Laparoscopic Pancreaticoduodenectomy: A Retrospective Review of 19 Cases. Surg Laparosc Endosc Percutan Tech. 2008;18:13-18. [PMID: 18287976 DOI: 10.1097/sle.0b013e3181581609]

Complexity and Experience Grading to Guide Patient Selection for Minimally Invasive Pancreatoduodenectomy: An International Study Group for Pancreatic Surgery (ISGPS) Consensus

OBJECTIVE

To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD).

BACKGROUND

Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience.

METHODS

The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions.

RESULTS

The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification.

CONCLUSIONS

This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries.

Low-cost model for pancreatojejunostomy simulation in minimally invasive pancreatoduodenectomy

Minimally invasive pancreatoduodenectomy (MIS PD) is a well reported technique with several advantages over conventional open pancreatoduodenectomy. In comparison to distal pancreatectomy, the adoption of MIS PD has been slow due to the technical challenges involved, particularly in the reconstruction phase of the pancreatojejunostomy (PJ) anastomosis. Hence, we introduce a low-cost model for PJ anastomosis simulation in MIS PD. We fashioned a model of a cut pancreas and limb of jejunum using economical and easily accessible materials comprising felt fabric and the modelling compound, Play-Doh. Surgeons can practice MIS PJ suturing using this model to help mount their individual learning curve for PJ creation. Our video demonstrates that this model can be utilized in simulation practice mimicking steps during live surgery. Our model is a cost-effective and easily replicable tool for surgeons looking to simulate MIS PJ creation in preparation for MIS PD.

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

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

Hybrid Laparoscopic Versus Open Pancreatoduodenectomy. A Meta-Analysis

INTRODUCTION

Hybrid laparoscopic techniques have been proposed as a good transition from open to complete minimally invasive approach especially in complex surgical procedures. This meta-analysis aimed to compare the outcomes of hybrid laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy.

METHODS

A systematic literature research was performed according to PRISMA guidelines. A broad search strategy with terms "laparoscopy" and "pancreatoduodenectomy" was used. Included studies were analyzed by quantitative meta-analysis using the metafor package for R software.

RESULTS

Of 655 identified articles, 627 were excluded and 28 articles fully assessed, including 14 comparative studies, 8 case series and 6 case reports. Extracted data included intraoperative variables and postoperative outcome parameters. The predefined inclusion criteria were met by 14 comparative studies, and 371 patients were pooled in the meta-analysis. Hybrid laparoscopic pacreatoduodenectomy was associated with significantly longer operative time (I² 0%, p = 0,01, Mean HPD 494,6 min, Mean OPD 421,6 min, WMD 67 min, 95% CI 14-120 min). For all other postoperative outcome parameters, no statistically significant differences were found. A nonsignificant reduction in intraoperative transfusion rate (I² 20%, p = 0,2, proportion HPD 2%, proportion OPD 1,6%, OR 0,44, 95% CI 0,16-1,27) and blood loss (I² 95%, p = 0,1, Mean HPD 397,2 ml, Mean OPD 1017,8 ml, MD - 601 ml, 95% CI - 1311-108) was observed for hybrid pancreatoduodenectomy in comparison to open surgery.

CONCLUSIONS

This meta-analysis demonstrates significantly increased operation time for hybrid laparoscopic compared to open pancreatoduodenectomy. Intraoperative variables as well as postoperative parameters and major morbidity were comparable for both techniques. Overall results of this meta-analysis demonstrated the hybrid technique as a safe procedure in high-volume centers offering aspects of a safe transition to fully laparoscopic pancreatoduodenectomy.

Assessing the perioperative complications and outcomes of robotic pancreaticoduodenectomy using the National Cancer Database: is it ready for prime time?

Robotic pancreaticoduodenectomy has generated significant interest in recent years. Our study aimed to evaluate the difference in surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) by either a robotic (RPD) or open approach (OPD). Using the National Cancer Database, we identified patients from 2010 and 2017 diagnosed with pancreatic adenocarcinoma and underwent pancreaticoduodenectomy by either robotic PD or open approach. Patients who underwent robotic PD during 2010 were compared to patients receiving the same procedure in 2017. In addition, a secondary analysis was performed to assess outcomes of robotic PD to open PD for the 2017 patient cohorts. Our primary outcomes included 30-day and 90-day mortality, length of stay, as well as 30-day readmission. Secondary outcome measures were surgical margins, lymph node yield, and adjuvant chemotherapy initiation within 12 weeks of surgery. When we compared the 2017 data to 2010 data, we found that robotic pancreaticoduodenectomy had lower 30- and 90-day mortality rates in 2017 compared to 2010. Additionally, we found that the lymph node yield in robotic PD increased during the study period. When we compared robotic PD to open PD for 2017, we found no statistically significant differences in readmission rates (10.1% vs. 9.7%: p-0.4), lymph node yield, or negative margin between the groups. Outcomes of robotic PD have improved over the years. In 2017, outcomes of robotic PD were similar to open PD.

Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) offers theoretical advantages to conventional laparoscopic surgery including improved instrument dexterity, 3D visualization and better ergonomics. This review aimed to determine if these theoretical advantages translate into improved patient outcomes comparing patients having either robotic pancreaticoduodenectomy or laparoscopic (LPD) equivalent.

METHOD

A systematic literature search was conducted for studies reporting minimally invasive surgery for pancreaticoduodenectomy either robotic assisted or totally laparoscopic. Meta-analysis of intra-operative (blood loss, operating times, conversion and R0 resections) and postoperative outcomes (overall complications, pancreatic fistula, length of hospital stay) was performed using a random effects model.

RESULT

This review identified 44 studies, of which six were non-randomised comparative studies including 3462 patients (1025 robotic and 2437 laparoscopic). Intraoperatively, RPD was associated with significantly lower conversion rates (OR 0.45, p < 0.001) and transfusion rates (OR: 0.60, p = 0.002) compared to LPD. However, no significant difference in blood loss (mean: 220 vs 287 mL, p = 0.1), operating time (mean: 405 vs 418 min, p = 0.3) was noted. Postoperatively RPD was associated with a shorter hospital stay (mean: 12 vs 11 days, p < 0.001) but no significant difference was noted in postoperative complications, incidence of pancreatic fistulae and R0 resection rates.

CONCLUSION

RPD appears to offer some advantages compared to conventional laparoscopic surgery, although both approaches appear to offer equivalent clinical outcomes. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomised trial comparing both techniques is needed.

Laparoscopic pancreaticoduodenectomy: are the best times coming?

BACKGROUND

The introduction of laparoscopic technology has greatly promoted the development of surgery, and the trend of minimally invasive surgery is becoming more and more obvious. However, there is no consensus as to whether laparoscopic pancreaticoduodenectomy (LPD) should be performed routinely.

MAIN BODY

We summarized the development of laparoscopic pancreaticoduodenectomy (LPD) in recent years by comparing with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD) and evaluated its feasibility, perioperative, and long-term outcomes including operation time, length of hospital stay, estimated blood loss, and overall survival. Then, several relevant issues and challenges were discussed in depth.

