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Kalayarasan R, Shukla A. Changing trends in the minimally invasive surgery for chronic pancreatitis. World J Gastroenterol 2023; 29:2101-2113. [PMID: 37122602 PMCID: PMC10130972 DOI: 10.3748/wjg.v29.i14.2101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/21/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023] Open
Abstract
Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.
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Affiliation(s)
- Raja Kalayarasan
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Ankit Shukla
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
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Varshney VK, Nayar R, Hussain S, Selvakumar B. Total robotic lateral pancreaticojejunostomy and modified Frey's procedure for chronic calcific pancreatitis. Langenbecks Arch Surg 2022; 408:1. [PMID: 36576590 DOI: 10.1007/s00423-022-02735-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/15/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical intervention has been shown to have good post-operative outcomes in patients with chronic pancreatitis with pain refractory to oral analgesics. We present our initial experience with robotic lateral pancreaticojejunostomy (LPJ) and modified Frey's procedure (MFP). METHODOLOGY Patients with chronic calcific pancreatitis were evaluated with routine biochemical and radiological investigations. The indication of surgery was intractable pain which was recorded by an Intensity Frequency, Consequence (IFC) pain score. The patient was placed in a reverse Trendelenburg position with four 8-mm robotic ports and one 12-mm assistant port. Robotic ultrasound was utilized to identify the pancreatic duct. After retrieving all the calculi, which was confirmed by pancreatoscopy with the help of a video choledochoscope and performing the head coring in particular cases, the Roux-en-Y LPJ was performed. RESULTS Among five patients (4 males, one female), robotic LPJ was performed in 2 and MFP in 3 patients. The cohort's median age was 32 (interquartile range (IQR), 28, 40) years, and the median (IQR) pancreatic duct size was 9 (9, 13) mm. The median (IQR) duration of the procedure was 385 (380, 405) minutes, with a median (IQR) blood loss of 100 (50-100) ml, and the patients were discharged on median post-operative day 5. The patients continue to do well at a median follow-up of 3-30 months without the requirement of oral analgesics. CONCLUSION Robotic LPJ and MFP are feasible in experienced hands with good post-operative outcomes and enhanced quality of life. Intra-operative pancreatoscopy with the help of a choledochoscope can be utilized to ascertain the complete clearance of pancreatic duct stones and the consequent pain relief.
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Affiliation(s)
- Vaibhav Kumar Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Basni Industrial Area, Phase-II, Jodhpur, 342005, Rajasthan, India.
| | - Raghav Nayar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Basni Industrial Area, Phase-II, Jodhpur, 342005, Rajasthan, India
| | - Sabir Hussain
- Department of Medical Gastroenterology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - B Selvakumar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Basni Industrial Area, Phase-II, Jodhpur, 342005, Rajasthan, India
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Morelli L, Furbetta N, Gianardi D, Guadagni S, Di Franco G, Bianchini M, Palmeri M, Masoni C, Di Candio G, Cuschieri A. Use of barbed suture without fashioning the "classical" Wirsung-jejunostomy in a modified end-to-side robotic pancreatojejunostomy. Surg Endosc 2020; 35:955-961. [PMID: 33025248 PMCID: PMC7820080 DOI: 10.1007/s00464-020-07991-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/14/2020] [Indexed: 02/08/2023]
Abstract
Background The treatment of the pancreatic stump is a critical step of pancreatoduodenectomy (PD). Robot-assisted surgery (RAS) can facilitate minimally invasive challenging abdominal procedures, including pancreatojejunostomy. However, one of the major limitations of RAS stems from its lack of tactile feedback that can lead to pancreatic parenchyma laceration during knot tying or during traction on the suture. Moreover, a Wirsung-jejunostomy is not always easy to execute, especially in cases with small diameter duct. Herein, we describe and video-report the technical details of a robotic modified end-to-side invaginated robotic pancreatojejunostomy (RmPJ) with the use of barbed suture instead of the “classical” Wirsung-jejunostomy. Methods The RmPJ technique consists of a double layer of absorbable monofilament running barbed suture (3–0 V-Loc), the outer layer is used to invaginate the pancreatic stump. Thereafter, a small enterotomy is made in the jejunum exactly opposite to the location of the pancreatic duct for stent insertion (usually 5 Fr) inside the duct. The internal layer provides a second barbed running suture placed between the pancreatic capsule/parenchyma and the jejunal seromuscular layer. Results A total of 14 patients underwent robotic PD with RmPJ at our Institution. The mean console time was (281.36 ± 31.50 min), while the mean operative time for fashioning the RmPJ was 37.31 ± 7.80 min. Ten out of 14 patients were discharged within postoperative day 8. No clinically relevant pancreatic fistulas were encountered, while two patients developed biochemical leaks. Conclusions RmPJ is feasible and reproducible irrespective of pancreatic duct size and parenchyma, and can enhance the surgical workflow of this operation. Specifically, the use of barbed sutures allows the exploitation of the potential advantages of the RAS, while minimizing the negative effect caused by the main disadvantage of the robotic approach, its absence of tactile feedback, by ensuring uniform tension on the continuous suture lines used, especially during the reconstructive phase of the operation. Electronic supplementary material The online version of this article (10.1007/s00464-020-07991-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy. .,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
| | - Niccolò Furbetta
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Caterina Masoni
- Vascular Surgery Unit, Department of Cardiovascular Surgery, University of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Alfred Cuschieri
- Institute for Medical Science and Technology, University of Dundee, Dundee, Scotland, UK
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Miksch RC, D'Haese JG, Werner J. Surgical Therapy of Chronic Alcoholic Pancreatitis: A Literature Review of Current Options. Visc Med 2020; 36:191-197. [PMID: 32775349 PMCID: PMC7383250 DOI: 10.1159/000508174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
Chronic pancreatitis (CP) is associated with alcohol abuse in 80% of cases. The primary treatment goals in CP are pain reduction and avoidance of pancreatitis-associated complications. CP should be treated in an interdisciplinary approach. A recent randomized clinical trial showed that early surgery compared with an endoscopy-first approach resulted in reduced pain levels. Surgical resections are, therefore, the most efficient treatment of pancreatitis-associated pain as well as other complications and should be performed early in the course of the disease. Since most of the patients pre-sent with chronic inflammation of the pancreatic head, pancreatic head resection is the most common treatment option. Duodenum-preserving pancreatic head resections are the surgical procedure of choice, but pancreaticoduodenectomies (Kausch-Whipple procedures) demonstrate similar outcome with regard to pain control, quality of life, and metabolic parameters. Other surgical procedures, including drainage procedures, pancreatic segmental resections, or left resections, are rarely indicated.
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Affiliation(s)
| | | | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University Munich, Munich, Germany
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