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van Bodegraven EA, Balduzzi A, van Ramshorst TME, Malleo G, Vissers FL, van Hilst J, Festen S, Abu Hilal M, Asbun HJ, Michiels N, Koerkamp BG, Busch ORC, Daams F, Luyer MDP, Ramera M, Marchegiani G, Klaase JM, Molenaar IQ, de Pastena M, Lionetto G, Vacca PG, van Santvoort HC, Stommel MWJ, Lips DJ, Coolsen MME, Mieog JSD, Salvia R, van Eijck CHJ, Besselink MG. Prophylactic abdominal drainage after distal pancreatectomy (PANDORINA): an international, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet Gastroenterol Hepatol 2024; 9:438-447. [PMID: 38499019 DOI: 10.1016/s2468-1253(24)00037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Prophylactic passive abdominal drainage is standard practice after distal pancreatectomy. This approach aims to mitigate the consequences of postoperative pancreatic fistula (POPF) but its added value, especially in patients at low risk of POPF, is currently being debated. We aimed to assess the non-inferiority of a no-drain policy in patients after distal pancreatectomy. METHODS In this international, multicentre, open-label, randomised controlled, non-inferiority trial, we recruited patients aged 18 years or older undergoing open or minimally invasive elective distal pancreatectomy for all indications in 12 centres in the Netherlands and Italy. We excluded patients with an American Society of Anesthesiology (ASA) physical status of 4-5 or WHO performance status of 3-4, added by amendment following the death of a patient with ASA 4 due to a pre-existing cardiac condition. Patients were randomly assigned (1:1) intraoperatively by permuted blocks (size four to eight) to either no drain or prophylactic passive drain placement, stratified by annual centre volume (<40 or ≥40 distal pancreatectomies) and low risk or high risk of grade B or C POPF. High-risk was defined as a pancreatic duct of more than 3 mm in diameter, a pancreatic thickness at the neck of more than 19 mm, or both, based on the Distal Pancreatectomy Fistula Risk Score. Other patients were considered low-risk. The primary outcome was the rate of major morbidity (Clavien-Dindo score ≥III), and the most relevant secondary outcome was grade B or C POPF, grading per the International Study Group for Pancreatic Surgery. Outcomes were assessed up to 90 days postoperatively and analysed in the intention-to-treat population and per-protocol population, which only included patients who received the allocated treatment. A prespecified non-inferiority margin of 8% was compared with the upper limit of the two-sided 95% CI (Wald) of unadjusted risk difference to assess non-inferiority. This trial is closed and registered in the Netherlands Trial Registry, NL9116. FINDINGS Between Oct 3, 2020, and April 28, 2023, 376 patients were screened for eligibility and 282 patients were randomly assigned to the no-drain group (n=138; 75 [54%] women and 63 [46%] men) or the drain group (n=144; 73 [51%] women and 71 [49%] men). Seven patients in the no-drain group received a drain intraoperatively; consequently, the per-protocol population included 131 patients in the no-drain group and 144 patients in the drain group. The rate of major morbidity was non-inferior in the no-drain group compared with the drain group in the intention-to-treat analysis (21 [15%] vs 29 [20%]; risk difference -4·9 percentage points [95% CI -13·8 to 4·0]; pnon-inferiority=0·0022) and the per-protocol analysis (21 [16%] vs 29 [20%]; risk difference -4·1 percentage points [-13·2 to 5·0]; pnon-inferiority=0·0045). Grade B or C POPF was observed in 16 (12%) patients in the no-drain group and in 39 (27%) patients in the drain group (risk difference -15·5 percentage points [95% CI -24·5 to -6·5]; pnon-inferiority<0·0001) in the intention-to-treat analysis. Three patients in the no-drain group died within 90 days; the cause of death in two was not considered related to the trial. The third death was a patient with an ASA score of 4 who died after sepsis and a watershed cerebral infarction at second admission, leading to multiple organ failure. No patients in the drain group died within 90 days. INTERPRETATION A no-drain policy is safe in terms of major morbidity and reduced the detection of grade B or C POPF, and should be the new standard approach in eligible patients undergoing distal pancreatectomy. FUNDING Ethicon UK (Johnson & Johnson Medical, Edinburgh, UK).
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Affiliation(s)
- Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Alberto Balduzzi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Tess M E van Ramshorst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, OLVG, Amsterdam, Netherlands
| | | | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery and Pulmonology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Olivier R C Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Marco Ramera
- Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giovanni Marchegiani
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy; Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Joost M Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, Netherlands
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Gabriella Lionetto
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Casper H J van Eijck
- Department of Surgery and Pulmonology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands.
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De Pastena M, van Bodegraven EA, Mungroop TH, Vissers FL, Jones LR, Marchegiani G, Balduzzi A, Klompmaker S, Paiella S, Tavakoli Rad S, Groot Koerkamp B, van Eijck C, Busch OR, de Hingh I, Luyer M, Barnhill C, Seykora T, Maxwell T T, de Rooij T, Tuveri M, Malleo G, Esposito A, Landoni L, Casetti L, Alseidi A, Salvia R, Steyerberg EW, Abu Hilal M, Vollmer CM, Besselink MG, Bassi C. Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation. Ann Surg 2023; 277:e1099-e1105. [PMID: 35797608 DOI: 10.1097/sla.0000000000005497] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively. BACKGROUND POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet. METHODS Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014-2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007-2016) to assess discrimination and calibration in an internal-external validation procedure. RESULTS Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11-1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32-1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78-0.88) and 0.73 (95% CI: 0.70-0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%-25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74-0.85). CONCLUSIONS The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com . The 3 distinct risk groups allow for personalized treatment and benchmarking.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Leia R Jones
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alberto Balduzzi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Shazad Tavakoli Rad
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Caleb Barnhill
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Thomas Seykora
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Massimiliano Tuveri
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Casetti
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
- Department of Surgery, University of California, San Francisco, CA
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
- Department of Surgery, Southampton University, Southampton, UK
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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Preliminary experience with a new robotic technique to facilitate distal pancreatectomy with spleen preservation: left lateral approach in right lateral decubitus position. J Robot Surg 2023:10.1007/s11701-023-01542-w. [PMID: 36932264 DOI: 10.1007/s11701-023-01542-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/02/2023] [Indexed: 03/19/2023]
Abstract
Spleen-preserving distal pancreatectomy (SP-DP), for patients with benign or small low-grade malignant tumors of the body or tail of the pancreas, is the ideal procedure although it is technically demanding. The robotic da Vinci system has been introduced to overcome these technical challenges and reduce operative risks. We report our experience of a new variation in surgical technique: the left lateral approach robotic spleen-preserving distal pancreatectomy (RSP-DP) in right lateral decubitus position. We performed this new variant of SP-DP, in five patients, using the da Vinci Xi system. Technical and clinical feasibility are described. The mean age and body mass index were 53.4 years and 31.4 kg/m2, respectively. The mean total operative time was 323 min. The estimated mean blood loss was 240 ml. In all patients, the spleen could be preserved. In four patients, the splenic vessels were also preserved. One patient required a Warshaw technique due to significant fibrosis attached to the splenic vein. The postoperative period of all patients was uneventful except the presence of biochemical leak (BL) in two patients that only required maintenance of the drainage at home. The mean length of hospital stay was 6 days after surgery. The left lateral approach robotic SP-DP in right lateral decubitus position is a feasible and safe procedure for distal benign or small low-grade malignant tumors of the left pancreas. The right lateral decubitus position associated to robotic surgery can facilitate this complex procedure, especially when splenic vessels preservation is indicated, with a lower risk of conversion and shortening of the learning curve.
