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Mcdonald JD, Dore L. A review of the works of Dr. Vic Velanovich in the field of pancreatic surgery. Am J Surg 2022; 224:819-820. [PMID: 34972541 DOI: 10.1016/j.amjsurg.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022]
Affiliation(s)
- James D Mcdonald
- University of South Florida, Morsani College of Medicine, Department of Surgery, United States.
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Cawich SO, Kluger MD, Francis W, Deshpande RR, Mohammed F, Bonadie KO, Thomas DA, Pearce NW, Schrope BA. Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres. World J Gastrointest Surg 2021; 13:1122-1135. [PMID: 34754382 PMCID: PMC8554718 DOI: 10.4240/wjgs.v13.i10.1122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/19/2021] [Accepted: 09/23/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.
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Affiliation(s)
- Shamir O Cawich
- Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Michael D Kluger
- Department of Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY 10032, United States
| | - Wesley Francis
- Department of Surgery, University of the West Indies, Nassau N-1184, Bahamas
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Fawwaz Mohammed
- Department of Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Kimon O Bonadie
- Department of Surgery, Health Service Authority, Georgetown 915 GT, Cayman Islands
| | - Dexter A Thomas
- Department of Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Neil W Pearce
- Department of Surgery, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Beth A Schrope
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, United States
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Xourafas D, Ashley SW, Clancy TE. Comparison of Perioperative Outcomes between Open, Laparoscopic, and Robotic Distal Pancreatectomy: an Analysis of 1815 Patients from the ACS-NSQIP Procedure-Targeted Pancreatectomy Database. J Gastrointest Surg 2017; 21:1442-1452. [PMID: 28573358 DOI: 10.1007/s11605-017-3463-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 05/23/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Robotic surgery is gaining acceptance for distal pancreatectomy (DP). Nevertheless, no multi-institutional data exist to demonstrate the ideal clinical circumstances for use and the efficacy of the robot compared to the open or laparoscopic techniques, in terms of perioperative outcomes. METHODS The 2014 ACS-NSQIP procedure-targeted pancreatectomy data for patients undergoing DP were analyzed. Demographics and clinicopathological and perioperative variables were compared between the three approaches. Univariate and multivariable analyses were used to evaluate outcomes. RESULTS One thousand eight hundred fifteen DPs comprised 921 open distal pancreatectomies (ODPs), 694 laparoscopic distal pancreatectomies (LDPs), and 200 robotic distal pancreatectomies (RDPs). The three groups were comparable with respect to demographics, ASA score, relevant comorbidities, and malignant histology subtype. Compared to the ODP group, patients undergoing RDP had lower T-stages of disease (P = 0.0192), longer operations (P = 0.0030), shorter hospital stays (P < 0.0001), and lower postoperative 30-day morbidity (P = 0.0476). Compared to the LDP group, RDPs were longer operations (P < 0.0001) but required fewer concomitant vascular resections (P = 0.0487) and conversions to open surgery (P = 0.0068). On multivariable analysis, neoadjuvant therapy (P = 0.0236), malignant histology (P = 0.0124), pancreatic reconstruction (P = 0.0006), and vascular resection (P = 0.0008) were the strongest predictors of performing an ODP. CONCLUSIONS The open, laparoscopic, and robotic approaches to distal pancreatectomy offer particular advantages for well-selected patients and specific clinicopathological contexts; therefore, clearly demonstrating the most suitable use and superiority of one technique over another remains challenging.
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Affiliation(s)
- Dimitrios Xourafas
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02215, USA.
| | - Stanley W Ashley
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02215, USA
| | - Thomas E Clancy
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02215, USA
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A Systematic Review and Meta-Analysis of Laparoscopic and Open Distal Pancreatectomy of Nonductal Adenocarcinomatous Pancreatic Tumor (NDACPT) in the Pancreatic Body and Tail. Surg Laparosc Endosc Percutan Tech 2017; 27:206-219. [DOI: 10.1097/sle.0000000000000416] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Cesaretti M, Bifulco L, Costi R, Zarzavadjian Le Bian A. Pancreatic resection in the era of laparoscopy: State of Art. A systematic review. Int J Surg 2017; 44:309-316. [PMID: 28689866 DOI: 10.1016/j.ijsu.2017.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/22/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Manuela Cesaretti
- Service de Chirurgie Hépatique, Pancréatique et Biliaire, Transplantation Hépatique, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot-VII, Clichy, 92110, France; Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Lelio Bifulco
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Renato Costi
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, 43100, Italy
| | - Alban Zarzavadjian Le Bian
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Laboratoire d'Ethique Médicale et de Médecine Légale, Université Paris Descartes - V, Paris, 75006, France.
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Zhang AB, Wang Y, Hu C, Shen Y, Zheng SS. Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center experience. J Zhejiang Univ Sci B 2017; 18:532-538. [PMID: 28585429 PMCID: PMC5482047 DOI: 10.1631/jzus.b1600541] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 03/04/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to compare complications and oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) at a single center. METHODS Distal pancreatectomies performed for pancreatic ductal adenocarcinoma during a 4-year period were included in this study. A retrospective analysis of a database of this cohort was conducted. RESULTS Twenty-two patients underwent LDP for pancreatic ductal adenocarcinoma, in comparison to seventy-six patients with comparable tumor characteristics treated by ODP. No patients with locally advanced lesions were included in this study. Comparing LDP group to ODP group, there were no significant differences in operation time (P=0.06) or blood loss (P=0.24). Complications (pancreatic fistula, P=0.62; intra-abdominal abscess, P=0.44; postpancreatectomy hemorrhage, P=0.34) were similar. There were no significant differences in the number of lymph nodes harvested (11.2±4.6 in LDP group vs. 14.4±5.5 in ODP group, P=0.44) nor the rate of patients with positive lymph nodes (36% in LDP group vs. 41% in ODP group, P=0.71). Incidence of positive margins was similar (9% in LDP group vs. 13% in ODP group, P=0.61). The mean overall survival time was (29.6±3.7) months for the LDP group and (27.6±2.1) months for ODP group. There was no difference in overall survival between the two groups (P=0.34). CONCLUSIONS LDP is a safe and effective treatment for selected patients with pancreatic ductal adenocarcinoma. A slow-compression of pancreas tissue with the GIA stapler is effective in preventing postoperative pancreatic fistula. The oncologic outcome is comparable with the conventional open approach. Laparoscopic radical antegrade modular pancreatosplenectomy contributed to oncological clearance.
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Nanno Y, Goto T, Toyama H, Asari S, Terai S, Shirakawa S, Mizumoto T, Ueda Y, Kido M, Ajiki T, Fukumoto T, Ku Y. Internal hernia through a transverse mesocolon defect after laparoscopic distal pancreatectomy: Report of a case. Asian J Endosc Surg 2017; 10:187-190. [PMID: 27863050 DOI: 10.1111/ases.12336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/11/2016] [Accepted: 09/11/2016] [Indexed: 12/29/2022]
Abstract
We report a case of an internal hernia through a transverse mesocolon defect after laparoscopic distal pancreatectomy. The patient was a 58-year-old man with an intraductal papillary mucinous neoplasm of the pancreatic body who underwent laparoscopic distal pancreatectomy. During surgery, an approximately 5-cm defect in the transverse mesocolon was inadvertently made. The defect was not closed as it was thought to be large enough to preclude incarceration. However, the patient developed a bowel obstruction 2 months postoperatively. Laparotomy revealed that a loop of the proximal jejunum herniated through the defect and was adherent to the stapled pancreatic stump. An additional loop of the jejunum was herniated through the narrowed mesenteric defect. To our knowledge, this is the first case of an internal hernia through a transverse mesocolon defect after laparoscopic distal pancreatectomy.
