Central pancreatectomy for benign or low-grade malignant pancreatic lesions - A single-center retrospective analysis of 116 cases

BackgroundCentral pancreatectomy (CP) is a parenchyma-sparing surgery for benign or low-grade malignant pancreatic tumors. This study aimed to evaluate the safety of the procedure and to analyze the long-term pancreatic function. The age-specific incidence ratio (IR) was calculated based on the incidence of diabetes mellitus in the general Italian population of Italy.Materials and methodsPatients submitted to CP from January 1990 to December 2017 at the Department of General and Pancreatic Surgery of the Pancreas Institute of Verona, Italy, were evaluated.ResultsThe final population was composed of 116 patients. There was a clear prevalence of females (74.1%), the mean age was 48 ± 15 years and the main indication for surgery was a pancreatic neuroendocrine tumor (45.7%). A pancreojejunal anastomosis was performed more frequently than a pancreogastric anastomosis (78.4% vs 11.6%). The mean length of stay was 20 ± 33 days.The overall abdominal complications rate was 62%. The frequency of clinically relevant postoperative pancreatic fistula (grades B and C) was 26.7%. The mortality rate was 0%. The rate of R1-resection was 0.8%, as was the recurrence rate. After a mean follow-up of 12.8 years ±6.5, 6 patients developed new-onset diabetes (NODM, 7.5%), and the IR was 1.36 (95%CI 0.49–2.96).ConclusionsCP is associated with high rates of abdominal complications, however, considering the amount of the normal pancreas that was spared, it might be indicated for selected benign or low-malignancy pancreatic tumors. CP patients have the same incidence of diabetes than the general population.     

Long term outcome after minimally invasive and open Warshaw and Kimura techniques for spleen-preserving distal pancreatectomy: International multicenter retrospective study

BackgroundThe Warshaw (WT) and the Kimura (KT) techniques are both used for open or minimally invasive (MI) spleen preserving distal pancreatectomy (SPDP). Multicenter studies on long-term outcome of WT and KT are lacking.MethodsMulticenter retrospective study with transversal follow-up moment, including patients who underwent SPDP from 2000 to 2017 at three high-volume centers in Italy and the Netherlands. Primary endpoint was the incidence of short and long term complications. Patients without regular follow-up were interviewed about symptoms and complications.ResultsIn total, 164 patients were enrolled, 55 WT (33.5%) and 109 kT (66.5%), of which 95 (57.9%) MI. There was no 30-day mortality (0%).The only significant difference in short-term outcome was more delayed gastric emptying (DGE) after WT (9.1% vs 1.8%, p = 0.043). MI-SPDP was associated with less blood loss (median 150 vs 250 ml, respectively, p < 0.001), less DGE (0% vs 10%, p = 0.002), less abdominal abscesses (8.4% vs 18.4%, p = 0.03) and less splenic infarctions (3.2% vs. 13%, p = 0.042), than open SPDP. Long-term follow-up (median 41 months) was available for 111 patients (67.7%) of whom 18 (16.2%) had an SPDP-related long-term sequela, mostly perigastric varices (n = 11, 9%) but without differences between WT and KT. Less long-term sequelae were reported after MI as compared to open SPDP (12.5% vs 21.2%, p = 0.032).ConclusionsIn this international retrospective study, the WT and KT had comparable short- and long-term outcomes. If a KT does not seem feasible during SPDP, a WT is recommended, rather than performing a splenectomy. MI-SPDP was associated with less short- and long term complications as compared to an open SPDP.     