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Vissers FL, Balduzzi A, van Bodegraven EA, van Hilst J, Festen S, Hilal MA, Asbun HJ, Mieog JSD, Koerkamp BG, Busch OR, Daams F, Luyer M, De Pastena M, Malleo G, Marchegiani G, Klaase J, Molenaar IQ, Salvia R, van Santvoort HC, Stommel M, Lips D, Coolsen M, Bassi C, van Eijck C, Besselink MG. Prophylactic abdominal drainage or no drainage after distal pancreatectomy (PANDORINA): a binational multicenter randomized controlled trial. Trials 2022; 23:809. [PMID: 36153559 PMCID: PMC9509576 DOI: 10.1186/s13063-022-06736-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C. METHODS/DESIGN Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality. DISCUSSION PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).
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Affiliation(s)
- F. L. Vissers
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - A. Balduzzi
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - E. A. van Bodegraven
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - J. van Hilst
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands ,grid.440209.b0000 0004 0501 8269Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - S. Festen
- grid.440209.b0000 0004 0501 8269Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - M. Abu Hilal
- grid.430506.40000 0004 0465 4079Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK ,grid.415090.90000 0004 1763 5424Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - H. J. Asbun
- grid.418212.c0000 0004 0465 0852Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, USA
| | - J. S. D. Mieog
- grid.10419.3d0000000089452978Department of Surgery, LUMC, Leiden, the Netherlands
| | - B. Groot Koerkamp
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - O. R. Busch
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - F. Daams
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - M. Luyer
- grid.413532.20000 0004 0398 8384Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - M. De Pastena
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Malleo
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Marchegiani
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - J. Klaase
- grid.4494.d0000 0000 9558 4598Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - I. Q. Molenaar
- grid.7692.a0000000090126352Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R. Salvia
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - H. C. van Santvoort
- grid.415960.f0000 0004 0622 1269Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - M. Stommel
- grid.10417.330000 0004 0444 9382Department of Surgery, Radboud UMC, Nijmegen, the Netherlands
| | - D. Lips
- grid.415214.70000 0004 0399 8347Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M. Coolsen
- grid.412966.e0000 0004 0480 1382Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, the Netherlands
| | - C. Bassi
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - C. van Eijck
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M. G. Besselink
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
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COSTA ACD, SPALDING D, CUNHA-FILHO GDA, SANTANA MB, PAI M, JIAO LR, HABIB N. HOW TO PERFORM LAPAROSCOPIC DISTAL PANCREATECTOMY USING THE CLOCKWISE TECHNIQUE. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1683. [PMID: 36134816 PMCID: PMC9484827 DOI: 10.1590/0102-672020220002e1683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/07/2022] [Indexed: 11/22/2022]
Abstract
Laparoscopic pancreatectomy is currently a widely used approach for benign and malignant lesions of the pancreas.
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Munoz C, Lindner C, Pizarro F, Pino C. MATURE CYSTIC TERATOMA OF THE PANCREAS: AN UNUSUAL INDICATION FOR LAPAROSCOPIC DISTAL PANCREATECTOMY. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1693. [PMID: 36383887 PMCID: PMC9668272 DOI: 10.1590/0102-672020220002e1693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Affiliation(s)
- César Munoz
- Regional Hospital, Chile; Catholic University of Maule, Chile
| | | | | | - Carlos Pino
- Catholic University of Maule, Chile; Regional Hospital, Chile
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Ban D, Nishino H, Ohtsuka T, Nagakawa Y, Abu Hilal M, Asbun HJ, Boggi U, Goh BKP, He J, Honda G, Jang JY, Kang CM, Kendrick ML, Kooby DA, Liu R, Nakamura Y, Nakata K, Palanivelu C, Shrikhande SV, Takaori K, Tang CN, Wang SE, Wolfgang CL, Yiengpruksawan A, Yoon YS, Ciria R, Berardi G, Garbarino GM, Higuchi R, Ikenaga N, Ishikawa Y, Kozono S, Maekawa A, Murase Y, Watanabe Y, Zimmitti G, Kunzler F, Wang ZZ, Sakuma L, Osakabe H, Takishita C, Endo I, Tanaka M, Yamaue H, Tanabe M, Wakabayashi G, Tsuchida A, Nakamura M. International Expert Consensus on Precision Anatomy for minimally invasive distal pancreatectomy: PAM-HBP Surgery Project. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:161-173. [PMID: 34719123 DOI: 10.1002/jhbp.1071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/29/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021). METHODS Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. RESULTS Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts. CONCLUSIONS The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.
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Affiliation(s)
- Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan.,Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Mohammed Abu Hilal
- Department of Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Horacio J Asbun
- Hepato-Biliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore City, Singapore
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | | | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, Georgia, USA
| | - Rong Liu
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | | | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Chinnusamy Palanivelu
- Division of Gastrointestinal Surgery and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chung-Ngai Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Christopher L Wolfgang
- Division of Hepatobiliary and Pancreas Surgery, NYU Langone Health System, NYU Grossman School of Medicine, New York, New York, USA
| | - Anusak Yiengpruksawan
- Minimally Invasive Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ruben Ciria
- Unit of Hepatobiliary Surgery and Liver Transplantation, University Hospital Reina Sofía, IMIBIC, Cordoba, Spain
| | - Giammauro Berardi
- Department of General Surgery and Liver Transplantation Service, San Camillo Forlanini Hospital of Rome, Rome, Italy
| | - Giovanni Maria Garbarino
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shingo Kozono
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Aya Maekawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiki Murase
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Watanabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Giuseppe Zimmitti
- Department of Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Filipe Kunzler
- Hepato-Biliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Zi-Zheng Wang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | | | - Hiroaki Osakabe
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masao Tanaka
- Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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8
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Updated outcomes using clockwise technique for laparoscopic distal pancreatectomy: Optimal treatment of benign and malignant disease of the left pancreas. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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9
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Ban D, Garbarino GM, Ishikawa Y, Honda G, Jang JY, Kang CM, Maekawa A, Murase Y, Nagakawa Y, Nishino H, Ohtsuka T, Yiengpruksawan A, Endo I, Tsuchida A, Nakamura M. Surgical approaches for minimally invasive distal pancreatectomy: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:151-160. [PMID: 33527758 DOI: 10.1002/jhbp.902] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/23/2020] [Accepted: 01/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking. METHODS A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP. RESULTS All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed. CONCLUSIONS In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP.
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Affiliation(s)
- Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Giovanni Maria Garbarino
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Aya Maekawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiki Murase
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Anusak Yiengpruksawan
- Minimally Invasive Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Nishino H, Zimmitti G, Ohtsuka T, Abu Hilal M, Goh BKP, Kooby DA, Nakamura Y, Shrikhande SV, Yoon YS, Ban D, Nagakawa Y, Nakata K, Endo I, Tsuchida A, Nakamura M. Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:136-150. [PMID: 33527704 DOI: 10.1002/jhbp.903] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/23/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP. METHODS A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology. RESULTS Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found. CONCLUSIONS The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.
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Affiliation(s)
- Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Giuseppe Zimmitti
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Mohammed Abu Hilal
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore City, Singapore
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | | | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, Seoul, Korea
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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11
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Watson MD, Baimas-George MR, Thompson KJ, Iannitti DA, Ocuin LM, Baker EH, Martinie JB, Vrochides D. Improved oncologic outcomes for minimally invasive left pancreatectomy: Propensity-score matched analysis of the National Cancer Database. J Surg Oncol 2020; 122:1383-1392. [PMID: 32772366 DOI: 10.1002/jso.26147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/17/2020] [Accepted: 07/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Minimally invasive (MIS) left pancreatectomy (LP) is increasingly used to treat pancreatic adenocarcinoma (PDAC). Despite improved short-term outcomes, no studies have demonstrated long-term benefits over open resection. METHODS The National Cancer Database was queried between 2010 and 2016 for patients with PDAC, grouped by surgical approach (MIS vs open). Demographics, comorbidities, clinical staging, and pathologic staging were used for propensity-score matching. Perioperative, short-term oncologic, and survival outcomes were compared. RESULTS After matching, both cohorts included 805 patients. There were no differences in baseline characteristics, staging, or preoperative therapy between cohorts. The MIS cohort had a shorter length of stay (6.8 ± 5.5 vs 8.5 ± 7.3 days; P < .0001) with the trend toward improved time to chemotherapy (53.9 ± 26.1 vs 57.9 ± 29.9 days; P = .0511) and margin-positive resection rate (15.3% vs 18.9%; P = .0605). Lymph node retrieval and receipt of chemotherapy were similar. The MIS cohort had higher median overall survival (28.0 vs 22.1 months; P = .0067). Subgroup analysis demonstrated the highest survival for robotic compared with laparoscopic and open LP (41.9 vs 26.6 vs 22.1 months; P < .0001). CONCLUSIONS This study demonstrates the safety of MIS LP and favorable long-term oncologic outcomes. The improved survival after MIS LP warrants further study with prospective, randomized trials.