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Affiliation(s)
- Yoshihide Nanno
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tadahiro Goto
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirochika Toyama
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sadaki Asari
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sachio Terai
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sachiyo Shirakawa
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takuya Mizumoto
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuki Ueda
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Kido
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tetsuo Ajiki
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takumi Fukumoto
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yonson Ku
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Pendola F, Gadde R, Ripat C, Sharma R, Picado O, Lobo L, Sleeman D, Livingstone AS, Merchant N, Yakoub D. Distal pancreatectomy for benign and low grade malignant tumors: Short-term postoperative outcomes of spleen preservation-A systematic review and update meta-analysis. J Surg Oncol 2017; 115:137-143. [PMID: 28133818 DOI: 10.1002/jso.24507] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 10/21/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The value of spleen preservation with distal pancreatectomy (DP) for benign and low grade malignant tumors remains unclear. The aim of this study was to evaluate the short-term postoperative clinical outcomes in patients undergoing DP with splenectomy (DPS) or spleen preservation (SPDP). METHODS Online database search was performed (2000 to present); key bibliographies were reviewed. Studies comparing patients undergoing DP with either DPS or SPDP, and assessing postoperative complications were included. RESULTS Meta-analysis of included data showed SPDP patients had significantly less operative blood loss, shorter duration of hospitalization, lower incidence of fluid collection and abscess, lower incidence of postoperative splenic and portal vein thrombosis, and lower incidence of new onset postoperative diabetes. For the whole group, there was no difference in incidence of postoperative pancreatic fistula (POPF) (RR = 0.95; 95%CI 0.65-1.40, P = 0.80), however, subgroup analysis of studies using ISGPF criteria showed that DPS patients had increased rates of Grade B/C POPF (RR = 1.35; 95%CI 1.08-1.70, P = 0.01). CONCLUSIONS SPDP for benign and low grade malignant tumors is associated with shorter hospital stay and decreased morbidity compared to DPS. J. Surg. Oncol. 2017;115:137-143. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Fiorella Pendola
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
| | - Rahul Gadde
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Caroline Ripat
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Rishika Sharma
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Omar Picado
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Laila Lobo
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Danny Sleeman
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Alan S Livingstone
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
| | - Danny Yakoub
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
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Left-sided pancreatic incidentalomas treated with laparoscopic approach: a report of 20 cases. World J Surg Oncol 2016; 14:204. [PMID: 27487847 PMCID: PMC4973032 DOI: 10.1186/s12957-016-0949-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/13/2016] [Indexed: 12/21/2022] Open
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Casadei R, Ricci C, D'Ambra M, Marrano N, Alagna V, Rega D, Monari F, Minni F. Laparoscopic versus open distal pancreatectomy in pancreatic tumours: a case-control study. Updates Surg 2016; 62:171-4. [PMID: 21052893 DOI: 10.1007/s13304-010-0027-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Laparoscopic distal pancreatectomy has become an increasingly used procedure in the surgical treatment of benign or borderline cystic and endocrine tumours. The feasibility and safety of this technique is well known but its results when compared with open distal pancreatectomy were rarely reported in literature. Data from 22 consecutive patients who underwent laparoscopic distal pancreatectomy were recorded in a prospective database from January 2006 to January 2010. These patients were matched with 22 patients who underwent open distal pancreatectomy from January 2000 to December 2005, regarding age, gender, American Society of Anesthesiologists score, pancreatic pathology. Intraoperative parameters and postoperative outcome were compared between the two groups. Blood loss, amount of analgesic drugs administered, postoperative mortality and morbidity and pancreatic fistula rate were similar in laparoscopic and open groups. Tumour size was significantly smaller in laparoscopic group (2.0 ± 3.3 vs. 5.0 ± 4.2 cm; P = 0.038). Operative time was significantly shorter in open group (145 ± 49 vs. 225 ± 83 min, P = 0.045). Time to adequate oral intake and length of postoperative hospital stay were significantly better in laparoscopic group than in open group (3.0 ± 0.8 vs. 4.0 ± 0.7 days; P = 0.030 and 8.0 ± 1.3 vs. 11.0 ± 3.0 days; P = 0.011, respectively). Laparoscopic distal pancreatectomy is a feasible and safe surgical approach as well as open distal pancreatectomy.
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Affiliation(s)
- Riccardo Casadei
- Dipartimento di Scienze Chirurgiche e Anestesiologiche, Chirurgia Generale-Minni, Alma Mater Studiorum, Università di Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti, 9, 40138, Bologna, Italy,
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Fernandez Ranvier GG, Shouhed D, Inabnet WB. Minimally Invasive Techniques for Resection of Pancreatic Neuroendocrine Tumors. Surg Oncol Clin N Am 2015; 25:195-215. [PMID: 26610782 DOI: 10.1016/j.soc.2015.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Surgical resection remains the treatment of choice for primary pancreatic neuroendocrine tumors (PNETs), because it is associated with increased survival. Minimally invasive procedures are a safe modality for the surgical treatment of PNETs. In malignant PNETs, laparoscopy is not associated with a compromise in terms of oncologic resection, and provides the benefits of decreased postoperative pain, better cosmetic results, shorter hospital stay, and a shorter postoperative recovery period. Further prospective, multicenter, randomized trials are required for the analysis of these minimally invasive surgical techniques for the treatment of PNETs and their comparison with traditional open pancreatic surgery.
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Affiliation(s)
- Gustavo G Fernandez Ranvier
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 5 East 98 street, box 1259, New York, NY 10029, USA
| | - Daniel Shouhed
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 5 East 98 street, box 1259, New York, NY 10029, USA
| | - William B Inabnet
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, First Ave at 16th street, Baird Hall, Suite 16BH20, New York, NY 10003, USA.
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12
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Kriger AG, Berelavichus SV, Smirnov AV, Gorin DS, Akhtanin EA. [Comparative results of open robot-assisted and laparoscopic distal pancreatic resection]. Khirurgiia (Mosk) 2015:23-29. [PMID: 25909547 DOI: 10.17116/hirurgia2015123-29] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
It was performed a retrospective analysis of the results of distal pancreatic resections (DPR) in 89 patients with different tumors. Conventional open operations were performed in 60 patients, robot-assisted - in 19 patients, laparoscopic - in 10 cases. Absolute indication for open surgery was pancreatic cancer T3-4 stages. Mini-invasive distal resections (robot-assisted and laparoscopic) were performed in cases of pancreatic cancer T1-2 stages, benign tumors and tumors with low potential of malignancy and diameter up to 4-5 cm. Results of robot-assisted and laparoscopic interventions are similar but robot-assisted technique provides more precise surgery. It improves quality of lymphadenectomy, decreases probability of intraoperative bleeding. Duration of robot-assisted and open operation did not differ significantly. Blood loss was significantly lower in group of robot-assisted method (mean 470 ml) while in cases of open and laparoscopic techniques this parameter was 1013.8 and 833.3 ml respectively. Postoperative complications in open, laparoscopic and robot-assisted groups developed in 45.1, 52.6 and 50% of observations respectively. Pancreatic fistulas were revealed in 58.8, 80 and 58.3% of cases respectively. There were not deaths after laparoscopic and robot-assisted pancreatic resections. 2 patients died after open surgery.
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Affiliation(s)
- A G Kriger
- Institut khirurgii im. A.V. Vishnevskogo Minzdrava RF, Moskva
| | | | - A V Smirnov
- Institut khirurgii im. A.V. Vishnevskogo Minzdrava RF, Moskva
| | - D S Gorin
- Institut khirurgii im. A.V. Vishnevskogo Minzdrava RF, Moskva
| | - E A Akhtanin
- Institut khirurgii im. A.V. Vishnevskogo Minzdrava RF, Moskva
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Results of 100 consecutive laparoscopic distal pancreatectomies: postoperative outcome, cost-benefit analysis, and quality of life assessment. Surg Endosc 2014; 29:1871-8. [PMID: 25294551 DOI: 10.1007/s00464-014-3879-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 09/02/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) has been recently proposed as the procedure of choice for lesions of the pancreatic body and tail in experienced centres. The purpose of this study is to assess the potential advantages of LDP in a consecutive series of 100 patients. METHODS Propensity score matching was used to identify patients for comparison between LDP and control open group. Match criteria were: age, gender, ASA score, BMI, lesion site and size, and malignancy. All patients were treated according to an early feeding recovery policy. Primary endpoint was postoperative morbidity rate. Secondary endpoints were operative time, blood transfusion, length of hospital stay (LOS), hospital costs, and quality of life. RESULTS Thirty patients of the LDP group had pancreatic adenocarcinoma. Conversion to open surgery was necessary in 23 patients. Mean operative time was 29 min shorter in the open group (p = 0.002). No significant difference between groups was found in blood transfusion rate and postoperative morbidity rate. LDP was associated with an early postoperative rehabilitation and a shorter LOS in uneventful patients. Economic analysis showed <euro> 775 extra cost per patient of the LDP group. General health perception and vitality were better in the LDP group one month after surgery. CONCLUSION Laparoscopic distal pancreatectomy improved short-term postoperative recovery and quality of life in a consecutive series of both cancer and non-cancer patients. Despite the extra cost, the laparoscopic approach should be considered the first option in patients undergoing distal pancreatectomy.
