Comparison of safety and effectiveness between laparoscopic and open pancreatoduodenectomy: A systematic review and meta-analysis

5-Year survival rate over 20 % in pancreatic ductal adenocarcinoma: A retrospective study from a Chinese high-volume center

Standardized clinical management of pancreatic adenocarcinoma (PDAC) remains challenging and high-volume centers provide essential insights for establishing effective multimodal treatment approaches. This retrospective observational study evaluated the impact of standardized, multimodal clinical management on survival outcomes in patients with PDAC across all stages, based on NCCN guidelines resectability criteria, at a high-volume center. From 2019, 4143 patients were diagnosed with PDAC, with 3268 patients receiving further treatment, including surgical resection and/or systemic therapy. The median overall survival (OS) was 18.5 (95 %CI 17.5-19.4) months for the treated cohort and the 5-year survival rate reached 23.3 %. Patients who underwent surgical resection had significantly improved median OS compared to those who received non-surgical treatments (28.4 months vs. 13.0 months, P < 0.001), with corresponding 5-year survival rates of 31.6 % vs. 15.0 %. Moreover, the patients who received NAT followed by surgical resection had improved survival outcomes compared to those who underwent upfront surgical resection in both resectable (median OS: 37.5 months vs. 28.9 months, P < 0.01) and borderline resectable group (median OS: 31.8 months vs. 18.4 months, P < 0.001). This study demonstrated a 5-year survival rate exceeding 20 % for PDAC across all stages at our center. The application of evidence-based treatment strategies through the multidisciplinary team, accompanying with standardized and comprehensive therapeutic managements, high patient adherence, have been considered as critical determinants in enhancing therapeutic efficacy and improving long-term prognosis for patients with PDAC.

The conventional method of blood-loss calculation can underestimate true blood loss during laparoscopic pancreaticoduodenectomy: a dual-institute experience

PURPOSE

This study investigated whether blood loss (BL) was. truly less in patients undergoing laparoscopic pancreaticoduodenectomy (LPD) than in those undergoing open pancreaticoduodenectomy (OPD).

METHODS

A total of 98 patients undergoing pancreaticoduodenectomy between 2021 and 2023 were divided into OPD and LPD groups and compared. Estimated BL was calculated from the perioperative changes in hematocrit, hemoglobin, or red blood cell volume. Actual BL was calculated using the conventional method as the sum of the intraoperative aspirated blood volume and surgical gauze weight.

RESULTS

Actual BL was significantly lower in the LPD group than in the OPD group (150 [80-350] ml vs. 345 [150-700] ml, p = 0.003). However, there were no significant differences in the estimated BL calculated from the hematocrit (461 [187-626] ml vs. 351 [153-737] ml, p = 0.972), hemoglobin, or red blood cell volume. Estimated BL showed a stronger linear correlation with actual BL in the OPD group (r = 0.447-0.669) than in the LPD group (r = 0.158-0.417). OPD was not a significant factor in the increased estimated BL.

CONCLUSIONS

The conventional method for calculating the BL in LPD may underestimate the actual loss, highlighting the need for a more accurate method of evaluation.

Comparison of Short-Term Outcomes Between Robotic-Assisted and Open Pancreatoduodenectomy: A Retrospective Cohort Study With Inverse Probability of Treatment Weighting (IPTW) Analysis

BACKGROUND

The advantages of robotic-assisted pancreatoduodenectomy (RPD) in comparison with open pancreatoduodenectomy (OPD) have not been well-established. We aimed to compare their short-term outcomes by inverse probability of treatment weighting (IPTW) analysis.

METHODS

Patients who underwent RPD/OPD at our hospital were recruited. Stabilised IPTW were performed to adjust observed covariates. Short-term outcomes were compared.

RESULTS

After IPTW, the effective sample comprised 807 patients (199 RPD, 608 OPD) with balanced clinicopathological characteristics. RPD had a longer operation time, fewer intraoperative blood loss (IBL), and lower blood transfusion rate than OPD. RPD was associated with a lower incidence of clinically relevant postoperative pancreatic fistula and reoperation but did not reach statistical significance. In pancreatic adenocarcinoma, RPD had a significantly higher number of lymph nodes examined. There were no significant differences in postoperative morbidities and length-of-stay.

