Appraisal of Laparoscopic Distal Pancreatectomy for Left-Sided Pancreatic Cancer: A Large Volume Cohort Study of 152 Consecutive Patients

Robotic versus laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

BACKGROUND

Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy (RDP) for pancreatic ductal adenocarcinoma (PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC.

METHODS

Patients who underwent RDP or laparoscopic distal pancreatectomy (LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed.

RESULTS

Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time (209.7 vs. 163.2 min; P = 0.003), lower open conversion rate (0% vs. 4.8%; P < 0.001), higher cost (15 722 vs. 12 699 dollars; P = 0.003), and a higher rate of achievement of an R0 resection margin (90.5% vs. 61.9%; P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant inter-group difference (9.5% vs. 9.5%). The median disease-free survival (34.5 vs. 17.3 months; P = 0.588) and overall survival (37.7 vs. 21.9 months; P = 0.171) were comparable between the groups.

CONCLUSIONS

RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.

Comparison of different pancreatic stump management strategies during robot-assisted distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) represents the most feared complication after distal pancreatectomy, and the possible role of robotic assistance in this setting is poorly investigated so far.

METHODS

We analysed short-term outcomes of 88 patients who had undergone robot-assisted distal pancreatectomy (RDP), dividing them according to pancreatic stump management: selective Wirsung duct ligation/hand sewn suture (WirsLIG group), use of robotic EndoWrist staplers (RobSTAP group), and use of laparoscopic staplers (LapSTAP group).

RESULTS

Mean operative time resulted significantly longer in WirsLIG group (291.1 ± 77.21 min vs. 245 ± 56.22 min in RobSTAP group vs. 221.77 ± 64.64 min in LapSTAP group). No significant differences were found in median hospital stay and in POPF occurrence.

CONCLUSIONS

No strategy for pancreatic stump management during RDP has proven superior to the others in reducing POPF rates. The hand-sewn technique resulted more time consuming, nevertheless it remains essential where there is not enough space to insert the stapler.

Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma

Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.

Minimally invasive distal pancreatectomy: Chronologic changes in the trends and clinical outcomes through a 15-year, single-center experience with 2212 patients

BACKGROUND

We identified the chronologic changes in the clinical outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors in a single high-volume center over a period of 15 years.

METHODS

Between 2005 and 2019, 2212 patients underwent planned MIDP. Chronologic changes were analyzed according to 5-year intervals (P1, P2, P3). Furthermore, we assessed the prognostic factors of open conversion and postoperative complications.

RESULTS

MIDP has steadily increased during the last 15 years when compared to open distal pancreatectomy, from 10.8% to 84.9%. Also, MIDP for pancreatic ductal adenocarcinoma (PDAC) has been steadily increasing from 5.6% to 68.4%. According to the 5-year intervals, lengths of hospital stay decreased, but age and American Society of Anesthesiologists (ASA) ≥3 increased; conversely, the rates of Clavien-Dindo classification ≥grade 3 (9.5%) and postoperative pancreatic fistula (39.7%) showed no differences. The 90-day mortality and open conversion rates were 0.2% and 3.5%, respectively. Multivariate logistic regression analysis revealed malignancy and extended pancreatectomy were risk factors for open conversion. Furthermore, the poor prognostic factors for severe complications were malignancy, extended pancreatectomy, and ASA ≥3.

CONCLUSION

MIDP has become a popular procedure not only for benign cases but also for malignant ones. However, well-organized training, experience and skill are necessary, especially for poor-performance patients and extensively malignant conditions.

Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma

BACKGROUND

Resection margin status is considered one of the few surgeon-controlled parameters affecting prognosis in pancreatic ductal adenocarcinoma (PDAC). While studies mostly focus on resection margins in pancreatoduodenectomy, little is known about their role in distal pancreatectomy (DP). This study aimed to investigate resection margins in DP for PDAC.

