Laparoscopic pancreatectomy: Indications and outcomes

Laparoscopic resection of pancreatic masses in 12 dogs

OBJECTIVE

To describe the surgical management and outcome of dogs undergoing laparoscopic pancreatic mass resection (LPMR).

STUDY DESIGN

Retrospective study.

ANIMALS

Twelve client-owned dogs.

METHODS

Data collected from medical records of dogs that underwent LPMR between 2012 and 2023 included signalment, clinical signs, mass location within pancreas, preoperative diagnostic imaging, laparoscopic approach, number of portals and device type used for LPMR, operating time, complications and clinical outcome.

RESULTS

Pancreatic tumors were located in the left lobe (7), in the right lobe (4) and in the body of the pancreas (1). A 3- or 4-port technique was used in nine and three dogs, respectively. LPMR was performed with the Ligasure in nine dogs, a harmonic scalpel in two dogs and an endoscopic stapler in one dog. The procedure was performed successfully, with no conversion to open laparotomy, in all cases with a median operating time of 69 min. Postoperative complications occurred in four dogs, which resolved with medical treatments. All dogs survived the surgical procedure, were discharged from the hospital and alive a minimum of 90 days postoperatively. The final follow-up time ranged between 105 and 245 days (median 147). Histopathological diagnosis included insulinoma (9) and pancreatic carcinoma (3).

CONCLUSION

LPMR was performed successfully using a 3- or 4-port technique and was associated with a low complication rate and a good clinical outcome.

CLINICAL SIGNIFICANCE

LPMR may be considered as an alternative to open celiotomy in dogs, particularly for small tumors located in the distal aspect of the pancreatic lobes.

Impact of conversion at time of minimally invasive pancreaticoduodenectomy on perioperative and long-term outcomes: Review of the National Cancer Database

Backgrounds/Aims

Current literature presents limited data regarding outcomes following conversion at the time of minimally invasive pancreaticoduodenectomy (MI-PD).

Methods

The National Cancer Database was queried for patients who underwent pancreaticoduodenectomy. Patients were stratified into three groups: MI-PD, converted to open pancreaticoduodenectomy (CO-PD), and open pancreaticoduodenectomy (O-PD). Multivariable modeling was applied to compare outcomes of MI-PD and CO-PD to those of O-PD.

Results

Of 17,570 patients identified, 12.5%, 4.2%, and 83.4% underwent MI-PD, CO-PD, and O-PD, respectively. Robotic pancreaticoduodenectomy (R-PD) resulted in a higher lymph node yield (n = 23.2 ± 12.2) even when requiring conversion (n = 22.4 ± 13.2, p < 0.001). Margin positivity was higher in the CO-PD group (26.6%) than in the MI-PD group (21.3%) and the O-PD (22.6%) group (p = 0.017). Length of stay was shorter in the MI-PD group (laparoscopic pancreaticoduodenectomy 10.4 ± 8.6, R-PD 10.6 ± 8.8) and the robotic converted to open group (10.7 ± 6.4) than in the laparoscopic converted to open group (11.2 ± 9) and the O-PD group (11.5 ± 8.9) (p < 0.001). After adjusting for patient and tumor characteristics, both MI-PD (odds ratio = 1.40; p < 0.001) and CO-PD (odds ratio = 1.24; p = 0.020) were significantly associated with an increased likelihood of long-term survival.

Conclusions

CO-PD does not negatively impact perioperative or oncologic outcomes.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy

Because distal pancreatectomy (DP) has no reconstructive steps and less frequent vascular involvement, it is thought to be the easier counterpart of pancreaticoduodenectomy. This procedure has a high surgical risk and the overall incidences of perioperative morbidity (mainly pancreatic fistula), and mortality are still high, in addition to the challenges that accompany delayed access to adjuvant therapies (if any) and prolonged impairment of daily activities. Moreover, surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes. From this perspective, new surgical approaches, and aggressive techniques, such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection, could lead to improved survival in those affected by more locally advanced tumors. Conversely, minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress. The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications, length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy. Because a dedicated multidisciplinary team is crucial to pancreatic surgery, hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign, borderline, and malignant diseases of the pancreas. The purpose of this review is to examine the state of the art in distal pancreatectomies, with a special focus on minimally invasive approaches and oncological-directed techniques. The widespread reproducibility, cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

Effect of Operative Time on Outcomes of Minimally Invasive Versus Open Pancreatoduodenectomy

OBJECTIVE

To evaluate how operative time interacts with outcomes among different approaches to pancreaticoduodenectomy (PD). Minimally invasive PDs (MIPD), which include laparoscopic (LPD) and robotic (RPD) approaches, are increasingly performed in the USA. MIPD are generally associated with longer operative times (OT) compared to open PD (OPD). Increased OT is associated with inferior outcomes for OPD; however, the effect of OT on MIPD is not well understood.