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Björnsson B, Sandström P. Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas. World J Gastroenterol 2014; 20:13402-13411. [PMID: 25309072 PMCID: PMC4188893 DOI: 10.3748/wjg.v20.i37.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 02/11/2014] [Accepted: 04/23/2014] [Indexed: 02/07/2023] Open
Abstract
Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.
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15
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Küper MA, Eisner F, Königsrainer A, Glatzle J. Laparoscopic surgery for benign and malign diseases of the digestive system: Indications, limitations, and evidence. World J Gastroenterol 2014; 20:4883-4891. [PMID: 24803799 PMCID: PMC4009519 DOI: 10.3748/wjg.v20.i17.4883] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/23/2013] [Accepted: 02/17/2014] [Indexed: 02/06/2023] Open
Abstract
The laparoscopic technique was introduced in gastrointestinal surgery in the mid 1980s. Since then, the development of this technique has been extraordinary. Triggered by technical innovations (stapling devices or coagulation/dissecting devices), nowadays any type of gastrointestinal resection has been successfully performed laparoscopically and can be performed laparoscopically dependent on the patient’s condition. This summary gives an overview over 30 years of laparoscopic surgery with focus on today’s indications and evidence. Main indications remain the more common procedures, e.g., appendectomy, cholecystectomy, bariatric procedures or colorectal resections. For all these indications, the laparoscopic approach has become the gold standard with less perioperative morbidity. Regarding oncological outcome there have been several high-quality randomized controlled trials which demonstrated equivalency between laparoscopic and open colorectal resections. Less common procedures like esophagectomy, oncological gastrectomy, liver and pancreatic resections can be performed successfully as well by an experienced surgeon. However, the evidence for these special indications is poor and a general recommendation cannot be given. In conclusion, laparoscopic surgery has revolutionized the field of gastrointestinal surgery by reducing perioperative morbidity without disregarding surgical principles especially in oncological surgery.
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Drymousis P, Raptis DA, Spalding D, Fernandez-Cruz L, Menon D, Breitenstein S, Davidson B, Frilling A. Laparoscopic versus open pancreas resection for pancreatic neuroendocrine tumours: a systematic review and meta-analysis. HPB (Oxford) 2014; 16:397-406. [PMID: 24245906 PMCID: PMC4008158 DOI: 10.1111/hpb.12162] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 06/11/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Over the last decade laparoscopic pancreatic surgery (LPS) has emerged as an alternative to open pancreatic surgery (OPS) in selected patients with neuroendocrine tumours (NET) of the pancreas (PNET). Evidence on the safety and efficacy of LPS is available from non-comparative studies. OBJECTIVES This study was designed as a meta-analysis of studies which allow a comparison of LPS and OPS for resection of PNET. METHODS Studies conducted from 1994 to 2012 and reporting on LPS and OPS were reviewed. Studies considered were required to report on outcomes in more than 10 patients on at least one of the following: operative time; hospital length of stay (LoS); intraoperative blood loss; postoperative morbidity; pancreatic fistula rates, and mortality. Outcomes were compared using weighted mean differences and odds ratios. RESULTS Eleven studies were included. These referred to 906 patients with PNET, of whom 22% underwent LPS and 78% underwent OPS. Laparoscopic pancreatic surgery was associated with a lower overall complication rate (38% in LPS versus 46% in OPS; P < 0.001). Blood loss and LoS were lower in LPS by 67 ml (P < 0.001) and 5 days (P < 0.001), respectively. There were no differences in rates of pancreatic fistula, operative time or mortality. CONCLUSIONS The nature of this meta-analysis is limited; nevertheless LPS for PNET appears to be safe and is associated with a reduced complication rate and shorter LoS than OPS.
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Affiliation(s)
- Panagiotis Drymousis
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College LondonLondon, UK
| | - Dimitri A Raptis
- Departmentof Visceral and Transplantation Surgery, University Hospital ZurichZurich, Switzerland
| | - Duncan Spalding
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College LondonLondon, UK
| | | | - Deepak Menon
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College LondonLondon, UK
| | | | - Brian Davidson
- Department of Surgery, Royal Free Campus, University College London Medical SchoolLondon, UK
| | - Andrea Frilling
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College LondonLondon, UK,Correspondence Andrea Frilling, Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0HR, UK. Tel: + 44 20 3313 3210. Fax: + 44 20 3313 3963. E-mail:
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Gumbs AA, Croner R, Rodriguez A, Zuker N, Perrakis A, Gayet B. 200 consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder. Surg Endosc 2013; 27:3781-91. [PMID: 23644837 DOI: 10.1007/s00464-013-2969-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 04/03/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Because of the potential benefit of robotics in pancreatic surgery, we review our experience at two minimally invasive pancreatic surgery centers that utilize a robotically controlled laparoscope holder to see if smaller robots that enable the operating surgeon to maintain contact with the patient may have a role in the treatment of pancreatic disease. METHODS From March 1994 to June 2011, a total of 200 laparoscopic pancreatic procedures utilizing a robotically controlled laparoscope holder were performed. RESULTS A total of 72 duodenopancreatectomies, 67 distal pancreatectomies, 23 enucleations, 20 pancreatic cyst drainage procedures, 5 necrosectomies, 5 atypical pancreatic resections, 4 total pancreatectomies, and 4 central pancreatectomies were performed. Fourteen patients required conversion to an open approach and eight a hand-assisted one. A total of 24 patients suffered a major complication. Sixteen patients developed a pancreatic leak and 19 patients required reoperation. Major complications occurred in 14 patients and pancreatic leaks occurred in 13 patients. Ten patients required conversion to a lap-assisted or open approach and six patients required reoperation. CONCLUSIONS Currently, a robotically assisted approach using a camera holder seems the only way to incorporate some of the benefits of robotics in pancreatic surgery while maintaining haptics and contact with the patient.
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Affiliation(s)
- Andrew A Gumbs
- Department of Surgical Oncology, Summit Medical Group, Berkeley Heights, NJ, 07922, USA,
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Hartmann D, Michalski CW, Kleeff J. Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Pankreas - Kontra-Position. Visc Med 2013; 29:375-381. [DOI: 10.1159/000357173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
<b><i>Hintergrund: </i></b>Für eine Vielzahl von Erkrankungen der Bauchspeicheldrüse gilt die chirurgische Resektion als die Therapie der Wahl. In den vergangenen Jahren wurden die offenen Operationsmethoden für Pankreaserkrankungen zunehmend standardisiert und können mittlerweile mit hoher Sicherheit durchgeführt werden. Unabhängig davon wird zunehmend über laparoskopische Pankreasresektionen berichtet. <b><i>Methode: </i></b>In diesem Artikel stellen wir die aktuelle Literatur zur minimalinvasiven Chirurgie der Bauchspeicheldrüse vor, um sie mit offenen Operationsverfahren zu vergleichen. Besondere Berücksichtigung finden laparoskopische und roboterassistierte Duodenopankreatektomien sowie laparoskopische Pankreasschwanzresektionen bei Patienten mit chronischer Pankreatitis sowie mit gutartigen und bösartigen Tumoren. <b><i>Ergebnisse: </i></b>Laparoskopische und roboterassistierte Pankreaskopfresektionen sollten nur in ausgewählten Fällen angewandt werden und gelten als technisch äußerst anspruchsvoll - mit einer erhöhten Inzidenz von Pankreasfisteln. Laparoskopische Pankreasschwanzresektionen sind sichere Verfahren mit einem Trend zu einer kürzeren Krankenhausaufenthaltsdauer, sollten jedoch nur für gutartige Tumoren in Betracht gezogen werden. Im Rahmen der onkologischen Chirurgie sollte die offene Pankreasresektion bevorzugt werden. Werden onkologische Eingriffe laparoskopisch durchgeführt, ist eine ausgezeichnete präoperative Diagnostik und gegebenenfalls der Einsatz eines intraoperativen laparoskopischen Ultraschalls notwendig. <b><i>Schlussfolgerungen: </i></b>Obwohl laparoskopische Pankreasresektionen in ausgewählten Fällen von Nutzen sein können, werden sie zukünftig wohl eher die Ausnahme darstellen. Eine allgemeine Umstellung auf laparoskopische Pankreasschwanzresektionen wird aufgrund des Mangels an eindeutigen Vorteilen gegenüber dem offenen Verfahren höchstwahrscheinlich nicht stattfinden.