Oncologic outcomes of minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: A systematic review and meta-analysis

In the absence of randomized trials, uncertainty regarding the oncologic efficacy of minimally invasive distal pancreatectomy (MIDP) remains. This systematic review aimed to compare oncologic outcomes after MIDP (laparoscopic or robot-assisted) and open distal pancreatectomy (ODP) in patients with pancreatic ductal adenocarcinoma (PDAC). Matched and non-matched studies were included. Pooled analyses were performed for pathology (e.g., microscopically radical (R0) resection and lymph node retrieval) and oncologic outcomes (e.g., overall survival). After screening 1760 studies, 21 studies with 11,246 patients were included. Overall survival (hazard ratio 0.86; 95% confidence interval (CI) 0.73 to 1.01; p = 0.06), R0 resection rate (odds ratio (OR) 1.24; 95%CI 0.97 to 1.58; p = 0.09) and use of adjuvant chemotherapy (OR 1.07; 95%CI 0.89 to 1.30; p = 0.46) were comparable for MIDP and ODP. The lymph node yield (weighted mean difference (WMD) −1.3 lymph nodes; 95%CI -2.46 to −0.15; p = 0.03) was lower after MIDP. Patients undergoing MIDP were more likely to have smaller tumors (WMD -0.46 cm; 95%CI -0.67 to −0.24; p < 0.001), less perineural (OR 0.48; 95%CI 0.33 to 0.70; p < 0.001) and less lymphovascular invasion (OR 0.53; 95%CI 0.38 to 0.74; p < 0.001) reflecting earlier staged disease as a result of treatment allocation bias. Based on these results we can conclude that in patients with PDAC, MIDP is associated with comparable survival, R0 resection, and use of adjuvant chemotherapy, but a lower lymph node yield, as compared to ODP. Due to treatment allocation bias and lower lymph node yield the oncologic efficacy of MIDP remains uncertain.     

机器人与腹腔镜微创手术治疗分化良好的胰腺神经内分泌瘤的临床研究

背景与目的:胰腺神经内分泌瘤(pancreatic neuroendocrine tumor,pNET)为少见肿瘤,目前仍缺乏总结微创手术治疗pNET的临床效果的大样本临床研究数据,本研究通过分析接受手术治疗的pNET患者的临床资料,以期为pNET的外科治疗提供参考。方法:回顾性分析2018年9月—2022年7月于复旦大学附属肿瘤医院胰腺外科行微创手术的118例分化良好的pNET患者的临床资料。根据微创手术方式分为机器人组和腹腔镜组,根据手术切除方式分为规则切除组和局部切除组。收集其手术及术后相关临床资料进行分析。结果:本研究纳入的118例pNET患者中,机器人组17例,腹腔镜组101例。局部切除组32例,规则切除组86例。机器人组和腹腔镜组在手术时间、术中出血量方面无显著差异(P>0.05)。局部切除组的手术时间[(145.3±55.5)min]明显短于规则切除组[(247.4±94.7)min](P<0.05)。同时,局部切除组的术中出血量[(71.8±23.2)mL]明显少于规则切除组[(147.5±59.9)mL](P<0.05)。机器人组的术后胃肠功能恢复早...     

Parenchyma-sparing pancreatectomies for benign or border-line tumors of the pancreas

Standard pancreatic resections, such as pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy, result in an important loss of normal pancreatic parenchyma and may cause impairment of exocrine and endocrine function. Whilst these procedures are mandatory for malignant tumors, they seem to be too extensive for benign or border-line tumors, especially in patients with a long life expectancy. In recent years, there has been a growing interest in parenchyma-sparing pancreatic surgery with the aim of achieving better functional results without compromising oncological radicality in patients with benign, border-line or low-grade malignant tumors. Several limited resections have been introduced for isolated or multiple pancreatic lesions, depending on the location of the tumor: central pancreatectomy, duodenum-preserving pancreatic head resection with or without segmental duodenectomy, inferior head resection, dorsal pancreatectomy, excavation of the pancreatic head, middle-preserving pancreatectomy, and other multiple segmental resections. All these procedures are technically feasible in experienced hands, with very low mortality, although with high morbidity rate when compared to standard procedures. Pancreatic endocrine and exocrine function is better preserved with good quality of life in most of the patients, and tumor recurrence is uncommon. Careful patient selection and expertise in pancreatic surgery are crucial to achieve the best results.     