CONCLUSION

The perioperative and long-term outcomes of LPD are no worse and even better in length of hospital stay and estimated blood loss than OPD and RPD except for a few reports. Though with strict control of indications, standardized training, and learning, ensuring safety and reducing cost are still and will always the keys to the healthy development of LPD; the best times for it are coming.

Minimally invasive pancreaticoduodenectomy for periampullary disease: a comprehensive review of literature and meta-analysis of outcomes compared with open surgery

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear.

METHODS

Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis.

RESULTS

One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes.

CONCLUSION

Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.

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

BACKGROUND

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

DATA SOURCE

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

RESULTS

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

CONCLUSIONS

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

Minimally Invasive Versus Open Pancreatoduodenectomy: Systematic Review and Meta-analysis of Comparative Cohort and Registry Studies

OBJECTIVE

This study aimed to appraise and to evaluate the current evidence on minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy only in comparative cohort and registry studies.

BACKGROUND

Outcomes after MIPD seem promising, but most data come from single-center, noncomparative series.

METHODS

Comparative cohort and registry studies on MIPD versus open pancreatoduodenectomy published before August 23, 2015 were identified systematically and meta-analyses were performed. Primary endpoints were mortality and International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula (POPF).

RESULTS

After screening 2293 studies, 19 comparative cohort studies (1833 patients) with moderate methodological quality and 2 original registry studies (19,996 patients) were included. For cohort studies, the median annual hospital MIPD volume was 14. Selection bias was present for cancer diagnosis. No differences were found in mortality [odds ratio (OR) = 1.1, 95% confidence interval (CI) = 0.6-1.9] or POPF [(OR) = 1.0, 95% CI = 0.8 to 1.3]. Publication bias was present for POPF. MIPD was associated with prolonged operative times [weighted mean difference (WMD) = 74 minutes, 95% CI = 29-118], but lower intraoperative blood loss (WMD = -385 mL, 95% CI = -616 to -154), less delayed gastric emptying (OR = 0.6, 95% = CI 0.5-0.8), and shorter hospital stay (WMD = -3 days, 95% CI = -5 to -2). For registry studies, the median annual hospital MIPD volume was 2.5. Mortality after MIPD was increased in low-volume hospitals (7.5% vs 3.4%; P = 0.003).

CONCLUSIONS

Outcomes after MIPD seem promising in comparative cohort studies, despite the presence of bias, whereas registry studies report higher mortality in low-volume centers. The introduction of MIPD should be closely monitored and probably done only within structured training programs in high-volume centers.

A Propensity Score-Matched Analysis of Robotic vs Open Pancreatoduodenectomy on Incidence of Pancreatic Fistula

Importance

The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD).

Objective

To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD.

Design, Setting, and Participants

Data were accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center-in a standardized fashion-by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement.

Interventions

Use of RPD or OPD.

Main Outcomes and Measures

The major outcome of interest was CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy.

Results

The overall cohort was 51.5% male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score-matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95% CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95% CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95% CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs ≥5 mm: 2 mm, OR, 2.1 [95% CI, 1.4-3.1]; P < .001; ≤1 mm, OR, 1.8 [95% CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs ≤400 mL: 401-700 mL, OR, 1.5 [95% CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95% CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95% CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95% CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6% vs 11.2%; P = .23). This relationship held for both grade B (6.6% vs 9.2%; P = .52) and grade C (0% vs 2.0%; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7% vs 66.4%; P = .21), severe complications (Accordion grade ≥3, 23.05% vs 23.7%; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4% vs 21.7%; P > .99), and 90-day mortality (3.3% vs 1.3%; P = .38).

Conclusions and Relevance

To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.

Contemporary review of minimally invasive pancreaticoduodenectomy

AIM

To assess the current literature describing various minimally invasive techniques for and to review short-term outcomes after minimally invasive pancreaticoduodenectomy (PD).

METHODS

PD remains the only potentially curative treatment for periampullary malignancies, including, most commonly, pancreatic adenocarcinoma. Minimally invasive approaches to this complex operation have begun to be increasingly reported in the literature and are purported by some to reduce the historically high morbidity of PD associated with the open technique. In this systematic review, we have searched the literature for high-quality publications describing minimally invasive techniques for PD-including laparoscopic, robotic, and laparoscopic-assisted robotic approaches (hybrid approach). We have identified publications with the largest operative experiences from well-known centers of excellence for this complex procedure. We report primarily short term operative and perioperative results and some short term oncologic endpoints.

RESULTS

Minimally invasive techniques include laparoscopic, robotic and hybrid approaches and each of these techniques has strong advocates. Consistently, across all minimally invasive modalities, these techniques are associated less intraoperative blood loss than traditional open PD (OPD), but in exchange for longer operating times. These techniques are relatively equivalent in terms of perioperative morbidity and short term oncologic outcomes. Importantly, pancreatic fistula rate appears to be comparable in most minimally invasive series compared to open technique. Impact of minimally invasive technique on length of stay is mixed compared to some traditional open series. A few series have suggested that initiation of and time to adjuvant therapy may be improved with minimally invasive techniques, however this assertion remains controversial. In terms of short-terms costs, minimally invasive PD is significantly higher than that of OPD.

CONCLUSION

Minimally invasive approaches to PD show great promise as a strategy to improve short-term outcomes in patients undergoing PD, but the best results remain isolated to high-volume centers of excellence.

Comparison Between Minimally Invasive and Open Pancreaticoduodenectomy: A Systematic Review

INTRODUCTION

Minimally invasive approaches (laparoscopic or robotic) are used in various operations. Our aim was to compare them with the open approach in pancreaticoduodenectomy.

METHODS

We conducted a search for articles published in MEDLINE database comparing minimally invasive (laparoscopic or robotic) with open pancreaticoduodenectomy on June 15, 2014.

RESULTS

Our search yielded 136 articles. We excluded 122 articles and we took into consideration 14 (10 for laparoscopic and 4 for robotic pancreaticoduodenectomies). Most cases were related to malignant diseases and tumors treated with minimally invasive operations tended to be smaller. There were relatively high conversion rates in both laparoscopic (0% to 15%) and robotic procedures (4.5% to 10%). There were no significant differences regarding resection margins, rates of pancreatic fistula formation, bile leak, and delayed gastric emptying, reoperation rates, and intraoperative and postoperative mortality. On the contrary, blood loss was less in minimally invasive than open operations, although this difference was not always significant. Moreover, totally laparoscopic and robotic procedures lasted longer than the open ones, whereas hand-assisted laparoscopic procedures did not. However, the findings regarding the number of the retrieved lymph nodes, the length of hospital stay, and costs were inconclusive and controversial.

CONCLUSIONS

Laparoscopic and robotic pancreaticoduodenectomy are feasible, safe, and oncologically equivalent alternatives to open pancreaticoduodenectomy. Minimally invasive operations have the advantage of the less blood loss, but totally laparoscopic and robotic procedures last longer than open procedures.

