Completely laparoscopic subtotal pancreatectomy with splenic artery preservation

Dual-Incision Laparoscopic Spleen-Preserving Distal Pancreatectomy: Merits Compared to the Conventional Method

BACKGROUND

Herein, we assess the safety and feasibility of dual-incision laparoscopic spleen-preserving distal pancreatectomy (DILSPDP) through lateral approach with reduced trocars for benign and low-grade malignancy in pancreas tail. We compare DILSPDP with surgical outcomes of conventional laparoscopic spleen-preserving distal pancreatectomy (LSPDP).

METHODS

Patients with benign pancreas tail mass that had been scheduled for LSPDP were selected to undergo DILSPDP. These patients had spleen-preserving distal pancreatectomy with the dissection in lateral-to-medial fashion using a multichannel trocar in the right lateral decubitus position of patient. We compared the demographics and operative outcomes of DILSPDP with those of conventional LSPDP which was performed with dissection in medial-to-lateral fashion using four or five trocars in supine position.

RESULTS

Twenty two cases of DILSPDP and 26 cases of conventional LSPDP were reviewed. There was no difference in terms of demographic features including diagnosis or tumor size, although the location of the tumor was fundamentally different between the two groups. Significantly shorter operative times and reduced blood loss were observed in DILSPDP group (p = 0.004 and 0.011, respectively) and the preservation of splenic vessels was more successful with DILSPDP than conventional surgery (95.5% vs. 65.4%, p = 0.013).

CONCLUSIONS

DILSPDP appears to be a feasible method of spleen-preserving distal pancreatectomy for benign or low-malignancy of pancreas tail and is accompanied by advantages in terms of splenic vessel preservation and reduced parietal trauma.

Laparoscopic splenic vessels and spleen-preserving extended distal pancreatectomy for single metastatic renal cell carcinoma

Laparoscopic splenic vessels and spleen-preserving (SVSP) distal pancreatectomy has been recommended to reduce long-term risk of developing infectious complications. Due to its technical challenge, most cases relate to <50% of the pancreatic gland being excised. We present our first case of a patient incidentally found to have a solitary pancreatic metastatic renal cell carcinoma (RCC), following left nephrectomy for kidney cancer 15 years ago. He underwent laparoscopic SVSP-extended distal pancreatectomy (EDP). Final histopathology confirmed the diagnosis and margins were clear. He made a good recovery and despite loosing >70% of his pancreas, hasn’t developed new-onset diabetes. No adjuvant chemotherapy was necessary, but he will require long-term follow-up. This case suggests that even when the pancreatic lesion is located more proximally, near or at the pancreatic neck, laparoscopic SVSP-EDP may still be considered a safe and preferable option despite its greater complexity, increased intraoperative bleeding risk and longer operative time.

Splenic vessel preservation versus splenic vessel resection in laparoscopic spleen-preserving distal pancreatectomy

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy for low-grade malignant pancreas tumours was recently demonstrated and can be performed with splenic vessel preservation (SVP) or splenic vessel resection (SVR). Whether one approach is superior to another is still a matter of debate.

METHODS

A systematic literature search (PubMed, Embase, Science Citation Index, Springer-Link and Cochrane Central Register of Controlled Trials) was performed. Pooled intra- and post-operative outcomes were evaluated. Stratified and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of the study qualities.

RESULTS

A total of six studies were included. There was no significant difference for SVR and SVP in terms of overall post-operative complications and the pooled odds ratio (OR) was 0.87 (95% confidence interval (CI) 0.55-1.38, I² = 25%). Meta-analysis on the pooled outcome of intraoperative operative time and blood loss favoured SVR; the mean differences were 18.64 min (95% CI 6.91-30.37 min, I² = 21%) and 65.67 mL (95% CI 18.88-112.45 mL, I² = 48%), respectively. Subgroup analysis showed a decrease incidences in perigastric varices (OR = 0.07, 95% CI 0.03-0.18, I² = 29%) and splenic infarction (OR = 0.16, 95% CI 0.08-0.32, I² = 0%) in SVP.

CONCLUSION

For selected patients who underwent laparoscopic spleen-preserving distal pancreatectomy, an increased preference for the SVP technique should be suggested considering its short-term benefits. However, in case of large tumours that distort and compress vessel course, SVR could be applied with acceptable splenic ischaemia and perigastric varices.

Lateral approach in laparoscopic distal pancreatectomy is safe and potentially beneficial compared to the traditional medial approach

INTRODUCTION

Laparoscopic distal pancreatectomy has become widely accepted for the treatment of left-sided pancreatic lesions. Traditionally, a medial laparoscopic distal pancreatectomy (MDLP) has been employed, with division of the gland followed by medial to lateral mobilization. Recent technical reports of lateral laparoscopic distal pancreatectomy (LLDP) suggest that it offers easier access and more precise dissection. Data on this technique remain sparse and inconclusive, with no formal comparison with MLDP. We sought to compare outcomes of LLDP to MLDP.

METHODS

We reviewed the charts of patients undergoing laparoscopic distal pancreatectomy at two academic institutions, from July 2009 to June 2013. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of sacrificed pancreas parenchyma, margins status, 30-day major morbidity (Clavien grade 3-5 complications), and length of stay. We reported data as proportions and medians. We performed comparative analysis using Chi square test or Fisher's exact test for categorical variables, and Mann-Whitney U test for continuous variables.