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Affiliation(s)
- Michael D Watson
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Maria R Baimas-George
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kyle J Thompson
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A Iannitti
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee M Ocuin
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin H Baker
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B Martinie
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Department of Surgery, Division of HPB Surgery, Carolinas Medical Center, Charlotte, North Carolina
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12
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Bashir MU, Kandilis A, Jackson NM, Parikh JA, Jacobs MJ. Distal pancreatectomy outcomes: Perspectives from a community-based teaching institution. Ann Hepatobiliary Pancreat Surg 2020; 24:156-161. [PMID: 32457260 PMCID: PMC7271100 DOI: 10.14701/ahbps.2020.24.2.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 12/14/2022] Open
Abstract
Backgrounds/Aims Distal pancreatic resections are intricate operations with potential for significant morbidity; there is controversy surrounding the appropriate setting regarding surgeon/hospital volume. We report our distal pancreatectomy experience from a community-based teaching hospital. Methods This study includes all patients who underwent laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and malignant lesions between June 2004 and October 2017. Both groups were compared for perioperative characteristics, parenchymal resection technique, and outcomes. Results 138 patients underwent distal pancreatectomy during this time. The distribution of LDP and ODP was 68 and 70 respectively. Operative time (146 vs. 174 min), blood loss (139 vs. 395 ml) and mean length of stay (4.8 vs. 8.0 days) were significantly lower in the laparoscopic group. The 30-day Clavien Grade 2/3 morbidity rate was 13.7% (19/138) and the incidence of Grade B/C pancreatic fistula was 6.5% (9/138), with no difference between ODP and LDP. 30-day mortality was 0.7% (1/138). 61/138 resections had a malignancy on final pathology. ODP mean tumor diameter was greater (6.4 cm vs. 2.9 cm), but there was no significant difference in the mean number of harvested nodes (8.6 vs. 7.4). The cost of hospitalization, including readmissions and surgery was significantly lower for LDP ($7558 vs. $11610). Conclusions This series of distal pancreatectomies indicates a shorter hospital stay, less operative blood loss and reduced cost in the LDP group, and comparable morbidity and oncologic outcomes between LDP and ODP. It highlights the feasibility and safety of these complex surgeries in a community setting.
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Affiliation(s)
- Muhammad Umair Bashir
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Apostolos Kandilis
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Nancy M Jackson
- Department of Research, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Janak A Parikh
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Michael J Jacobs
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
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Björnsson B, Larsson AL, Hjalmarsson C, Gasslander T, Sandström P. Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial. Br J Surg 2020; 107:1281-1288. [DOI: 10.1002/bjs.11554] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/13/2019] [Accepted: 01/21/2020] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss and recovery. Only one randomized study is available, which showed enhanced functional recovery after LDP compared with ODP.
Methods
Consecutive patients evaluated at a multidisciplinary tumour board and planned for standard distal pancreatectomy were randomized prospectively to LDP or ODP in an unblinded, parallel-group, single-centre superiority trial. The primary outcome was postoperative hospital stay.
Results
Of 105 screened patients, 60 were randomized and 58 (24 women, 41 per cent) were included in the intention-to-treat analysis; there were 29 patients of mean age 68 years in the LDP group and 29 of mean age 63 years in the ODP group. The main indication was cystic pancreatic lesions, followed by neuroendocrine tumours. The median postoperative hospital stay was 5 (i.q.r. 4–5) days in the laparoscopic group versus 6 (5–7) days in the open group (P = 0·002). Functional recovery was attained after a median of 4 (i.q.r. 2–6) versus 6 (4–7) days respectively (P = 0·007), and duration of surgery was 120 min in both groups (P = 0·482). Blood loss was less with laparoscopic surgery: median 50 (i.q.r. 25–150) ml versus 100 (100–300) ml in the open group (P = 0·018). No difference was found in the complication rates (Clavien–Dindo grade III or above: 4 versus 8 patients respectively). The rate of delayed gastric emptying and clinically relevant postoperative pancreatic fistula did not differ between the groups.
Conclusion
LDP is associated with shorter hospital stay than ODP, with shorter time to functional recovery and less bleeding. Registration number: ISRCTN26912858 (www.isrctn.com).
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Affiliation(s)
- B Björnsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - A Lindhoff Larsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - C Hjalmarsson
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - T Gasslander
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - P Sandström
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Morikawa T, Ishida M, Takadate T, Hata T, Iseki M, Kawaguchi K, Ohtsuka H, Mizuma M, Hayashi H, Nakagawa K, Motoi F, Kamei T, Naitoh T, Unno M. The superior approach with the stomach roll-up technique improves intraoperative outcomes and facilitates learning laparoscopic distal pancreatectomy: a comparative study between the superior and inferior approach. Surg Today 2019; 50:153-162. [DOI: 10.1007/s00595-019-01855-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022]
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15
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Björnsson B, Sandström P, Larsson AL, Hjalmarsson C, Gasslander T. Laparoscopic versus open distal pancreatectomy (LAPOP): study protocol for a single center, nonblinded, randomized controlled trial. Trials 2019; 20:356. [PMID: 31196166 PMCID: PMC6567450 DOI: 10.1186/s13063-019-3460-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Earlier nonrandomized studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss, and recovery. Only one randomized study has been conducted showing reduced time to functional recovery after LDP compared with ODP. METHODS LAPOP is a prospective randomized, nonblinded, parallel-group, single-center superiority trial. Sixty patients with lesions in the pancreatic body or tail that are found by a multidisciplinary tumor board to need surgical resection will be randomized to receive LDP or ODP. The primary outcome variable is postoperative hospital stay, and secondary outcomes include functional recovery (defined as no need for intravenous medications or fluids and as the ability of an ambulatory patient to perform activities of daily life), perioperative bleeding, complications, need for pain medication, and quality of life comparison. DISCUSSION The LAPOP trial will test the hypothesis that LDP reduces postoperative hospital stay compared with ODP. TRIAL REGISTRATION ISRCTN, 26912858 . Registered on 28 September 2015.
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Affiliation(s)
- Bergthor Björnsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Per Sandström
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Anna Lindhoff Larsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Claes Hjalmarsson
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden and Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Thomas Gasslander
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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16
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Asbun HJ, Van Hilst J, Tsamalaidze L, Kawaguchi Y, Sanford D, Pereira L, Besselink MG, Stauffer JA. Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement. Surg Endosc 2019; 34:231-239. [DOI: 10.1007/s00464-019-06757-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/18/2019] [Indexed: 02/07/2023]
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Abstract
In pancreatic cancer, resection combined with neoadjuvant and/or adjuvant therapy remains the only chance for cure and/or prolonged survival. A minimally invasive approach to pancreatic cancer has gained increased acceptance and popularity. The aim of minimally invasive surgery of the pancreas includes limiting trauma, decreasing length of hospitalization, lessening cost, decreasing blood loss, and allowing for a more meticulous oncologic dissection. New advances and routine use in practice have helped progress the field making the minimally invasive approach more feasible. In this article, the minimally invasive surgical approaches to proximal, central, and distal pancreatic cancer are described and literature reviewed.