METHODS

National Surgical Quality Improvement Program (NSQIP)-targeted pancreatectomy dataset was utilized (2014-2019). Propensity score matching, logistic regression, and mixed effect modeling were performed to determine the effect of OT on outcomes following PD. OTs were stratified by quartiles for each approach, and outcomes were subsequently compared.

RESULTS

Among 23,988 PDs, 22,185 were OPD and 1803 MIPD. Increased OT was associated with greater overall morbidity in all approaches. When comparing OT quartiles, MIPD was consistently associated with improved overall morbidity compared to OPD in matched cohorts. However, for upper quartiles, prolonged OT in MIPD was associated with significantly increased reoperation rates and mortality. The effect of OT on overall morbidity and other outcomes was comparable among LPD and RPD.

CONCLUSIONS

In this study, increased OT was associated with incremental increases in overall morbidity after PD, irrespective of approach. While MIPD was associated with improved overall morbidity compared to OPD when stratified by OT quartile, higher mortality rates were observed with prolonged OT only with MIPD. Those data suggest that MIPD is a safe alternative to OPD when OT is optimized. NSQIP was used to compare the effect of operative time (OT) on outcomes following pancreaticoduodenectomy (PD), stratified by approach. Increased OT was associated with inferior outcomes following open, laparoscopic, and robotic PD. Surgeons should attempt to optimize OT, regardless of the approach to PD.

An assessment of perioperative outcomes for open, laparoscopic, and robot-assisted pancreaticoduodenectomy in New York State

BACKGROUND

Minimally invasive techniques for pancreaticoduodenectomy (PD) are increasing in practice, however, data remains limited regarding perioperative outcomes. Our study sought to compare patients undergoing open pancreaticoduodenectomy (OPD) with those undergoing laparoscopic (LPD) or robot-assisted pancreaticoduodenectomy (RPD).

METHODS

Patients who underwent PD during 2016-2018 were identified from the New York State Planning and Research Cooperative System database.

RESULTS

Of the 1954 patients identified, 1708 (87.4%) underwent OPD, 165 (8.4%) underwent LPD, and 81 (4.2%) underwent RPD. The majority of patients were White (63.8%), males (53.3%) with a mean age of 65.4 years. RPD patients had a lower median Charlson Comorbidity Index (2) than OPD (3) or LPD (3, p = 0.01) and had a lower 30-day rate of complications (35.8% vs. 48.3% vs. 43.6% respectively, p = 0.05). After propensity-score matching, however, there were no differences between the groups regarding overall complications, surgical site infections, anastomotic leaks, or mortality (p = NS for all). OPD demonstrated a longer length of stay (median 8 days) compared to LPD (7 days) or RPD (7 days, p < 0.01).

CONCLUSIONS

Patients undergoing LPD and RPD have a shorter length of hospital stay compared to OPD and there was no difference in overall morbidity or mortality when matched to similar patients.

Comparison of robotic and open pancreaticoduodenectomy for primary nonampullary duodenal adenocarcinoma: a retrospective cohort study

PURPOSE

Robotic surgery has been increasingly applied in pancreatic surgery and showed many advantages over conventional open surgery. The robotic pancreaticoduodenectomy (RPD) is a surgical option for primary nonampullary duodenal adenocarcinoma (PNDA). However, whether RPD is superior to open pancreaticoduodenectomy (OPD) for PNDA has not been reported. The comparative study was designed to analyze the short- and long-term outcomes of RPD versus OPD on patients with PNDA.

METHODS

Demographics, perioperative, and survival outcomes among patients who underwent RPD (n = 49) versus OPD (n = 43) for PNDAs between January 2013 and March 2018 were collected and analyzed RESULTS: Demographic characteristics were comparable between the RPD group and the OPD group. The RPD group demonstrated a decreased estimated blood loss (100 vs. 200 ml, p < 0.001), time to oral intake (4.0 vs. 4.0 days, p = 0.04), and postoperative hospital stay (12.9 vs. 15.0 days, p = 0.01) compared with the OPD group. However, no differences were observed between the two groups in terms of operative time and the rates of major complications, grade B and C POPF, PPH, grade B and C DGE, biliary fistular, reoperation, and 90-day readmission. No patient died within 90 days. There were no significant differences in tumor size, differentiation, TNM stage, number of harvested lymph nodes, and the rates of nerve invasion, lymph node invasion, R0 resection, and the median overall survival between the two groups (p > 0.05) CONCLUSIONS: RPD is a safe, feasible, and effective treatment for PNDA compared with OPD and can be used as an alternative for surgeons in the treatment of PNDA. Further multicenter randomized controlled trials are needed to evaluate the effectiveness of RPD in patients with PNDA.

Registrar performance in minimally invasive distal pancreatectomy and effects on postoperative outcomes

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is nowadays an established standard procedure for non-locally advanced pancreatic lesions without celio-mesenteric vascular invasion. However, little is known about how the involvement of junior surgeons in MIDP affects postoperative outcomes. We performed a retrospective case series study in order to determine whether registrar involvement in MIDP is associated with adverse outcomes.