CONCLUSIONS

RPD was associated with fewer IBL and transfusion rates than OPD. RPD can be considered feasible and safe.

Retrospective analysis of delta hemoglobin and bleeding-related risk factors in pancreaticoduodenectomy

BACKGROUND

Objective and accurate assessment of blood loss during pancreaticoduodenectomy (PD) is crucial for ensuring the safety and efficacy of the procedure. While the visual method remains the most common clinical metric, many scholars argue that it significantly differs from actual blood loss and is inherently subjective.

AIM

To assess blood loss in PD via delta hemoglobin (ΔHb) and compare it with the visual method to predict bleeding-related risk factors.

METHODS

In this retrospective analysis, 1722 patients who underwent PD from 2017 to 2022 at Shandong Provincial Hospital were divided into three groups: Open PD (OPD), laparoscopic PD (LPD), and conversion to OPD (CTOPD). Intraoperative ΔHb (IΔHb) was calculated via preoperative and 72-hour-postoperative hemoglobin concentrations, and its association with visually obtained estimated blood loss (EBL) was analyzed. Perioperative ΔHb (PΔHb) was calculated via preoperative and predischarge hemoglobin concentrations. We compared the differences in IΔHb and PΔHb among the three groups, and performed univariate and multivariate regression analyses of IΔHb and PΔHb.

RESULTS

The preoperative general information of patients showed no statistically significant difference among the three groups (P > 0.05). The IΔHb in the OPD, LPD, and CTOPD groups were 22.00 (12.00, 36.00), 21.00 (10.00, 33.00), and 33.00 (18.12, 52.24) g/L, respectively; And the PΔHb in the OPD, LPD, and CTOPD groups were 25.87 (13.51, 42.00), 25.00 (14.00, 45.00), and 37.48 (21.64, 59.65) g/L, respectively, values significantly differed (P < 0.05). IΔHb and EBL were significantly correlated (r = 0.337, P < 0.001). The results of univariate and multivariate regression analyses indicated that American Society of Anesthesiologists (ASA) classification IV [95% confidence interval (CI): 2.330-37.811, P = 0.049] and preoperative total bilirubin > 200 μmol/L (95%CI: 2.805-8.673, P < 0.001) were independent risk factors for IΔHb (P < 0.05), and ASA classification IV (95%CI: 45.934-105.485, P < 0.001), body mass index > 24 kg/m2 (95%CI: 1.285-9.890, P = 0.011), and preoperative total bilirubin > 200 μmol/L (95%CI: 6.948-16.797, P < 0.001) were independent risk factors for PΔHb (P < 0.05).

CONCLUSION

There is a correlation between IΔHb and EBL in PD, so we can assess the patients' intraoperative blood loss by the ΔHb method. ASA classification IV, body mass index > 24 kg/m², and preoperative total bilirubin > 200 μmol/L increased perioperative bleeding risk.

Perioperative risk factors for overall survival of patients with pancreatic ductal adenocarcinoma underwent laparoscopic pancreaticoduodenectomy

The postoperative overall survival of patients with pancreatic ductal adenocarcinoma is not optimal. The aim of this study was to explore the perioperative risk factors for overall survival after laparoscopic pancreaticoduodenectomy (LPD) in patients with pancreatic ductal adenocarcinoma (PDAC). From January 2015 to January 2022, consecutive patients who underwent LPD with a pathological diagnosis of PDAC at our center were included in the study. LASSO regression and multivariate Cox regression were used to explore perioperative risk factors associated with overall survival. A total of 159 patients were included in the study. The median overall survival was 21 months. In the multivariate analysis, the level of direct bilirubin in serum (HR: 1.01, 95% CI 1.00-1.02, P = 0.043), postoperative pancreatic fistula (HR: 0.36, 95% CI 0.18-0.86, P = 0.010), and adjuvant therapy after surgery within 12 weeks (HR: 0.53, 95% CI 0.34-0.83, P = 0.001) were identified as independent risk factors associated with overall survival. A high level of direct bilirubin in the serum, happened with postoperative pancreatic fistula and delayed postoperative adjuvant therapy are prognostic risk factors affecting the overall survival of patients with PDAC after LPD.