RESULTS

We retrieved 43 cases (19 LLDP, 24 MLDP). Median operative time was shorter (166 vs 190 min; p = 0.03) and estimated blood loss lower (50 vs 250 mL; p < 0.01) with LLDP. No margin was positive with LLDP compared to 2 (8.3%) with MLDP. Major morbidity did not differ (LLDP 21.0% vs MLDP 25.0%; p = 0.76). Trends toward lower conversion rate (16.7 vs 5.3%; p = 0.36) and shorter length of stay (5 vs 4 days; p = 0.35) were not significant.

CONCLUSION

LLDP is a feasible and safe approach for distal lesions of the pancreatic tail, associated with shorter operative time and decreased blood loss compared to traditional MLDP. Potential of decreased conversion rate and length of stay exists. These hypotheses need to be confirmed in larger prospective studies.

Lateral approach in laparoscopic distal pancreatectomy is safe and potentially beneficial compared to the traditional medial approach

INTRODUCTION

Laparoscopic distal pancreatectomy has become widely accepted for the treatment of left-sided pancreatic lesions. Traditionally, a medial laparoscopic distal pancreatectomy (MDLP) has been employed, with division of the gland followed by medial to lateral mobilization. Recent technical reports of lateral laparoscopic distal pancreatectomy (LLDP) suggest that it offers easier access and more precise dissection. Data on this technique remain sparse and inconclusive, with no formal comparison with MLDP. We sought to compare outcomes of LLDP to MLDP.

METHODS

We reviewed the charts of patients undergoing laparoscopic distal pancreatectomy at two academic institutions, from July 2009 to June 2013. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of sacrificed pancreas parenchyma, margins status, 30-day major morbidity (Clavien grade 3-5 complications), and length of stay. We reported data as proportions and medians. We performed comparative analysis using Chi square test or Fisher's exact test for categorical variables, and Mann-Whitney U test for continuous variables.

RESULTS

We retrieved 43 cases (19 LLDP, 24 MLDP). Median operative time was shorter (166 vs 190 min; p = 0.03) and estimated blood loss lower (50 vs 250 mL; p < 0.01) with LLDP. No margin was positive with LLDP compared to 2 (8.3%) with MLDP. Major morbidity did not differ (LLDP 21.0% vs MLDP 25.0%; p = 0.76). Trends toward lower conversion rate (16.7 vs 5.3%; p = 0.36) and shorter length of stay (5 vs 4 days; p = 0.35) were not significant.

CONCLUSION

LLDP is a feasible and safe approach for distal lesions of the pancreatic tail, associated with shorter operative time and decreased blood loss compared to traditional MLDP. Potential of decreased conversion rate and length of stay exists. These hypotheses need to be confirmed in larger prospective studies.

Laparoscopic spleen-preserving distal pancreatectomy in elderly subjects: splenic vessel sacrifice may be associated with a higher rate of splenic infarction

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy has gained popularity in recent years. Splenic preservation can be achieved with or without splenic vessel preservation (SVP). The potential morbidity of this approach in patients aged >70 years has not been well defined.

METHODS

Ten patients aged >70 years underwent attempted laparoscopic spleen-preserving distal pancreatectomy within a 2-year period. Multiple patient parameters were examined and chi-squared analysis was used to evaluate the association between the operative technique (SVP or splenic vessel division [SVD]) and splenic infarction. The Mann-Whitney test was used to compare the SVP and SVD groups with regard to age, estimated blood loss (EBL), operating time, splenic volume and length of stay (LoS).

RESULTS

Median age was 81 years (range: 71-92 years). Operating room time, LoS, EBL and complication rates were similar to those reported in published series of younger patients. In four patients, the splenic vessels were divided in a manner relying on short gastric collateral flow; SVP was achieved in all other patients. All four patients who underwent SVD developed splenic infarcts and three required splenectomy to manage this (P=0.002). Median LoS was increased in the SVD group (9.3 days vs. 4.3 days; P=0.053). Estimated blood loss was higher in the SVP group (200 ml vs. 100 ml; P=0.091). One pancreatic leak occurred. There were no mortalities.

CONCLUSIONS

Spleen-preserving laparoscopic distal pancreatectomy can be performed safely in elderly patients, with results comparable with those achieved in younger subjects. However, elderly patients undergoing division of the splenic artery and vein may be at higher risk for splenic infarct and the aetiology of this is unclear.

Lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy

AIM

We sought to evaluate the feasibility of the lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy (LA-SVPDP).

BACKGROUND

Complete preservation of the splenic vessels is an ideal outcome in spleen-preserving distal pancreatectomy (SPDP). However, the preservation of the vessels is challenging in laparoscopic surgery because the splenic vein is often embedded in the pancreatic parenchyma. Herein we have described LA-SVPDP, the most feasible method for laparoscopic SPDP, and the outcome of our initial experience.

PATIENTS

Twenty-three patients underwent laparoscopic SPDP. Before we adopted LA-SVPDP, 8 patients underwent the Warshaw method and 6 underwent SVPDP. After the adoption of LA-SVPDP, 8 patients underwent LA-SVPDP and 1 donor underwent the Warshaw method.

RESULTS

None of patients undergoing LA-SVPDP required conversion to an open operation, whereas 2 patients undergoing the other procedures were converted to open operations. Five out of 8 patients who underwent the Warshaw method showed engorgement of the gastric veins, revealed by computed tomography. However, only 1 of the 5 patients showed mild gastric varices on endoscopy.

CONCLUSION

Although the Warshaw method is acceptable with a low incidence of gastric varices in our analysis, SVPDP is a feasible approach for SPDP. Our LA-SVPDP technique may contribute to safer and easier SVPDP in laparoscopic surgery.