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Laparoscopic Distal Pancreatectomy: Our Experience in a Tertiary Referral Center. Surg Laparosc Endosc Percutan Tech 2019; 29:285-289. [PMID: 30676539 DOI: 10.1097/sle.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite an increase in the number of laparoscopic distal pancreatectomy (LDP) procedures being performed, the long-term oncology and operative results are still unclear. The aim of this study was to present the surgical and long-term results of patients undergoing LDP for the treatment of distal pancreatic tumors. MATERIALS AND METHODS A retrospective review was made of patients who underwent LDP in our clinic, between 2006 and 2018, and who were diagnosed with pancreas tail, neck, and corpus tumors. For the purposes of this study, the data related to the preoperative, operative, and postoperative characteristics of the patients were determined. RESULTS A total of 46 patients were identified as suitable for inclusion in the study. Of these, 52.1% were female individuals, and the average age of the whole group was 63 years. Previous surgery for malignant diseases was recorded for 54.3% of the patients, due to premalignant diseases in 13% and benign diseases in 32.7%. On average, 10 lymph nodes were removed from patients diagnosed with malignant tumors. The conversion rate was found to be 2.1%. The postoperative pancreatic fistula rate was 26%, and there was 1 complication each of grades III and IV according to the Clavien-Dindo classification. The mortality rate was 0%. CONCLUSIONS It was concluded that LDP of distal pancreas tumors seems to be both safe and effective in respect of the long-term results in addition to the early results of the operation.
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Fingerhut A, Uranues S, Khatkov I, Boni L. Laparoscopic distal pancreatectomy: better than open? Transl Gastroenterol Hepatol 2018; 3:49. [PMID: 30225383 PMCID: PMC6131158 DOI: 10.21037/tgh.2018.07.04] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/27/2018] [Indexed: 12/14/2022] Open
Abstract
Distal pancreatectomy is well suited to the laparoscopic approach. Laparoscopic distal pancreatectomy (LDP) provides the same postoperative recovery advantages reputed to minimal access surgery. However, there have been fears as to the safety of LDP in terms of life-threatening intra-operative events and post-operative complications, adequate carcinological outcomes as compared to traditional (open) distal pancreatectomy (ODP) when performed for cancer, as well as to whether the laparoscopic approach is well adapted to the variety of diseases that may affect the pancreas (ranging from trauma to benign or malignant disease) and whether the minimal access approach is well adapted to perform pancreatic surgery safely in the obese, the elderly or the frail. In this review of the literature, we sought to determine whether LDP was as safe, provided the same oncological outcomes and was applicable to all diseases involving the body and tail of the pancreas, and to particular patient characteristics, compared to the traditional open approach. Last we looked at cost issues. We concluded that this review of the literature allowed to state that laparoscopic distal pancreatectomy is feasible and safe for a wide range of diseases, both benign and malignant. Morbidity, mortality, and probably, also, carcinological outcomes are comparable to open surgery. The overall costs are similar but the advantages of minimal access surgery make it the preferred approach, once the surgical expertise is acquired and present.
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Affiliation(s)
- Abe Fingerhut
- Section for Surgical Research, Department of Surgery, University of Graz, Graz, Austria
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, University of Graz, Graz, Austria
| | - Igor Khatkov
- Department of Surgical Oncology Moscow Clinical Scientific Center, Moscow, Russia
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Palanivelu C, Takaori K, Abu Hilal M, Kooby DA, Wakabayashi G, Agarwal A, Berti S, Besselink MG, Chen KH, Gumbs AA, Han HS, Honda G, Khatkov I, Kim HJ, Li JT, Duy Long TC, Machado MA, Matsushita A, Menon K, Min-Hua Z, Nakamura M, Nagakawa Y, Pekolj J, Poves I, Rahman S, Rong L, Sa Cunha A, Senthilnathan P, Shrikhande SV, Gurumurthy SS, Sup Yoon D, Yoon YS, Khatri VP. International Summit on Laparoscopic Pancreatic Resection (ISLPR) "Coimbatore Summit Statements". Surg Oncol 2017; 27:A10-A15. [PMID: 29371066 DOI: 10.1016/j.suronc.2017.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 12/20/2022]
Abstract
The International Summit on Laparoscopic Pancreatic Resection (ISLPR) was held in Coimbatore, India, on 7th and 8th of October 2016 and thirty international experts who regularly perform laparoscopic pancreatic resections participated in ISPLR from four continents, i.e., South and North America, Europe and Asia. Prior to ISLPR, the first conversation among the experts was made online on August 26th, 2016 and the structures of ISPLR were developed. The aims of ISPLR were; i) to identify indications and optimal case selection criteria for minimally invasive pancreatic resection (MIPR) in the setting of both benign and malignant diseases; ii) standardization of techniques to increase the safety of MIPR; iii) identification of common problems faced during MIPR and developing associated management strategies; iv) development of clinical protocols to allow early identification of complications and develop the accompanying management plan to minimize morbidity and mortality. As a process for interactive discussion, the experts were requested to complete an online questionnaire consisting of 65 questions about the various technical aspects of laparoscopic pancreatic resections. Two further web-based meetings were conducted prior to ISPLR. Through further discussion during ISPLR, we have created productive statements regarding the topics of Disease, Implementation, Patients, Techniques, and Instrumentations (DIPTI) and hereby publish them as "Coimbatore Summit Statements".
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Affiliation(s)
- Chinnusamy Palanivelu
- Division of Gastrointestinal Surgery and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, India.
| | - Kyoichi Takaori
- Division of Hapato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mohammad Abu Hilal
- Division of HPB Surgery, Southampton General Hospital (NHS), Southampton, UK
| | - David A Kooby
- Department of Surgery, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, United States
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Anil Agarwal
- Department of Surgical Gastroenterology, G B Pant Hospital, Delhi, India
| | - Stefano Berti
- Division of Miniinvasive Surgery, S. Andrea Hospital, La Spezia, Italy
| | - Marc G Besselink
- Hepato-Pancreato- Biliary (HPB) Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Kuo Hsin Chen
- Department of Surgery, Far-Eastern Memorial Hospital, Taiwan
| | - Andrew A Gumbs
- Department of Surgical Oncology, Summit Medical Group-MD Anderson Cancer Center, Berkeley Heights, NJ, USA
| | - Ho-Seong Han
- Comprehensive Cancer Center, Seoul National University Bundang Hospital, Bundang, South Korea
| | - Goro Honda
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Igor Khatkov
- Surgical Oncology, Moscow Clinical Scientific Center, Moscow, Russia
| | - Hong Jin Kim
- Department of HBP Surgery, Yeungnam University Hospital, Daegu, South Korea
| | - Jiang Tao Li
- Department of Surgery, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Tran Cong Duy Long
- Department of General Surgery, University Medical Center in Ho Chi Minh City Vietnam, Ho Chi Minh, Viet Nam
| | | | - Akira Matsushita
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Krish Menon
- Division and/or Department - Institute of Liver Studies, Department of Liver Transplantation and HPB, King's College Hospital NHS Trust, Camberwell, UK
| | - Zheng Min-Hua
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Juan Pekolj
- General Surgery Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ignasi Poves
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Shahidur Rahman
- Hepatobiliary Pancreatic and Liver Transplant Division, Bangobandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Liu Rong
- The Military Institute of Hepato-Pancreatico-Biliary Surgery and Second Department of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China
| | - Antonio Sa Cunha
- Department of HPB Surgery, AP-HP Hôpital Paul Brousse, Paris, France
| | - Palanisamy Senthilnathan
- Division of Minimally Invasive, Liver Transplantation & HPB Surgery, GEM Hosptial & Research Centre, Coimbatore, India
| | - Shailesh V Shrikhande
- Division of Cancer Surgery / Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - S Srivatsan Gurumurthy
- Division of HPB & Minimal Access Surgery, GEM Hosptial & Research Centre, Coimbatore, India
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Vijay P Khatri
- Department of Oncology, California Northstate University College of Medicine, Elk Grove, California, USA
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Laparoscopic distal resection of the pancreas. Can be all resections of body and tail of the pancreas called the same? Contemp Oncol (Pozn) 2017; 21:174-177. [PMID: 28947889 PMCID: PMC5611508 DOI: 10.5114/wo.2017.68627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 02/15/2017] [Indexed: 11/23/2022] Open
Abstract
Introduction Distal resection of the pancreas is a routine procedure in high-volume centres. However, the volume of this procedure can vary. This variation plays a very important role in laparoscopic approach of pancreatic surgery and can be a real challenge if the anatomical situation is underestimated. Aim of the study To present our experience in minimally invasive treatment of the pancreatic tumours and to discuss different approaches to different anatomical situations. Material and methods We performed a retrospective analysis of patients, who underwent laparoscopic pancreas resection for pancreatic cancer in our hospital since 2014 to 2016 February. According to extension of operation, patients were divided into two groups: distal pancreatectomy and left hemipancreatectomy for cases that required preparation of the portal vein. Demographic characteristics, and operative and postoperative data were compared between both groups. Results Out of 16 patients, distal pancreatectomy was performed for 7 (43.8%) and left hemipancreatectomy for 9 (56.2%) patients. For 1 (14.3%) laparoscopic distal pancreatectomy and for 2 (22.2%) laparoscopic left hemipancreatectomy patients surgical conversion to laparotomy was performed. The average operation time was 205 (195–245) min for distal pancreatectomy and 412.5 (280–520) min for left hemipancreatectomy group (p = 0.001), blood loss 125 (20–250) ml and 250 (50–1800) ml accordingly (p = 0.138). Totally postoperative fistula occurred in 7 (43.8%) cases; out of them, 5 (71.4%) patients were from the left hemipancreatectomy group. Conclusions Laparoscopic left hemipancreatectomy is more complicated than distal pancreatectomy. Extension and technique selection of distal resection of the pancreas depends on the Yonsei criteria and tumour relation to the portal vein.
