Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatec tomy(LDP) appeared in the 1990 s, the procedure ha been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Man earlier publications have shown LDP to be a good alter native to open distal pancreatectomy for benign lesions although this has never been studied in a prospective randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as we established. The purpose of this review is to evaluat the current evidence for LDP in cases of pancreati adenocarcinoma. We conducted a review of English language publications reporting LDP results between1990 and 2013. All studies reporting results in patient with histologically proven pancreatic adenocarcinom were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pan creatic adenocarcinoma(potential double publication were not eliminated). Most LDP procedures are per formed in selected cases and generally involve smalle tumors than open distal pancreatectomy(ODP) proce dures. Some of the papers report unselected cases andinclude procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.     

Laparoscopic vs open distal pancreatectomy for solid pseudopapillary tumor of the pancreas

AIM:To compare short-and long-term outcomes of laparoscopic vs open distal pancreatectomy for solid pseudopapillary tumor(SPT)of the pancreas.METHODS:This retrospective study included 28 patients who underwent distal pancreatectomy for SPT of the pancreas between 1998 and 2012.The patients were divided into two groups based on the surgical approach:the laparoscopic surgery group and the open surgery group.The patients’demographic data,operative results,pathological reports,hospital courses,morbidity and mortality,and follow-up data were compared between the two groups.RESULTS:Fifteen patients with SPT of the pancreas underwent laparoscopic distal pancreatectomy(LDP),and 13 underwent open distal pancreatectomy(ODP).Baseline characteristics were similar between the two groups except for a female predominance in the LDP group(100.0%vs 69.2%,P=0.035).Mortality,morbidity(33.3%vs 38.5%,P=1.000),pancreatic fistula rates(26.7%vs 30.8%,P=0.728),and reoperation rates(0.0%vs 7.7%,P=0.464)were similar in the two groups.There were no significant differences in the operating time(171 min vs 178 min,P=0.755)between the two groups.The intraoperative blood loss(149 mL vs 580 mL,P=0.002),transfusion requirement(6.7%vs 46.2%,P=0.029),first flatus time(1.9d vs 3.5 d,P=0.000),diet start time(2.3 d vs 4.9 d,P=0.000),and postoperative hospital stay(8.1 d vs 12.8d,P=0.029)were significantly less in the LDP group than in the ODP group.All patients had negative surgical margins at final pathology.There were no significant differences in number of lymph nodes harvested(4.6 vs6.4,P=0.549)between the two groups.The median follow-up was 33(3-100)mo for the LDP group and 45(17-127)mo for the ODP group.All patients were alive with one recurrence.CONCLUSION:LDP for SPT has short-term benefits compared with ODP.Long-term outcomes of LDP are similar to those of ODP.     

Laparoscopic three-port distal pancreatectomy

Aims

Laparoscopic distal pancreatectomy is becoming a more commonly used procedure, which may involve the use of four to seven ports, depending on the technique. Initial data on feasibility, safety and outcome with the three-port laparoscopic distal pancreatectomy are presented.

Methods

The patient is placed in a partial thoracoabdominal position exposing the left flank in a reverse Trendelenberg position. A 10-mm Hassan trocar is inserted through a subcostal anterior axillary incision. A 5-mm midclavicular and 10-mm posterior axillary line trocar are placed. The specimen is retrieved from the anterior axillary line port.

Results

Ten women and seven men, aged 26–88 years (mean 61 years), were evaluated. Their body mass indexes ranged from 18–37 (mean 27). Pancreatic lesion size ranged from 1.0–5.5 cm (mean 3.0 cm). Operative time was 116–296 min (mean 170 min). Blood loss was 10–300 ml (mean 142 ml). No operation required conversion or additional trocar placement. Post-operative stay was 2–7 days (mean 4 days). No patient developed a pancreatic fistula.

Conclusion

Operative time, blood loss and post-operative stay of this three-port technique compare favourably with published data.     