METHODS

Data were analyzed from a prospectively created database of consecutive patients undergoing MIDP. Only data from 91 patients who underwent MIDP for non-PDAC lesions were included. Patients were divided in 3 groups: Consultant P1 (first 20 MIDP, n=20), Consultant P2 (after 20 MIDP, n=44), and Registrar group (n=27). Conversion rates and 90-day postoperative outcomes were compared.

RESULTS

Conversion rates were 5%, 0%, and 14% in Consultant P1 and P2 and Registrar groups, respectively (P1 vs. P2, p = 0.312 and P1 vs. Registrar, p=0.376). Only Comprehensive Complication Index was higher in Registrar group compared to Consultant P1 group (13 vs. 3.7; p = 0.041). Comparison between Consultant P2 and Registrar groups resulted in a significant higher conversion rate (0 vs. 14%, p = 0.029), increased blood loss (77 vs. 263 ml, p = 0.018), and longer surgery duration (156 vs. 212 min, p=0.001) for registrars MIDP. However, no differences were found in clinically relevant postoperative pancreatic fistula (CR-POPF) (16 vs. 7.5%, p=0.282), Clavien-Dindo severe complication ≥3 score (11 vs. 4%, p=0.396), or length of hospital stay (9 vs. 9 days; p=0.614) between the consultant and registrar cohorts.

CONCLUSIONS

With all the limitations of a retrospective study with a small sample size, junior surgeons' involvement in MIDP for non-PDAC lesions resulted in higher conversion rate, blood loss and duration of surgery without statistically significant difference on clinical outcomes compared to a consultant.

The Landmark Series: Minimally Invasive Pancreatic Resection

BACKGROUND

Pancreatic resections are among the most technically demanding procedures, including a high risk of potentially life-threatening complications and outcomes strongly correlated to hospital volume and individual surgeon experience. Minimally invasive pancreatic resections (MIPRs) have become a part of standard surgical practice worldwide over the last decade; however, in comparison with other surgical procedures, the implementation of minimally invasive approaches into clinical practice has been rather slow.

OBJECTIVE

The aim of this study was to highlight and summarize the available randomized controlled trials (RCTs) evaluating the role of minimally invasive approaches in pancreatic surgery.

METHODS

A WHO trial registry and Pubmed database literature search was performed to identify all RCTs comparing MIPRs (robot-assisted and/or laparoscopic distal pancreatectomy [DP] or pancreatoduodenectomy [PD]) with open pancreatic resections (OPRs).

RESULTS

Overall, five RCTs on MIPR versus OPR have been published and seven RCTs are currently recruiting. For DP, the results of two RCTs were in favor of minimally invasive distal pancreatectomy (MIDP) in terms of shorter hospital stay and less intraoperative blood loss, with comparable morbidity and mortality. Regarding PD, two RCTs showed similar advantages for MIPD. However, concerns were raised after the early termination of the third multicenter RCT on MIPD versus open PD due to higher complication-related mortality in the laparoscopic group and no clear other demonstrable advantages. No RCTs on robot-assisted pancreatic procedures are available as yet.

CONCLUSION

At the current level of evidence, MIDP is thought to be safe and feasible, although oncological safety should be further evaluated. Based on the results of the RCTs conducted for PD, MIPD cannot be proclaimed as the superior alternative to open PD, although promising outcomes have been demonstrated by experienced centers. Future studies should provide answers to the role of robotic approaches in pancreatic surgery and aim to identity the subgroups of patients or indications with the greatest benefit of MIPRs.

Minimally invasive pancreatic surgery—will robotic surgery be the future?

Due to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.

A novel hydrogel sheet prevents postoperative pancreatic fistula in a rat model

Aim

To evaluate the efficacy of a novel hydrogel sheet in preventing postoperative pancreatic fistula (POPF).

Background

Postoperative pancreatic fistula is a life‐threatening complication. As no study has reported the use of hydrogel sheets in preventing POPF, their effectiveness for that purpose remains unclear.

Methods

A novel hydrogel sheet made of polyvinyl alcohol (PVA) was prepared by the freeze‐thaw method. The pancreatic ducts and surrounding pancreatic parenchyma of rats were transected to induce a pancreatic fistula. Next, the sheet was attached to the transection site. Ascitic fluid amylase and lipase concentrations were measured. Neoveil^®, a nonwoven polyglycolic acid (PGA) felt, is already clinically used as an absorbable reinforcing material at pancreatic transection sites. Neoveil^® was used for comparison, as was VIEWGEL^®, which is marketed as a wound dressing.

Results

The hydrogel sheet remained in place 48 hours postoperatively. The ascitic amylase concentrations in the control, VIEWGEL^®‐treated, Neoveil^®‐treated, and hydrogel‐treated rats, respectively, were 4992.4 ± 5355.7, 1068.4 ± 269.1, 730.2 ± 425.2, and 303.1 ± 240.1 IU/L; the ascitic lipase concentrations were 2279.8 ± 3395.2, 169.5 ± 100.6, 90.4 ± 71.0, and 86.8 ± 59.8 IU/L. The ascitic amylase and lipase levels were significantly lower in the hydrogel group than in the other groups (P < .05).

