adenocarcinoma: A retrospective propensity score-matched study

BACKGROUND

Robotic distal pancreatectomy exhibits short-term benefits over laparoscopic distal pancreatectomy. The use of minimal invasive techniques to carry out distal pancreatosplenectomy (DPS) for pancreatic ductal adenocarcinoma (PDAC) remains controversial and has not gained popular acceptance. A comparative study was designed to analyze the short- and mid-term outcomes of robotic DPS (RDPS) versus laparoscopic DPS (LDPS) on patients with PDAC.

METHODS

The baseline characteristics, perioperative outcomes and survival data among patients who underwent RDPS (n = 35) versus LDPS (n = 35) for PDAC between December 2011 and December 2015 were compared after a 1:1 propensity score matching.

RESULTS

There were no significant differences in the operative time, blood loss, blood transfusion rate, and morbidity and pancreatic fistula rates between the RDPS and LDPS groups. RDPS significantly reduced the rate of conversion to laparotomy (5.7% vs. 22.9% when compared with LDPS, p = 0.04). There were no significant differences in R0 resection rates, number of harvested lymph nodes, positive to harvested lymph node ratios, and disease-free survival and overall survival rates between the two groups. A Cox proportional hazards analysis showed N1 stage to be significantly associated with worse survival and suggested that chemotherapy might prolong overall survival in these PDAC patients.

CONCLUSIONS

This single-center study demonstrated that RDPS was safe and efficacious in treatment of PDAC. When compared with LDPS, RDPS was associated with a reduced rate of conversion to open surgery. There were no significantly differences in oncological outcomes and mid-term survival rates between the groups of patients who underwent RDPS or LDPS.

The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000–2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Evolution of minimally invasive distal pancreatectomies at a single institution

Introduction

This study aims to study the changing trends and outcomes associated with the adoption of minimally invasive distal pancreatectomy (MIDP) at a single centre.

Materials and Methods

Retrospective review of sixty consecutive patients who underwent MIDP from September 2006 to November 2016 at a single institution. To study the evolution of MIDP, the study population was divided into three groups consisting of twenty patients (Group I, Group II and Group III).

Results

Sixty patients underwent MIDP with 11 (18.3%) requiring open conversions. The median operation time was 305 (range: 85-775) min and the median post-operative stay was 6 (range: 3-73) days. Fifteen procedures were spleen-saving pancreatectomies. Major post-operative morbidity (>Grade 2) occurred in 12 (20.0%) patients and there was no mortality or reoperations. There were 33 (55.0%) pancreatic fistulas, of which 15 (25.0%) were Grade B fistulas of which 12 (20.0%) required percutaneous drainage. Comparison between the three groups demonstrated a statistically significant increase in the frequency of procedures performed, increase in robotic-assisted procedures and proportion of asymptomatic tumours resected. There also tended to be non-significant decrease in open conversion rates from 25% to 5% between the three groups and increase in tumour size resected from 24 to 40 mm.

Conclusion

Comparison between the three groups demonstrated that MIDP was performed with increased frequency. There was a statistically significant increase in the frequency of resections performed for asymptomatic tumours and resections performed through robotic assistance. There was also a non-significant trend towards a decrease in open conversions and increase in the size of tumours resected.

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.

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

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

Laparoscopic management of neuroendocrine tumors: state-of-the-art

Over recent years, minimally invasive pancreatic resections have increasingly been reported in the literature. Even though pancreatic surgery is still considered a challenge for surgeons due to its technical difficulties and high morbidity, the consolidation of minimally invasive pancreatic surgery has included the treatment of pancreatic neuroendocrine tumors (PNETs). This article presents a systematic review of the literature with regards to the laparoscopic treatment of PNETs in order to assess the safety and feasibility of laparoscopic pancreatic resections.

Splenic vessel preservation versus splenic vessel resection in laparoscopic spleen-preserving distal pancreatectomy

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy for low-grade malignant pancreas tumours was recently demonstrated and can be performed with splenic vessel preservation (SVP) or splenic vessel resection (SVR). Whether one approach is superior to another is still a matter of debate.

METHODS

A systematic literature search (PubMed, Embase, Science Citation Index, Springer-Link and Cochrane Central Register of Controlled Trials) was performed. Pooled intra- and post-operative outcomes were evaluated. Stratified and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of the study qualities.

RESULTS

A total of six studies were included. There was no significant difference for SVR and SVP in terms of overall post-operative complications and the pooled odds ratio (OR) was 0.87 (95% confidence interval (CI) 0.55-1.38, I² = 25%). Meta-analysis on the pooled outcome of intraoperative operative time and blood loss favoured SVR; the mean differences were 18.64 min (95% CI 6.91-30.37 min, I² = 21%) and 65.67 mL (95% CI 18.88-112.45 mL, I² = 48%), respectively. Subgroup analysis showed a decrease incidences in perigastric varices (OR = 0.07, 95% CI 0.03-0.18, I² = 29%) and splenic infarction (OR = 0.16, 95% CI 0.08-0.32, I² = 0%) in SVP.