Laparoscopic distal pancreatectomy for pancreatic cystadenomas

BACKGROUND: Cystic neoplasms are an uncommon group among pancreatic tumors. These lesions are seen more frequently in recent surgical practice, probably because of advances in diagnostic and surgical techniques. Total tumor resection provides the best chance of cure and may remove the risk of malignant transformation of the cystadenomas, particularly of the mucinous type. Minimally invasive techniques have been revolutionary and provide clinical evidence of decreased morbidity and comparable efficacy to traditional, open surgery. However, laparoscopic pancreatic resection is not an established treatment for tumors of the pancreas. AIM: The authors present their initial experience with laparoscopic distal pancreatectomy for pancreatic cystadenomas. MATERIAL AND METHODS: Three female patients (mean age, 55 years) underwent laparoscopic pancreatic resection between September 2001 and December 2003. RESULTS: Laparoscopic pancreatic resection was successfully performed in all patients. Operative time varied between 4 and 6 hours. Intraoperative bleeding was minimal. Due to a thick pancreas, the application of vascular endoscopic stapler was difficult in one patient. Two patients presented postoperative pancreatic leakage with spontaneous resolution. CONCLUSIONS: Resection of the pancreas can be safely performed via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.     

Laparoscopic distal pancreatectomy as the total biopsy of the pancreas: tool of minimally invasive surgery

Because of recent progress in imaging modalities, the opportunities to detect pancreatic cystic neoplasms are increasing. However, serous cystadenoma is still uncommon. We report a case of serous cystadenoma treated by laparoscopic distal pancreatectomy. A 52-year-old woman presented with mild upper abdominal pain. Dynamic computed tomography (CT) revealed a solitary cystic lesion 3?cm in diameter in the pancreatic tail. Endoscopic ultrasound showed a honeycomb pattern, indicative of serous cystadenoma. To obtain the final diagnosis of the tumor, we performed laparoscopic distal pancreatectomy. A histopathological study showed microcystadenoma with no evidence of malignancy.     

Laparoscopic distal pancreatectomy for insulinoma with preservation of the spleen

We report on a successful laparoscopic distal pancreatectomy due to insulinoma, preserving the spleen and the splenic vessels in a 29-year-old male patient who presented with repeated syncope due to hypoglycemia. The ultrasound exam did not show the pancreatic lesion; it was only the angiotomography of the pancreas that revealed a 3-cm mass located at the transition from the body to the tail of the pancreas. The laparoscopic distal pancreatectomy was performed using a harmonic scalpel (Ethicon EndoSurgery/UltraCision), without mechanical suturing. There were no intra- or postoperative complications or hypoglycemias during the 6 months of follow-up. When it is performed by experienced laparoscopic surgeons, this is a technically feasible procedure, safe for the treatment of benign lesions of the pancreas body and tail.     

Laparoscopic distal pancreatectomy: a comparative study

BACKGROUND/AIMS: This article aims to describe the different techniques of laparoscopic distal pancreatectomy and to compare the results of our series of 9 laparoscopic resections against the historical open control in the same institution. With the advent of laparoscopic surgery, there is an increasing number of patients with different pancreatic pathologies that can now be managed by minimal access surgery. The initial results of laparoscopic pancreatectomy are quite promising particularly for those small neuroendocrine and cystic neoplasms located at the body and tail of pancreas. METHODOLOGY: The different techniques of laparoscopic distal pancreatectomy are described in detail with special emphasis on the need of "hand assistance" and the different methods of splenic preservation. The perioperative data of 9 laparoscopic distal pancreatectomies are analyzed and compared against the 5 historical open controls in the same institution. RESULTS: There were 9 laparoscopic pancreatic resections performed in our institution since 1999. Indications for surgery included 5 cystic neoplasms (1 patient with concomitant splenic artery aneurysm), 1 chronic pancreatitis with pancreatic duct stricture and a small pseudocyst, 1 pseudopancreatic tumor secondary to seal off perforated posterior gastric ulcer, 1 pseudopapillary tumor and 1 neuroendocrine tumor. There were 6 females and 3 males with median age of 61 years (range 18-79). The majority of patients was of low anesthetic risk (ASA 1 or 2). Total laparoscopic resection was performed in 7 cases and 2 resections were performed using the hand-assisting technique. Out of the 4 cases with splenic preservation, only one patient had both splenic artery and vein successfully preserved, whereas the other 3 cases had to rely on the short gastric arcade. Median operating time was 180 minutes (range 120-250) and median blood loss was 100cc (range 50-500). Pancreatic leak occurred in two patients (22.2%) and 1 patient developed intraabdominal collection, all of which settled upon conservative treatment. In our series, clear resection margin was obtained for all the neoplastic cases. Median hospital stay was 7 days (4-53). Postoperatively, patients consumed an average of 15 tablets of dologesic. No other complications were observed upon a median follow-up of 15 months (1-50). When results were compared to the 5 historical open controls (excluding those malignant tumors), patients managed with this new approach had significantly less intraoperative blood loss (100 vs. 450 mL, P = 0.021). CONCLUSIONS: Our initial experience not only confirmed the feasibility oflaparoscopic pancreatectomy, but also demonstrated the promising results of this approach in selected patients.     