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Jin T, Altaf K, Xiong JJ, Huang W, Javed MA, Mai G, Liu XB, Hu WM, Xia Q. A systematic review and meta-analysis of studies comparing laparoscopic and open distal pancreatectomy. HPB (Oxford) 2012; 14:711-24. [PMID: 23043660 PMCID: PMC3482667 DOI: 10.1111/j.1477-2574.2012.00531.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Currently, laparoscopic distal pancreatectomy (LDP) is regarded as a safe and effective surgical approach for lesions in the body and tail of the pancreas. This review compares outcomes of the laparoscopic technique with those of open distal pancreatectomy (ODP) and assesses the efficacy, safety and feasibility of each type of procedure. METHODS Comparative studies published between January 1996 and April 2012 were included. Studies were selected based on specific inclusion and exclusion criteria. Evaluated endpoints were operative outcomes, postoperative recovery and postoperative complications. RESULTS Fifteen non-randomized comparative studies that recruited a total of 1456 patients were analysed. Rates of conversion from LDP to open surgery ranged from 0% to 30%. Patients undergoing LDP had less intraoperative blood loss [weighted mean difference (WMD) -263.36.59 ml, 95% confidence interval (CI) -330.48 to -196.23 ml], fewer blood transfusions [odds ratio (OR) 0.28, 95% CI 0.11-0.76], shorter hospital stay (WMD -4.98 days, 95% CI -7.04 to -2.92 days), a higher rate of splenic preservation (OR 2.98, 95% CI 2.18-3.91), earlier oral intake (WMD -2.63 days, 95% CI -4.23 to 1.03 days) and fewer surgical site infections (OR 0.37, 95% CI 0.18-0.75). However, there were no differences between the two approaches with regard to operation time, time to first flatus and the occurrence of pancreatic fistula and other postoperative complications. CONCLUSIONS Laparoscopic resection results in improved operative and postoperative outcomes compared with open surgery according to the results of the present meta-analyses. It may be a safe and feasible option for patients with lesions in the body and tail of the pancreas. However, randomized controlled trials should be undertaken to confirm the relevance of these early findings.
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Affiliation(s)
- Tao Jin
- Pancreatic Diseases Research Group, Department of Integrated Traditional and Western MedicineChengdu, China,Liverpool National Institute of Health Research (NIHR) Pancreas Biomedical Research Unit, Royal Liverpool University HospitalLiverpool, UK
| | - Kiran Altaf
- Liverpool National Institute of Health Research (NIHR) Pancreas Biomedical Research Unit, Royal Liverpool University HospitalLiverpool, UK
| | - Jun J Xiong
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan UniversityChengdu, China
| | - Wei Huang
- Pancreatic Diseases Research Group, Department of Integrated Traditional and Western MedicineChengdu, China,Liverpool National Institute of Health Research (NIHR) Pancreas Biomedical Research Unit, Royal Liverpool University HospitalLiverpool, UK
| | - Muhammad A Javed
- Liverpool National Institute of Health Research (NIHR) Pancreas Biomedical Research Unit, Royal Liverpool University HospitalLiverpool, UK
| | - Gang Mai
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan UniversityChengdu, China
| | - Xu B Liu
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan UniversityChengdu, China
| | - Wei M Hu
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan UniversityChengdu, China
| | - Qing Xia
- Pancreatic Diseases Research Group, Department of Integrated Traditional and Western MedicineChengdu, China
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Laparoscopic Radiofrequency Ablation of Functioning Pancreatic Insulinoma. Surg Laparosc Endosc Percutan Tech 2012; 22:e312-5. [DOI: 10.1097/sle.0b013e318264b607] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Fisher SB, Kooby DA. Laparoscopic pancreatectomy for malignancy. J Surg Oncol 2012; 107:39-50. [PMID: 22991263 DOI: 10.1002/jso.23253] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/09/2012] [Indexed: 12/15/2022]
Abstract
Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.
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Affiliation(s)
- Sarah B Fisher
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Rosales-Velderrain A, Bowers SP, Goldberg RF, Clarke TM, Buchanan MA, Stauffer JA, Asbun HJ. National trends in resection of the distal pancreas. World J Gastroenterol 2012; 18:4342-9. [PMID: 22969197 PMCID: PMC3436049 DOI: 10.3748/wjg.v18.i32.4342] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/23/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate national trends in distal pancreatectomy (DP) through query of three national patient care databases. METHODS From the Nationwide Inpatient Sample (NIS, 2003-2009), the National Surgical Quality Improvement Project (NSQIP, 2005-2010), and the Surveillance Epidemiology and End Results (SEER, 2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy. Utilization of laparoscopy was defined in NIS by the International Classification of Diseases, Ninth Revision correspondent procedure code; and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes. In SEER, patients were identified by the International Classification of Diseases for Oncology, Third Edition diagnosis codes and the SEER Program Code Manual, third edition procedure codes. We analyzed the databases with respect to trends of inpatient outcome metrics, oncologic outcomes, and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection. RESULTS NIS, NSQIP and SEER identified 4242, 2681 and 11,082 DP resections, respectively. Overall, laparoscopy was utilized in 15% (NIS) and 27% (NSQIP). No significant increase was seen over the course of the study. Resection was performed for malignancy in 59% (NIS) and 66% (NSQIP). Neither patient Body mass index nor comorbidities were associated with operative approach (P = 0.95 and P = 0.96, respectively). Mortality (3% vs 2%, P = 0.05) and reoperation (4% vs 4%, P = 1.0) was not different between laparoscopy and open groups. Overall complications (10% vs 15%, P < 0.001), hospital costs [44,741 dollars, interquartile range (IQR) 28 347-74 114 dollars vs 49 792 dollars, IQR 13 299-73 463, P = 0.02] and hospital length of stay (7 d, IQR 4-11 d vs 7 d, IQR 6-10, P < 0.001) were less when laparoscopy was utilized. One and two year survival after resection for malignancy were unchanged over the course of the study (ductal adenocarinoma 1-year 63.6% and 2-year 35.1%, P = 0.53; intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%, P = 0.25). The majority of resections were performed in teaching hospitals (77% NIS and 85% NSQIP), but minimally invasive surgery (MIS) was not more likely to be used in teaching hospitals (15% vs 14%, P = 0.26). Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles (88% vs 43%, P < 0.001), but were no more likely to utilize MIS at resection. Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching (15% vs 14%, P = 0.72) and lower volume hospitals (14% vs 15%, P = 0.99). No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year (P = 0.17 and P = 0.96, respectively). CONCLUSION There appears to be an overall underutilization of laparoscopy for DP. Centralization does not appear to be occurring. Survival and lymph node harvest have not changed.
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Kaplan M. A case report of an ampullary tumor presenting with spontaneous perforation of an aberrant bile duct and treated with total laparoscopic pancreaticoduodenectomy. World J Surg Oncol 2012; 10:142. [PMID: 22788965 PMCID: PMC3506572 DOI: 10.1186/1477-7819-10-142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 06/25/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This case report discusses a patient who presented with bile peritonitis due to spontaneous perforation of an aberrant bile duct that originated in the triangular ligament of the liver. It was associated with an ampullary tumor and treated with total laparoscopic pancreaticoduodenectomy (TLPD). CASE REPORT A 58-year-old male patient was admitted to the emergency department of Medical Park Gaziantep Hospital in September 2009 with acute abdominal findings. He underwent an urgent laparoscopy, and, interestingly, bile peritonitis due to the rupture of an aberrant bile duct in the triangular ligament was noted. After laparoscopic treatment of the acute conditions, the follow-up examinations of the patient showed the finding of obstructive jaundice. Endoscopic retrograde cholangio-pancreatography revealed a 1-cm polypoid mass located at the ampulla of Vater (duodenal papilla) with possible extension to the ampullary sphincter. A stent was inserted for temporary biliary drainage, and subsequent endoscopic biopsy showed the pathological finding of adenocarcinoma.After waiting for a 1-month period for the peritonitis to heal, the patient underwent pylorus-preserving TLPD and was discharged without any major complications on postoperative day 7. CONCLUSION In patients with bile peritonitis, it should be considered that the localization of the perforation may be in an aberrant bile duct localized at the triangular ligament and the etiology may be associated with an obstructing periampullary tumor. Laparoscopic pancreaticoduodenectomy is a feasible operative procedure in carefully selected patients. This technique can achieve adequate margins and follows oncological principles. Randomized comparative studies are needed to establish the superiority of minimally invasive surgery over traditional open surgery.