CONCLUSION

For selected patients who underwent laparoscopic spleen-preserving distal pancreatectomy, an increased preference for the SVP technique should be suggested considering its short-term benefits. However, in case of large tumours that distort and compress vessel course, SVR could be applied with acceptable splenic ischaemia and perigastric varices.

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

BACKGROUND

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

DATA SOURCE

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic versus open distal pancreatectomy for nonfunctioning pancreatic neuroendocrine tumors: a large single-center study

BACKGROUND

Pancreatic neuroendocrine tumors (PNETs) account for 1-2% of all pancreatic neoplasms. Nonfunctioning PNETs (NF-PNETs) account for 60-90% of all PNETs. Laparoscopic distal pancreatectomy (LDP) is becoming the treatment of choice for benign lesions in the body and tail of the pancreas. However, LDP has not yet been widely accepted as the gold standard for NF-PNETs. The purpose of this study is to evaluate the clinical and oncologic outcomes after laparoscopic versus open distal pancreatectomy (ODP) for NF-PNETs.

METHODS

Between April 1995 and September 2016, 94 patients with NF-PNETs underwent open or laparoscopic distal pancreatectomy at Samsung Medical Center. Patients were divided into two groups: those who underwent LDP and those who underwent ODP. Both groups were compared in terms of clinical and oncologic variables.

RESULTS

LDP patients had a significantly shorter hospital stay compared with ODP patients, amounting to a mean difference of 2 days (p < 0.001). Overall complication rates did not differ significantly between the ODP and LDP groups (p = 0.379). The 3-year overall survival rates in the ODP and LDP groups were 93.7 and 100%, respectively (p = 0.069).

CONCLUSIONS

In this study, LDP for NF-PNETs had similar oncologic outcomes compared with ODP. In addition, LDP was associated with a shorter hospital stay compared with ODP. Therefore, LDP is a safe and effective procedure for patients with NF-PNETs. A multicenter study and a randomized controlled trial are needed to better assess the clinical and oncologic outcomes.

Laparoscopic distal pancreatectomy for pancreatic cancer is safe and effective

PURPOSE

To compare the short-term and oncologic outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) undergoing laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP).

METHODS

Consecutive cases of distal pancreatectomy (DP) (n = 422) were reviewed at a single high-volume institution over a 10-year period (2005-2014). Inclusion criteria consisted of any patient with PDAC by surgical pathology. Ninety-day outcomes were monitored through a prospectively maintained pancreatic resection database. The Social Security Death Index was used for 5-year survival. Two-way statistical analyses were used to compare categories; variance was reported with standard error of the mean; * indicates P value <0.05.

RESULTS

Seventy-nine patients underwent DP for PDAC. Thirty-three underwent LDP and 46 ODP. There were no statistical differences in demographics, BMI, and ASA classification. Intraoperative and surgical pathology variables were comparable for LDP versus ODP: operative time (3.9 ± 0.2 vs. 4.2 ± 0.2 h), duct size, gland texture, stump closure, tumor size (3.3 ± 0.3 vs. 4.0 ± 0.4 cm), lymph node harvest (14.5 ± 1.1 vs. 17.5 ± 1.2), tumor stage (see table), and negative surgical margins (77 vs. 87%). Patients who underwent LDP experienced lower blood loss (310 ± 68 vs. 597 ± 95 ml; P = 0.016*) and required fewer transfusions (0 vs. 13; P = 0.0008*). Patients who underwent LDP had fewer positive lymph nodes (0.8 ± 0.2 vs. 1.6 ± 0.3; P = 0.04*) and a lower incidence of type C pancreatic fistula (0 vs. 13%; P = 0.03*). Median follow-up for all patients was 11.4 months. Long-term oncologic outcomes revealed similar outcomes including distant or local recurrence (30 vs. 52%; P = 0.05) and median survival (18 vs. 15 months), as well as 1-year (73 vs. 59%), 3-year (22 vs. 21%), and 5-year (20 vs. 15%) survival for LDP and ODP, respectively.

CONCLUSIONS

The results of this series suggest that LDP is a safe surgical approach that is comparable from an oncologic standpoint to ODP for the management of pancreatic adenocarcinoma.

Laparoscopy-Assisted Spleen-Preserving Distal Pancreatectomy for Living-Donor Pancreas Transplantation

BACKGROUND

Living pancreas transplantation plays an important role in the treatment of patients with severe type 1 diabetes. However, pancreatectomy is very invasive for the donor, and less-invasive surgical procedures are needed. Although some reports have described hand-assisted laparoscopic surgery for distal pancreatectomy in living-donor operations, less-invasive laparoscopy-assisted (LA) procedures are expected to increase the donor pool. We herein report the outcomes of four cases of LA spleen-preserving distal pancreatectomy (Warshaw technique [WT]) in living pancreas donors.

