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Tsunematsu M, Shirai Y, Hamura R, Haruki K, Furukawa K, Onda S, Matsumoto M, Okui N, Taniai T, Ikegami T. The conventional method of blood-loss calculation can underestimate true blood loss during laparoscopic pancreaticoduodenectomy: a dual-institute experience. Surg Today 2025:10.1007/s00595-025-03040-y. [PMID: 40232398 DOI: 10.1007/s00595-025-03040-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Accepted: 03/03/2025] [Indexed: 04/16/2025]
Abstract
PURPOSE This study investigated whether blood loss (BL) was. truly less in patients undergoing laparoscopic pancreaticoduodenectomy (LPD) than in those undergoing open pancreaticoduodenectomy (OPD). METHODS A total of 98 patients undergoing pancreaticoduodenectomy between 2021 and 2023 were divided into OPD and LPD groups and compared. Estimated BL was calculated from the perioperative changes in hematocrit, hemoglobin, or red blood cell volume. Actual BL was calculated using the conventional method as the sum of the intraoperative aspirated blood volume and surgical gauze weight. RESULTS Actual BL was significantly lower in the LPD group than in the OPD group (150 [80-350] ml vs. 345 [150-700] ml, p = 0.003). However, there were no significant differences in the estimated BL calculated from the hematocrit (461 [187-626] ml vs. 351 [153-737] ml, p = 0.972), hemoglobin, or red blood cell volume. Estimated BL showed a stronger linear correlation with actual BL in the OPD group (r = 0.447-0.669) than in the LPD group (r = 0.158-0.417). OPD was not a significant factor in the increased estimated BL. CONCLUSIONS The conventional method for calculating the BL in LPD may underestimate the actual loss, highlighting the need for a more accurate method of evaluation.
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Affiliation(s)
- Masashi Tsunematsu
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan.
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Yoshihiro Shirai
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ryoga Hamura
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Shinji Onda
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Michinori Matsumoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Norimitsu Okui
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Tomohiko Taniai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
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Poggi E, Lillo-Araya FJ, Garcia Rubio D, Pérez Duarte FJ, Gutiérrez Del Sol J, Izzo F, Cinti F. Laparoscopic resection of pancreatic masses in 12 dogs. Vet Surg 2024; 53:860-871. [PMID: 38093590 DOI: 10.1111/vsu.14057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/27/2023] [Accepted: 11/24/2023] [Indexed: 07/11/2024]
Abstract
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.
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Affiliation(s)
| | - Felipe J Lillo-Araya
- Escuela de Medicina Veterinaria, Facultad Ciencias de la Vida, Universidad Andres Bello, Vina del Mar, Chile
| | | | - Francisco J Pérez Duarte
- VETMI. Servicio de Cirugía de Mínima Invasión Veterinaria. C/Paraíso Terrenal N°3, Cáceres, Spain
| | - Jorge Gutiérrez Del Sol
- VETMI. Servicio de Cirugía de Mínima Invasión Veterinaria. C/Paraíso Terrenal N°3, Cáceres, Spain
| | | | - Filippo Cinti
- San Marco Veterinary Clinic and Laboratory, Padova, Italy
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Comparative Efficacy of Robot-Assisted and Laparoscopic Distal Pancreatectomy: A Single-Center Comparative Study. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7302222. [PMID: 35024102 PMCID: PMC8747902 DOI: 10.1155/2022/7302222] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 01/08/2023]
Abstract
Background Laparoscopic distal pancreatectomy (LDP) has become a routine procedure in pancreatic surgery. Although robotic distal pancreatectomy (RDP) has not been popularized yet, it has shown new advantages in some aspects, and exploring its learning curve is of great significance for guiding clinical practice. Methods 149 patients who received RDP and LDP in our surgical team were enrolled in this retrospective study. Patients were divided into two groups including LDP group and RDP group. The perioperative outcomes, histopathologic results, long-term postoperative complications, and economic cost were collected and compared between the two groups. The cumulative summation (CUSUM) analysis was used to explore the learning curve of RDP. Results The hospital stay, postoperative first exhaust time, and first feeding time in the RDP group were better than those in the LDP group (P < 0.05). The rate of spleen preservation in patients with benign and low-grade tumors in the RDP group was significantly higher than that of the LDP group (P=0.002), though the cost of operation and hospitalization was significantly higher (P < 0.001). The learning curve of RDP in our center declined significantly with completing 32 cases. The average operation time, the hospital stay, and the time of gastrointestinal recovery were shorter after the learning curve node than before. Conclusion RDP provides better postoperative recovery and is not difficult to replicate, but the high cost was still a major disadvantage of RDP.
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Laparoscopic duodenum-preserving pancreatic head resection: a narrative review. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Matched Case-Control Comparative Study of Laparoscopic Versus Open Pancreaticoduodenectomy for Malignant Lesions. Surg Laparosc Endosc Percutan Tech 2018; 28:47-51. [PMID: 28212257 DOI: 10.1097/sle.0000000000000381] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Advances in surgical technologies allowed safe laparoscopic pancreaticoduodenectomy (LPD). The aim of this study is to compare the oncologic outcomes of LPD to open pancreaticoduodenectomy (OPD) in terms of safety and recurrence rate. MATERIALS AND METHODS A cohort of 30 patients were matched for age, sex, American Society of Anaesthesiologists, tumor size, pancreatic duct diameter, and histopathologic diagnosis on a 1:1 basis (15 LPD, 15 OPD). Comparison between groups was performed on intention-to-treat basis. Survival following resection was compared using the Kaplan-Meier survival analysis. RESULTS The median operating time for LPD group was longer than for OPD group (470 vs. 310 min; P=0.184). However, estimated blood loss (300 vs. 620 mL; P=0.023), high dependency unit stay (2.0 vs. 6.0 d; P=0.013) and postoperative hospital stay (9.0 vs. 17.4 d; P=0.017) were significantly lower in the LPD group. There was no significant difference in postoperative rates of morbidity (40% vs. 67%; P=0.431) and mortality (0% vs. 6.7%; P=0.99). The surgical resection margins R0 status (87% vs. 73%; P=0.79) and the number of lymph nodes (18 vs. 20; P=0.99) in the resected specimens were comparable between the 2 groups. There was no significant difference in overall survival outcomes. CONCLUSIONS In selected patients, the laparoscopic approach to pancreaticoduodenectomy in the hands of the experienced offers advantages over open surgery without compromising the oncologic resection.