Imaging of neuroendocrine tumors of the pancreas

Summary Background. Neuroendocrine tumors of the pancreas are uncommon neoplasms of the pancreas that can occur sporadically or in association with various syndromes such as multiple endocrine neoplasia type 1 (MEN 1). Patients can present with a specific clinical syndrome related to biochemically functioning tumors or with nonspecific symptoms related to mass effect or metastases. The size, function, consistency, and malignant behavior of neuroendocrine tumors are integrally related. Imaging has a major role in the preoperative localization of the primary tumor and detection of metastases. Several techniques are available including ultrasound, endoscopic ultrasound, computed tomography (CT), MR, somatostatin receptor scintigraphy, angiography, and arterial stimulation with venous sampling; each with unique advantages and limitations. The reported performance for these techniques vary widely, and as a result, recommended imaging algorithms are controversial. Recent technical advances in ultrasound, CT, and MRI have occurred that may improve the sensitivity of some of the techniques. Further improvements are likely in the future. In this chapter we will review imaging techniques used to study the pancreas as it relates to the detection of neuroendocrine tumors, imaging findings of these tumors using various imaging modalities, and the advantages, limitations and results obtained with each technique.     

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.     

Multiple neuroendocrine tumors of the pancreas associated with pancreas divisum

Pancreas divisum is the most common congenital anomaly of the pancreas, characterized by missing fusion of the ventral and dorsal pancreatic duct. It may cause pancreatitis, but is rarely associated with malignancy.We report herein for the first time the rare association, in a symptomless patient, of multiple neuroendocrine tumors of the pancreas with pancreas divisum and a failure of the exocrine system. Diagnosis was made incidentally by routine abdominal ultrasound. Laboratory examinations and a fine-needle aspiration revealed the neuroendocrine nature of the tumor. Spleen-preserving left pancreas resection was performed, with evidence of multiple neuroendocrine tumors of the pancreas with the typical histological characteristics. Eighteen months later the patient is still free of tumor burden.     

Laparoscopic distal pancreatectomy: the Brisbane experience of forty-six cases

Background and aims. Laparoscopic distal pancreatectomy (LDP) is a safe alternative to conventional open distal pancreatectomy, with advantages that include smaller incisions, less pain, and shorter postoperative recovery. Despite these apparent advantages, however, uptake of the procedure has been slow, with only a handful of series published. Material and methods. All LDPs performed in Brisbane, Australia, over a 10-year period (May 1996 to June 2006) were retrospectively reviewed. Results. Forty-six consecutive LDPs were performed. A variety of lesions were resected, including nine cancers. Twelve patients were converted for oncological (6) or technical reasons (6). The spleen was retained in 14/29 patients, either by main splenic vessel preservation (9) or solely supported by the short gastric vessels (5), resulting in inferior pole infarction in 2 patients. Overall morbidity was 39%, including 15% pancreatic fistula. All fistulas resolved after a median of 6 weeks without re-operation. A non-significant trend toward fewer fistulas with stapled rather than sutured stump closure was observed (13% vs 19%; p=0.43). Median operative duration and hospital stay were 157 min and 7 days, respectively. There was no mortality. Conclusion. LDP is a safe alternative to conventional resection for a wide range of lesions. As with open resection, pancreatic fistula is the dominant morbidity, but is generally indolent. While spleen preservation is often possible, care must be taken to avoid infarction of the inferior pole if the Warshaw technique is utilized.     