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Affiliation(s)
- Mehmet Kaplan
- Department of General Surgery, Medical Park Gaziantep Hospital, Gaziantep, Turkey.
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Braga M, Ridolfi C, Balzano G, Castoldi R, Pecorelli N, Di Carlo V. Learning curve for laparoscopic distal pancreatectomy in a high-volume hospital. Updates Surg 2012; 64:179-83. [DOI: 10.1007/s13304-012-0163-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 06/09/2012] [Indexed: 12/13/2022]
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Sui CJ, Li B, Yang JM, Wang SJ, Zhou YM. Laparoscopic versus open distal pancreatectomy: A meta-analysis. Asian J Surg 2012; 35:1-8. [DOI: 10.1016/j.asjsur.2012.04.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/25/2011] [Accepted: 12/01/2011] [Indexed: 12/25/2022] Open
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Boutros C, Ryan K, Katz S, Espat NJ, Somasundar P. Total Laparoscopic Distal Pancreatectomy: Beyond Selected Patients. Am Surg 2011. [DOI: 10.1177/000313481107701145] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Laparoscopic distal pancreatectomy (LDP) has emerged as the procedure of choice for selected patients. This study is to evaluate the feasibility of LDP and procedural outcomes in a series of consecutive nonselected patients. All patients undergoing distal pancreatectomy over 18 months were identified from a prospectively maintained database, under institutional review board approval. A completely laparoscopic (non hand-assisted) procedure was performed using a 4-trocar technique. Conversion to an open procedure, operative time (OR), estimated blood loss (EBL), transfusion requirements, postoperative length of stay (LOS), and complications were assessed. Sixteen patients were identified; 2/16 patients had undergone distal pancreatectomy as a component of another multiorgan open procedure, and were thus excluded. The remaining 14 patients had consented for LDP. Conversion occurred in 4/14 cases. Converted patients trended towards increased OR, EBL, and LOS ( P = not significant). No mortalities occurred, and overall morbidities included: pancreatic fistula (n = 2), splenic abscess (n = 1), and pneumonia (n = 1). LDP-splenectomy (n = 3/14) was associated with both increased EBL (683 mL ± 388 vs 168 ± 141, P < 0.002) and increased transfusion rate (3/3 vs 3/11, P = 0.05), as compared with LDP-splenic preservation. LDP with splenic artery preservation (LDP-SAP) was completed in 7 of 14 patients, with less OR (2 hours 29 minutes ± 53 minutes vs 3 hours 40 minutes ± 1 hour, P < 0.05), a decreased transfusion rate (14% vs 71%, P = 0.05), and decreased LOS (2.8 days vs 6.8 days, P = 0.002) compared with LDP without SAP. Pathology was intraductal papillary mucinous neoplasm (IPMN) (n = 5), ductal carcinoma (n = 3), high grade dysphasia (n = 2), neuroendocrine tumor (n = 2), and pancreatitis (n = 2). Patients undergoing LDP-SAP demonstrated superior peri-procedural outcomes. This series of nonselected consecutive patients supports that LDP is technically feasible with a comparable procedural outcome to the selected-patient literature, suggesting potentially expanded indications for LDP.
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Affiliation(s)
- Cherif Boutros
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristin Ryan
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
| | - Steven Katz
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
| | - N. Joseph Espat
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
| | - Ponnandai Somasundar
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
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Shrikhande SV, Barreto SG, Shukla PJ. Laparoscopy in pancreatic tumors. J Minim Access Surg 2011; 3:47-51. [PMID: 21124651 PMCID: PMC2980720 DOI: 10.4103/0972-9941.33272] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Recently, increasing number of manuscripts - original articles and case reports have attempted to provide evidence of the forays of minimal access surgery into pancreatic diseases. Many, based on the lack of Level I evidence, still believe that laparoscopy in pancreatic surgery is experimental. This article attempts to look into data exploring the existing use of minimally invasive surgery in pancreatic disease to answer a vital question - what does the evidence say on the current status of laparoscopic surgery in pancreatic tumors.
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Affiliation(s)
- S V Shrikhande
- Department of Gastrointestinal and Hepatopancreatobiliary Surgical Oncology, Tata Memorial Hospital, Mumbai - 400012, India
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Li W, An L, Liu R, Yao K, Hu M, Zhao G, Tang J, Lv F. Laparoscopic ultrasound enhances diagnosis and localization of insulinoma in pancreatic head and neck for laparoscopic surgery with satisfactory postsurgical outcomes. ULTRASOUND IN MEDICINE & BIOLOGY 2011; 37:1017-1023. [PMID: 21640474 DOI: 10.1016/j.ultrasmedbio.2011.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 04/04/2011] [Accepted: 04/08/2011] [Indexed: 05/30/2023]
Abstract
This study explored the value of laparoscopic ultrasonography (LUS) for tumor localization in laparoscopic pancreatic surgery of insulinomas, especially for tumors located at anatomically unfavorable positions. Twenty-eight patients with insulinomas were enrolled in this study between July 2007 and March 2009. Various image examinations were performed preoperatively. An iU22 ultrasound system equipped with a 5.0-9.0 MHz transducer was used for LUS. The tumor localization and postsurgical outcomes were evaluated. Intraoperative LUS precisely localized 33 insulinomas in 26 of 28 patients, whereas the preoperative imaging studies detected 27 of 33 (82%) tumors. No definite tumor in the pancreas and extra-pancreatic organs was identified in two patients by both preoperative and intraoperative imaging examinations. Of 33 tumors, 32 (97%) were localized in the pancreas (14 in the head and neck, 18 in the body and tail), whereas one (3%) was found in the duodenal ligament. Successful laparoscopic resection of insulinoma was performed in 21 of 26 patients, including resection of 11 tumors located in the head and neck of the pancreas. Five patients required conversion to open surgery. All insulinomas were benign with a mean size 13.8 mm. Four patients had pancreatic-related complications that spontaneously healed within 3 weeks after surgery. The median hospital stay was 8.5 days. Our study demonstrates that laparoscopic pancreatic resection under the guidance of advanced LUS is not only feasible and safe for tumors located at the body and tail but also for tumors located at the head and neck of the pancreas.
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Affiliation(s)
- Wenxiu Li
- Department of Ultrasound, Chinese People's Liberation Army General Hospital of Airforce, Beijing, P.R. China.
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Ammori BJ, Ayiomamitis GD. Laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a UK experience and a systematic review of the literature. Surg Endosc 2011; 25:2084-99. [PMID: 21298539 DOI: 10.1007/s00464-010-1538-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 12/02/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Advances in operative techniques and technology have facilitated laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD). METHODS All distal pancreatectomies were attempted laparoscopically, while selected patients underwent LPD. The literature was systematically reviewed. RESULTS Between 2002 and 2008, 21 patients underwent LDP (n=14) or LPD (n = 7). The mean operating time, blood loss, and hospital stay after LDP were 265 min, 262 ml, and 7.7 days, respectively, and after LPD they were 628 min, 350 ml, and 11.1 days, respectively. The conversion, morbidity, pancreatic fistula, readmission, reoperation, and mortality after LDP were 7.1, 35.7, 28.4, 28.4, 0, and 7.1% respectively, and after LPD they were 0, 28.6, 14.3, 28.6, 0, and 0% respectively. The literature review identified 987 LDP and 126 LPD. Most LDP were for benign disease (83.9%) while most LPD were for malignancy (91.5%). The mean operating time, morbidity, pancreatic fistula, mortality, and hospital stay after LDP were 221.5 min, 24.7%, 16.4%, 0.4%, and 7.7 days, respectively, and after LPD they were 448.3 min, 28.6%, 11.6%, 2.1%, and 16 days, respectively. CONCLUSION LDP, particularly for benign disease and low-grade malignancy, is increasingly becoming the gold standard approach in experienced hands. In selected patients, LPD is feasible and safe. Long-term follow-up data are needed.