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Cesaretti M, Bifulco L, Costi R, Zarzavadjian Le Bian A. Pancreatic resection in the era of laparoscopy: State of Art. A systematic review. Int J Surg 2017; 44:309-316. [PMID: 28689866 DOI: 10.1016/j.ijsu.2017.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/22/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Manuela Cesaretti
- Service de Chirurgie Hépatique, Pancréatique et Biliaire, Transplantation Hépatique, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot-VII, Clichy, 92110, France; Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Lelio Bifulco
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Renato Costi
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, 43100, Italy
| | - Alban Zarzavadjian Le Bian
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Laboratoire d'Ethique Médicale et de Médecine Légale, Université Paris Descartes - V, Paris, 75006, France.
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Lianos GD, Christodoulou DK, Katsanos KH, Katsios C, Glantzounis GK. Minimally Invasive Surgical Approaches for Pancreatic Adenocarcinoma: Recent Trends. J Gastrointest Cancer 2017; 48:129-134. [PMID: 28326457 DOI: 10.1007/s12029-017-9934-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic resection for cancer represents a real challenge for every surgeon. Recent improvements in laparoscopic experience, minimally invasive surgical techniques and instruments make now the minimally invasive approach a real "triumph." There is no doubt that minimally invasive surgery has replaced with great success conventional surgery in many fields, including surgical oncology. METHODS AND RESULTS However, its progress in pancreatic resection for adenocarcinoma has been dramatically slow. Recent evidence supports the notion that minimally invasive distal pancreatectomy is safe and feasible and that is becoming the procedure of choice mainly for benign or low-grade malignant lesions in the distal pancreas. On the other side, minimally invasive pancreatoduodenectomy has not yet been widely accepted and there is enormous skepticism when applied for pancreatic head adenocarcinoma. In this review, we summarize the current evidence on the potential applications of minimally invasive surgical approaches for this aggressive, heterogeneous, and enigmatic type of cancer. CONCLUSIONS Moreover, the potential future applications of these approaches are discussed with the hope to improve the quality of life as well as the survival rates of pancreatic cancer patients.
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Affiliation(s)
- Georgios D Lianos
- Department of Surgery, School of Medicine, University of Ioannina, University Hospital of Ioannina, 451 10, Ioannina, Greece.
| | - Dimitrios K Christodoulou
- Department of Gastroenterology, School of Medicine, University of Ioannina, University Hospital of Ioannina, 451 10, Ioannina, Greece
| | - Konstantinos H Katsanos
- Department of Gastroenterology, School of Medicine, University of Ioannina, University Hospital of Ioannina, 451 10, Ioannina, Greece
| | - Christos Katsios
- Department of Surgery, School of Medicine, University of Ioannina, University Hospital of Ioannina, 451 10, Ioannina, Greece
| | - Georgios K Glantzounis
- Department of Surgery, School of Medicine, University of Ioannina, University Hospital of Ioannina, 451 10, Ioannina, Greece
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de Rooij T, van Hilst J, Vogel JA, van Santvoort HC, de Boer MT, Boerma D, van den Boezem PB, Bonsing BA, Bosscha K, Coene PP, Daams F, van Dam RM, Dijkgraaf MG, van Eijck CH, Festen S, Gerhards MF, Groot Koerkamp B, Hagendoorn J, van der Harst E, de Hingh IH, Dejong CH, Kazemier G, Klaase J, de Kleine RH, van Laarhoven CJ, Lips DJ, Luyer MD, Molenaar IQ, Nieuwenhuijs VB, Patijn GA, Roos D, Scheepers JJ, van der Schelling GP, Steenvoorde P, Swijnenburg RJ, Wijsman JH, Abu Hilal M, Busch OR, Besselink MG. Minimally invasive versus open distal pancreatectomy (LEOPARD): study protocol for a randomized controlled trial. Trials 2017; 18:166. [PMID: 28388963 PMCID: PMC5385082 DOI: 10.1186/s13063-017-1892-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/08/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Observational cohort studies have suggested that minimally invasive distal pancreatectomy (MIDP) is associated with better short-term outcomes compared with open distal pancreatectomy (ODP), such as less intraoperative blood loss, lower morbidity, shorter length of hospital stay, and reduced total costs. Confounding by indication has probably influenced these findings, given that case-matched studies failed to confirm the superiority of MIDP. This accentuates the need for multicenter randomized controlled trials, which are currently lacking. We hypothesize that time to functional recovery is shorter after MIDP compared with ODP even in an enhanced recovery setting. METHODS LEOPARD is a randomized controlled, parallel-group, patient-blinded, multicenter, superiority trial in all 17 centers of the Dutch Pancreatic Cancer Group. A total of 102 patients with symptomatic benign, premalignant or malignant disease will be randomly allocated to undergo MIDP or ODP in an enhanced recovery setting. The primary outcome is time (days) to functional recovery, defined as all of the following: independently mobile at the preoperative level, sufficient pain control with oral medication alone, ability to maintain sufficient (i.e. >50%) daily required caloric intake, no intravenous fluid administration and no signs of infection. Secondary outcomes are operative and postoperative outcomes, including clinically relevant complications, mortality, quality of life and costs. DISCUSSION The LEOPARD trial is designed to investigate whether MIDP reduces the time to functional recovery compared with ODP in an enhanced recovery setting. TRIAL REGISTRATION Dutch Trial Register, NTR5188 . Registered on 9 April 2015.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, AZ 1105, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, AZ 1105, The Netherlands
| | - Jantien A Vogel
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, AZ 1105, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, PO Box 2500, Nieuwegein, EM 3430, The Netherlands
| | - Marieke T de Boer
- Department of Surgery, University Medical Center Groningen, PO Box 30 001, Groningen, RB 9700, The Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, PO Box 2500, Nieuwegein, EM 3430, The Netherlands
| | - Peter B van den Boezem
- Department of Surgery, Radboud University Nijmegen Medical Center, PO Box 9101, Nijmegen, HB 6500, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, PO Box 9600, Leiden, ZA 2333, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, Den Bosch, ME 5200, The Netherlands
| | - Peter-Paul Coene
- Department of Surgery, Maasstad Hospital, PO Box 9100, Rotterdam, AC 3007, The Netherlands
| | - Freek Daams
- Department of Surgery, VU University Medical Center, PO Box 7057, Amsterdam, HV 1081, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, Maastricht, AZ 6202, The Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, PO Box 22660, Amsterdam, DD 1100, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, Amsterdam, HM 1090, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, Amsterdam, HM 1090, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, PO Box 85 500, Utrecht, GA 3508, The Netherlands
| | - Erwin van der Harst
- Department of Surgery, Maasstad Hospital, PO Box 9100, Rotterdam, AC 3007, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, PO Box 1350, Eindhoven, ZA 5602, The Netherlands
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, Maastricht, AZ 6202, The Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, PO Box 5800, Maastricht, AZ 6202, The Netherlands
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center, PO Box 7057, Amsterdam, HV 1081, The Netherlands
| | - Joost Klaase
- Department of Surgery, Medisch Spectrum Twente, PO Box 50 000, Enschede, KA 7500, The Netherlands
| | - Ruben H de Kleine
- Department of Surgery, University Medical Center Groningen, PO Box 30 001, Groningen, RB 9700, The Netherlands
| | - Cornelis J van Laarhoven
- Department of Surgery, Radboud University Nijmegen Medical Center, PO Box 9101, Nijmegen, HB 6500, The Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, Den Bosch, ME 5200, The Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, PO Box 1350, Eindhoven, ZA 5602, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, PO Box 85 500, Utrecht, GA 3508, The Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Clinics, PO Box 10 400, Zwolle, AB 8025, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graag Gasthuis, PO Box 5011, Delft, GA 2600, The Netherlands
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graag Gasthuis, PO Box 5011, Delft, GA 2600, The Netherlands
| | | | - Pascal Steenvoorde
- Department of Surgery, Medisch Spectrum Twente, PO Box 50 000, Enschede, KA 7500, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Leiden University Medical Center, PO Box 9600, Leiden, ZA 2333, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, PO Box 90 158, Breda, RK 4800, The Netherlands
| | - Moh'd Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, SO166YD, UK
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, DD 1100, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, DD 1100, The Netherlands.
