Laparoscopic versus open distal pancreatectomy for benign and low-grade malignant lesions of the pancreas: a single-center comparative study

Intraoperative Video Analysis of Pancreatic Stump and Stapler Closure-Induced Pancreatic Fistula in Laparoscopic Distal Pancreatectomy: A Retrospective Study

Objectives Pancreatic stump closure in laparoscopic distal pancreatectomy (Lap-DP) is commonly performed using an automatic stapler. Herein, the magnification effect of laparoscopy was used to observe the pancreatic stump and retrospectively investigate factors that may cause postoperative pancreatic fistula. Methods This is a single-center retrospective study. We selected 62 cases of Lap-DP performed between March 2016 and May 2022. We retrospectively analyzed 54 cases where pancreatic transection sites could be observed using an intraoperative video. Pancreatic transection was performed using the Powered ECHELON FLEX®+ GST® System (Ethicon, Somerville, USA). For quantitative studies, we investigated the factors that cause pancreatic fistula and other factors causing pancreatic fistula. Results Pancreatic parenchymal hemorrhage and injury occurred in 22.2% and 29.6% of cases, respectively. International Study Group of Pancreatic Surgery grade B/C pancreatic fistula was observed in 12 cases (22.2%). Univariate analysis of pancreatic (n = 12) and nonpancreatic (n = 42) fistula groups showed no significant differences in pancreatic thickness. The pancreatic fistula group had a significantly high incidence of the hard pancreas (p = .009), pancreatic parenchymal bleeding (p = .002), and pancreatic parenchymal damage (p < .001). Multivariate analysis revealed that pancreatic parenchymal damage was an independent cause of pancreatic fistula (hazard ratio, 81.4 (8.5-772.3), p < .001). Conclusion Pancreatic parenchymal damage due to compression during pancreatic stump closure using an automatic stapler in Lap-DP may cause pancreatic fistula.

Central pancreatectomy for benign or low-grade malignant pancreatic tumors in the neck and body of the pancreas

BACKGROUND

For tumors in the neck and body of the pancreas, distal pancreatectomy (DP) has been the standard surgical procedure for the last few decades and central pancreatectomy (CP) is an alternative surgical option. Whether CP better preserves remnant pancreatic endocrine and exocrine functions after surgery remains a subject of debate.

AIM

To evaluate the safety and efficacy of CP compared with DP for benign or low-grade malignant pancreatic tumors in the neck and body of the pancreas.

METHODS

This retrospective study enrolled 296 patients who underwent CP or DP for benign and low-malignant neoplasms at the same hospital between January 2016 and March 2020. Perioperative outcomes and long-term morbidity of endocrine/exocrine function were prospectively evaluated.

RESULTS

No significant difference was observed in overall morbidity or clinically relevant postoperative pancreatic fistula between the two groups (P = 0.055). Delayed gastric emptying occurred more frequently in the CP group than in the DP group (29.4% vs 15.3%; P < 0.005). None of the patients in the CP group had new-onset or aggravated distal metastasis, whereas 40 patients in the DP group had endocrine function deficiency after surgery (P < 0.05). There was no significant difference in the incidence of diarrhea immediately after surgery, but at postoperative 12 mo, a significantly higher number of patients had diarrhea in the DP group than in the CP group (0% vs 9.5%; P < 0.05).

CONCLUSION

CP is a generally safe procedure and is better than DP in preserving long-term pancreatic endocrine and exocrine functions. Therefore, CP might be a better option for treating benign or low-grade malignant neoplasms in suitable patients.

"Plane first" approach for laparoscopic radical antegrade modular pancreatosplenectomy

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has not been widely performed due to its technical challenging. We introduce a novel approach, named "Plane first" approach, for L-RAMPS in this study.

METHODS

From January 2015 to August 2021, we performed 51 cases of L-RAMPS. Patients were divided into two groups basing on the surgical approach: conventional approach (group 1) and "Plane first" approach (group 2). Data were retrospectively collected in terms of demographic characteristics, intra-operative variables, post-operative variables, and follow-up outcomes.

RESULTS

The age, sex, BMI, and tumor size were comparable between two groups. Two patients in the group 1 required converting to open surgery. The patients in the group 2 required fewer operative time (210.5 ± 65.5 min vs. 252.4 ± 24.7 min, p < 0.01). They also suffered from less blood loss (136.0 ± 100.0 ml vs. 158.8 ± 137.0 ml, p = 0.15). The overall complications for patients in two groups were comparable. In terms of oncological outcomes, posterior margin was positive in two patients (10.5%) in the group 1. One patient (3.1%) in the group 2 had positive pancreatic neck margin. The number of lymph nodes harvested and overall survival between the two groups were comparable.

CONCLUSION

"Plane first" approach RAMPS for patients with pancreatic adenocarcinoma in the left pancreas is safe and feasible, even in patients with PV/SMV involvement.

Systematic review and meta-analysis of risk factors of postoperative pancreatic fistula after distal pancreatectomy in the era of 2016 International Study Group pancreatic fistula definition

BACKGROUND

Risk factors for the development of clinically relevant POPF (CR-POPF) following distal pancreatectomy (DP) need clarification particularly following the 2016 International Study Group of Pancreatic Fistula (ISGPF) definition.

METHODS

A systemic search of MEDLINE, Pubmed, Scopus, and EMBASE were conducted using the PRISMA framework. Studies were evaluated for risk factors for the development CR-POPF after DP using the 2016 ISGPF definition. Further subgroup analysis was undertaken on studies ≥10 patients in exposed and non-exposed subgroups.