Active-Targeted ICG for Surgical Navigation and Fluorescence-Guided Laparoscopic Photothermal Ablation in Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy, but there is limited improvement in its treatment. Near-infrared fluorescence (NIRF) imaging could potentially address the clinical challenges of PDAC. Indocyanine green (ICG) has been widely used in clinical practice; however, its short half-life and lack of active targeting greatly limit its application in pancreatic surgery. In this study, the active targeting peptide KTLLPTP (which actively recognizes PDAC cell surface overexpression Plectin-1) was modified to the ICG to create the novel contrast agent ICG-PTP, which actively targets PDAC cells. It was successfully applied to the NIRF imaging of the PDAC orthotopic mice model, achieving an improved tumor signal background ratio (T/N ratio) of 4.28, compared to 2.34 in the free ICG group. Next, Fluorescence-guided excision of subcutaneous/orthotopic PDAC using ICG-PTP was performed, accurately identifying the tumor margin and significantly facilitating resection efficiency. Finally, PDAC metastases were identified, and interventional photothermal ablation (iPTA) was performed under fluorescence laparoscope guidance. ICG-PTP exhibits good biosafety and clinical transitional potential. Thus, they can provide surgeons with efficient real-time tumor information and offer new treatment strategies for metastases. Accordingly, modification of probes for clinical use and adaptation studies of current equipment are the current focus.

Comparison of short-term outcomes of robotic versus open pancreaticoduodenectomy: a meta-analysis of randomized controlled trials and propensity-score-matched studies

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) is used more commonly, but this surge is mostly based on observational data. This meta-analysis aimed to compare the short-term outcomes between RPD and open pancreaticoduodenectomy (OPD) using data collected from randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies.

METHODS

We searched PubMed, Cochrane Library, Embase, and Web of Science databases for RCTs and PSM studies comparing RPD and OPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Twenty-four studies, encompassing two RCTs and 22 PSM studies, were included, with a total of 9393 patients (RPD group: 3919 patients; OPD group: 5474 patients). Although RPD was associated with a longer operative time (MD, 61.61 min), patients may benefit from reduced blood loss (MD, -154.05 ml), shorter length of stay (MD, -1.60 days), lower blood transfusion rate (RR, 0.85), and wound infection rate (RR, 0.61). There were no significant differences observed in 30-day readmission (RR, 0.99), 90-day mortality (RR, 0.97), overall morbidity (RR, 0.88), major complications (RR, 1.01), reoperation (RR, 1.08), bile leak (RR, 1.01), chylous leak (RR, 0.98), postoperative pancreatic fistula (RR, 0.97), post-pancreatectomy hemorrhage (RR, 1.15), delayed gastric emptying (RR, 0.88), number of harvested lymph nodes (MD, -0.12), and R0 resection (RR, 1.01) between the groups.

CONCLUSIONS

Although some short-term outcomes were similar between RPD and OPD, RPD exhibited reduced intraoperative blood loss, shorter hospital stays, lower wound infection, and blood transfusion rates. In the future, RPD may become a safe and effective alternative to OPD.

Perioperative outcomes in elderly patients undergoing pancreatoduodenectomy: a propensity-matched analysis

BACKGROUND

To investigate perioperative outcomes of pancreatoduodenectomy in elderly patients.

METHOD

Data for 977 patients who underwent pancreatoduodenectomy from January 2018 to January 2023 were retrospectively analysed. Patients aged 75 years or older (n = 81) were matched with patients younger than 75 years (n = 896) using nearest neighbour propensity scores matching in a 1:1 ratio.