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Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference. Surg Endosc 2017; 31:2023-2041. [PMID: 28205034 DOI: 10.1007/s00464-017-5414-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/07/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients. METHODS An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey. RESULTS LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case-control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe. CONCLUSIONS LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.
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Stauffer JA, Coppola A, Mody K, Asbun HJ. Laparoscopic Versus Open Distal Pancreatectomy for Pancreatic Adenocarcinoma. World J Surg 2017; 40:1477-84. [PMID: 26847665 DOI: 10.1007/s00268-016-3412-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) has been shown to have short-term benefits over open distal pancreatectomy (ODP). Its application for pancreatic ductal adenocarcinoma (PDAC) remains controversial. METHODS From 1995 to 2014, 72 patients underwent distal pancreatectomy for PDAC at a single institution and were included in the study. Postoperative and long-term outcomes of patients undergoing LDP (n = 44) or ODP (n = 28) were compared. RESULTS LDP was associated with less blood loss (332 vs. 874 mL, p = 0.0012) and lower transfusion rates than ODP (18.2 vs. 50 %, p = 0.0495). Operative time was similar (254 vs. 266 min) for LDP and ODP; five patients (11.4 %) required conversion to ODP. Pancreatic fistulas (13.6 vs. 7.1 %) and major complications (13.6 vs. 25 %), were similar between LDP and ODP, respectively. Length of hospital stay (5.1 vs. 9.4 days, p = 0.0001) and time to initiate adjuvant therapy (69.4 vs. 95.6 days, p = 0.0441) was shorter for LDP than ODP. Tumor characteristics were similar but LDP was associated with more resected lymph nodes than ODP (25.9 vs. 12.7, p = 0.0001). One-, three-, and five-year survival rates were similar between LDP (69, 41, and 41 %, respectively) and ODP (78, 44, and 32 %, respectively). CONCLUSION LDP is associated with less blood loss and need for blood transfusion, shorter hospital stay, and faster time to initiate adjuvant therapy than ODP for patients with PDAC. Postoperative outcomes and long-term survival are similar between the two groups. LDP appears to be safe in the treatment of patients with PDAC.
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Affiliation(s)
- John A Stauffer
- Division of General Surgery, Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Alessandro Coppola
- Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Kabir Mody
- Department of Hematology and Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.
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Wang K, Fan Y. Minimally Invasive Distal Pancreatectomy: Review of the English Literature. J Laparoendosc Adv Surg Tech A 2016; 27:134-140. [PMID: 27828724 DOI: 10.1089/lap.2016.0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Recently, the superiority of the minimally invasive approach, which results in a better cosmetic result, faster recovery, and shorter length of hospital stay, is a technique that has been progressively recognized as it has developed. And the minimally invasive approach has been applied to distal pancreatectomy (DP), which is a standard method for the treatment of benign, borderline, and part of malignant lesions of the pancreatic body and tail. This article aims to analyze the types, postoperative recovery, and outcomes of laparoscopic distal pancreatectomy (LDP). MATERIALS AND METHODS A systematic search of the scientific literature was performed using PubMed, EMBASE, online journals, and the Internet for all publications on LDP. Articles were selected if the abstract contained patients who underwent LDP for pancreatic diseases. All selected articles were reviewed and analyzed. RESULTS If there were no contraindications for LDP, this operation is suitable for benign, borderline, or malignant tumors of the pancreatic body and tail, which should try to be performed with preservation of the spleen. LDP is safe and feasible under some conditions to experienced surgeon. Single-incision laparoscopic distal pancreatectomy (S-LDP) and robotic laparoscopic distal pancreatectomy (R-LDP) perioperative outcomes are similar with conventional multi-incision laparoscopic distal pancreatectomy (C-LDP). And the advantages of S-LDP and R-LDP require further exploration. With the application of enhanced recovery program (ERP), length of hospital stay and costs are reduced. CONCLUSIONS LDP is safe and feasible under some conditions. Compared with open distal pancreatectomy, LDP has a lot of advantages; a trend was observed for LDP to replace traditional open surgery. LDP combined with ERP is expected to become standard in the treatment of pancreatic body and tail lesions.
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Affiliation(s)
- Kai Wang
- Department of the Second General Surgery, Shengjing Hospital, China Medical University , Shenyang, China
| | - Ying Fan
- Department of the Second General Surgery, Shengjing Hospital, China Medical University , Shenyang, China
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Salman B, Yilmaz TU, Dikmen K, Kaplan M. Laparoscopic distal pancreatectomy. J Vis Surg 2016; 2:141. [PMID: 29078528 DOI: 10.21037/jovs.2016.07.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 07/18/2016] [Indexed: 12/24/2022]
Abstract
After technological advances and increased experiences, more complicated surgeries including distal pancreatectomy can be easily performed with acceptable oncologic results, and decreased mortality and morbidity. Laparoscopic distal pancreatectomy (LDP) has been shown to have several advantages including less blood loss, less hospital stay, less pain. Several studies comparing open distal pancreatectomy (ODP) and LDP resulted that both techniques have similar results according to pancreas fistulas, oncological results, costs and operation indications. Morbidity is very low in high volume centers, for this reason at least ten cases should be performed for the learning curve. Several authors remarked important technical points in LDP in order to perform safe and acceptable LDP in several studies. Here in this review, we aimed to overview the results of previous studies about LDP and discuss the technical points of LDP.