Current status of laparoscopic pancreaticoduodenectomy and pancreatectomy

This review describes the recent advances in, and current status of, minimally invasive pancreatic surgery (MIPS). Typical MIPS procedures are laparoscopic pancreaticoduodenectomy (LPD), laparoscopic distal pancreatectomy (LDP), laparoscopic central pancreatectomy (LCP), and laparoscopic total pancreatectomy (LTP). Some retrospective studies comparing LPD or LDP and open procedures have demonstrated the safety and feasibility as well as the intraoperative outcomes and postoperative recovery of these procedures. In contrast, LCP and LTP have not been widely accepted as common laparoscopic procedures owing to their complicated reconstruction and limited indications. Nevertheless, our concise review reveals that LCP and LTP performed by expert laparoscopic surgeons can result in good short-term and long-term outcomes. Moreover, as surgeons' experience with laparoscopic techniques continues to grow around the world, new innovations and breakthroughs in MIPS will evolve. Well-designed and suitably powered randomized controlled trials of LPD, LDP, LCP, and LTP are now warranted to demonstrate the superiority of these procedures.

Minimally invasive pancreaticoduodenectomy: A comprehensive review

BACKGROUND

While an increasing number of open procedures are now routinely performed laparoscopically or robotically, minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging operations in abdomen. The aim of this study is to evaluate the current status and development of MIPD.

METHODS

Embase, Medline, and PubMed databases were searched to identify studies up to and including Feb 2016 using the keywords "laparoscopic", or "laparoscopy", or "hand-assisted", or "minimally invasive", or "robotic", or "da vinci" combined with "pancreaticoduodenectomy", or "duodenopancreatectomy", "Whipple", or "pancreatic resection". Articles written in English with more than 10 cases were included for review.

RESULTS

Thirty-two articles representing 2209 patients were included for review. The weighted average operative time and intraoperative blood loss was 427.3 min and 289.4 mL respectively. A total of 375 patients required conversion to open pancreaticoduodenectomy (OPD), with an overall conversion rate of 17.8%. The postoperative severe complications (the Clavien-Dindo Classification ≥ III) occurred in 3.8%-33.0% patients, with an overall severe morbidity of 14.3%. Particularly, the overall incidence of clinically significant postoperative pancreatic fistula (POPF) was 8.0%. There were 26 perioperative death cases in total, with an overall postoperative mortality rate of 2.3%. The weighted average number of collected lymph nodes was 17.9, and R0 resection ranged from 60.0% to 100.0%. Comparisons between MIPD and OPD showed that MIPD increased operative time, decreased intraoperative blood loss and shortened the length of hospital stay, but the overall morbidity and mortality were comparable.

CONCLUSIONS

MIPD is technically feasible and safe in highly selected patients and can offer acceptable oncological outcomes. But concerns such as long-term outcomes, cost-effectiveness analysis, and learning curve analysis should be fully demonstrated before the popularization of this challenging procedure.

Oncologic and Perioperative Outcomes Following Selective Application of Laparoscopic Pancreaticoduodenectomy for Periampullary Malignancies

BACKGROUND

Data are sparse regarding patient selection criteria or evaluating oncologic outcomes following laparoscopic pancreaticoduodenectomy (LPD). Having prospectively limited LPD to patients with resectable disease defined by National Comprehensive Cancer Network (NCCN) criteria, we evaluated perioperative and long-term oncologic outcomes of LPD compared to a similar cohort of open pancreaticoduodenectomy (OPD).

METHODS

Consecutive patients (November 2010-February 2014) undergoing pancreaticoduodenectomy (PD) for periampullary adenocarcinoma were reviewed. Patients were excluded from further analysis for benign pathology, conversion to OPD for portal vein resection, and contraindications for LPD not related to their malignancy. Outcomes of patients undergoing LPD were analyzed in an intention-to-treat manner against a cohort of patients undergoing OPD.

RESULTS

These selection criteria resulted in offering LPD to 77 % of all cancer patients. Compared to the OPD cohort, LPD was associated with significant reductions in wound infections (16 vs. 34 %; P = 0.038), pancreatic fistula (17 vs. 36 %; P = 0.032), and median hospital stay (9 vs. 12 days; P = 0.025). Overall survival (OS) was not statistically different between patients undergoing LPD vs. OPD for periampullary adenocarcinoma (median OS 27.9 vs. 23.5 months; P = 0.955) or pancreatic adenocarcinoma (N = 28 vs. 22 patients; median OS 20.7 vs. 21.1 months; P = 0.703).

CONCLUSIONS

The selective application of LPD for periampullary malignancies results in a high degree of eligibility as well as significant reductions in length of stay, wound infections, and pancreatic fistula. Overall survival after LPD is similar to OPD.

Minimally Invasive Pancreatic Resection: Is It Really the Future?

The introduction and widespread application of minimally invasive surgery has been one of the most important innovations that radically changed the practice of surgery during the last few decades. The application to pancreatic surgery of minimally invasive approach has only recently emerged: both laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD) can be competently performed. LDP and LPD are advocated to improved perioperative outcomes, including decreased blood loss, shorter length of stay, reduced postoperative pain and expedited time to functional recovery. However, the indication to minimally invasive approach for pancreatic surgery is often benign or low-grade malignant pathologies. In this review, we summarize the current data on minimally invasive pancreatic surgery, focusing on indication, perioperative and oncological outcomes.

Getting Started with Minimally Invasive Pancreaticoduodenectomy: Is It Worth It?

BACKGROUND

This study evaluates the safety and cost of introducing minimally invasive pancreaticoduodenectomy (MIPD) to a surgeon's practice.

SUBJECTS AND METHODS

All MIPDs performed between December 2011 and July 2013 were compared with open pancreaticoduodenectomy (OPD) cases by the same surgeon. The primary outcomes were mortality, major morbidity, and re-operation. Secondary outcomes were perioperative and oncologic outcomes and cost. MIPD include total laparoscopic pancreaticoduodenectomy (TLPD) and laparoscopic-assisted pancreaticoduodenectomy (LAPD), where a small incision is used for reconstruction. Bivariate comparisons of outcomes were performed using nonparametric tests.

RESULTS

In total, 44 pancreaticoduodenectomies were performed: 15 MIPDs (2 TLPDs and 13 LAPDs) and 29 OPDs. One death occurred in each group. Major complication rates were not significantly different (33% for MIPD versus 17% for OPD); however, there was a trend toward more re-operation after MIPD compared with OPD (20% versus 3%; P = .07). The incidence of pancreatic leak (20% for MIPD versus 14% for OPD), biliary leak (0% versus 7%, respectively), abscess formation (27% versus 14%, respectively), and intraabdominal hemorrhage (13% versus 3%, respectively) were not significantly different. MIPD achieved equivalent oncologic outcomes as OPD with 100% R0 margin and adequate lymph node retrieval. There was no statistical difference in median operative time (342 minutes for MIPD versus 358 minutes for OPD), length of stay (8 versus 9 days, respectively), operating room expenses (Canadian) ($7246.0 versus $6912.0, respectively), or total cost (Canadian) per case ($15,034.0 versus $18,926.0, respectively).