RESULT

After matching, there were no significant differences in perioperative characteristics between the old group (n = 80) and the young group (n = 80). Regarding perioperative outcomes, we observed a higher incidence of postpancreatectomy haemorrhage (13.8% vs. 3.8%; P = 0.025) and pulmonary infection (26.3% vs. 8.8%; P = 0.004) in the old group. The major morbidity (Clavien-Dindo ≥3), cardiovascular complications and length of stay were higher in the old group before matching, however, no difference was observed between the matched cohorts (P > 0.05). The multivariate analysis revealed ASA score ≥3 (OR = 3.672, 95% CI 1.367-9.863; P = 0.010) and longer operative time (OR = 1.006, 95% CI 1.000-1.011; P = 0.039) were independently identified as risk factors for major morbidity. Moreover, the subgroup analysis demonstrated that laparoscopic surgery significantly mitigated the incidence of major morbidity in elderly patients.

CONCLUSION

With careful patient selection and perioperative management, elderly patients may achieve comparable short-term outcomes to those of their younger counterparts.

Clinicopathologic features and surgery-related outcomes of duodenal adenocarcinoma: A multicenter retrospective study

BACKGROUND

The incidence of duodenal adenocarcinoma is increasing, with limited studies on this disease published. This multicenter retrospective study aimed to analyze the clinicopathologic features of duodenal adenocarcinoma and identify prognostic factors for postoperative survival.

METHODS

Demographic characteristics, clinicopathologic features, treatment outcomes, and survival of patients with duodenal adenocarcinoma undergoing surgical treatment at 16 Chinese medical centers from 2012 to 2023 were retrospectively analyzed.

RESULTS

Among the 2,189 patients with duodenal adenocarcinoma included, 50.07% had extra-ampullary duodenal adenocarcinoma and 49.93% had peri-ampullary duodenal adenocarcinoma. The 1-, 3-, and 5-year overall survival rates for patients who underwent radical surgery were 91.78%, 69.30%, and 55.86%, respectively. The median overall survival was 73 months (range, 64-84), and the median progression-free survival was 64 months (range, 52-76). No differences in survival were observed between the laparotomy and minimally invasive surgery groups (log-rank P = .562); furthermore, no significant between-group differences in operation time, lymph node dissection, postoperative complications, or in-hospital mortality were observed (P > .05). The minimally invasive surgery group experienced less intraoperative blood loss (250 mL vs 100 mL, P < .001), fewer intraoperative blood transfusions (24.97% vs 18.84%, P = .002), and shorter hospital stays (28 days vs 23 days, P < .001). Multivariate Cox regression analysis revealed that advanced age, advanced stage, longer operation time, intraoperative blood transfusion, and postoperative hemorrhage were independent risk factors for poor prognosis.

CONCLUSION

Radical surgery was associated with favorable overall survival among patients with duodenal adenocarcinoma, and no difference in survival was observed between patients with extra-ampullary duodenal adenocarcinoma and peri-ampullary duodenal adenocarcinoma. Minimally invasive surgery is a reliable alternative for duodenal adenocarcinoma treatment.

Minimally invasive pancreatoduodenectomy with combined venous vascular resection: A comparative analysis with open approach

Backgrounds/Aims

This study aimed to compare the minimally invasive pancreatoduodenectomy with venous vascular resection (MI-PDVR) and open pancreatoduodenectomy with venous vascular resection (O-PDVR) for periampullary cancer.

Methods

Data of 124 patients who underwent PDVR (45 MI-PDVR, 79 O-PDVR) between January 1, 2016, and December 31, 2023, was retrospectively reviewed.

