Laparoscopic versus open pancreaticoduodenectomy for pancreatic neuroendocrine tumors: a single-center experience

The Value of Textbook Outcome in Benchmarking Pancreatoduodenectomy for Nonfunctioning Pancreatic Neuroendocrine Tumors

BACKGROUND

Textbook outcome (TO) is a composite variable that can define the quality of pancreatic surgery. The aim of this study is to evaluate TO after pancreatoduodenectomy (PD) for nonfunctioning pancreatic neuroendocrine tumors (NF-PanNETs).

PATIENTS AND METHODS

All patients who underwent PD for NF-PanNETs (2007-2016) in different centers were included in this retrospective study. TO was defined as the absence of severe postoperative complications and mortality, length of hospital stay ≤ 19 days, R0 resection, and at least 12 lymph nodes harvested.

RESULTS

Overall, 477 patients were included. The TO rate was 32%. Tumor size [odds ratio (OR) 1.696; p = 0.013], a minimally invasive approach (OR 12.896; p = 0.001), and surgical volume (OR 2.062; p = 0.023) were independent predictors of TO. The annual frequency of PDs increased over time as well as the overall rate of TO. At a median follow-up of 44 months, patients who achieved TO had similar disease-free (p = 0.487) and overall survival (p = 0.433) rates compared with patients who did not achieve TO. TO rate in patients with NF-PanNET > 2 cm was 35% versus 27% in patients with NF-PanNET ≤ 2 cm (p = 0.044). Considering only NF-PanNETs > 2 cm, patients with TO and those without TO had comparable 5-year overall survival rates (p = 0.766) CONCLUSIONS: TO is achieved in one-third of patients after PD for NF-PanNETs and is not associated with a benefit in terms of long-term survival.

Long-Term Outcomes of Endoscopic Ultrasound-Guided Ablation Vs Surgery for Pancreatic Cystic Tumors

BACKGROUND & AIMS

Endoscopic ultrasound-guided pancreatic cyst ablation (EUS-PCA) is performed as an alternative to surgical resection in selected patients with pancreatic cystic tumors (PCTs). We aimed to directly compare the long-term outcomes between EUS-PCA and surgery for PCTs.

METHODS

We reviewed a PCT database to identify patients with unilocular or oligolocular PCTs who underwent EUS-PCA or surgery between January 2004 and July 2019. We performed 1:1 propensity score matching based on potential confounding factors. The primary outcome was long-term morbidities. Secondary outcomes included early (≤14 days) and late (>14 days) major adverse events (MAEs), development of diabetes mellitus, readmission, length of hospital stay, and therapeutic efficacy.

RESULTS

A total of 620 patients (EUS-PCA, n = 310; surgery, n = 310) were selected after propensity score matching. The EUS-PCA group showed a lower 10-year rate of cumulative long-term morbidities (1.6% vs 33.5%; P = .001) as well as lower rates of early MAE (1.0% vs 8.7%; P = .001), late MAE (0.3% vs 5.5%; P = .001), and readmission (1.0% vs 15.2%; P = .001). The EUS-PCA group had a shorter hospital stay (3.5 vs 10.3 d; P = .001) and a lower incidence of diabetes mellitus (2.2% vs 22.8%; P = .001), whereas the surgery group had a higher complete resolution rate (76.5% vs 100%; P = .001) and a lower relapse rate (4.6% vs 0.3%; P = .001).

CONCLUSIONS

For select patients with PCTs, EUS-PCA showed superior results to surgery in terms of long-term safety profile and preservation of pancreatic function.