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Affiliation(s)
- Basil J Ammori
- Department of Hepato-Pancreato-Biliary Surgery, North Manchester General Hospital, and The University of Manchester, Delaunays Road, Manchester, UK.
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Laparoscopic distal pancreatectomy for solid and cystic pancreatic neoplasms: outpatient postoperative management. Surg Laparosc Endosc Percutan Tech 2011; 19:470-3. [PMID: 20027089 DOI: 10.1097/sle.0b013e3181c4775f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy is a challenging procedure that has been reported in the last decade. The aim of this study is to describe our experience with laparoscopic distal pancreatectomy and an outpatient postoperative management after an early hospital discharge. METHODS Retrospective study of 11 laparoscopic distal pancreatectomies carried out at our institution between November 2005 and June 2007 for cystic and solid pancreatic neoplasms. Mean age was 55.5 years and 10 patients were females. A splenopancreatectomy was carried out in 9 cases, and a spleen-preserving resection was carried out in 2 cases. RESULTS Mean blood loss was 73.6 mL and mean operative time was 238.3 minutes. Patients were able to tolerate regular diet after a mean of 1.2 days and were discharged with a drain after a mean of 2.3 days. Two patients developed a mild pancreatic fistula that resolved with conservative management. One patient developed a pancreatic pseudocyst that was followed up with an MRI. CONCLUSIONS Laparoscopic distal pancreatectomy is feasible with a fast postoperative recovery. We recommend close follow-up of the patient in the outpatient clinic and maintaining the intraabdominal drain until a pancreatic fistula can be ruled out based on biochemical analysis of the fluid.
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DiNorcia J, Schrope BA, Lee MK, Reavey PL, Rosen SJ, Lee JA, Chabot JA, Allendorf JD. Laparoscopic distal pancreatectomy offers shorter hospital stays with fewer complications. J Gastrointest Surg 2010; 14:1804-12. [PMID: 20589446 PMCID: PMC3081877 DOI: 10.1007/s11605-010-1264-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 06/07/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. The aim of this study was to investigate short-term outcomes after LDP compared to open distal pancreatectomy (ODP) at a single, high-volume institution. METHODS We reviewed records of patients who underwent distal pancreatectomy (DP) and compared perioperative data between LDP and ODP. Continuous variables were compared using Student's t or Wilcoxon rank-sum tests. Categorical variables were compared using chi-square or Fisher's exact test. RESULTS A total of 360 patients underwent DP. Beginning in 2001, 95 were attempted, and 71 were completed laparoscopically with a 25.3% conversion rate. Compared to ODP, LDP had similar rates of splenic preservation, pancreatic fistula, and mortality. LDP had lower blood loss (150 vs. 900 mL, p < 0.01), smaller tumor size (2.5 vs. 3.6 cm, p < 0.01), and shorter length of resected pancreas (7.7 vs. 10.0 cm, p < 0.01). LDP had fewer complications (28.2% vs. 43.8%, p = 0.02) as well as shorter hospital stays (5 vs. 6 days, p < 0.01). CONCLUSIONS LDP can be performed safely and effectively in patients with benign or low-grade malignant neoplasms of the distal pancreas. When feasible in selected patients, LDP offers fewer complications and shorter hospital stays.
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Affiliation(s)
- Joseph DiNorcia
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Aly MYF, Tsutsumi K, Nakamura M, Sato N, Takahata S, Ueda J, Shimizu S, Redwan AA, Tanaka M. Comparative study of laparoscopic and open distal pancreatectomy. J Laparoendosc Adv Surg Tech A 2010; 20:435-40. [PMID: 20518689 DOI: 10.1089/lap.2009.0412] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) has been shown to be an effective surgical option for benign lesions in the body and tail of the pancreas. However, its advantages and disadvantages have not been well characterized. In this study, we compared the outcomes of LDP and open pancreatectomy performed in our clinic. MATERIALS AND METHODS Peri- and postoperative outcomes were retrospectively compared between patients with benign pancreatic disorders who underwent open distal pancreatectomy (ODP) (n = 35) and those who underwent LDP (n = 40). The peri- and postoperative factors analyzed included operative time, blood loss, hospital stay, postoperative recovery, biochemical findings, and complications. RESULTS LDP was associated with significantly less operative blood loss (363 versus 606 mL; P = 0.001) and shorter hospital stay (22 versus 27 day; P = 0.009), but longer operative time (342 versus 250 min; P = 0.000), compared with ODP. There were no significant differences between the two groups in complication rates or postoperative recovery, except for the significantly shorter duration of postoperative pain-killer intake and earlier improvement of the biochemical analysis in LDP than in ODP. CONCLUSIONS LDP appears to be a safe, desirable procedure for the management of benign pancreatic diseases, with outcomes similar to ODP.
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Affiliation(s)
- Mohamed Y F Aly
- Department of Endoscopic Diagnostics and Therapeutics, Kyushu University Hospital, Fukuoka, Japan
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Preoperative endoscopic tattooing of pancreatic body and tail lesions decreases operative time for laparoscopic distal pancreatectomy. Surgery 2010; 148:371-7. [PMID: 20554299 DOI: 10.1016/j.surg.2010.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 04/13/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Precise and expedient localization of small pancreatic tumors during laparoscopic distal pancreatectomy can be difficult owing to the decreased tactile ability of laparoscopy and the homogenous appearance of the surrounding retroperitoneal fat. Precise localization of the lesion is critical to achieving adequate margins of resection while preserving as much healthy pancreas as possible. The objective in this study was to determine the effect of endoscopic tattooing of the distal pancreas on operative time. METHODS We reviewed retrospectively 36 consecutive patients who had a laparoscopic distal pancreatectomy at our institution over a 4-year period (2006-2009). Ten patients underwent preoperative tattooing via an endoscopic transgastric technique using ultrasound guidance. The tattoo was performed using 2-4 cc of sterile purified carbon particles injected immediately proximal and anterior to the pancreatic lesion. Operative times were compared according to the presence of a tattoo. RESULTS The endoscopically placed tattoo was easily visible upon entering the lesser sac in all 10 patients at laparoscopy. Patients with a tattoo had a shorter operative time (median, 128.5 minutes; range, 53-180) compared with patients without a tattoo (median, 180 minutes; range, 120-240; P < .01). None of the tattoo group required repeat surgery, whereas 1 patient who was not tattooed required re-resection for a lesion missed in the initial specimen. There were no complications associated with the endoscopic ultrasound-guided tattoo. CONCLUSION Endoscopic ultrasound-guided tattooing of pancreas lesions before a laparoscopic distal pancreatectomy is safe and is associated with decreased operative time compared with nontattooed patients. This technique can allow for quick and precise localization of the lesion, allowing for optimal preservation of pancreas parenchyma and demarcating an appropriate line of resection.
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Optimal technical management of stump closure following distal pancreatectomy: a retrospective review of 215 cases. J Gastrointest Surg 2010; 14:998-1005. [PMID: 20306151 DOI: 10.1007/s11605-010-1185-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 02/23/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic fistula (PF) is a major source of morbidity following distal pancreatectomy (DP). Our aim was to identify risk factors related to PF following DP and to determine the impact of technique of transection and stump closure. METHODS We performed a retrospective review of 215 consecutive patients who underwent DP. Perioperative and postoperative data were collected and analyzed with attention to PF as defined by the International Study Group of Pancreatic Fistula. RESULTS PF developed in 36 patients (16.7%); fistulas were classified as Grade A (44.4%), B (44.4%), or C (11.1%). The pancreas was transected with stapler (n = 139), cautery (n = 70), and scalpel (n = 3). PF developed in 19.8% of remnants which were stapled/oversewn and 27.7% that were stapled alone (p = 0.4). Of the 69 pancreatic remnants transected with cautery and oversewn, a fistula developed in 4.3% (p = 0.004 compared to stapled/oversewn; p = 0.006 compared to stapled/not sewn). The median length of postoperative hospital stay was significantly increased in patients who developed PF (10 vs. 6 days, p = 0.002) CONCLUSION The method of transection and management of the pancreatic remnant plays a critical role in the formation of PF following DP. This series suggests that transection using electrocautery followed by oversewing of the pancreatic remnant has the lowest risk of PF.
