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Wang S, Zhang K, Hu JL, Wu WC, Liu X, Ge N, Guo JT, Wang GX, Sun SY. Endoscopic resection of the pancreatic tail and subsequent wound healing mechanisms in a porcine model. World J Gastroenterol 2019; 25:2623-2635. [PMID: 31210714 PMCID: PMC6558443 DOI: 10.3748/wjg.v25.i21.2623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopic resection of the pancreatic body and tail is the predominant methodology to remove lesions in these locations; its safety and surgical planning are relatively mature, but it remains a complex and high-precision surgical operation, requiring abundant experience and skills in laparoscopic surgery, with a 10% rate of complications.
AIM To verify the feasibility and safety, as well as to examine the complications of endoscopic pancreatectomy and healing mechanisms of pancreatic wounds after endoscopic resection.
METHODS Transgastric endoscopic resections of varying sizes of pancreases were performed in 15 healthy Bama miniature pigs. The technical success rate, the incidence of serious complications, and the survival of the animals were studied. The healing of the wounds was evaluated by sacrificing the animals at various time points. Finally, the expression of transforming growth factor-β1 and Smad3/Smad7 in the surgical site was examined by immunohistochemistry to explore the role of these factors in wound healing of the pancreas.
RESULTS Partial and total resections were successfully performed in two groups of animals, respectively. The technical success rate and the survival rate of the pigs were both 100%. We obtained 12 pancreatic tissue samples by endoscopic resection. The pancreatic wounds were closed with metal clips in one group and the wounds healed well by forming scars. There was a small amount of pancreatic leakage in the other group, but it can be fully encapsulated. The level of transforming growth factor-β1 (TGF-β1) in the wounds increased during the inflammatory and fibrous hyperplasia phases, and decreased in the scar phase. The expression of Smad3 paralleled that of TGF-β1, while the expression of Smad7 had an inverse relationship with the expression of TGF-β1.
CONCLUSION Purely transgastric endoscopic resection of the pancreas is a safe, effective, and feasible procedure, but the incidence of pancreatic leakage in total pancreatic tail resection is high. The expression of TGF-β1 and Smad3/Samd7 is related to the progression of pancreatic wound healing.
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Affiliation(s)
- Sheng Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Kai Zhang
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Jin-Long Hu
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Wei-Chao Wu
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Xiang Liu
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Nan Ge
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Jin-Tao Guo
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Guo-Xin Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Si-Yu Sun
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Chopinet S, Fuks D, Rinaudo M, Massol J, Gregoire E, Lamer C, Belgaumkar A, Hardwigsen J, Le Treut YP, Gayet B. Postoperative Bleeding After Laparoscopic Pancreaticoduodenectomy: the Achilles' Heel? World J Surg 2018; 42:1138-1146. [PMID: 29018911 DOI: 10.1007/s00268-017-4269-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding, and its impact on postoperative outcomes remains controversial. OBJECTIVE To compare short-term outcomes between laparoscopic versus open pancreaticoduodenectomy (OPD) in order to assess the safety of LPD. METHODS From 2002 to 2014, all consecutive patients undergoing LPD or OPD at two tertiary centers were retrospectively analyzed. Patients were matched for demographics, comorbidities, pathological diagnosis, and pancreatic texture. Results for the two groups were compared for postoperative outcomes. RESULTS Sixty-five LPD were performed and compared to 290 OPD. In the whole population, postoperative pancreatic fistula (PF) was higher in the LPD group, but the proportion of ampullary adénocarcinoma (25 vs. 10%, p = 0.004) and soft pancreatic parenchyma (52 vs. 38%, p = 0.001) were higher in the LDP group. After matching (n = 65), LPD was associated with longer operative time (429 vs. 328 min, p < 0.001) and lower blood loss (370 vs. 515 mL, p = 0.047). The PF rate and its severity were similar (33 vs. 27%, p = 0.439, p = 0.083) in the two groups. However, both complications (78 vs. 71%, p = 0.030) and major complications (40 vs. 23%, p = 0.033) were more frequent in the LPD group. LPD patients experience more postoperative bleeding (21 vs. 14%, p = 0.025) compared to their open counterparts. In multivariate analysis, perioperative transfusion (OR = 5 IC 95% (1.5-16), p = 0.008), soft pancreas (OR = 2.5 IC 95% (1.4-4.6), p = 0.001), and ampullary adenocarcinoma (OR = 2.6 IC 95% (1.2-5.6), p = 0.015) were independent risks factors of major complications. CONCLUSION Despite lower blood loss and lower intraoperative transfusion, LPD leads to higher rate of postoperative complications with postoperative bleeding in particular.