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Training for laparoscopic pancreaticoduodenectomy. Surg Today 2018; 49:103-107. [DOI: 10.1007/s00595-018-1668-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/27/2018] [Indexed: 12/16/2022]
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Palanivelu C, Takaori K, Abu Hilal M, Kooby DA, Wakabayashi G, Agarwal A, Berti S, Besselink MG, Chen KH, Gumbs AA, Han HS, Honda G, Khatkov I, Kim HJ, Li JT, Duy Long TC, Machado MA, Matsushita A, Menon K, Min-Hua Z, Nakamura M, Nagakawa Y, Pekolj J, Poves I, Rahman S, Rong L, Sa Cunha A, Senthilnathan P, Shrikhande SV, Gurumurthy SS, Sup Yoon D, Yoon YS, Khatri VP. International Summit on Laparoscopic Pancreatic Resection (ISLPR) "Coimbatore Summit Statements". Surg Oncol 2018; 27:A10-A15. [PMID: 29371066 DOI: 10.1016/j.suronc.2017.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 12/20/2022]
Abstract
The International Summit on Laparoscopic Pancreatic Resection (ISLPR) was held in Coimbatore, India, on 7th and 8th of October 2016 and thirty international experts who regularly perform laparoscopic pancreatic resections participated in ISPLR from four continents, i.e., South and North America, Europe and Asia. Prior to ISLPR, the first conversation among the experts was made online on August 26th, 2016 and the structures of ISPLR were developed. The aims of ISPLR were; i) to identify indications and optimal case selection criteria for minimally invasive pancreatic resection (MIPR) in the setting of both benign and malignant diseases; ii) standardization of techniques to increase the safety of MIPR; iii) identification of common problems faced during MIPR and developing associated management strategies; iv) development of clinical protocols to allow early identification of complications and develop the accompanying management plan to minimize morbidity and mortality. As a process for interactive discussion, the experts were requested to complete an online questionnaire consisting of 65 questions about the various technical aspects of laparoscopic pancreatic resections. Two further web-based meetings were conducted prior to ISPLR. Through further discussion during ISPLR, we have created productive statements regarding the topics of Disease, Implementation, Patients, Techniques, and Instrumentations (DIPTI) and hereby publish them as "Coimbatore Summit Statements".
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Affiliation(s)
- Chinnusamy Palanivelu
- Division of Gastrointestinal Surgery and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, India.
| | - Kyoichi Takaori
- Division of Hapato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mohammad Abu Hilal
- Division of HPB Surgery, Southampton General Hospital (NHS), Southampton, UK
| | - David A Kooby
- Department of Surgery, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, United States
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Anil Agarwal
- Department of Surgical Gastroenterology, G B Pant Hospital, Delhi, India
| | - Stefano Berti
- Division of Miniinvasive Surgery, S. Andrea Hospital, La Spezia, Italy
| | - Marc G Besselink
- Hepato-Pancreato- Biliary (HPB) Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Kuo Hsin Chen
- Department of Surgery, Far-Eastern Memorial Hospital, Taiwan
| | - Andrew A Gumbs
- Department of Surgical Oncology, Summit Medical Group-MD Anderson Cancer Center, Berkeley Heights, NJ, USA
| | - Ho-Seong Han
- Comprehensive Cancer Center, Seoul National University Bundang Hospital, Bundang, South Korea
| | - Goro Honda
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Igor Khatkov
- Surgical Oncology, Moscow Clinical Scientific Center, Moscow, Russia
| | - Hong Jin Kim
- Department of HBP Surgery, Yeungnam University Hospital, Daegu, South Korea
| | - Jiang Tao Li
- Department of Surgery, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Tran Cong Duy Long
- Department of General Surgery, University Medical Center in Ho Chi Minh City Vietnam, Ho Chi Minh, Viet Nam
| | | | - Akira Matsushita
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Krish Menon
- Division and/or Department - Institute of Liver Studies, Department of Liver Transplantation and HPB, King's College Hospital NHS Trust, Camberwell, UK
| | - Zheng Min-Hua
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Juan Pekolj
- General Surgery Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ignasi Poves
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Shahidur Rahman
- Hepatobiliary Pancreatic and Liver Transplant Division, Bangobandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Liu Rong
- The Military Institute of Hepato-Pancreatico-Biliary Surgery and Second Department of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China
| | - Antonio Sa Cunha
- Department of HPB Surgery, AP-HP Hôpital Paul Brousse, Paris, France
| | - Palanisamy Senthilnathan
- Division of Minimally Invasive, Liver Transplantation & HPB Surgery, GEM Hosptial & Research Centre, Coimbatore, India
| | - Shailesh V Shrikhande
- Division of Cancer Surgery / Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - S Srivatsan Gurumurthy
- Division of HPB & Minimal Access Surgery, GEM Hosptial & Research Centre, Coimbatore, India
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Vijay P Khatri
- Department of Oncology, California Northstate University College of Medicine, Elk Grove, California, USA
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Inoue Y, Saiura A, Sato T, Ishizawa T, Arita J, Takahashi Y, Hiki N, Sano T, Yamaguchi T. Laparoscopic pancreatoduodenectomy combined with a novel self-assessment system and feedback discussion: a phase 1 surgical trial following the IDEAL guidelines. Langenbecks Arch Surg 2016; 401:1123-1130. [PMID: 27329105 DOI: 10.1007/s00423-016-1466-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 06/14/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE Pancreatoduodenectomy (PD) is the standard yet complicated procedure for periampullary tumors. To introduce a laparoscopic approach for PD (Lap-PD), a robust and objective assessment system to evaluate the quality of this approach is needed. We describe a phase 1 surgical trial of Lap-PD (Registration ID: UMIN000015328) as a triad of surgery, novel self-assessment system, and feedback discussion implementing the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) guidelines. METHODS This was a surgical phase I trial (corresponding to IDEAL stage 1) approved by the Ethics Committee of our hospital. The resection sequence was divided into 10 parts that were assessed and classified into one of four grades of achievement. Evaluation of each part was then integrated, and the whole Lap-PD was categorized into three grades of achievement. We set discontinuance criteria based on historical surgical outcome of open PD. The previous case was discussed before each new case, and measures to overcome problems were implemented. Five patients underwent Lap-PD. RESULTS All Lap-PDs were completed laparoscopically and reconstructed via mini-laparotomy. One patient suffered recurrent ileus requiring re-laparotomy to resolve a severe adhesion. After 1 year, no patient suffered disease recurrence or complication. Based on the self-assessment system, four Lap-PDs were successful, whereas one was rated as feasible owing to bleeding requiring conversion of resection sequence. CONCLUSIONS Our triad system for evaluating Lap-PD could be a useful tool for the safe introduction and maintenance of Lap-PD.
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Affiliation(s)
- Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Takafumi Sato
- Department of Gastroenterological Surgery, Nagoya City University, Nagoya, Japan
| | - Takeaki Ishizawa
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Junichi Arita
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yu Takahashi
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Naoki Hiki
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeshi Sano
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiharu Yamaguchi
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Abstract
Artery-first pancreatectomy is a technique to ligate the feeding artery before the division of the pancreas with intents to reduce the blood loss and to perform more oncologic resection; for example, the splenic artery (SA) is ligated first for artery-first distal pancreatectomy (DP). Potential merits of artery-first DP include early determination of resectability in the setting of pancreatic cancer with possible involvement of SA and/or celiac artery. However, due to difficulties in exposing the origin of SA, especially in open surgery, artery-first DP has been rarely performed. Through the experience of laparoscopic DP, we have developed a technique of artery-first DP by the 'Tora-no-Ana' approach, which consists of posterior dissection of the pancreatic body thorough a division of the ligament of Treitz. A hanging maneuver of the pancreatic parenchyma with SA and vein is another key for a successful artery-first DP. By the hanging maneuver, the origin of SA is well visualized and clearly identified either by open, laparoscopic or robotic approach so that oncologic resection can be achieved. In conclusion, artery-first DP is safe and feasible if the surgical principals by the Tora-no-Ana approach and hanging maneuver of the pancreatic body are adhered.