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Abstract
The rapid growth of minimally invasive technology and experience in recent decades has revolutionized many aspects of oncologic surgery. Adoption of laparoscopic pancreatectomy has been slow due to the inherent anatomic complexity of pancreatic surgery, as well as concerns of perioperative complications and compromised oncologic results. With increasing surgeon experience and growing data, laparoscopic pancreatic resection is generating considerable attention and enthusiasm. This article provides an overview of laparoscopic pancreatic tumor surgery with respect to tumor biology and technical approaches. Current applications of laparoscopic approaches to left pancreatectomy, tumor enucleation, central pancreatectomy, and pancreaticoduodenectomy for treatment of pancreatic tumors are considered in light of available evidence demonstrating feasibility, safety, and oncologic efficacy. Future directions in minimally invasive pancreatic surgery are explored.
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Affiliation(s)
- Carrie K Chu
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road, NE, H120, Atlanta, GA 30322, USA
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Barreto SG, Shukla PJ, Shrikhande SV. Tumors of the Pancreatic Body and Tail. World J Oncol 2010; 1:52-65. [PMID: 29147182 PMCID: PMC5649906 DOI: 10.4021/wjon2010.04.200w] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2010] [Indexed: 12/11/2022] Open
Abstract
Tumors of the pancreatic body and tail are uncommon. They have a propensity to present late and often attain a large size with local invasion before they produce any clinical symptoms. The current review aims at comprehensively analysing these tumors with respect to their pathology, presentation, the investigation of these tumors, and finally the latest trends in their surgical and medical management.
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Affiliation(s)
- Savio George Barreto
- Department of General and Digestive Surgery, Flinders Medical Centre, Adelaide - South Australia
| | - Parul J Shukla
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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Abstract
Solid lesions of the body and tail of the pancreas challenge all the diagnostic and technical skills of the modern gastrointestinal surgeon. The information available from modern computed tomography (CT), magnetic resonance (MR), and endoscopic ultrasound (EUS) imaging provide diagnostic and anatomic data that give the surgeon precise information with which to plan an operation and to discuss with the patient during the preoperative visit. A preoperative evaluation includes a thorough history and a pancreas protocol CT scan, supplemented by MR imaging and EUS when needed, to differentiate between the various potential diagnoses. These same modalities can be essential in proper staging in the case of malignant lesions, thus aiding in management decisions. Most lesions ultimately require operative resection, barring metastatic disease, with the notable exception of autoimmune pancreatitis.
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Boutros C, Espat NJ, Somasundar P. Completely laparoscopic subtotal pancreatectomy with splenic artery preservation. J Gastrointest Surg 2010; 14:171-4. [PMID: 19727972 DOI: 10.1007/s11605-009-0995-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 08/10/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Laparoscopic distal pancreatectomy has emerged as an attractive minimally invasive alternative for selected patients. Although technically challenging, distal pancreatectomy with splenic artery preservation has consistently been correlated with reduced blood loss and perioperative morbidity in multiple studies. Herein presented is our technique for completely laparoscopic (non-hand-assisted) subtotal pancreatectomy with splenic artery preservation (LSP-SAP). METHODS An 87-year-old woman with an incidentally identified 3-cm cystic lesion in the pancreatic body-tail interface underwent EUS, which supported side-branch intraductal papillary mucinous neoplasm. The patient subsequently underwent laparoscopic resection. A completely laparoscopic procedure was performed using a four-trochar technique. The tail and body of the pancreas were dissected off of the retroperitoneum along the embryologic plane and separated from the colonic splenic flexure. Next, the splenic artery was dissected, isolated, and preserved, while the splenic vein was dissected off the ventral pancreas up to the level of the splenic-portal vein confluence. The technique employed a bipolar cutter-sealing device for dissection and hemostasis. Pancreatic parenchymal transection was performed with a standard vascular load endomechanical stapling device. RESULTS Total procedure time was 210 min, and the estimated blood loss was 200 mL. Postoperatively, the patient was admitted, advanced to regular diet the next day, and discharged home on postoperative day 3. The pathological review of the specimen revealed high-grade dysplasia with a non-invasive malignant component, classified as intraductal carcinoma. Foci of PanIN 1-3 were identified with no high grade dysplasia at the surgical margin. Five lymph nodes were included in the specimen and were negative for malignancy. CONCLUSION Completely LSP-SAP can be safely performed in selected patients. This procedure may be an optimal alternative to open surgery.
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Affiliation(s)
- Cherif Boutros
- Hepatobiliary and Surgical Oncology, Roger Williams Medical Center, Providence, RI 02908, USA
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Merchant NB, Parikh AA, Kooby DA. Should all distal pancreatectomies be performed laparoscopically? Adv Surg 2009; 43:283-300. [PMID: 19845186 DOI: 10.1016/j.yasu.2009.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.
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Affiliation(s)
- Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232-6860, USA.
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Laparoscopic Distal Pancreatectomy. J Am Coll Surg 2009; 209:758-65; quiz 800. [DOI: 10.1016/j.jamcollsurg.2009.08.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Revised: 08/12/2009] [Accepted: 08/19/2009] [Indexed: 12/14/2022]
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Giger U, Michel JM, Wiesli P, Schmid C, Krähenbühl L. Laparoscopic surgery for benign lesions of the pancreas. J Laparoendosc Adv Surg Tech A 2009; 16:452-7. [PMID: 17004867 DOI: 10.1089/lap.2006.16.452] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Minimally invasive pancreatic surgery, although known to be feasible and safe, is still not considered a standard procedure. We report our experience with laparoscopic pancreatic surgery in a retrospective case series. MATERIALS AND METHODS Fifteen consecutive patients (3 male, 12 female) underwent primarily laparoscopic pancreatic surgery from February 2000 to June 2005. Histologically confirmed diagnoses were: neuroendocrine pancreatic tumors (n = 11), adult nesidioblastosis (n = 1), serous cystadenoma (n = 1), and pseudocysts due to chronic pancreatitis (n = 2). RESULTS Enucleation (n = 3) or left pancreatic resection with spleen preservation (n = 6) was performed laparoscopically in 9 patients. The mean (+/-standard deviation) operative time was 173 +/- 48 minutes (range, 120-250 minutes) and the mean postoperative hospital stay was 5.5 +/- 1.2 days (range, 5-8 days) for the laparoscopic cases. Conversion to open surgery was necessary in 6 patients because of: closeness of the lesion to the portal/mesenteric vein (n = 3), inadequate intraoperative tumor localization (n = 2), or stapler device dysfunction (n = 1). In these patients, open enucleation (n = 1), middle segment pancreatectomy (n = 2), left pancreatic resection (n = 2), and pylorus-preserving Whipple resection (n = 1) were performed. The mean operative time was 268 +/- 74 minutes (range, 150-360 minutes) with a mean postoperative hospital stay of 8 +/- 2 days (range, 6-10 days). Both operative time and hospital stay were significantly longer in patients with secondary open surgery compared to patients with successful laparoscopic operations. CONCLUSION Laparoscopic enucleation or distal pancreatectomy with spleen preservation for benign lesions located in the body or tail of the pancreas can be performed safely, with all the potential benefits of minimally invasive surgery. Preoperative tumor localization is of utmost importance to limit pancreatic mobilization and to avoid blind pancreatic resection and conversion to open surgery.
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Affiliation(s)
- Urs Giger
- Department of Surgery, Hôpital Cantonal Fribourg, Fribourg, Switzerland
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43
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Langer P, Fendrich V, Bartsch DK. [Minimally invasive resection of neuroendocrine pancreatic tumors]. Chirurg 2009; 80:105-12. [PMID: 19099267 DOI: 10.1007/s00104-008-1613-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pancreatic endocrine tumors (PET) are a heterogeneous group of lesions with an annual incidence of 0.1 to 0.4 per 100,000. They account for 2-4% of pancreatic neoplasms. Due to their mostly small size, some are suited to a laparoscopic approach. Preoperative localization, intraoperative laparoscopic ultrasonography, and considerable experience in pancreatic endocrine surgery and sophisticated laparoscopic techniques are essential for successful laparoscopic treatment of these tumors. If definite or highly suspicious signs of malignancy occur, a conventional open approach should be preferred. Insulinomas and small nonfunctioning PET in the pancreatic body or tail or near the surface of the pancreatic head and not in contact with the portal vein or the main pancreatic duct are suited to a laparoscopic approach. Patients with MEN1 who have insulinomas or small nonfunctioning PET may also benefit from a laparoscopic spleen-preserving distal pancreatic resection. Neither sporadic and MEN1-associated gastrinomas nor the very rare glucagonomas and vasoactive intestinal peptide-producing tumors (vipomas), which are often large and malignant, should also be tackled laparoscopically.