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Affiliation(s)
- Sophie Chopinet
- Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris-Descartes, 42 Boulevard Jourdan, 75014, Paris, France.
- Department of Digestive Surgery, Hôpital de la Conception, Marseille, France.
| | - David Fuks
- Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris-Descartes, 42 Boulevard Jourdan, 75014, Paris, France
- Université Paris Descartes, 12 rue de l'Ecole de Médecine, Paris, France
| | - Mathieu Rinaudo
- Department of Digestive Surgery, Hôpital de la Conception, Marseille, France
| | - Julien Massol
- Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris-Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Emilie Gregoire
- Department of Digestive Surgery, Hôpital de la Conception, Marseille, France
| | - Christian Lamer
- Department of Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Ajay Belgaumkar
- Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris-Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Jean Hardwigsen
- Department of Digestive Surgery, Hôpital de la Conception, Marseille, France
| | | | - Brice Gayet
- Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris-Descartes, 42 Boulevard Jourdan, 75014, Paris, France
- Université Paris Descartes, 12 rue de l'Ecole de Médecine, Paris, France
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Aloia TA, Kim BJ, Segraves-Chun YS, Cata JP, Truty MJ, Shi Q, Holmes A, Soliz JM, Popat KU, Rahlfs TF, Lee JE, Wang XS, Morris JS, Gottumukkala VNR, Vauthey JN. A Randomized Controlled Trial of Postoperative Thoracic Epidural Analgesia Versus Intravenous Patient-controlled Analgesia After Major Hepatopancreatobiliary Surgery. Ann Surg 2017; 266:545-54. [PMID: 28746153 DOI: 10.1097/SLA.0000000000002386] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The primary objective of this randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient-controlled analgesia (IV-PCA) for pain control over the first 48 hours after hepatopancreatobiliary (HPB) surgery. Secondary endpoints were patient-reported outcomes, total narcotic utilization, and complications. BACKGROUND Although adequate postoperative pain control is critical to patient and surgeon success, the optimal analgesia regimen in HPB surgery remains controversial. METHODS Using a 2.5:1 randomization strategy, 140 patients were randomized to TEA (N = 106) or intravenous patient-controlled analgesia (N = 34). Patient-reported pain was measured on a Likert scale (0-10) at standard time intervals. Cumulative pain area under the curve was determined using the trapezoidal method. RESULTS Between the study groups key demographic, comorbidity, clinical, and operative variables were equivalently distributed. The median area under the curve of the postoperative time 0- to 48-hour pain scores was lower in the TEA group (78.6 vs 105.2 pain-hours, P = 0.032) with a 35% reduction in patients experiencing ≥7/10 pain (43% vs 62%, P = 0.07). Patient-reported outcomes and total opiate use further supported the benefit of TEA on patient experience. Anesthesia-related events requiring change in analgesic therapy were comparable (12.2% vs 2.9%, respectively, P = 0.187). Grade 3 or higher surgical complications (6.6% vs 9.4%), median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the operating room (0.9% vs 3.1%) were similar (all P > 0.05). There were no mortalities in either group. CONCLUSIONS In major HPB surgery, TEA provides a superior patient experience through improved pain control and less narcotic use, without increased length of stay or complications.
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Abstract
Total laparoscopic pancreaticoduodenectomy (TLP) represents perhaps one of the most challenging abdominal operations. This procedure is gaining popularity in recent years, mostly due to the numerous reports underling its safety and feasibility in the setting of several benign and malignant pancreatic pathologies. Minimal-invasive pancreatic surgery is rapidly becoming a reality in many centers around the globe and its benefits, compared to the traditional open approach, have been extensively proven in the setting of distal pancreatic resection. The many advantages of a laparoscopic approach, such as the improved visual magnification, the theoretical improved tissue exposure, and the potential for a more delicate manipulation of tissues are reasonably expected to be applicable to other pancreatic procedures including TLP. Herein we describe a technique for a TLP; we provide some suggestions on patient selection, pre-operative preparation, equipment, postoperative management, and finally discuss some of the most common pitfalls encountered during the procedure.