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Affiliation(s)
- Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Laparoscopic Distal Pancreatectomy with or without Preservation of the Spleen for Solid Pseudopapillary Neoplasm. Case Rep Surg 2015; 2015:487639. [PMID: 26587305 PMCID: PMC4637475 DOI: 10.1155/2015/487639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Solid pseudopapillary neoplasm (SPN) is a rare tumor of the pancreas. Laparoscopic distal pancreatectomy (DP) is a feasible and safe procedure, and successful spleen preservation rates are higher using a laparoscopic approach. We hypothesized that certain patients with SPN would be good candidates for laparoscopic surgery; however, few surgeons have reported laparoscopic DP for SPN. We discuss the preoperative assessment and surgical simulation for two SPN cases. A simulation was designed because we consider that a thorough preoperative understanding of the procedure based on three-dimensional image analysis is important for successful laparoscopic DP. We also discuss the details of the actual laparoscopic DP with or without splenic preservation that we performed for our two SPN cases. It is critical to use appropriate instruments at appropriate points in the procedure; surgical instruments are numerous and varied, and surgeons should maximize the use of each instrument. Finally, we discuss the key techniques and surgical pitfalls in laparoscopic DP with or without splenic preservation. We conclude that experience alone is inadequate for successful laparoscopic surgery.
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Laparoscopic Lateral Pancreaticojejunostomy and Laparoscopic Berne Modification of Beger Procedure for the Treatment of Chronic Pancreatitis. Surg Laparosc Endosc Percutan Tech 2014; 24:e178-82. [DOI: 10.1097/sle.0b013e31829ce803] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Kuroki T, Eguchi S. Laparoscopic distal pancreatosplenectomy for pancreatic ductal adenocarcinoma. Surg Today 2014; 45:808-12. [DOI: 10.1007/s00595-014-1021-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 08/10/2014] [Indexed: 01/11/2023]
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Zhao G, Hu M, Liu R, Zhiming Z, Xu Y, Zhou H, Wang X, Zhang X. Two Anatomical Pathways for Retroperitoneoscopic Pancreatectomy: Indications for the Posterior and Lateral Approaches. World J Surg 2014; 38:3023-32. [DOI: 10.1007/s00268-014-2654-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Gnoni A, Licchetta A, Scarpa A, Azzariti A, Brunetti AE, Simone G, Nardulli P, Santini D, Aieta M, Delcuratolo S, Silvestris N. Carcinogenesis of pancreatic adenocarcinoma: precursor lesions. Int J Mol Sci 2013; 14:19731-62. [PMID: 24084722 PMCID: PMC3821583 DOI: 10.3390/ijms141019731] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/04/2013] [Accepted: 09/10/2013] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma displays a variety of molecular changes that evolve exponentially with time and lead cancer cells not only to survive, but also to invade the surrounding tissues and metastasise to distant sites. These changes include: genetic alterations in oncogenes and cancer suppressor genes; changes in the cell cycle and pathways leading to apoptosis; and also changes in epithelial to mesenchymal transition. The most common alterations involve the epidermal growth factor receptor (EGFR) gene, the HER2 gene, and the K-ras gene. In particular, the loss of function of tumor-suppressor genes has been documented in this tumor, especially in CDKN2a, p53, DPC4 and BRCA2 genes. However, other molecular events involved in pancreatic adenocarcinoma pathogenesis contribute to its development and maintenance, specifically epigenetic events. In fact, key tumor suppressors that are well established to play a role in pancreatic adenocarcinoma may be altered through hypermethylation, and oncogenes can be upregulated secondary to permissive histone modifications. Indeed, factors involved in tumor invasiveness can be aberrantly expressed through dysregulated microRNAs. This review summarizes current knowledge of pancreatic carcinogenesis from its initiation within a normal cell until the time that it has disseminated to distant organs. In this scenario, highlighting these molecular alterations could provide new clinical tools for early diagnosis and new effective therapies for this malignancy.
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Affiliation(s)
- Antonio Gnoni
- Medical Oncology Unit, Hospital Vito Fazzi, Lecce 73100, Italy; E-Mails: (A.G.); (A.L.)
| | - Antonella Licchetta
- Medical Oncology Unit, Hospital Vito Fazzi, Lecce 73100, Italy; E-Mails: (A.G.); (A.L.)
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona, Verona 37121, Italy; E-Mail:
| | - Amalia Azzariti
- Clinical and Preclinical Pharmacology Laboratory, National Cancer Research Centre Istituto Tumori “Giovanni Paolo II”, Bari 70124, Italy; E-Mail:
| | - Anna Elisabetta Brunetti
- Scientific Direction, National Cancer Research Centre Istituto Tumori “Giovanni Paolo II”, Bari 70124, Italy; E-Mail: (A.E.B.); (S.D.)
| | - Gianni Simone
- Histopathology Unit, National Cancer Research Centre Istituto Tumori “Giovanni Paolo II”, Bari 70124, Italy; E-Mail:
| | - Patrizia Nardulli
- Hospital Pharmacy Unit - National Cancer Research Centre Istituto Tumori “Giovanni Paolo II”, Bari 70124, Italy; E-Mail:
| | - Daniele Santini
- Medical Oncology Department, University Campus Bio-Medico, Rome 00199, Italy; E-Mail:
| | - Michele Aieta
- Medical Oncology Unit - CROB-IRCCS, 85028, Rionero in Vulture, Potenza 85100, Italy; E-Mail:
| | - Sabina Delcuratolo
- Scientific Direction, National Cancer Research Centre Istituto Tumori “Giovanni Paolo II”, Bari 70124, Italy; E-Mail: (A.E.B.); (S.D.)
| | - Nicola Silvestris
- Medical Oncology Unit, National Cancer Research Centre Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, Bari 70124, Italy
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Kuroki T, Eguchi S. Laparoscopic parenchyma-sparing pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:323-7. [PMID: 24027045 DOI: 10.1002/jhbp.29] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In recent years laparoscopic pancreatic procedures have developed rapidly, and reports of laparoscopic resection including laparoscopic distal pancreatectomy and laparoscopic pancreaticoduodenectomy have increased in number. On the other hand, many benign and low-grade malignant pancreatic lesions have recently been detected by the improved diagnostic modalities. Parenchyma-sparing pancreatectomy is a preferred surgical procedure for such benign and low-malignancy pancreatic lesions, because parenchyma-sparing pancreatectomy can avoid the unnecessary resection of the normal pancreatic parenchyma, thereby preserving the endocrine and exocrine functions of the pancreas. Simultaneously, laparoscopic surgery has contributed to minimally invasive approaches for various pancreatic surgical procedures. The combination of laparoscopic surgery and parenchyma-sparing pancreatectomy is an ideal surgical procedure for benign and low-grade malignant pancreatic lesions. For laparoscopic parenchyma-sparing pancreatectomy to become more widely known and its indications clarified, it is necessary to demonstrate the clinical benefits, technical feasibility, and safety of this complex and difficult surgical procedure.