Results

MI-PDVR is significantly better than O-PDVR in terms of perioperative outcomes (median operation time [452.69 minutes vs. 543.91 minutes; p = 0.004], estimated blood loss [410.44 mL vs. 747.59 mL; p < 0.01], intraoperative transfusion rate [2 cases vs. 18 cases; p = 0.01], and hospital stay [18.16 days vs. 23.91 days; p = 0.008]). The complications until the discharge day showed no significant difference between the two groups (Clavien-Dindo < 3, 84.4% vs. 82.3%; Clavien-Dindo ≥ 3, 15.6% vs. 17.7%; p = 0.809). In terms of long-term oncological outcomes, there was no statistical difference in overall survival (OS, 51.55 months [95% CI: 35.95-67.14] vs. median 49.92 months [95% CI: 40.97-58.87]; p = 0.340) and disease-free survival (DFS, median 35.06 months [95% CI: 21.47-48.65] vs. median 38.77 months [95% CI: 29.80-47.75]; p = 0.585), between the two groups. Long-term oncological outcomes for subgroup analysis focusing on pancreatic ductal adenocarcinoma also showed no statistical differences in OS (40.86 months [95% CI: 34.45-47.27] vs. 48.48 months [95% CI: 38.16-58.59]; p = 0.270) and DFS (24.42 months [95% CI: 17.03-31.85] vs. 34.35 months, [95% CI: 25.44-43.27]; p = 0.740).

Conclusions

MI-PDVR can provide better perioperative outcomes than O-PDVR, and has similar oncological impact.

Drainage posterior to pancreaticojejunostomy reduces the severity of postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common postoperative complication after pancreaticoduodenectomy (PD) and is associated with severe complications. Drainage is an effective method to treat POPF and prevent POPF-related complications. However, controversy still exists about whether different drainage methods reduce the incidence or the severity of POPF after PD.

METHODS

A closed suction drainage was placed posterior to pancreaticojejunostomy in PD except for other routine drainage placements. A retrospective study was conducted to calculate the incidence and severity of CR-POPF and POPF-related complications and to evaluate the efficacy of this drainage method.

RESULTS

295 patients who underwent PD were enrolled in this study, 130 patients in the trial group and 165 patients in the control group. The two groups were comparable in both preoperative and intraoperative characteristics. The overall incidence of CR-POPF was similar between the two groups. The trial group had a significantly decreased incidence of grade C POPF (0% vs. 3.6%, p < 0.05), post-pancreatectomy hemorrhage (PPH) (0% vs. 6.1%, p = 0.003), reoperation (0% vs. 3.6%, p = 0.036), intra-abdominal infection (13.1% vs. 25.5%, p = 0.008), and delayed gastric emptying (DGE) (2.3% vs. 8.5%, p = 0.024) than the control group. Subgroup analysis of patients with intermediate/high risk for CR-POPF mirrored these results. Logistic regression identified obstructive jaundice, biliary fistula, POPF, and DGE as independent risk factors for PPH and reoperation, though the results were not significant in multivariate analysis.

CONCLUSIONS

The drainage posterior to pancreaticojejunostomy reduces the severity of POPF and the incidence of POPF-related complications after PD.

The optimal choice for patients underwent minimally invasive pancreaticoduodenectomy: a systematic review and meta-analysis including patient subgroups

The aim of this meta-analysis was to evaluate the efficacy and safety of robotic pancreaticoduodenectomy (RPD) in improving perioperative aspects and postoperative complications in patients.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library database systems for studies that compared RPD with laparoscopic pancreaticoduodenectomy (LPD). Meta-analysis was performed for 24 relevant outcomes, including perioperative outcomes and postoperative complications. Subsequently, a subgroup analysis based on geographical regions was conducted to investigate the impact of regional differences on the perioperative outcomes of the RPD group and the LPD group.

RESULTS

This review found 19 studies with 12,731 individuals (3539 RPD and 9192 LPD). In comparison to LPD, RPD had lower rates of Conversion (OR = 0.58, P < 0.00001), Blood Transfusion (OR = 0.59, P = 0.02), Length of Stay (MD = - 0.54, P = 0.01), postoperative complications [Pneumonia (OR = 0.31, P < 0.0001), and Wound Disruption (OR = 0.26, P = 0.0007)], and more thorough lymph node harvesting (MD = 1.25, P = 0.001). Subgroup analysis showed that Blood Transfusion (I2 = 55%, P = 0.02), Conversion (I2 = 30%, P < 0.00001), Length of Stay (I2 = 71%, P = 0.01), and Lymph Node Harvested (I2 = 87%, P = 0.001) were statistically significant. Interestingly, compared to China, other countries had lower rates of Conversion and more lymph nodes harvested for RPD surgery.