CONCLUSIONS

MIPD and OPD had similar safety and cost in this introductory series. However, a trend toward a higher rate of re-operation for pancreatic leak suggests the need for caution in introducing this novel technique.

Systemic Review of the Feasibility and Advantage of Minimally Invasive Pancreaticoduodenectomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD), which includes laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is a complex procedure that needs to be performed by experienced surgeons. However, the safety and oncologic performance have not yet been conclusively determined.

METHODS

A systematic literature search was performed using the Embase, Medline, and PubMed databases to identify all studies published up to March 2015. Articles written in English containing the keywords: "pancreaticoduodenectomy" or "Whipple operation" combined with "laparoscopy," "laparoscopic," "robotic," "da vinci," or "minimally invasive surgery" were selected. Furthermore, to increase the power of evidence, articles describing more than ten MIPDs were selected for this review.

RESULTS

Twenty-six articles matched the review criteria. A total of 780 LPDs and 248 RPDs were included in the current review. The overall conversion rate to open surgery was 9.1 %. The weighted average operative time was 422.6 min, and the weighted average blood loss was 321.1 mL. The weighted average number of harvested lymph nodes was 17.1, and the rate of microscopically positive tumor margins was 8.4 %. The cumulative morbidity was 35.9 %, and a pancreatic fistula was reported in 17.0 % of cases. The average length of hospital stay was 12.4 days, and the mortality rate was 2.2 %.

CONCLUSIONS

In conclusion, after reviewing one-thousand cases in the current literature, we conclude that MIPD offers a good perioperative, postoperative, and oncologic outcome. MIPD is feasible and safe in well-selected patients.

The Standardization of Pancreatoduodenectomy: Where Are We?

Pancreaticoduodenectomy (PD) represents an important challenge for surgeons due to the complexity of the operation, requirement for technical skills and experience, and postoperative management involving important and life-threatening complications. Despite efforts to reduce mortality in high-volume centers, the morbidity rate is still high (approximately 40-50%). The PD standardization process of surgical aspects and preoperative and postoperative settings is essential to permit pancreatic surgeons to communicate in the same language, compare experiences and results, and to improve the short- and long-term outcomes. The aim of this article is to assess the state of the art practices for important matters of debate for PD (the role of mini invasive approach, the definition and the role of mesopancreas, the extent of lymphadenectomy, the different methods of reconstructions, the prophylactic drainage of the abdominal cavity), and to suggest possible future studies.

Robotic-assisted pancreatic surgery

BACKGROUND

Pancreatic surgery is a challenging application of minimally invasive surgery. Due to the complexity of the surgical technique, requiring dissection along major abdominal vessels as well as delicate reconstruction involving biliary, pancreatic and enteric anastomoses, reports on laparoscopic pancreatic surgery have been scanty. With the advent of robotic-assisted surgery, however, the increased dexterity granted by endo-wristed instruments, the improved three-dimensional vision and the computer filtration of the surgeon's movements have brought minimally invasive pancreatic surgery into a new era.

METHODS

As the surgical group which has performed the highest number of robotic-assisted pancreatic procedures worldwide, we review the state of the art of minimally invasive robotic-assisted pancreatic surgery. Clinical results from all major robotic-assisted pancreatic surgery series are considered.

RESULTS

Preliminary reports from the published major pancreatic surgery series show encouraging results, with morbidity and mortality comparable to open surgery. Preliminary data on cancer survival rates also appear to be similar to open series.

CONCLUSION

Robotic-assisted pancreatic surgery is safe and feasible for all pancreatic diseases. The complexity of pancreatic procedures warrant them to be carried out in specialised centres, where short- and long-term outcomes seem to be similar to the ones achieved in open surgery.

Minimally Invasive Pancreaticoduodenectomy Does Not Improve Use or Time to Initiation of Adjuvant Chemotherapy for Patients With Pancreatic Adenocarcinoma

BACKGROUND

The modifiable variable best proven to improve survival after resection of pancreatic adenocarcinoma is the addition of adjuvant chemotherapy. A theoretical advantage of minimally invasive pancreaticoduodenectomy (MI-PD) is the potential for greater use and earlier initiation of adjuvant therapy, but this benefit remains unproven.

METHODS

The 2010-2012 National Cancer Data Base (NCDB) was queried for patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. Subjects were classified as MI-PD versus open pancreaticoduodenectomy (O-PD). Baseline variables were compared between groups. The independent effect of surgical approach on the use and timing of adjuvant chemotherapy was estimated using multivariable regression analyses.

RESULTS

For this study, 7967 subjects were identified: 1191 MI-PD (14.9%) and 6776 O-PD (85.1%) patients. Patients who underwent MI-PD were more likely to have been treated at academic hospitals. Otherwise, the groups had no baseline differences. In both the MI-PD and O-PD groups, approximately 50% of the patients received adjuvant chemotherapy, initiated at a median of 54 versus 55 days postoperatively (p = 0.08). After multivariable adjustment, surgical approach was not independently associated with use (odds ratio 1.00; p = 0.99) or time to initiation of adjuvant chemotherapy (-2.3 days; p = 0.07). Younger age, insured status, lower comorbidity score, higher tumor stage, and the presence of lymph node metastases were independently associated with the use of adjuvant chemotherapy.

CONCLUSIONS

At a national level, MI-PD does not result in greater use or earlier initiation of adjuvant chemotherapy. As surgeons and institutions continue to gain experience with this complex procedure, it will be important to revisit this benchmark as a justification for its increasing use for patients with pancreatic cancer.

Matched Case-Control Analysis Comparing Laparoscopic and Open Pylorus-preserving Pancreaticoduodenectomy in Patients With Periampullary Tumors

OBJECTIVES

To evaluate the safety, feasibility, and oncologic outcomes of laparoscopic pylorus-preserving pancreaticoduodenectomy (L-PPPD) to treat periampullary tumors. The clinical outcomes of L-PPPD were compared with open pylorus-preserving pancreaticoduodenectomy (O-PPPD).

BACKGROUND

Despite recent advances in laparoscopic pancreatic surgery, few studies have compared L-PPPD with O-PPPD. The safety, short-term clinical benefits, and oncologic outcomes of L-PPPD remain controversial.

METHODS

Between January 2007 and December 2012, a total of 2192 patients diagnosed with periampullary tumors were treated with curative resection at our institution. Of these patients, 137 underwent a laparoscopic approach and 2055 an open technique. A retrospective study was performed to evaluate the safety, feasibility, and oncologic outcomes of L-PPPD compared with O-PPPD.

RESULTS

The mean operation time for the L-PPPD group was longer than for the O-PPPD group (P < 0.001). Estimated blood loss was similar, as was the incidence of complications, such as pancreatic fistula and delayed gastric empting (P > 0.05). The mean number of analgesic injections administered was lower in the L-PPPD group than in the O-PPPD group (P < 0.001), and the mean duration of the postoperative hospital stays was shorter (P < 0.001). The surgical resection margins and the number of lymph nodes in the resected specimens did not differ between the 2 groups, and there was no significant difference in overall survival curves.