Conclusions

This novel hydrogel sheet effectively prevents pancreatic fistulas and has promising clinical application potential.

Application of artificial intelligence for the diagnosis, treatment, and prognosis of pancreatic cancer

Pancreatic cancer is a complex cancer of the digestive tract. Diagnosis and treatment can be very difficult because of unclear early symptoms, the deep anatomical location of cancer tissues, and the high degree of cancer cell invasion. The prognosis is extremely poor; the 5-year survival rate of patients with pancreatic cancer is less than 1%. Artificial intelligence (AI) has great potential for application in the medical field. In addition to AI-based applications, such as disease data processing, imaging, and pathological image recognition, robotic surgery has revolutionized surgical procedures. To better understand the current role of AI in pancreatic cancer and predict future development trends, this article comprehensively reports the application of AI to the diagnosis, treatment, and prognosis of pancreatic cancer.

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH OR WITHOUT SPLEEN PRESERVATION: COMPARATIVE ANALYSIS OF SHORT AND LONG-TERM OUTCOMES

Background:

Laparoscopic distal pancreatectomy (LDP) is the preferred approach for resection of tumors in the distal pancreas because of its many advantages over the open approach.

Aim:

To analyse and compare short and long-term outcomes from LDP performed through two different techniques: with splenectomy vs. spleen preservation and splenic vessel preservation.

Method:

Fifty-eight patients were operated and subsequently divided between two groups: Group 1, LDP with splenectomy (LDPS); and Group 2, LDP with spleen preservation and preservation of splenic vessels (LDPSPPSV).

Results:

The epidemiological characteristics were statistically similar between the two groups (age, gender, BMI and lesion size). Both the mean of operative time (p=0.04) and the mean of intra-operative blood loss (p=0,03) were higher in Group 1. The mean of resected lymph nodes was also higher in Group 1 (p<0.000). There were no statistic differences between the groups in relation to open conversion, morbidity or early postoperative mortality. The mean hospital stay was similar between groups. Pancreatic fistula (grade B and C) was similar between the groups. The mean of overall follow-up was 37.6 months (5-96). Late complications were similar between the groups.

Conclusion:

Both techniques were superimposable; however, LDPS presented, respectively, higher intra-operative bleeding, longer duration of the operation and higher number of lymph nodes resected. No differences were observed in the studied period in relation to the appearance of infections or neoplasm related to splenectomy during follow-up. Maintenance of the spleen avoided periodic immunizations in patients in LDPSPSV. It is indicated in small pancreatic lesions with indolent course.

Stepwise implementation of laparoscopic pancreatic surgery. Case series of a single centre's experience

BACKGROUND

Laparoscopic pancreatic surgery still represents a challenge for surgeons. However, in recent decades the experience is expanding. Recent systematic reviews and meta-analyses confirm that laparoscopic pancreatic resection (LPR) is safe, feasible and worthwhile. This study analyses the first 100 consecutive LPRs in our centre.

METHODS

A retrospective analysis was conducted of the first 100 LPRs in a single supra-regional Belgian centre, performed between January 2012 and January 2019. Pre-, peri- and postoperative data were retrieved from a prospectively maintained database. All procedures were performed laparoscopically by two attending surgeons, specialized in minimally invasive and hepatopancreatobiliary surgery.

RESULTS

Of 100 procedures, 62 laparoscopic pancreatoduodenectomies (LPD) and 36 laparoscopic distal pancreatectomies (LDP) were performed, along with 1 enucleation and 1 central pancreatectomy. Indication was malignancy in 70%. Conversion rate was 24,2% in LPD and 11% in LDP. Median operative time was 330 min (IQR 300-360) in LPD and 150 min (IQR 142.5-210) in LDP. Median blood loss was 200 mL (IQR 100-487.5) in LPD and 150 mL (IQR 50-500) in LDP, transfusion rate was 22.6% and 8.3% respectively. Median length of stay (LOS) was 13 days (IQR 10-19.25) in LPD and 9 days (IQR 9-14) in LDP. R0 resection rate was 88.6% (62/70). Major complication rate (Clavien-Dindo grade III-IV) was 12%. Thirty-day mortality was 0%, 90-day mortality was 2%.

CONCLUSION

Our results confirm that LPR is a feasible and safe alternative to open pancreatic surgery. Safe implementation with a clear strategy is fundamental to gain experience and overcome the learning curve of this technically demanding procedures.