Perioperative Outcomes and Long-Term Survival of Laparoscopic Pancreaticoduodenectomy: A Retrospective Study of 653 Cases in a Single Institution

Introduction: Laparoscopic pancreaticoduodenectomy (LPD) is gaining wide acceptance within pancreatic surgery. However, longitudinal data are lacking. The aim of this study was to analyze and assess the short-term outcomes and long-term survival of LPD over a duration of 8 years. Methods: Patients who underwent LPD in our institution between November 2013 and September 2021 were included in this study. The perioperative outcomes were statistically analyzed. The long-term survival was studied over a median follow-up duration of 13 months. Results: In total, 653 consecutive patients treated at our institution were included, of which 617 cases underwent standard LPD and 36 cases underwent LPD with vascular resection. The rate of death in hospital, reoperation, postpancreatectomy hemorrhage, postoperative pancreatic fistula, and delayed gastric emptying were 4.4%, 10.3%, 11.9%, 12.9%, and 6.1% respectively. There were statistical differences in the intraoperative blood loss and transfusion, operation time, and the R0 resection rate between the LPD cases and LPD with vascular resection cases. A total of 526 cases were pathologically diagnosed of cancer. The 1-, 3-, and 5-year survival rates were 49.2%, 17.9%, and 17.9%, respectively, for pancreatic cancer with the median survival time of 12 months. The 1-, 3-, and 5-year survival rates were 76.9%, 60.8%, and 52.5%, respectively, for bile duct cancer with the median survival time of 35 months. The 1-, 3-, and 5-year survival rates were 80.2%, 62.2%, and 52.9%, respectively, for duodenal cancer with the median survival time of 53 months. The 1-, 3-, and 5-year survival rates were 72.5%, 54.5%, and 50%, respectively, for ampullary cancer with the median survival time of 55 months. Conclusion: LPD is a feasible and oncologically acceptable procedure with satisfying perioperative outcomes and long-term survival in a high-volume institution.

Comparisons of short-term and long-term results between laparoscopic between open pancreaticoduodenectomy for pancreatic tumors: A systematic review and meta-analysis

Objective: The efficacy of pancreaticoduodenectomy and open pancreaticoduodenectomy for pancreatic tumors is controversial. The study aims to compare the efficacy of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in the treatment of pancreatic tumors through systematic evaluation and meta-analysis. Methods: PubMed, Embase, Cochrane Library and Web of science databases were searched for clinical studies on the treatment of pancreatic tumors with LPD and OPD. The end time for the searches was 20 July 2022. Rigorous inclusion and exclusion criteria were used to screen the articles, the Cochrane manual was used to evaluate the quality of the included articles, and the stata15.0 software was used for statistical analysis of the indicators. Results: In total, 16 articles were included, including two randomized controlled trials and 14 retrospective studies. Involving a total of 4416 patients, 1275 patients were included in the LPD group and 3141 patients in the OPD group. The results of the meta-analysis showed that: the operation time of LPD was longer than that of OPD [WMD = 56.14,95% CI (38.39,73.89), p = 0.001]; the amount of intraoperative blood loss of LPD was less than that of OPD [WMD = -120.82,95% CI (-169.33, -72.30), p = 0.001]. No significant difference was observed between LPD and OPD regarding hospitalization time [WMD = -0.5,95% CI (-1.35, 0.35), p = 0.250]. No significant difference was observed regarding postoperative complications [RR = 0.96,95% CI (0.86,1.07, p = 0.463]. And there was no significant difference regarding 1-year OS and 3-year OS: 1-year OS [RR = 1.02,95% CI (0.97,1.08), p = 0.417], 3-year OS [RR = 1.10 95% CI (0.75, 1.62), p = 0.614%]. Conclusion: In comparison with OPD, LPD leads to less blood loss but longer operation time, therefore the bleeding rate per unit time of LPD is less than that of OPD. LPD has obvious advantages. With the increase of clinical application of LPD, the usage of LPD in patients with pancreatic cancer has very good prospect. Due to the limitations of this paper, in future studies, more attention should be paid to high-quality, multi-center, randomized controlled studies.