CONCLUSIONS

L-PPPD had the typical advantages of minimally invasive abdominal procedures, such as less pain, shorter hospital stay, and quicker recovery. It is technically safe and feasible, and has favorable oncologic outcomes in comparison with O-PPPD in patients with periampullary tumors.

Robotic pancreaticoduodenectomy for pancreatic adenocarcinoma: role in 2014 and beyond

Minimally invasive surgery (MIS) for pancreatic adenocarcinoma has found new avenues for performing pancreaticoduodenectomy (PD) procedures, a historically technically challenging operation. Multiple studies have found laparoscopic PD to be safe, with equivalent oncologic outcomes as compared to open PD. In addition, several series have described potential benefits to minimally invasive PD including fewer postoperative complications, shorter hospital length of stay, and decreased postoperative pain. Yet, despite these promising initial results, laparoscopic PDs have not become widely adopted by the surgical community. In fact, the vast majority of pancreatic resections performed in the United States are still performed in an open fashion, and there are only a handful of surgeons who actually perform purely laparoscopic PDs. On the other hand, robotic assisted surgery offers many technical advantages over laparoscopic surgery including high-definition, 3-D optics, enhanced suturing ability, and more degrees of freedom of movement by means of fully-wristed instruments. Similar to laparoscopic PD, there are now several case series that have demonstrated the feasibility and safety of robotic PD with seemingly equivalent short-term oncologic outcomes as compared to open technique. In addition, having the surgeon seated for the procedure with padded arm-rests, there is an ergonomic advantage of robotics over both open and laparoscopic approaches, where one has to stand up for prolonged periods of time. Future technologic innovations will likely focus on enhanced robotic capabilities to improve ease of use in the operating room. Last but not least, robotic assisted surgery training will continue to be a part of surgical education curriculum ensuring the increased use of this technology by future generations of surgeons.

Laparoscopic pancreaticoduodenectomy: a descriptive and comparative review

Laparoscopic pancreaticoduodenectomy (LPD) is an extremely challenging surgery. First described in 1994, it has been slow to gain in popularity. Recently, however, we have seen an increase in the number of centers performing this operation, including our own institution, as well as an increase in the quantity of published data. The purpose of this review is to describe the current status of LPD as described in the literature. We performed a literature search in the PubMed database using MeSH terms "laparoscopy" and "pancreaticoduodenectomy". We then identified articles in the English language with over 20 patients that focused on LPD only. Review articles were excluded and only one article per institution was used for descriptive analysis in order to avoid overlap. There were a total of eight articles meeting review criteria, consisting of 492 patients. On descriptive analysis we found that percent of LPD due to high-grade malignancy averaged 47% over all articles. Average operative time was 452 minutes, blood loss 369 cc's, pancreatic leak rate 15%, delayed gastric emptying 8.6%, length of hospital stay 9.4 days, and short term mortality 2.3%. Comparison studies between open pancreaticoduodenectomy (OPD) and LPD suggested decreased blood loss, longer operative time, similar post-operative complication rate, decreased pain, and shorter hospital length of stay for LPD. There was also increased number of lymph nodes harvested and similar margin free resections with LPD in the majority of studies. LPD is a safe surgery, providing many of the advantages typically associated with laparoscopic procedures. We expect this operation to continue to gain in popularity as well as be offered in increasingly more complex cases. In future studies, it will be beneficial to look further at the oncologic outcome data of LPD including survival.

Minimally invasive pancreatic surgery - a review

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

Early National Experience with Laparoscopic Pancreaticoduodenectomy for Ductal Adenocarcinoma: A Comparison of Laparoscopic Pancreaticoduodenectomy and Open Pancreaticoduodenectomy from the National Cancer Data Base

BACKGROUND

There is considerable debate about the safety and clinical equivalence of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for pancreatic ductal adenocarcinoma (PDCA).

STUDY DESIGN

We queried the National Cancer Data Base to identify patients undergoing LPD and OPD for PDCA between 2010 and 2011. Chi-square and Student's t-tests were used to evaluate differences between the 2 approaches. Multivariable logistic regression modeling was performed to identify patient, tumor, or facility factors associated with perioperative mortality.

RESULTS

Four thousand and thirty-seven (91%) patients underwent OPD. Three hundred and eighty-four (9%) patients underwent LPD. There were no statistical differences between the 2 surgical cohorts with regard to age, race, Charlson score, tumor size, grade, stage, or treatment with neoadjuvant chemoradiotherapy. Laparoscopic pancreaticoduodenectomy demonstrated a shorter length of stay (10 ± 8 days vs 12 ± 9.7 days; p < 0.0001) and lower rates of unplanned readmission (5% vs 9%; p = 0.027) than OPD. In an unadjusted comparison, there was no difference in 30-day mortality between the LPD and OPD cohorts (5.2% vs 3.7%; p = 0.163). Multivariable logistic regression modeling predicting perioperative mortality controlling for age, Charlson score, tumor size, nodal positivity, stage, facility type, and pancreaticoduodenectomy volume identified age (odds ratio [OR] = 1.05; p < 0.0001), positive margins (OR = 1.45; p = 0.030), and LPD (OR = 1.89; p = 0.009) as associated with an increased probability of 30-day mortality; higher hospital volume was associated with a lower risk of 30-day mortality (OR = 0.98; p < 0.0001). In institutions that performed ≥10 LPDs, the 30-day mortality rate of the laparoscopic approach was equal to that for the open approach (0.0% vs 0.7%; p = 1.00).

CONCLUSIONS

Laparoscopic pancreaticoduodenectomy is equivalent to OPD in length of stay, margin-positive resection, lymph node count, and readmission rate. There is a higher 30-day mortality rate with LPD, but this appears driven by a surmountable learning curve for the procedure.

Long-term results of laparoscopic pancreaticoduodenectomy for pancreatic and periampullary cancer-experience of 130 cases from a tertiary-care center in South India

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD), although an advanced surgical procedure, is being increasingly used for pancreatic head and periampullary tumors. We present our experience of 15 years with the largest series in total LPD for periampullary and pancreatic head tumors with data on oncological outcome and long-term survival.

MATERIALS AND METHODS

Prospective and retrospective data of patients undergoing LPD from March 1998 to April 2013 were reviewed. Of the 150 cases, 20 cases of LPD (7 cases done for chronic pancreatitis and 13 cases for benign cystic tumors of the pancreas) have been excluded, which leaves us with 130 cases of LPD performed for malignant indications.

RESULTS

In total, 130 patients were chosen for the study. The male:female ratio was 1:1.6, with a median age of 54 years. We had one conversion to open surgery in our series, the overall postoperative morbidity was 29.7%, and the mortality rate was 1.53%. The pancreatic fistula rate was 8.46%. The mean operating time was 310±34 minutes, and the mean blood loss was 110±22 mL. The mean hospital stay was 8±2.6 days. Resected margins were positive in 9.23% of cases. The mean tumor size was 3.13±1.21 cm, and the mean number of retrieved lymph nodes was 18.15±4.73. The overall 5-year actuarial survival was 29.42%, and the median survival was 33 months.