Patients get more long-term benefit from central pancreatectomy than distal resection: A meta-analysis

Aims

Central pancreatectomy (CP) protects more normal pancreatic parenchyma than distal pancreatectomy (DP), but the safety, feasibility and long-term benefit of CP are inconclusive. This meta-analysis aims to ascertain the relative merits of CP.

Methods

A systematic literature research was performed to identify comparative studies on CP and DP. Perioperative and long-term outcomes constituted the end points. Pooled risk ratios (RR) and weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either fixed effects or random effects model.

Results

Nine studies with 735 patients were included in this meta-analysis. Although CP cost more operative time than DP, the two groups had no significant differences in the volume of intraoperative blood loss, rate of intraoperative blood transfusion and length of postoperative hospital stay. According to the postoperative outcomes, although the CP group had higher overall complication rate (Fixed effects model; RR: 1.30; 95% CI: 1.05–1.62; P < 0.05) as well as overall pancreatic fistula rate (Fixed effects model; RR: 1.58; 95% CI: 1.20–2.08; P < 0.05), the two groups did not differ significantly in the fateful surgical complications such as clinically significant pancreatic fistula (Grades B and C), postoperative bleeding, reoperation and intra-abdominal effusion/abscess. Furthermore, the perioperative mortality rate was comparable between the two groups. During the follow-up period, the patients after DP were more likely to suffer pancreatic exocrine insufficiency (Fixed effects model; RR: 0.53; 95% CI: 0.32–0.86; P < 0.05) and endocrine impairment (Fixed effects model; RR: 0.19; 95% CI: 0.11–0.33; P < 0.05).

Conclusion

CP was still an acceptable and feasible procedure, especially when considering the postoperative pancreatic function preservation ability by CP.     

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using retroperitoneal-first laparoscopic approach (Retlap): A novel minimally invasive approach for determining resectability and achieving tumor-free resection margins of locally advanced pancreatic body cancer

BackgroundConventional open distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using the ventral approach is technically challenging, highly invasive, and not easy to ensure ample dorsal surgical margins. Hence, we describe a novel minimally invasive strategy for DP-CAR using the retroperitoneal-first laparoscopic approach (Retlap), i.e., Retlap DP-CAR, for locally advanced pancreatic body cancer (LAPC), and assess its utility.MethodsRetlap DP-CAR was performed in 10 patients with LAPC that was categorized as either unresectable (UR-LA, n = 4) or borderline (BR-A, n = 6). Neoadjuvant chemotherapy was applied on 8 patients and upfront surgery on 2. Retlap was used to create a working space in the retroperitoneal cavity between the pancreatic body and the left kidney and confirm technical resectability, such as securing the celiac axis and preserving the superior mesenteric artery in an early operative stage. Retlap DP-CAR was laparoscopic in 8 patients and robotic in 2. Surgical procedures are directly manipulated from the dorsal side of the pancreas and tumor, facilitating confirmation of technical resectability and obtaining ample dorsal margins in a no-touch isolation approach. Once technical resectability was confirmed, the procedure was converted to the ventral approach for completing DP-CAR.ResultsMedian operating time and blood loss during Retlap were 271 min and 10 mL, respectively, while median resection time and intraoperative blood loss were 582 min and 412 mL, respectively. Tumor-free resection margins were obtained in all cases. The major morbidity rate (C-D > IIIa) was 10%. No mortality was recorded within 90 days. Median overall survival was 53.8 months [95% confidence interval 32.7–75.0].ConclusionsRetlap DP-CAR is a novel minimally invasive procedure for resecting LAPC located close to the celiac axis. It is both safe and feasible, enables determination of technical resectability, achieves dorsal surgical margins, and can improve outcomes and QOL in patients with LAPC.     