METHODS

Patients who underwent DP for PDAC between October 2004 and February 2020 were included (n = 124). Resection margins and associated parameters were studied in two consecutive time periods during which different pathology examination protocols were used: non-standardized (period 1: 2004-2014) and standardized (period 2: 2015-2020). Microscopic margin involvement (R1) was defined as ≤1 mm clearance.

RESULTS

Laparoscopic and open resections were performed in 117 (94.4%) and 7 (5.6%) patients, respectively. The R1 rate for the entire cohort was 73.4%, increasing from 60.4% in period 1 to 83.1% in period 2 (p = 0.005). A significantly higher R1 rate was observed for the posterior margin (35.8 vs. 70.4%, p < 0.001) and anterior pancreatic surface (based on a 0 mm clearance; 18.9 vs. 35.4%, p = 0.045). Pathology examination period, poorly differentiated PDAC, and vascular invasion were associated with R1 in the multivariable model. Extended DP, positive anterior pancreatic surface, lymph node ratio, perineural invasion, and adjuvant chemotherapy, but not R1, were significant prognostic factors for overall survival in the entire cohort.

CONCLUSIONS

Pathology examination is a key determinant of resection margin status following DP for PDAC. A high R1 rate is to be expected when pathology examination is meticulous and standardized. Involvement of the anterior pancreatic surface affects prognosis.

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

BACKGROUNDS/AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of Tumor Size on the Outcomes of Patients with Resectable Distal Pancreatic Cancer: Lessons Learned from a Series of 158 Radical Resections

BACKGROUND

Neoadjuvant therapy is used for borderline resectable pancreatic ductal adenocarcinoma (PDAC) with high risk of incomplete resection and early recurrence. Because distal PDAC is rare, the optimal criteria for neoadjuvant therapy specific for distal PDAC remain unclear. We hypothesized large distal PDAC would recur earlier than small distal PDAC.

OBJECTIVE

The aim of this study was to identify the risk factors for failure of upfront resection for resectable distal PDAC.

METHODS

The study cohort comprised 158 patients with resectable distal PDAC who underwent radical resection. The long-term outcomes were recurrence-free survival (RFS), disease-specific survival (DSS), and post-recurrence survival (PRS).

RESULTS

R0 resection was achieved in 92% of patients, and median DSS for the entire cohort was 31 months. Among 103 patients who developed recurrence, 32 (31%) developed recurrence within 6 months. The median PRS and DSS for those with early recurrence was 6 and 10 months, respectively, compared with 11 and 30 months, respectively, for those with late recurrence (p = 0.017 and p < 0.001, respectively). Patients with tumors > 4 cm had higher rates of R1 resection (16%) and concomitant resection of another organ (19%) than those with smaller tumors (4% and 2%, p = 0.009 and p < 0.001, respectively). In multivariate analysis, tumor > 4 cm remained a significant predictor of early recurrence (p < 0.001, hazard ratio [HR] 6.51), shorter RFS (p = 0.018, HR 1.71), and shorter DSS (p = 0.002, HR 2.07).

CONCLUSION

Tumor size > 4 cm is a reliable predictor of early recurrence after resection of distal PDAC, and neoadjuvant therapy may help select patients who can benefit from radical resection.

Registrar performance in minimally invasive distal pancreatectomy and effects on postoperative outcomes

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is nowadays an established standard procedure for non-locally advanced pancreatic lesions without celio-mesenteric vascular invasion. However, little is known about how the involvement of junior surgeons in MIDP affects postoperative outcomes. We performed a retrospective case series study in order to determine whether registrar involvement in MIDP is associated with adverse outcomes.

METHODS

Data were analyzed from a prospectively created database of consecutive patients undergoing MIDP. Only data from 91 patients who underwent MIDP for non-PDAC lesions were included. Patients were divided in 3 groups: Consultant P1 (first 20 MIDP, n=20), Consultant P2 (after 20 MIDP, n=44), and Registrar group (n=27). Conversion rates and 90-day postoperative outcomes were compared.