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Affiliation(s)
- P Langer
- Klinik für Visceral-, Thorax- und Gefässchirurgie, Universitätsklinikum Giessen und Marburg GmbH, Standort Marburg, Baldingerstrasse, Marburg, Germany.
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Abstract
BACKGROUND A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications. METHODS 129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications. RESULTS T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others. CONCLUSIONS Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications.
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Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, Praveen Raj P. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. ACTA ACUST UNITED AC 2009; 16:731-40. [PMID: 19652900 DOI: 10.1007/s00534-009-0157-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/31/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy is a technically demanding surgery performed only at few centers in the world. This article aims to describe the evolution of the technique and summarizes the results in our institute over the years. METHODS Prospective data of patients undergoing laparoscopic pancreaticoduodenectomy from March 1998 to January 2009 was retrospectively reviewed. RESULTS There were a total of 75 patients (22 females and 53 males) with a mean age of 62 (range, 28-76) years. Conversion rate was 0%, overall postoperative morbidity was 26.7% and mortality rate was 1. 33%. Pancreatic fistula was seen in 6.67%. The mean operating time was 357 min (range 270-650), and the mean blood loss was 74 ml (range 35-410). The average time to the first bowel movement was 3 days and mean hospital stay was 8.2 days (range 6-42). Resected margins were positive in 2.6% of cases. The mean number of retrieved lymph nodes for the malignant lesions was 14 (range 8-22). CONCLUSION Laparoscopic pancreaticoduodenectomy can be safely performed by highly skilled laparoscopic surgeons. This technique can achieve adequate margins and follow oncological principles. Randomized comparative trials are needed to establish the superiority of laparoscopy versus open surgery.
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Affiliation(s)
- C Palanivelu
- GEM Hospital, 45-A, Pankaja Mill Road, Ramnathapuram, Coimbatore, 641045, India.
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Finan KR, Cannon EE, Kim EJ, Wesley MM, Arnoletti PJ, Heslin MJ, Christein JD. Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes. Am Surg 2009. [DOI: 10.1177/000313480907500807] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.
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Affiliation(s)
- Kelly R. Finan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily E. Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eugenia J. Kim
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary M. Wesley
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pablo J. Arnoletti
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Martin J. Heslin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John D. Christein
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Briggs CD, Mann CD, Irving GRB, Neal CP, Peterson M, Cameron IC, Berry DP. Systematic review of minimally invasive pancreatic resection. J Gastrointest Surg 2009; 13:1129-37. [PMID: 19130151 DOI: 10.1007/s11605-008-0797-z] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Accepted: 12/11/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic resection is associated with a significant morbidity. Efforts to reduce hospital stay and enhance recovery have seen the introduction of minimally invasive surgical techniques. This article reviews the current published literature on the safety and efficacy of minimally invasive surgery of the pancreas. METHODS An electronic search of the PubMed and Embase databases was performed from 1996 to May 2008 to identify all relevant publications; studies meeting predefined inclusion criteria were retrieved and analyzed using a standardized protocol. Data on the safety and efficacy of minimally invasive surgery of the pancreas were recorded and analyzed. RESULTS Of 565 abstracts reviewed, 39 studies were identified as eligible for inclusion. There were 37 case series and two case control studies. Compared with open pancreatic surgery, minimally invasive pancreatic resection is similar in terms of morbidity and mortality. Blood loss and length of stay are decreased. CONCLUSIONS Laparoscopic distal pancreatic resection and enucleation of insulinoma appear to be safe procedures with reduced hospital stay, though morbidity remains significant. The evidence for laparoscopic pancreaticoduodenectomy is in its infancy, but the authors feel it is unlikely that many centers will achieve sufficient case load to make the introduction of minimally invasive resection feasible.
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Affiliation(s)
- Christopher D Briggs
- Cancer Biomarkers and Prevention Group, Department of Cancer Studies and Molecular Medicine, Bio centre, University of Leicester, University Road, Leicester LE1 7RH, UK.
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Abu Hilal M, Jain G, Kasasbeh F, Zuccaro M, Elberm H. Laparoscopic distal pancreatectomy: critical analysis of preliminary experience from a tertiary referral centre. Surg Endosc 2009; 23:2743-7. [PMID: 19462202 DOI: 10.1007/s00464-009-0499-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 02/20/2009] [Accepted: 03/25/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic pancreatic surgery has been slow to gain wide acceptance due to the complex pancreatic anatomy and physiology. The aim of this study was to analyze our preliminary results and highlight the impact of centralization on surgeon workload and pancreatic surgical innovation. METHODS A retrospective analysis was performed on all patients who underwent laparoscopic distal pancreatectomy from May 2007 to October 2008. RESULTS Laparoscopic distal pancreatectomy was performed in 17 patients during that period. Median operative time was 180 min (range 120-300 min). Median blood loss was 100 ml (range 50-500 ml). Splenectomy was performed in 12 patients. None of the patients was converted to open operation. All patients were kept in high-dependency unit for median duration of 1 day (range 0-1 day). One patient with previous cardiac disease was kept in intensive therapy unit for one night, but discharged home on 7th postoperative day without any complications. Postoperative recovery was uneventful in 13 patients, while four patients had pancreatic leak. One pancreatic leak was observed in the last 11 patients, in which pancreatic stump was oversewn. In three patients, pancreatic leaks (PL) were minor and settled with conservative management, while one patient needed a computed tomography (CT)-guided drainage and subsequent minilaparotomy for wash out of the intra abdominal collection. None of the patients died in this series. Median hospital stay was 5 days (range 4-7 days). CONCLUSIONS Laparoscopic distal pancreatic resection is feasible, safe, and efficient. However, this surgery should only be performed in specialized centres with extensive experience in pancreatic and laparoscopic surgery. Oversewing the pancreatic stump after transaction with Endostapler may reduce the incidence of pancreatic leak. Centralization of pancreatic surgery has a positive impact on building up surgical expertise, resulting in obvious benefits for both patients and institutions.
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Affiliation(s)
- Mohammed Abu Hilal
- Hepato pancreatico biliary Unit, Surgical Academic Unit, F Level Southampton General Hospital, Southampton, UK.
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Luo Y, Liu R, Hu MG, Mu YM, An LC, Huang ZQ. Laparoscopic surgery for pancreatic insulinomas: a single-institution experience of 29 cases. J Gastrointest Surg 2009; 13:945-50. [PMID: 19224293 DOI: 10.1007/s11605-009-0830-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Accepted: 01/28/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic approach has been increasingly used in the treatment of pancreatic benign diseases. This report evaluates our experience with laparoscopic surgery for pancreatic insulinomas. METHODS Between July 2000 and December 2007, laparoscopic pancreatectomy was attempted in 29 consecutive patients with insulinomas. The localization of tumors, operating characteristics, and clinical outcomes were analyzed. RESULTS Tumors were precisely localized in 28 of 29 (96.6%) patients by a combination of preoperative imaging techniques and intraoperative ultrasonography. Laparoscopic pancreatectomy was successfully performed in 26 patients, including enucleation (n = 14), hand-assisted enucleation (n = 2), and distal pancreatectomy with (n = 9) or without (n = 1) spleen preservation. Two conversions to open procedure were required because of unfavorable locations of the tumors. The pancreatic fistula occurred in four patients who underwent tumor enucleation. The median hospital stay was 5.5 days (range, 3-18 days) after laparoscopic procedure. Twenty-eight patients with pancreatic resection were free of symptoms and remained normoglycemic after a median follow-up period of 19 months (range, 10-36 months). CONCLUSION Laparoscopic pancreatic resection is a feasible and safe procedure for patients with insulinomas. Further studies are required to evaluate the potential application of the hand-assisted approach for tumors located at anatomically unfavorable positions.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, The General Hospital of Chinese People Liberation Army, 28 Fu Xing Road, Beijing, China
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Hirota M, Ichihara A, Furuhashi S, Tanaka H, Takamori H, Baba H. Spleen and gastrosplenic ligament preserving distal pancreatectomy under a minimum incision approach assisted by laparoscopy. ACTA ACUST UNITED AC 2009; 16:792-5. [DOI: 10.1007/s00534-009-0113-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 03/30/2009] [Indexed: 10/20/2022]
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