Robotic central hepatectomy for hepatocarcinoma by glissonean approach (with video)

BackgroundCentral bisegmentectomy of the liver implies excising Couinaud's segments IV, V and VIII (Couinaud and Le Foie, 1957) [1]. In a recent classification of laparoscopic liver resections, it belongs to the highly advanced level procedure group (Kawaguchi and et al., 2018 Jan) [2]. Improvement in laparoscopic devices should lead to a wider accessibility of such indications that are currently expert prerogatives. In order to illustrate the assets of robotic-assistance in the management of highly difficult mini-invasive hepatic resections, we present the case of a robotic central hepatectomy.MethodsThis video illustrates robotic central hepatectomy in a 70-year-old male. A liver tumor involving segments IV, V and VIII was incidentally detected during abdominal ultrasonography. CT scan and MRI suggested the diagnosis of a seventy-millimeter centrally located hepatocellular carcinoma and surgical resection was decided.ResultsThe patient was placed supine in anti-Trendelenburg position. Four robotic trocars were placed and the da Vinci X robotic system was docked. Two laparoscopic ports were placed for the second surgeon (ultrasonic dissector and suction/irrigation set). Central hepatectomy was performed with a glissonean approach. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Postoperative course was uneventful. The patient was discharged on postoperative day eight.ConclusionThe recent publication of an International consensus statement demonstrates the growing involvement of robotics in liver surgery (Liu and et al., 2019 March 28) [3]. Robotic advantages (flexibility, absence of fulcrum effect and visual field stability) could improve accessibility to minimal invasive approach for difficult liver resection.     

中段胰腺切除术治疗胰腺颈体部肿瘤

目的探讨中段胰腺切除术在胰腺颈、体部肿瘤等占位性病变治疗中的安全性和有效性。方法回顾性分析1999—2006年在中国医学科学院肿瘤医院实施中段胰腺切除术的14例患者的临床资料。结果12例患者为胰腺良性肿瘤，其中微囊性腺瘤2例、实性假乳头状瘤5例、无功能性胰岛细胞瘤2例、胰腺良性囊腺瘤1例、海绵状血管瘤1例、浆液性囊肿1例，1例为中分化腺鳞癌，1例为慢性胰腺炎。术后胰瘘4例（28．6％），腹腔感染1例（7．1％）。无术后死亡，无胰腺内、外分泌功能障碍的发生。无肿瘤复发和转移。结论中段胰腺切除术应用于胰腺良性、低度恶性肿瘤的外科治疗，可有效地保留胰腺内、外分泌功能和脾脏功能，是安全、有益和有效的手术方式。     

Robotic distal pancreatectomy for a neuroendocrine tumor in an 11-year-old child

IntroductionOver the past decade, robotic pancreatic surgery has gained popularity. Although anatomically comparable, the small size of pediatric patients might impede the use of the surgical robot due to the size of the robotic arms. Pediatric pancreatic resection is rarely indicated, hence only few cases of pediatric robotic pancreatic resection have been described (Hagendoorn et al., 2018; Lalli Raj, 2019-4) [1,2]. To the best our knowledge, no video literature exists on robotic pediatric pancreatic tail resections. Aim of this video was to demonstrate the set-up and surgical technique of robotic distal pancreatectomy in a child.MethodsThis video illustrates fully robotic distal pancreatectomy in an eleven-year-old child. The patient had a past medical history of tuberous sclerosis complex. On surveillance imaging a non-functional neuroendocrine tumor was detected in the pancreatic tail for which a distal pancreatectomy was indicated.ResultsAfter general anesthesia, the patient was placed in supine position on a split-leg table in anti-Trendelenburg. Four robotic trocars were placed and the da Vinci Xi robotic system was docked. Two laparoscopic assistant ports were placed. A spleen-preserving distal pancreatectomy was performed. Postoperative recovery was unremarkable and the patient was discharged on postoperative day 6.ConclusionThis video illustrates robotic distal pancreatectomy in an eleven-year-old child. Meticulous port placement, adjusted to the patient's habitus, is an essential element.     