RESULTS

Forty-three studies with 8864 patients were included in the meta-analysis. The weighted rate of CR-POPF was 20.4% (95%-CI: 17.7-23.4%). Smoking (OR 1.29, 95%-CI: 1.08-1.53, p = 0.02) and open DP (OR 1.43, 95%-CI: 1.02-2.01, p = 0.04) were found to be significant risk factors of CR-POPF. Diabetes (OR 0.81, 95%-CI: 0.68-0.95, p = 0.02) was a significant protective factor against CR-POPF. Substantial heterogeneity was observed in the comparisons of pancreatic texture and body mass index. Seventeen risk factors achieved significance in a univariate or multivariate comparison as reported by individual studies in the narrative synthesis, however, they remain difficult to interpret as statistically significant comparisons were not uniform.

CONCLUSION

This meta-analysis found smoking and open DP to be risk factors and diabetes to be protective factor of CR-POPF in the era of 2016 ISGPF definition.

Efficacy of the slow firing method using a reinforced triple-row stapler for preventing postoperative pancreatic fistula during laparoscopic distal pancreatectomy

PURPOSE

Postoperative pancreatic fistula (POPF) remains the most clinically relevant complication of laparoscopic distal pancreatectomy (LDP). The present study evaluated the efficacy of the "slow firing method" using a reinforced triple-row stapler (Covidien, Tokyo, Japan) during LDP.

METHODS

This retrospective single-center study included 73 consecutive patients who underwent LDP using the slow firing method. A black cartridge was used in all patients. The primary endpoint was the rate of clinically relevant POPF (CR-POPF) after LDP. Secondary endpoints included perioperative outcomes and factors associated with CR-POPF as well as the correlation between the transection time and thickness of the pancreas.

RESULTS

Four patients (5.5%) developed CR-POPF (grade B). Overall morbidity rates, defined as grade ≥ II and ≥ III according to the Clavien-Dindo classification, were 21 and 11%, respectively. The median postoperative hospital stay was 10 days. Preoperative diabetes (13.6 vs. 0.2%, P = 0.044) and thickness of the pancreas ≥ 15 mm (13.8% vs. 0%, P = 0.006) were identified as independent risk factors for CR-POPF. The median transection time was 16 (8-29) min.

CONCLUSION

The slow firing method using a reinforced triple-row stapler for pancreatic transection is simple, safe, and effective for preventing CR-POPF after LDP.

Surgical and oncological outcomes of laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma

PURPOSE

To compare the outcomes of laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) with those of open RAMPS (O-RAMPS) in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

We reviewed, retrospectively, the medical records of 50 patients who underwent RAMPS for PDAC without resection of major vessels and adjacent organs between 2007 and 2019, and analyzed the relationship between the operative method and surgical and oncological outcomes.

RESULTS

Nineteen of the 50 patients underwent L-RAMPS and 31 patients underwent O-RAMPS. L-RAMPS was associated with significantly less blood loss (P = 0.034) but a longer operative time (P = 0.001) than O-RAMPS. There were no significant differences in patient characteristics, tumor factors, or postoperative course; or in the rates of recurrence-free survival (P = 0.084) or overall survival (P = 0.402) between the L-RAMPS and O-RAMPS groups.

CONCLUSION

L-RAMPS for PDAC resulted in less blood loss but a longer operative time than O-RAMPS. Although L-RAMPS may be feasible, the operative time needs to be reduced by standardizing the procedure.

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review

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.

Comparison of 3 Minimally Invasive Methods Versus Open Distal Pancreatectomy: A Systematic Review and Network Meta-Analysis

Supplemental Digital Content is available in the text.

The efficacy and safety of open distal pancreatectomy (DP), laparoscopic DP, robot-assisted laparoscopic DP, and robotic DP have not been established. The authors aimed to comprehensively compare these 4 surgical methods using a network meta-analysis.

Conversion to open laparotomy during laparoscopic distal pancreatectomy: lessons from a single-center experience in 70 consecutive patients

PURPOSE

The purpose of this study was to determine the factors influencing conversion from laparoscopic distal pancreatectomy (LDP) to open surgery, and the effect of such conversion on the outcome.

METHODS

This retrospective single-center study included 70 consecutive patients undergoing LDP. The primary endpoint was the rate of conversion to open surgery during LDP. The secondary endpoints were determining the reasons for conversion to open surgery, with detailed analyses of these cases and a comparison of the surgical outcome with and without conversion.

RESULTS

Seven patients (10%) required conversion to open surgery during LDP. Pancreatic ductal adenocarcinoma (PDAC) was identified as a risk factor for conversion (p = 0.010). The reasons for conversion included technical difficulty (two bleeding, one severe adhesion) and pancreatic stump-related issues (two margin-positive, two stapling failures). Although the overall morbidity rate (29 vs. 11%, p = 0.48) and the rate of clinically relevant postoperative pancreatic fistula (14 vs. 5%, p = 0.82) were no different for the patients with or without open conversion, the postoperative hospital stay was significantly longer in the former (median 15 vs. 10 days, p = 0.03).

CONCLUSIONS

Careful preoperative assessment is required when planning LDP for PDAC. Although conversion to open surgery does not result in failure of LDP, efforts to reduce the duration of postoperative hospital stay and the occurrence of complications are desirable to improve the outcome of LDP.

A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients

BACKGROUND

Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system.

METHODS

Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836.

RESULTS

Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD.

CONCLUSION

LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.