Surgical methods influence on the risk of anastomotic fistula after pancreaticoduodenectomy: a systematic review and network meta-analysis

BACKGROUND

Pancreaticoduodenectomy is the first choice surgical intervention for the radical treatment of pancreatic tumors. However, an anastomotic fistula is a common complication after pancreaticoduodenectomy with a high mortality rate. With the development of minimally invasive surgery, open pancreaticoduodenectomy (OPD), laparoscopic pancreaticoduodenectomy (LPD), and robotic pancreaticoduodenectomy (RPD) are gaining interest. But the impact of these surgical methods on the risk of anastomosis has not been confirmed. Therefore, we aimed to integrate relevant clinical studies and explore the effects of these three surgical methods on the occurrence of anastomotic fistula after pancreaticoduodenectomy.

METHODS

A systematic literature search was conducted for studies reporting the RPD, LPD, and OPD. Network meta-analysis of postoperative anastomotic fistula (Pancreatic fistula, biliary leakage, gastrointestinal fistula) was performed.

RESULTS

Sixty-five studies including 10,026 patients were included in the network meta-analysis. The rank of risk probability of pancreatic fistula for RPD (0.00) was better than LPD (0.37) and OPD (0.62). Thus, the analysis suggests the rank of risk of the postoperative pancreatic fistula for RPD, LPD, and OPD. The rank of risk probability for biliary leakage was similar for RPD (0.15) and LPD (0.15), and both were better than OPD (0.68).

CONCLUSIONS

This network meta-analysis provided ranking for three different types of pancreaticoduodenectomy. The RPD and LPD can effectively improve the quality of surgery and are safe as well as feasible for OPD.

Simulation training of laparoscopic pancreaticojejunostomy and stepwise training program on a 3D-printed model

AIM

Laparoscopic pancreaticojejunostomy is among the most difficult and high-risk operations. Surgeons with low or moderate seniority rarely are allowed to perform this surgery in clinics. Therefore, there is an urgent need to develop a reliable simulation training model focused on laparoscopic pancreaticojejunostomy and an effective stepwise training program.

METHODS

Surgeons with different working experiences or exposure to different training programs at Sir Run Run Shaw Hospital were divided into four groups. Each was required to perform laparoscopic pancreaticojejunostomy using a designed three-dimensional dry lab model. All surgeons' baseline characteristics and surgical performance, including operation time and score, were recorded and analysed. The authenticity of the model was evaluated by four senior surgeons.

RESULTS

The surgeon group with higher seniority had an older average age, longer working time, and had completed more laparoscopic cholecystectomy and laparoscopic common bile duct exploration procedures. Meanwhile, the surgeon group with higher seniority presented better operation performance, including shorter operation time and higher operation score in their initial simulation training. Resident surgeons who underwent stepwise training with the laparoscopic biliary-enteric anastomosis training program showed better initial performance than resident surgeons who underwent stepwise training with the laparoscopic basic suture training program. After repeated training, the surgeons showed improved surgical performance.

CONCLUSION

Our pancreaticojejunostomy model showed a good degree of discernibility, as surgeons with more experience performed better with the model for their initial simulation training in laparoscopic pancreaticojejunostomy. Stepwise training of the laparoscopic biliary-enteric anastomosis training program helped surgeons obtain a better initial performance, and repeated simulation training on this model improved the surgeon's operative performance.

Clinical Analysis of C-Shaped Embedded Pancreaticojejunostomy in Pancreaticoduodenectomy

Background

Comparing the effects of C-shaped embedded anastomosis and pancreatic duct-jejunal mucosal anastomosis on the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) to find a better pancreaticojejunal anastomosis method that can reduce the occurrence of complications during the operation and benefit the patients.