CONCLUSION

The benefits of RPD surgery over LPD surgery in terms of therapy and an optimistic short-term prognosis are clearly supported by this study. Moreover, subgroup analysis based on regional differences revealed statistically significant results for Conversion, Length of Stay (days), Number of Lymph Nodes Harvested and the rate of Blood Transfusion, indicating significant variability across regions. This study provides a solid theoretical foundation and basis for the advancement of RPD in clinical practice.

Laparoscopic Right Hemicolectomy With Gastrocolic Trunk Resection for Advanced Transverse Colon Cancer

Locally advanced right-sided colon cancer sometimes requires advanced procedures in addition to normal complete mesocolic excision. We describe laparoscopic right hemicolectomy with gastrocolic trunk (GCT) resection. A 48-year-old woman was diagnosed with right transverse colon cancer and severe lymph node metastasis. Bulky lymph nodes were in contact with the superior mesenteric vein (SMV) that invaded the root of the GCT. Curative laparoscopic right hemicolectomy with GCT resection was performed. GCT resection was performed using both cranial and caudal approaches. First, we ligated the distal side of the GCT from the cranial side and dissected the mesocolonic root from the pancreas. Then, we moved to the caudal view. The root of the GCT was ligated, and the resected GCT was mobilized from the pancreatic head while carefully coagulating the anterior superior pancreaticoduodenal veins (ASPDVs) using an ultrasonically activated device (USAD). The patient's postoperative course was favorable. Approaching the GCT from both the cranial and caudal sides, considering the limited handling axis of laparoscopy, is useful for performing this procedure safely. The cranial approach is important for creating a cranial safety zone before transitioning to the caudal approach. The pitfall is that the ASPDVs should not be managed in this step because the head of the USAD will contact the pancreatic head owing to the handling axis. ASPDVs should be managed using the caudal approach with a cranial safety zone. Although rarely performed, this procedure is sometimes essential for the treatment of advanced right-sided colon cancer.

Laparoscopic Pancreatoduodenectomy: Twenty years later, where are we?

In its 20th anniversary, laparoscopic pancreatoduodenectomy, while feasible and safe in the hands of experienced surgeons, has not seen the anticipated popularity observed in other digestive surgery procedures. The primary hurdle remains the absence of a clear advantage over traditional open surgery, paired with the procedures complexity and a consequent steep learning curve. In regions with limited pancreatic surgery services, conducting this procedure without adequate training can have serious repercussions. Given the advent of robotic platforms and the anticipation of prospective and randomized studies on this new technology, it is imperative to engage in comprehensive discussions, endorsed by surgical societies, on the value, application, and implementation strategies for various minimally invasive pancreatoduodenectomy techniques. Such dialogue is crucial for advancing the field and ensuring optimal patient outcomes.

Laparoscopic versus open pancreaticoduodenectomy for ampullary cancer: A retrospective study

INTRODUCTION

Studies comparing laparoscopic pancreaticoduodenectomy (LPD) with open pancreaticoduodenectomy (OPD) for ampullary carcinoma (AC) are limited. This study aimed to compare short- and long-term outcomes between LPD and OPD for AC.

METHODS

This study included patients with AC who underwent pancreaticoduodenectomy (PD) with curative intention at Ogaki Municipal Hospital from April 2008 to March 2023.