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Affiliation(s)
- Alessandro Paniccia
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brandon Chapman
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Barish H Edil
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Wang YF, Shi BM. Minimally invasive techniques of biliary surgery in new era. Shijie Huaren Xiaohua Zazhi 2016; 24:2957-2963. [DOI: 10.11569/wcjd.v24.i19.2957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the rapid development of technology and improvement of surgical skills, many types of minimally invasive techniques have been developed, including laparoscopic technique, combined endoscopic-laparoscopic technique, robotic surgery, and percutaneous transhepatic cholangial drainage technique. Different techniques own their special advantages for different types of biliary diseases. In the current review, I discuss the progress in minimally invasive techniques dealing with biliary diseases in the new era.
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Abstract
Contrary to many other gastrointestinal operations, minimal access approaches in pancreatic surgery have gained ground slowly. Laparoscopic distal pancreatectomy has gained wide acceptance. It is associated with reduced blood loss and shorter duration of stay (DOS) while oncologic results and morbidity are similar to open surgery. In recent years the number of laparoscopic pancreatoduodenectomies has also increased. While oncological outcome seems comparable to the open approach, operative times are longer while DOS and blood loss are reduced. One added advantage of the laparoscopic approach to pancreatic cancer seems to be that adjuvant treatment can start earlier. Minimal access total pancreatectomy, only reported in small numbers (mostly robot assisted), has also been shown to be feasible and safe. Enucleation (EN) of small pancreatic lesions is the most common tissue sparing resection. Although no reconstruction is necessary, the risk of pancreatic fistula is high, related to excision margins equal or smaller than 2 mm to the main pancreatic duct. Compared to the open approach, laparoscopic EN has shown comparable results in terms of morbidity, pancreatic function and fistula rate, with shorter operation times and faster recovery. Experience in robot assisted pancreatic surgery is increasing. However reports are still small in numbers, lacking randomization and mostly limited to dedicated centers. The learning curve for minimal access pancreatic surgery is steep. Low patient volume leads to longer DOS, higher costs and negatively impacts outcome.
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Affiliation(s)
| | - Abe Fingerhut
- Section for Surgical Research, Medical University of Graz, Graz, Austria
| | - Igor Khatkov
- Moscow Clinical Scientific Center, Moscow, Russia
| | - Selman Uranues
- Section for Surgical Research, Medical University of Graz, Graz, Austria
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Sun Z, Zhu Y, Zhang N. The detail of the en bloc technique and prognosis of spleen-preserving laparoscopic distal pancreatectomy for pancreatic cancer. World J Surg Oncol 2015; 13:322. [PMID: 26607990 PMCID: PMC4660836 DOI: 10.1186/s12957-015-0735-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/12/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although laparoscopic spleen-preserving distal pancreatectomy surgery is more and more popular, the reports about the en bloc technique used for pancreatic cancer were still rare. The aim of our study was to illustrate the detail of the spleen-preserving en bloc technique as well as the short-term and long-term outcomes. METHODS The detail of the en bloc technique with pictures was described. The prognosis of the successive 23 cases that underwent the laparoscopic distal pancreatectomy (LDP) surgery was evaluated. RESULTS There were 17 cases that underwent spleen-preserving LDP while six cases underwent spleen-resecting LDP. The average surgery time was 203 ± 54 min, and the average blood loss volume was 208 ± 264 ml; one case transferred to open surgery because of severe adhesion. The complication rate was 47 % (n = 8) shortly after surgery. Pancreatic fistula rate was 41 % (n = 7). No lethal case occurred. The average diameter of the tumor was 32 ± 12 mm. The average number of the lymph nodes obtained was 19.8 ± 9.3. All the cutting edges were negative. Survival rates of the patient after 1, 3, and 5 years are 64.7, 52.9, and 41.2 %, respectively. These records showed no statistical significance compared with spleen-resecting LDP and open distal pancreatectomy (ODP) surgeries. CONCLUSIONS The en bloc spleen-preserving LDP can be performed by experienced surgeons. This surgery has good short-term and long-term outcomes.
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Affiliation(s)
- Zhipeng Sun
- Oncology Surgery Department, Peking University Ninth School of Clinical Medicine (Beijing Shijitan Hospital, Capital Medical University), 334room, Administrative Building, Beijing, China.
| | - Yubing Zhu
- Oncology Surgery Department, Peking University Ninth School of Clinical Medicine (Beijing Shijitan Hospital, Capital Medical University), 334room, Administrative Building, Beijing, China.
| | - Nengwei Zhang
- Oncology Surgery Department, Peking University Ninth School of Clinical Medicine (Beijing Shijitan Hospital, Capital Medical University), 334room, Administrative Building, Beijing, China.
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