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Affiliation(s)
- Bulent Salman
- Department of General Surgery, Gazi University School of Medicine, Ankara, Turkey
| | - Tonguc Utku Yilmaz
- Department of General Surgery, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Kursat Dikmen
- Department of General Surgery, Gazi University School of Medicine, Ankara, Turkey
| | - Mehmet Kaplan
- Department of General Surgery, Bahcesehir University School of Medicine, Istanbul, Turkey
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Liao CH, Yeh CN, Yang SJ, Wang SY, Ouyang CH, Tsai CY, Liu KH, Liu YY, Kuo IM, Fu CY, Yeh TS. Effectiveness and feasibility of laparoscopic distal pancreatectomy on patients at high anesthetic risk. J Laparoendosc Adv Surg Tech A 2015; 24:865-71. [PMID: 25387123 DOI: 10.1089/lap.2014.0255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is the most acceptable procedure in laparoscopic pancreatic surgery. Nevertheless, knowledge regarding patients at a high anesthetic risk during lengthy and technically demanding LDP is controversial. This study aims to assess the feasibility and safety of LDP in patients with high anesthetic risk. PATIENTS AND METHODS We conducted a prospective collection retrospective review of patients underwent LDP and open distal pancreatectomy (ODP) from January 2011 until December 2013. By the American Society of Anesthesiologists score, patients were divided into low- and high-risk patients. We compared the clinical, perioperative, and postoperative results in these patients. RESULTS The cohort included 77 patients: 20 underwent LDP, and 57 underwent ODP. There were 30 patients in the low-risk group and 47 patients in the high-risk group. In high-risk patients, LDP, compared with ODP, presented a shorter operating time (mean, 220.8±101.1 minutes versus 299.4±124.3 minutes; P=.038), less blood loss (409.3±569.9 mL versus 1083.1±1583.0 mL; P=.039), higher rate of spleen preservation (73.3% versus 43.8%, P=.037), and shorter length of postoperative hospital stay (LOS) (9.5±3.0 days versus 15.7±9.4 days; P=.044). CONCLUSIONS In conclusion, LDP provides early recovery and better cosmetic appearance. In high anesthetic risk patients, LDP shows less operative time, less perioperative blood loss, a higher rate of spleen preservation, slighter complication, and shorter LOS, which might explain why LDP is a feasible and effective procedure.
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Affiliation(s)
- Chien-Hung Liao
- 1 Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University , Taoyuan, Taiwan
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Technical Aspects of Laparoscopic Distal Pancreatectomy for Benign and Malignant Disease: Review of the Literature. Gastroenterol Res Pract 2015; 2015:472906. [PMID: 26240565 PMCID: PMC4512582 DOI: 10.1155/2015/472906] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 06/07/2015] [Indexed: 02/05/2023] Open
Abstract
Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. The most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Spleen preservation can be achieved preferably by preserving the splenic vessels (Kimura technique), but also by resecting the splenic vessels and maintaining vascularity through the short gastric vessels and left gastroepiploic artery (Warshaw technique). Several studies have suggested a higher rate of spleen preservation with laparoscopy. The radical antegrade modular pancreatosplenectomy has become mainstay for treating pancreatic cancer and can be performed laparoscopically as well. Evidence on the feasibility and safety of laparoscopic distal pancreatectomy for cancer is scarce. Despite the obvious advantages of laparoscopic surgery, postoperative morbidity remains relatively high, mainly because of the high incidence of pancreatic fistula. For decades, surgeons have tried to prevent these fistulas but to date no strategy has been confirmed to be effective in 2 consecutive randomized studies. Pragmatic multicenter studies focusing on technical aspects of laparoscopic distal pancreatectomy are lacking and should be encouraged.
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Poves I, Burdío F, Grande L. The Posterior Approach for Laparoscopic Distal Pancreatectomy: A Valid Choice for Resection of Complex Lesions of the Distal Pancreas. J Laparoendosc Adv Surg Tech A 2015; 25:555-60. [PMID: 26076336 DOI: 10.1089/lap.2014.0674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Laparoscopic distal pancreatectomy (LDP) is replacing open surgery as the technique of choice for benign and premalignant lesions of the left pancreas. In most laparoscopic series, the supine decubitus or semilateral position is preferred. A posterior approach with the patient in full right lateral decubitus (PA-FRLD) has been proposed as an alternative. PATIENTS AND METHODS From July 2012 to November 2014 we performed 14 LDPs. PA-FRLD was chosen in 8 patients; in 6 patients splenectomy was also performed. RESULTS Definitive diagnoses were 3 cases of pancreatic ductal adenocarcinoma, 2 cases of nonfunctioning neuroendocrine tumors, 1 case of bulky serous cystic neoplasm, 1 case of inflammatory chronic pancreatitis, and 1 case of pancreatic trauma (duct disruption). No conversions were required. No postoperative pancreatic fistula was detected. No patient required transfusion. Two patients had Clavien II and IIIb postoperative complications. In both cases in which preservation of the splenic vessels was attempted, it was successfully achieved. CONCLUSIONS The PA-FRLD position is a valid alternative to the supine or semilateral position for LDP. This approach is especially beneficial for resection of complex and bulky lesions of the tail of the pancreas and those in close contact with retroperitoneal organs and can also facilitate spleen-preserving LDP.
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Affiliation(s)
- Ignasi Poves
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Autonomous University of Barcelona , Barcelona, Spain
| | - Fernando Burdío
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Autonomous University of Barcelona , Barcelona, Spain
| | - Luís Grande
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Autonomous University of Barcelona , Barcelona, Spain
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Björnsson B, Sandström P. Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas. World J Gastroenterol 2014; 20:13402-13411. [PMID: 25309072 PMCID: PMC4188893 DOI: 10.3748/wjg.v20.i37.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 02/11/2014] [Accepted: 04/23/2014] [Indexed: 02/07/2023] Open
Abstract
Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.
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Balzano G, Carvello M, Piemonti L, Nano R, Ariotti R, Mercalli A, Melzi R, Maffi P, Braga M, Staudacher C. Combined laparoscopic spleen-preserving distal pancreatectomy and islet autotransplantation for benign pancreatic neoplasm. World J Gastroenterol 2014; 20:4030-4036. [PMID: 24744593 PMCID: PMC3983459 DOI: 10.3748/wjg.v20.i14.4030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 02/05/2013] [Accepted: 03/07/2013] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the safety and feasibility of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with autologous islet transplantation (AIT) for benign tumors of the pancreatic body-neck.
METHODS: Three non-diabetic, female patients (age 37, 44 and 35 years, respectively) were declared candidates for surgery, between May and September 2011, because of pancreatic body/neck cystic lesions. The planned operation was an LSPDP associated with AIT from the normal pancreas distal to the neoplasm. Islets isolation was performed on the residual pancreatic parenchyma after frozen section examination of the margin. Purified autologous islets were infused into the portal vein by a percutaneous transhepatic approach the day after surgery.
RESULTS: The procedure was performed successfully in all the three cases, and the spleen was preserved along with its vessels. Mean operation time was 283 ± 52 min and average blood loss was 133 ± 57 mL. Residual pancreas weights were 33, 22 and 30 g, and 105.200, 40.390 and 94.790 islet equivalents were isolated, respectively. Surgical complications occurred in one patient (grade A pancreatic fistula). Postoperative stays were 6, 6 and 7 d, respectively. Histopathological evaluation revealed mucinous cystic neoplasm in cases 1 and 3, and serous cystic neoplasm in patient 2. No postoperative insulin administration was required. One patient developed a transient partial portal thrombosis 2 mo after islet infusion. Patients are insulin independent at a mean follow up of 8 ± 2 mo.
CONCLUSION: Combination of LSPDP and AIT is feasible and could be effective to minimize the surgical impact for benign neoplasm of pancreatic body-neck.