Methods

A retrospective subresearch method was used to select the clinical data of patients who have undergone pancreaticoduodenectomy in our hospital from December 2019 to March 2021. The indicators to be collected for this study include gender, age, body mass index, preoperative liver function (total bilirubin, alanine aminotransferase, and albumin), preoperative comorbidities (diabetes, chronic pancreatitis), and pancreatic condition (texture, pancreatic duct diameter). The patients were divided into two groups according to the method of pancreaticojejunostomy: C-shaped embedded anastomosis group (n = 38) and pancreatic duct-jejunal mucosal anastomosis group (n = 30). The duration of pancreaticojejunostomy, biliary-enteric anastomosis, gastrointestinal anastomosis, intraoperative blood loss, upper abdominal surgery history, pathological type, intraoperative blood loss, pancreaticojejunostomy time, combined pancreatic fistula, biliary fistula, hemorrhage, and abdominal infection were observed and compared. According to the different methods of pancreaticojejunostomy during operation, they were divided into group A: C-shaped embedded pancreaticojejunostomy group (38 cases), and group B: pancreatic duct-jejunal mucosal anastomosis group (30 cases). The postoperative complications were compared between the two groups, and the observed indicators were analyzed with statistical methods.

Results

The average pancreaticojejunostomy time in group A was 32.13 ± 4.52 min, and the average pancreaticojejunostomy time in group B was 43.23 + 4.31 min. The difference was statistically significant (p < 0.05). Neither group A nor group B had a grade C fistula. The incidence of biochemical fistula in group A was 21.05% (8/38), and the incidence of biochemical fistula in group B was 13.3% (4/30). The difference was not statistically significant (p > 0.05). The incidence of grade B fistula in group A was 5.20% (2/38), and the incidence of grade B fistula in group B was 26.67% (8/30). The difference was statistically significant (p < 0.05). There were no perioperative deaths in the two groups.

Conclusion

According to the results of data analysis, it can be seen that both the two types of pancreaticojejunostomy have good clinical effects, but that in terms of reducing the grade of pancreatic fistula, the C-shaped embedded pancreaticojejunostomy is obviously better and safer. At the same time, the C-shaped embedded pancreaticojejunostomy can shorten the time of pancreaticojejunostomy and is easier to operate, thus worthy of clinical promotion.

Comparison of outcomes between laparoscopic and open pancreaticoduodenectomy without radical lymphadenectomy: Results of coarsened exact matching analysis using national database systems

INTRODUCTION

Laparoscopic pancreaticoduodenectomy has recently been covered under Japan's insurance system for patients not requiring lymph node dissection. Only high-volume hospitals that meet specific criteria are permitted to perform laparoscopic pancreaticoduodenectomy. Although open and laparoscopic pancreaticoduodenectomy outcomes with lymph node dissection have been described previously, procedures performed without lymph node dissection have not been compared using a nationwide database. This study aimed to review the results of laparoscopic pancreaticoduodenectomy and compare them to those of open pancreaticoduodenectomy (OPD) using records from a nationwide database.

METHODS

We collected patient demographic and medical data of 2900 patients who underwent pancreaticoduodenectomy (laparoscopic, n = 162; open, n = 2738) without lymph node dissection between 2016 and 2018 from the National Clinical Database in Japan. Coarsened exact matching was used to match patients in the laparoscopic and open pancreaticoduodenectomy groups.

RESULTS

In-hospital mortality was not observed in the laparoscopic pancreaticoduodenectomy group. The rate of conversion to an open procedure was 6.8% (11 cases). After 1:1 matching, we obtained 141 pairs of patients for comparison. The mortality rate was comparable in the laparoscopic and open pancreaticoduodenectomy groups (0.0% vs 0.7%, respectively; P = 1.00). The laparoscopic approach showed more favorable results in terms of median blood loss. Postoperative pancreatic fistula formation and complications were comparable between the two groups.

CONCLUSIONS

Our results indicate that laparoscopic pancreaticoduodenectomy could be introduced successfully, and the outcomes achieved by the institutions included in our study were comparable to those of open pancreaticoduodenectomy.

Laparoscopic Pancreaticoduodenectomy Versus Conventional Open Approach for Patients With Pancreatic Duct Adenocarcinoma: An Up-to-Date Systematic Review and Meta-Analysis

Background

To compare perioperative and oncological outcomes of pancreatic duct adenocarcinoma (PDAC) after laparoscopic versus open pancreaticoduodenectomy (LPD vs. OPD), we performed a meta-analysis of currently available propensity score matching studies and large-scale retrospective cohorts to compare the safety and overall effect of LPD to OPD for patients with PDAC.