Mammotome真空辅助旋切系统在乳腺良性肿块微创切除中的应用

目的探讨超声引导下Mammotome真空辅助旋切系统对乳腺良性病灶进行微创切除的治疗价值。方法2005年10月至2006年12月,对82例患者218个超声检查诊断为良性的乳腺病灶在超声引导下进行Mammotome切除术,对其进行回顾性分析,评价其在乳腺微创外科的应用价值。结果全部肿块均顺利切除,术后病理学诊断全部为良性,患者第2天可恢复上肢正常活动。术后3,6个月接受复查,乳腺外形及皮肤感觉正常,超声未发现病灶残留,术后切口瘢痕不明显。结论应用超声引导下Mammotome切除术对乳腺良性病灶可进行完整切除,具有微创、美观、术后对触觉无影响、操作简单、安全等优点,是一种值得推广的微创手术方法。     

肝内胆管细胞癌微创治疗现状及进展#br#

肝内胆管细胞癌(ICC)是一类高侵袭性的恶性肿瘤,远期预后差,手术切除仍是其主要的治疗手段。目前,包括腹腔镜、机器人等在内的微创治疗已越来越广泛地应用于各类患者,其中相当部分是肿瘤患者。近几年国内外部分学者开始尝试应用微创手段治疗ICC患者,但关于其适应证选择及远期疗效尚存争议。该文就腹腔镜、机器人、热消融治疗ICC的研究现状及进展进行了论述。     

Safety and efficacy for robot-assisted versus open pancreaticoduodenectomy and distal pancreatectomy: A systematic review and meta-analysis

Background

This meta-analysis was conducted to compare the clinical safety and efficacy of robot-assisted pancreaticoduodenectomy (RAPD) or robot-assisted distal pancreatectomy (RADP) with open surgery.

Introducing nerve-sparing approach during minimally invasive radical hysterectomy for locally-advanced cervical cancer: A multi-institutional experience

Objective

To evaluate the impact of nerve-sparing (NS) approach on outcomes of patients undergoing minimally invasive radical hysterectomy (MRH) for locally advanced stage cervical cancer (LACC).

Integration of robotics into two established programs of minimally invasive surgery for endometrial cancer appears to decrease surgical complications

Objective

To compare peri- and postoperative outcomes and complications of laparoscopic vs. robotic-assisted surgical staging for women with endometrial cancer at two established academic institutions.

Methods

Retrospective chart review of all women that underwent total hysterectomy with pelvic and para-aortic lymphadenectomy by robotic-assisted or laparoscopic approach over a four-year period by three surgeons at two academic institutions. Intraoperative and postoperative complications were measured. Secondary outcomes included operative time, blood loss, transfusion rate, number of lymph nodes retrieved, length of hospital stay and need for re-operation or re-admission.

Results

Four hundred and thirty-two cases were identified: 187 patients with robotic-assisted and 245 with laparoscopic staging. Both groups were statistically comparable in baseline characteristics. The overall rate of intraoperative complications was similar in both groups (1.6% vs. 2.9%, p=0.525) but the rate of urinary tract injuries was statistically higher in the laparoscopic group (2.9% vs. 0%, p=0.020). Patients in the robotic group had shorter hospital stay (1.96 days vs. 2.45 days, p=0.016) but an average 57 minutes longer surgery than the laparoscopic group (218 vs. 161 minutes, p=0.0001). There was less conversion rate (0.5% vs. 4.1%; relative risk, 0.21; 95% confidence interval, 0.03 to 1.34; p=0.027) and estimated blood loss in the robotic than in the laparoscopic group (187 mL vs. 110 mL, p=0.0001). There were no significant differences in blood transfusion rate, number of lymph nodes retrieved, re-operation or re-admission between the two groups.

Conclusion

Robotic-assisted surgery is an acceptable alternative to laparoscopy for staging of endometrial cancer and, in selected patients, it appears to have lower risk of urinary tract injury.     

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1).MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2).ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way.ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.