CONCLUSIONS

LPD has evolved over a period of two decades and has the potential to become the standard of care for select periampullary and pancreatic head tumors with acceptable oncological outcomes, especially in high-volume centers. Randomized controlled trials are needed to establish the advantages of LPD.

Laparoscopic pancreaticoduodenectomy: single-surgeon experience

BACKGROUND

Innovations in surgical strategies and technologies have facilitated laparoscopic pancreaticoduodenectomy (LPD). However, data regarding the short-term and long-term results of LPD are sparse, and this procedure is the primary focus of the current study.

METHODS

Between October 2010 and October 2013, a total of 31 consecutive patients received LPD, including hand-assisted laparoscopic pancreaticoduodenectomy, total laparoscopic pancreaticoduodenectomy, and laparoscopic pylorus-preserving pancreaticoduodenectomy. Data regarding short-term surgical outcomes and long-term oncological results were collected prospectively.

RESULTS

The median operative time was 515.0 min (interquartile range 465.0-585.0 min). The median intraoperative estimated blood loss was 260.0 mL (interquartile range 150.0-430.0 mL). Conversion to open pancreaticoduodenectomy was required in three patients (9.7%) due to intraoperative pneumoperitoneum intolerance (n = 1, 3.2%) and tumor adherence to the superior mesenteric vein (n = 2, 6.5%). No significant differences between the surgical approaches were observed in regard to intraoperative and postoperative data. Postoperative severe complications (Clavien ≥ III) were detected in three (9.7%) patients, including one grade C pancreatic fistula, one grade B postoperative bleeding event, and one afferent loop obstruction. There were no deaths within 30 days following LPD. The final pathological results revealed duodenal adenocarcinoma in 14 (45.2%) patients, ampullary adenocarcinoma in four (12.9%) patients, distal common bile duct cancer in six (19.4%) patients, pancreatic ductal adenocarcinoma in five (16.1%) patients, gastrointestinal stroma tumor in one (3.2%) patient, and chronic pancreatitis in one (3.2%) patient. All patients suffering from tumors underwent R0 resection (n = 30, 100.0%), with the optimal number of collected lymph nodes (median: 13, interquartile range 11-19). At the most recent follow-up, 20 patients were still alive, and the 1-, and 3-year overall survival for patients with duodenal adenocarcinoma were 100.0 and 71.4%, respectively.

CONCLUSIONS

According to this study, LPD is feasible and technically safe for highly selected patients and can offer acceptable oncological outcomes and long-term survival.

Laparoscopic pancreaticoduodenectomy via a reverse-''V'' approach with four ports: Initial experience and perioperative outcomes

AIM: To evaluate the feasibility, safety, and efficacy of laparoscopic pancreaticoduodenectomy (LPD) using a reverse-“V” approach with four ports.

METHODS: This is a retrospective study of selected patients who underwent LPD at our center between April 2011 and April 2012. The following data were collected and reviewed: patient characteristics, tumor histology, surgical outcome, resection margins, morbidity, and mortality. All patients were thoroughly evaluated preoperatively by complete hematologic investigations, triple-phase helical computed tomography, upper gastrointestinal endoscopy, and biopsy of ampullary lesions (when present). Magnetic resonance cholangiopancreatography was performed for doubtful cases of lower common bile duct lesions.

RESULTS: There was no perioperative mortality. LPD was performed with tumor-free margins in all patients, including patients with pancreatic ductal adenocarcinoma (n = 6), ampullary carcinoma (n = 6), intra-ductal papillary mucinous neoplasm (n = 2), pancreatic cystadenocarcinoma (n = 2), pancreatic head adenocarcinoma (n = 3), and bile duct cancer (n = 2). The mean patient age was 65 years (range, 42-75 years). The median blood loss was 240 mL, and the mean operative time was 368 min.

CONCLUSION: LPD using a reverse-“V” approach can be performed safely and yields good results in elective patients. Our preliminary experience showed that LDP can be performed via a reverse-“V” approach. This approach can be used to treat localized malignant lesions irrespective of histopathology.

Laparoscopic resection of pancreatic adenocarcinoma: Dream or reality?

Laparoscopic pancreatic surgery is in its infancy despite initial procedures reported two decades ago. Both laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD) can be performed competently; however when minimally invasive surgical (MIS) approaches are implemented the indication is often benign or low-grade malignant pathologies. Nonetheless, LDP and LPD afford improved perioperative outcomes, similar to those observed when MIS is utilized for other purposes. This includes decreased blood loss, shorter length of hospital stay, reduced post-operative pain, and expedited time to functional recovery. What then is its role for resection of pancreatic adenocarcinoma? The biology of this aggressive cancer and the inherent challenge of pancreatic surgery have slowed MIS progress in this field. In general, the overall quality of evidence is low with a lack of randomized control trials, a preponderance of uncontrolled series, short follow-up intervals, and small sample sizes in the studies available. Available evidence compiles heterogeneous pathologic diagnoses and is limited by case-by-case follow-up, which makes extrapolation of results difficult. Nonetheless, short-term surrogate markers of oncologic success, such as margin status and lymph node harvest, are comparable to open procedures. Unfortunately disease recurrence and long-term survival data are lacking. In this review we explore the evidence available regarding laparoscopic resection of pancreatic adenocarcinoma, a promising approach for future widespread application.

Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach

BACKGROUND

Minimally invasive pancreatic surgery has evolved rapidly, but total laparoscopic pancreaticoduodenectomy has not been widely adopted owing to its technical complexity. Hybrid laparoscopy-assisted pancreaticoduodenectomy (HLAPD) combines the relative ease of open surgery with the benefits of a minimally invasive approach. This study evaluates the safety and effectiveness of the hybrid approach compared with open surgery.

METHODS

We retrospectively analyzed data of consecutive patients undergoing either hybrid or open pancreaticoduodenectomy (OPD) at our institution between September 2009 and December 2013. Demographic, operative and oncologic data were collected to compare outcomes between HLAPD and OPD.

RESULTS

Our analysis included 33 patients (HLAPD: n = 13; OPD: n = 20). There were no differences in patient demographics, comorbidities or surgical indications. The HLAPD group had significantly lower intraoperative blood loss (450 mL v. 1000 mL, p = 0.023) and shorter length of hospital stay (8 v. 12 d, p = 0.025) than the OPD group. Duration of surgery did not differ significantly between the groups. There were no differences in postoperative analgesic requirements, Clavien grade I/II or grade III/IV complications or 90-day mortality. Oncologic outcomes showed no significant differences in tumour size, R1 resection rate or number of lymph nodes harvested.

CONCLUSION

In select patients, HLAPD is a safe and effective procedure with comparable outcomes to conventional open surgery. Wider adoption of the hybrid approach will allow a greater number of patients to benefit from a less invasive procedure while facilitating the transition toward purely minimally invasive pancreaticoduodenectomy.

Laparoscopic pancreaticoduodenectomy: a systematic literature review

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is gaining momentum, but there is still uncertainty regarding its safety, reproducibility, and oncologic appropriateness. This review assesses the current status of LPD.