PATIENTS AND METHODS

Four living pancreas donors underwent LA-WT at our institution from September 2010 to January 2013. All donors fulfilled the donor criteria established by the Japan Society for Pancreas and Islet Transplantation.

RESULTS

The median donor age was 54 years. Two donors underwent left nephrectomy in addition to LA-WT for simultaneous pancreas-kidney transplantation. The median donor operation time for pancreatectomy was 340.5 minutes. The median pancreas warm ischemic time was 3 minutes. The median donor blood loss was 246 g. All recipients immediately achieved insulin independence. One donor required reoperation because of obstructive ileus resulting from a port-site hernia. Another donor developed a pancreatic fistula (International Study Group of Pancreatic Fistula grade B), which was controlled with conservative management. After a maximum follow-up of 73 months, no clinically relevant adverse events had occurred. These results were comparable with those of previous studies concerning living-donor pancreas transplantation.

CONCLUSION

The LA-WT is a safe and acceptable operation for living-donor pancreas transplantation.

Obesity-related CpG Methylation (cg07814318) of Kruppel-like Factor-13 (KLF13) Gene with Childhood Obesity and its cis-Methylation Quantitative Loci

The cg07814318 hypermethylation of Kruppel-like factor 13 (KLF13) gene has been reported for its relevancy with Body Mass Index (BMI) from European origin. We explored the cg07814318 methylation and its cis-meQTL (cis-methylation quantitative loci) of KLF13 from a childhood obesity cohort. The cg07814318 methylation in blood was significantly associated with obesity and correlated with several obesity-related physical and biochemical traits. We examined the same loci from purified three human cell types (n = 47), i.e., pre-adipocytes, adipocytes and islets. The cg07814318 methylation pattern in pre-adipocytes and islets were significant higher in cells from subjects with a higher BMI compared with control subjects. By exome sequencing of KLF13 gene in blood with the same cohort, we found nine SNPs (single nucleotide polymorphisms) within its gene body, and two SNPs (rs11537749 and rs12595641) were as cis-meQTL of cg07814318. There was the 2.01% methylation change of cg07814318 between homozygous dominant and recessive genotypes, especially, in rs12595641. The sequencing variations within KLF13 genes could drive dynamic modifications of obesity-related CpG methylation. Differential DNA methylation patterns in the KLF13 gene determined from separate blood samples showed that this criterion could be used as a surrogate for representing overall epigenetic changes in cells related to obesity.

The Largest European Single-Center Experience: 300 Laparoscopic Pancreatic Resections

BACKGROUND

Although laparoscopic pancreatic resection (LPR) has become routine, large single-center series are still lacking. Our aim was to analyze the results of a large European single-center series of LPR.

STUDY DESIGN

Between January 2008 and September 2015, 300 LPRs were performed and studied prospectively, including 165 (55%) distal pancreatectomies, 68 (23%) pancreaticoduodenectomies (PDs), 30 (10%) enucleations, 35 (11%) central pancreatectomies, and 2 (1%) total pancreatectomies.

RESULTS

Mean age was 54 ± 15.4 years old (range 17 to 87 years), and most patients were women (58%). Laparoscopic pancreatic resection was performed for malignancy (46%), low potential malignant (44%), or benign (10%) diseases. The mean operative durations were 211 ± 102 minutes (range 30 to 540 minutes) for the entire population and 351 ± 59 minutes (range 240 to 540 minutes) for PD, and decreased with the learning curve. Mean blood loss was 229 ± 269 mL (range 0 to 1,500 mL), and 13 patients (4%) received transfusions. Conversion to an open procedure was required in 12 patients (4%), and only 5 in the last 250 patients (14% vs 2%; p < 0.001). Mortality occurred in 4 (1.3%) patients and only after PD (5.8%). Common complications were pancreatic fistula (n = 124, 41%), bleeding (n = 35, 12%), and reoperation (n = 28, 9%). The postoperative outcomes were less favorable in procedures with a reconstruction phase (n = 105) than in those without (n = 195), with increased mortality (3.8% vs 0%; p = 0.04), overall morbidity (76% vs % 52%; p < 0.001), and mean hospital stay (26 ± 15 days vs 16 ± 10 days; p < 0.001).

CONCLUSIONS

Laparoscopic pancreatic resection without a reconstruction phase has excellent outcomes; LPR with a reconstruction phase, especially PD, has less favorable outcomes, and further randomized studies are required to draw conclusions on the safety and benefits of this approach.