Pre- and intraoperative diagnostic requirements, benefits and risks of minimally invasive and robotic surgery for neuroendocrine tumors of the pancreas

Pancreatic neuroendocrine tumours (PanNET) are rare tumours, accounting for 1%-2% of all pancreatic neoplasms. These tumors are classified as functioning neuroendocrine tumours (F-PanNETs) or non-functioning (NF-PanNETs) depends on whether the tumour is associated with clinical hormonal hypersecretion syndrome or not. In the last decades, diagnosis of PanNETs has increased significantly due to the widespread of cross-sectional imaging. Whenever possible, surgery is the cornerstone of PanNETs management and the only curative option for these patients. Indeed, after R0 resection, the 5-year overall survival rate is around 90-100% for low grade lesions but significantly drops after incomplete resections. Compared to standard resections, pancreatic sparing surgery, i.e. enucleation and central pancreatectomy, significantly decreased the risk of pancreatic insufficiency. It should be performed in patients with good general condition and normal pancreatic function to limit the operative risk and enhance the benefit of surgery. Nowadays, due to many known advantages of minimally invasive surgery, there is an ongoing trend towards laparoscopic and robotic pancreatic surgery. The aim of this study is to describe the pre- and intraoperative diagnostic requirements for the management of PanNETs and the benefits and risks of minimally invasive surgery including laparoscopic and robotic approach in view of the recent literature.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Robotic and laparoscopic surgery of the pancreas: an historical review

Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas including distal pancreatectomy and pancreatoduodenectomy. The progression from open surgery to laparoscopy to robotic surgery has occurred for many operations including adrenalectomy, thyroidectomy, colon resection, prostatectomy, gastrectomy and others. Data to show a benefit to the patient are scarce for robotic surgery, although both laparoscopic and robotic surgery of the pancreas have been shown not to be inferior with regard to major operative and oncologic outcomes. While there were serious concerns when laparoscopy was first used in patients with malignancies, robotic surgery has been used in many benign and malignant conditions with no obvious deterioration of outcomes. Robotic surgery for malignancies of the pancreas is well accepted and expanding to more centers. The importance of centers of excellence, surgeon experience supported by a codified mastery-based training program and international registries is widely accepted. Robotic pancreatic surgery is associated with slightly decreased blood loss and decreased length of stay compared to open surgery. Major oncologic outcomes appear to have been preserved, with some studies showing higher rates of R0 resection and tumor-free margins. Patients with lesions of the pancreas should find a surgeon they trust and do not need to be concerned with the operative approach used for their resection. The step-wise approach that has characterized the growth in robotic surgery of the pancreas, in contradistinction to the frenzy that accompanied the introduction of laparoscopic cholecystectomy, has allowed the identification of areas for improvement, many of which lie at the junction of engineering and medical practice. Refinements in robotic surgery depend on a partnership between engineers and clinicians.

The treatment indication and optimal management of fluid collection after laparoscopic distal pancreatectomy

BACKGROUND

Recently, laparoscopic distal pancreatectomy (LDP) has become the standard procedure for resection of left-sided pancreatic tumors. Fluid collection (FC) at the resection margin of the pancreatic stump after LDP is a frequent radiological finding. However, there have been few treatment guidelines and the optimal management for this clinical finding is unclear. The aim of present study is to define the incidence of FC and suggest the optimal management for FC after LDP.

METHODS

A total of 1227 patients who underwent LDP between March 2005 and December 2015 were collected. FC was considered present when the longest diameter of the lesion on CT scan was > 3 cm.

RESULTS

A follow-up with at least two CT image was available for 1102 patients. Of these, 689 (62.5%) patients showed initial fluid collection (IFC) at the pancreas resection site in immediate postoperative CT. IFC (+) group had higher proportion of men, BMI, and higher rate of concomitant splenectomy than IFC (-) group. Among patients with FC after LDP, the treatment group had more frequent leukocytosis and accompanying symptoms than the observation group. Seventy-seven patients underwent therapeutic interventions for FC after LDP. Among them, 55 (71.4%) patients underwent endoscopic ultrasonography-guided gastrocystostomy (EUS-GC). EUS-GC group had a higher success rate (85.6 vs. 63.6%, p < 0.033) and shorter hospital stay after the intervention (5.2 vs. 13.3 days, p < 0.001) than those who underwent other procedures.

CONCLUSIONS

High BMI, male, and concomitant splenectomy contribute to the occurrence of FC after LDP. In most cases, FC after LDP resolved spontaneously over time with observation. The patients with symptomatic FC ultimately required treatment. EUS-GC is the optimal intervention therapy for FC after LDP.

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH SPLEEN PRESERVATION

Background:

Laparoscopic distal pancreatectomy has been the choice for resection of distal pancreas lesions due many advantages over open approach. Spleen preservation technique seems minimizes infectious complications in long-term outcome.

Aim:

To present the results of laparoscopic distal pancreatectomies with spleen preservation by Kimura´s technique (preservation of spleen blood vessels) performed by single surgical team.

Methods:

Retrospective case series aiming to evaluate both short and long-term outcomes of laparoscopic distal pancreatectomies with spleen preservation.

