Laparoscopic Spleen-Preserving Total Pancreatectomy for a Main-Duct Intraductal Papillary Mucinous Neoplasm

Robotic-assisted versus open total pancreatectomy: a propensity score-matched study

Background

Total pancreatectomy (TP) is a complex surgical procedure with significant postoperative morbidity. Despite the narrowed range of indications for TP, the introduction of neoadjuvant chemotherapy and the increasing complexity of surgical resections performed in high-volume centers has increased the number of annually performed TPs, especially regarding malignant disease. The introduction of robotic-assisted pancreatic surgery has provided a novel and minimally invasive approach for TP, yet the feasibility of this technique is still unknown. This study assessed the safety and efficacy of robotic-assisted total pancreatectomy (RTP) compared to conventional open total pancreatectomy (OTP).

Methods

All patients who underwent TP between March 2015 and July 2019 in a high-volume institution for pancreatic surgery were included in this retrospective study. Clinical data and perioperative outcomes were derived from the prospectively maintained institutional database. A 1:1 propensity score matching (PSM) method was utilized to compare the RTP and OTP cohorts to minimize bias.

Results

A standardized surgical protocol was utilized for RTP following a learning curve of RPD and RDP. The median operative time for patients who underwent RTP was significantly decreased compared to those who underwent OTP [300 (IQR, 250-360) vs. 360 min (IQR, 300-525), P=0.031]. Additionally, en bloc resection and spleen-preserving rates were also higher in the RTP cohort. Major 30-day morbidity (Clavien-Dindo > IIIa) and 90-day mortality were similar between the two cohorts. After a median follow-up time of 15 (IQR, 8-24) months, both the RTP and OTP cohorts had a comparable quality of life regarding exocrine and endocrine insufficiency.

Conclusions

RTP appears to be safe and feasible when utilized in high-volume centers for the indicated management of benign and highly selected malignant pancreatic disease. However, further prospective randomized studies are needed to assess the feasibility of this approach.

A novel surgical approach for en-bloc resection laparoscopic total pancreatectomy

Laparoscopic total pancreatectomy (LTP) is technical challenging and rarely reported in the literature. Herein, we introduced a safe and feasible approach to perform LTP basing on our own experience.Over the period of July 2015 to August 2018, we performed 13 cases of LTP at our institution. Demographic characteristics, intraoperative and postoperative variables, and follow-up outcomes were prospectively collected. The surgical procedures were also described in this study.Seven male and six female patients were included in this study. The median age of the patients was 51 years (range 29-79 years). The median operative time was 355 minutes (range 300-470 minutes). The median estimated blood loss was 200 mL (range 50-1000 mL). The median postoperative hospital stay was 17 days (range 12-23 days). One patient suffered from bile leakage and another patient suffered from delayed gastric emptying. Both patients cured with conservative therapy.Laparoscopic total pancreatectomy can be safely and feasibly performed in well-selected patients.

Laparoscopic duodenum and spleen-preserving total pancreatectomy: A novel surgical technique for pancreatic intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is no longer a rarely diagnosed disease, because of the development of medical imaging. With a high incidence of canceration, especially in the main duct type, surgery is strongly recommended. Pancreatoduodenectomy, distal pancreatectomy and central pancreatectomy are applied in those cases. For this potentially malignant disease, function-preserving surgery seems more appropriate. An old female was enrolled in our research, who was diagnosed with IPMN. Diameter of the main pancreatic duct (MPD) was > 5 mm and lesions distributed to the whole pancreas. laparoscopic duodenum and spleen-preserving total pancreatoduodenectomy was carried out, which has not reported previously. We successfully performed laparoscopic duodenum and spleen-preserving total pancreatectomy, without major complications such as severe pancreatic fistula, postoperative bleeding, and delayed ischemia of duodenum and spleen. We consider laparoscopic duodenum and spleen-preserving total pancreatectomy is technically feasible, but a large sample of randomized controlled trials is needed to evaluate its safety, effectiveness and long-term outcome.

[Minimally invasive and robot-assisted surgery for pancreatic cystic tumors]

BACKGROUND

The indications for resection of pancreatic cystic lesions (PCL) are often complex and the operative risk has to be balanced against the risk of malignant transformation. The aim of the study was to provide a synopsis of the current treatment results of minimally invasive surgery for PCL.

METHODS

A systematic literature search was performed using the Medline database (PubMed). Subsequently, the retrieved literature was selectively reviewed.

RESULTS

No published prospective randomized controlled trials have yet addressed the comparison of open and minimally invasive surgery of PCL; however, retrospective case studies have demonstrated the feasibility, safety and a comparable morbidity after minimally invasive distal pancreatectomy (DP), pancreatoduodenectomy (PD), central (CP) or total pancreatectomy and enucleation. Whereas most DPs are performed laparoscopically, the experience of minimally invasive PD has been consolidated for the robot-assisted approach but is concentrated in only a few centers. The number of published reports on minimally invasive organ-sparing pancreas procedures (e. g. CP or enucleation) for PCL is scarce; however, the available (selected) results are promising.

CONCLUSION

Minimally invasive surgery for PCL has the potential to reduce the operative trauma to the patients, while at the same time causing comparable or less morbidity. This requires an increasing specialization of complex minimally invasive resections. The clinical use of robotic systems will grow for the latter cases. A prospective registry of the results should be mandatory for quality management.

Surgical Management of Pancreatic Cysts: A Shifting Paradigm Toward Selective Resection

Due to the widespread use of high-quality cross-sectional imaging, pancreatic cystic neoplasms are being diagnosed with increasing frequency. Clinicians are therefore asked to counsel a growing number of patients with pancreatic cysts diagnosed incidentally at an early, asymptomatic stage. Over the last two decades, accumulating knowledge on the biologic behavior of these neoplasms along with improved diagnostics through imaging and endoscopic cyst fluid analysis have allowed for a selective therapeutic approach toward these neoplasms. On one end of the management spectrum, observation is recommended for typically benign lesions (serous cystadenoma), and on the other end, upfront resection is recommended for likely malignant lesions (main duct IPMN, mucinous cystadenoma, solid pseudopapillary tumor, and cystic pancreatic neuroendocrine tumors). In between, management of premalignant lesions (branch duct IPMN) is dictated by the presence of high-risk features. In general, resection should be considered whenever the risk of malignancy is higher than the risk of the operation. This review aims to describe the evolution and current status of evidence guiding the selection of patients with pancreatic cystic neoplasms for surgical resection, along with a specific discussion on the type of resection required and expected outcomes.