The superior approach with the stomach roll-up technique improves intraoperative outcomes and facilitates learning laparoscopic distal pancreatectomy: a comparative study between the superior and inferior approach

Effect of differences in vascular anatomy on surgical outcomes of left pancreatectomy: a retrospective study

BACKGROUND

Minimally invasive left pancreatectomy (MILP) is increasingly performed worldwide, necessitating the need for improved understanding of vascular anatomy during surgery. However, the effect of differences in vascular anatomy on surgical outcomes remains unclear. In this study, we aimed to evaluate the effect of vascular anatomical variations on surgical outcomes and identify factors that influence open and minimally invasive surgery (MIS) outcomes.

METHODS

This was a single-center retrospective study involving 123 patients who underwent left pancreatectomy (LP). We analyzed the correlation between vascular anatomical variations, namely, (i) the root of the splenic artery (SpA; types 1 and 2), (ii) the parent artery of the dorsal pancreatic artery, (iii) confluence patterns of the left gastric vein, and (iv) the inferior mesenteric vein, and surgical outcomes. We also performed a risk analysis of prolonged operation time, considering surgery-related factors.

RESULTS

SpA type 2 was only significantly associated with longer operation time (p < 0.01) in LP procedures. In all LP cases, the pancreatic resection line (above the portal vein: odds ratio [OR] 3.47; 95% confidence interval [CI] 1.69-11.18; p < 0.01), the SpA type (type 2; OR 2.77; 95% CI 1.16-6.94; p = 0.02), and surgery type (MIS; OR 5.24; 95% CI 2.17-14.00; p < 0.001) were independently associated with prolonged operation times. In open-LP cases, high body mass index (> 24 kg/m2; OR 7.24; 95% CI 1.89-36.34; p < 0.01), tumor location (pancreatic body; OR 6.89; 95% CI 1.79-33.79; p < 0.01), and the SpA type (type 2; OR 5.86; 95% CI 1.72-24.65; p < 0.01) showed significant association with prolonged operations. In MILP cases, sex (male; OR 9.07; 95% CI 2.61-38.65; p < 0.001) and the pancreatic resection line (above the portal vein; OR 4.12; 95% CI 1.18-17.08; p = 0.03) showed significant associations.

CONCLUSIONS

SpA type 2 may negatively affect surgical outcomes. Therefore, it is important to recognize and approach vascular anatomy appropriately. MIS, especially robotic surgery, may be effective in mitigating the negative effects of variations in vascular anatomy.

Successful laparoscopic resection for giant mature cystic teratoma of the pancreas: a case report and surgical refinements

BACKGROUND

Mature cystic teratomas or dermoid cysts of the pancreas complicate surgical approaches because of their anatomical position and ever-growing size. Herein, we report a case of a giant mature cystic teratoma of the pancreas that was successfully resected via complete laparoscopic distal pancreatectomy (LDP).

CASE PRESENTATION

A 39-year-old female patient was referred to our hospital for the evaluation of a pancreatic tumor. Three years of follow-up revealed that the tumor had increased in size to 18 cm, with hyperintense solid components on diffusion-weighted magnetic resonance imaging. Considering the possibility of malignancy, we decided to perform an LDP. The capsule appeared solid enough to withstand the retraction of the endoscopic forceps. Tumor size made it difficult to dissect the dorsal side of the tumor from the caudal to the cranial side. Early transection of the pancreas and additional ports facilitated dissection of the dorsal side of the tumor. We completed the LDP without intraoperative cyst rupture. On pathological examination, the tumor was diagnosed as a mature cystic teratoma originating from the pancreatic tail. The patient was discharged on postoperative day 13 with no complications.

CONCLUSION

LDP may be an option for surgical procedures in patients with large cystic lesions of the pancreatic body or tail. Intraoperative observation of the tumor and surgical refinement are necessary to complete the laparoscopic procedure without tumor rupture.

Precision anatomy for minimally invasive spleen-preserving distal pancreatectomy in children: A case report of solid-pseudopapillary neoplasm in a 12-year-old girl

INTRODUCTION

Solid pseudopapillary neoplasm (SPN) is a rare and low malignant tumor found mainly in young females. There is no standardized procedure for SPN of the pancreatic body and tail in children. In adults, an international consensus on precision anatomy for minimally invasive distal pancreatectomy (MIDP) was established recently (PAM-HBP Surgery Project). The aim of this study is to demonstrate that precision anatomy can also be safely and effectively implemented in the pediatric population.

PRESENTATION OF CASE

A 12-year-old girl with an incidentally found SPN located in the pancreatic tail was referred to our hospital. She successfully underwent an R0 resection by laparoscopic spleen-preserving distal pancreatectomy (LSPDP) under the concept of precision anatomy. The patient recovered uneventfully and was discharged on day 7.

DISCUSSION

This is the first successful report of LSPDP under the concept of precision anatomy in children. In accordance with the recommendations from the international consensus, the "anterior approach" was selected to dissect and encircle the splenic artery based on the vascular anatomy identified by preoperative imaging. The dorsal dissection border of the pancreas along the anterior layer above the Gerota's fascia was carefully maintained and the splenic vessels were preserved taking into consideration the low malignant potential of SPN and to decrease the risk of complications associated with splenectomy, which were also the essential issues of the consensus.

CONCLUSION

The implementation of precision anatomy for pediatric pancreas surgery should facilitate the safe diffusion of MIDP for SPN and other benign or low-malignant tumors in children.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos)

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear.

PATIENTS AND METHODS

Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups.

RESULTS

The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification.

CONCLUSIONS

The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.

International Expert Consensus on Precision Anatomy for minimally invasive distal pancreatectomy: PAM-HBP Surgery Project

BACKGROUND

Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021).

METHODS

Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting.

RESULTS

Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts.

CONCLUSIONS

The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

Surgical approaches for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking.

METHODS

A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP.

RESULTS

All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed.

CONCLUSIONS

In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP.

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP.

METHODS

A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology.

RESULTS

Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found.

CONCLUSIONS

The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

Systematic review and meta-analysis of risk factors of postoperative pancreatic fistula after distal pancreatectomy in the era of 2016 International Study Group pancreatic fistula definition

BACKGROUND

Risk factors for the development of clinically relevant POPF (CR-POPF) following distal pancreatectomy (DP) need clarification particularly following the 2016 International Study Group of Pancreatic Fistula (ISGPF) definition.

METHODS

A systemic search of MEDLINE, Pubmed, Scopus, and EMBASE were conducted using the PRISMA framework. Studies were evaluated for risk factors for the development CR-POPF after DP using the 2016 ISGPF definition. Further subgroup analysis was undertaken on studies ≥10 patients in exposed and non-exposed subgroups.

RESULTS

Forty-three studies with 8864 patients were included in the meta-analysis. The weighted rate of CR-POPF was 20.4% (95%-CI: 17.7-23.4%). Smoking (OR 1.29, 95%-CI: 1.08-1.53, p = 0.02) and open DP (OR 1.43, 95%-CI: 1.02-2.01, p = 0.04) were found to be significant risk factors of CR-POPF. Diabetes (OR 0.81, 95%-CI: 0.68-0.95, p = 0.02) was a significant protective factor against CR-POPF. Substantial heterogeneity was observed in the comparisons of pancreatic texture and body mass index. Seventeen risk factors achieved significance in a univariate or multivariate comparison as reported by individual studies in the narrative synthesis, however, they remain difficult to interpret as statistically significant comparisons were not uniform.

CONCLUSION

This meta-analysis found smoking and open DP to be risk factors and diabetes to be protective factor of CR-POPF in the era of 2016 ISGPF definition.