Results:

A total of 54 laparoscopic distal pancreatectomies were performed, in which 26 were laparoscopic distal pancreatectomies with spleen preservation by Kimura´s technique. Mean age was 47.9 years-old (21-75) where 61.5% were female. Mean BMI was 28.5 kg/m² (18-38.8). Mean diameter of lesion was 4.3 cm (1.8-7.5). Mean operative time was 144.1 min (90-200). Intraoperative bleeding was 119.2 ml (50-600). Conversion to laparotomy 3% (n=1). Postoperative morbidity was 11.5%. Postoperative mortality was null. Mean of hospital stay was 4.8 days (2-14). Mean time of follow-up period was 19.7 months (2-60). There was no neoplasm recurrence or mortality on evaluated period. There was no infectious complication.

Conclusion:

Laparoscopic distal pancreatectomy with spleen and splenic vessels preservation is feasible, safe, and effective procedure. This technique presented both low morbidity and null mortality on this sample. There were neither infectious complications nor neoplasm recurrence on long-term follow-up period.

Laparoscopic pancreatic resections in two medium-sized medical centres

To analyze the clinical outcomes of patients undergoing minimally invasive surgery for pancreatic neoplasms, in two medium-volume centers in Northern Italy, a retrospective chart review was performed in the operative registries, searching for patients who had undergone pancreatic surgery via laparoscopy, irrespective of the final pathological nature of the resected neoplasm. For each case, a standard data extraction form was completed and the following data was extracted: age and sex, type of resection, estimated blood loss, length of the operation, number of harvested nodes, post-operative pancreatic fistula, major post-operative complications, mortality and final pathological diagnosis. The systematic literature research was also undertaken and the reported results were analyzed. A total of 55 cases were recorded, including 39 distal pancreatectomies and 16 pancreaticoduodenectomies. The most frequent indications leading to surgery were ductal adenocarcinoma (26 pts) and cystic neoplasm (22 pts). No post-operative death occurred in this series; pancreatic fistula occurred in 64% of distal pancreatectomies and 22% of pancreaticoduodenectomies. The mean operating times were 178' and 572', respectively. Both distal pancreatectomy and pancreaticoduodenectomy proved to be feasible and were safely performed by laparoscopy, in two centers with medium-volume pancreatic caseload.

A Modified Technique for Laparoscopic Spleen Preserving Distal Pancreatectomy

Spleen preserving laparoscopic distal pancreatectomy is considered as first choice operation for symptomatic benign or small malignant lesions located at the body or tail of the pancreas. The two main surgical techniques that have been proposed and widely adopted for spleen preserving laparoscopic distal pancreatectomy are the Warshaw and Kimura techniques. A novel modified approach for laparoscopic spleen preserving distal pancreatectomy is presented. The technique was initially performed in a 57-year-old female patient with mucinous cystadenoma. Following the surgical planes created by the fascia fusion and the organ rotation during embryogenesis (fascia of Toldt and renal fascia) with the patient in a right lateral decibutus position, the tumor was accessed retroperitoneally, without dividing the gastrocolic ligament and entering the lesser sac. The tail of the pancreas was mobilized anteriorly and medially, the lesion was visually identified and resected, and short gastric and left gastroepiploic vessels were preserved. We present the technical details and tips; we define the surgical anatomy of it and discuss the perioperative course of the patient as well as the possible benefits of the proposed technique. The proposed technique seems to be safe, easy to perform, and may present a promising alternative approach for patients with pancreatic disease that can be treated by laparoscopic pancreatectomy.

Pancreatic solid serous cystadenoma treated by laparoscopy: Presentation of a new case report and review of the literature

•

Solid-type serous cystadenoma of the pancreas is pauci-symptomatic.

•

Preoperative diagnosis is often misdiagnosis with other solid pancreatic tumors.

•

Laparoscopic resection is feasible for treatment with good prognosis.

Solid serous cystadenoma is an uncommon benign pancreatic tumor, with only, including this case, 21 cases published so far. It is often misdiagnosis with other malignant pancreatic tumors.

Below we report a new case of a solid serous cystadenoma of the pancreas treated by laparoscopic distal pancreatectomy in 53-year-old female who presented with epigastric pain. Histological and immunohistochemical examination revealed a solid serous cystadenoma of the pancreas. Preoperative diagnosis of this subtype of serous cystadenoma is difficult, and, due to its benign nature, conservative resection of the tumor is the recommended treatment.

After analyzing the literature, including this case from our department, we discuss clinical presentation, imaging characteristics and histopathological findings, considering in particular difficulties in preoperative diagnosis, feasibility of laparoscopic resection.

Minimally Invasive Surgical Approaches for Pancreatic Adenocarcinoma: Recent Trends

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.

Robotic Pancreaticoduodenectomy: Operative Steps (With Video)

Robotic pancreaticoduodenectomy represents actually an emerging procedure for robot-assisted surgery. Considering complexity, extensive dissection, and difficult restoration of the digestive continuity, it remains a challenge for surgeons. The embedded video (Supplemental Digital Content 1, http://links.lww.com/SLE/A146) reports our standardized technique for robotic pancreaticoduodenectomy. In conclusion, robotic pancreaticoduodenectomy is feasible and can be safely performed. Further evaluation with clinical trials is required to validate its real benefits.

Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference

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.

Laparoscopic versus open distal pancreatectomy-a propensity score-matched analysis from the German StuDoQ|Pancreas registry

PURPOSE

The aim of this study was to assess intraoperative, postoperative, and oncologic outcome in patients undergoing laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) for benign and malignant lesions of the pancreas.

METHODS

Data from patients undergoing distal pancreatic resection were extracted from the StuDoQ|Pancreas registry of the German Society for General and Visceral Surgery. After propensity score case matching, groups of LDP and ODP were compared regarding demography, comorbidities, operative details, histopathology, and perioperative outcome.

RESULTS

At the time of data extraction, the StuDoQ|Pancreas registry included over 3000 pancreatic resections from over 50 surgical departments in Germany. Data from 353 patients undergoing ODP (n = 254) or LDP (n = 99) from September 2013 to February 2016 at 29 institutions were included in the analysis. Baseline data showed a strong selection bias in LDP patients, which disappeared after 1:1 propensity score matching. A comparison of the matched groups disclosed a significantly longer operation time, higher rate of spleen preservation, more grade A pancreatic fistula, shorter hospital stay, and increased readmissions for LDP. In the small group of patients operated for pancreatic cancer, a lower lymph node yield with a lower lymph node ratio was apparent in LDP.

CONCLUSIONS

LDP needed more time but potential advantages include increased spleen preservation and shorter hospital stay, as well as a trend for less transfusion, ventilation, and mortality. LDP for pancreatic cancer was performed rarely and will need critical evaluation in the future. Data from a prospective randomized registry trial is needed to confirm these results.

Current status of laparoscopic pancreaticoduodenectomy and pancreatectomy

This review describes the recent advances in, and current status of, minimally invasive pancreatic surgery (MIPS). Typical MIPS procedures are laparoscopic pancreaticoduodenectomy (LPD), laparoscopic distal pancreatectomy (LDP), laparoscopic central pancreatectomy (LCP), and laparoscopic total pancreatectomy (LTP). Some retrospective studies comparing LPD or LDP and open procedures have demonstrated the safety and feasibility as well as the intraoperative outcomes and postoperative recovery of these procedures. In contrast, LCP and LTP have not been widely accepted as common laparoscopic procedures owing to their complicated reconstruction and limited indications. Nevertheless, our concise review reveals that LCP and LTP performed by expert laparoscopic surgeons can result in good short-term and long-term outcomes. Moreover, as surgeons' experience with laparoscopic techniques continues to grow around the world, new innovations and breakthroughs in MIPS will evolve. Well-designed and suitably powered randomized controlled trials of LPD, LDP, LCP, and LTP are now warranted to demonstrate the superiority of these procedures.

Robotic pancreatectomies

Pancreatic surgery represents one of the most challenging fields in general surgery. Its complexity is related to the severity of the disease and the technical skills required for surgical approach. Given this, most pancreatic resections are performed through classic open surgery. Minimally invasive approaches are gradually gaining widespread popularity also in this specific setting, as for distal resections and enucleations. The robotic platform, due to its 3-dimensional vision and articulated movements, represents the natural progress of laparoscopic surgery overcoming the technical defaults and opening up the possibility to perform major pancreatic resections as pancreaticoduodenectomies. This review focuses on the impact of robotic platform in pancreatic surgery in terms of surgical and oncological outcome.

Postoperative Omental Infarct After Distal Pancreatectomy: Appearance, Etiology Management, and Review of Literature

INTRODUCTION

The clinico-radiological characteristics and the natural history of postoperative omental infarct (OI) in patients who underwent distal pancreatectomy (DP) and splenectomy have not been defined.

MATERIALS AND METHODS

Twelve patients who underwent DP over a period of 2 years and were postoperatively diagnosed with OI based on computed tomography (CT) findings were identified.

RESULTS

A total of 12 patients were diagnosed with an OI based on their postoperative imaging. Seven (58.3 %) patients had previously undergone laparoscopic DP, one (8.3 %) had undergone a robotic DP, and in one (8.3 %), a laparoscopic DP was converted to an open procedure. The remaining three (25.1 %) were treated with open DP. In five (41.6 %) patients, the diagnosis of OI was made during routine follow-up. One patient underwent surgical resection of OI, and two had drains placed in the mass. Nine patients were managed conservatively. During the study period, on review of CT imaging, the minimum prevalence of postoperative OI after DP was found to be 22.8 %. A review of literature identified nine articles that reported a total of 34 patients who were diagnosed with OI after abdominal surgery.

CONCLUSION

The management of an asymptomatic postoperative OI should be conservative while an early invasive intervention should be performed in patients who are symptomatic or have infected OI.