RESULTS

Conversion rates were 5%, 0%, and 14% in Consultant P1 and P2 and Registrar groups, respectively (P1 vs. P2, p = 0.312 and P1 vs. Registrar, p=0.376). Only Comprehensive Complication Index was higher in Registrar group compared to Consultant P1 group (13 vs. 3.7; p = 0.041). Comparison between Consultant P2 and Registrar groups resulted in a significant higher conversion rate (0 vs. 14%, p = 0.029), increased blood loss (77 vs. 263 ml, p = 0.018), and longer surgery duration (156 vs. 212 min, p=0.001) for registrars MIDP. However, no differences were found in clinically relevant postoperative pancreatic fistula (CR-POPF) (16 vs. 7.5%, p=0.282), Clavien-Dindo severe complication ≥3 score (11 vs. 4%, p=0.396), or length of hospital stay (9 vs. 9 days; p=0.614) between the consultant and registrar cohorts.

CONCLUSIONS

With all the limitations of a retrospective study with a small sample size, junior surgeons' involvement in MIDP for non-PDAC lesions resulted in higher conversion rate, blood loss and duration of surgery without statistically significant difference on clinical outcomes compared to a consultant.

Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS)

BACKGROUND

The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines.

METHODS

Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each.

RESULTS

Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains.

CONCLUSION

Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.

Propensity score-matching analysis comparing laparoscopic and open pancreaticoduodenectomy in elderly patients

There is little evidence on the safety and benefits of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients; therefore, we evaluated the feasibility and efficacy of this procedure by comparing perioperative and oncological outcomes between LPD and open pancreaticoduodenectomy (OPD) in elderly patients. We retrospectively reviewed the data of 1,693 patients who underwent PD to manage periampullary tumours at a single institution between January 2014 and June 2017. Of these patients, 326 were elderly patients aged ≥70 years, with 56 patients allocated to the LPD group and 270 to the OPD group. One-to-one propensity score matching (56:56) was used to match the baseline characteristics of patients who underwent LPD and OPD. LPD was associated with significantly fewer clinically significant postoperative pancreatic fistulas (7.1% vs. 21.4%), fewer analgesic injections (10 vs. 15.6 times; p = 0.022), and longer operative time (321.8 vs. 268.5 minutes; p = 0.001) than OPD in elderly patients. There were no significant differences in 3-year overall and disease-free survival rates between the LPD and OPD groups. LPD had acceptable perioperative and oncological outcomes compared with OPD in elderly patients. LPD is a reliable treatment option for elderly patients with periampullary tumours.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Different biological behaviors in left-sided pancreatic cancer according to Yonsei criteria: Proposal of a modified Yonsei criteria score

BACKGROUND/OBJECTIVES

Our institutional experience has demonstrated that bloodless and margin-negative resection is the most potent prognostic factor in treating left-sided pancreatic cancer and we developed selection guideline. The Yonsei criteria (YC) is selection criteria for oncologically safe and effective resection of left-sided pancreatic cancer by a minimally invasive approach. In this study, we investigated whether left-sided pancreatic cancer with YC can be more individualized to predict long-term survival by using clinically and pathologically detectable parameters.

METHODS

From January 2000 to December 2015, 105 patients underwent distal pancreatectomy for left-sided pancreatic cancer. The medical records of the patients were retrospectively reviewed.

RESULTS

Among clinically and pathologically detectable parameters to predict tumor conditions, radiologically determined tumor size (p = 0.080) and SUVmax (p = 0.086) were identified as predictors of early tumor recurrence with marginal significance. Among them, 20% of the patients with YC were identified as having the most favoring tumor condition, with an modified YC score of 3. The patient group with the lowest mYC score was found to have a very long disease-free survival time, with a mean of 108 months, which was statistically different from those with other mYC scores (mYC score = 4, mean 47.1 months [95% CI: 27.8-69.5] vs. mYC score = 5, mean 36.7 months [95% CI: 12.7-60.7], vs. mYC score = 6, mean 10.7 months [95% CI: 3.9-17.4]).

CONCLUSIONS

Modified Yonsei criteria score can predict long-term survival in resected left-sided pancreatic cancer. And patients within YC with a mYC score = 3 could have a favorable survival outcome.