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Laparoscopic versus open distal splenopancreatectomy for the treatment of pancreatic body and tail cancer: a retrospective, mid-term follow-up study at a single academic tertiary care institution. Surg Endosc 2014; 28:2584-91. [PMID: 24705732 DOI: 10.1007/s00464-014-3507-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 03/05/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVE Laparoscopic distal splenopancreatectomy (DSP) is an effective and safe surgical modality for treating benign and borderline distal pancreatic tumors, but rarely for pancreatic cancer. This study aimed to examine the feasibility, effectiveness, and safety of laparoscopic versus laparotomic DSP in pancreatic body-tail cancer (PBTC) patients. METHODS Thirty-four PBTC patients were consecutively and retrospectively hospitalized for elective laparoscopic DSP (n = 11) or laparotomy (n = 23) between January 2007 and December 2011. The primary outcome measure was mean overall survival (OS). RESULTS All patients underwent DSP via laparoscopy or laparotomy as scheduled and were followed-up for 12-72 months. The two groups showed statistically similar mean operative time (laparoscopy vs. laparotomy, 150 ± 54 vs. 160 ± 48 min), median volume of intraoperative bleeding (100 [50-400] vs. 150 [50-350] ml), and rate of postoperative pancreatic fistula (18.2 vs. 21.7 %). The laparoscopy group had a significantly shorter median duration of hospitalization (5 [3-12] vs. 8 [7-22] d, P < 0.05). All patients had a clear resection margin and showed statistically similar tumor size (2.8 ± 1.5 vs. 3.1 ± 1.7 cm), number of lymph nodes dissected (14.8 ± 4.5 vs. 16.1 ± 5.7), and mean OS (42.0 ± 8.6 vs. 54.0 ± 5.8 mo, P > 0.05). CONCLUSIONS Laparoscopic DSP is a feasible, effective, and safe alternative to laparotomy in carefully selected PBTC patients and is associated with a more rapid postoperative recovery.
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Stauffer JA, Rosales-Velderrain A, Goldberg RF, Bowers SP, Asbun HJ. Comparison of open with laparoscopic distal pancreatectomy: a single institution's transition over a 7-year period. HPB (Oxford) 2013; 15:149-55. [PMID: 23297726 PMCID: PMC3719922 DOI: 10.1111/j.1477-2574.2012.00603.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 09/20/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Many studies have shown laparoscopic distal pancreatectomy (LDP) to have benefits over open distal pancreatectomy (ODP). This institution made a unique abrupt transition from an exclusively open approach to a preference for the laparoscopic technique. This study aimed to compare outcomes in patients undergoing LDP and ODP, respectively, over the period of transition. METHODS A retrospective review of all patients undergoing LDP (n = 82) or ODP (n = 90) was performed. Surrogate oncologic markers for the subgroup of patients with malignant disease were also studied. RESULTS The ODP and LDP groups were well matched with regard to demographics, comorbidities and tumour characteristics. Significant differences were noted in favour of the LDP group in which decreases were seen in estimated blood loss (<0.001), need for packed red blood cell transfusions (<0.001), length of hospital stay (<0.001) and intensive care unit stay (<0.001). No other significant differences in the occurrence of complications or oncologic outcomes were seen. Rates of Grade B and C fistulae were 10% and 6% in the ODP and LDP groups, respectively. Grade III-V complications occurred in 20% and 13% of the ODP and LDP groups, respectively. CONCLUSIONS Laparoscopic distal pancreatectomy continues to compare favourably with ODP when well-matched patient series are reviewed. The results show a decreased need for blood transfusions and hospital resources in LDP. Additionally, there may be oncologic advantages associated with LDP compared with ODP in pancreatic malignancies.
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Affiliation(s)
- John A Stauffer
- Department of General Surgery, Mayo Clinic, Jacksonville, FL 32224, USA.
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Poves I, Burdío F, Dorcaratto D, Grande L. [Results of the laparoscopic approach in left-sided pancreatectomy]. Cir Esp 2012; 91:25-30. [PMID: 23218526 DOI: 10.1016/j.ciresp.2012.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 04/27/2012] [Accepted: 05/19/2012] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Laparoscopic left-sided pancreatectomy (LLP) is an accepted technique for the treatment of benign and pre-malignant lesions of the left side of the pancreas, but there is still controversy on its use for malignant ones. OBJECTIVE To evaluate our results in LLP as a routine technique for primary lesions of the left pancreas. PATIENTS AND METHODS We performed LLP in 15 patients for primary lesions of the pancreas from November 2007 to November 2011. An intra-abdominal drainage was left in all cases, and the recommendations of the International Study Group for Pancreatic Fistula were followed. RESULTS The mean age of the patients was 64±13 years. Six radical spleno-pancreatectomies, 3 corporo-caudal with preservation of the spleen, and 6 pure distal (4 with preservation of the spleen). There was one conversion. The mean surgical time was 230±69 minutes. The mean post-operative stay was 8.1±7.6 days. At 90 days, complications were detected in 4 patients; 3 grade II and one grade V according to the modified classification of Clavien. There was one grade B pancreatic fistula. The diagnosis was a malignant neoplasm in 53% of cases. The number of resected lymph nodes in the cases where a radical resection was planned due to cancer was 21.7±11.5, there being negative margins in all cases. CONCLUSIONS LLP may be considered as a suitable technique for the treatment of primary pancreatic lesions, including malignant ones, provided that it is performed by groups with experience in pancreatic surgery and highly trained in laparoscopic surgery.
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Affiliation(s)
- Ignasi Poves
- Unidad de Cirugía Hepato-Bilio-Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari del Mar, Universitat Autònoma de Barcelona, Barcelona, España.
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Iacobone M, Citton M, Nitti D. Laparoscopic distal pancreatectomy: Up-to-date and literature review. World J Gastroenterol 2012; 18:5329-37. [PMID: 23082049 PMCID: PMC3471101 DOI: 10.3748/wjg.v18.i38.5329] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/19/2012] [Accepted: 05/13/2012] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.
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Rosales-Velderrain A, Bowers SP, Goldberg RF, Clarke TM, Buchanan MA, Stauffer JA, Asbun HJ. National trends in resection of the distal pancreas. World J Gastroenterol 2012; 18:4342-9. [PMID: 22969197 PMCID: PMC3436049 DOI: 10.3748/wjg.v18.i32.4342] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/23/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate national trends in distal pancreatectomy (DP) through query of three national patient care databases. METHODS From the Nationwide Inpatient Sample (NIS, 2003-2009), the National Surgical Quality Improvement Project (NSQIP, 2005-2010), and the Surveillance Epidemiology and End Results (SEER, 2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy. Utilization of laparoscopy was defined in NIS by the International Classification of Diseases, Ninth Revision correspondent procedure code; and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes. In SEER, patients were identified by the International Classification of Diseases for Oncology, Third Edition diagnosis codes and the SEER Program Code Manual, third edition procedure codes. We analyzed the databases with respect to trends of inpatient outcome metrics, oncologic outcomes, and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection. RESULTS NIS, NSQIP and SEER identified 4242, 2681 and 11,082 DP resections, respectively. Overall, laparoscopy was utilized in 15% (NIS) and 27% (NSQIP). No significant increase was seen over the course of the study. Resection was performed for malignancy in 59% (NIS) and 66% (NSQIP). Neither patient Body mass index nor comorbidities were associated with operative approach (P = 0.95 and P = 0.96, respectively). Mortality (3% vs 2%, P = 0.05) and reoperation (4% vs 4%, P = 1.0) was not different between laparoscopy and open groups. Overall complications (10% vs 15%, P < 0.001), hospital costs [44,741 dollars, interquartile range (IQR) 28 347-74 114 dollars vs 49 792 dollars, IQR 13 299-73 463, P = 0.02] and hospital length of stay (7 d, IQR 4-11 d vs 7 d, IQR 6-10, P < 0.001) were less when laparoscopy was utilized. One and two year survival after resection for malignancy were unchanged over the course of the study (ductal adenocarinoma 1-year 63.6% and 2-year 35.1%, P = 0.53; intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%, P = 0.25). The majority of resections were performed in teaching hospitals (77% NIS and 85% NSQIP), but minimally invasive surgery (MIS) was not more likely to be used in teaching hospitals (15% vs 14%, P = 0.26). Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles (88% vs 43%, P < 0.001), but were no more likely to utilize MIS at resection. Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching (15% vs 14%, P = 0.72) and lower volume hospitals (14% vs 15%, P = 0.99). No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year (P = 0.17 and P = 0.96, respectively). CONCLUSION There appears to be an overall underutilization of laparoscopy for DP. Centralization does not appear to be occurring. Survival and lymph node harvest have not changed.
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