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Affiliation(s)
- Tamotsu Kuroki
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
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Abstract
These authors conclude that laparoscopic distal pancreatectomy can be safely and effectively performed by surgeons skilled in basic laparoscopy and does not require specialized training or to be performed in a specialized center. Background: Laparoscopic management of distal pancreatic malignancies has been slow to gain a foothold in all but high-volume tertiary referral centers. The aim of this study was to assess the safety and outcomes of laparoscopic distal pancreatectomy (LDP) performed in a low-volume community hospital by a diverse group of surgeons, none of whom have a specialized laparoscopic background. Methods: We conducted a retrospective review of all patients who underwent open distal pancreatectomies (ODPs) and LDPs between August 2001 and June 2008. Data included type of surgery, open versus laparoscopy, demographics, operative time, blood loss, length of hospital stay, histopathologic diagnosis, postoperative complications, American Society of Anesthesiologists score, and mortality. Results: Twenty-seven patients with pancreatic masses underwent distal pancreatic resection during the study period. Fifty-nine percent (n = 16) underwent LDP, and 41% (n = 11) underwent ODP. Mean patient age was 66 y (range, 40 to 86) for the LDP group and 62 (range, 40 to 84) for the ODP group. Mean operative time was 231 min (range, 195 to 305) for LDP and 240 (range, 150 to 210) for the ODP technique. Mean length of stay for LDP and ODP was 8 (range, 3 to 22) and 12 d (range, 5 to 2), respectively. Morbidity was 25% (n = 4) in the LDP group and 36% (n = 4) in the ODP group. None of the differences between the LDP and ODP groups were statistically significant. No mortalities occurred in either group. Conclusion: This study supports the idea that LDP can be safely and effectively performed by any surgeon comfortable with basic laparoscopy and may not require specialized training or a specialized center. Further data are required to make more definitive conclusions.
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Abu Hilal M, Takhar AS. Laparoscopic left pancreatectomy: current concepts. Pancreatology 2013; 13:443-8. [PMID: 23890145 DOI: 10.1016/j.pan.2013.04.196] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/17/2013] [Accepted: 04/17/2013] [Indexed: 12/11/2022]
Abstract
The minimally invasive approach has been slow to gain acceptance in the field of pancreatic surgery even though its advantages over the open approach have been extensively documented in the medical literature. The reasons for the reluctant use of the technique are manifold. Laparoscopic distal or left sided pancreatic resections have slowly become the standard approach to lesions of the pancreatic body and tail as a result of evolution in technology and experience. A number of studies have shown the potential advantages of the technique in terms of safety, blood loss, oncological and economic feasibility, hospital stay and time to recovery from surgery. This review aims to provide an overview of the recent advances in the field of laparoscopic left pancreatectomy (LLP) and discuss potential future developments.
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Affiliation(s)
- Mohammad Abu Hilal
- University Surgical Unit, Southampton General Hospital, Southampton, United Kingdom.
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Corcione F, Pirozzi F, Cuccurullo D, Piccolboni D, Caracino V, Galante F, Cusano D, Sciuto A. Laparoscopic pancreaticoduodenectomy: experience of 22 cases. Surg Endosc 2013; 27:2131-6. [PMID: 23355144 DOI: 10.1007/s00464-012-2728-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 12/01/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center. METHODS From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed. RESULTS Mean operative time was 392 (range, 327-570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12-35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14-20). CONCLUSIONS The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.
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Affiliation(s)
- Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, Azienda Ospedaliera dei Colli-Monaldi Hospital, Via Leonardo Bianchi, 80131, Naples, Italy.
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Misawa T, Ito R, Futagawa Y, Fujiwara Y, Kitamura H, Tsutsui N, Shiba H, Wakiyama S, Ishida Y, Yanaga K. Single-incision laparoscopic distal pancreatectomy with or without splenic preservation: how we do it. Asian J Endosc Surg 2012; 5:195-9. [PMID: 23095300 DOI: 10.1111/j.1758-5910.2012.00155.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Recent interest in improving cosmetic outcomes has led to single-incision laparoscopic surgery (SILS) being performed in a variety of organs. However, this innovative technique has rarely been introduced in pancreatic surgery, as it is considered to be a challenging procedure. We report herein our technique of single-incision laparoscopic distal pancreatectomy with or without splenic preservation. MATERIALS AND SURGICAL TECHNIQUE A 2.5-cm intraumbilical mini-laparotomy was made for the placement of a SILS Port as a single access site. The overall procedures were similar to those performed in the standard laparoscopic distal pancreatectomy with multiple trocars. To obtain better exposure of the operative field, we made technical refinements by employing gastric suspension with sutures, the tug-exposure technique, a balloon retractor, and gravity by changing the patient's position. The pancreas was transected with a linear stapler, and the specimen was extracted through the umbilical wound. DISCUSSION Patients were discharged without any complications. The umbilical wounds were almost invisible 1 month after surgery. We believe that SILS, with some technical refinements, can be safely applied for distal pancreatectomy. Although the cosmetic benefits of single-incision laparoscopic distal pancreatectomy are obvious, several issues such as the extent of invasiveness, cost, indications, and learning curve need to be investigated.
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Affiliation(s)
- Takeyuki Misawa
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
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Iacobone M, Citton M, Nitti D. Laparoscopic distal pancreatectomy: Up-to-date and literature review. World J Gastroenterol 2012; 18:5329-37. [PMID: 23082049 PMCID: PMC3471101 DOI: 10.3748/wjg.v18.i38.5329] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/19/2012] [Accepted: 05/13/2012] [Indexed: 02/06/2023] Open
Abstract
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.
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Cho A, Yamamoto H, Kainuma O, Ota T, Park S, Yanagibashi H, Arimitsu H, Ikeda A, Souda H, Nabeya Y, Takiguchi N, Nagata M. RETRACTED ARTICLE: Totally laparoscopic pancreas-sparing duodenectomy. Surg Today 2012; 42:1032-5. [DOI: 10.1007/s00595-012-0285-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 08/28/2011] [Indexed: 10/28/2022]
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Araki Y, Kaibori M, Matsumura S, Kwon AH, Ito S. Novel strategy for the control of postoperative pain: long-lasting effect of an implanted analgesic hydrogel in a rat model of postoperative pain. Anesth Analg 2012; 114:1338-45. [PMID: 22556212 DOI: 10.1213/ane.0b013e31824b26a2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is the most common nonopioid analgesic currently used for postoperative pain management. We tested the sustained analgesic effect of ketoprofen emanating from a biodegradable gelatin hydrogel in a rat model of postoperative pain. METHODS A sheet of analgesic-infiltrated hydrogel was inserted below the plantaris muscle at the end of surgery. Mechanical thresholds were measured by use of von Frey filaments before and 2 weeks after the operation. The effect of ketoprofen on the postoperative pain was also assessed immunohistochemically by assessing microglial activation in the spinal cord with anti-OX-42 and phosphorylated p38 mitogen-activated protein kinase antibodies. RESULTS Implantation of ketoprofen-infiltrated gelatin hydrogel exerted a sustained analgesic effect for 1 week after the operation. Preemptive analgesia with zaltoprofen, another NSAID, produced an additive analgesic effect in conjunction with the ketoprofen-infiltrated hydrogel. Microglial activation was attenuated by the treatment with ketoprofen-infiltrated hydrogel on day 3 after the incision. CONCLUSIONS These results demonstrate that ketoprofen was effective in reducing mechanical hypersensitivity for 1 week in a rat model of postoperative pain and that the implantation of NSAID-infiltrated gelatin hydrogel may serve as a useful analgesic method for the long-term relief of patients after surgery.