Chronologic changes in clinical and survival features of pancreatic ductal adenocarcinoma since 2000: A single-center experience with 2,029 patients

BACKGROUND

To identify chronologic changes in clinical and survival features of pancreatic ductal adenocarcinoma based on diagnosis and treatment strategy development since 2000.

METHODS

Among 2,029 patients enrolled in this study, 746 and 1,283 were treated between 2000 and 2009 (group 1) and between 2010 and 2016 (group 2), respectively. We used patient clinicopathologic, biologic, and molecular factors to assess the prognostic factors.

RESULTS

Group 2 had a better survival outcome than group 1 (median survival time: 24.9 versus 18.4 months; 5-year survival rate: 27.6% versus 22.3%). The tendency for early diagnosis (lower CA19-9 levels, smaller size, and earlier T stage), use of neoadjuvant chemotherapy, decreased morbidity, early recovery (lesser hospital stay and more minimally invasive surgery), and standardization of surgical techniques appeared to improve patient survival. Multivariable analysis for prognosis revealed that tumor biologic factors (increased preoperative serum CA19-9 level, tumor size, tumor differentiation, N stage, and presence of lymphovascular invasion), operational factors (status of the resection margin, type of operation, and year of operation), and genetic factors (K-ras mutations) correlated with patient survival.

CONCLUSION

Early diagnosis and combined efforts, such as neoadjuvant chemotherapy and an established system of patient care, have gradually enhanced patient survival after operative resection for pancreatic ductal adenocarcinoma. Hence, multiplex prognostic parameters could provide additional information for improved prognostic estimation of pancreatic cancer exhibiting heterogeneous results.

Can standardized pathology examination increase the lymph node yield following laparoscopic distal pancreatectomy for ductal adenocarcinoma?

BACKGROUND

Lymph node yield (LNY) is an indicator of oncological adequacy of surgery in patients with pancreatic ductal adenocarcinoma (PDAC). Our hypothesis is that standardized pathology examination (SPE) aimed at accurate staging can increase the LNY without changing surgical technique.

METHODS

After the introduction of SPE for distal pancreatosplenectomy specimens at Oslo University Hospital, prospective data were collected on patients with PDAC undergoing laparoscopic distal pancreatosplenectomy (LDP). Their data were compared with retrospective data from specimens examined in a non-standardized way (NSPE).

RESULTS

SPE and NSPE were applied to 20 and 33 specimens, respectively. SPE was associated with a higher LNY and a higher median number of positive lymph nodes (PLN) in the specimen (18 vs 7, P = 0.001 and 4 vs 1, P = 0.005, respectively). In the stepwise regression model, SPE and younger age resulted in an increased LNY. In the logistic regression model, increased LNY and larger tumor size positively correlated with the presence of PLN.

CONCLUSION

SPE of distal pancreatosplenectomy specimens is associated with higher LNY in patients with PDAC, which increases the likelihood of detecting PLN and reduces the risk of understaging. These findings also indicate that the LDP technique provides an adequate LNY in patients with PDAC.

Yonsei criteria: a clinical reflection of stage I left-sided pancreatic cancer

In this study, we examined associations between pancreatic cancer that met the Yonsei criteria (YC) and classifications from the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. Clinicopathological and survival data were collected from132 patients who underwent distal pancreatectomy for left-sided pancreatic ductal adenocarcinoma between January 2000 and December 2015, and the utility of the YC for selecting treatment and predicting survival was evaluated using the 8th AJCC staging manual. Of the 102 patients who ultimately qualified for the study, 45 patients were reclassified as stage I based on the 8th AJCC cancer staging system. Disease-free survival and disease-specific survival periods were longer in stage I patients who met the YC than in those who did not. Clinicopathological characteristics did not differ between stage I patients who did and did not meet the YC. These results suggest that meeting the YC criteria may be a clinical indicator that left-sided pancreatic cancer patients who are candidates for resection have early-stage disease according to the 8th edition of the AJCC staging manual.