Age-related risks of complications after distal pancreatectomy for neuroendocrine and cystic neoplasms

BackgroundDistal pancreatic neuroendocrine tumors (PNET) and pancreatic cystic neoplasms (PCN) are often incidentally found in older adults, requiring careful consideration between operative management and watchful waiting. This study analyzes the short-term complications associated with distal pancreatectomy (DP) for PNET and PCN in older adults to inform clinical decision-making.MethodsPatients undergoing DP for PNET and PCN were analyzed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the pancreatectomy procedure-targeted dataset. Associations between decade of age and 30-day outcomes were evaluated.Results1626 patients were analyzed from 2014 to 2015. 692 (42.6%) were younger than 60 years, 507 (31.2%) were sexagenarians, 342 (21.0%) were septuagenarians, and 85 (5.2%) were octogenarians. Minimally invasive approaches were used in 62.7%. While septuagenarians and octogenarians constituted 26.3% of the cohort, they were affected by 55.6% of reintubations, 66.7% of failures to wean, 82.4% of myocardial infarctions, and 57.1% of septic shock. Septuagenarians and octogenarians had longer hospital stays, as compared to those younger than 60 years.ConclusionSeptuagenarians and octogenarians are disproportionately affected by perioperative complications after DP for PNET and PCN. Careful patient selection and thorough counseling should be provided when surgery is considered.     

Laparoscopic resection of pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors(PNETs)are a rare heterogeneous group of endocrine neoplasms.Surgery remains the best curative option for this type of tumor.Over the past two decades,with the development of laparoscopic pancreatic surgery,an increasingly larger number of PNET resections are being performed by these minimally-invasive techniques.In this review article,the various laparoscopic surgical options for the excision of PNETs are discussed.In addition,a summary of the literature describing the outcome of these treatment modalities is presented.     

Laparoscopic and robotic donor pancreatectomy for living donor pancreas and pancreas–kidney transplantation

Pancreas transplantation is a widely accepted procedure that can efficiently restore euglycemia and prevent progression of complications. In most instances, the limiting factor for deceased donor organ transplantation is the availability and quality of the available organs. Living donor pancreas transplant was introduced at the University of Minnesota in 1979. Because of the potential risks for the donor and the technical challenges in the recipient operation, this procedure has not become very popular since then. In 1999, in the attempt to decrease the morbidity associated with open distal pancreatectomy, the first laparoscopic donor distal pancreatectomy with hand-assisted technique was performed at the same institution. In 2000, the FDA approved the robotic surgical system Da Vinci for general use. Since then, the system has been extensively used at our institution to perform living donor nephrectomy. The only case reported worldwide of robotic distal pancreatectomy and nephrectomy for living donor pancreas–kidney transplantation was successfully performed by our team in 2006 at the University of Illinois at Chicago and proved as a promising technique. The application of minimally invasive techniques has allowed an increased acceptance of the procedure among potential donors and may, therefore, increase the number of donors for this life-saving transplant. The initial results are encouraging and clearly prove feasibility.     

Laparoscopic distal pancreatectomy for solid pseudopapillary neoplasm of the pancreas-report of two cases

Solid pseudopapillary neoplasm of the pancreas is a rare pathologic entity. Although the role of laparoscopy in surgery of the pancreas is still controversial, the feasibility and safety of laparoscopic distal pancreatectomy has been reported with good results. We present two cases of laparoscopic distal pancreatectomy in female patients of incidentally found pancreatic solid pseudopapapillary neoplasm, with review of disease and technical aspect. They underwent laparoscopic distal pancreatectomy with and without preservation of splenic vessels and spleen respectively. We used four trocars with the patients' posture in strict right lateral decubitus. The operating time was 180 and 240 minutes respectively. There were no critical postoperative complications. The postoperative hospital stay was 10 and 7 days respectively. This minimal invasive surgery can be safely applied to benign or low-grade malignant tumor of the pancreas especially in young and female patients.     