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Affiliation(s)
- Yoshiro Araki
- Department of Surgery, Kansai Medical University, Osaka, Japan
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Limongelli P, Belli A, Russo G, Cioffi L, D'Agostino A, Fantini C, Belli G. Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis. Surg Endosc 2012; 26:1830-6. [PMID: 22258300 DOI: 10.1007/s00464-011-2141-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 12/15/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies comparing open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) have found advantages related to minimal-access surgery. Few studies have compared direct and associated costs after LDP versus ODP. The purpose of the current study was to compare perioperative outcomes of patients undergoing LDP and ODP and to assess whether LDP was a cost-effective procedure compared with the traditional ODP. METHODS A retrospective analysis of a prospectively maintained database of 52 distal pancreatic resections that were performed during a 10-year period was performed. RESULTS Patients included in the analysis were 16 in the LDP group and 29 in the ODP. Tumors operated laparoscopically were smaller than those removed at open operation, but the length of pancreatic resection was similar. The mean operating time for LDP was longer than ODP (204 ± 31 vs. 160 ± 35; P < 0.0001), whereas blood loss was higher in the open group (365 ± 215 vs. 160 ± 185, P < 0.0001). Morbidity (25 vs. 41; P = 0.373) and pancreatic fistula (18 vs. 20%; P = 0.6) rates were similar after LDP and ODP, as was 30-day mortality (0 vs. 2%; P = 0.565). LDP had a shorter mean length of hospital stay than ODP (6.4 (2.3) vs. 8.8 (1.7) days; P < 0.0001). Operative cost for LDP was higher than ODP (<euro>2889 vs. <euro>1989; P < 0.0001). The entire cost of the associated hospital stay was higher in the ODP group (<euro>8955 vs. <euro>6714; P < 0.043). The total cost was comparable in LDP and ODP groups (<euro>9603 vs. <euro>10944; P = 0.204). CONCLUSIONS Laparoscopic distal pancreatectomy for left-sided lesions can be performed safely and effectively in selected patients, with reduced hospital stay and operative blood loss. Major complications, including pancreatic leak, were not reduced, whereas total cost was comparable between LDP and ODP. A selective use of LDP seems to be an effective and cost-efficient alternative to ODP.
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Affiliation(s)
- Paolo Limongelli
- Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, Italy
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Zhao G, Xue R, Ma X, Hu M, Gu X, Wang B, Zhang X, Liu R. Retroperitoneoscopic pancreatectomy: a new surgical option for pancreatic disease. Surg Endosc 2011; 26:1609-16. [DOI: 10.1007/s00464-011-2078-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 11/09/2011] [Indexed: 01/23/2023]
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Horiguchi A, Uyama I, Ito M, Ishihara S, Asano Y, Yamamoto T, Ishida Y, Miyakawa S. Robot-assisted laparoscopic pancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:488-92. [PMID: 21491102 DOI: 10.1007/s00534-011-0383-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND In the field of gastroenterological surgery, laparoscopic surgery has advanced remarkably, and now accounts for most gastrointestinal operations. This paper outlines the current status of and future perspectives on robot-assisted laparoscopic pancreatectomy. METHODS A review of the literature and authors' experience was undertaken. RESULTS The da Vinci Surgical System is a robot for assisting laparoscopy and is safer than conventional endoscopes, thanks to the 3-dimensional hi-vision images it yields, high articular function with the ability to perform 7 types of gripping, scaling function enabling 2:1, 3:1, and 5:1 adjustment of surgeon hand motion and forceps motions, a filtering function removing shaking of the surgeon's hand, and visual magnification. By virtue of these functions, this system is expected to be particularly useful for patients requiring delicate operative manipulation. CONCLUSIONS Issues of importance remaining in robot-assisted laparoscopic pancreatectomy include its time of operation, which is longer than that of open surgery, and the extra time needed for application of the da Vinci compared with ordinary laparoscopic surgery. These issues may be resolved through accumulation of experience and modifications of the procedure. Robot-assisted laparoscopic pancreatectomy appears likely to become a standard procedure in the near future.
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Affiliation(s)
- Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University, 1-98 Dengakugakubo Kutsukakecho, Toyoake, Aichi, Japan.
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Laparoscopic pancreaticoduodenectomy combined with minilaparotomy. Surg Today 2011; 42:509-13. [PMID: 22127534 DOI: 10.1007/s00595-011-0064-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/14/2011] [Indexed: 12/13/2022]
Abstract
Laparoscopic pancreatic surgery is evolving rapidly; however, the surgical treatment of periampullary tumors is still fraught with challenges, such as technical difficulty and the appropriateness of oncologic treatment for these patients. We describe how we performed laparoscopic pancreaticoduodenectomy (LPD) combined with minilaparotomy successfully in six consecutive patients. This procedure consisted of two surgical phases: safe laparoscopic surgery, including the Kocher maneuver, tunneling behind the pancreatic neck, and dissecting along the uncinate process with magnified vision; and a secure open approach with complete skeletonization of the hepatoduodenal ligament and alimentary tract reconstruction, performed similarly to conventional pancreaticoduodenectomy, under direct visualization through the minilaparotomy. By performing this procedure, we combined a safe and secure minilaparotomy approach under direct vision with a less invasive laparoscopic approach providing a magnified image. Our experience demonstrates that LPD combined with minilaparotomy is technically feasible for selected patients with periampullary tumors.
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Zhang T, Du X, Zhao Y. Laparoscopic surgery for pancreatic lesions: current status and future. Front Med 2011; 5:277-82. [DOI: 10.1007/s11684-011-0147-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 07/05/2011] [Indexed: 02/08/2023]
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Nigri GR, Rosman AS, Petrucciani N, Fancellu A, Pisano M, Zorcolo L, Ramacciato G, Melis M. Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies. Surg Endosc 2011; 25:1642-1651. [PMID: 21184115 DOI: 10.1007/s00464-010-1456-5] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 10/19/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND The current literature suggests that minimally invasive distal pancreatectomy (MIDP) is associated with faster recovery and less morbidity than open surgery. However, most studies have been limited by a small sample size and a single-institution design. To overcome this problem, the first metaanalysis of studies comparing MIDP and open distal pancreatectomy (ODP) has been performed. METHODS A systematic literature review was conducted to identify studies comparing MIDP and ODP. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model. RESULTS For the metaanalysis, 10 studies including 349 patients undergoing MIDP and 380 patients undergoing ODP were considered suitable. The patients in the two groups were similar with respect to age, body mass index (BMI), American Society of Anesthesiology (ASA) classification, and indication for surgery. The rate of conversion from full laparoscopy to hand-assisted procedure was 37%, and that from minimally invasive to open procedure was 11%. Patients undergoing MIDP had less blood loss, a shorter time to oral intake, and a shorter postoperative hospital stay. The mortality and reoperative rates did not differ between MIDP and ODP. The MIDP approach had fewer overall complications [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27-0.89], major complications (OR, 0.57; 95% CI, 0.34-0.96), surgical-site infections (OR, 0.32; 95% CI, 0.19-0.53), and pancreatic fistulas (OR, 0.68; 95% CI, 0.47-0.98). CONCLUSIONS The MIDP procedure is feasible, safe, and associated with less blood loss and overall complications, shorter time to oral intake, and shorter postoperative hospital stay. Furthermore, the minimally invasive approach reduces the rate of pancreatic leaks and surgical-site infections after ODP.
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Affiliation(s)
- Giuseppe R Nigri
- Department of Surgery, St. Andrea Hospital, Sapienza University of Rome, 5-Ovest, Via di Grottarossa 1035, 00189, Rome, Italy.