Minimally invasive pancreatic surgery - a review

During the past 20 years the application of a minimally invasive approach to pancreatic surgery has progressively increased. Distal pancreatectomy is the most frequently performed procedure, because of the absence of a reconstructive phase. However, middle pancreatectomy and pancreatoduodenectomy have been demonstrated to be safe and feasible as well. Laparoscopic distal pancreatectomy is recognized as the gold standard treatment for small tumors of the pancreatic body-tail, with several advantages over the traditional open approach in terms of patient recovery. The surgical treatment of lesions of the pancreatic head via a minimally invasive approach is still limited to a few highly experienced surgeons, due to the very challenging resection and complex anastomoses. Middle pancreatectomy and enucleation are indicated for small and benign tumors and offer the maximum preservation of the parenchyma. The introduction of a robotic platform more than ten years ago increased the interest of many surgeons in minimally invasive treatment of pancreatic diseases. This new technology overcomes all the limitations of laparoscopic surgery, but actual benefits for the patients are still under investigation. The increased costs associated with robotic surgery are under debate too. This article presents the state of the art of minimally invasive pancreatic surgery.

Laparoscopic pancreatectomy: Did the indications change? A review from literature

Pancreatic Cancer (PC) is the fourth cause of death for tumors in Western countries. Symptoms are not specific, and can vary according to the tumor size and place. Diagnostic workup includes CA 19-9, CT and MRI. Surgery is the only treatment for PC, associated to radio-chemo therapy. Laparoscopic approaches are actually used for PC treatment in few specialized centers, and could be an alternative to laparotomic surgery. The aim of our study is to evaluate the efficacy of laparoscopy for PC treatment compared to laparotomy. We reviewed 19 articles in literature to assess the feasibility and efficacy of Laparoscopic Distal Pancreatectomy (LDP) and Laparoscopic Pancreaticoduodenectomy (LPD). The results have shown that LDP is nowadays a safe technique, and the outcomes are comparable to laparotomic surgery. Regarding to LPD instead, results are controversial and the data are still not sufficient to consider this technique as a valid alternative to laparotomic surgery.

Distal pancreatic resection for neuroendocrine tumors: is laparoscopic really better than open?

BACKGROUND

The latest studies on surgical and cost-analysis outcomes after laparoscopic distal pancreatectomy (LDP) highlight mixed and insufficient results. Whereas several investigators have compared surgical outcomes of LDP vs. open distal pancreatectomy (ODP) for adenocarcinomas, few similar studies have focused on pancreatic neuroendocrine tumors (PNETs).

METHODS

We reviewed the medical records of PNET patients undergoing distal pancreatectomy between 2004 and 2014. Patients were divided into LDP vs. ODP groups. Demographics, relevant comorbidities, oncologic variables, and cost-analysis data were assessed. Survival and Cox proportional hazards analyses were used to evaluate outcomes.

RESULTS

Of the 171 distal pancreatectomies for PNETs, 73 were laparoscopic, whereas 98 were open. Patients undergoing LDP demonstrated significantly lower rates of postoperative complications (P=0.028) and had significantly shorter hospital stays (P=0.008). On multivariable analysis, positive resection margins (P=0.046), G3 grade (P=0.036), advanced WHO classification (P=0.016), TNM stage (P=0.018), and readmission (P=0.019) were significantly associated with poor survival; however, method of resection (LDP vs. ODP) was not (P=0.254). The median total direct costs of LDP vs. ODP did not differ significantly.

CONCLUSIONS

In response to the recent considerable controversy surrounding the costs and surgical outcomes of LDP vs. ODP, our results show that LDP for PNETs is cost-neutral and significantly reduces postoperative morbidity without compromising oncologic outcomes and survival.

Distal pancreatic resection for neuroendocrine tumors: is laparoscopic really better than open?

BACKGROUND

The latest studies on surgical and cost-analysis outcomes after laparoscopic distal pancreatectomy (LDP) highlight mixed and insufficient results. Whereas several investigators have compared surgical outcomes of LDP vs. open distal pancreatectomy (ODP) for adenocarcinomas, few similar studies have focused on pancreatic neuroendocrine tumors (PNETs).

METHODS

We reviewed the medical records of PNET patients undergoing distal pancreatectomy between 2004 and 2014. Patients were divided into LDP vs. ODP groups. Demographics, relevant comorbidities, oncologic variables, and cost-analysis data were assessed. Survival and Cox proportional hazards analyses were used to evaluate outcomes.

RESULTS

Of the 171 distal pancreatectomies for PNETs, 73 were laparoscopic, whereas 98 were open. Patients undergoing LDP demonstrated significantly lower rates of postoperative complications (P=0.028) and had significantly shorter hospital stays (P=0.008). On multivariable analysis, positive resection margins (P=0.046), G3 grade (P=0.036), advanced WHO classification (P=0.016), TNM stage (P=0.018), and readmission (P=0.019) were significantly associated with poor survival; however, method of resection (LDP vs. ODP) was not (P=0.254). The median total direct costs of LDP vs. ODP did not differ significantly.

CONCLUSIONS

In response to the recent considerable controversy surrounding the costs and surgical outcomes of LDP vs. ODP, our results show that LDP for PNETs is cost-neutral and significantly reduces postoperative morbidity without compromising oncologic outcomes and survival.