Gastric bleeding risk following spleen preserving distal pancreatectomy with excision of the splenic vessels: a long-term follow-up

BACKGROUND

Spleen-preserving distal pancreatectomy with resection of the splenic vessels (VR-SPDP) is an effective procedure. However, hemodynamic changes in splenogastric circulation may lead to the development of gastric varices (GV) with a risk of gastrointestinal (GI) bleeding. This retrospective study aimed to assess the long-term postoperative clinical follow-up of patients and review the late postoperative abdominal computed tomography (CT) or endoscopic examination.

METHODS

From 1988 to 2015, 48 consecutive VR-SPDP for benign or low-grade malignant disease were included. Late postoperative follow-up was undertaken with the use of a prospective database and assessment undertaken by CT and/or endoscopy.

RESULTS

The median follow-up was 76 months (range: 12-334 months). Two patients were lost to follow-up. Gastrointestinal hemorrhage occurred in one patient. Endoscopy and abdominal CT showed submucosal GV in five patients. Ten patients had perigastric varices (27%), but none developed clinical complications from their varices. All varices occurred within one year after distal pancreatectomy and remained stable during follow-up.

DISCUSSION

Asymptomatic varices frequently occurred in patients who underwent VR-SPDP, but bleeding risk seemed low. Abdominal CT could identify GV and distinguish submucosal varices with a higher risk of gastric bleeding.

Reduced morbidity with minimally invasive distal pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

Minimally invasive distal pancreatectomy (MISDP) has been shown to be safe relative to open distal pancreatectomy (ODP). However, MISDP has been slow to adopt for pancreatic adenocarcinoma (PDAC). This study sought to compare outcomes following MISDP vs. ODP for PDAC.

METHODS

Data were prospectively collected from 2011 to 2014 for DP by the American College of Surgeons-National Surgical Quality Improvement Program. Patients without PDAC on surgical pathology were excluded. Impact of minimally invasive approach on morbidity and mortality was analyzed using two-way statistical analyses.

RESULTS

Of 6198 patients undergoing DP, 501 (7.5%) had a pathologic diagnosis of PDAC. MISDP was undertaken in 166 (33.1%) patients, ODP was performed in 335 (66.9%). MISDP and ODP were not different in preoperative comorbidities or pathologic stage. Overall morbidity (MISDP 31%, ODP 42%; p = 0.024), transfusion (MISDP 6%, ODP 23%; p = 0.0001), pneumonia (MISDP 1%, ODP 7%; p = 0.004), surgical site infections (MISDP 8%, OPD 17%; p = 0.013), sepsis (MISDP 2%, ODP 8%; p = 0.007), and length of stay (MISDP 5.0 days, ODP 7.0 days; p = 0.009) were lower in the MIS group. Mortality (MISDP 0%, ODP 1%; p = 0.307), pancreatic fistula (MISDP 12%, ODP 19%; p = 0.073), and delayed gastric emptying (MISDP 3%, ODP 7%; p = 0.140) were similar.

CONCLUSIONS

This analysis of a large multi-institution North American experience of DP for treatment of pancreatic adenocarcinoma suggests that short-term postoperative outcomes are improved with MISDP.

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.

Minimally Invasive Distal Pancreatectomy: Review of the English Literature

BACKGROUND

Recently, the superiority of the minimally invasive approach, which results in a better cosmetic result, faster recovery, and shorter length of hospital stay, is a technique that has been progressively recognized as it has developed. And the minimally invasive approach has been applied to distal pancreatectomy (DP), which is a standard method for the treatment of benign, borderline, and part of malignant lesions of the pancreatic body and tail. This article aims to analyze the types, postoperative recovery, and outcomes of laparoscopic distal pancreatectomy (LDP).

MATERIALS AND METHODS

A systematic search of the scientific literature was performed using PubMed, EMBASE, online journals, and the Internet for all publications on LDP. Articles were selected if the abstract contained patients who underwent LDP for pancreatic diseases. All selected articles were reviewed and analyzed.

RESULTS

If there were no contraindications for LDP, this operation is suitable for benign, borderline, or malignant tumors of the pancreatic body and tail, which should try to be performed with preservation of the spleen. LDP is safe and feasible under some conditions to experienced surgeon. Single-incision laparoscopic distal pancreatectomy (S-LDP) and robotic laparoscopic distal pancreatectomy (R-LDP) perioperative outcomes are similar with conventional multi-incision laparoscopic distal pancreatectomy (C-LDP). And the advantages of S-LDP and R-LDP require further exploration. With the application of enhanced recovery program (ERP), length of hospital stay and costs are reduced.

CONCLUSIONS

LDP is safe and feasible under some conditions. Compared with open distal pancreatectomy, LDP has a lot of advantages; a trend was observed for LDP to replace traditional open surgery. LDP combined with ERP is expected to become standard in the treatment of pancreatic body and tail lesions.