Methods

A meta-analysis was registered at PROSPERO and the registration number is CRD42021250395. PubMed, Web of Science, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Data on operative times, blood loss, 30-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien-Dindo ≥3 complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, overall survival, and long-term survival) were subjected to meta-analysis.

Results

Overall, we identified 10 retrospective studies enrolling a total of 11,535 patients (1,514 and 10,021 patients underwent LPD and OPD, respectively). The present meta-analysis showed that there were no significant differences in overall survival time, 1-year survival, 2-year survival, 30-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, and lymph node dissection between the LPD and OPD groups. Nevertheless, compared with the OPD group, LPD resulted in significantly higher rate of R0 resection (OR: 1.22; 95% CI 1.06-1.40; p = 0.005), longer operative time (WMD: 60.01 min; 95% CI 23.23-96.79; p = 0.001), lower Clavien-Dindo grade ≥III rate (p = 0.02), less blood loss (WMD: -96.49 ml; 95% CI -165.14 to -27.83; p = 0.006), lower overall morbidity rate (OR: 0.65; 95% CI 0.50 to 0.85; p = 0.002), shorter LOS (MD = -2.73; 95% CI -4.44 to -1.03; p = 0.002), higher 4-year survival time (p = 0.04), 5-year survival time (p = 0.001), and earlier time to starting adjuvant chemotherapy after surgery (OR: -10.86; 95% CI -19.42 to -2.30; p = 0.01).

Conclusions

LPD is a safe and feasible alternative to OPD for patients with PDAC, and compared with OPD, LPD seemed to provide a similar OS.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Minimally Invasive Versus Open Pancreatectomy for Right-Sided and Left-Sided G1/G2 Nonfunctioning Pancreatic Neuroendocrine Tumors: A Multicenter Matched Analysis with an Inverse Probability of Treatment-Weighting Method

BACKGROUND

Limited evidence exists for the safety and oncologic efficacy of minimally invasive surgery (MIS) for nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) according to tumor location. This study aimed to compare the surgical outcomes of MIS and open surgery (OS) for right- or left-sided NF-PNETs.

METHODS

The study collected data on patients who underwent surgical resection (pancreatoduodenectomy, distal/total/central pancreatectomy, duodenum-preserving pancreas head resection, or enucleation) of a localized NF-PNET between January 2000 and July 2017 at 14 institutions. The inverse probability of treatment-weighting method with propensity scores was used for analysis.

RESULTS

The study enrolled 859 patients: 478 OS and 381 MIS patients. A matched analysis by tumor location showed no differences in resection margin, intraoperative blood loss, or complications between MIS and OS. However, MIS was associated with a longer operation time for right-sided tumors (393.3 vs 316.7 min; P < 0.001) and a shorter postoperative hospital stay for left-sided tumors (8.9 vs 12.9 days; P < 0.01). The MIS group was associated with significantly higher survival rates than the OS group for right- and left-sided tumors, but survival did not differ for the patients divided by tumor grade and location. Multivariable analysis showed that MIS did not affect survival for any tumor location.

CONCLUSION

The short-term outcomes offered by MIS were comparable with those of OS except for a longer operation time for right-sided NF-PNETs. The oncologic outcomes were not compromised by MIS regardless of tumor location or grade. These findings suggest that MIS can be performed safely for selected patients with localized NF-PNETs.

Laparoscopic vs. Open Pancreaticoduodenectomy After Learning Curve: A Systematic Review and Meta-Analysis of Single-Center Studies

Background: Although laparoscopic pancreaticoduodenectomy (LPD) is a safe and feasible treatment compared with open pancreaticoduodenectomy (OPD), surgeons need a relatively long training time to become technically proficient in this complex procedure. In addition, the incidence of complications and mortality of LPD will be significantly higher than that of OPD in the initial stage. This meta-analysis aimed to compare the safety and overall effect of LPD to OPD after learning curve based on eligible large-scale retrospective cohorts and randomized controlled trials (RCTs), especially the difference in the perioperative and short-term oncological outcomes.