METHODS

Our literature review was conducted in Pubmed. Articles written in English containing five or more LPD were selected.

RESULTS

Twenty-five articles matched the review criteria. Out of a total of 746 LPD, 341 were reported between 1997 and 2011 and 405 (54.2 %) between 2012 and June 1, 2013. Pure laparoscopy (PL) was used in 386 patients (51.7 %), robotic assistance (RA) in 234 (31.3 %), laparoscopic assistance (LA) in 121 (16.2 %), and hand assistance in 5 (0.6 %). PL was associated with shorter operative time, reduced blood loss, and lower rate of pancreatic fistula (vs LA and RA). LA was associated with shorter operative time (vs RA), but with higher blood loss and increased incidence of pancreatic fistula (vs PL and RA). Conversion to open surgery was required in 64 LPD (9.1 %). Operative time averaged 464.3 min (338-710) and estimated blood 320.7 mL (74-642). Cumulative morbidity was 41.2 %, and pancreatic fistula was reported in 22.3 % of patients (4.5-52.3 %). Mean length of hospital stay was 13.6 days (7-23), showing geographic variability (21.9 days in Europe, 13.0 days in Asia, and 9.4 days in the US). Operative mortality was 1.9 %, including one intraoperative death. No difference was noted in conversion rate, incidence of pancreatic fistula, morbidity, and mortality when comparing results from larger (≥30 LPD) and smaller (≤29 LPD) series. Pathology demonstrated ductal adenocarcinoma in 30.6 % of the specimens, other malignant tumors in 51.7 %, and benign tumor/disease in 17.5 %. The mean number of lymph nodes examined was 14.4 (7-32), and the rate of microscopically positive tumor margin was 4.4 %.

CONCLUSIONS

In selected patients, operated on by expert laparoscopic pancreatic surgeons, LPD is feasible and safe.

Does minimally-invasive pancreaticoduodenectomy have advantages over its open method? A meta-analysis of retrospective studies

Background

While more and more open procedures now routinely performed using laparoscopy, minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging abdominal procedures. Therefore, we carried out this meta-analysis to evaluate whether MIPD is safe, feasible and worthwhile.

Methods

PubMed, EMBASE, and Cochrane Library were searched to identify studies published between January 1994 and November 2013 comparing MIPD with open pancreaticoduodenectomy (OPD). Intraoperative outcomes, oncologic safety, postoperative complications, and postoperative recovery were evaluated.

Results

11 retrospective studies representing 869 patients (327 MIPDs, 542 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (MD −361.93 ml, 95% CI −519.22 to −204.63 ml, p<0.001, I² = 94%), wound infection (OR 0.41, 95% CI 0.22 to 0.78, p = 0.007, I² = 0%), and hospital stay (MD −2.64 d, 95% CI −4.23 to −1.05 d, p = 0.001, I² = 78%). However, it brings longer operative time (MD 105 min, 95% CI 49.73 to 160.26 min, p<0.001, I² = 93%). There were no significant differences between the two procedures in likelihood of overall complications (p = 0.05), pancreatic fistula (PF) (p = 0.86), delayed gastric empting (DGE) (p = 0.96), positive surgical margins (p = 0.07), retrieval of lymph nodes (p = 0.48), reoperation (p = 0.16) and mortality (p = 0.64).

Conclusions

Our results suggest that MIPD is currently safe, feasible and worthwhile. But considering the selection bias, complexity of MIPD and lack of long-term oncologic outcomes, we suggest it be performed in a high-volume pancreatic surgery center in selected patients.

Laparoscopic approach to gastrointestinal malignancies: toward the future with caution

After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.

Laparoscopic pancreaticoduodenectomy assisted by mini-laparotomy

PURPOSE

Pancreaticoduodenectomy (PD) is the treatment of choice for periampullary disease. Even with the increasing number of successful reports from around the globe, laparoscopic pancreaticoduodenectomy (LPD) is still not fully accepted. We report the results of our experience of LPD assisted by mini-laparotomy.

METHOD

This retrospective review study included 42 patients who received LPD assisted by mini-laparotomy between March 2009 and April 2012. Clinical outcomes, such as patient age, pathologic diagnosis, pancreas nature, operation time, conversion rate, hospital stay, postoperative complication, and mortality rates, were reviewed.

RESULTS

A total of 42 patients (age range, 42 to 70 y ) received LPD assisted by mini-laparotomy. The mean incision length for the laparotomy was 5.2 cm. Mean operative time was 404 minutes, and 3 cases required conversion to open surgery. Mean postoperative hospital stay was 17 days. There were 3 cases of pancreaticogastrostomy leakage, 2 cases of postoperative bleeding, 4 cases of delayed gastric emptying, 1 case of bile leakage, and 5 cases of pulmonary complications. Of the 5 patients with pulmonary complications, 1 died.

CONCLUSIONS

When performed by a surgeon with ample experience in laparoscopic surgery, LPD assisted by mini-laparotomy is a safe, feasible alternative to conventional PD for select cases. The method described in this study can be used to perform pancreaticoenteric anastomosis in the same manner as an open PD, while taking advantage of the merits of minimally invasive surgery.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

200 consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder

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.

Total laparoscopic pancreaticoduodenectomy

INTRODUCTION

Total laparoscopic pancreaticoduodenectomy (TLPD) remains one of the most advanced laparoscopic procedures. Owing to the evolution in laparoscopic technology and instrumentation within the past decade, laparoscopic pancreaticoduodenectomy is beginning to gain wider acceptance.

METHODS

Data were collected for all patients who underwent a TLPD at our institution. Preoperative evaluation consisted of computed tomography scan with pancreatic protocol and selective use of magnetic resonance imaging and/or endoscopic ultrasonography. The TLPD was done with 6 ports on 3 patients and 5 ports in 2 patients and included a celiac, periportal, peripancreatic, and periduodenal lymphadenectomy. Pancreatic stents were used in all 5 cases, and intestinal continuity was re-established by intracorporeal anastomoses.

RESULTS

Five patients underwent a TLPD for suspicion of a periampullary tumor. There were 3 women and 2 men with a mean age of 60 years and a mean body mass index of 32.8. Intraoperatively, the mean operative time was 9 hours 48 minutes, with a mean blood loss of 136 mL. Postoperatively, there were no complications and a mean length of stay of 6.6 days. There was no lymph node involvement in 4 out of 5 specimens. The pathological results included intraductal papillary mucinous neoplasm in 2 patients, pancreatic adenocarcinoma in 1 patient (R0 resection), benign 4-cm periampullary adenoma in 1 patient, and a somatostatin neuroendocrine carcinoma in 1 patient (R0, N1).

CONCLUSION

TLPD is a viable alternative to the standard Whipple procedure. Our early experience suggests decreased length of stay, quicker recovery, and improved quality of life. Complication rates appear to be improved or equivalent.

Total laparoscopic pancreaticoduodenectomy

INTRODUCTION

Total laparoscopic pancreaticoduodenectomy (TLPD) remains one of the most advanced laparoscopic procedures. Owing to the evolution in laparoscopic technology and instrumentation within the past decade, laparoscopic pancreaticoduodenectomy is beginning to gain wider acceptance.