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Current state of surgical management of pancreatic cancer. Cancers (Basel) 2011; 3:1253-73. [PMID: 24212660 PMCID: PMC3756412 DOI: 10.3390/cancers3011253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 02/19/2011] [Accepted: 03/10/2011] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer is still associated with a poor prognosis and remains—as the fourth leading cause of cancer related mortality—a therapeutic challenge. Overall long-term survival is about 1–5%, and in only 10–20% of pancreatic cancer patients is potentially curative surgery possible, increasing five-year survival rates to approximately 20–25%. Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care. Standardized resections can be carried out with low morbidity and mortality below 5% in high volume institutions. Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes. The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.
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Hand-assisted laparoscopic total pancreatectomy for a main duct intraductal papillary mucinous neoplasm of the pancreas. Surg Today 2011; 41:306-10. [DOI: 10.1007/s00595-010-4248-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 01/21/2010] [Indexed: 12/31/2022]
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Abstract
Cysts of the pancreas most often develop after chronic or acute inflammation of the pancreas. Cystic neoplasia of the pancreas have been increasingly recognized in clinical practice and 90% are represented by four types: serous microcystic (SCN), mucinous cystic (MCN), intraductal papillary-mucinous (IPMN) and solid pseudopapillary (SPN) neoplasia. IPMN is the most common form nowadays and main duct and branch duct types can be differentiated by morphology. This classification is of prognostic and therapeutic relevance. While main duct IPMNs have a high risk of malignant progression and resection is therefore recommended, branch duct IPMNs have a much lower risk of harboring malignancy. Small branch duct IPMNs (<2 cm) without symptoms or mural nodules can be managed by periodic surveillance. Recently, it has become clear that IPMN constitutes a heterogeneous group with at least four subtypes. Their stratification reveals that the various subtypes of IPMN have different biological properties with different prognostic implications, but the subclassification is usually not known prior to surgery. Moreover, even differentiation between inflammatory and neoplastic cysts can be challenging. Clear indications for resection are local complications (jaundice or gastric outlet obstruction), large and increasing tumors, symptoms or secretion of mucinous fluid from the papilla of Vater.
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Testini M, Gurrado A, Lissidini G, Venezia P, Greco L, Piccinni G. Management of mucinous cystic neoplasms of the pancreas. World J Gastroenterol 2010; 16:5682-92. [PMID: 21128317 PMCID: PMC2997983 DOI: 10.3748/wjg.v16.i45.5682] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to investigate the actual management of mucinous cystic neoplasm (MCN) of the pancreas. A systematic review was performed in December 2009 by consulting PubMed MEDLINE for publications and matching the key words “pancreatic mucinous cystic neoplasm”, “pancreatic mucinous cystic tumour”, “pancreatic mucinous cystic mass”, “pancreatic cyst”, and “pancreatic cystic neoplasm” to identify English language articles describing the diagnosis and treatment of the mucinous cystic neoplasm of the pancreas. In total, 16 322 references ranging from January 1969 to December 2009 were analysed and 77 articles were identified. No articles published before 1996 were selected because MCNs were not previously considered to be a completely autonomous disease. Definition, epidemiology, anatomopathological findings, clinical presentation, preoperative evaluation, treatment and prognosis were reviewed. MCNs are pancreatic mucin-producing cysts with a distinctive ovarian-type stroma localized in the body-tail of the gland and occurring in middle-aged females. The majority of MCNs are slow growing and asymptomatic. The prevalence of invasive carcinoma varies between 6% and 55%. Preoperative diagnosis depends on a combination of clinical features, tumor markers, computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound with cyst fluid analysis, and positron emission tomography-CT. Surgery is indicated for all MCNs.
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Røsok BI, Marangos IP, Kazaryan AM, Rosseland AR, Buanes T, Mathisen O, Edwin B. Single-centre experience of laparoscopic pancreatic surgery. Br J Surg 2010; 97:902-909. [PMID: 20474000 DOI: 10.1002/bjs.7020] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic resection is regarded as safe and feasible in selected patients with benign pancreatic tumours. Few data exist on laparoscopic surgery for malignant lesions and larger neoplasms in unselected patients. METHODS The study included all patients admitted to Oslo University Hospital, Rikshospitalet, from March 1997 to March 2009 for surgery of lesions in the body and tail of the pancreas, and selected patients with lesions in the pancreatic head, who underwent surgery by a laparoscopic approach with curative intent. RESULTS A total of 166 patients had 170 operations, including 138 pancreatic resections, 18 explorations, nine resections of peripancreatic tissue and five other therapeutic procedures. Four patients had repeat procedures. There were 53 endocrine tumours (31.0 per cent), 28 pancreatic carcinomas (16.4 per cent), five cases of metastases (2.9 per cent), 48 cystic tumours (28.1 per cent) and 37 other lesions (21.6 per cent). The total morbidity rate was 16.5 per cent. Fistula was the most common complication (10.0 per cent). Three patients needed reoperation for complications. There were three hospital deaths (1.8 per cent). Median hospital stay following surgery was 4 days. CONCLUSION Laparoscopic resection of lesions in the body and tail of the pancreas in an unselected patient series was safe and feasible, and should be the method of choice for this patient group in specialized centres.
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Affiliation(s)
- B I Røsok
- Division of Surgery, Section for Gastrointestinal Surgery, Oslo University Hospital (OUH), Rikshospitalet, 0027 Oslo, Norway
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Mukherjee K, Morrow SE, Yang EY. Laparoscopic Distal Pancreatectomy in Children: Four Cases and Review of the Literature. J Laparoendosc Adv Surg Tech A 2010; 20:373-7. [DOI: 10.1089/lap.2009.0247] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kaushik Mukherjee
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stephen E. Morrow
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Edmund Y. Yang
- Department of Pediatric Surgery, Cardinal Glennon Children's Medical Center at St. Louis University, St. Louis, Missouri
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Abstract
OBJECTIVES Minimally invasive surgery is beneficial for complex operations; robotics may improve performance in these procedures; however, robotic pancreaticoduodenectomy (PD) has been plagued by long operative times. We describe a small series (n = 5) of patients who underwent a hybrid PD for treatment of obstructive jaundice and pancreatic mass. METHODS After diagnostic laparoscopy, the gallbladder was retracted cephalad and the porta hepatis was dissected. The lesser sac was opened to expose the superior mesenteric vein below the pancreas. Once the vein was cleared, the bile duct, stomach, pancreas, and jejunum were transected. After the uncinate process was cleared, the specimen was removed. The da Vinci S Surgical Robotic System was docked to perform a mucosa-to-mucosa pancreaticojejunostomy and an end-to-side choledochojejunostomy. A stapled gastrojejunostomy and drain placement completed the operation. RESULTS Five patients underwent hybrid PD between May 2006 and June 2007. All patients had a history of pancreatitis and presented with obstructive jaundice and a pancreatic mass. The operations were completed with 5 ports. The mean operative time was 7 hours. The mean hospital stay was 9.6 days. At 6 months after the operation, all patients were disease-free. CONCLUSIONS Complex procedures such as PD can be accomplished with minimally invasive surgical techniques using robotic instrumentation.