Methods: PubMed, Web of Science, EMBASE, Cochrane Central Register, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Only clinical studies reporting more than 40 cases for LPD were included. Data on operative times, blood loss, and 90-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien–Dindo ≥III complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, positive lymph node numbers, and tumor size) were subjected to meta-analysis.

Results: Overall, the final analysis included 13 retrospective cohorts and one RCT comprising 2,702 patients (LPD: 1,040, OPD: 1,662). It seems that LPD has longer operative time (weighted mean difference (WMD): 74.07; 95% CI: 39.87–108.26; p < 0.0001). However, compared with OPD, LPD was associated with a higher R0 resection rate (odds ratio (OR): 1.43; 95% CI: 1.10–1.85; p = 0.008), lower rate of wound infection (OR: 0.35; 95% CI: 0.22–0.56; p < 0.0001), less blood loss (WMD: −197.54 ml; 95% CI −251.39 to −143.70; p < 0.00001), lower blood transfusion rate (OR: 0.58; 95% CI 0.43–0.78; p = 0.0004), and shorter LOS (WMD: −2.30 day; 95% CI −3.27 to −1.32; p < 0.00001). No significant differences were found in 90-day mortality, overall morbidity, Clavien–Dindo ≥ III complications, reoperation, POPF, DGE, PPH, lymph node dissection, positive lymph node numbers, and tumor size between LPD and OPD.

Conclusion: Comparative studies indicate that after the learning curve, LPD is a safe and feasible alternative to OPD. In addition, LPD provides less blood loss, blood transfusion, wound infection, and shorter hospital stays when compared with OPD.

The clinicopathologic and operative characteristics of patients with small nonfunctioning pancreatic neuroendocrine tumors

BACKGROUND

Incidentally detected, small nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) are increasingly diagnosed on imaging modalities. This retrospective investigation evaluated the clinicopathologic characteristics and perioperative and oncologic outcomes in patients with small NF-PNETs undergoing curative resection.

METHODS

The medical records of 444 patients who underwent pancreatic resection for NF-PNETs at a single, large-volume institution between January 2000 and December 2018 were retrospectively reviewed. Patients were divided into those with small (≤2 cm) and large (>2 cm) tumors based on the largest tumor diameter on preoperative computed tomography (CT). Outcomes were also evaluated in subgroups of patients with small NF-PNET who did and did not undergo lymphadenectomy.

RESULTS

Of the 444 patients with NF-PNETs, 195 (43.9%) had small (≤2 cm) and 249 (56.1%) had large (>2 cm) NF-PNETs. The rate of parenchyma-preserving surgery (14.4% vs. 7.2%, p = 0.014) and the ratio of spleen preservation for left-sided pancreatectomy (65.6% vs. 38.3%, p < 0.001) were higher in the small NF-PNET group. Size on CT >2 cm (p < 0.001, hazard ratio [HR]: 5.836, 95% confidence interval [CI]: 2.474-13.769), presence of perineural invasion (p < 0.001, HR: 3.025, 95% CI: 1.640-5.577), World Health Organization (WHO) Grade 2 (p = 0.007, HR: 2.861, 95% CI: 1.325-6.176), and WHO Grade 3 (p < 0.001, HR: 11.537, 95% CI: 5.282-25.199) were independent predictors of disease-free survival (DFS). DFS did not differ significantly in patients with small NF-PNETs who did and did not undergo lymphadenectomy (p = 0.886).

CONCLUSIONS

Assessment of long-term oncologic outcomes suggests that surgical resection may cure small NF-PNETs. Minimally invasive surgery and organ-preserving surgery are acceptable treatment options for select patients with small NF-PNETs. The effect on survival outcomes of lymph node dissection for small NF-PNETs remains unclear.