METHODS

Data were collected for all patients who underwent a TLPD at our institution. Preoperative evaluation consisted of computed tomography scan with pancreatic protocol and selective use of magnetic resonance imaging and/or endoscopic ultrasonography. The TLPD was done with 6 ports on 3 patients and 5 ports in 2 patients and included a celiac, periportal, peripancreatic, and periduodenal lymphadenectomy. Pancreatic stents were used in all 5 cases, and intestinal continuity was re-established by intracorporeal anastomoses.

RESULTS

Five patients underwent a TLPD for suspicion of a periampullary tumor. There were 3 women and 2 men with a mean age of 60 years and a mean body mass index of 32.8. Intraoperatively, the mean operative time was 9 hours 48 minutes, with a mean blood loss of 136 mL. Postoperatively, there were no complications and a mean length of stay of 6.6 days. There was no lymph node involvement in 4 out of 5 specimens. The pathological results included intraductal papillary mucinous neoplasm in 2 patients, pancreatic adenocarcinoma in 1 patient (R0 resection), benign 4-cm periampullary adenoma in 1 patient, and a somatostatin neuroendocrine carcinoma in 1 patient (R0, N1).

CONCLUSION

TLPD is a viable alternative to the standard Whipple procedure. Our early experience suggests decreased length of stay, quicker recovery, and improved quality of life. Complication rates appear to be improved or equivalent.

Laparoscopic parenchyma-sparing pancreatectomy

In recent years laparoscopic pancreatic procedures have developed rapidly, and reports of laparoscopic resection including laparoscopic distal pancreatectomy and laparoscopic pancreaticoduodenectomy have increased in number. On the other hand, many benign and low-grade malignant pancreatic lesions have recently been detected by the improved diagnostic modalities. Parenchyma-sparing pancreatectomy is a preferred surgical procedure for such benign and low-malignancy pancreatic lesions, because parenchyma-sparing pancreatectomy can avoid the unnecessary resection of the normal pancreatic parenchyma, thereby preserving the endocrine and exocrine functions of the pancreas. Simultaneously, laparoscopic surgery has contributed to minimally invasive approaches for various pancreatic surgical procedures. The combination of laparoscopic surgery and parenchyma-sparing pancreatectomy is an ideal surgical procedure for benign and low-grade malignant pancreatic lesions. For laparoscopic parenchyma-sparing pancreatectomy to become more widely known and its indications clarified, it is necessary to demonstrate the clinical benefits, technical feasibility, and safety of this complex and difficult surgical procedure.

Laparoscopic and robotic resection for pancreatic cancer

Minimally invasive surgical approaches for pancreatic resection have been established as feasible and safe. Whereas widespread application of laparoscopic distal pancreatectomy is in progress, the utilization of laparoscopic pancreaticoduodenectomy is still localized to a few centers because of the added complexity and advanced laparoscopic skills required. Comparative studies have demonstrated the typical advantages of minimally invasive approaches for pancreatic resection, namely, less blood loss and shorter hospital stay. Robotic assistance for laparoscopic approaches is gaining interest, but the true value added is still undefined. Significant discussion revolves around the appropriateness of minimally invasive approaches in pancreatic cancer. Although limited data and only short-term follow-up engender ongoing skepticism, the technical feasibility, existing reports in pancreatic cancer, and the lack of negative outcomes in other gastrointestinal cancers spark ongoing clinical evaluation. Minimally invasive surgical approaches have significant potential to improve the outcomes of pancreatic resection especially in pancreatic cancer patients in whom an optimal recovery is important for adjuvant treatment options. Larger experiences are forthcoming, and controlled trials are eagerly awaited; however, the feasibility of such is questionable because of the low incidence of resectable pancreatic cancer and the small number of centers performing minimally invasive pancreatectomy for malignancy.

Current status of robot-assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a comprehensive review

BACKGROUND

This article reviews the current status of robot-assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy.

METHOD

Searches of MEDLINE and PubMed databases were conducted using the keywords "laparoscopic pancreatectomy," "robotic surgery," "pancreaticoduodenectomy" and "distal pancreatectomy" to find articles published between January 1990 and September 2012. Additional papers were identified by a manual search of the references in key articles.

RESULTS

Only cases reports, cohort series and nonrandomized comparative studies were available to validate the outcomes of robotic pancreaticoduodenectomy and distal pancreatectomy. There was no randomized controlled trial comparing the robotic approach to the laparoscopic or open approach. To the best of our knowledge, only four studies have compared the robotic approach and the open approach for pancreaticoduodenectomy, and four studies have been published comparing the robotic approach and the laparoscopic approach for distal pancreatectomy. The data were difficult to interpret because of the heterogeneity of the pathologies and techniques used. Robotic-assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy for appropriately selected patients can be performed safely, with postoperative complication rates and mortality rate comparable to results observed with laparoscopic or open techniques. Robotic surgical systems also seem to improve the spleen-preservation rate in distal pancreatectomy. The oncologic outcomes have not yet been adequately evaluated.

CONCLUSIONS

Robotic pancreaticoduodenectomy and distal pancreatectomy are safe and feasible in appropriately selected patients. However, because of uncertainties regarding long-term oncologic outcome, caution should be exercised in assessing the appropriateness of this operation for individual patients. Further randomized and controlled studies are required to support the routine use of the robotic technology for pancreatectomy.

Feasibility of robotic pancreaticoduodenectomy

BACKGROUND

Laparoscopic pancreaticoduodenectomy is feasible, but requires adaptations to established surgical techniques. The improved dexterity offered by robotic assistance provides the opportunity to see whether laparoscopic pancreaticoduodenectomy can be performed safely when faithfully reproducing the open operation.

METHODS

Patients were selected for robotic pancreaticoduodenectomy when generally suitable for laparoscopy. Obese patients were excluded, and those with pancreatic cancer were highly selected. A prospectively designed database was used for data collection and analysis.

RESULTS

Of 238 patients undergoing pancreaticoduodenectomy, 34 (14·3 per cent) were operated on robotically. No procedure was converted to conventional laparoscopy or open surgery, despite three patients requiring segmental resection of the superior mesenteric/portal vein and reconstruction. The mean duration of operation was 597 (range 420-960) min. The mean number of lymph nodes retrieved and analysed from patients with neoplasia was 32 (range 15-76). Four patients required blood transfusions and five developed postoperative complications exceeding Clavien-Dindo grade II. There were four grade B pancreatic fistulas. One patient died on postoperative day 40. Excess mean operative cost compared with open resection was €6193.

CONCLUSION

Selected patients can safely undergo robotic pancreaticoduodenectomy. The main downsides are high costs and prolonged operating times compared with open resection.

Laparoscopic pancreaticoduodenectomy: experience of 22 cases

BACKGROUND

Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center.

METHODS

From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed.

RESULTS

Mean operative time was 392 (range, 327-570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12-35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14-20).

CONCLUSIONS

The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.

Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Pankreas - Kontra-Position

<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.