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms: A retrospective study

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.METHODS: The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively. Surgical techniques for LSPDP included preservation of the splenic artery and vein (Kimura’s technique) and ligation of the splenic pedicle with preservation of the short gastric vessels (Warshaw’s technique).RESULTS: There were no conversions to open surgery in the 38 patients. Splenic vessels were conserved during spleen-preserving pancreatectomy, except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels. The mean operation time was 123.2 ± 52.4 min, the mean intraoperative blood loss was 78.2 ± 39.5 mL, and the mean postoperative hospital stay was 7.6 ± 2.9 d. The overall rate of postoperative complications was 18.4% (7/38), and the rate of clinical pancreatic fistula was 13.2% (5/38). All postoperative complications were treated conservatively. The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions. During a median follow-up of 38 mo (range: 5-133 mo), no recurrence was observed.CONCLUSION: LSPDP is a safe, feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.     

Modified extended distal pancreatectomy for carcinoma of body and tail of pancreas

The prognosis of carcinoma in the body and tail of the pancreas is disappointing due to the low rate of resectability, since it is usually presented at an advanced stage with local invasion of adjacent major vessels. However, the postoperative survival, if resectable, is similar to carcinoma of the pancreatic head. Aggressive approach, by applying extended distal pancreatectomy with the resection of the celiac axis, may increase the resectability but promote the potential risk of hepatic dysfunction and biliary necrosis after the sudden interruption of the common hepatic artery. We modified the procedure by reanastomosis between the stump of the celiac axis and common hepatic artery without vascular graft to manage a 50-year-old woman with locally advanced carcinoma of the body and tail of pancreas. She had 2 years of disease-free survival. This modified extended pancreatectomy may be a feasible and safer procedure.     

Laparoscopic distal pancreatectomy in patients with poor physical status

BackgroundLaparoscopic distal pancreatectomy (LDP) is advantageous over open surgery in the treatment of benign pancreatic lesions and low-grade malignancies. Yet the evidence on the relationship between comorbidities and the outcomes of LDP remains scarce.MethodsPatients who had undergone LDP for all indications between April 1997 and December 2019 were included. Preoperative physical status was defined according to the American Society of Anesthesiology (ASA) criteria. Perioperative outcomes were compared between the patients with high (ASA III–IV) and low/moderate anesthetic risk (ASA I–II).ResultsA total of 605 patients were eligible for analysis including 190 with ASA III–IV and 415 with ASA I–II. The former was associated with older age, male gender, preexisting medical conditions, greater total number of comorbidities and red blood cell transfusion. The rate of medical complications was significantly higher in high-risk patients. Multivariable analysis identified ASA III–IV and operative time as independent predictors for medical complications. Overall/severe morbidity, surgical complications and mortality rates were similar.ConclusionsPoor physical status defined as ASA grades III–IV predicts medical complications, but has a limited impact on surgical complications and severe morbidity of LDP. Thus, it should not be considered as a contraindication for LDP.     

Indications and outcomes of enucleation versus formal pancreatectomy for pancreatic neuroendocrine tumors

BackgroundPancreatoduodenectomy (PD) or distal pancreatectomy (DP) are common procedures for patients with a pancreatic neuroendocrine tumor (pNET). Nevertheless, certain patients may benefit from a pancreas-preserving resection such as enucleation (EN). The aim of this study was to define the indications and differences in long-term outcomes among patients undergoing EN and PD/DP.MethodsPatients undergoing resection of a pNET between 1992 and 2016 were identified. Indications and outcomes were evaluated, and propensity score matching (PSM) analysis was performed to compare long-term outcomes between patients who underwent EN versus PD/DP.ResultsAmong 1034 patients, 143 (13.8%) underwent EN, 304 (29.4%) PD, and 587 (56.8%) DP. Indications for EN were small size (1.5 cm, IQR:1.0–1.9), functional tumors (58.0%) that were mainly insulinomas (51.7%). After PSM (n = 109 per group), incidence of postoperative pancreatic fistula (POPF) grade B/C was higher after EN (24.5%) compared with PD/DP (14.0%) (p = 0.049). Median recurrence-free survival (RFS) was comparable among patients who underwent EN (47 months, 95% CI:23–71) versus PD/DP (37 months, 95% CI: 33–47, p = 0.480).ConclusionComparable long-term outcomes were noted among patients who underwent EN versus PD/DP for pNET. The incidence of clinically significant POPF was higher after EN.