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Laparoscopic enucleation of a gastroenteric duplication cyst arising in a pancreatic tail that did not communicate with the pancreatic duct: report of a case. Surg Today 2010; 40:281-4. [PMID: 20180086 DOI: 10.1007/s00595-008-4051-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 09/30/2008] [Indexed: 01/11/2023]
Abstract
Gastroenteric duplication rarely occurs in locations such as the pancreas. We report a case of gastroenteric duplication of the pancreatic tail, which was noncontiguous with the stomach and had no communication with the pancreatic duct, in a 3-year-old girl. The cyst was enucleated by laparoscopy, without the need for pancreatic resection. The optimal treatment procedures vary considerably, depending on where the gastroenteric duplication is located in the pancreas and, most importantly, whether there is communication with the pancreatic duct.
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Busquets J, Fabregat J, Borobia FG, Jorba R, Valls C, Serrano T, Ramos E, Pelaez N, Rafecas A. Organ-preserving surgery for benign lesions and low-grade malignancies of the pancreatic head: a matched case-control study. Surg Today 2010; 40:125-31. [PMID: 20107951 DOI: 10.1007/s00595-008-4038-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Accepted: 10/29/2008] [Indexed: 01/19/2023]
Abstract
PURPOSE To compare the postoperative results of various preservative surgery (PS) techniques with those of two types of pancreatoduodenectomy (PD). METHODS The subjects of this study were 65 patients treated surgically for chronic pancreatitis, or benign or borderline tumors. We defined PS as any of the following: duodenum-preserving pancreatic head resection (DPPHR), uncinatectomy (UC), and cystic tumor enucleation (EN). The two types of PD were Whipple pancreatoduodenectomy (WPD) and pylorus-preserving pancreatoduodenectomy (PPPD). RESULTS Benign lesions were treated with PD in 41 patients and PS in 24 patients. Whipple pancreatoduodenectomy was performed in 17 patients, PPPD in 24, DPPHR in 20, EN in 3, and UC in 1. The main indication for surgery was chronic pancreatitis (66%). Delayed gastric emptying (DGE) was seen in 41% of patients in the PD group but none in the PS group (P = 0.04). However, there were no differences between the two groups in the incidence of pancreatic fistulas or other complications. Reoperation was required in five of the PD patients, but none of the PS patients. CONCLUSION Surgical techniques for preserving pancreatic tissue are effective for carefully selected patients with benign pancreatic disorders.
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Affiliation(s)
- Juli Busquets
- Department of General and Digestive Surgery, Bellvitge University Hospital, C/Feixa Llarga s/n, Hospitalet de Llobregat, Barcelona, Spain
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Liem NT, Son TN, Hoan NT. Laparoscopic Near-Total Pancreatectomy for Persistent Hyperinsulinemic Hypoglycemia of Infancy: Report of Two Cases. J Laparoendosc Adv Surg Tech A 2010; 20:115-7. [DOI: 10.1089/lap.2008.0316] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nguyen T. Liem
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Tran N. Son
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Nguyen T. Hoan
- Department of Endocrinology, Metabolism, and Genetics, National Hospital of Pediatrics, Hanoi, Vietnam
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Laparoscopic resection of an epidermoid cyst originating from an intrapancreatic accessory spleen: report of a case. Surg Today 2009; 40:72-5. [PMID: 20037845 DOI: 10.1007/s00595-009-4006-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Accepted: 02/19/2009] [Indexed: 02/07/2023]
Abstract
A 67-year-old man underwent an investigation of epigastric pain and weight loss. Preoperative imaging findings suggested the presence of a tumor, which developed as an epidermoid cyst and originated from an intrapancreatic accessory spleen; however, the possibility of malignancy could not be ruled out. We therefore performed a laparoscopic-assisted distal pancreatectomy with a splenectomy for both diagnostic and treatment purposes. Five laparoscopic ports were created. After the spleen and pancreatic tail were dissected from the retroperitoneum laparoscopically, they were pulled out through a 7-cm left subcostal incision and resected with an endoscopic linear stapler. The operative time was 227 min and the blood loss was 400 ml. The postoperative course was uneventful. The final pathological diagnosis was in agreement with the preoperative diagnosis. This case demonstrates that the minimally invasive approach of laparoscopic surgery can be used safely and successfully for difficult-to-diagnose pancreatic tumors. This is the first report describing a laparoscopic resection of an epidermoid cyst originating from an intrapancreatic accessory spleen.
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40
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Sahm M, Pross M, Schubert D, Lippert H. Laparoscopic distal pancreatic resection: our own experience in the treatment of solid tumors. Surg Today 2009; 39:1103-8. [PMID: 19997811 DOI: 10.1007/s00595-008-3999-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 02/03/2008] [Indexed: 12/21/2022]
Abstract
A laparoscopic resection is a new treatment for pancreatic tumors. Articles by surgeons who are writing about their first experience in carrying out this treatment have appeared in the literature, reporting that laparoscopic surgery can be used for the treatment of pancreatitis, benign lesions, and solid tumors. This is a study of three patients with pancreatic tumors who were treated by means of a laparoscopic distal pancreatic resection with preservation of the spleen and splenic vessels. In three cases a laparoscopic distal resection was performed for the tumor. The histologic examinations showed one insulinoma and two mucinous cystadenomas. No patient suffered from intra- or postoperative complications. A laparoscopic resection of the distal pancreas is a new alternative for the treatment of pancreatic tumors. This method takes advantage of the benefits of minimally invasive surgery.
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Affiliation(s)
- Maik Sahm
- Department of Surgery, DRK Kliniken Berlin Köpenick, Salvador-Allende-Strasse 2-8, 12559, Berlin, Germany
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Merchant NB, Parikh AA, Kooby DA. Should all distal pancreatectomies be performed laparoscopically? Adv Surg 2009; 43:283-300. [PMID: 19845186 DOI: 10.1016/j.yasu.2009.02.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.
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Affiliation(s)
- Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232-6860, USA.
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Langer P, Fendrich V, Bartsch DK. [Minimally invasive resection of neuroendocrine pancreatic tumors]. Chirurg 2009; 80:105-12. [PMID: 19099267 DOI: 10.1007/s00104-008-1613-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pancreatic endocrine tumors (PET) are a heterogeneous group of lesions with an annual incidence of 0.1 to 0.4 per 100,000. They account for 2-4% of pancreatic neoplasms. Due to their mostly small size, some are suited to a laparoscopic approach. Preoperative localization, intraoperative laparoscopic ultrasonography, and considerable experience in pancreatic endocrine surgery and sophisticated laparoscopic techniques are essential for successful laparoscopic treatment of these tumors. If definite or highly suspicious signs of malignancy occur, a conventional open approach should be preferred. Insulinomas and small nonfunctioning PET in the pancreatic body or tail or near the surface of the pancreatic head and not in contact with the portal vein or the main pancreatic duct are suited to a laparoscopic approach. Patients with MEN1 who have insulinomas or small nonfunctioning PET may also benefit from a laparoscopic spleen-preserving distal pancreatic resection. Neither sporadic and MEN1-associated gastrinomas nor the very rare glucagonomas and vasoactive intestinal peptide-producing tumors (vipomas), which are often large and malignant, should also be tackled laparoscopically.
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Affiliation(s)
- P Langer
- Klinik für Visceral-, Thorax- und Gefässchirurgie, Universitätsklinikum Giessen und Marburg GmbH, Standort Marburg, Baldingerstrasse, Marburg, Germany.