RESULTS

Fifty-five patients underwent LPD (n = 26) or OPD (n = 29). There were no significant differences in the demographics between the two groups. The LPD group had a significantly longer operative time (268 vs. 225 min), less blood loss (125 vs. 450 mL), and shorter postoperative hospital stay (18 vs. 23 days) than the OPD group. There was no significant difference in the morbidity ratio. Fewer lymph nodes were harvested in the LPD group than OPD group (9.5 vs. 16.0), but there were no significant differences in lymph node metastasis or pathological stages. There were no significant differences in overall survival (OS) or recurrence-free survival (RFS). The 3- and 5-year OS rates in the LPD group and the OPD group were 63.0% and 54%, 64.8%, and 61.2%, respectively. The 3- and 5-year RFS rates were 57.4% and 57.4%, 58.1%, and 54.4%, respectively.

CONCLUSIONS

LPD for AC had short- and long-term outcomes comparable with those of OPD. LPD could be considered the standard treatments for AC because of less blood loss and a shorter hospital stay.

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.

Laparoscopic Radical Total Gastrectomy and Pancreatosplenectomy for Synchronous Cancer of the Stomach and Pancreas

The safety of laparoscopic surgery for advanced gastric and pancreatic cancers has been established individually, but there is little evidence for synchronous cancers. In this case, a 59-year-old man with a history of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) treatment for diffuse large B-cell lymphoma underwent laparoscopic surgery for a suspected pancreatic invasion of advanced gastric cancer. Pathology revealed double cancer of the stomach and pancreas. Laparoscopic total gastrectomy and distal pancreatectomy were successfully performed. The patient had a pancreatic leak on postoperative day seven but was discharged from the hospital on postoperative day 21. This case suggests the possibility of expanding the indications for laparoscopic surgery for similar cancers in the future. Additionally, the anatomical reticulum can be resected as a single mass using laparoscopy alone.

Extended lymphadenectomy based on the TRIANGLE for pancreatic head cancer: a single-center experience

BACKGROUND

This study was to compare the safety and efficacy of different lymphadenectomy methods in patients with pancreatic head cancer undergoing pancreaticoduodenectomy (PD).

MATERIAL AND METHODS

A total of 150 patients were included in this study. Patients were divided into Group A (n = 79), Group B (n = 44), and Group C (n = 27) according to the different lymphadenectomy methods. The clinical endpoint was time to progression (TTP) and overall survival (OS). Postoperative complications of different lymphadenectomy methods were compared respectively. TTP and OS of the three groups were compared by Kaplan-Meier curves.

RESULTS

There were no significant differences between the three groups in operative time (P = 0.300), death in the hospital (P = 0.253), postoperative hemorrhage (P = 0.863), postoperative pancreatic fistula (POPF) B/C (P = 0.306), bile leakage (P = 0.215), intestinal fistula (P = 0.177), lymphatic leakage (P = 0.267), delayed gastric emptying [(DGE) (P = 0.283)], ICU stay (P = 0.506), and postoperative hospital stay [(PHS) (P = 0.810)]. Median TTP in Groups B and C was significantly longer than in Group A (log-rank test, A vs B: P = 0.0005, A vs C: P = 0.0001). Median OS between the three groups has no statistical difference (P = 0.1546).

CONCLUSIONS

Extended lymphadenectomy methods based on the TRIANGLE do not increase perioperative complications significantly and can effectively delay tumor progression in patients with pancreatic head cancer.

Laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy for carcinoma of the ampulla of Vater in a medium-volume center: a propensity score matching analysis

OBJECTIVE

To compare the efficacy of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in a medium-volume medical center.

METHODS

Data for patients who underwent OPD or LPD for carcinoma of the ampulla of Vater (VPC) between January 2017 and June 2022 were acquired retrospectively. Propensity score-matching (PSM) analysis was performed to balance the baseline characteristics between the groups. The primary outcome was disease-free survival (DFS). Cox regression analysis was used to explore the independent risk factors for DFS.

RESULTS

A total of 124 patients with pathologically diagnosed VPC were included. After 1:1 matching, there were 23 cases each in the OPD and LPD groups. Kaplan-Meier survival analyses showed that the median DFS in the OPD and LPD groups was identical (16.0 months vs 16.0 months, respectively). Multivariate Cox regression analysis showed that low levels of alkaline phosphatase and γ-glutamyl transpeptidase, positive surgical margin, and lymph node enlargement were independent risk factors for DFS.