An essential technique for modern hepato-pancreato-biliary surgery: minimally invasive biliary reconstruction

Introduction: Minimally invasive reconstruction of the biliary tract is complex and involves multiple steps. The procedure is challenging and has been an essential technique in modern hepato-pancreato-biliary surgery in recent years. Additionally, the quality of the reconstruction directly affects long-and short-term complications and affects the prognosis and quality of life. Various minimally invasive reconstruction methods have been developed to improve the reconstruction effect; however, the optimal method remains controversial. Areas covered: In this study, were viewed published studies of minimally invasive biliary reconstruction within the last 5 years and discussed the current status and main complications of minimally invasive biliary reconstruction. More importantly, we introduced the current reconstruction strategies and technical details of minimally invasive biliary reconstruction, which may be potentially helpful for surgeons to choose reconstruction methods and improve reconstruction quality. Expert opinion: Although several improved and modified methods for biliary reconstruction have been developed recently, no single approach is optimal or adaptable to all situations. Patient-specific selection of appropriate technical strategies according to different situations combined with sophisticated and skilled minimally invasive techniques effectively improves the quality of anastomosis and reduces complications.

Long-term survival after minimally invasive resection versus open pancreaticoduodenectomy for periampullary cancers: a systematic review, meta-analysis and meta-regression

BACKGROUND

It remains unclear whether minimally invasive pancreaticoduodenectomy (MIPD) and open pancreaticoduodenectomy (OPD) influences long-term survival in periampullary cancers. This review aims evaluate long-term survival between MIPD and OPD for periampullary cancers.

METHODS

A systematic review was performed to identify studies comparing long-term survival after MIPD and OPD. The I₂ test was used to test for statistical heterogeneity and publication bias using Egger test. Random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year survival, and disease-specific 5-year and 3-year survival. Meta-regression was performed for the 5-year and 3-year survival outcomes with adjustment for study (region, design, case matching), hospital (centre volume), patient (ASA grade, gender, age), and tumor (stage, neoadjuvant therapy, subtype (i.e. ampullary, distal bile duct, duodenal, pancreatic)). Sensitivity analyses performed on studies including pancreatic ductal adenocarcinoma (PDAC) only.

RESULTS

The review identified 31 relevant studies. Among all 58,622 patients, 8716 (14.9%) underwent MIPD and 49,875 (85.1%) underwent OPD. Pooled analysis revealed similar 5-year overall survival after MIPD compared with OPD (HR: 0.78, 95% CI 0.50-1.22, p = 0.2). Meta-regression indicated case matching, and ASA Grade II and III as confounding covariates. The statistical heterogeneity was limited (I₂ = 12, χ² = 0.26) and the funnel plot was symmetrical both according to visual and statistical testing (Egger test = 0.32). Sensitivity subset analyses for PDAC demonstrated similar 5-year overall survival after MIPD compared with OPD (HR 0.69, 95% CI: 0.32-1.50, p = 0.3).

CONCLUSION

Long-term survival after MIPD is non-inferior to OPD. Thus, MIPD can be recommended as a standard surgical approach for periampullary cancers.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Achilles'heel of laparoscopic pancreatectomy: reconstruction of the remnant pancreas

INTRODUCTION

Laparoscopic pancreatic reconstruction is a challenging procedure and is considered the Achilles' heel of laparoscopic pancreatectomy. Multiple techniques of laparoscopic pancreatic reconstruction have been reported, but the optimal technique remains unclear.

AREAS COVERED

This paper provides a brief introduction to the developmental status and major related complications of laparoscopic pancreatic reconstruction. We reviewed all published literature on the technology of laparoscopic pancreatic reconstruction within the last 5 years and herein discuss the advantages and disadvantages of different reconstruction methods. We also discuss several details of different reconstruction techniques in terms of their significance to the operation and complications.

EXPERT OPINION

No individual method of laparoscopic pancreatic reconstruction is considered optimal for all conditions. The reconstruction strategy should be based on the surgeon's proficiency with laparoscopic technology and the patient's individual risk factors. Personalized methods of pancreatic reconstruction may more effectively reduce morbidity and mortality.