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Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, Praveen Raj P. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. ACTA ACUST UNITED AC 2009; 16:731-40. [PMID: 19652900 DOI: 10.1007/s00534-009-0157-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/31/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy is a technically demanding surgery performed only at few centers in the world. This article aims to describe the evolution of the technique and summarizes the results in our institute over the years. METHODS Prospective data of patients undergoing laparoscopic pancreaticoduodenectomy from March 1998 to January 2009 was retrospectively reviewed. RESULTS There were a total of 75 patients (22 females and 53 males) with a mean age of 62 (range, 28-76) years. Conversion rate was 0%, overall postoperative morbidity was 26.7% and mortality rate was 1. 33%. Pancreatic fistula was seen in 6.67%. The mean operating time was 357 min (range 270-650), and the mean blood loss was 74 ml (range 35-410). The average time to the first bowel movement was 3 days and mean hospital stay was 8.2 days (range 6-42). Resected margins were positive in 2.6% of cases. The mean number of retrieved lymph nodes for the malignant lesions was 14 (range 8-22). CONCLUSION Laparoscopic pancreaticoduodenectomy can be safely performed by highly skilled laparoscopic surgeons. This technique can achieve adequate margins and follow oncological principles. Randomized comparative trials are needed to establish the superiority of laparoscopy versus open surgery.
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Affiliation(s)
- C Palanivelu
- GEM Hospital, 45-A, Pankaja Mill Road, Ramnathapuram, Coimbatore, 641045, India.
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Finan KR, Cannon EE, Kim EJ, Wesley MM, Arnoletti PJ, Heslin MJ, Christein JD. Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes. Am Surg 2009. [DOI: 10.1177/000313480907500807] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.
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Affiliation(s)
- Kelly R. Finan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily E. Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eugenia J. Kim
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary M. Wesley
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pablo J. Arnoletti
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Martin J. Heslin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John D. Christein
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Cho A, Yamamoto H, Nagata M, Takiguchi N, Shimada H, Kainuma O, Souda H, Gunji H, Miyazaki A, Ikeda A, Tohma T, Matsumoto I. Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization. ACTA ACUST UNITED AC 2009; 16:705-10. [PMID: 19629373 DOI: 10.1007/s00534-009-0144-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/31/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties. METHODS We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy. CONCLUSION Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.
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Affiliation(s)
- Akihiro Cho
- Division of Gastroenterological Surgery, Chiba Cancer Center Hospital, 666-2 Nitonachou, Chuouku, Chiba, 260-8717, Japan.
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Laparoscopic pancreatic resection: some benefits of evolving surgical techniques. ACTA ACUST UNITED AC 2009; 16:741-8. [DOI: 10.1007/s00534-009-0140-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/31/2009] [Indexed: 11/26/2022]
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Abstract
In recent years, improved laparoscopic skill sets have expanded surgical management of pancreatic disease to encompass pancreatic resection, tumor enucleation, debridement, and drainage. With the aid of radiologically guided drainage catheters, necrosectomy for acute pancreatitis can be delayed and accomplished laparoscopically in a select patient population. Pancreatic pseudocysts from chronic pancreatitis can now be approached via minimally invasive strategies, including emerging combined laparoscopic procedures and natural orifice transluminal endoscopic surgery. It is clear that laparoscopic pancreaticoduodenectomy is possible in experienced hands; pancreatic neoplasms in the body and tail are more suitable for laparoscopic procedures because distal pancreatic resection requires no reconstruction of the biliary or enteric tract. Laparoscopic staging of pancreatic tumors has decreased as preoperative radiographic imaging becomes more sensitive. Similarly, laparoscopic palliative procedures have decreased because of the emergence of other minimally invasive options for relieving gastric outlet obstruction and biliary obstruction. Nonetheless, major advances in minimally invasive pancreatic surgery will continue as technology and skill sets advance.
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48
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Is there a place for N.O.T.E.S. in the diagnosis and treatment of neoplastic lesions of the pancreas? Surg Oncol 2009; 18:139-46. [DOI: 10.1016/j.suronc.2008.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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49
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Abu Hilal M, Jain G, Kasasbeh F, Zuccaro M, Elberm H. Laparoscopic distal pancreatectomy: critical analysis of preliminary experience from a tertiary referral centre. Surg Endosc 2009; 23:2743-7. [PMID: 19462202 DOI: 10.1007/s00464-009-0499-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 02/20/2009] [Accepted: 03/25/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic pancreatic surgery has been slow to gain wide acceptance due to the complex pancreatic anatomy and physiology. The aim of this study was to analyze our preliminary results and highlight the impact of centralization on surgeon workload and pancreatic surgical innovation. METHODS A retrospective analysis was performed on all patients who underwent laparoscopic distal pancreatectomy from May 2007 to October 2008. RESULTS Laparoscopic distal pancreatectomy was performed in 17 patients during that period. Median operative time was 180 min (range 120-300 min). Median blood loss was 100 ml (range 50-500 ml). Splenectomy was performed in 12 patients. None of the patients was converted to open operation. All patients were kept in high-dependency unit for median duration of 1 day (range 0-1 day). One patient with previous cardiac disease was kept in intensive therapy unit for one night, but discharged home on 7th postoperative day without any complications. Postoperative recovery was uneventful in 13 patients, while four patients had pancreatic leak. One pancreatic leak was observed in the last 11 patients, in which pancreatic stump was oversewn. In three patients, pancreatic leaks (PL) were minor and settled with conservative management, while one patient needed a computed tomography (CT)-guided drainage and subsequent minilaparotomy for wash out of the intra abdominal collection. None of the patients died in this series. Median hospital stay was 5 days (range 4-7 days). CONCLUSIONS Laparoscopic distal pancreatic resection is feasible, safe, and efficient. However, this surgery should only be performed in specialized centres with extensive experience in pancreatic and laparoscopic surgery. Oversewing the pancreatic stump after transaction with Endostapler may reduce the incidence of pancreatic leak. Centralization of pancreatic surgery has a positive impact on building up surgical expertise, resulting in obvious benefits for both patients and institutions.
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Affiliation(s)
- Mohammed Abu Hilal
- Hepato pancreatico biliary Unit, Surgical Academic Unit, F Level Southampton General Hospital, Southampton, UK.
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50
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A totally laparoscopic pylorus-preserving pancreaticoduodenectomy and reconstruction. Surg Today 2009; 39:359-62. [PMID: 19319649 DOI: 10.1007/s00595-008-3853-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 09/18/2008] [Indexed: 10/21/2022]
Abstract
Although many reports have described laparoscopic pancreatic surgery, laparoscopic pancreaticoduodenectomy (PD) has not been widely employed because of technical difficulties. This paper describes a totally laparoscopic pylorus-preserving PD performed for an intraductal papillary-mucinous neoplasm. After the laparoscopic resection, an end-to-side pancreaticojejunostomy including duct-to-mucosa anastomosis without a stenting tube, an approximation of the pancreas stump and jejunal wall, an end-to-side hepaticojejunostomy, and an end-to-side duodenojejunostomy were performed intracorporeally. The patient recovered without any complications and was discharged on the 14th postoperative day. The surgical margin was free of neoplastic changes. Although the experience is limited and the appropriate indications must await future studies, this case indicates that a laparoscopic pylorus-preserving PD can be feasible, safe, and effective in highly selected patients.
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