CONCLUSION

LPD in medium-volume centers with acceptable technical conditions may approach or even achieve the efficacy of LPD in large-volume centers.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

Comparison of laparoscopic and open pancreaticoduodenectomy for the treatment of distal cholangiocarcinoma: A propensity score matching analysis

BACKGROUND

There are few studies comparing the oncological outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for distal cholangiocarcinoma (DCC). Our objective was to assess the short-term efficacy and long-term survival of LPD and OPD in patients with DCC.

METHODS

The data of 124 DCC patients who underwent LPD or OPD at the Third Affiliated Hospital of Soochow University from May 2010 to May 2021 were retrospectively analyzed. Propensity score matching was performed to balance the two groups of baseline characteristics. After 1:1 matching, the overall survival (OS) of the two groups was compared by the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were used to identify independent predictors of OS.

RESULTS

The original cohort consisted of 124 patients. Nineteen patients were excluded because of incomplete baseline or follow-up data, and the remaining 105 patients were divided into two cohorts (45 in the LPD group and 60 in the OPD group). The LPD group showed more favorable results in OS analysis (LPD vs. OPD, 56.4 [46.2-66.5] vs. 48.9 [36.4-61.4], months, P=0. 01). PSM analysis identified 30 pairs of patients, and differences between matching groups were still significant (LPD vs. OPD, 67.9[58.2-77.6] vs. 47.4[31.4-67.5], months, P=0.002). Moreover, the LPD group experienced less intraoperative bleeding (LPD vs. OPD, 292.67 vs. 519.17 mL, P=0.002). Univariate analysis showed that surgical modality (P=0.012), carbohydrate antigen 19-9 (P=0.043), carcinoembryonic antigen (P=0.003), neutrophil-to-lymphocyte ratio (P=0.012), blood transfusion (P=0.031), clinically relevant postoperative pancreatic fistula (P<0.001) and lymphatic metastasis (P=0.004) were predictors of OS. Multivariate Cox analysis demonstrated that carbohydrate antigen 19-9 (P=0.048), carcinoembryonic antigen (P=0.031) and lymphatic metastasis (P=0.023) were independent predictive factors of OS. However, adjuvant therapy had no significant effect on the OS of DCC patients after radical pancreaticoduodenectomy (P>0.05).

CONCLUSIONS

For DCC patients, LPD may be a more recommended procedure because of its advantages over OPD in terms of intraoperative bleeding and long-term survival.

Laparoscopic Pancreatoduodenectomy in Elderly Patients: A Systematic Review and Meta-Analysis

Background and Aims: Recent single-center retrospective studies have focused on laparoscopic pancreatoduodenectomy (LPD) in elderly patients, and compared the outcomes between the laparoscopic and open approaches. Our study aimed to determine the outcomes of LPD in the elderly patients, by performing a systematic review and a meta-analysis of relevant studies. Methods: A comprehensive literature review was conducted utilizing the Embase, Medline, PubMed, Scopus and Cochrane databases to identify all studies that compared laparoscopic vs. open approach for pancreatoduodenectomy (PD). Results: Five retrospective studies were included in the final analysis. Overall, 90-day mortality rates were significantly decreased after LPD in elderly patients compared with open approaches (RR = 0.56; 95%CI: 0.32−0.96; p = 0.037, I2 = 0%). The laparoscopic approach had similar mortality rate at 30-day, readmission rate in hospital, Clavien−Dindo complications, pancreatic fistula grade B/C, complete resection rate, reoperation for complications and blood loss as the open approach. Additionally, comparing with younger patients (<70 years old), no significant differences were seen in elderly cohort patients regarding mortality rate at 90 days, readmission rate to hospital, and complication rate. Conclusions: Based on our meta-analysis, we identify that LPD in elderly is a safe procedure, with significantly lower 90-day mortality rates when compared with the open approach. Our results should be considered with caution, considering the retrospective analyses of the included studies; larger prospective studies are required.